2011-07-08T14:23:35-05:00 2010-09-30 Arnett & Foster PLLC P O Box 2629 Charleston WV 25329 990 2009-10-01 550422958 Stonewall Jackson Memorial Hospital Company STON 3042698050 230 Hospital Plaza Weston WV 26452 Dodie Arbogast 3042698050 2011-07-06 1 Harry C Harless 3043460441 2009 2016-02-24 21:20:13Z X David D Shaffer 230 Hospital Plaza Weston WV 26452 50381121 0 X www.stonewallhospital.com X 1959 WV The mission is to provide quality medical care to the citizens of Lewis and surrounding counties regardless of the patient's ability to pay. To enable the citizens of our service area to receive quality care close to home. 9 8 560 45 5474 4474 35598 56866 39977663 39331770 731463 989387 198451 203771 40943175 40581794 20000 35400 0 20856151 21776127 0 0 18526984 16750135 39403135 38561662 1540040 2020132 54889849 57875135 8945066 8198777 45944783 49676358 It is the mission of Stonewall Jackson Memorial Hospital to provide the best possible combination of primary care in a safe, efficient, and compassionate manner. It is, and always shall be, our duty to assess the quality of care provided and to continue to seek methods of improving both our evaluation of and delivery of patient care. It is our unswerving faith in this mission that assures our role as a vital community hospital and as an economic resource for our community. 0 0 26378101 39289395 Stonewall Jackson Memorial Hospital provides Acute medical and outpatient services to residents of Weston, West Virginia and surrounding communities which covers 9 different counties. Including 11,161 hospital days, 59,046 outpatient visits, 11,458 emergency room visits, 2,072 Ambulatory surgery visits, 4,744 Home Health visits and 34,560 Physician Clinic visits. 42375 16400 42375 Annual Blood Screening - Provide low-cost laboratory diagnostic tests to approximately 1,050 individuals. Stonewall Jackson Memorial Hospital provides all supplies and staff to operate the program. Excess revenue is forwarded to the local Rotary Club to promote charitable services.Other programs include: Glucose & Blood Pressure screenings at local Senior Center, Scoliosis Screening at county elementary and middle schools, Cardiac Project aimed at 5th graders to educate and monitor heart health, October fest program to promote healthy choices to children under 12 years old, school physicals for middle school and high school athletes, events for free Osteoporosis screenings, events for free Dermascans for screen for skin cancer and Weston Walk-Run to promote exercise as a way to improve cardiac health. 19000 19000 18183 William Adler Scholarship Fund - Stonewall Jackson Memorial Hospital sponsored program to provide scholarships to local graduating high school seniors who are pursuing a career in the health care field through an accredited program. It is hoped that this program will encourage more students to seek health care professions and lessen the health care staffing shortage. 26439476 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 1 0 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 52 0 1 560 1 1 1 0 0 0 0 1 1 0 9 8 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X X Dodie Arbogast 3042698050 230 Hospital Plaza Weston WV 264528558 John E Law 1.00 X 0 0 0 John L Spiker 1.00 X 0 0 0 R Gerald Wood 1.00 X 0 0 0 Denver R Turner 1.00 X 0 0 0 Richard Cronin 1.00 X 0 0 0 RG Lockard 1.00 X 0 0 0 Jean Bennett 1.00 X 0 0 0 J A Snead 37.50 X 237984 0 26302 Debbie Bennett 1.00 X 0 0 0 David Shaffer 37.50 X 271374 0 25864 Avah Stalnaker 37.50 X 160182 0 13468 Delphia Arbogast 37.50 X 116703 0 17400 Peter Edgerton 37.50 X 421485 0 33420 John Wyllie 37.50 X 381455 0 24552 Mario Estolano 37.50 X 285282 0 0 Salvatore Lanasa 37.50 X 326301 0 28661 Jack Marcum 37.50 X 274996 0 26095 2475762 0 195762 24 0 1 0 Mountain Radiology Services 21 W Third Street Washington MO 63090 Radiology 445200 Lab Corp PO Box 12140 Burlington NC 27216 Laboratory Services 268911 CPS PO Box 1000 Memphis TN 38148 Consulting 264857 Michael Gregory MD 230 Hospital Plaza Weston WV 26452 Medical 222219 Steptoe & Johnson P O Box 1732 Clarksburg WV 26302 Legal 181447 5 13500 43366 56866 Patient Services 622110 39331770 39331770 39331770 946861 946861 47148 8400 74214 2926 -27066 5474 -21592 5474 -27066 9757013 9714487 42526 42526 42526 8500 13500 7700 800 800 Cafeteria Sales 722310 123309 123309 Vending Machines 454210 67194 67194 Miscellaneous 900099 34060 34060 224563 40581794 39331770 5474 1187684 16400 16400 19000 19000 909436 599045 310391 17982126 11844826 6137300 671498 442316 229182 1012861 667172 345689 1200206 790576 409630 184249 184249 102166 102166 43862 43862 1503426 990307 513119 150005 98808 51197 7303349 4810716 2492633 550786 362803 187983 74681 49192 25489 72679 47874 24805 1595684 1051077 544607 157521 103759 53762 Bad Debts 3066820 3066820 Repairs & Maintenance 940607 619578 321029 Medicaid Provider Tax 400658 400658 Physician Recruitment 155410 155410 Continuing Education 148798 98013 50785 299434 205126 94308 38561662 26439476 12122186 0 968885 162232 1018682 23096 6831102 6631588 1105458 1068843 339410 342751 31012764 21148264 9677642 9864500 33592554 38342445 75402 75402 1280714 1364278 54889849 57875135 6899794 5962876 26758 26758 2018514 2209143 8945066 8198777 X 45944783 49676358 45944783 49676358 54889849 57875135 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 48898 597116 646014 1544574 10086965 8614255 3017284 17870332 12534009 5336323 864879 864879 9864500 40581794 38561662 2020132 1711443 1711443 3731575 42217632 1711443 29992 1741435 40476197 43862 61735 105597 40581794 38486057 29992 29992 38456065 43862 61735 105597 38561662 Part X: Description of Uncertain Tax Positions Under FIN 48: The organization had no uncertain tax positions under Fin 48 as reported in the financial statements. Part XII, Line 2d - Other Adjustments: Rental loss: 27066. Van rent depreciation: 2926. Part XII, Line 4b - Other Adjustments: Scholarships netted against donations in the financial statements: 19000. Grants: 16400. Misc Exp reclassed: 26335. Part XIII, Line 2d - Other Adjustments: Rental loss: 27066. Van Rental Depreciation : 2926. Part XIII, Line 4b - Other Adjustments: Scholarships: 19000. Grants: 16400. Misc Exp reclassed: 26335. Charity Golf Tournament 22000 13500 8500 1000 6000 700 22000 13500 8500 1000 6000 700 7700 800 1 1 X 1 X 1 X 1 1 0 0 421296 421296 0.01190 8451096 4977993 3473103 0.09780 281355 162089 119266 0.00340 9153747 5140082 4013665 0.11310 3000 50650 34000 16650 0.00050 3 28 25000 15500 9500 0.00030 5385 5385 0.00020 3 3028 81035 49500 31535 0.00100 3 3028 9234782 5189582 4045200 0.11410 155398 155398 0.00440 155398 155398 0.00440 1 1650256 8631573 8787930 -156357 X 1 1 Stonewall Jackson Memorial Hospital

230 Hospital Plaza Weston WV 26452

X X X Part I, Line 3c: We review the patients income, assets, expenses and medical bills to determine the amount of free or discounted care to give to the patient. Part I, Line 7: The cost of charity care was estimated using a cost to charge ratio derived from Worksheet 2 of the Schedule H instructions.The unreimbursed cost of Medicaid was estimated using a cost to charge ratio derived from Worksheet 2 of the Schedule H instructions. Part I, Line 7g: Part I, Line 7f: Part III, Line 4: Patient accounts receivable are carried at the original charge less an estimate made for doubtful or uncollectible accounts. The allowance is based upon a review of the outstanding balances aged by financial class. Management uses collection percentages based upon historical collection experience to determine collectibility. Management also reviews troubled, aged accounts to determine collection potential. Patient accounts receivable are written off when deemed uncollectible. Recoveries of accounts previously written off are recorded as a reduction to bad debt expense when received. Interest is not charged on patient accounts receivable Part III, Line 9b: Our collections policy applies to all patients regardless of financial class or any other classification. During our collections process, if the patient indicates they do not have the ability to pay their bill, the credit staff offers exoneration. Part VI, Line 3: Information about our charity program is posted in the Emergency department and at the Registration windows. We also offer the applications to uninsured inpatients and have the applicatons available in all of our hospital-based physicians' offices. Part VI, Line 4: Stonewall Jackson Memorial Hospital serves a relatively large rural population of about 65,000 people with an average household income of $32,000. 30% of the population is disabled. Approximately 30% are Medicaid Eligible or are uninsured. We are the largest hospital in our service area, which includes two other hospitals, one being a Critical Access Hospital. We are located in a federally-designated medically underserved area. Part VI, Line 5: We recruit physicians to this area based entirely on what services the patients need. For example, our population has a high rate of COPD and other pulmonary diseases. We recruited a Pulmonologist who can address these needs in the community. Also, based on the high population of elderly patients, we have the need for Orthopedists and have recruited two in the past year. We also added an OB-Gyn to our Obstetrics/Gynechology clinic because of the high volume of patients needing care. Part VI, Line 6: Stonewall Jackson Memorial Hospital (SJMH) is a 70 bed rural acute hospital located in Lewis county West Virginia. SJMH is the only hospital located in the county as such it is solely responsible for the healthcare of this rural community. SJMH provides 24 hours Emergency Room and Obstetrics services and provides care regardless of the patients ability to pay. The majority of the governing body is comprised of community members. Medical privileges are offered to all qualified physicians in the community and SJMH has worked diligently to provide other physician services by expanding the services they provide.SJMH continues to make capital improvement to the facility and expand patient care services to meet the needs of the community. 1 Rotary Club of Weston PO Box 222 Weston WV 26452 550371556 501(c) (4) 16400 The purpose of the donation is to promote charitable services. Nursing School Scholarships for recent high school graduates. 19 19000 1 X X X X 0 0 0 0 0 0 0 0 0 J A Snead 237984 0 0 0 0 0 0 0 26302 0 264286 0 0 0 David Shaffer 271374 0 0 0 0 0 13707 0 14453 0 299534 0 0 0 Avah Stalnaker 135182 0 25000 0 0 0 8070 0 6652 0 174904 0 0 0 Peter Edgerton 421485 0 0 0 0 0 21262 0 14453 0 457200 0 0 0 John Wyllie 381455 0 0 0 0 0 19154 0 7693 0 408302 0 0 0 Mario Estolano 285282 0 0 0 0 0 0 0 2148 0 287430 0 0 0 Salvatore Lanasa 326301 0 0 0 0 0 16503 0 14453 0 357257 0 0 0 Jack Marcum 274996 0 0 0 0 0 13938 0 13718 0 302652 0 0 0 Form 990, Part VI, Section A, line 3 Management duties customarily are performed under the direct supervision of officers, directors, trustees or key employees, but the Hospital has contracted their Dietary Management. The owner of the dietary company is considered a department head. She employs only one dietician. The remainder of the dietary department is employed by the Hospital. The Hospital contracts out the management duties of the Maintenance department. The manager of the Maintenance department (also considered a department head) is employed by the Maintenance company. All other Maintenance staff are employees of the Hospital. The Hospital contracts out the management duties of the Pharmacy department. The manager of the Pharmacy department (also considered a department head) is employed by the Pharmacy company. All other Pharmacy staff are employees of the Hospital. Form 990, Part VI, Section B, line 11 The process the Hospital uses to review their 990 before filing with the IRS is the CFO is responsible for reviewing the form 990 for completeness and accuracy. A completed copy is provided for the board. It is then signed and submitted to the IRS. Form 990, Part VI, Section B, line 12c All board members disclose possible conflicts of interest prior to appointment and periodically throughout their terms as trustees. Form 990, Part VI, Section B, line 15 The Hospital obtains salary survey data. Performance Evaluations are done on each of these personnel & financial conditions are considered. Form 990, Part VI, Section C, line 19 The Hospital places a publication in the local newspaper stating the governing documents, conflicts of interest policy and financial statements are available upon request. The policies and procedures are on the Stonewall Jackson website. Part XI Line 2c Committee That Assumes Audit Responsibility The Finance committee shall review audits of the company's financial actions and status, and such audits shall take place at least on an annual basis. This committee shall meet at least monthly. Stonewall Home Oxygen Therapy Inc 100 Market Place Mall Suite 8 Weston WV 26452 550754278 Oxygen Therapy Services WV N/A C 40848 253617 1.00000 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 Stonewall Home Oxygen Therapy Inc A 47083 Stonewall Home Oxygen Therapy Inc P 267879 Stonewall Home Oxygen Therapy Inc Q 19207 In a letter from the Internal Revenue Service dated June 13, 2011, the Service denied a second extension to file the Form 990 for the tax period ending September 30, 2010 because the second extension did not provide a statement explaining why additional time is needed to file the return. We understand that since our gross receipts are in excess of $1,000,000 your office will assess a penalty of $100 per day. We concede that second extension for the Form 990 was filed in error and that a penalty for late filing will be assessed but respectfully request full abatement of such penalty as we have reasonable cause for the error in filing the second extension Form 990. Reasonable cause exists as circumstances beyond our control were responsible as described below. Reasonable cause exists due to a clerical error on the part of our Accounting firm in which the explanation for a second extension was inadvertently omitted. The second extension was needed in order to gather the appropriate information necessary to file a complete and accurate return. The additional data requirements of Schedule H is the primary reason the second extension was requested. Fiscal Year 09/30/2010 is the first year we had to address all of the additional Schedule H reporting criteria. Reasonable cause also exists because we have a proven track record of filing our reports in a timely matter. Our prior Forms 990, payroll reports and other reports filed with the IRS have always been filed on time. Additionally, a penalty assessment would be an undue burden on our operations since we are a small rural hospital which serves a large volume of Medicare, Medicaid and Uncompensated care patients. Any of these reasons standing alone may not constitute reasonable cause, however, all of them together, would in anyones mind constitute reasonable cause especially since the return is being filed by the due date of a properly filed second extension. We understand your office may subject us to a penalty under Section 6652 (c) which imposes a penalty on an organization for failing to file a return required under Section 6033 (a)(1) of the Internal Revenue Code. Section 6652(c)(4) of the Internal Revenue Code provides that no penalty shall be imposed under this subsection with respect to any failure if it is shown that such failure is due to reasonable cause. Reasonable cause is not clearly defined in the Internal Revenue Code or the relevant Treasury Regulations. The Internal Revenue Code provides no guidance at all, and certain regulations applicable to other Sections of the Internal Revenue Code provide only minimal help. One regulation applicable to the failure to properly file certain information returns states that reasonable cause exists if there were significant mitigating factors or the failure arose from events beyond the taxpayers control. The Internal Revenue Service has issued limited guidance on what qualifies as reasonable cause. Various court decisions have also addressed the definition of reasonable cause. Many of the cases involved the taxpayers reliance on a tax expert or third party. In United States vs. Boyle, 55 AFTR 2d 85-1535 (105 S.Ct. 687), the United States Supreme Court established a bright line rule for when reliance on a tax advisor does not constitute reasonable cause. In this estate tax case in which the taxpayer owed significant taxes, the Supreme Court held that a taxpayer cannot avoid the penalties under Section 6651(a)(1) of the Internal Revenue Code by relying on an agent to file the return. Nonetheless, we do not believe this case is applicable to the case at hand. First, and foremost, potential penalties may be imposed under Section 6652(c) of the Internal Revenue Code whereas the Supreme Court case involved Section 6651(a)(1). Secondly, in our case, no taxes are due or will be paid late. In the Supreme Court case, the taxpayer owed and paid late several hundred thousand dollars in taxes. Third, the standard for escaping the tax under Section 6651(a)(1) is a higher standard than that under Section 6652(c). Under Section 6651(a)(1) the taxpayer must prove both that the failure did not result from willful neglect, and (emphasis added) that the failure was due to reasonable cause. Last but not least, we were not relying on the tax expert to file the return but to file an extension. Accordingly, we believe that United States vs. Boyle AFTR 2d 85-1535 (105 S.Ct. 687), is not applicable to the case at hand and that reasonable cause also exists as we relied upon a tax expert to file the extension. In summary, we respectfully request abatement of any potential late filing penalty as we have reasonable cause. Reasonable cause exists as circumstances beyond our control directly contributed to the late filing of the Form 990. It was our intention to file for an extension and hired a third-party tax expert to prepare and file such extension. Reliance on a third-party tax expert, our record of timely filing, and our unique position in providing care to a large volume of Medicare, Medicaid, and Uncompensated care patients in an underserved area combine to provide reasonable cause to abate any potential penalty. We also believe that our fact pattern can be differentiated from the Supreme Court decision in United States vs. Boyle AFTR 2d 85-1535 (105 S.Ct. 687), and that our reliance on a third party is also reasonable cause. The events described above in addition to the following provide additional support that reasonable cause existed and that the penalty should not be imposed:1. A timely extension was filed, but a description explaining why additional time was needed was inadvertently omitted resulting in rejection; otherwise the tax return would have been timely filed; 2. A lay person does not normally know the due date of a Form 990 especially when the accounting period is not a calendar year end;3. No harm was done as no taxes were due or payable;4. We acted in good faith;5. Late filing was not a conscious, intentional failure or reckless indifference, i.e. it was not due to willful neglect;6. We filed the tax return without being requested to by the Internal Revenue Service other than the request with the denial of the extension; and7. Based on our knowledge, we have never paid a penalty in a prior period for filing the Form 990 late.