TY 2011 Form 990

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.	(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses
1	Grants and other assistance to governments and organizations in the United States. See Part IV, line 21	0
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	0
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	117,075	106,538	10,537
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages	2,895,889	2,749,171	146,718
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	204,275	193,840	10,435
9	Other employee benefits .......	558,251	529,114	29,137
10	Payroll taxes ...........	221,899	210,406	11,493
11	Fees for services (non-employees):
a	Management ......	100,980		100,980
b	Legal .........	34,582		34,582
c	Accounting ...........	27,000		27,000
d	Lobbying ...........	2,121		2,121
e	Professional fundraising. See Part IV, line 17..	0
f	Investment management fees ......	0
g	Other ..........	1,453,384	1,444,898	8,486
12	Advertising and promotion ....	1,254		1,254
13	Office expenses .......	238,779	203,635	35,144
14	Information technology ......	13,394	13,394
15	Royalties ..	0
16	Occupancy ...........	525,818	415,711	110,107
17	Travel ............	6,784	75	6,709
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	0
20	Interest ...........	3,677		3,677
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	31,042	30,646	396
23	Insurance ..............	40,303		40,303
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24f. If line 24f amount exceeds 10% of line 25, column (A) amount, list line 24f expenses on Schedule O.)
a	MEDICAL SUPPLIES	994,927	994,927
b	BAD DEBT EXPENSE	159,053	159,053
c	OTHER TAXES AND LICENSES	217,197	217,084	113
d	DUES	14,040		14,040
e
f	All other expenses	8,904	2,466	6,438
25	Total functional expenses. Add lines 1 through 24f	7,870,628	7,270,958	599,670	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet
	1	Cashnon-interest-bearing ..........	1,142,453	1	1,325,626
2	Savings and temporary cash investments .......	0	2	256,119
3	Pledges and grants receivable, net .........	0	3	0
4	Accounts receivable, net .........	1,660,800	4	1,824,006
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........	0	5	0
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........	0	6	0
7	Notes and loans receivable, net .............	0	7	0
8	Inventories for sale or use ..............	65,451	8	56,512
9	Prepaid expenses and deferred charges ............	55,084	9	41,896
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	542,905
b	Less: accumulated depreciation. .....	10b	440,596	124,782	10c	102,309
11	Investments—publicly traded securities ..........	0	11	0
12	Investments—other securities. See Part IV, line 11 ......	0	12	0
13	Investments—program-related. See Part IV, line 11 ..	0	13	0
14	Intangible assets .........	0	14	0
15	Other assets. See Part IV, line 11 ...........	140,132	15	103,974
16	Total assets. Add lines 1 through 15 (must equal line 34)...	3,188,702	16	3,710,442
	17	Accounts payable and accrued expenses .	794,666	17	923,955
18	Grants payable ..........	0	18	0
19	Deferred revenue ..........	0	19	0
20	Tax-exempt bond liabilities ..........	0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..	0	21	0
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........	0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..	0	23	0
24	Unsecured notes and loans payable to unrelated third parties ....	0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.....	971,258	25	693,079
26	Total liabilities. Add lines 17 through 25.....	1,765,924	26	1,617,034
		Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....	1,422,778	27	2,093,408
28	Temporarily restricted net assets .....	0	28	0
29	Permanently restricted net assets .....	0	29	0
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances .....	1,422,778	33	2,093,408
34	Total liabilities and net assets/fund balances .....	3,188,702	34	3,710,442

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

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. right arrow

See separate instructions.

OMB No. 1545-0047

2011

Open to Public
Inspection

Name of the organization

COMMONWEALTH REGIONAL SPECIALTY HOSPITAL INC

Employer identification number

54-2142034

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.)

A church, convention of churches, or association of churches. section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in

section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in

section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross

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.)

An organization organized and operated exclusively to test for public safety. Seesection 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.

Type I

Type II

Type III - Functionally integrated

Type III - Other

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).

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 ..................................................

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

and (iii) below, the governing body of the the supported organization? ................

11g(i)

(ii) a family member of a person described in (i) above? ......................

11g(ii)

(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................

11g(iii)

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(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?
(i) Name of supported organization	(ii) EIN	Yes	No	Yes	No	Yes	No	(vii) Amount of support?


Total

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 11285F

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).

Gross receipts from related activities, etc. (See instructions.) ..................

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.......................................... right arrow

Section C. Computation of Public Support Percentage

Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f)) .........

Public Support Percentage for 2009 Schedule A, Part II, line 14 ...............

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 ...................... right arrow

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 ..................... right arrow

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 .................................................. right arrow

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 .............................................. right arrow

Private Foundation If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions ................................................... right arrow

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.).

Section C. Computation of Public Support Percentage

Public Support Percentage for 2011 (line 8 column (f) divided by line 13 column (f)) .........

Public support percentage from 2010 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f)) ......

Investment income percentage from 2010 Schedule A, Part III, line 17 .............

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 .......... right arrow

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 .... right arrow

Private Foundation If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions ..... right arrow

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 C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet

Complete if the organization is described below.
SchCMd Bullet

Attach to Form 990 or Form 990-EZ. SchCMd Bullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public
Inspection

If the organization answered “Yes” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet

Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet

Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet

Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)) Complete Part II-A. Do not complete Part II-B.
Round Bullet

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, line 35c (Proxy Tax), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

COMMONWEALTH REGIONAL SPECIALTY HOSPITAL INC

Employer identification number

54-2142034

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV.

Political expenditures .................................... SchCMd Bullet

Volunteer hours ........................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ......... SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ...... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............

Yes No

Was a correction made? .........................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c) except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ................................... SchCMd Bullet

Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b.. SchCMd Bullet

Did the filing organization file Form 1120-POL for this year? ..........................

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.

For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2011

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(b) Affiliated group totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......
b	Total lobbying expenditures to influence a legislative body (direct lobbying) .......
c	Total lobbying expenditures (add lines 1a and 1b) ...................
d	Other exempt purpose expenditures ........................
e	Total exempt purpose expenditures (add lines 1c and 1d) ...............
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) .................
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ................
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ................
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ......................................	Yes No

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) Total

2a	Lobbying non-taxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots nontaxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2011

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

Volunteers? .........................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....

Media advertisements? ....................................

Mailings to members, legislators, or the public? .........................

Publications, or published or broadcast statements? .......................

Grants to other organizations for lobbying purposes? .......................

Direct contact with legislators, their staffs, government officials, or a legislative body? ........

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......

Other activities? ..........................

Yes

2,121

Total. Add lines 1c through 1i ...............................

2,121

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 .................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ................

Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2 are answered “No” OR (b) Part III-A, line 3 is answered “Yes”.

Dues, assessments and similar amounts from members .....................

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).

Current year .........................................

Carryover from last year ....................................

Total ...........................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................

Taxable amount of lobbying and political expenditures (see instructions) ..............

Part IV

Supplemental Information

Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, Part II-A; line 5; and Part ll-B, line 1.
Also, complete this part for any additional information.

Identifier	Return Reference	Explanation
LOBBYING ACTIVITIES	SCHEDUE C, PART II(B)(I)	------------------------- THE CORPORATION IS A MEMBER OF THE KENTUCKY HOSPITAL ASSOCIATION AND THE NATIONAL ASSOCIATION OF LONG TERM HOSPITALS. OF THE DUES PAID TO THE KENTUCKY HOSPITAL ASSOCIATION, $945 WAS ALLOCATED TO LOBBYING ACTIVITIES. OF THE DUES PAID TO THE NATIONAL ASSOCIATION OF LONG TERM HOSPITALS, $1,176 WAS ALLOCATED TO LOBBYING ACTIVITIES. COSTS ATTRIBUTABLE TO LOBBYING TOTAL $2,121.

Schedule C (Form 990 or 990EZ) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

COMMONWEALTH REGIONAL SPECIALTY HOSPITAL INC

Employer identification number

54-2142034

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .......
2	Aggregate contributions to (during year) ...
3	Aggregate grants from (during year) ...
4	Aggregate value at end of year .......

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements .......................	2a
b	Total acreage restricted by conservation easements ..................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register ....................	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................

Yes No

Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................

Yes No

In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.

If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:

(i)

Revenues included in Form 990, Part VIII, line 1 ........................ SchDMd Bullet

(ii)

Assets included in Form 990, Part X .............................. SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958), relating to these items:

Revenues included in Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990

Cat. No. 52283D

Schedule D (Form 990) 2011

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.

During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No

If "Yes," explain the arrangement in Part XIV and complete the following table:


c	Beginning balance .................................	1c
d	Additions during the year ..............................	1d
e	Distributions during the year .............................	1e
f	Ending balance ...................................	1f

Did the organization include an amount on Form 990, Part X, line 21? .....................

Yes No

If “Yes,” explain the arrangement in Part XIV.

Part V

Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.

		(a)Current Year	(b)Prior Year	(c)Two Years Back	(d)Three Years Back	(e)Four Years Back
1a	Beginning of year balance ....
b	Contributions ........
c	Net investment earnings, gains, and losses ...
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........
f	Administrative expenses ....
g	End of year balance ......

Provide the estimated percentage of the year end balance (line 1g) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

The percentages in lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) unrelated organizations ........................

3a(i)

(ii) related organizations ........................

3a(ii)

If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIV the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment. See Form 990, Part X, line 10.

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................
b	Buildings ................
c	Leasehold improvements ............
d	Equipment ................	540,055	438,363	101,692
e	Other .................	2,850	2,233	617
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				102,309

Schedule D (Form 990) 2011

Page 3

Part VII

InvestmentsOther Securities. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)		(b)Book value	(c) Method of valuation: Cost or end-of-year market value
(1)Financial derivatives
(2)Closely-held equity interests
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

InvestmentsProgram Related. See Form 990, Part X, line 13.

(a) Description of investment type		(b) Book value	(c) Method of valuation: Cost or end-of-year market value









Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. See Form 990, Part X, line 15.

(a) Description				(b) Book value









Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities. See Form 990, Part X, line 25.

1.(a) Description of Liability		(b) Book value
Federal Income Taxes		0
PAYABLE TO AFFILIATE		227,989
ESTIMATED THIRD PARTY SETTLEMENT		361,164
ESTIMATED MALPRACTICE LIABILITY		103,926






Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		693,079
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).

Schedule D (Form 990) 2011

Page 4

Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1	Total revenue (Form 990, Part VIII, column (A), line 12) ....................	1	8,143,628
2	Total expenses (Form 990, Part IX, column (A), line 25) .....................	2	7,870,628
3	Excess or (deficit) for the year. Subtract line 2 from line 1 .............	3	273,000
4	Net unrealized gains (losses) on investments ..........................	4	6,639
5	Donated services and use of facilities .............................	5
6	Investment expenses ...................................	6
7	Prior period adjustments ..................................	7
8	Other (Describe in Part XIV.) .................................	8	390,991
9	Total adjustments (net). Add lines 4 through 8 .........................	9	397,630
10	Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 .........	10	670,630

Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1	Total revenue, gains, and other support per audited financial statements .......			1	8,150,267
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains on investments ..........	2a	6,639
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIV.) ............	2d
e	Add lines 2a through 2d .....................			2e	6,639
3	Subtract line 2e from line 1.....................			3	8,143,628
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part XIV.) ...........	4b
c	Add lines 4a and 4b.......................			4c
5	Total Revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......			5	8,143,628

Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1	Total expenses and losses per audited financial statements .............		1	7,870,628
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities ..........	2a
b	Prior year adjustments ..............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIV.) ............	2d
e	Add lines 2a through 2d......................		2e
3	Subtract line 2e from line 1.....................		3	7,870,628
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a
b	Other (Describe in Part XIV.) ............	4b
c	Add lines 4a and 4b.......................		4c
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......		5	7,870,628

Part XIV

Supplemental Information

Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.

Identifier	Return Reference	Explanation
INCOME TAX STATUS	SCHEDULE D, PART X, LINE 2	------------------------- THE HOSPITAL IS EXEMPT FROM FEDERAL INCOME TAXES AND RELATED INCOME PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE (IRC) AS AN ORGANIZATION DESCRIBED IN SECTION 501(C)(3) OF THE IRC. THE HOSPITAL FILES FEDERAL INCOME TAX RETURNS AS WELL AS AN INCOME TAX RETURN IN KENTUCKY. THE HOSPITAL IS NO LONGER SUBJECT TO U.S. FEDERAL INCOME TAX EXAMINATIONS BY TAX AUTHORITIES FOR YEARS BEFORE 2009. FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ACCOUNTING STANDARDS CODIFICATION TOPIC 740 CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN A COMPANY'S FINANCIAL STATEMENTS AND PRESCRIBES A RECOGNITION THRESHOLD AND MEASUREMENT ATTRIBUTE FOR THE FINANCIAL STATEMENT RECOGNITION AND MEASUREMENT OF A TAX POSITION TAKEN, OR EXPECTED TO BE TAKEN IN A TAX RETURN. TOPIC 740 ALSO PROVIDES GUIDANCE ON DESCRIPTION, CLASSIFICATION, INTEREST AND PENALTIES, ACCOUNTING IN INTERIM PERIODS, DISCLOSURE AND TRANSITION. THE HOSPITAL DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS RECOGNIZED FOR 2012 OR 2011. THE HOSPITAL'S PRACTICE IS TO RECOGNIZE INTEREST AND/OR PENALTIES RELATED TO INCOME TAX MATTERS IN INCOME TAX EXPENSE.
OTHER CHANGE IN NET ASSETS	SCHEDULE D, PART XI, LINE 8	------------------------- OTHER CHANGES IN NET ASSETS: EQUITY TRANSFER FROM COMMONWEALTH HEALTH CORPORATION, INC., A RELATED 501(C)(3) ORGANIZATION $390,991

Schedule D (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H (Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

COMMONWEALTH REGIONAL SPECIALTY HOSPITAL INC

Employer identification number

54-2142034

Part I

Charity Care and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a....

Yes

If "Yes," was it a written policy? .......................

Yes

If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.

Did the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care?

If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:

Yes

100% 150% 200% Other

Did the organization use FPG to determine eligibility for providing discounted care? If "Yes," indicate which of the

following was the family income limit for eligibility for discounted care: ............

200% 250% 300% 350% 400% Other

If the organization did not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.

Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

Yes

Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount?......

Yes

If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care?...............

Did the organization prepare a community benefit report during the tax year?...........

Yes

If "Yes," did the organization make it available to the public? ...............

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Financial Assistance and Certain Other Community Benefits at Cost

	(c) Total community benefit expense	(e) Net community benefit expense	(f) Percent of total expense
a Financial Assistance at cost (from Worksheet 1) ..	234,167	234,167	3.040 %
b Medicaid (from Worksheet 3, column a) .....
c Costs of other means-tested government programs (from Worksheet 3, column b) .
dTotal Financial Assistance and Means-Tested Government Programs .....	234,167	234,167	3.040 %
Other Benefits e Community health improvement services and community benefit operations (from (Worksheet 4) ....	70,854	70,854	0.920 %
f Health professions education (from Worksheet 5) ..
g Subsidized health services (from Worksheet 6) ..
h Research (from Worksheet 7)
i Cash and in-kind contributions for community benefit (from Worksheet 8) ....
jTotal Other Benefits ...	70,854	70,854	0.920 %
kTotal. Add lines 7d and 7j. ..	305,021	305,021	3.960 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2011

Schedule H (Form 990) 2011

Page

Part II

Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support
4	Environmental improvements
5	Leadership development and training for community members	1	1	13,124	13,124	0.170 %
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other
10	Total	1	1	13,124	13,124	0.170 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................

Yes

Enter the amount of the organization's bad debt expense........

159,053

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy .....

Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense. In addition, describe the costing methodology used in determining the amounts reported on lines 2 and 3, and rationale for including a portion of bad debt amounts as community benefit.

Section B. Medicare

Enter total revenue received from Medicare (including DSH and IME).....

5,035,529

Enter Medicare allowable costs of care relating to payments on line 5.....

6,767,295

Subtract line 6 from line 5. This is the surplus or (shortfall)........

-1,731,766

Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Did the organization have a written debt collection policy during the tax year? ..........

Yes

If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

Yes

Part IV

Management Companies and Joint Ventures

(see instructions)

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership%	(e) Physicians' profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2011

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest) How many hospital facilities did the organization operate during the tax year?1 Name and address		Other (Describe)
1	COMMONWEALTH REGIONAL SPECIALTY HOSPITAL 800 PARK STREET BOWLING GREEN,KY42101	X

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)

COMMONWEALTH REGIONAL SPECIALTY HOSPITAL

Name of Hospital Facility:

Line Number of Hospital Facility (from Schedule H, Part V, Section A):1

				Yes	No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2011)
1	During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. .....................		1
	If “Yes,” indicate what the Needs Assessment describes (check all that apply):
	a	A definition of the community served by the hospital facility
	b	Demographics of the community
	c	Existing health care facilities and resources within the community that are available to respond to the health needs of the community
	d	How data was obtained
	e	The health needs of the community
	f	Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
	g	The process for identifying and prioritizing community health needs and services to meet the community health needs
	h	The process for consulting with persons representing the community’s interests
	i	Information gaps that limit the hospital facility’s ability to assess the community’s health needs
	j	Other (describe in Part VI)
2	Indicate the tax year the hospital facility last conducted a Needs Assessment: 20
3	In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted.		3
4	Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................		4
5	Did the hospital facility make its Needs Assessment widely available to the public? ...........		5
	If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
	a	Hospital facility’s website
	b	Available upon request from the hospital facility
	c	Other (describe in Part VI)
6	If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
	a	Adoption of an implementation strategy to address the health needs of the hospital facility’s community
	b	Execution of the implementation strategy
	c	Participation in the development of a community-wide community benefit plan
	d	Participation in the execution of a community-wide community benefit plan
	e	Inclusion of a community benefit section in operational plans
	f	Adoption of a budget for provision of services that address the needs identified in the Needs Assessment
	g	Prioritization of health needs in the community
	h	Prioritization of services that the hospital facility will undertake to meet health needs in its community
	i	Other (describe in Part VI)
7	Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs. ....		7
Financial Assistance Policy
	Did the hospital facility have in place during the tax year a written financial assistance policy that:
8	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?		8	Yes
9	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........		9	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 200.% If "No," explain in Part VI the criteria the hospital facility used.

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

				Yes	No
10	Used FPG to determine eligibility for providing discounted care?.................		10		No
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: % If "No," explain in Part VI the criteria the hospital facility used.
11	Explained the basis for calculating amounts charged to patients?.................		11	Yes
	If “Yes,” indicate the factors used in determining such amounts (check all that apply):
	a	Income level
	b	Asset level
	c	Medical indigency
	d	Insurance status
	e	Uninsured discount
	f	Medicaid/Medicare
	g	State regulation
	h	Other (describe in Part VI)
12	Explained the method for applying for financial assistance?...................		12	Yes
13	Included measures to publicize the policy within the community served by the hospital facility?.......		13	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
	a	The policy was posted on the hospital facility’s web site
	b	The policy was attached to all billing invoices
	c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
	d	The policy was posted in the hospital facility’s admissions offices
	e	The policy was provided, in writing, to patients upon admission to the hospital facility
	f	The policy was available upon request
	g	Other (describe in Part VI)
Billing and Collections
14	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?.......		14	Yes
15	Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
16	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........		16		No
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
17	Indicate which efforts the hospital facility made before initiating any of the actions checked in line 16 (check all that apply):
	a	Notified patients of the financial assistance policy upon admission
	b	Notified patients of the financial assistance policy prior to discharge
	c	Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
	d	Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy
	e	Other (describe in Part VI)

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
				Yes	No
18	Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?..........		18	Yes
	If “No,” indicate why:
	a	The hospital facility did not provide care for any emergency medical conditions
	b	The hospital facility’s policy was not in writing
	c	The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
	d	Other (describe in Part VI)
Individuals Eligible for Financial Assistance
19	Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
	a	The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
	b	The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
	c	The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
	d	Other (describe in Part VI)
20	Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?.........		20		No
	If “Yes,” explain in Part VI.
21	Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?...............................		21		No
	If “Yes,” explain in Part VI.

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?
Name and address		Type of Facility (describe)
1
2
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2011

Page

Part VI

Supplemental Information

Complete this part to provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 9, 10, 11h, 13g, 15e, 16e, 17e, 18d, 19d, 20, and 21.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.

Identifier	ReturnReference	Explanation
CRITERIA FOR DETERMINING ELIGIBILITY FOR FREE OR DISCOUNTED CARE	SCH H, PART I, LINE 3C	--------------- The income limit for charity care is 200% of the Federal Poverty Level. Discounts are provided to all patients who are uninsured whose income exceeds the limits to qualify for Charity Care. Self-pay discounts are not limited based on income. The hospital also provides payment plans for self-pay patients.
COMMUNITY BENEFIT REPORT	SCH H, PART I, LINE 6	--------------- The annual report to the community is made available to the public via newspaper inserts, direct mailings, and is posted on the Commonwealth Health Corporation's website at www.chc.net.
BENEFITS AT COST	SCH H, PART I, LINE 7	--------------- Bad Debts Included in Part IX, Line 25 totaled $159,053. This amount has been removed from total expenses calculated in Column F on Schedule H, Part I and II. COST OF CHARITY CARE WAS CALCULATED WITH A COST TO CHARGE RATIO USING WORKSHEET 2. THE COSTS RELATED TO MEDICAID PATIENTS WAS DETERMINED USING THE HOSPITAL COST ACCOUNTING SYSTEM.
BAD DEBT EXPENSE	SCH H, PART III, LINE 4	--------------- The organization's audited financial statements do not contain a footnote that describes bad debt expense. Bad Debt is classified as an operating expense. This treatment is consistent with the HFMA principles and practice board statement no. 15 and with the AICPA audit and accounting guide for health care organizations.
CALCULATION OF MEDICARE ALLOWABLE COSTS	SCH H, PART III, LINE 8	--------------- Costs reported on Line 6 are obtained from the Medicare Cost Report which are based on a cost to charge ratio.
COLLECTION PRACTICES	SCH H, PART III, LINE 9B	--------------- Commonwealth Regional Specialty Hospital ("CRSH") provides care to patients who meet certain criteria under their care policy without charge or at amounts less than their established rates. Because CRSH does not pursue collection of amounts determined to qualify as charity care, revenue is not recorded for such services. CRSH maintains records to identify and monitor the level of charity care they provide. These records include the amount of charges forgone for services and supplies furnished under their charity care policy. Other uncompensated care relates principally to contractual allowances for government payers, discounts taken by commercial payers and bad debts. Benefits for the poor include services provided to persons who cannot afford health care because of inadequate resources or who are uninsured. This includes traditional charity care at standard billing rates and the costs of treating Medicaid beneficiaries in excess of government payments. CRSH does not pursue the collection of amounts determined to be traditional charity care. Therefore, these amounts are not included in net patient service revenue.
NEEDS ASSESSMENT	SCH H, PART VI, QUESTION 2	--------------- Commonwealth Regional Specialty Hospital ("CRSH") is built upon the foundation of serving our community, day in and day out, with quality dependable healthcare. CRSH has not historically completed formal health needs assessments; however, as needs arise in the community and surrounding counties, CRSH responds. CRSH is part of an integrated healthcare Delivery system as described in Question 6 below.
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE	SCH H, PART VI, QUESTION 3	--------------- Upon registration, patients are provided a Patient Handbook which contains information regarding Financial Assistance. Additionally, signage and brochures describing Financial Assistance policies are available at admissions areas. Each patient will receive a statement referred to as a First Notice. The First Notice states that it is not a bill, but it is summary of the patient's charges. This notice and each subsequent statement contains information concerning financial assistance as well as contact information for questions.
COMMUNITY INFORMATION	SCH H, PART VI, QUESTION 4	--------------- Commonwealth Regional Specialty Hospital (CRSH) is designated by Medicare as a Long Term Acute Care Hospital (LTACH). CRSH is located in Bowling Green, Kentucky. CRSH serves patients throughout an area comprising ten counties, called the Barren River Area Development District (The District), in south central Kentucky. The population of CRSH's primary service area is approximately 286,000 people. The community is growing and we also serve a growing uninsured and underinsured population. There are two acute care hospitals in the community. The percentage of uninsured persons in the counties served by CRSH ranges from 18% to 24%, which is higher than the Kentucky average. THE NUMBER OF RESIDENTS IN THE DISTRICT IN HOUSEHOLDS BELOW THE FEDERAL POVERTY GUIDELINES VARY BY COUNTY AND RANGEs FROM 18.5% TO 27.1% COMPARED TO THE KENTUCKY POVERTY RATE OF 17.7%. THE THREE HIGHEST POPULATED COUNTIES IN THE DISTRICT ARE WARREN, BARREN AND ALLEN WHOSE AVERAGE MEDIAN HOUSEHOLD INCOME IS $43,954, $38,374 AND $35,247 RESPECTIVELY. APPROXIMATELY 64% OF THE DISTRICT'S POPULATION IS CLASSIFIED AS RURAL. THE PERCENTAGE OF THE POPULATION IN THE COMMUNITY OVER 65 YEARS OLD IS APPROXIMATELY 15%. ACCORDING TO THE EVERYBODY SURVEY CONDUCTED BY THE BARREN RIVER DISTRICT HEALTH DEPARTMENT, THE MOST SERIOUS HEALTH PROBLEMS IN THE COMMUNITY ARE OBESITY, ALCOHOL AND DRUG ADDITION, HEART ATTACK, STROKE, HIGH BLOOD PRESSURE, CANCER AND DIABETES. THIS SURVEY ALSO IDENTIFIED PROBLEM HEALTH BEHAVIORS FOR THE DISTRICT WHICH INCLUDE ALCOHOL AND DRUG ABUSE, NOT ENOUGH PHYSICAL ACTIVITY, TOBACCO USE AND POOR DIET.
AFFILIATED HEALTH CARE SYSTEM ROLES	SCH H, PART VI, QUESTION 6	------------------ The Commonwealth Regional Specialty Hospital ("CRSH") is owned and controlled by Commonwealth Health Corporation ("CHC). CHC has been determined to be a publicly supported organization described in Section 509(a)(3) of the Code and a charitable organization as described in Section 501(c)(3) of the Code and is exempt from federal income taxation by virtue of Sections 501(a) and 501(c)(3) of the Code. CRSH is a long-term acute care hospital that operates as a hospital within a hospital by leasing 28 beds from The Medical Center on The Medical Center's Bowling Green campus. It is an acute care hospital for those patients requiring an extended hospital stay (anticipated length of stay between 18-35 days) and generally having complex or chronic medical conditions. COMMONWEALTH HEALTH CORPORATION ----------------------------------- CHC is a holding company for a total of twelve for-profit and nonprofit corporations and partnerships (collectively, the "Affiliates") engaged in various aspects of the healthcare industry. CHC has established various divisions for its operations, including (1) Bowling Green Warren County Community Hospital ("The Medical Center"), (2) Commonwealth Health Free Clinic, Inc., (3) The Medical Center at Franklin, Inc., (4) Commonwealth Regional Specialty Hospital, Inc., and (5) various for-profit corporations and partnerships. CHC OWNS AND OPERATES NINE PHYSICIAN PRACTICES EMPLOYING GENERAL PRACTITIONERS, CARDIAC SURGEONS, VASCULAR SURGEONS, A NEUROSURGEON, NEUROLOGISTS, OBSTETRIC/GYNECOLOGISTS, HOSPITALISTS, AN OTOLARYNGOLOGIST AND PSYCHIATRISTS. CHC HAS ACQUIRED THE PHYSICIAN PRACTICES IN ORDER TO ATTRACT AND RETAIN HIGHLY SKILLED PHYSICIANS IN SPECIALTIES THAT SUPPORT THE MISSION OF CHC AND ITS AFFILIATES. IN ADDITION, CHC OPERATES AND PROVIDES VARIOUS CORPORATE SUPPORT SERVICES INCLUDING PATIENT BILLING, COLLECTIONS, ACCOUNTING, MATERIALS MANAGEMENT, ENGINEERING, SECURITY, HUMAN RESOURCES, INFORMATION SYSTEMS, AND ADMINISTRATIVE SUPPORT. SINCE 1990, CHC'S WHOLLY-OWNED CENTERCARE HEALTH BENEFITS PROGRAM ("CENTERCARE"), A PREFERRED PROVIDER ORGANIZATION (PPO), HAS ASSISTED EMPLOYERS IN MANAGING THE RISING COST OF THEIR HEALTHCARE. THE PPO OFFERS EMPLOYER GROUPS IN THIS REGION A COMPREHENSIVE NETWORK OF PHYSICIANS AND FACILITIES WITH GREATER COST SAVINGS POTENTIAL THAN OTHER NATIONAL ORGANIZATIONS. TODAY, CENTERCARE SERVES AS THE STATEWIDE NETWORK FOR TWO MANAGED CARE ORGANIZATIONS PROVIDING MEDICAID MANAGED CARE SERVICE FOR THE STATE OF KENTUCKY. IT ALSO SERVICES OVER 380,000 MEMBERS BY PROVIDING ACCESS TO OVER 17,000 PROVIDERS IN KENTUCKY, TENNESSEE, INDIANA, OHIO, AND ILLINOIS. SINCE 2008, CHC HAS BEEN THE SOLE OWNER OF BLUEGRASS OUTPATIENT CENTER OF BOWLING GREEN, LLC ("BLUEGRASS"). BLUEGRASS PROVIDES COMPREHENSIVE OUTPATIENT REHABILITATION THERAPY SERVICES. CHC'S FOR-PROFIT ACTIVITIES INCLUDE URGENTCARE OF BOWLING GREEN, INC. ("URGENTCARE"). URGENTCARE IS A WHOLLY-OWNED CORPORATION WHICH SERVES AS A 50% OWNER IN A PRIMARY CARE CENTER. BOWLING GREEN-WARREN COUNTY COMMUNITY HOSPITAL CORPORATION --------------------------------------------------------- THE BOWLING GREEN-WARREN COUNTY COMMUNITY HOSPITAL CORPORATION IS A NON-STOCK, NONPROFIT KENTUCKY CORPORATION THAT OPERATES A HOSPITAL FACILITY IN BOWLING GREEN, KENTUCKY, UNDER THE NAME "THE MEDICAL CENTER" OR "THE MEDICAL CENTER AT BOWLING GREEN" AND, SINCE OCTOBER 1996, A HOSPITAL AND NURSING HOME FACILITY IN SCOTTSVILLE, KENTUCKY, UNDER THE NAME "THE MEDICAL CENTER AT SCOTTSVILLE." The Medical Center AT BOWLING GREEN: Bowling Green Warren County Community Hospital's Bowling Green Facility is a general acute care hospital licensed for 337 beds, with 330 beds in use. In 1980, the Bowling Green Facility moved into a new, six-story, state-of-the-art facility, occupying 298,000 square feet on a 17-acre campus. Since 1980, because of an expanding demand for outpatient services, several additions to the Bowling Green Facility have been made and both clinical and patient areas have been renovated and modernized. Today, the campus includes 56 acres and the buildings on the campus contain a total of approximately 462,000 square feet of space. IN ADDITION, THE HOSPITAL OPERATES THE WHOLLY OWNED MEDICAL CENTER EMS, LLC WHICH PROVIDES THE ONLY EMERGENCY MEDICAL SERVICE IN WARREN COUNTY. THE HOSPITAL IS ALSO A 50% PARTNER WITH ANOTHER NONPROFIT IN OPERATING THE NON-PROFIT BARREN RIVER REGIONAL CANCER CENTER, INC., AN OUTPATIENT ONCOLOGY CENTER LOCATED IN GLASGOW, KENTUCKY. The Medical Center AT SCOTTSVILLE: To more fully serve the health needs of south central Kentucky, The Medical Center merged in October 1996 with an affiliated entity, Health Endowment Properties A-C, Inc., a Kentucky non-stock, nonprofit corporation, which owned and operated The Medical Center at Scottsville (the "Scottsville Facility"). The Scottsville Facility opened in 1996 and is comprised of a 25-bed critical access hospital and 110 nursing care beds. These beds are located in an 85,000 square foot building on approximately 13 acres of land in Allen County, near Scottsville, Kentucky. Commonwealth Health Free Clinic, Inc. ------------------------------------ ("CHFC") was organized to operate a clinic, which provides basic medical and dental diagnostic and treatment services for charitable purposes for the "working poor" of South-central Kentucky. The "working poor" are those individuals who have done their best to stay in the work force but do not have insurance or any form of social assistance and do not have the means to pay for their healthcare. CHFC offers services including: non-emergency clinical services, dentistry, senior citizen's pharmaceutical program, community health education and counseling, disease/condition specific education and counseling. In addition, the dental program has been expanded to include individuals with income at or below 225% of Federal Poverty Guidelines. The Medical Center at Franklin, Inc. ------------------------------------ ("MCF") operates a hospital in the community of Franklin, Simpson County, Kentucky. This location is just 20 miles from The Medical Center's Bowling Green campus. MCF is a Medicare designated critical access hospital offering acute care inpatient and outpatient programs in its 25 bed acute care facility. COMMONWEALTH HEALTH FOUNDATIOn -------------------------------- CHC ENDORSED THE ESTABLISHMENT OF COMMONWEALTH HEALTH FOUNDATION ("THE FOUNDATION") FOR THE PURPOSE OF FOSTERING, SUPPORTING AND INITIATING ACTIVITIES FOR THE ADVANCEMENT OF THE HEALTH CARE OBJECTIVES OF CHC AND THE MEDICAL CENTER AND/OR AFFILIATED NON-PROFIT 501(C)(3) ORGANIZATIONS. THE CHAIRMAN OF CHC'S BOARD OF DIRECTORS OR HIS/HER DESIGNEE, CHC'S PRESIDENT AND CEO, AND THE CHIEF FINANCIAL OFFICER OF THE MEDICAL CENTER SERVE AS EX OFFICIO DIRECTORS OF THE FOUNDATION. THEY ALL THREE ARE COUNTED FOR QUORUM PURPOSES AND HAVE THE RIGHTS AND PRIVILEGES OF OTHER DIRECTORS INCLUDING THE RIGHT TO VOTE ON ALL MATTERS PROPERLY BEFORE THE BOARD.
CRITERIA FOR DETERMINING ELIGIBILITY OF DISCOUNTED CARE	SCH H, PART V, LINE 10	--------------- DURING THE YEAR ENDED 3/31/12, COMMONWEALTH REGIONAL SPECIALTY HOSPITAL discontinued providing discounted care for patients with incomes between 150% and 200% of the Federal Poverty level. Instead, COMMONWEALTH REGIONAL SPECIALTY HOSPITAL UPDATED THEIR FINANCIAL ASSISTANCE POLICY TO PROVIDE FREE CARE FOR PERSONS AT OR BELOW 200% OF THE FEDERAL POVERTY LEVEL.
OTHER FACTORS USED IN DETERMINING AMOUNTS CHARGED TO PATIENTS	SCH H, PART V, LINE 11	--------------- NUMBER IN HOUSEHOLD IS USED FOR DETERMINING FPL FOR COMPARISON TO REPORTED INCOME
INDIVIDUALS ELIGIBLE FOR FINANCIAL ASSISTANCE	SCH H, PART VI, LINE 19	--------------- THE HOSPITAL FACILITY WROTE OFF 100% OF CHARGES TO FAP - ELIGIBLE INDIVIDUALS.

Schedule H (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet

Attach to Form 990. SchJMediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

COMMONWEALTH REGIONAL SPECIALTY HOSPITAL INC

Employer identification number

54-2142034

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all the expenses described above? If "No," complete Part III to explain....

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....

Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? ...............

Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........

Yes

Participate in, or receive payment from, an equity-based compensation arrangement? ........

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.

For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 5a or 5b, describe in Part III.

For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 6a or 6b, describe in Part III.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................

If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990

Cat. No. 50053T

Schedule J (Form 990) 2011

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.

For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and column (E) for that individual.

(A) Name		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(A) Name		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(1) BARBARA JEAN CHERRY	(i) (ii)	0 364,739	0 0	0 74,344	0 28,842	0 8,309	0 476,234	0 0
(2) RONALD G SOWELL	(i) (ii)	0 365,232	0 0	0 60,346	0 34,529	0 7,815	0 467,922	0 0
(3) SARAH MOORE	(i) (ii)	0 228,185	0 0	0 5,590	0 90,018	0 6,696	0 330,489	0 0
(4) BETSY KULLMAN	(i) (ii)	0 240,426	0 0	0 5,850	0 79,262	0 12,630	0 338,168	0 0

Schedule J (Form 990) 2011

Page 3

Part III

Supplemental Information

Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.

Identifier	Return Reference	Explanation
SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN	SCHEDULE J, PART I, LINE 4B	--------------------- CERTAIN EXECUTIVES OF COMMONWEALTH HEATH CORPORATION PARTICIPATE IN A SUPPLEMENTAL RETIREMENT PLAN. THE CURRENT YEAR INCREASE IN THE ACCRUED BENEFIT, AS ACTUARIALLY DETERMINED, IS REPORTED AS COMPENSATION. THE FOLLOWING ARE THE INDIVIDUALS PARTICIPATING IN THE PLAN AND THE CURRENT YEAR INCREASES REPORTED AS COMPENSATION: CONNIE SMITH $188,650 RONALD SOWELL $53,974 JEAN CHERRY $68,921

Schedule J (Form 990) 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.
MediumBullet

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2011

Open to Public
Inspection

Name of the organization

COMMONWEALTH REGIONAL SPECIALTY HOSPITAL INC

Employer identification number

54-2142034

Identifier	Return Reference	Explanation
STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS	FORM 990, PART III, LINE 4A	------------------------- COMMONWEALTH REGIONAL SPECIALTY HOSPITAL, INC. WAS ESTABLISHED TO ACT AND OPERATE EXCLUSIVELY FOR CHARITABLE PURPOSES IN MEETING AN EXISTING NEED FOR LONG-TERM ACUTE CARE HOSPITAL SERVICES IN THE COMMUNITY OF BOWLING GREEN, WARREN COUNTY, KENTUCKY. LONG-TERM ACUTE CARE HOSPITALS (AS RECOGNIZED BY 42 CFR 412.23(E)) GENERALLY PROVIDE DIAGNOSTIC AND MEDICAL TREATMENT OR REHABILITATION TO PATIENTS WITH CHRONIC DISEASE OR COMPLEX MEDICAL CONDITIONS WHOSE AVERAGE LENGTH OF STAY IN THE HOSPITAL EXCEEDS 25 DAYS. RECOGNIZING A NEED FOR SUCH HEALTH CARE ACCESS IN THE COMMUNITY, AND AS A KEY ELEMENT OF THE CONTINUUM OF CARE NEEDED TO PROVIDE AN APPROPRIATE VENUE FOR PATIENTS WHO NEED ACUTE SERVICES BEYOND THOSE GENERALLY AVAILABLE IN THE GENERAL ACUTE CARE HOSPITAL SETTING, COMMONWEALTH HEALTH CORPORATION FORMED COMMONWEALTH REGIONAL SPECIALTY HOSPITAL, INC. TO PROMOTE HEALTH, A CHARITABLE PURPOSE, IN SOUTHCENTRAL KENTUCKY. COMMONWEALTH REGIONAL SPECIALTY HOSPITAL, INC. IS A LONG-TERM, ACUTE CARE HOSPITAL OFFERING A RANGE OF NURSING AND ACUTE CARE INPATIENT AND OUTPATIENT PROGRAMS IN ITS 28 BED LONG-TERM ACUTE CARE FACILITY. AS SUCH, IT IS PRIMARILY ENGAGED IN PROVIDING TO INPATIENTS, BY OR UNDER THE SUPERVISION OF PHYSICIANS, DIAGNOSTIC AND THERAPEUTIC SERVICES FOR MEDICAL DIAGNOSIS, TREATMENT, AND CARE OF INJURED, DISABLED, OR SICK PERSONS, OR REHABILITATION SERVICES FOR THE REHABILITATION OF INJURED, DISABLED, OR SICK PERSONS. AS A HOSPITAL, IT MAINTAINS CLINICAL RECORDS ON ALL PATIENTS AND HAS BYLAWS IN EFFECT CONCERNING ITS STAFF OF PHYSICIANS. IT REQUIRES THAT EVERY PATIENT BE UNDER THE CARE OF A PHYSICIAN AND PROVIDES 24-HOUR NURSING SERVICE BY OR SUPERVISED BY A REGISTERED PROFESSIONAL NURSE, AND HAS A LICENSED PRACTICAL NURSE OR REGISTERED PROFESSIONAL NURSE ON DUTY AT ALL TIMES. IT HAS IN EFFECT A HOSPITAL UTILIZATION REVIEW PLAN AND IS LICENSED OR IS APPROVED BY THE STATE OF KENTUCKY AS MEETING THE STANDARDS ESTABLISHED FOR SUCH LICENSING. IT ALSO MEETS OTHER HEALTH AND SAFETY REQUIREMENTS OF THE SECRETARY OF HEALTH AND HUMAN SERVICES. THIS HOSPITAL IS NOT PRIMARILY FOR THE CARE AND TREATMENT OF MENTAL DISEASES. SERVICES OFFERED INCLUDE: - ACUTE MEDICAL CARE - ONCOLOGY - MEDICALLY COMPLEX ACUTE MEDICAL CARE - WOUND CARE - RESPIRATORY THERAPY FOR DISORDERS INCLUDING TRACHEOTOMY - LABORATORY - PHARMACY SERVICES - VENTILATOR DEPENDENT SERVICES - EMERGENCY TREATMENT - CARDIAC/CARDIOVASCULAR CONDITION SERVICES - RADIOLOGY SERVICES - RENAL DISEASE SERVICES THE HOSPITAL'S PROFESSIONAL STAFF INCLUDES PHYSICIANS WHO ARE ENGAGED IN THE PRACTICE OF MEDICINE AND WHO REPRESENT MULTIPLE SPECIALTIES, INCLUDING FAMILY PRACTICE, PULMONARY, CARDIAC, RADIATION THERAPY AND REHABILITATIVE CARE. THE STAFF ALSO INCLUDES NURSES, PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPISTS, RESPIRATORY THERAPISTS, PHARMACISTS, SOCIAL WORKERS, INFECTION CONTROL SPECIALISTS, NUTRITIONISTS AND OTHERS. USING AN INTERDISCIPLINARY TEAM APPROACH, THE STAFF WORK COLLABORATIVELY TO PROVIDE CARE CONSISTING OF INPATIENT SERVICES OF A GENERAL AND SPECIALIZED NATURE FOR PATIENTS REQUIRING AN EXTENDED LENGTH OF STAY DUE TO THE CRITICAL NATURE OF THEIR ILLNESS. AS A HOSPITAL, COMMONWEALTH REGIONAL SPECIALTY HOSPITAL, INC.: (1) IS ORGANIZED AS A NONPROFIT CHARITABLE ORGANIZATION FOR THE PURPOSE OF OPERATING AS A HOSPITAL FOR THE CARE OF THE SICK, (2) IS OPERATED FOR THE CARE OF ALL PERSONS IN THE COMMUNITY REGARDLESS OF ABILITY TO PAY THE COST THEREOF, EITHER DIRECTLY OR THROUGH THIRD-PARTY REIMBURSEMENT, (3) WILL NOT RESTRICT USE OF ITS FACILITIES TO A PARTICULAR GROUP OF PHYSICIANS AND SURGEONS TO THE EXCLUSION OF ALL OTHER QUALIFIED DOCTORS, (4) AND WILL NOT PERMIT ANY OF ITS EARNINGS TO INURE DIRECTLY OR INDIRECTLY TO THE BENEFIT OF ANY PRIVATE SHAREHOLDER OR INDIVIDUAL. THE HOSPITAL BEGAN OPERATIONS JUNE 9, 2004, AT FACILITIES AT 250 PARK STREET, BOWLING GREEN, KENTUCKY. ADMINISTRATIVE AND PATIENT SERVICES ARE PROVIDED BY EMPLOYEES OF THE CORPORATION. MANAGEMENT SERVICES ARE PROVIDED BY COMMONWEALTH HEALTH CORPORATION, INCORPORATED, A KENTUCKY NON-STOCK, NON-PROFIT CORPORATION EXEMPT FROM INCOME TAXES UNDER SECTION 501( C) (3) OF THE INTERNAL REVENUE CODE OF 1986. DURING FISCAL YEARS 2012 AND 2011, THE HOSPITAL ADMITTED 230 AND 251 PATIENTS, RESPECTIVELY. DURING FISCAL YEARS 2012 AND 2011, THE HOSPITAL PROVIDED 6,554 AND 6,495 DAYS OF PATIENT CARE PER YEAR, RESPECTIVELY.
ORGANIZATION MEMBERS	FORM 990, PART VI, SECTION A, LINE 6	------------------------- COMMONWEALTH HEALTH CORPORATION ("CHC") IS THE SOLE CORPORATE MEMBER OF THE ORGANIZATION.
GOVERNING BODY - NATURE OF RIGHTS	FORM 990, PART VI, SECTION A, LINE 7A	------------------------- COMMONWEALTH HEALTH CORPORATION HAS THE POWER TO APPOINT AND REMOVE CORPORATE DIRECTORS. PURSUANT TO THE BYLAWS, THERE ARE NINE DIRECTORS AND TWO EX-OFFICIO DIRECTORS, CONSISTING OF THE ADMINISTRATOR OF THE HOSPITAL AND THE CHIEF MEDICAL OFFICER OF THE HOSPITAL. AT ALL TIMES, FIVE VOTING DIRECTORS SHALL BE INDEPENDENT DIRECTORS AND FOUR CORPORATE DIRECTORS.
PROCESS USED BY MANAGEMENT &/OR GOVERNING BODY TO REVIEW 990	FORM 990, PART VI, SECTION B, LINE 11	------------------------- FORM 990 IS PLACED ELECTRONICALLY ON A COMPANY WEBSITE USED TO SHARE INFORMATION WITH BOARD MEMBERS. EACH BOARD MEMBER IS PROVIDED ACCESS TO THE WEBSITE AND IS ASKED TO REVIEW FORM 990 PRIOR TO A DESIGNATED DATE ON WHICH THE RETURN WILL BE FILED. AT LEAST TWO WEEKS OF ADVANCE NOTICE IS GIVEN TO BOARD MEMBERS SO THEY MAY REVIEW THE RETURN.
PROCESS FOR MONITORING COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY	FORM 990, PART VI, SECTION B, LINE 12C	------------------------- THE COMMONWEALTH HEALTH CORPORATION (CHC) (APPLICABLE TO THE CORPORATION AND/OR ITS AFFILIATES) CODE OF CONDUCT EXPLICITLY STATES MEMBERS OF THE BOARD, ADMINISTRATION, THE MEDICAL STAFF AND ALL EMPLOYEES ARE EXPECTED TO AVOID CONFLICTS OF INTEREST IN A TIMELY MANNER. ALL INDIVIDUALS SIGN AN ACKNOWLEDGEMENT UPON EMPLOYMENT THAT THEY HAVE RECEIVED A COPY OF THE CODE OF CONDUCT, ARE FAMILIAR WITH ITS CONTENT AND UNDERSTAND THEIR RESPONSIBILITIES TO AVOID NON-COMPLIANT ACTIVITY. CHC'S REGULATORY COMPLIANCE COMMITTEE (RCC) REVIEWS AND APPROVES ALL CONTRACTS FOR CHC AND/OR AFFILIATES. THE REVIEW IS DESIGNED TO IDENTIFY POTENTIAL CONFLICTS OF INTEREST BY BOARD MEMBERS AND/OR OFFICERS. RCC MEMBERS ARE PROHIBITED FROM TAKING PART IN DECISIONS REGARDING TRANSACTIONS WITH WHICH HE/SHE HAS A CONFLICT OF INTEREST. ANNUALLY, WRITTEN INQUIRY IS MADE-BY QUESTIONNAIRE-OF BOARD MEMBERS AND OFFICERS SEEKING DISCLOSURE OF CONFLICTS OF INTEREST OR INFORMATION THAT RELATES TO FAMILY MEMBERS. TRANSACTIONS ARISING ARE REVIEWED BY MANAGEMENT AS THEY OCCUR.
PROCESS FOR DETERMINING COMPENSATION	FORM 990, PART VI, SECTION B, LINE 15A	------------------------- COMPENSATION IS REVIEWED INDEPENDENTLY BY THE MANAGEMENT COMPANY WHO USES MARKET RATE COMPARISONS AND OUTSIDE CONSULTANTS TO EVALUATE COMPARABLE POSITIONS.
MAKING DOCUMENTS AVAILABLE TO THE PUBLIC	FORM 990, PART VI, SECTION C, LINE 19	------------------------- DOCUMENTS ARE MADE AVAILABLE IF REQUIRED, AND IN THE MANNER REQUIRED, BY THE GOVERNING AGENCY.
RECONCILIATION OF NET ASSETS	FORM 990, PART VI, LINE 5	------------------------- OTHER CHANGES IN NET ASSETS: EQUITY TRANSFER FROM COMMONWEALTH HEALTH CORPORATION, INC., A RELATED 501(C)(3) ORGANIZATION $390,991 UNREALIZED GAINS $6,639 --------- $397,630
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:BARBARA JEAN CHERRY TITLE:EXECUTIVE VICE PRESIDENT HOURS:48
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:RONALD G. SOWELL TITLE:CFO/EXECUTIVE VICE PRESIDENT HOURS:48
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:SARAH MOORE TITLE:EXECUTIVE VICE PRESIDENT HOURS:48
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:BETSY KULLMAN TITLE:CNO/EXECUTIVE VICE PRESIDENT HOURS:48

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

COMMONWEALTH REGIONAL SPECIALTY HOSPITAL INC

Employer identification number

54-2142034

Part I

Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)

(a) Name, address, and EIN of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity

Part II

Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled organization
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) BOWLING GREEN-WARREN CTY COMM HOSP CORP 800 PARK STREET BOWLING GREEN,KY42101 61-0920842	hospital	KY	501(c)(3)	3	CHC INC		No
(2) COMMONWEALTH HEALTH FOUNDATION INC 800 PARK STREET BOWLING GREEN,KY42101 61-1362000	SUPPORT	KY	501(c)(3)	7	CHC INC		No
(3) COMMONWEALTH HEALTH FREE CLINIC INC 800 PARK STREET BOWLING GREEN,KY42101 61-1292739	HEALTHCARE	KY	501(c)(3)	3	CHC INC		No
(4) THE MEDICAL CENTER AT FRANKLIN 800 PARK STREET BOWLING GREEN,KY42101 61-1362001	HOSPITAL	KY	501(c)(3)	3	CHC INC		No
(5) COMMONWEALTH HEALTH CORPORATION 800 PARK STREET BOWLING GREEN,KY42102 31-1118087	SUPPORT	KY	501(c)(3)	9	NA		No

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2011

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) URGENTCARE PROP 800 PARK STREET BOWLING GREEN,KY42101 61-1197268	REAL ESTATE	KY	NA	excluded	0	0		No	0		No	0 %
(2) MED PLAZA PTRS 800 PARK STREET BOWLING GREEN,KY42101 61-1080340	REAL ESTATE	KY	NA	excluded	0	0		No	0		No	0 %

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(h) Percentage ownership
(1) URGENTCARE OF BOWLING GREEN INC 800 PARK STREET BOWLING GREEN,KY42101 61-1035393	Healthcare	KY	NA	C	0	0	0 %

Schedule R (Form 990) 2011

Page 3

Part V

Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)

Note. Complete line 1 if any entity is listed in Parts II, III or IV.

Yes

1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?

a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .

b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

f Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

g Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

h Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

j Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

k Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .

Yes

l Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .

Yes

m Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .

n Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

o Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

p Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

q Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

r Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of other organization	(b) Transaction type(a-r)	(c) Amount involved	(d) Method of determining amount involved
(1) COMMONWEALTH HEALTH CORPORATION	C	361,000	FMV
(1)
(2)
(3)
(4)
(5)
(6)

Schedule R (Form 990) 2011

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(e) Are all partners section 501(c)(3) organizations?		(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2011

Page 5

Part VII

Supplemental Information

Complete this part to provide additional information for responses to questions on Schedule R (see instructions).

Identifier	Return Reference	Explanation

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: THE HOSPITAL IS DESIGNED TO MEET THE MEDICAL, THERAPEUTIC AND FAMILIAL NEEDS RELATED TO PROVIDING LONG-TERM ACUTE CARE SERVICES REQUIRED BY INDIVIDUALS WITH CRITICAL DISEASE OR DISORDERS.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a).....	3	9
4	Number of independent voting members of the governing body (Part VI, line 1b) ....	4	9
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...	5	109
6	Total number of volunteers (estimate if necessary) ....	6	2
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ..	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 ..	7b	0

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	20	30
9	Program service revenue (Part VIII, line 2g) .........	7,922,315	8,107,393
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	0	509
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	49,577	35,696
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	7,971,912	8,143,628
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
14	Benefits paid to or for members (Part IX, column (A), line 4).....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	3,971,080	3,997,389
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f)....	3,823,513	3,873,239
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	7,794,593	7,870,628
19	Revenue less expenses. Subtract line 18 from line 12.......	177,319	273,000
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	3,188,702	3,710,442
21	Total liabilities (Part X, line 26).............	1,765,924	1,617,034
22	Net assets or fund balances. Subtract line 21 from line 20.....	1,422,778	2,093,408

Sign Here

	Signature of officer	Date

	Type or print name and title.


4a	(Code: ) (Expenses $ 7,270,958 including grants of $ ) (Revenue $ 8,107,393 )
	THE HOSPITAL PROVIDES LONG-TERM ACUTE CARE SERVICES IN THE COMMUNITY OF BOWLING GREEN, WARREN COUNTY, KENTUCKY. GENERALLY, THE HOSPITAL PROVIDES DIAGNOSTIC AND MEDICAL TREATMENT OR REHABILITATION TO PATIENTS WITH CHRONIC DISEASE OR COMPLEX MEDICAL CONDITIONS. SEE SCHEDULE O FOR FURTHER INFORMATION.

4b	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4c	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses$ 7,270,958

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)		(D) Reportable compensation from the organization (W- 2/1099-MISC)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and Title
(1) TOMMY HOLDERFIELD CHAIRMAN	2.0	X	X	0	0	0
(2) DONNA WHITE DIRECTOR	2.0	X		0	0	0
(3) JUDGE WILLIAM FUQUA DIRECTOR	2.0	X		0	0	0
(4) KATHERINE HIGGINS DIRECTOR	2.0	X		0	0	0
(5) JOE DAVIS DIRECTOR	2.0	X		0	0	0
(6) VICKIE ELROD SECRETARY	2.0	X	X	0	0	0
(7) TOMMY LOVING VICE CHAIRMAN	2.0	X	X	0	0	0
(8) JACQUELINE POPE-TARRENCE DIRECTOR	2.0	X		0	0	0
(9) JUDGE MICHAEL BUCHANON DIRECTOR	2.0	X		0	0	0
(10) BARBARA JEAN CHERRY EXECUTIVE VICE PRESIDENT	2.0		X	0	439,083	37,151
(11) RONALD G SOWELL CFO/EXECUTIVE VICE PRESIDENT	2.0		X	0	425,578	42,344
(12) EMILY MARTIN PART YEAR ADMINISTRATOR	40.0		X	22,599	0	0
(13) SARAH MOORE EXECUTIVE VICE PRESIDENT	2.0		X	0	233,775	96,714
(14) BETSY KULLMAN CNO/EXECUTIVE VICE PRESIDENT	2.0		X	0	246,276	91,892
(15) SHERRI GOLDSMITH PART YEAR ADMINISTRATOR	40.0		X	85,496	3,955	8,981

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	108,095	1,348,667	277,082

(A) Name and business address	(B) Description of services	(C) Compensation
ACUTE DIALYSIS OF KENTUCKY INC 1834 LYDA AVENUE BOWLING GREEN,KY42104	CLINICAL SERVICES	154,860




2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 1

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d
e	Government grants (contributions)1e

f	All other contributions, gifts, grants, and similar amounts not included above1f		30
g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			30
			Business Code
2a	INPATIENT SVCS PROVIDED L-T ACUTE CARE		623,000	8,107,393	8,107,393
b
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			8,107,393
3	Investment income (including dividends, interest
	and other similar amounts).....			520			520
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties............			0
		(i) Real	(ii) Personal
6a	Gross rents
b	Less: rental expenses
c	Rental income or (loss)
d	Net rental income or (loss).......
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory
b	Less: cost or other basis and sales expenses		11
c	Gain or (loss)		-11
d	Net gain or (loss)..........			-11			-11
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...			0
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Miscellaneous Revenue			Business Code
11a	CONTRACT LABOR		623,000	35,513			35,513
b	PURCHASE DISCOUNT		900,099	183			183
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......			35,696
12	Total revenue. See Instructions....			8,143,628	8,107,393		36,205


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing ..........			1,142,453	1	1,325,626
2	Savings and temporary cash investments .......			0	2	256,119
3	Pledges and grants receivable, net .........			0	3	0
4	Accounts receivable, net .........			1,660,800	4	1,824,006
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........			0	5	0
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........			0	6	0
7	Notes and loans receivable, net .............			0	7	0
8	Inventories for sale or use ..............			65,451	8	56,512
9	Prepaid expenses and deferred charges ............			55,084	9	41,896
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	542,905
b	Less: accumulated depreciation. .....	10b	440,596	124,782	10c	102,309
11	Investments—publicly traded securities ..........			0	11	0
12	Investments—other securities. See Part IV, line 11 ......			0	12	0
13	Investments—program-related. See Part IV, line 11 ..			0	13	0
14	Intangible assets .........			0	14	0
15	Other assets. See Part IV, line 11 ...........			140,132	15	103,974
16	Total assets. Add lines 1 through 15 (must equal line 34)...			3,188,702	16	3,710,442
17	Accounts payable and accrued expenses .			794,666	17	923,955
18	Grants payable ..........			0	18	0
19	Deferred revenue ..........			0	19	0
20	Tax-exempt bond liabilities ..........			0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..			0	21	0
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........			0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..			0	23	0
24	Unsecured notes and loans payable to unrelated third parties ....			0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.....			971,258	25	693,079
26	Total liabilities. Add lines 17 through 25.....			1,765,924	26	1,617,034
	Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....			1,422,778	27	2,093,408
28	Temporarily restricted net assets .....			0	28	0
29	Permanently restricted net assets .....			0	29	0
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances .....			1,422,778	33	2,093,408
34	Total liabilities and net assets/fund balances .....			3,188,702	34	3,710,442