2011-02-15T11:53:25-06:00 2010-06-30 Arnett & Foster PLLC P O Box 2629 Charleston WV 25329 990 2009-07-01 556000526 Grafton City Hospital GRAF 3042656401 500 Market Street Grafton WV 26354 Jeff Lilley 3042656401 2011-02-11 1 Steven S Robey 3043460441 2009 2016-02-24 21:20:13Z Jeff Lilley 500 Market Street Grafton WV 26354 17437293 0 X www.graftonhospital.com X 1972 WV To provide inpatient hospital care, outpatient services, emergency room services and long-term care to the residents of Taylor County, WV and surrounding communities. 10 10 448 0 0 0 17017 44895 16764064 17255915 1468 6783 111082 129700 16893631 17437293 0 0 11090116 11597682 0 0 5554845 5776298 16644961 17373980 248670 63313 7033378 7108950 5717559 5729818 1315819 1379132 To provide inpatient hospital care, outpatient services, emergency room services and long-term care to the residents of Taylor County, WV and surrounding communities. 0 0 10577207 17255915 The Hospital provided health care services including 1,619 acute hospital days; 23,431 long-term care days; 2,621 swing-bed days; 290 observation patient days; 17,367 rural health clinic visits; 17,367 rural health visits;276 surgeries. Additionally, the Hospital provided charity care without charge or at less than its established rates to patients who meet certain criteria under its charity care policy. Charges foregone for charity care during the year amounted to $1,571,861. 10577207 1 0 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 4 0 1 448 1 0 0 0 0 0 1 1 0 10 10 0 0 0 0 0 0 0 1 1 0 0 1 1 0 1 1 1 1 1 0 X Brian Kelbaugh 3042656401 500 Market Street Grafton WV 26354 John Whitescarver 1.00 X 0 0 0 John L Bord 1.00 X 0 0 0 Joan E Hawkins 1.00 X 0 0 0 Paul Shroyer 1.00 X 0 0 0 Samuel M Santibanez M 1.00 X 0 0 0 Ronald L Cole 1.00 X 0 0 0 Nancy Virginia Fowler 1.00 X 0 0 0 Jeff May 1.00 X 0 0 0 Kenny Peters 1.00 X 0 0 0 Wanda Taylor 1.00 X 0 0 0 Jeff Lilley 45.00 X 134912 0 6107 Brian Kelbaugh 40.00 X 90488 0 4996 Joseph Duvert 40.00 X 265016 0 6625 David Bender 40.00 X 213550 0 5339 Chris Villaraza 40.00 X 187981 0 4700 James Woodford 40.00 X 190481 0 4762 Thomas Wilshire 40.00 X 244120 0 6103 1326548 0 38632 10 0 1 0 Insight Health PO Box 847689 Dallas TX 75284 Mobile MRI 200000 Mid-state Mechanical PO Box 607 Bridgeport WV 26330 Repair O2 & Suction Lines 139461 Therapy Services 1085 VanVoorhis Rd Morgantown WV 26505 ST & OT 125700 3 44895 44895 Net patient services 622110 17255915 17255915 17255915 6783 6783 Cafeteria 722212 77606 77606 Other income 900099 52094 52094 129700 17437293 17385615 0 6783 236504 141902 94602 9332480 5599488 3732992 231022 138613 92409 930508 558305 372203 867168 520301 346867 20940 20940 27627 27627 777725 466635 311090 2424956 1454974 969982 380760 228456 152304 20081 12049 8032 130566 78340 52226 493123 295874 197249 464770 278862 185908 Medicaid provider tax 422931 422931 Maintenance & Repairs 416232 249739 166493 Dues & subscriptions 42991 25795 17196 Physician recruitment 31966 31966 Professional developmen 25237 15142 10095 96393 57835 38558 17373980 10577207 6796773 0 177775 163444 19869 145549 2614438 2587745 267464 245239 100833 208476 14990646 11816291 3502253 3174355 51700 350746 532442 7033378 7108950 3057335 3245560 1124486 1060764 492032 469422 1043706 954072 5717559 5729818 X 1315819 1379132 1315819 1379132 7033378 7108950 X 0 1 1 X 0 X 0 0 0 0 0 0 0 0 1 2269 2269 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: Part II-B, Line(i), Other Lobbying Activities: Grafton City Hospital pays dues to the West Virginia Hospital Association. The West Virginia Hospital Association represents hospitals and health systems. For the year ended 06/30/10, the amount of dues related to lobbying activities was $2,269. 26597 26597 274995 7179796 5681093 1773698 7509258 6135198 1374060 3174355 Estimated third-party payor settlements 502710 Other receivables 29732 532442 Capital leases 455007 Accrued pension 499065 954072 17437293 17373980 63313 0 63313 17437293 0 17437293 0 17437293 17373980 0 17373980 0 17373980 Part X: Description of Uncertain Tax Positions Under FIN 48: There was not a FIN 48 disclose included on the audited financial statements. 1 1 1 X 1 X 1 1 1 0 0 1 885 1653384 1294837 358547 0.02340 1 885 1653384 1294837 358547 0.02340 6 51564 35370 16194 0.00110 6 51564 35370 16194 0.00110 7 885 1704948 1330207 374741 0.02450 1 1630424 4576923 4613754 -36831 X 1 0 Grafton City Hospital Inc

500 Market Street Grafton WV 25354

X X X X 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. Part III, Line 4: Patient Accounts Receivable: Patient accounts receivable are carried at the original charge less an estimate made for doubtful or uncollectable 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 reduction to bad debt expense when received. Interest is not charged on patient accounts receivable. Part VI, Line 2: To assess the health care needs of the population base of Grafton City Hospital, the facility is heavily involved with the areas community forums. Through this venue the hospital takes the inquiries that are voiced and applies an economic forecast to the program to verify its stability. The facility also uses the Bureau for Public Health, for risk factors that would have an impact on the lives of the population that Grafton City Hospital serves. Part VI, Line 3: The patient population is educated and informed of the financial assistance programs through the financial counselors and admission personnel. The hospital also has this information published in the public areas within the hospital. Part VI, Line 4: The main population the facility serves is Taylor County. Grafton City Hospital is the only hospital within its county. Taylor County has a population of 16,328, with a estimated median household income of $34,192 as compared to WV estimated median household income of $37,435. Taylor County cost of living index is at 81.0 as compared to the United States average of 100.0. Part VI, Line 5: The organization's health care facilities further its exempt purpose in the following ways: The organization's governing body is comprised of persons who reside in the organization's primary service area and are neither employees or contractors of the organization, nor family members thereof. The organization extends medical staff privileges to all qualified providers in its community for some or all of its departments. The organization operates an emergency room available to all, regardless of ability to pay. Specialized services offered by the organization that are not available elsewhere include pulmonology, critical care medicine, general surgery, internal medicine, obstetrics and gynecology, and family medicine. The organization serves as a vehicle for attracting charitable support, as well as a source of community volunteer activities. Part VI, Line 6: The organization's health care facilities further its exempt purpose in the following ways: The organization's governing body is comprised of persons who reside in the organization's primary service area and are neither employees or contractors of the organization, nor family members thereof. The organization extends medical staff privileges to all qualified providers in its community for some or all of its departments. The organization operates an emergency room available to all, regardless of ability to pay. Specialized services offered by the organization that are not available elsewhere include pulmonology, critical care medicine, general surgery, internal medicine, obstetrics and gynecology, and family medicine. The organization serves as a vehicle for attracting charitable support, as well as a source of community volunteer activities. X X X 0 0 0 0 0 0 0 0 0 Joseph Duvert 265016 0 0 0 0 0 6625 0 0 0 271641 0 0 0 David Bender 213550 0 0 0 0 0 5339 0 0 0 218889 0 0 0 Chris Villaraza 187981 0 0 0 0 0 4700 0 0 0 192681 0 0 0 James Woodford 190481 0 0 0 0 0 4762 0 0 0 195243 0 0 0 Thomas Wilshire 244120 0 0 0 0 0 6103 0 0 0 250223 0 0 0 Form 990, Part VI, Section B, line 11 The form 990 will be reviewed by the CEO and CFO before it is filed. A copy of the final form 990 will be provided to the board of directors prior to filing. Form 990, Part VI, Section B, line 12c Trustees are made aware of the conflict of interest policy. Should a Trustee feel there is a subject in which they have a conflict, they recuse themself from the discussion and any possible action. Form 990, Part VI, Section B, line 15 A compensation committeee determines the compensation of the CEO and other officers by comparing salaries with other hospitals located in West Virginia Critical Access Hospital Network with board approval. Form 990, Part VI, Section C, line 18 The organization makes its governing documents, conflict of interest policy and financial statements available to the public upon request. Form 990, Part VI, Section C, line 19 The organization makes its governing documents, conflict of interest policy and financial statements available to the public upon request. Form 990, Part XI, Line 2c explanation Audit Oversight Committee The board of directors has a separate audit oversight committee, which has not changed since last year.