2011-08-15T16:14:10-05:00 2010-09-30 Deloitte Tax LLP 191 Peachtree Street Suite 2000 Atlanta GA 30303 990 2009-10-01 560845796 Cumberland County Hospital System Inc CUMB 9106154829 PO Box 2000 Fayetteville NC 283022000 SANDRA WILLIAMS CFO 9106154829 2011-08-15 1 CHARLES B FREEMAN II 4042201500 2009 2016-02-24 21:20:13Z Sandra Williams PO Box 2000 Fayetteville NC 283022000 907113969 0 X www.capefearvalley.com X 1956 NC Cumberland County Hospital System, Inc. exists to meet the health care needs of the residents of Cumberland and Bladen counties, and the surrounding area in North Carolina. 20 20 6268 395 -27277 -27277 952505 862041 649090521 673153915 1666474 10386182 6844600 6688549 658554100 691090687 23200 6207 0 322013303 335263359 0 0 334893722 350120051 656930225 685389617 1623875 5701070 777026539 846966837 467038234 512905652 309988305 334061185 Cumberland County Hospital System, Inc. exists to meet the health care needs of the residents of Cumberland and Bladen counties, and the surrounding area in North Carolina. 0 0 653973909 6207 673153915 As part of meeting the health care needs of the service area, CCHS, Inc. admitted 32,572 patients, provided patient 201,668 days of care, had 137,964 emergency room visits and had over 390,997 outpatient visits for other services. 653973909 1 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 487 0 1 6268 1 1 1 1 CJ 0 0 0 0 0 1 1 20 20 0 0 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 1 1 0 NC X James Dupe 9106154829 P O Box 2000 Fayetteville NC 283022000 Jeannette Council 2.00 X 0 0 0 Jerry Dean 2.00 X 0 0 0 Mary Dickey 2.00 X 0 0 0 Kenneth Edge 2.00 X 0 0 0 Marshall Faircloth 2.00 X 0 0 0 Phillip Gilfus 2.00 X 0 0 0 John Griffin 2.00 X 0 0 0 John Henley 2.00 X 0 0 0 Jimmy Keefe 2.00 X 0 0 0 Billy King 2.00 X 0 0 0 Ed Melvin 2.00 X 0 0 0 Marion Gillis Olion 2.00 X 0 0 0 Divyang Patel 2.00 X 0 0 0 Donald L Porter 2.00 X 0 0 0 Rueben Rivers 2.00 X 0 0 0 W Dickson Schaefer 2.00 X 0 0 0 David Schutzer 2.00 X 0 0 0 Sanjay Shah 2.00 X 0 0 0 Jennifer Twaddell 2.00 X 0 0 0 Denise Mahone Wyatt 2.00 X 0 0 0 James Martin 2.00 X 0 0 0 William Hurley 2.00 X 0 0 0 Michael Nagowski 55.00 X 603584 0 61624 Sandra Williams 55.00 X 420353 0 8697 Joyce Korzen 55.00 X 465862 0 30434 Richard Osenbach 55.00 X 726756 0 10652 John Spitalieri 55.00 X 723361 0 4867 John Reed 55.00 X 534784 0 13496 Stuart Shelton 55.00 X 484849 0 10797 Samuel Skarote 55.00 X 447525 0 7092 4407074 0 147659 353 0 1 0 Allied Barton Security Services PO Box 534265 Atlanta GA 303534265 Security Services 3779346 Aramark Clinical Technology Services 12483 Collection Ctr Dr Chicago IL 60693 Professional Services 3767523 Fayetteville Kidney Center PO Box 101518 Atlanta GA 30392 Professional Services 2471744 K & L Gates LLP 210 Sixth Avenue Pittsburgh PA 15222 Legal Services 1727805 Aramark Healthcare Support Services PO Box 905810 Charlotte NC 28290 Professional Services 1705759 49 101818 760223 862041 Patient service revenu 900099 672955679 672955679 Education/Outreach 611710 198236 198236 673153915 9562718 9562718 192405 192405 30896 8340 22556 22556 22556 216615501 30500 215971735 43207 643766 -12707 631059 631059 Cafeteria and parking 900099 3006660 3006660 Purchase rebates, disc 812900 2708487 2708487 Employee daycare reven 624410 978123 978123 -27277 -27277 6665993 691090687 673153915 -27277 17102008 6207 6207 1542879 1388591 154288 270466477 270466477 9725334 8752800 972534 35120256 31608230 3512026 18408413 16567571 1840842 5329191 4796272 532919 782399 704159 78240 407743 407743 75000 75000 678915 611023 67892 4347962 3913166 434796 9618687 8656818 961869 12058477 10852629 1205848 91239 45619 45620 1041285 520643 520642 14036650 14036650 30425825 27383242 3042583 19173712 17256341 1917371 Medical supplies and ot 101661190 91495071 10166119 0 Bad debt 83330022 83330022 0 0 Purchased services 20971233 18874109 2097124 0 Repairs and Maintenance 11518006 11518006 0 0 Contract labor 6527267 5874540 652727 0 28045248 25240723 2804525 685389617 653973909 31415708 0 863670 5288284 52938750 62713782 97611241 93667312 8760903 9040533 4723233 4595501 622393044 326424548 287173424 295968496 177086026 213961693 147869292 161731236 777026539 846966837 75382621 74262155 88947 119227 310260593 304484909 81306073 134039361 467038234 512905652 X 0 0 0 0 309988305 322932674 309988305 334061185 777026539 846966837 X 0 1 0 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 1 75000 0 0 75000 0 15610783 15610783 375594831 153992542 221602289 586915 430303 156612 220305528 163671335 56634193 10294987 8330368 1964619 295968496 Other Receivables 59356865 Self Insurance Trusts 44831449 Trusts - Bond Funds 29810750 Other Assets 12511216 Construction in Progress 15220956 161731236 Estimated Prof Liability & Worker Comp Costs 44910420 Due to Payor Agencies 52031343 Derivative Instrument 37097598 134039361 1 1 X 1 X 1 X 500.000000000000 1 0 0 1 1 21784000 1720626 20063374 0.02930 33389000 21808895 11580105 0.01690 55173000 23529521 31643479 0.04620 77000 77000 0.00010 3334065 3234349 99716 0.00010 10522937 3405321 7117616 0.01040 10000 10000 0.00000 13944002 6639670 7304332 0.01060 69117002 30169191 38947811 0.05680 158000 158000 0.00020 41000 41000 0.00010 199000 199000 0.00030 0 21069000 0 165061507 173485918 -8424411 X 1 1 Bladen County Hospital

501 South Poplar Street Elizabethtown NC 28337

X X X Highsmith Rainey Hospital

150 Robeson Street Fayetteville NC 28301

Long Term Acute Care Hospital Cape Fear Valley Health System

1630 Owen Drive Fayetteville NC 28304

X X X Part I, Line 7f: Part III, Line 4: A patient's record is reviewed for possible charity care and if the patient does not qualify for charity and the patient then does not pay, their charges are written-off as bad debt. Amounts in 2 are determined by calculating a cost-to-charge ratio. Part III, Line 8: Cumberland County Hospital Systems, Inc. treats the total shortfall of Medicare reimbursement compared to the amount of computed Medicare allowable costs as a community benefit. The hospital improves access to patient care by providing services regardless of a patient's ability to pay or the hospital's ability to receive full cost reimbursement for services. The hospital also relieves the government of a financial burden when it provides care to publicly insured patients where reimbursement is less than cost of providing the service. Part III, Line 9b: If determined to qualify for charity, account is written-off to charity rather than bad debt. Cumberland County Hospital System files a community benefit report annually in the state of North Carolina to the NC Hospital Association. Part VI, Line 2: The mission of Cape Fear Valley Health System is to strengthen the health and well-being of the greater Cape Fear Valley region through high-quality, compassionate care provided to all who need it. As a community not-for-profit organization, we take seriously our responsibility to invest our resources and energies into understanding and meeting the diverse health care needs of all, and ensure that everyone, regardless of their ability to pay, receive the care they need. Our facility is a member of a group called Greater Fayetteville Futures. As a member of this group we participate in community meetings to gain insight needs and community suggestions. The Senior Administrative team serves in various capacities on several local community boards and groups. As members of these various groups, they are able to gain insight to needs of the community. Our community partners are critical to helping us improve the health and well-being of the Cape Fear Valley region. Together, we can combine resources and strengths, positively impacting the greatest number of people. By working closely with the community leaders, we also build a greater sense of community and a shared commitment toward our common goal of improving the community's health. The results help us to determine our short and long term priorities as well as strategies for improving community health. Those community groups and partners CCCC, SRAHEC, CCMAP, Chamber of Commerce, Fayetteville Area PR Alliance, Cumberland County Education Foundation, Communities in Schools of NC, Fort Bragg Regional Alliance, Care Clinic, and the Methodist University Physician Assistant program. Part VI, Line 3: Uninsured patients are screened at the time of registration for their ability to pay for their health care services. If the patient has no ability to pay and is deemed ineligible for governmental programs (Medicare, Medicaid, etc.) then they are informed of the Hospital Charity program. They are provided with an application and a listing of the appropriate documents necessary to establish eligibility for the Hospital Charity program. All patients receive a copy of our Charity Care Application accompanying the first billing statement. Part VI, Line 4: Cumberland County Hospital System, Inc. ("CCHS") doing business as Cape Fear Valley Medical Center ("CFVMC") is the flag ship of Cape Fear Valley Health System ("CFVHS"). CFVHS operates a variety of healthcare facilities from its headquarters in Fayetteville, North Carolina including a tertiary acute care hospital, a long-term acute care hospital, a critical access hospital, an inpatient rehabilitation facility, county emergency medical services, an outpatient psychiatric facility, a detoxification facility, a wellness center, 14 primary care clinics, 16 specialty care clinics, 5 walk-in clinics, and Health Pavilion North, an outpatient complex.Cape Fear Valley Health System serves a six-county service area made up of the five counties contiguous to Cumberland County, NC, which is its Primary Service Area. Per information from the 2010 Census Data, Cumberland has a population of over 319,000 residents; this was a growth of 5.4% from the 2000 Census Data. Approximately 48.6% of the 319,000 residents in our primary service area are minorities, compared to 31.5% for the state. Part VI, Line 5: Cumberland County Hospital System, Inc. ("CCHS") reported coalition building and workforce development details in the Community Building Activities Part II. Coalition building promotes the health of the communities it serves by networking with other community agencies to address the health and safety issues of the community. The employees of CCHS utilize their clinical expertise to collaborate with other community agencies and county and state health departments to provide education and other initiatives that benefit the health of people in the community. Workforce development activities include the recruitment of physicians and other health professionals to medical shortage areas. Part VI, Line 6: Chronic diseases like diabetes and obesity are increasing within our community. Our facility has opened a diabetes and endocrine clinic to help those patients diagnosed with diabetic. Our healthplex provides both nutritional and exercise programs to help those in the community address the problem of obesity. The goal is to help all residents learn to manage their conditions and live healthier lives by addressing the challenges associated with these conditions. Example of Program at Cape Fear Valley:Cape Fear Valley Health System's Take Charge of Your Health Program began as an initiative to close the healthcare gap between African-Americans and non-Hispanic Whites in Cumberland County through public service announcements, health fairs, screenings and speaking engagements. It has since broadened its focus to all of Cumberland County. Darvin Jones is the Coordinator of Take Charge of Your Health Program. He serves on the Board of Directors of Community Health Interventions & Sickle Cell Agency, a non-profit that works with individuals with sickle cell disease, hypertension and diabetes. Darvin is also a member of the Cumberland County Council for Healthy Living, a group assembled by the Health Department, and the Cumberland County Schools School Health Advisory Council. Take Charge of Your Health is affiliated with Eat Smart, Move More North Carolina, a statewide initiative.At Cape Fear Valley Health System, it is important to us to give back to our community. In addition to employee United Way donations and volunteer time, our employees participate in a variety of community service initiatives, to include Habitat for Humanity and the Friends of Cancer River Walk. Last year our employees gave over $150,000 in donations to various community organizations. Part VI, Line 7: Cumberland County Hospital System is a stand-alone health care organization and is not a part of an affiliated health care system. NC 1 X Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: Cumberland County Hospital System awards grants to patients for purposes of assisting them in paying various bills and other expenses which the patients cannot pay due their excessive medical expenses required for treating illness. Patients apply and applications are reviewed by hospital social workers . Any funds granted are not paid directly to the patients, instead the funds are paid directly to the organization for which patient owes the bill and/or expense. X X X X 1 0 0 0 0 0 0 0 0 Michael Nagowski 449482 0 124563 0 29539 0 54154 0 7470 0 665208 0 0 0 Sandra Williams 288133 0 103250 0 28970 0 4900 0 3797 0 429050 0 0 0 Joyce Korzen 326918 0 96100 0 42844 0 23902 0 6532 0 496296 0 0 0 Richard Osenbach 709016 0 16500 0 1240 0 4900 0 5752 0 737408 0 0 0 John Spitalieri 722551 0 0 0 810 0 0 0 4867 0 728228 0 0 0 John Reed 391991 0 22000 0 120793 0 4900 0 8596 0 548280 0 0 0 Stuart Shelton 338616 0 92510 0 53723 0 4900 0 5897 0 495646 0 0 0 Samuel Skarote 352434 0 26096 0 68995 0 4900 0 2192 0 454617 0 0 0 Part I, Line 4a: Joyce Korzen received severance in the amount of $116,934. North Carolina Medical Care Commission 521309402 6579022Y7 2006-05-04 37995351 Construction and equipment 0 0 North Carolina Medical Care Commission 521309402 65821DAL5 2008-09-23 285335000 Refund a prior issue 0 0 39439715 5147613 1036018 12370 38391327 2008 0 0 1 1 285335000 15898972 3722000 10007178 2008 1 0 1 1 0 0 1 0 1 1 0 0 1 0 1 1 0 0 0 0 0 1 0 1 0 1 Morgan Stanley 1.100000000000 1 0 1 Form 990, Part VI, Section A, line 7a The Board of Trustees of Cumberland County Hospital System shall be comprised of seven Trustees who are the seven members of the Cumberland County Board of Commissioners. The Board of Trustees will also have eight at large Trustees who are appointed by the Board of Commissioners. The remaining five at large members are appointed by the Board of Trustees. Form 990, Part VI, Section B, line 11 The process the organization uses to review the Form 990 consists of providing the Form 990 to the Cumberland County Hospital System's Board of Trustees by electronic copy. Board Members will be given time to do a thorough review before the filing date of August 15, 2011. Form 990, Part VI, Section B, line 12c Cumberland County Hospital System, Inc. regularly and consistently monitors and enforces compliance with the conflict of interest policy in that any director, principal officer, or member of a committee with governing board delegated powers, who has a direct or indirect financial interest, must disclose the existence of the financial interest and be given the opportunity to disclose all material facts to the directors and members of the committees with governing board delegated powers considering the proposed transaction or arrangement. The remaining individuals on the governing board or committee meeting will decide if conflicts of interest exist. Each director, principal officer and member of a committee with governing board delegated powers annually signs a statement which affirms such person has received a copy of the conflicts of interest policy, has read and understands the policy, has agreed to comply with the policy, and understands that the organization is charitable and in order to maintain its federal tax exemption it must engage primarily in activities which accomplish its tax-exempt purpose. Form 990, Part VI, Section B, line 15 A human resources consulting firm is retained by Cumberland County Hospital Systems, Inc. to review the competitiveness and reasonableness of the compensation provided to the CEO and other top management personnel. Form 990, Part VI, Section C, line 19 Provided upon request. Schedule K, Line 2, Column A The $5,147,613 is in a debt service fund. Schedule K, Line 2, Column B Of the $15,898,972, $4,499,669 is in a debt service fund and the remaining balance of $11,399,303 is in a reserve fund. Schedule K, Line 5, Column A Of the $1,036,018, $683,338 is a credit enhancement and $352,680 is costs of issuance. Cape Fear Insurance LTD PO BOX 30600 SMBWest Bay Road FC Grand Cayman Cayman Islands CJ 980449284 Insurance CJ 11052137 38124141 N/A Bladen County Healthcare LLC C/O PO Box 2000 Fayetteville NC 28302 800164702 Health Services NC 30638649 11302473 N/A Cumberland Health Affiliates LLC PO Box 2000 Fayetteville NC 28302 562275588 Health Services NC N/A Valley Health Facilities LLC PO Box 2000 Fayetteville NC 28302 204268819 Health Services NC N/A Highsmith-Rainey Medical Arts Center Association Inc PO Box 2000 Fayetteville NC 28302 561747424 Rental Association NC N/A C 122017 811663 0.82000 Cumberland Health Partners Inc Po Box 2000 fayetteville NC 28302 562043978 Behavioral Health Care NC N/A C 1.00000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 Highsmith-Rainey Medical Arts Center Association Inc Q 145402