Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
EPHRAIM MCDOWELL HEALTH INC
Employer identification number
61-1324736
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization?
................
11g(i)
No
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
No
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
No
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of support?
Yes
No
Yes
No
Yes
No
(1)
EPHRAIM MCDOWELL REGIONAL MEDICAL CENTER
610492356
03
Yes
Yes
Yes
0
Total
0
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3..
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public Support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2011.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2010.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2011.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c
Add lines 7a and 7b..
8
Public Support (Subtract line 7c from line 6.)
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
9
Amounts from line 6...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13
Total support (Add lines 9, 10c, 11 and 12.).
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2011 (line 8 column (f) divided by line 13 column (f))
.........
15
16
Public support percentage from 2010 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f))
......
17
18
Investment income percentage from 2010 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2011.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2010.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 4
Part IV
Supplemental Information.
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2011
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
EPHRAIM MCDOWELL HEALTH INC
Employer identification number
61-1324736
Identifier
Return Reference
Explanation
PROCESS TO REVIEW FORM 990
form 990, PART VI, SECTION B, LINE 11
--------------------- COPIES OF THE FORM 990 ARE SUBMITTED TO THE FULL BOARD VIA EMAIL PRIOR TO FILING.
MONITORING THE CONFLICT OF INTEREST POLICY
FORM 990, PART VI, SECTION B, LINE 12B AND 12C
--------------------- All governing board members are required to fill out conflict of interest forms annually.
PROCESS FOR DETERMINING COMPENSATION
FORM 990, PART VI, SECTION B, LINE 15A AND 15B
--------------------- THE MERCER GROUP, INDEPENDENT CONSULTANTS, CONDUCTED A REVIEW IN 2012 FOR ESTABLISHING REASONABLE COMPENSATION OF OFFICERS AND KEY EMPLOYEES. THE ORGANIZATION ALSO UTILIZED COMPENSATION STUDIES. THE COMPENSATION IS APPROVED BY THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS. THE DECISION AND PROCESS IS DOCUMENTED BY THE COMMITTEE.
MAKING FORMS AVAILABLE TO THE PUBLIC
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.
COMMON PAYMASTER
FORM 990, PART V, LINE 2A
--------------------- EPHRAIM MCDOWELL REGIONAL MEDICAL CENTER IS THE COMMON PAYMASTER FOR EPHRAIM MCDOWELL HEALTH, INC. ALL SALARIES AND PAYROLL TAXES ARE REPORTED ON A CONSOLIDATED FORM 941. THE EIN ON THE FORM 941 IS 61-0492356.
PROGRAM SERVICE ACCOMPLISHMENTS
FORM 990, PART III, LINE 4
--------------------- The top community health priorities for Ephraim McDowell Health (EMH) have been based on the 2011 Community Health Assessment conducted by Professional Research Consultants of Omaha, Nebraska. The top three priorities are: 1. Cardiovascular disease and related risk factors 2. Cancer and related risk factors 3. Childhood obesity and related risk factors. Other identified needs were deferred due to resource limitations and the fact that addressing health behaviors and risks associated with the top three would improve overall health and well-being. Targeted populations were the uninsured, underinsured and at-risk groups based on age, gender, ethnicity or socio-economic factors. All screenings were free of charge to the client. A logic chain model was used to plan events with our community partners and to evaluate the effectiveness of each event. Senior Leadership serves in many capacities within the larger community to improve the lives of those we serve. The recorded community benefit cost for the senior leadership team totaled $31,393. Not reported are the many hours spent as a volunteer to establish a community garden in cooperation with The Salvation Army. The produce was used to enhance the diets of Salvation Army and Hope Clinic clients. Also not reported were the hours spent manning the booths at the 2nd Annual Kentucky BBQ Festival, Brass Band Festival or Re-enactment of the Battle of Perryville to increase tourism in Danville/Boyle County this does not reflect the time and efforts in advocacy giving testimony at the local, state and national level to improve access to care or environmental impact and/or economic improvement. Senior leadership participated either as volunteer or leading a community benefit activity at 148 recorded events impacting 620 people at those events. Financial Donations for the Community - In-Kind ----------------------------------------------- Personnel/Administrative Support - included board membership of the YMCA, Heart of Danville, Heart of Kentucky United Way, Midway College Nursing Advisory Board, Chamber of Commerce, Heart of Danville Main Street Program, McDowell House, Kentucky Hospital Association, Kentucky Organization of Nurse Leaders, Premier, and The Salvation Army. Community Building Activities ------------------------------ Senior leadership serves with local and regional Big Brother/Big Sister programs. Services include board membership, fund raising activities, speaking engagement to raise public awareness and support of the potentially life changing services of Big Brother/Big Sister for clients. Senior leaders assisted in the Salvation Army Kettle drive fund raiser for those in need during a time of economic challenge in the region due to increased unemployment and under employment. Coalition Building - included serving on Heart of Danville Board, Chamber of Commerce, Economic Development Council, assisted with the Heart of Danville Lawn Chair Theatre for the community, board member of Kentucky Organization of Nurse Leaders, member of Rotary with committee responsibilities, board member of The Salvation Army, Heart of Kentucky United Way Investment committee member, board member of YMCA and board member of McDowell House. The marketing department also helped with the logistics of the United Way Day of Action, and The Salvation Army Annual Banquet. Senior leaders of the organization also participate in the Annual EMRMC Auxiliary Membership Event and annual volunteer recognition dinner. Community Health Improvement Advocacy - Senior leaders gave testimony at the City Commissioners meeting, served on the KHA legislative committee, conducted forums with Congressional members related to healthcare issues in rural south central Kentucky. Under other activities senior leaders assisted The Salvation Army in raising a community garden in 2012. The produce was given away to recipients of services at the Salvation Army and Hope Clinic clients. The time spent in the various community benefit activities by senior leaders is valued at $31,393. Leadership Development/Training for Community Members - mentoring by the senior leaders included resume building, interview practice, and individual coaching sessions for young professionals Community Benefit Operation --------------------------- Senior leadership reviews and approves both the community health assessment and the work plan to address the priority health risks for the population served and presents to the board for approval. They also allocate resources, both financially and personnel to address the work plan. Annually there is a budget approved by senior leadership and presented for board approval for community benefit. The senior leadership receives an annual update related the work plan objectives and outcomes. The 2011 health risk assessment showed improvement trends related to cardiovascular risk in Boyle County from the 2008 assessment. The focused community benefit efforts began in Boyle County in FY 2008.
RECONCILIATION OF NET ASSETS
FORM 990, PART XI, LINE 5
--------------------- OTHER CHANGES IN NET ASSETS: UNREALIZED LOSS ON INVESTMENTS ($1,918,466) ROUNDING ($5) ------------- ($1,918,471)
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:DENA DEMAREE TITLE:BOARD MEMBER HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:JOHN CUNY TITLE:BOARD MEMBER HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:JUDY HAMMONS TITLE:BOARD MEMBER HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:DAVID HOPPER MD TITLE:BOARD MEMBER HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:JAMES JACOBUS TITLE:VICE CHAIR HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:MARK MORGAN TITLE:BOARD MEMBER HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:KIM RAGLAND PH D TITLE:BOARD MEMBER HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:SHEREE GILLIAM TITLE:BOARD MEMBER HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:WILLIAM RUTH III TITLE:CHAIR HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:REV. QUENTIN SCHOLTZ III TITLE:BOARD MEMBER HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:ERIC GUERRANT MD TITLE:BOARD MEMBER HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:DALE KIHLMAN TITLE:SECRETARY HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:DONALD HAMNER MD TITLE:BOARD MEMBER HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:GARY AHNQUIST MD TITLE:BOARD MEMBER HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:RODNEY BATES MD TITLE:BOARD MEMBER HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:BOB ROWLAND TITLE:TREASURER HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:WILLIAM SNAPP III TITLE:VP & CFO HOURS:39
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:VICKI DARNELL TITLE:CEO HOURS:39
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.