2012-05-04T10:17:33-05:00 2011-06-30 EIDE BAILLY LLP 3999 PENNSYLVANIA AVE SUITE 100 DUBUQUE IA 52002 990 2010-07-01 421231996 VIRGINIA GAY HOSPITAL INC VIRG 3194726255 502 N 9TH AVENUE VINTON IA 523492254 MICHAEL RIEGE 3194726200 2012-05-01 1 CARMEN KRANTZ 5635561790 2012-05-01 2010 2016-02-24 21:20:13Z MICHAEL RIEGE 502 N 9TH AVENUE VINTON IA 523492254 21516042 0 X WWW.VGHINC.COM X 1923 IA PROVISION FOR HEALTH CARE SERVICES 9 7 287 31 0 0 1458927 662237 18396585 20795066 55159 58739 0 0 19910671 21516042 0 8569 0 0 10179616 11101951 0 0 54100 8180769 9004957 18360385 20115477 1550286 1400565 22529722 23734012 9442947 9192210 13086775 14541802 X OUR PURPOSE IS TO PROVIDE QUALITY HEALTH CARE SERVICES BY USING INNOVATIVE, GROWTH-ORIENTED TECHNIQUES AND MAINTAINING A SOUND FINANCIAL BASE. 0 0 17999577 8569 20795066 VIRGINIA GAY HOSPITAL LEADS DELIVERY OF HEALTHCARE TO ITS REGION THROUGH OVER 225 ASSOCIATES (INCLUDING 9 PROVIDERS) WHICH COORDINATE CARE TO DELIVER PATIENT CARE AS AN INTEGRATED UNIT. VIRGINIA GAY HOSPITAL AND ITS AFFILIATES ALSO WORK SEAMLESSLY TO MEET THE NEEDS OF THE COMMUNITIES THEY SERVE. TO FULFILL ITS MISSION OF COMMUNITY SERVICE, THE HOSPITAL PROVIDES CARE TO PATIENTS AND RESIDENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. REVENUE FROM SERVICES TO THESE PATIENTS AND RESIDENTS IS RECORDED IN THE ACCOUNTING SYSTEM AT THE ESTABLISHED RATES, BUT THE HOSPITAL DOES NOT PURSUE COLLECTION OF THE AMOUNTS. THE RESULTING ADJUSTMENTS ARE RECORDED AS ADJUSTMENTS TO PATIENT AND RESIDENT SERVICE REVENUE, DEPENDING ON THE TIMING OF THE CHARITY DETERMINATION.THE HOSPITAL MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY CARE IT PROVIDES. THESE RECORDS INCLUDE THE AMOUNT OF CHARGES FOREGONE FOR SERVICES AND SUPPLIES FURNISHED UNDER ITS CHARITY CARE POLICY. THE AMOUNTS OF CHARGES FOREGONE, BASED ON ESTABLISHED RATES, WERE $206,338 FOR THE YEAR ENDED JUNE 30, 2011. THE ESTIMATED COSTS OF THE CHARGES FOREGONE, BASED UPON AN OVERALL COST-TO-CHARGE RATIO CALCULATION, FOR THE YEAR ENDED JUNE 30, 2011 WERE $135,000.IN ADDITION, THE HOSPITAL PROVIDES SERVICES TO OTHER MEDICALLY INDIGENT PATIENTS UNDER CERTAIN GOVERNMENT-REIMBURSED PUBLIC AID PROGRAMS. SUCH PROGRAMS PAY PROVIDERS AMOUNTS WHICH ARE LESS THAN ESTABLISHED CHARGES FOR THE SERVICES PROVIDED TO THE RECIPIENTS, AND FOR SOME SERVICES THE PAYMENTS ARE LESS THAN THE COST OF RENDERING THE SERVICES PROVIDED.THE HOSPITAL ALSO COMMITS SIGNIFICANT TIME AND RESOURCES TO ENDEAVORS AND CRITICAL SERVICES WHICH MEET OTHERWISE UNFULFILLED COMMUNITY NEEDS. MANY OF THESE ACTIVITIES ARE SPONSORED WITH THE KNOWLEDGE THAT THEY WILL NOT BE SELF-SUPPORTING OR FINANCIALLY VIABLE.VIRGINIA GAY HOSPITAL ALSO MAKES MEDICAL CARE ACCESSIBLE TO THE ENTIRE COMMUNITY IT SERVES. THE HOSPITAL OPERATES A FULL-TIME EMERGENCY ROOM AND PROVIDES EMERGENCY CARE REGARDLESS OF ABILITY TO PAY. VIRGINIA GAY HOSPITAL HAD OVER 2,760 EMERGENCY ROOM VISITS THIS YEAR. THE HOSPITAL PROVIDES CLINICAL SERVICES NEEDED TO OPERATE THE EMERGENCY ROOM AND PROVIDES ON-SITE EMERGENCY MEDICAL CARE AND MEDICAL TRANSPORTATION SERVICES THROUGH AN AREA AMBULANCE SERVICE, VAN SERVICE, AND AN ONSITE HELIPAD. 17999577 1 1 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 23 0 1 287 1 0 0 0 0 0 0 0 0 0 0 X 9 7 1 0 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IA X JULIA MEADOWS 3194726255 502 N 9TH AVENUE VINTON IA 52349 X MARK MOSSMAN 0.50 X X 0 0 0 JOHN KETCHEN 0.50 X X 0 0 0 DAVID VERMEDAHL 0.50 X X 0 0 0 JOHN YUNDT 0.50 X X 0 0 0 JAMES HODGSON 0.50 X 0 0 0 DR BRIAN MEEKER DO 0.50 X 520027 0 34591 MARIE THERESE FOTH 0.50 X 0 0 0 JOHN WATSON 0.50 X 0 0 0 DR MARK DEARDEN DO 0.50 X 253672 0 27001 MICHAEL RIEGE 40.00 X 123089 0 28256 JULIA MEADOWS 40.00 X 86852 0 10480 DR MICHELLE ELGIN DO 40.00 X 135216 0 14461 MICHELE BURNES 40.00 X 198075 0 7710 RITA TAYLOR-STEWART 40.00 X 196583 0 9414 DR GENE LARIVIERE 40.00 X 324478 0 33148 MATT WILDEN 40.00 X 115227 0 22492 1953219 0 187553 8 0 1 0 ALBERICI 8800 PAGE AVENUE ST LOUIS MO 63114 CONSTRUCTION CONTRACTOR 1688663 REHABVISIONS 11623 ARBOR STREET OMAHA NE 68144 PT/OT/ST 908434 HEALTH ENTERPRISES 4250 GLASS ROAD CEDAR RAPIDS IA 524022513 CRNA & ULTRASOUND 370004 CPSI 6600 WALL STREET MOBILE IL 36695 COMPUTER SOFTWARE/HARDWARE 357493 ALLIANCE HEALTHCARE PO BOX 96485 CHICAGO IL 60693 CT/MRI SCANS 249270 5 632342 24895 5000 662237 PATIENT & RESIDENT REV 622110 20597322 20597322 SUPPORTING REVENUE 900099 168235 168235 OUTPATIENT CLINICS 621400 29509 29509 20795066 58739 58739 21516042 20795066 0 58739 8569 8569 1041610 796321 245289 8493033 7896808 570445 25780 90650 69149 21501 862252 822622 39630 614406 554810 55834 3762 9590 9590 67745 66170 1575 3510478 3223543 286935 29481 18495 10986 2205319 1935753 258247 11319 384304 384304 61492 54824 6668 44210 39055 4477 678 396053 65012 331041 1397975 1397975 170997 38400 132597 PROVISION FOR BAD DEBTS 671028 671028 GRANT EXPENDITURES 44889 11777 33112 11396 11132 264 20115477 17999577 2061800 54100 1208448 2797948 2390323 3012522 12583 7150 242431 308103 49282 50927 25299572 9979955 14502247 15319617 3510690 2168841 24359 8171 589359 60733 22529722 23734012 1530899 1559363 6300885 5382756 1611163 2250091 9442947 9192210 X 12970115 14425142 116660 116660 13086775 14541802 22529722 23734012 X 1400565 54462 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1617150 46377 35401 1628126 1617150 33261 33261 1617150 1617150 13589 13589 1617150 0.00000 1.00000 0.00000 0 0 63494 63494 151876 16494845 5646581 11000140 6745188 3989956 2755232 1844169 343418 1500751 15319617 CAPITALIZED LEASE OBLIGATIONS 1819804 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 430287 2250091 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: $1,435,490 ENDOWMENT FUND WITH THE INCOME TO BE USED FOR REPAIRS AND MAINTENANCE AND CAPITAL IMPROVEMENTS. $116,660 ENDOWMENT FUND WHICH CAN BE LOANED TO THE GENERAL FUND FOR OPERATING NEEDS. $75,976 ENDOWMENT FUND WITH THE DISTRIBUTIONS TO BE USED FOR THE BENEFIT OF VIRGINIA GAY HEALTH CARE FOUNDATION. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. 1 1 X 1 X 1 X 1 1 0 1 0 135000 135000 0.00690 192219 176387 15832 0.00080 327219 176387 150832 0.00770 943 105365 3600 101765 0.00520 13 10845 10845 0.00060 3079573 3039263 40310 0.00210 1160 3392 3392 0.00020 2116 3199175 3042863 156312 0.00810 2116 3526394 3219250 307144 0.01580 5000 6150 6150 0.00030 5000 6150 6150 0.00030 0 405906 0 5540232 5402864 137368 X 1 1 1 1 VIRGINIA GAY HOSPITAL INC

502 N 9TH AVENUE VINTON IA 523492254

X X X X NOT REQUIRED 1 5 VINTON FAMILY MEDICAL CLINIC

502 N 9TH AVENUE VINTON IA 52349

PHYSICIAN CLINIC VIRGINIA GAY NURSING & REHAB

502 N 9TH AVENUE VINTON IA 52349

INTERMEDIATE CARE FACILITY URBANA FAMILY MEDICAL CLINIC

1002 WEST MAIN URBANA IA 52345

PHYSICIAN CLINIC VAN HORNE FAMILY MEDICAL CLINIC

205 MAIN STREET VAN HORNE IA 52346

PHYSICIAN CLINIC VIRGINIA GAY HOSPITAL HOME HEALTH AGENCY

309 1ST AVENUE VINTON IA 52349

SKILLED NURSING CARE PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON LINE 7A BASED ON AN OVERALL COST-TO-CHARGE RATIO WHICH ADDRESSES ALL PATIENT SEGMENTS. UNREIMBURSED MEDICAID ON LINE 7B WAS CALCULATED USING THE COSTING METHODS TO PREPARE THE COST REPORTS. COMMUNITY HEALTH IMPROVEMENT SERVICES, HEALTH PROFESSIONS EDUCATION, AND CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS, LINES 7E, 7F, AND 7I ARE REPORTED BASED ON ACTUAL EXPENSES. THE COST FOR SUBSIDIZED HEALTH SERVICES ON LINE 7G WAS DETERMINED USING THE MEDICARE COST REPORT. PART I, L7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE BACKED OUT OF TOTAL EXPENSES TO DETERMINE THE PERCENTAGE WAS $671,028. PART II: COMMUNITY HEALTH IMPROVEMENT ADVOCACY EXPENSES INCLUDE OUTREACH FOR SENIOR CITIZENS, MEDICAL VOLUNTEER FOR HIGHSCHOOL FOOTBALL SIDELINES, AND BOARD OF HEALTH MEETINGS. THESE PROGRAMS PROMOTE THE HEALTH OF THE COMMUNITY BY PROVIDING ACCESS TO HEALTH CARE SERVICES. PART III, LINE 4: THE ORGANIZATION'S BAD DEBT EXPENSE WAS CONVERTED TO COST USING THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2.PRIOR TO ANY ACCOUNT BEING CLASSIFIED AS BAD DEBT, ALL PAYMENTS ARE APPLIED INCLUDING CONTRACTUAL ALLOWANCES AND DISCOUNTS, AND EVERY EFFORT IS MADE WITH THE PATIENT IN AN ATTEMPT TO COLLECT THE OUTSTANDING BALANCE. PAYMENTS ON ACCOUNTS THAT WERE WRITTEN OFF AS BAD DEBT REDUCES BAD DEBT EXPENSE IN THE CURRENT YEAR. VIRGINIA GAY HOSPITAL CONTINUES TO SERVE PATIENTS IN EMERGENCY SITUATIONS EVEN AFTER THE PATIENTS HAVE GENERATED SIGNIFICANT BAD DEBT.VIRGINIA GAY HOSPITAL MONITORS THE LEVEL OF CHARITY CARE IT PROVIDES. VIRGINIA GAY HOSPITAL HAS SEVERAL PROCEDURES IN PLACE TO DETERMINE WHICH PATIENTS WOULD QUALIFY FOR CHARITY EVEN IF THE APPLICATIONS ARE NOT COMPLETED. THEREFORE, THE HOSPITAL FEELS CONFIDENT THAT NO AMOUNT OF BAD DEBT EXPENSE IS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY. FOOTNOTE TO FINANCIAL STATEMENTS:THE CARRYING AMOUNT OF PATIENT AND RESIDENT RECEIVABLES IS REDUCED BY A VALUATION ALLOWANCE THAT REFLECTS MANAGEMENT'S ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS, RESIDENTS, AND THIRD-PARTY PAYORS. MANAGEMENT REVIEWS PATIENT AND RESIDENT RECEIVABLES BY PAYOR CLASS AND APPLIES PERCENTAGES TO DETERMINE ESTIMATED AMOUNTS THAT WILL NOT BE COLLECTED FROM THIRD PARTIES UNDER CONTRACTUAL AGREEMENTS AND AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS AND RESIDENTS DUE TO BAD DEBTS. MANAGEMENT CONSIDERS HISTORICAL WRITE OFF AND RECOVERY INFORMATION IN DETERMINING THE ESTIMATED BAD DEBT PROVISION. MANAGEMENT ALSO REVIEWS ACCOUNTS TO DETERMINE IF CLASSIFICATION AS CHARITY CARE IS APPROPRIATE. PART III, LINE 8: TOTAL REVENUE RECEIVED FROM MEDICARE IS THE GROSS REIMBURSEMENT PLUS SETTLEMENT. BOTH TOTAL REVENUE RECEIVED FROM MEDICARE AND THE MEDICARE ALLOWABLE COSTS ARE REPORTED FROM THE MEDICARE COST REPORT. PART III, LINE 9B: FOR PATIENTS WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE AND WHO QUALIFY FOR 100% DISCOUNT, THERE WILL BE NO COLLECTION EFFORTS. IF A PATIENT QUALIFIES FOR A PARTIAL WRITE-OFF OF THEIR BILL, ANY PERSONAL PORTION DUE THAT IS DELINQUENT WOULD FOLLOW THE SAME COLLECTION PROCEDURES AS OTHER PATIENTS. VIRGINIA GAY HOSPITAL TRIES TO IDENTIFY PATIENTS WHO ARE UNINSURED OR UNDER-INSURED AND PATIENTS WHO MEET THE PRESUMPTIVE ELIGIBILITY CRITERIA. ACCEPTABLE PROGRAMS ARE: THE FOOD STAMP PROGRAM, MOTHERS AND CHILDREN (MAC), IOWA FAMILY PLANNING NETWORK (IFPN), MEDICALLY NEEDY PROGRAM, LIMITED ELIGIBILITY, COUNTY RELIEF PROGRAMS, AND DECEASED PATIENTS WITH NO KNOWN ESTATE. IF A PATIENT QUALIFIES FOR ASSISTANCE AFTER THEIR ACCOUNT HAS ALREADY BEEN SENT TO COLLECTIONS, ALL COLLECTION EFFORTS CEASE IMMEDIATELY AND ALL CREDIT ISSUES ARE REVERSED. IF A PATIENT ENTERS INTO AN EXTENDED PAYMENT PLAN, VIRGINIA GAY HOSPITAL WILL NOT IMPOSE WAGE GARNISHMENTS, OR LIENS ON PRIMARY RESIDENCES, WILL NOT SEND UNPAID BILLS TO OUTSIDE COLLECTION AGENCIES, AND WILL CEASE ALL COLLECTION EFFORTS, AS LONG AS THE PATIENT COMPLIES WITH THEIR PAYMENT AGREEMENT, OR CONTACTS VIRGINIA GAY HOSPITAL WITH CHANGED FINANCIAL INFORMATION. PART VI, LINE 2: EVERY THREE TO FIVE YEARS, VIRGINIA GAY HOSPITAL AND THE BENTON COUNTY PUBLIC HEALTH DIVISION MEET WITH OTHER LOCAL AGENCIES AND BUSINESS LEADERS FOR THEIR OPINIONS ON MEETING THE NEEDS OF OUR COMMUNITY. THE INTENT OF THIS MEETING IS TO ASSESS THE NEEDS OF THE UNDERSERVED AND THE MOST VULNERABLE POPULATIONS THAT WOULD IMPACT THEIR ECONOMIC, SOCIAL AND HEALTH NEEDS. THE MOST RECENT MEETING WAS HELD IN SEPTEMBER OF THIS YEAR. DURING THIS ASSESSMENT MEETING, THE ORGANIZATIONS IDENTIFIED FOUR AREAS TO BE FOCUSED ON. THOSE AREAS OF CONCERN ARE EDUCATING TEENS ON SEX AND PROMISCUITY, STD'S, TEEN DRINKING AND THE AREA OF EDUCATING THE CITIZENS OF BENTON COUNTY ON PUBLIC HEALTH ISSUES. AN AREA THAT SHOWED GREAT IMPROVEMENT SINCE THE LAST NEEDS ASSESSMENT WAS IN THE AREA OF IDENTIFYING AND REDUCING THE NUMBER OF PATIENTS WITH COLON CANCER. THE REDUCTION IN COLON CANCER FOR THIS AREA WAS IN PART DUE TO THE AGGRESSIVE PLAN ESTABLISHED THROUGH THE NEEDS ASSESSMENT PROCESS WHEREBY VIRGINIA GAY HOSPITAL INCREASED THE NUMBER OF COLONOSCOPY SCREENINGS. PART VI, LINE 3: VIRGINIA GAY HOSPITAL IS COMMITTED TO PROVIDING CHARITY CARE TO PERSONS WHO HAVE HEALTHCARE NEEDS AND ARE UNINSURED, UNDERINSURED, INELIGIBLE FOR A GOVERNMENT PROGRAM, OR OTHERWISE UNABLE TO PAY FOR MEDICALLY NECESSARY CARE BASED ON THEIR INDIVIDUAL FINANCIAL SITUATION. VIRGINIA GAY HOSPITAL STRIVES TO ENSURE THAT THE FINANCIAL CAPACITY OF PEOPLE WHO NEED HEALTH CARE SERVICES DOES NOT PREVENT THEM FROM SEEKING OR RECEIVING CARE. PATIENTS ARE EXPECTED TO COOPERATE WITH VIRGINIA GAY HOSPITAL'S PROCEDURES FOR OBTAINING CHARITY CARE OR OTHER FORMS OF PAYMENT OF FINANCIAL ASSISTANCE, AND TO CONTRIBUTE TO THE COST OF THEIR CARE BASED ON THEIR INDIVIDUAL ABILITY TO PAY. THE CHARITY CARE POLICY INCLUDES ALL DEPARTMENTS OF THE FACILITY, INCLUDING THE VINTON FAMILY MEDICAL CLINIC, THE URBANA FAMILY MEDICAL CLINIC, THE VAN HORNE FAMILY MEDICAL CLINIC, AND THE NURSING AND REHAB. THE VIRGINIA GAY HOSPITAL HOME HEALTH AGENCY HAS A SEPARATE FINANCIAL ASSISTANCE PROCEDURE, DUE TO THEIR PUBLIC HEALTH ROLE IN THE COMMUNITY.NOTIFICATION ABOUT CHARITY CARE IS AVAILABLE BY THE PUBLICATION OF NOTICES IN PATIENT BILLS, POSTING OF NOTICES IN EMERGENCY ROOMS, ADMITTING AND REGISTRATION DEPARTMENTS, THE BUSINESS OFFICE, AND OTHER PUBLIC PLACES THE HOSPITAL MAY ELECT. INFORMATION IS ALSO INCLUDED ON THE FACILITY WEBSITE, AND IN THE PATIENT INFORMATION PACKETS. A REQUEST FOR CHARITY MAY BE MADE BY THE PATIENT OR A FAMILY MEMBER, CLOSE FRIEND OR ASSOCIATE OF THE PATIENT, SUBJECT TO THE APPLICABLE PRIVACY LAWS. PART VI, LINE 4: VIRGINIA GAY HOSPITAL IS A CRITICAL ACCESS HOSPITAL SERVING AN ESTIMATED POPULATION OF 27,000. VIRGINIA GAY HOSPITAL IS LOCATED IN VINTON, IOWA, THE COUNTY SEAT OF BENTON COUNTY. VINTON HAS A POPULATION OF APPROXIMATELY 5,000 PEOPLE. THE CLOSEST HOSPITALS ARE LOCATED 37 MILES AWAY IN CEDAR RAPIDS, IOWA. VIRGINIA GAY HOSPITAL CURRENTLY OPERATES THREE SEPARATE CLINICS; ONE CLINIC IS LOCATED ON THE HOSPITAL CAMPUS IN VINTON, ANOTHER CLINIC IS LOCATED IN THE RURAL TOWN OF VAN HORNE, IOWA WHICH IS 15 MILES FROM VINTON AND THE OTHER CLINIC IS LOCATED IN THE RURAL COMMUNITY OF URBANA, 13 MILES FROM VINTON. THE HOSPITAL AND CLINICS SERVE A LARGE NUMBER OF MEDICARE AND MEDICAID PATIENTS THAT REPRESENT ADMISSIONS AND REGISTRATIONS OF 65% AND 10% RESPECTIVELY. IN 2005, BENTON COUNTY REPORTED THAT 10.8% OF OUR RESIDENTS UNDER 65 WERE UNINSURED AND THE POVERTY LEVEL IN 2008 WAS 9.8 WITH 4.5% LIVING BELOW 50% OF THE POVERTY LEVEL. POVERTY IN VINTON IS 0.7% HIGHER IN VINTON THAN THE STATE AVERAGE. THE RECESSION HAS HAD A HEAVY IMPACT ON VINTON AND BENTON COUNTY AND UNEMPLOYMENT RATES ARE UP AS A RESULT. PART VI, LINE 6: VIRGINIA GAY HOSPITAL IS PROUDLY RECOGNIZED AS HAVING ONE OF THE LOWEST COSTS PER STAY RATES IN THE STATE OF IOWA. THE HOSPITAL OFFERS TWENTY-FIVE BEDS IN AN ACUTE CARE SETTING WITH STATE OF THE ART TECHNOLOGY AND PROFESSIONAL SERVICES. VIRGINIA GAY HOSPITAL ALSO OFFERS 24 HOUR ACUTE CARE, SHORT TERM SKILLED NURSING SERVICES, RADIOLOGY, RESPIRATORY CARE, CARDIO-PULMONARY REHABILITATION, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, LABORATORY SERVICES, SURGICAL SERVICES, OUTPATIENT CLINICS AND EMERGENCY CARE. IN ADDITION, OUR STAFF HAS CONTRIBUTED MULTIPLE HOURS PROVIDING UNCOMPENSATED TIME IN AREAS SUCH AS FAMILY/PARENTING/SIBLING EDUCATION, MEDICAL EXPERTISE FOR THE SCHOOLS ATHLETIC TEAMS, HEALTH FAIRS, INFORMATION AND REFERRALS TO COMMUNITY SERVICES, SAFETY CLASSES, SPORTS PHYSICALS AND MANY OTHER UNCOMPENSATED SERVICES. REQUIREMENTS OF THE IRS COMMUNITY BENEFIT STANDARD FOR TAX-EXEMPT ORGANIZATIONS ARE INTEGRAL TO THE HOSPITAL'S LARGER CHARITABLE MISSION OF IMPROVING HEALTH AND QUALITY OF LIFE. SPECIFICALLY, VIRGINIA GAY HOSPITAL IS GOVERNED BY AN INDEPENDENT BOARD INCLUDING COMMUNITY LEADERS, PHYSICIANS, CONSUMER REPRESENTATIVES, BUSINESS EXPERTS AND CLINICAL HEALTHCARE EXPERTS WHO RESIDE IN OUR PRIMARY SERVICE AREA. THE BOARD HAS A HISTORY OF COMMITMENT TO ACTING WITH THE HIGHEST INTEGRITY AND HAS BEEN PROACTIVELY EVALUATING OPPORTUNITIES TO VOLUNTARILY ADOPT GOVERNANCE BEST PRACTICES TO ENSURE THE ORGANIZATION CONTINUES TO OPERATE WITH THE HIGHEST OF INTEGRITY FOR THE BENEFIT OF THE COMMUNITY. TO MEET THE NEEDS OF OUR COMMUNITY, THE HOSPITAL EXTENDS PRIVILEGES TO MEDICAL STAFF THAT ARE QUALIFIED THROUGH LICENSURE IN THE STATE OF IOWA. VIRGINIA GAY'S HOME HEALTH AGENCY OFFERS A VARIETY OF SERVICES TO THE AGING RURAL POPULATION OF BENTON COUNTY. THE HOSPITAL ALSO OFFERS SUCH SERVICES AS SKILLED SERVICE HOME CARE, IMMUNIZATION CLINICS, WELL CHILD AND GROUP TEACHING CLASSES SUCH AS CARDIOPULMONARY RESUSCITATION (CPR), ADVANCED LIFE SUPPORT (ALS) AND PEDIATRIC ADVANCED LIFE SUPPORT (PALS). EXCESS FUNDS ARE REINVESTED AND USED FOR PATIENT CARE AND FACILITY UPGRADES.IN ADDITION, VIRGINIA GAY HOSPITAL, THROUGH ITS INTEGRATED NETWORK OF PROVIDERS, PROVIDES NON-EMERGENCY SERVICES TO THE COMMUNITY IT SERVES. IT MAKES THESE SERVICES ACCESSIBLE TO THE COMMUNITY THROUGH PARTICIPATION IN GOVERNMENT PROGRAMS LIKE MEDICARE AND MEDICAID AND BY OFFERING ASSISTANCE THROUGH THEIR FINANCIAL ASSISTANCE PROGRAM. VIRGINIA GAY HOSPITAL'S FINANCIAL ASSISTANCE POLICY PROVIDES DISCOUNTED AND FREE SERVICES TO PATIENTS WHO LACK THE RESOURCES TO BE FULLY RESPONSIBLE FOR THE HEALTH CARE THEY RECEIVE. THE FINANCIAL ASSISTANCE POLICY IS DESIGNED TO ENSURE THE ENTIRE COMMUNITY SERVED BY THE HOSPITAL HAS ACCESS TO NEEDED HEALTHCARE SERVICES. VIRGINIA GAY HOSPITAL TAKES ITS MISSION TO IMPROVE THE HEALTH AND QUALITY OF LIFE OF THE PEOPLE IT SERVES A STEP FURTHER BY REACHING OUT TO MEET THE BROAD HEALTH NEEDS OF THE COMMUNITY. IT STRIVES TO IDENTIFY COMMUNITY NEEDS BEYOND BASIC HEALTHCARE, THEN RESPOND TO THEM, AIMING TO MAKE A POSITIVE, LIFE-ENHANCING DIFFERENCE IN THE COMMUNITY. CONTRIBUTING TO COMMUNITY EDUCATION: THE NURSING STAFF AND HOME HEALTH AGENCY NURSES PARTICIPATE IN COUNTY WIDE COMMUNITY HEALTH FAIRS. THESE EVENTS PROVIDE INFORMATION AND GUIDELINES TO THOSE IN NEED OF MEDICAL INFORMATION.PREVENTIVE CARE A PRIORITY: THE HOSPITAL HAS TAKEN STEPS TO ENHANCE PREVENTIVE CARE FOR PEOPLE OF ALL AGES BY ENSURING THAT THOSE WHO COME HERE FOR PREVENTIVE CARE RECEIVE THE SCREENINGS AND RECOMMENDATIONS APPROPRIATE TO THEIR PERSONAL AND FAMILY HISTORY. REPORTS FILED WITH STATES PART VI, LINE 7 IA 1 ACADEMIC SUPPORT TO NURSING STUDENTS 5 8569 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: INTERESTED HIGH SCHOOL SENIORS ENTERING THE FIELD OF HEALTH CARE MUST COMPLETE AN APPLICATION. A COMMITTEE OF THE HOSPITAL BOARD REVIEWS THE APPLICATIONS, SELECTS THE RECIPIENTS, AND FORWARDS THE APPLICATIONS TO THE FULL BOARD FOR REVIEW. THE SCHOLARSHIP MONEY IS GIVEN TO DOLLARS FOR SCHOLARS AND THEY HANDLE THE DISTRIBUTION OF FUNDS. DOLLARS FOR SCHOLARS IS A NON-PROFIT ORGANIZATION ESTABLISHED TO HELP STUDENTS GOING INTO THE HEALTH CARE FIELD WITH ACADEMIC EXPENSES. THE ORGANIZATION MATCHES THE FUNDS THEY RECEIVE TO DISTRIBUTE TO STUDENTS. X X X 0 0 0 0 0 0 0 0 0 DR BRIAN MEEKER DO 273883 0 246144 0 0 0 4484 0 30107 0 554618 0 0 0 DR MARK DEARDEN DO 185145 0 68527 0 0 0 2586 0 24415 0 280673 0 0 0 MICHAEL RIEGE 123089 0 0 0 0 0 12584 0 15671 0 151344 0 0 0 MICHELE BURNES 86465 0 111610 0 0 0 1565 0 6145 0 205785 0 0 0 RITA TAYLOR-STEWART 78617 0 117966 0 0 0 1600 0 7814 0 205997 0 0 0 DR GENE LARIVIERE 324478 0 0 0 0 0 3041 0 30107 0 357626 0 0 0 CITY OF VINTON IOWA 426005303 2008-02-28 6800000 NEW PATIENT UNIT, EMERGENCY, PHYSICAL/OCCUPATIONAL THERAPY, & IMAGING DEPT 0 0 0 1417244 6800000 6800000 2010 0 0 1 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CONSISTS OF THE OFFICERS OF THE BOARD OF DIRECTORS. THE EXECUTIVE COMMITTEE HAS POWER TO TRANSACT ALL REGULAR BUSINESS OF THE HOSPITAL DURING THE PERIOD BETWEEN THE MEETINGS OF THE GOVERNING BOARD, SUBJECT TO ANY PRIOR LIMITATION IMPOSED BY THE GOVERNING BOARD AND WITH THE UNDERSTANDING THAT ALL MATTERS OF MAJOR IMPORTANCE WILL BE REFERRED TO THE GOVERNING BOARD. MINUTES OF THE EXECUTIVE COMMITTEE MEETINGS ARE SUBMITTED TO THE BOARD, AND ITS ACTIONS ARE SUBJECT TO APPROVAL OR DISAPPROVAL AT THE NEXT REGULAR BOARD MEETING. FORM 990, PART VI, SECTION A, LINE 2 JOHN KETCHEN, VICE CHAIR OF THE BOARD, AND MARK MOSSMAN, CHAIR OF THE BOARD, HAVE A BUSINESS RELATIONSHIP. MARK MOSSMAN, DAVID VERMEDAHL, JOHN KETCHEN, ALL BOARD MEMBERS, MICHAEL RIEGE, CEO, AND JULIA MEADOWS, CFO, HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 7A ONE OF THE DIRECTORS OF THE BOARD IS THE MAYOR OF THE CITY OF VINTON, IOWA. TWO DIRECTORS ARE APPOINTED BY THE MAYOR AND APPROVED BY THE CITY COUNCIL OF THE CITY OF VINTON FOR SUCH TERMS AS THE CITY COUNCIL DETERMINES. ONE OF THESE APPOINTMENTS IS A PHYSICIAN IN ACTIVE PRACTICE AND A RESIDENT OF BENTON COUNTY, IOWA. THE SECOND DIRECTOR APPOINTED BY THE CITY OF VINTON IS A RESIDENT OF BENTON COUNTY, IOWA. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS DISTRIBUTED TO THE BOARD MEMBERS PRIOR TO FILING. THE 990 IS REVIEWED BY THE HOSPITAL'S CEO AND CFO. FORM 990, PART VI, SECTION B, LINE 12C ANY DIRECTOR, OFFICER, KEY EMPLOYEE, MEDICAL STAFF MEMBER OR COMMITTEE MEMBER HAVING AN EXISTING OR POTENTIAL INTEREST IN A CONTRACT OR OTHER TRANSACTION PRESENTED TO THE BOARD OF DIRECTORS FOR DELIBERATION, AUTHORIZATION, APPROVAL, OR RATIFICATION, OR ANY SUCH PERSON WHO REASONABLY BELIEVES SUCH AN INTEREST EXISTS IN ANOTHER PERSON SHOULD MAKE A PROMPT, FULL, AND FRANK DISCLOSURE OF THE INTEREST TO THE BOARD OR COMMITTEE PRIOR TO ITS ACTING ON SUCH CONTRACT OR TRANSACTION. THE INTERESTED PARTY IS REQUIRED TO DISCLOSE THE NATURE AND EXTENT OF HIS/HER INTEREST AND ANY RELEVANT AND MATERIAL FACTS KNOWN TO HIM/HER ABOUT THE CONTRACT OR TRANSACTION WHICH MIGHT REASONABLY BE CONSTRUED TO BE ADVERSE TO THE ORGANIZATION'S INTEREST. THE BOARD REQUIRES ANNUAL STATEMENTS FROM OFFICERS, DIRECTORS, KEY EMPLOYEES, AND KEY MEMBERS OF THE MEDICAL STAFF. THE BODY TO WHICH SUCH DISCLOSURE IS MADE DETERMINES, BY MAJORITY VOTE, WHETHER THE DISCLOSURE SHOWS THAT THE NON-VOTING AND NON-PARTICIPATION PROVISIONS BELOW MUST BE OBSERVED. IF SO, SUCH PERSONS SHOULD NOT VOTE ON, NOR USE HIS/HER PERSONAL INFLUENCE ON, NOR PARTICIPATE (OTHER THAN TO PRESENT FACTUAL INFORMATION OR TO RESPOND TO QUESTIONS) IN THE DISCUSSIONS OR DELIBERATIONS WITH RESPECT TO SUCH CONTRACT OR TRANSACTION. SUCH PERSONS MAY NOT BE COUNTED IN DETERMINING THE EXISTENCE OF A QUORUM AT ANY MEETING WHERE THE CONTRACT OR TRANSACTION IS UNDER DISCUSSION OR IS BEING VOTED UPON. THE MINUTES OF THE MEETING REFLECT THE DISCLOSURE MADE AND, WHERE APPLICABLE, THE ABSTENTION FROM VOTING AND PARTICIPATION AND WHETHER A QUORUM WAS PRESENT. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD WAGE & SALARY COMMITTEE AND FULL BOARD REVIEWS COMPENSATION INCREASES FOR THE CEO BASED ON ANNUAL EVALUATIONS AND THE IHA SALARY SURVEY. COMPARISONS TO STATE AVERAGES ARE USED. SUBSTANTIATION OF THE DELIBERATION AND DECISION IS DOCUMENTED IN THE BOARD MINUTES. THE PROCESS IS COMPLETED ANNUALLY AND WAS LAST COMPLETED IN MAY 2011. THE CEO DETERMINES COMPENSATION FOR THE CFO AND KEY EMPLOYEES, WITH APPROVAL FROM THE BOARD WAGE & SALARY COMMITTEE AND FULL BOARD, BASED ON ANNUAL PERFORMANCE EVALUATIONS AND THE IHA SALARY SURVEY. CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION IS PROVIDED FOR ANY ACTIONS TAKEN REGARDING COMPENSATION. THE PROCESS IS COMPLETED ANNUALLY AND WAS LAST COMPLETED IN MAY 2011. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT AVAILABLE TO THE PUBLIC. FINANCIAL INFORMATION IS AVAILABLE THROUGH THE PUBLIC DISCLOSURE COPY OF THE 990. FORM 990, PAGE 7, PART VII: THE FOLLOWING INDIVIDUALS DEVOTED TIME PROVIDING SERVICES TO RELATED ORGANIZATIONS. VIRGINIA GAY HEALTH CARE FOUNDATION DR. MICHELLE ELGIN .3 HOURS PER WEEK DR. MARK DEARDEN, DO .3 HOURS PER WEEK JAMES HODGSON .3 HOURS PER WEEK MICHAEL RIEGE 2 HOURS PER WEEK JULIA MEADOWS 2 HOURS PER WEEK VIRGINIA GAY TRUST MARK MOSSMAN .3 HOURS PER WEEK DAVID VERMEDAHL .3 HOURS PER WEEK JOHN KETCHEN .3 HOURS PER WEEK JOHN WATSON .3 HOURS PER WEEK JAMES HODGSON .3 HOURS PER WEEK DR. MARK DEARDEN, DO .3 HOURS PER WEEK MARIE THERESE FOTH .3 HOURS PER WEEK MICHAEL RIEGE 1 HOUR PER WEEK JULIA MEADOWS 1 HOUR PER WEEK CEDAR VIEW, INC. MARK MOSSMAN .3 HOURS PER WEEK JOHN KETCHEN .3 HOURS PER WEEK DAVID VERMEDAHL .3 HOURS PER WEEK JOHN YUNDT .3 HOURS PER WEEK MICHAEL RIEGE 1 HOUR PER WEEK JULIA MEADOWS 1 HOUR PER WEEK CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 54,462. VIRGINIA GAY TRUST 502 N 9TH AVENUE VINTON IA 523492299 426367590 PROVIDE FINANCIAL SUPPORT FOR VIRGINIA GAY HOSPITAL INC. IA 501(C)(3) LINE 11B, II VIRGINIA GAY HOSPITAL INC 1 VIRGINIA GAY HOSPITAL HEALTH CARE FOUNDATION 502 N 9TH AVENUE VINTON IA 52349 421391891 DEVELOP AND EXTEND FACILITIES AND SERVICES OF VIRGINIA GAY HOSPITAL INC. IA 501(C)(3) LINE 7 N/A 0 VERNON S FLECHNER TRUST 502 N 9TH AVENUE VINTON IA 52349 426351376 PROVIDE INCOME FOR MAINT OF THE HOSPITAL AND ANNEX BUILDINGS IA N/A T 98149 1422152 1.00000 JW FRY TRUST 502 N 9TH AVENUE VINTON IA 52349 426287710 PROVIDE UNRESTRICTED AND CORPUS RESTRICTED INCOME FOR HOSPITAL ADDITIONS IA N/A T 129585 1314044 1.00000 CEDAR VIEW INC 502 N 9TH AVENUE VINTON IA 52349 421398570 PROVIDE AN 18-UNIT HOUSING ALTERNATIVE FOR THE ELDERLY IA N/A C 343272 1634176 1.00000 0 0 1 1 0 0 0 0 0 0 0 1 1 1 0 0 0 0 VERNON S FLECHNER TRUST C 200000 GENERAL LEDGER JW FRY TRUST CEDAR VIEW INC VIRGINIA GAY TRUST