2012-08-12T11:27:46-05:00 2011-09-30 COHEN RUTHERFORD KNIGHT PC 6903 ROCKLEDGE DRIVE SUITE 500 BETHESDA MD 208171800 990 2010-10-01 521366700 CULPEPER REGIONAL HEALTH SYSTEM CULP 5408298803 501 SUNSET LANE CULPEPER VA 227010592 H LEE KIRK JR 2012-08-09 3018281008 2010 2016-02-24 21:20:13Z H LEE KIRK JR 501 SUNSET LANE CULPEPER VA 22701 3577156 false X www.CulpeperHospital.com X 1985 VA THE ORGANIZATION'S MISSION IS TO SUPPORT THE MISSION OF CULPEPER REGIONAL HOSPITAL. 11 11 0 0 0 0 338406 433354 1577366 1595251 318622 215403 708853 925691 2943247 3169699 11424 437245 0 0 1323057 1387543 0 0 10944 1763765 1492299 3098246 3317087 -154999 -147388 24994875 23954089 505646 442031 24489229 23512058 THE ORGANIZATION'S MISSION IS TO SUPPORT THE MISSION OF CULPEPER REGIONAL HOSPITAL. false false 1814531 POWELL WELLNESS CENTER, LLC, A WHOLLY-OWNED SUBSIDIARY AND DISREGARDED ENTITY, BEGAN OPERATIONS IN AUGUST 2007 AND OPERATES A WELLNESS CENTER CONSISTENT WITH, AND IN SUPPORT OF, THE MISSION OF CULPEPER MEMORIAL HOSPITAL. 355721 355721 CRHS Foundation was organized & is operated for the purpose of soliciting, receiving, & administering gifts, grants & contributions for the benefit of Culpeper Memorial Hospital, DBA Culpeper Regional Hospital. 81524 81524 CRHS manages real estate properties, AN AUXILIARY, A FREE CLINIC AND PROVIDES SCHOLARSHIPS for the purpose of promoting the vision & mission of Culpeper Memorial Hospital, DBA Culpeper Regional Hospital. 2251776 true true false false false false false false false true false false false true false false true false false false false false false true false false true true true false false false false false false false false false false false false true true true true false false true 19 0 0 false false false false false true true false false false false false X 11 11 false false false false false false false true true false false true true true true true true true true false VA X H LEE KIRK JR 5408298803 501 SUNSET LANE CULPEPER VA 227010592 X X CONSTANCE KINCHELOE 4.0 X 0 0 0 KARL BEIER MD 4.0 X 0 0 0 MICHAEL ARMM 5.0 X X 0 0 0 WILLIAM CANNON JR 4.0 X X 0 0 0 JOAN PROCTOR 4.0 X 0 0 0 TOM REYNOLDS MD 4.0 X X 0 0 0 CHARLES CRIST 2.0 X 0 0 0 DAVID JONES 2.0 X 0 0 0 C WAYNE HAWKINS 2.0 X X 0 0 0 H B SEDWICK 2.0 X 0 0 0 BREVARD WALLACE MD 2.0 X 0 0 0 SAMUEL MORGAN 8.0 X 0 189930 5167 H LEE KIRK JR 12.0 X 0 387901 18941 JOHN G MAXWELL 8.0 X 0 169933 20041 0 747764 44149 0 true true false 0 12026 19722 16640 384966 433354 PWC MEMBERSHIP DUES 1518234 1518234 0 PWC ASSESSMENT FEES 77017 77017 1595251 137496 137496 0 0 874345 364561 509784 509784 509784 77907 77907 77907 77907 28128 19722 42896 -14768 -14768 0 0 PWC CAFE 21746 21746 PWC MISC INCOME 19644 19644 PWC KID'S CORNER 9375 9375 379910 379910 430675 3169699 2025926 0 710419 353471 353471 83774 83774 0 0 0 0 1159651 639465 520186 0 0 0 0 0 227892 148546 79346 0 0 0 0 0 0 0 0 0 1085 0 1085 0 35505 0 35505 0 0 0 0 0 0 0 21308 0 21308 0 0 0 0 0 105755 45243 60312 200 158874 124347 31153 3374 0 0 0 0 0 0 0 0 29861 29861 0 0 0 0 0 0 0 0 0 0 24046 0 24046 0 0 0 0 0 0 399036 394306 4730 0 30787 28060 2727 0 UTILITIES 220883 220110 773 0 MINOR EQUIPMENT 4488 4488 0 0 REPAIRS AND MAINTENANCE 56281 56246 35 0 TRAINING 4574 0 4574 0 DUES AND SUBCRIPTIONS 3122 0 3122 0 396694 123859 265465 7370 3317087 2251776 1054367 10944 2197262 1310621 633997 466558 16177 88620 243676 149062 8561 11336 16994 10534 19676910 4095606 15109946 15581304 5821096 5552811 945822 783243 1344 0 24994875 23954089 356485 279456 13914 15006 135247 147569 505646 442031 X 23045685 22353171 1279359 993126 164185 165761 24489229 23512058 24994875 23954089 X -147388 -829783 X false true true X false X X X X false false false CULPEPER MEMORIAL HOSPITAL DBA CULPEPER REGIONAL HOSPITAL 540622371 03 true true true 353471 1 353471 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2528632 2528632 13302347 2817343 10485004 0 3188597 1256600 1931997 657334 21663 635671 15581304 0 DUE TO CMH 119768 ANNUITY PAYABLE 27801 147569 GALA 26250 10290 15960 17666 2500 7995 GOLF 21600 9432 12168 2593 3265 8877 0 47850 19722 28128 2593 20931 2500 16872 42896 -14768 true CULPEPER regional HOSPITAL 501 sunset lane CULPEPER VA 22701 353471 DONATIONS FROM FOUNDATION FOR HOSPITAL PPE SCHOLARSHIPS 25 83774 part I, line 2 Local Scholarships Two graduating high school students from each of the two Culpeper high schools who are pursuing a nursing or other medical career are eligible to apply for scholarships awarded by the Foundation. Applicants must submit an application that includes an essay explaining their desire to pursue the designated area of study. Guidance staff at the respective high schools review applications and select the winners. Part I, line 2 CRHS Scholarships Employees of CRH & CRHS that are employed full-time, part-time or leased and have been accepted into a program identified as an area of need within the organization are eligible to apply for assistance from CRHS. Applicants must: - apply prior to commencement of the course or program of study - complete an application, incuding a 400-500 word essay - provide course registration, tuition bill and other documentation supporting request - provide letter of acceptance into program, as applicable - provide transcripts and maintain a minimum GPA of 3.0 The Education Assistance Committee reviews all applications and approves the assistance request based on the applicant's course of study and education track as relevant to the needs of CRHS. Assistance is granted annually and paid by semesters. Approvals are only valid for courses approved each semester and the recipient must submit applications for renewal each semester, along with transcripts of the previous semester's grades to ensure the minimum GPA of 3.0 is being met. Tuition assistance amounts are intended to cover tuition, fees, books and other necessary items needed to complete the courses. Documentation of proof of cost is necessary. part i, line 2 CULPEPER REGIONAL HEALTH SYSTEM PROVIDES FUNDS TO CULPEPER REGIONAL HOSPITAL TO PROVIDE FUNDS FOR PROPERTY, PLANT AND EQUIPMENT. false false false false false false false false false SAMUEL MORGAN 0 177180 0 12750 0 0 0 1831 0 3336 0 195097 H LEE KIRK JR 0 372901 0 0 0 15000 0 2990 0 15951 0 406842 JOHN G MAXWELL 0 158082 0 11851 0 0 0 0 0 20041 0 189974 top managment compensation CRHS relies upon CMH, DBA Culpeper Regional Hospital, which uses an independent compensation consultant, written employment contract, compensation survey or study, and approval by board or compensation committee establish the compensation of the CEO. MONITORING CONFLICTS OF INTEREST PART VI, SECTION B, 12C The organization has adopted a conflict of interest policy adopted by Culpeper Regional Hospital. Annually, each board member must disclose any conflicts of interest with the organization or any other board members. In addition to the annual disclosure, each meeting of the Board begins with a voluntary verbal self-disclosure of any conflicts with any items on the agenda. As additional issues arise during the course of a meeting, a similar self-disclosure is expected to be made. If self-disclosures are not forth-coming, the board members are encouraged to raise the possibility of potential conflicts with regard to other board members. During the course of doing business, if conflicts are suspected by anyone affiliated with the organizataion with regard to key employees, officers, or board members, they are encouraged to notify the Chief Executive Officer of their suspicions. The CEO will investigate, employing legal counsel as necessary, and will resolve as appropriate. Ultimately it is the responsibility of the Chief Executive Officer and the Chairman of the Board to enforce the policy. REVIEWING THE 990 PART VI, LINE 11 The Form 990 is prepared with assistance from an outside accounting firm, and reviewed by the Chief Financial Officer and Controller of the Hospital, as well by a subcommittee of the Board of Directors, as appointed, of the organization. A copy of the Form 990 is made available to each of the Organization's Board members for their review and comment prior to filing. MAKING DOCUMENTS AVAILABLE PART VI, LINE 19 THIS ORGANIZATION MAKES its GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. part xi, line 5 reconciliation of net assets unrealized loss $(447,251) unrealized gain 1,576 book invest in ptrshp 63,202 scholarships 73,774 foundation bad debt 3,065 grant to hospital 353,471 fy11 drop it move to liab (121,548) net assets released (752,345) k-1 pob ( 3,727) ----------- total (829,783) HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:CONSTANCE KINCHELOE TITLE:BOARD MEMBER HOURS:2 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:KARL BEIER MD TITLE:IMMEDIATE PAST BOARD CHAIR HOURS:5 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:MICHAEL ARMM TITLE:CHAIR HOURS:5 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:WILLIAM CANNON JR TITLE:TREASURER HOURS:5 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:JOAN PROCTOR TITLE:CHAIR- CRHS AUXILIARY HOURS: HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:TOM REYNOLDS MD TITLE:VICE CHAIR HOURS:5 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:CHARLES CRIST TITLE:CHAIR, FREE CLINIC OF CULPEPER HOURS: HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:DAVID JONES TITLE:CHAIR CRHS FOUNDATION HOURS: HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:C WAYNE HAWKINS TITLE:SECRETARY HOURS:5 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:H B SEDWICK TITLE:CHAIR, CRHS REAL ESTATE HOURS: HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:BREVARD WALLACE MD TITLE:CHAIR POWELL WELLNESS CENTER HOURS: HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:SAMUEL MORGAN TITLE:SENIOR VICE PRESIDENT & CFO HOURS:36 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:H LEE KIRK JR TITLE:PRESIDENT/CEO HOURS:34 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:JOHN G MAXWELL TITLE:SR VICE PRESIDENT & COO HOURS:36 POWELL WELLNESS CENTER 1005 GOLF DRIVE CULPEPER VA 22701 204803079 WELLNESS CENT VA 2195630 10077661 CRHS CULPEPER REGIONAL HOSPITAL 501 SUNSET LANE CULPEPER VA 22701 540622371 COMMUNITY HOS VA 501(C)(3) 170B1(A)III CRHS CULPEPER PHYSICIAN HOSPITAL ORGANIZATION PO BOX 592 CULPEPER VA 22701 541703526 MEMBERSHIP ORG VA CMH C CORP 0 0 0.00000 false true true false false false false false true false true false true true true false false false crh i 349350