2012-05-15T12:20:28-05:00 2011-06-30 CLIFTONLARSONALLEN LLP 600 WASHINGTON AVENUE SUITE 1800 ST LOUIS MO 63101 990 2010-07-01 710329353 JEFFERSON HOSPITAL ASSOCIATION INC JEFF 8705417100 1600 WEST 40TH AVENUE PINE BLUFF AR 71603 BRYAN JACKSON 8705417100 2012-05-15 1 JEFF PARKER 3149254300 2010 2016-02-24 21:20:13Z WALTER JOHNSON 1600 WEST 40TH AVENUE PINE BLUFF AR 71603 190925871 0 X WWW.JRMC.ORG X 1959 AR HEALTH CARE SERVICE PROVIDER 15 6 2196 100 183772 -117946 645225 1829103 189590548 176838047 2285079 3109092 6455843 9142934 198976695 190919176 685020 684521 0 0 84385904 87400453 0 0 6695 102679472 91302870 187750396 179387844 11226299 11531332 215609044 230604629 60177727 61659025 155431317 168945604 X JEFFERSON REGIONAL MEDICAL CENTER IS COMMITTED TO PROVIDING MEASURABLE QUALITY HEALTH SERVICES IN A CARING ENVIRONMENT, WHICH FULFILL THE NEEDS OF OUR PATIENTS, PHYSICIANS, EMPLOYERS, EMPLOYEES AND COMMUNITY. 0 0 163023280 684521 176871121 JEFFERSON HOSPITAL ASSOCIATION, INC. (JHA) OPERATES JEFFERSON REGIONAL MEDICAL CENTER (JRMC), A 471 BED TERTIARY CARE FACILITY LOCATED IN SOUTHEAST ARKANSAS THAT SERVES A POPULATION BASE OF 222,000 PEOPLE LIVING IN 11 COUNTIES. JRMC IS A NOT-FOR-PROFIT, SOLE COMMUNITY HOSPITAL, LICENSED BY THE ARKANSAS STATE HEALTH DEPARTMENT AND ACCREDITED BY THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS.JRMC HAS A LONG TRADITION OF PROVIDING SIGNIFICANT BENEFITS TO OUR COMMUNITY WHICH IS ROOTED IN OUR MISSION, "TO PROVIDE MEASURABLE QUALITY HEALTH SERVICES IN A CARING ENVIRONMENT WHICH FULFILL THE NEEDS OF OUR PATIENTS, PHYSICIANS, EMPLOYERS, EMPLOYEES AND COMMUNITY" AND VISION, "TO BE WIDELY RECOGNIZED AS THE HEALTH CARE LEADER AND REFERRAL CENTER OF CHOICE FOR SOUTH ARKANSAS BY PROVIDING QUALITY HEALTH CARE SERVICES IN A COST EFFECTIVE MANNER."WE PROVIDE SEVERAL CENTERS OF EXCELLENCE PROVIDING A WIDE RANGE OF PROGRAMS AND MEDICAL SERVICES. THESE INCLUDE CARDIOLOGY, SURGERY, CRITICAL CARE, REHABILITATION, PSYCHIATRY, LABORATORY, GASTROENTEROLOGY, ORTHOPEDICS, NEUROLOGY, EMERGENCY, OBSTETRICS/GYNECOLOGY, RADIOLOGY, HOSPICE, AND MANY MORE. WE ALSO OPERATE AND MANAGE SEVERAL SATELLITE CLINICS WHICH PROVIDE PRIMARY AND SPECIALTY HEALTHCARE TO THE COMMUNITY AND OUTLYING AREAS.JRMC OPERATES AN EMERGENCY ROOM THAT IS OPEN TO ALL PERSONS REGARDLESS OF ABILITY TO PAY; HAS AN OPEN MEDICAL STAFF WITH PRIVILEGES AVAILABLE TO ALL QUALIFIED PHYSICIANS IN THE AREA; HAS A GOVERNING BODY THAT IS COMPRISED OF INDIVIDUALS WHO ARE REPRESENTATIVE OF THE COMMUNITY; ENGAGES IN THE TRAINING AND EDUCATION OF HEALTH CARE PROFESSIONALS; AND PARTICIPATES IN MEDICAID, MEDICARE CHAMPUS, TRICARE AND/OR OTHER GOVERNMENT-SPONSORED HEALTH CARE PROGRAMS.COMMUNITY SERVICE AND EDUCATION CONTINUED TO BE A SIGNIFICANT PART OF OUR MISSION. JRMC PROVIDES NUMEROUS SPONSORSHIPS WITHIN THE COMMUNITY, AND OFFERS DOZENS OF FREE HEALTH SCREENINGS AND EDUCATIONAL EVENTS EACH YEAR. NOT ONLY IS INFORMATION SHARED ABOUT HEALTHCARE RELATED ISSUES, BUT PARTICIPANTS ARE GIVEN THE OPPORTUNITY TO VISIT ONE-ON-ONE WITH PHYSICIANS AND OTHER HEALTHCARE PROFESSIONALS. APPROXIMATELY 334,000 LIVES WERE TOUCHED THROUGH CHARITABLE SOCIOECONOMIC DEVELOPMENT ACTIVITIES, AT AN ESTIMATED COST OF $307,000, WHILE OUTREACH AND COMMUNITY EDUCATION ACTIVITIES TOUCHED APPROXIMATELY 54,000 LIVES AT AN ESTIMATED COST OF $194,000 DURING FISCAL YEAR 2011.OUR COMMITMENT TO BRING NEW AND INNOVATIVE PROGRAMS AND SERVICES TO SOUTHEAST ARKANSAS IS EVIDENT. DURING FISCAL YEAR 2011, JRMC INVESTED APPROXIMATELY $6.8 MILLION IN CAPITAL ADDITIONS AND IMPROVEMENTS TO OUR FACILITIES AND EQUIPMENT. THIS WAS ACCOMPLISHED BY CONNECTING THOUGHTFUL, DELIBERATE, DISCIPLINED PLANNING, BUDGETING AND SPENDING WITH THE NEED TO PROVIDE STATE-OF-THE-ART TECHNOLOGIES IN A CARING ENVIRONMENT. JRMC CONTINUES TO BE THE FIRST OR ONE OF THE FIRST HOSPITALS IN THE STATE TO ACQUIRE AND IMPLEMENT MANY LEADING HEALTHCARE TECHNOLOGIES. WE ARE PROUD THAT WE CAN CONTINUE TO PROVIDE LEADING HEALTHCARE SERVICES TO EVERYONE IN SOUTHEAST ARKANSAS, REGARDLESS OF ABILITY TO PAY.JRMC CONTINUES TO BE A LEADER IN ELECTRONIC MEDICAL RECORD SYSTEM ADVANCEMENT. THE HEALTHCARE INFORMATION AND MANAGEMENT SYSTEMS SOCIETY (HIMSS) MAINTAINS A SYSTEM FOR MEASURING THE PROGRESS AND IMPACT OF ELECTRONIC MEDICAL RECORDS SYSTEMS. THERE ARE A TOTAL OF 8 STAGES (0-7) A HOSPITAL CAN ACHIEVE WITH A GOAL OF REACHING STAGE 7, WHERE PAPER CHARTS ARE NOT USED TO MANAGE THE DELIVERY OF PATIENT CARE AND CLINICAL DATA IS USED FOR THE PERFORMANCE IMPROVEMENT AND ANALYTICS OF HEALTHCARE. HIMSS CURRENTLY RECOGNIZES JRMC AS A STAGE 6 PROVIDER, WHICH PUTS JRMC IN THE TOP 3% OF PROVIDERS NATIONALLY. DURING FISCAL YEAR 2011, JRMC WAS AMONG THE FIRST PROVIDERS IN THE NATION TO MEET STAGE 1 OF THE MEANINGFUL USE REQUIREMENTS SET FORTH AS PART OF THE AMERICAN RECOVERY AND REINVESTMENT ACT OF 2009.JRMC HAS BEEN RECOGNIZED BY THE JOINT COMMISSION AS ONE OF THE NATION'S TOP PERFORMERS ON KEY QUALITY MEASURES FOR HEART ATTACK, HEART FAILURE, AND PNEUMONIA TREATMENT. THE ORGANIZATION HAS BEEN AWARDED MONETARY INCENTIVES IN BOTH ARKANSAS MEDICAID AND CENTERS FOR MEDICARE AND MEDICAID SERVICES QUALITY PROGRAMS BY ACHIEVING PERFORMANCE GOALS IN QUALITY, DOCUMENTATION AND VALIDATION EXCELLENCE. JRMC CONTINUOUSLY REVIEWS ITS PERFORMANCE UNDER MEDICARE'S VALUE-BASED PURCHASING INITIATIVE, WHICH COMBINES BOTH QUALITY AND HCAHPS PATIENT SATISFACTION MEASURES, TO IDENTIFY OPPORTUNITIES TO ADJUST PROCESSES AND IMPROVE THE OVERALL PATIENT EXPERIENCE AT JRMC. DURING THE PAST SEVERAL YEARS, THE BOARD OF DIRECTORS VIA ITS AUDIT COMMITTEE HAS FOCUSED ON MAINTAINING RECOMMENDATIONS MADE BY FITCH RATING WHICH URGED NOT-FOR-PROFIT HEALTHCARE PROVIDERS TO ADOPT NINE SPECIFIC PROVISIONS OF SARBANES-OXLEY COMPLIANCE. DURING THIS PERIOD WE HAVE CONTINUED TO MAINTAIN COMPLIANCE WITH ALL NINE OF THE FITCH/SOX PROVISIONS. THESE INCLUDE: PROHIBITION OF SPECIFIED NON-AUDIT SERVICES BY AUDITORS, FIVE YEAR AUDIT PARTNER ROTATION, AUDITOR COMMUNICATIONS, AUDIT COMMITTEE STANDARDS, MANAGEMENT CERTIFICATION OF FINANCIAL STATEMENTS, BONUS FORFEITURE, ADOPTION OF A CODE OF ETHICS, AUDIT COMMITTEE FINANCIAL EXPERT, AND INTERNAL CONTROL EVALUATION. IN ADDITION TO THE COMPLETE ADOPTION OF THE FITCH/SOX PROVISIONS, THE JHA BOARD OF DIRECTORS HAS UNDERTAKEN A COMPREHENSIVE SELF-ASSESSMENT REGARDING ITS NOT-FOR-PROFIT STATUS UTILIZING A COMPLIANCE CHECK TOOL AND PROPOSED GUIDELINES PUBLISHED BY THE IRS. JHA HAS NO REASON TO BELIEVE ITS TAX EXEMPT STATUS HAS EVER BEEN IN JEOPARDY. THIS INITIATIVE IS PART OF A LARGER COMPLIANCE PROGRAM INTENDED TO ENSURE JHA CONTINUALLY SELF EVALUATES ITS REGULATORY COMPLIANCE.TODAY'S PUBLIC DEMANDS MORE INFORMATION IN A FULLY TRANSPARENT MANNER. TO BE TRANSPARENT, WE MUST PROVIDE INFORMATION OPENLY, CANDIDLY, AND ACCURATELY. WE PROVIDE INFORMATION ON THE FOLLOWING TOPICS: INPATIENT PRICING, OUTPATIENT PRICING, QUALITY OUTCOMES, AND PATIENT SATISFACTION. THIS GOES OVER AND BEYOND THE EFFORTS AND REQUIREMENTS OF THE ARKANSAS HOSPITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION. THE COMPLETE INFORMATION CAN BE VIEWED AT WWW.JRMC.ORG 163023280 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 1 1 1 1 1 0 0 0 0 0 1 1 1 0 0 0 0 0 1 1 1 0 0 1 209 0 1 2196 1 1 1 0 0 0 0 0 0 0 0 0 X 15 6 1 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 0 1 1 X BRYAN JACKSON 8705417141 1600 WEST 40TH AVENUE PINE BLUFF AR 71603 ANTHONY FRANK 1.00 X 0 0 0 ATKINSON DREW 1.00 X 0 0 0 BOAST JERREL 1.00 X 0 0 0 BROWN DAVID 1.00 X X 0 0 0 CAMPBELL MD JAMES A 1.00 X 0 0 0 CASTEEL MARTY 1.00 X 0 0 0 COPELAND ED 1.00 X 0 0 0 FORESTIERE MD LEE 1.00 X 69003 0 0 KLINE ANNETTE 1.00 X X 0 0 0 MAKRIS GEORGE 1.00 X X 0 0 0 MAYS JOANN B MD 1.00 X 0 0 0 MORGAN CHUCK 1.00 X 0 0 0 ROAF DDS CLIFTON 1.00 X 0 0 0 ROBERSON MD GEORGE 1.00 X 76550 0 0 TROTTER H FORD III 1.00 X 0 0 0 COLEMAN MD DOUG 15.00 X 32500 0 0 JOHNSON WALTER 40.00 X X 555748 0 21536 HARBUCK THOMAS 40.00 X 540746 0 24976 THOMAS BRIAN 40.00 X 232586 0 12090 VANGENDEREN NATHAN 40.00 X 348101 0 20976 HOLMAN BROCK 40.00 X 153248 0 16869 JACKSON BRYAN G 40.00 X 0 0 0 HICKMAN LOUISE 40.00 X 269200 0 19818 REMETICH JAMES 40.00 X 68611 0 3021 CLARK CHARLES A 40.00 X 271666 0 11249 ALNASHIF ALI 40.00 X 387428 0 14088 ALSEBAI MD TAMER 40.00 X 400261 0 24482 IMRAN ADIL 40.00 X 250036 0 20589 KUPERMAN AARON 40.00 X 278610 0 8133 ATKINSON ROBERT P 40.00 X 878914 0 22106 4813208 0 219933 56 1 1 0 EMURGENT CARE INC 8 SHACKLEFORD PLAZA LITTLE ROCK AR 72211 PHYSICIAN SERVICES 3679325 REHAB CARE GROUP INC PO BOX 502096 ST LOUIS MO 63150 THERAPY SERVICES 3237588 SODEXHO INC & AFFILIATES PO BOX 536922 ATLANTA GA 30353 NUTRITIONAL SERVICES 2479327 UAMS-AHEC 4010 MULBERRY ST PINE BLUFF AR 71603 PHYSICIAN SERVICES 1862895 JEFFERSON ANESTHESIOLOGY PO BOX 1272 PINE BLUFF AR 71613 PROFESSIONAL SERVICES 1793282 45 22319 1521729 285055 1829103 PATIENT SERVICE REVENU 621400 176838047 176838047 176838047 3109092 3109092 489040 489040 489040 489040 0 22319 6695 -6695 -6695 EHR INCENTIVE 900099 2438066 2438066 OP PHARMACY AND GIFT S 446110 1279821 1279821 CAFETERIA 722320 994300 994300 3948402 33074 183772 3731556 8660589 190919176 176871121 183772 12035180 175348 175348 509173 509173 2539345 239394 2299951 70548814 64247904 6300910 2716241 2395938 320303 6067774 5335342 732432 5528279 4876377 651902 4150080 3793893 356187 17128 17128 281933 281933 19952 19952 26123177 24147289 1975888 123879 36584 87295 33597615 31509311 2081609 6695 1090408 926847 163561 2383467 2196487 186980 197681 101093 96588 131525 99062 32463 1565729 1506335 59394 1674099 1667326 6773 9551930 9189592 362338 3078540 3043979 34561 PROVISION FOR BAD DEBTS 5058086 5058086 LICENSE/TAXES 1843143 1827143 16000 DUES & FEES 390479 122901 267578 MINOR EQUIPMENT 15344 14800 544 OTHER MISCELLANEOUS 8675 3076 5599 179387844 163023280 16357869 6695 45985632 60318674 21038766 19119495 8245334 8281091 5153372 4620638 2484947 2386171 198122688 137609389 62584950 60513299 38777907 42037752 1917418 2381010 29420718 30946499 215609044 230604629 30029231 31894107 2973178 3480502 26755618 25686548 419700 597868 60177727 61659025 X 155431317 168945604 155431317 168945604 215609044 230604629 X 11531332 1982955 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 19952 19952 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: A PORTION OF DUES PAID TO ARKANSAS HOSPITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION ARE USED FOR LOBBYING EXPENSES. 4805853 4805853 82543580 52420261 30123319 109120742 85189128 23931614 1652513 1652513 60513299 DEFERRED FINANCING COSTS 345705 457 PLAN - FMV ASSET 597868 DUE FROM AFFILIATES 30002926 30946499 457 PLAN 597868 597868 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE ASSOCIATION HAS BEEN RECOGNIZED AS EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND A SIMILAR PROVISION OF STATE LAW. HOWEVER, THE ASSOCIATION IS SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. THE ASSOCIATION APPLIES THE INCOME TAX STANDARD FOR UNCERTAIN TAX POSITIONS. THIS STANDARD CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ORGANIZATION'S FINANCIAL STATEMENTS. THIS STANDARD PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE ASSOCIATION'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE ASSOCIATION IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS. THE ASSOCIATION IS NOT AWARE OF ANY ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OR OTHER TAXES THAT ARE NOT CURRENTLY BEING RECOGNIZED. THE TAX RETURNS FOR TAX YEARS 2008 TO 2010 ARE OPEN TO EXAMINATION BY FEDERAL, LOCAL, AND STATE AUTHORITIES. FUNDRAISING-WEE CARE FUNDRAISERS 13315 13315 6695 6 9004 9004 22319 22319 6695 6695 -6695 1 1 X 1 X 1 X 1 1 1 0 1 1 10603 13519646 13519646 0.07540 8867 537473 537473 0.00300 19470 14057119 14057119 0.07840 55 54398 193741 193741 0.00110 13 45026 5578801 2049320 3529481 0.01970 3 10452 1878755 1180015 698740 0.00390 116 174848 174848 0.00100 187 109876 7826145 3229335 4596810 0.02570 187 129346 21883264 3229335 18653929 0.10410 52 334174 306700 107565 199135 0.00110 52 334174 306700 107565 199135 0.00110 1 1136373 0 61388805 60360906 1027899 X 1 1 1 JEFFERSON SURGERY CENTER PLLC AMBULATORY SURGERY CENTER 0.62500 0.01000 0.36500 1 1 JEFFERSON REGIONAL MEDICAL CENTER

1600 W 40TH AVE PINE BLUFF AR 71603

X X X X NOT REQUIRED IN 2010 1 7 HEALTH CARE PLUS

209 N BLAKE PINE BLUFF AR 71603

PHYSICIAN CLINIC CENTER ON AGING

4747 DUSTY LAKE DR SUITE 101 PINE BLUFF AR 71603

PHYSICIAN CLINIC RHUEMATOLOGY CLINIC

1609 W 40TH SUITE 207 PINE BLUFF AR 71603

PHYSICIAN CLINIC PINE BLUFF SPECIALTY CLINIC

1601 W 40TH SUITE 301 PINE BLUFF AR 71603

PHYSICIAN CLINIC CARDIOLOGY ASSOCIATES

1601 W 40TH SUITE 301 PINE BLUFF AR 71603

PHYSICIAN CLINIC ENDOCRINOLOGY OF SOUTH ARKANSAS

7500 DOLLARWAY RD WHITE HALL AR 71602

PHYSICIAN CLINIC SOUTH ARKANSAS ORTHOPEADICS CENTER

1609 W 40TH SUITE 501 PINE BLUFF AR 71603

PHYSICIAN CLINIC PART II: SEE STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS ON FORM 990, PART III, LINE 4A PART III, LINE 4: ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT. PART III, LINE 8: AN OVERALL COST-TO-CHARGE RATIO METHODOLOGY IS USED TO ESTIMATE THE ORGANIZATIONS COST OF BAD DEBT. PART III, LINE 9B: PATIENT ACCOUNTS QUALIFYING FOR CHARITY CARE WOULD NOT INTENTIONALLY BE PLACED WITH A DEBT COLLECTION SERVICE. FROM TIME TO TIME, INFORMATION THAT RESULTS IN THE DETERMINATION OF CHARITY QUALIFICATION IS OBTAINED SUBSEQUENT TO A PATIENT'S ACCOUNT BEING PLACED WITH A DEBT COLLECTION AGENCY. THE ORGANIZATION'S "COLLECTION AGENCY POLICY" REQUIRES CONTRACTED COLLECTION AGENTS, IN ADDITION TO MANY OTHER PRUDENT PROCEDURES, TO INFORM THE DEBTOR OF THE APPROPRIATE HOSPITAL FINANCIAL ASSISTANCE PROFESSIONAL TO CONTACT IF THE COLLECTION AGENT IS MADE AWARE OF A PATIENT'S FINANCIAL HARDSHIP. THE COLLECTION AGENT IS ALSO REQUIRED TO NOTIFY THE ORGANIZATION OF THE PATIENT'S FINANCIAL HARDSHIP SO THE ORGANIZATION CAN ASSIST THE PATIENT IN ACCESSING THE ORGANIZATION'S FINANCIAL ASSISTANCE PROGRAMS. PART I, LINE 6B: THE ORGANIZATION MAKES ITS ANNUAL COMMUNITY BENEFIT REPORT AVAILABLE UPON REQUEST. PART VI, LINE 3: A FINANCIAL COUNSELOR INITIATES A FINANCIAL SCREENING ON ALL INPATIENTS, OBSERVATION PATIENTS AND OUTPATIENTS OCCUPYING A BED HAVING NO INSURANCE INDICATED ON THEIR ACCOUNT. THIS PROCESS INCLUDES SCREENING FOR CHARITY CARE ASSISTANCE, MEDICAID COVERAGE AND OTHER THIRD PARTY COVERAGE. OUTPATIENTS RECEIVE A FINANCIAL ASSISTANCE GUIDE SHEET SUMMARIZING ASSISTANCE OFFERED BY JRMC AT THE TIME OF REGISTRATION. PART VI, LINE 4: SEE STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS ON FORM 990, PART III, LINE 4A PART VI, LINE 6: SEE STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS ON FORM 990, PART III, LINE 4A PART VI, LINE 7: THIS IS NOT APPLICABLE FOR TAX YEAR 2010. 1 AR AFFILIATE OF SUSAN G KOMEN FOR THE CURE 904 AUTUMN RD STE 500 LITTLE ROCK AR 72211 710724439 501C(3) 5000 RACE FOR THE CURE SPONSORSHIP GREATER PINE BLUFF CHAMBER OF COMMERCE PO BOX 5069 PINE BLUFF AR 71611 710765850 501C(6) 72502 PARTNERS IN PROGRESS PLEDGE OF SUPPORT WHITE HALL BASEBALL INC PO BOX 20085 WHITE HALL AR 71612 710789189 501C(3) 7225 SPONSOR- BATTING CAGES UNITED WAY OF SE ARKANSAS PO BOX 8702 PINE BLUFF AR 71611 710236869 501C(3) 37500 PLEDGE OF SUPPORT FOR 2010 3 1 FEDERAL PELL GRANTS (US DEPT OF ED) 56 176294 WIA ADULT PROGRAM GRANTS (US DEPT OF LABOR) 13 39186 G.O. GRANTS (STATE OF AR) 15 9000 ACADEMIC CHALLENGE SCHOLARSHIPS (STATE OF AR) 16 22750 FEDERAL FAMILY EDUCATION LOANS (US DEPT OF ED) 51 250100 REHABILITATION STUDENT GRANTS (STATE OF AR) 7 10483 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: JEFFERSON HOSPITAL ASSOCIATION, INC. MAINTAINED RECORDS TO SUBSTANTIATE THE AMOUNT OF THE GRANTS OR ASSISTANCE, THE GRANTEES' ELIGIBILITY FOR THE GRANTS OR ASSISTANCE, AND THE SELECTION CRITERIA USED TO AWARD GRANDS OR ASSISTANCE. X 0 1 X X X X X X 0 1 0 0 0 0 0 1 0 JOHNSON WALTER 302275 0 90176 0 163297 0 10368 0 13435 0 579551 0 0 0 HARBUCK THOMAS 283190 0 93515 0 164041 0 10368 0 16869 0 567983 0 0 0 THOMAS BRIAN 141947 0 35000 0 55639 0 5437 0 7025 0 245048 0 0 0 VANGENDEREN NATHAN 187177 0 47016 0 113908 0 10368 0 12187 0 370656 0 0 0 HOLMAN BROCK 109744 0 20108 0 23396 0 6836 0 15391 0 175475 0 0 0 HICKMAN LOUISE 148782 0 35779 0 84639 0 9930 0 11189 0 290319 0 0 0 CLARK CHARLES A 37042 0 212435 0 22189 0 9457 0 2151 0 283274 0 0 0 ALNASHIF ALI 370624 0 0 0 16804 0 10368 0 6230 0 404026 0 0 0 ALSEBAI MD TAMER 299881 0 85383 0 14997 0 10368 0 15648 0 426277 0 0 0 IMRAN ADIL 232918 0 5000 0 12118 0 10510 0 11685 0 272231 0 0 0 KUPERMAN AARON 194252 0 67730 0 16628 0 3154 0 5613 0 287377 0 0 0 ATKINSON ROBERT P 299471 0 99641 0 479802 0 10368 0 13119 0 902401 0 0 0 PART I, LINE 1A COUNTRY CLUB DUES ARE MAINTAINED BY THE ORGANIZATION AND UTILIZED BY SPECIFIED EMPLOYEES OF THE ORGANIZATION. PART I, LINE 1B THERE IS NO WRITTEN POLICY REGARDING PAYMENT OF THOSE SPECIFIC DUES. PART I, LINE 4B WALTER JOHNSON $69,245.03; THOMAS HARBUCK $67,428.08; BRIAN THOMAS $22,484.90; LOUISE HICKMAN $41,245.36; NATHAN VANGENDEREN $45,062.57; ROBERT ATKINSON $53,807.69. PART I, LINE 7 THE ORGANIZATION PROVIDES DEFINED MEMBERS OF MANAGEMENT A NON-FIXED PERFORMANCE BASED INCENTIVE PLAN. THE PLAN'S COMPONENTS ARE ESTABLISHED AND EVALUATED BY THE ORGANIZATION'S EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS. SUPPLEMENTAL INFORMATION PART III REPORTED COMPENSATION FOR ROBERT P. ATKINSON, FORMER OFFICER, DOES NOT INCLUDE SEVERANCE OR CHANGE-OF-CONTROL PAYMENTS. DURING CALENDAR YEAR 2010, MR. ATKINSON RECEIVED TERMINAL PAYMENT OF ACCRUED TIME OFF IN CONJUNCTION WITH RETIREMENT FROM HIS ROLE AS AN OFFICER. ATKINSON REMAINED EMPLOYED IN A PART-TIME CAPACITY THROUGHOUT THE TAX YEAR REPORTED. CENTRAL MOLONEY SEE SCHEDULE O. SEE SCH. O 0 CINDY FORESTIERE SEE SCHEDULE O. SEE SCH. O 0 RICHARD MORGAN SEE SCHEDULE O. SEE SCH. O 0 SIMMONS FIRST NAT'L BANK SEE SCHEDULE O. SEE SCH. O 0 STACY COLEMAN SEE SCHEDULE O. SEE SCH. O 0 FORM 990, PART VI, SECTION A, LINE 2 CHUCK MORGAN (JHA DIRECTOR) AND ANNETTE KLINE (JHA DIRECTOR) HAVE A BUSINESS RELATIONSHIP. MARTY CASTEEL (JHA DIRECTOR) AND DR. CLIFTON ROAF (JHA DIRECTOR) HAVE A BUSINESS RELATIONSHIP. GEORGE MAKRIS (JHA DIRECTOR) AND DR. CLIFTON ROAF (JHA DIRECTOR) HAVE A BUSINESS RELATIONSHIP. GEORGE MAKRIS (JHA DIRECTOR) AND MARTY CASTEEL (JHA DIRECTOR) HAVE A BUSINESS RELATIONSHIP. H. FORD TROTTER III (JHA DIRECTOR) AND DR. CLIFTON ROAF (JHA DIRECTOR) HAVE A BUSINESS RELATIONSHIP. H. FORD TROTTER III (JHA DIRECTOR) AND MARTY CASTEEL (JHA DIRECTOR) HAVE A BUSINESS RELATIONSHIP. H. FORD TROTTER III (JHA DIRECTOR) AND GEORGE MAKRIS (JHA DIRECTOR) HAVE BUSINESS RELATIONSHIPS. CHUCK MORGAN (JHA DIRECTOR) AND ED COPELAND (JHA DIRECTOR) HAVE A BUSINESS RELATIONSHIP. DR. DOUG COLEMAN (JHA DIRECTOR) AND JERREL BOAST (JHA DIRECTOR) HAVE A BUSINESS RELATIONSHIP. GEORGE MAKRIS (JHA DIRECTOR) AND DAVID BROWN (JHA DIRECTOR) HAVE A BUSINESS RELATIONSHIP. FRANK ANTHONY (JHA DIRECTOR) AND DAVID BROWN (JHA DIRECTOR) HAVE A BUSINESS RELATIONSHIP. MARTY CASTEEL (JHA DIRECTOR) AND CHUCK MORGAN (JHA DIRECTOR) HAVE A BUSINESS RELATIONSHIP. H. FORD TROTTER III (JHA DIRECTOR) AND DAVID BROWN (JHA DIRECTOR) HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS A MEMBERSHIP CONSISTING OF 30 JEFFERSON COUNTY ARKANSAS RESIDENTS. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERSHIP OF THE ORGANIZATION HAS THE RESPONSIBILITY OF ELECTING THE BOARD OF DIRECTORS AT THE ANNUAL MEMBERSHIP MEETING. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF FORM 990 AND 990-T IS REVIEWED BY THE GOVERNING BODY BEFORE IT IS FILED. THE RETURN IS FORMALLY PRESENTED TO THE BOARD OF DIRECTORS' AT A REGULARLY SCHEDULED BOARD OF DIRECTORS MEETING. A FINAL DRAFT OF THE 990 IS POSTED TO AN INTERNAL WEBSITE AVAILABLE TO THE BOARD OF DIRECTORS UNTIL THE RETURN IS FILED. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION REQUIRES NOT ONLY AN ANNUAL CONFLICT OF INTEREST DISCLOSURE, BUT ALSO WHEN SITUATIONS SUBSEQUENT TO THE ANNUAL DISCLOSURE DEVELOP THAT WOULD POTENTIALLY PLACE THE INDIVIDUAL IN A CONFLICT OF INTEREST. IN THOSE SITUATIONS, IMMEDIATE DISCLOSURE IS REQUIRED. THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS CONDUCTS THE ANNUAL REVIEW OF CONFLICT OF INTEREST DISCLOSURES. IN THE EVENT THE EXECUTIVE COMMITTEE DETERMINES THAT A CONFLICT EXISTS, LEGAL COUNSEL IS CONSULTED. IF LEGAL COUNSEL DETERMINES THAT A CONFLICT EXISTS, THE PERSON IS INFORMED AND THE MATTER IS REPORTED TO THE BOARD FOR ACTION. ANY DIRECTOR OR OFFICER WHOSE TRANSACTIONS ARE BEING REVIEWED WOULD ABSENT HIMSELF/HERSELF FROM THE REVIEW. FORM 990, PART VI, SECTION B, LINE 15A THE BOARD OF DIRECTORS ESTABLISHED A SEPERATE COMPENSATION COMMITTEE CHARGED WITH PERFORMING AN ANNUAL PERFORMANCE REVIEW OF THE CEO AND REVIEWING THE CEO'S COMPENSATION PACKAGE. THE COMPENSATION COMMITTEE ENGAGED A THIRD-PARTY GLOBAL HUMAN CAPITAL CONSULTING FIRM TO: (1) DEVELOP AN ANNUAL CEO PERFORMANCE REVIEW PROCESS, INCLUDING A NEW EVALUATION FORM, AND (2) DEVELOP A COMPENSATION PACKAGE BASED ON ITS KNOWLEDGE OF SIMILARLY SIZED NON-PROFIT ORGANIZATIONS IN ORDER TO ENSURE THAT THE COMPENSATION PAID TO THE CEO IS REASONABLE. ALL MEMBERS OF THE BOARD COMPLETE AN ANNUAL EVALUATION, WHICH THE COMPENSATION COMMITTEE SUMMARIZES AND REVIEWS. THE COMPENSATION COMMITTEE THEN MAKES A RECOMMENDATION TO THE FULL BOARD OF DIRECTORS FOR ANY COMPENSATION ADJUSTMENTS. FORM 990, PART VI, SECTION C, LINE 19 ALTHOUGH NOT A REQUIREMENT, THE ORGANIZATION PROVIDES PHOTOCOPIES OF ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, FINANCIAL STATEMENTS, AND OTHER DOCUMENTS TO ALL WHO REQUEST ONE OR MORE OF THE ITEMS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 1,982,955. AUDIT COMMITTEE FORM 990, PAGE 12, PART XII, LINE 2C THE ORGANIZATION'S POLICY REGARDING OVERSIGHT OF AUDIT IS CONSISTENT WITH THE PRIOR YEAR. BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS: SCHEDULE L, PART IV, COLUMNS B, C, & D (A) NAME OF PERSON: CENTRAL MOLONEY (B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: ENTITY IN WHICH ED COPELAND AND CHUCK MORGAN, JHA DIRECTORS, ARE OFFICERS. (C) TRANSACTION AMOUNTS ARE REPORTED AS GREATER THAN $100,000 (D) DESCRIPTION OF TRANSACTION: HEALTHCARE PAYMENTS (A) NAME OF PERSON: CINDY FORESTIERE (B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: FAMILY MEMBER OF LEE FORESTIERE, JHA DIRECTOR. (C) TRANSACTION AMOUNTS ARE REPORTED AS GREATER THAN $10,000 (D) DESCRIPTION OF TRANSACTION: EMPLOYEE OF JEFFERSON REGIONAL MEDICAL CENTER (A) NAME OF PERSON: RICHARD MORGAN (B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: FAMILY MEMBER OF CHUCK MORGAN, JHA DIRECTOR. (C) TRANSACTION AMOUNTS ARE REPORTED AS GREATER THAN $10,000 (D) DESCRIPTION OF TRANSACTION: EMPLOYEE OF JEFFERSON REGIONAL MEDICAL CENTER. (A) NAME OF PERSON: SIMMONS FIRST NAT'L BANK (B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: ENTITY IN WHICH DR. CLIFTON ROAF, MARTY CASTEEL, GEORGE MAKRIS AND H. FORD TROTTER III ARE OFFICERS. (C) TRANSACTION AMOUNTS ARE REPORTED AS GREATER THAN $100,000 (D) DESCRIPTION OF TRANSACTION: INTEREST INCOME & BANK/TRUSTEE FEES (A) NAME OF PERSON: STACY COLEMAN (B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: FAMILY MEMBER OF DR. DOUG COLEMAN, JHA DIRECTOR. (C) TRANSACTION AMOUNTS ARE REPORTED AS GREATER THAN $10,000 (D) DESCRIPTION OF TRANSACTION: EMPLOYEE OF JRMC. 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