Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2012
Open to Public Inspection
A For the 2012 calendar year, or tax year beginning 07-01-2012 , 2012, and ending 06-30-2013
BCheck if applicable:
CName of organization
SMYTH COUNTY COMMUNITY HOSPITAL
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
PO BOX 880
 
Room/suite
City or town, state or country, and ZIP + 4
MARION, VA24354
D Employer identification number

54-0794913
E Telephone number

G Gross receipts $ 46,051,757
F Name and address of principal officer:
LINDA P WHITE
PO BOX 880
MARION,VA24354
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.MSHA.COM
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1961
M State of legal domicile: VA
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: PART I, LINE I - ORGANIZATION'S MISSION: SMYTH COUNTY COMMUNITY HOSPITAL (SCCH) IS COMMITTED TO BRINGING LOVING CARE TO HEALTH CARE. WE EXIST TO IDENTIFY AND RESPOND TO THE HEALTH CARE NEEDS OF INDIVIDUALS AND COMMUNITIES IN OUR REGION AND TO ASSIST THEM IN ATTAINING THEIR HIGHEST POSSIBLE LEVEL OF HEALTH.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 13
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 8
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...... 5 1
6 Total number of volunteers (estimate if necessary) ............. 6 50
7a Total unrelated business revenue from Part VIII, column (C), line 12 ........ 7a 159,032
b Net unrelated business taxable income from Form 990-T, line 34 ......... 7b 44,809
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 38,238 106,933
9 Program service revenue (Part VIII, line 2g) ......... 40,449,630 44,574,461
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 1,340,112 565,379
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 1,125,043 675,303
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 42,953,023 45,922,076
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 12,821 10,732
14 Benefits paid to or for members (Part IX, column (A), line 4).....   0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 23,446,103 22,759,121
16a Professional fundraising fees (Part IX, column (A), line 11e).....   0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 22,877,592 24,328,438
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 46,336,516 47,098,291
19 Revenue less expenses. Subtract line 18 from line 12....... -3,383,493 -1,176,215
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 106,754,092 104,424,818
21 Total liabilities (Part X, line 26)............. 24,852,213 22,633,834
22 Net assets or fund balances. Subtract line 21 from line 20..... 81,901,879 81,790,984
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name MediumBullet

Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ............
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2012)
Form 990 (2012)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III ...............
1
Briefly describe the organization’s mission: PART I, LINE I - ORGANIZATION'S MISSION: SMYTH COUNTY COMMUNITY HOSPITAL (SCCH) IS COMMITTED TO BRINGING LOVING CARE TO HEALTH CARE. WE EXIST TO IDENTIFY AND RESPOND TO THE HEALTH CARE NEEDS OF INDIVIDUALS AND COMMUNITIES IN OUR REGION AND TO ASSIST THEM IN ATTAINING THEIR HIGHEST POSSIBLE LEVEL OF HEALTH.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ......................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ............................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 36,913,040 including grants of $ 10,732 ) (Revenue $ 44,574,461 )
SMYTH COUNTY COMMUNITY HOSPITAL (SCCH) HAS A 45-PLUS YEAR HISTORY OF PROVIDING HEALTHCARE SERVICES WITHIN THE COMMUNITY OF MARION, VIRGINIA. SCCH IS A 44-BED COMMUNITY-BASED HOSPITAL THAT OFFERS BOTH ACUTE CARE AND INPATIENT REHABILITATION CARE. THE HOSPITAL PROVIDES COMPREHENSIVE OUTPATIENT SERVICES AND A VARIETY OF OUTREACH PROGRAMS SUCH AS HOMECARE. ADDITIONALLY, SCCH HAS A 109-BED NURSING CARE FACILITY, FRANCIS MARION MANOR HEALTH AND REHABILITATION. (CONTINUED ON SCHEDULE O) AS A NOT-FOR-PROFIT HOSPITAL, ALL OF SCCH'S NET INCOME IS INVESTED IN IMPROVING HEALTHCARE IN THE COMMUNITY. WITH A STRONG COMMITMENT TO QUALITY PATIENT CARE AND A HERITAGE OF SERVICES, SCCH CONTINUES TO MEET THE HEALTHCARE NEEDS OF SMYTH AND THE ADJOINING COUNTIES. THROUGHOUT THE YEAR, SCCH PROVIDES A RANGE OF EVENTS AND PROGRAMS FOR THE COMMUNITY. A FEW EXAMPLES ARE: ADVANCED DIRECTIVES DAY: THIS WAS A DAY TO EDUCATE COMMUNITY MEMBERS ABOUT LEGAL DOCUMENTS THEY MAY WISH TO HAVE IN ORDER TO EXPRESS THE TYPE OF MEDICAL CARE WANTED WHEN ILL AND TO MAKE CLEAR THEIR DECISIONS FOR THEIR OWN END OF LIFE CARE. SINCE A MEDICAL CRISIS CAN OCCUR AT ANY AGE, THIS ADVANCED CARE PLANNING IS AN IMPORTANT STEP TOWARD ENSURING AN INDIVIDUAL'S WISHES ARE FOLLOWED IF HE/SHE IS TOO ILL TO MAKE HIS/HER OWN HEALTHCARE DECISIONS. TWELVE SCCH TEAM MEMBERS WERE INVOLVED WITH THIS EDUCATION DAY. MSHA FACILITIES, INCLUDING SCCH, SERVE AS CLINICAL TRAINING AREAS FOR HEALTH PROFESSIONAL EDUCATION STUDENTS. SCCH HAS DEDICATED STAFF TO WORK WITH REGIONAL COLLEGES AND UNIVERSITIES TO COORDINATE THE PLACEMENT OF HEALTHCARE PROFESSIONAL STUDENTS AS PART OF THEIR EDUCATIONAL CURRICULUM. IN ADDITION TO CLINICAL TRAINING, THE HEALTH CARE STUDENTS ENTERING OUR SYSTEM ARE REQUIRED TO HAVE ORIENTATION AND COMPUTER TRAINING. PARTICIPANTS RECEIVING CLINICAL EXPERIENCE AT SCCH DURING FY13 INCLUDED 50 NURSING STUDENTS FROM VARIOUS COLLEGES, UNIVERSITIES AND PROGRAMS. THIS NURSING CLINICAL EXPERIENCE REQUIRED EXTENSIVE SCCH NURSING STAFF INVOLVEMENT. THE CLINICAL SETTING AND HANDS-ON INSTRUCTION COST SCCH 100,328. SCCH PROVIDED A CLINICAL SETTING FOR ANOTHER 101 STUDENTS TRAINING IN HEALTH-RELATED PROGRAMS SUCH AS RADIOLOGY, PHARMACY, PHYSICAL THERAPY, EMT/PARAMEDIC AND OTHER ALLIED-HEALTH DISCIPLINES. THESE ADDITIONAL CLINICAL STUDENTS COST SCCH 88,368. SMYTH COUNTY LPN STUDENTS RECEIVE THEIR CLINICAL TRAINING AT SCCH. BECAUSE OF THE CLOSE TIE BETWEEN THE STUDENTS AND SCCH, THE STUDENTS ALWAYS ASK TO HAVE THEIR GRADUATION CEREMONY HELD AT THE HOSPITAL. THE HOSPITAL IS VERY PLEASED TO HOST THE CEREMONY FOR THE STUDENTS AND THEIR FAMILIES. REFRESHMENTS ARE PROVIDED AND SCCH'S CEO AND CNO ATTEND THE CEREMONY. SCCH OFFERS A SUPPORT GROUP FOR PEOPLE WITH DIABETES. TWO SCCH TEAM MEMBERS PROVIDE EDUCATION REGARDING SELF-CARE, INCLUDING NUTRITION COUNSELING. SCCH HAS PARTNERED WITH THE COMPANY, FIRSTSOURCE SOLUTIONS USA, TO WORK WITH SELF-PAYING PATIENTS WHO HAVE LIMITED FINANCIAL RESOURCES. FIRSTSOURCE REPRESENTATIVES WERE ABLE TO DETERMINE GOVERNMENTAL MEDICAL ASSISTANCE (MEDICAID) ELIGIBILITY, AND TO HELP WITH THE APPLICATION PROCESS AND FOLLOW-UP. ONCE A PERSON IS APPROVED FOR MEDICAID THROUGH THIS PROGRAM OFFERED THROUGH SCCH, THEY RETAIN COVERAGE FOR FUTURE MEDICAL CARE. FIRSTSOURCE IS COMPENSATED BY SCCH. DURING FY13, SCCH'S COST FOR THIS PROGRAM WAS 67,998. SCCH TEAM MEMBERS PARTICIPATE IN A LOCAL NUTRITION NETWORK, A COLLABORATION OF SPONSORS AND AGENCIES WHO GRAPPLE WITH THE ISSUES OF POVERTY, HUNGER, AND LACK OF KNOWLEDGE REGARDING HEALTH CONSEQUENCES OF POOR NUTRITION. THE NETWORK SERVES TO EDUCATE THE COMMUNITY ABOUT OBESITY RELATED HEALTH PROBLEMS SUCH AS DIABETES, HYPERTENSION, HIGH CHOLESTEROL, AND HEART DISEASE. THE NETWORK'S GOAL IS TO ADDRESS POVERTY AND THE WIDESPREAD USE OF INEXPENSIVE, PROCESSED FOODS WHICH CONTRIBUTE TO THE OBESITY RISK. SINCE THE SOLUTION TO OBESITY AND ITS RELATED DISEASES DOES NOT REQUIRE HIGH TECH TREATMENT OR CUTTING EDGE MEDICATIONS, REPRESENTATIVES FROM SCCH, VIRGINIA DEPARTMENT OF HEALTH, VIRGINIA TECH, FARMERS MARKETS AND GROCERY STORES, LOCAL SCHOOLS AND CHARITY ORGANIZATIONS ARE DEEMED TO BE THE BEST PLACE TO START THE PROCESS OF REDUCING OBESITY WITHIN THE COMMUNITY. A VARIETY OF SCREENINGS, SUPPORT GROUPS, HEALTH EDUCATION, AND HEALTH FAIRS WERE PROVIDED ON AN ONGOING BASIS THROUGHOUT THE YEAR. SOME OF THE SERVICES PROVIDED DURING THE YEAR INCLUDE: LAB SERVICES FOR A FREE PUBLIC CLINIC, CPR TRAINING TO THE PUBLIC, PHYSICALS FOR LOCAL SCHOOLS, AND FIRST AID CLASSES. THE COST OF PROVIDING THESE FREE SERVICES WAS MORE THAN 16,000. FOR MANY YEARS, SCCH HAS PROVIDED ASSISTANCE TO LOCAL LIFESAVING ORGANIZATIONS SUCH AS AMBULANCE SERVICES, FIRE DEPARTMENTS AND RESCUE SQUADS. SCCH DONATES FREE MEDICATIONS AND PHARMACEUTICAL SUPPLIES TO THESE NON-PROFIT ORGANIZATIONS. THE COST OF DONATED MEDICATIONS TO RESCUE ORGANIZATIONS DURING FY13 WAS 11,695. PLANS ARE UNDERWAY TO ESTABLISH AN AFTERHOURS URGENT CARE FOR COUNTY RESIDENTS SO THAT SCCH'S EMERGENCY DEPARTMENT IS NOT THE ONLY OPTION. THE SMYTH COUNTY HOSPITAL HEALTH TRUST WILL SOON BEGIN RAISING MONEY FOR THE MUCH NEEDED URGENT CARE CLINIC PROJECT. PATIENT CARE SERVICES INCLUDE, BUT ARE NOT LIMITED TO: 24-HOUR EMERGENCY DEPARTMENT: SCCH HAS A PHYSICIAN ON DUTY 24 HOURS A DAY, 7 DAYS A WEEK TO TAKE CARE OF MEDICAL NEEDS. IN ADDITION TO OUR PHYSICIANS, WE ALSO STAFF EITHER A FAMILY NURSE PRACTITIONER OR PHYSICIAN ASSISTANT 7 DAYS A WEEK FROM 11AM UNTIL 10PM TO EXPAND CARE BY TREATING EAR ACHES, SORE THROATS, BURNS, SIMPLE FRACTURES, AND MOST OTHER MINOR EMERGENCIES. TOTAL ER VISITS DURING THE YEAR EXCEEDED 18,000. SCCH HAS A HELIPAD FOR AIR EMERGENCY VEHICLES SUCH AS WINGS AIR RESCUE. INPATIENT CARE: THE MEDICAL/SURGICAL UNITS DELIVER COMPREHENSIVE CARE, INCLUDING TELEMETRY SERVICES. A CLINICAL NURSE SPECIALIST OVERSEES CLINICAL MANAGEMENT OF PATIENT CARE AND AN ENTEROSTOMAL NURSE ASSESSES PATIENTS FOR PREVENTION OF SKIN PROBLEMS AND COMPLICATED WOUNDS. SCCH ALSO PROVIDES INPATIENT REHABILITATION AND SKILLED NURSING CARE. INPATIENT ADMISSIONS WERE 1,712 DURING FY13, WHILE INPATIENT DAYS WERE 7,729. CARDIAC & PULMONARY: CARDIAC AND PULMONARY REHABILITATION IS A PROGRAM DESIGNED TO OFFER MORE REHABILITATIVE SERVICES AS WELL AS DIAGNOSTIC TESTING TO INDIVIDUALS SO THEY DO NOT HAVE TO TRAVEL TO LARGER MORE URBAN AREAS. UPON PHYSICIAN REFERRAL WITH HEART AND LUNG DISEASES THAT INCLUDE, BUT ARE NOT LIMITED TO, CORONARY ANGIOPLASTY, HEART ATTACK, CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) AND DYSPNEA (SHORTNESS OF BREATH). CARDIAC REHABILITATION, STRESS TESTING, AND RESPIRATORY THERAPY ARE FOR PATIENTS WHO HAVE EXPERIENCED CARDIAC ILLNESS. THE CARDIAC REHAB DEPARTMENT FOCUSES ON RISK FACTOR MODIFICATION AND LIFESTYLE CHANGES FOR THOSE WHO HAVE EXPERIENCED A HEART ATTACK, OR WHO HAVE HAD CARDIAC SURGERY, BALLOON ANGIOPLASTY OR CORONARY STENTS, KNOWN HEART DISEASE SUCH AS STABLE ANGINA OR CONGESTIVE HEART FAILURE. THIS YEAR, SCCH'S CARDIAC AND PULMONARY REHABILITATION PROGRAM RECEIVED CERTIFICATION FROM THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION (AACVPR) AFTER A TWO-YEAR DOCUMENTATION AND APPLICATION PROCESS. THE COVETED CERTIFICATION MEANS THAT THE OUPATIENT CARDIAC SERVICES OFFERED AT SCCH MEET AACVPR'S STRICT GUIDELINES FOR APPROPRIATE AND EFFECTIVE EARLY OUTPATIENT CARE OF CARDIAC PATIENTS. SINCE THE INCEPTION OF THIS PROGRAM 15 YEARS AGO, THE FACILITY'S SQUARE FOOTAGE HAS DOUBLED AND THE NUMBER OF REHABILITATION SESSIONS HAS GROWN MORE THAN 5 TIMES THE RATES SEEN IN EARLY YEARS. PHYSICIANS IN SEVERAL STATES NOW REFER PATIENTS TO SCCH'S CARDIAC REHABILITATION PROGRAM. LABORATORY SERVICES: LABORATORY SERVICES FOR SCCH ARE AVAILABLE TO MEET THE NEEDS OF OUR PATIENTS. LABORATORY SERVICES ARE INSPECTED AND ACCREDITED BY THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS AND THE VIRGINIA DEPARTMENT OF HEALTH. LABORATORY SERVICES ALSO PARTICIPATE IN THE COLLEGE OF AMERICAN PATHOLOGISTS' PROGRAMS FOR QUALITY CONTROL. TESTING IS PERFORMED AND SUPERVISED BY COLLEGE TRAINED AND DEGREED TECHNICIANS AND TECHNOLOGISTS CERTIFIED BY THE AMERICAN SOCIETY OF CLINICAL PATHOLOGISTS AND THE AMERICAN SOCIETY OF MEDICAL TECHNOLOGISTS. SATELLITE TESTING IS PROVIDED BY LICENSED NURSES TRAINED AND SUPERVISED BY LABORATORY STAFF. JUST UNDER 160,000 LAB TESTS WERE PERFORMED DURING THE YEAR. IN JANUARY 2013, AN UNANNOUNCED EXTERNAL INSPECTION OF THE LAB WAS CONDUCTED BY THE COLLEGE OF AMERICAN PATHOLOGISTS(CAP). THE INSPECTION WENT VERY WELL WITH SCCH'S LAB RECEIVING THE DESIGNATION OF EXCELLENCE. ONE OF THE INSPECTORS REMARKED THAT THE SCCH LAB INSPECTION WAS THE BEST HE HAS ENCOUNTERED OVER THE COURSE OF THE 12 YEARS HE HAS BEEN A LAB INSPECTOR. SURGICAL SERVICES: SURGICAL SERVICES PROVIDED BY SCCH INCLUDE: UROLOGY, SINUPLASTY AND OTHER ENT, OPTHALMOLOGY, ORTHOPEDICS, PLASTICS, GYN, PODIATRY, ORAL, AND GENERAL SURGERY, LASER OPTHALMOLOGY AND REFRACTORY PROCEDURES ARE PERFORMED IN THE OPERATING ROO
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 expensesMediumBullet36,913,040
Form 990 (2012)
Form 990 (2012)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment........................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? Click to see attachment...
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part IClick to see attachment..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If “Yes,” complete Schedule C, Part IIClick to see attachment........
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C,
Part IIIClick to see attachment............................
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part IClick to see attachment........................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,” complete Schedule D, Part IVClick to see attachment..............
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment......
10
 
No
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10?
If “Yes,” complete Schedule D, Part VI.Click to see attachment...................
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIClick to see attachment.......
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIIClick to see attachment.......
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IXClick to see attachment............
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part XClick to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part XClick to see attachment.........................
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI and XII Click to see attachment.................
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E....
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?.....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Parts I and IV.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the United States? If “Yes,” complete Schedule F, Parts II and IV
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the United States? If “Yes,” complete Schedule F, Parts III and IV...
16
 
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I (see instructions)....
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II............
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospital facilities? If “Yes,” complete Schedule H.... Click to see attachment
20a
Yes
 
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statements to this return? Click to see attachment
20b
Yes
 
Form 990 (2012)
Form 990 (2012)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II... Click to see attachment
21
Yes
 
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........ Click to see attachment
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, line 3, 4, or 5 about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J....................... Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I........ Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................... Click to see attachment
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highest compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II.......................... Click to see attachment
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III......... Click to see attachment
27
 
No
28
Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV .......................... Click to see attachment
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV..................... Click to see attachment
28b
Yes
 
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner? If “Yes,” complete Schedule L, Part IV... Click to see attachment
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M..
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M.............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Part II, III, or IV, and Part V, line 1........................ Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
35b
Yes
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2............. Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2012)
Form 990 (2012)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V ...............
Yes
No
1a
Enter the number reported in Box 3 of Form 1096 Enter -0- if not applicable ..
1a
91
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable .
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................
2a
1
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?...
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
Yes
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)?..........................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes,” to line 5a or 5b, did the organization file Form 8886-T? ............
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions?...
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?............................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?............................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?..........................
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?............
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?..........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?.......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year. ....................
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....
13b
 
c
Enter the amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2012)
Form 990 (2012)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI ...............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year .....................
1a
13
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent ...................
1b
8
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? ...........................
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O.......
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done.......................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
VA
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization:
MediumBulletERICA DILLARDPO BOX 880MARIONVA24354 (276) 378-1000
Form 990 (2012)
Form 990 (2012)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII ...............
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(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
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) ANN FLEMING........................................................................
DIRECTOR
 3.00
.......................57.00 		X           0 426,280 66,282
(2) JOHN SCHARIO........................................................................
DIRECTOR
 3.00
.......................57.00 		X           0 401,522 31,188
(3) CHELSEA HAMMAN MD........................................................................
DIRECTOR
 3.00
.......................   		X           19,019 0 0
(4) ALLEN ABEL........................................................................
DIRECTOR
 3.00
.......................   		X           0 0 0
(5) JIM BEAR JR........................................................................
TREASURER
 3.00
.......................   		X           0 0 0
(6) RUTH COX........................................................................
DIRECTOR
 3.00
.......................   		X           0 0 0
(7) BOB FEATHERS........................................................................
DIRECTOR
 3.00
.......................9.00 		X           0 0 0
(8) JOANNE GROSECLOSE........................................................................
VICE CHAIR
 3.00
.......................   		X           0 0 0
(9) ANDY BLEVINS........................................................................
DIRECTOR
 3.00
.......................   		X           0 0 0
(10) JIM MCDOWELL MD........................................................................
DIRECTOR
 3.00
.......................   		X           0 0 0
(11) JAMES PATTERSON MD........................................................................
DIRECTOR
 3.00
.......................   		X           0 0 0
(12) BOB SHULTS........................................................................
CHAIRMAN
 3.00
.......................   		X           0 0 0
(13) CLEM WILKES JR........................................................................
DIRECTOR
 3.00
.......................11.00 		X           0 0 0
(14) LINDA WHITE........................................................................
VP/CEO
 3.00
.......................52.00 		    X       0 217,263 43,482
(15) JEFFREY HUNDMAN........................................................................
CFO
 3.00
.......................47.00 		    X       0 114,784 20,164
(16) MATTHEW JUSTUS........................................................................

 40.00
.......................   		        X   0 174,622 5,929
(17) SAMUEL SMALL........................................................................

 40.00
.......................   		        X   0 160,594 4,816
Form 990 (2012)
Form 990 (2012)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(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
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) STEPHANIE POLLARD........................................................................

 40.00
.......................   		        X   0 136,376 21,876
(19) BELDON FLEMING........................................................................

 40.00
.......................   		        X   0 135,501 28,442
(20) MARK MONTGOMERY........................................................................

 40.00
.......................   		        X   0 107,544 22,765




















1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 19,019 1,874,486 244,944
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet2
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual ..............
3
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person ........
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
SKANSKA USA BUILDING INC1633 LITTLETON ROADPARSIPPANYNJ07054 CONSTRUCTION 9,126,022
MORRISON MANAGEMENT SPECIALISTSPO BOX 102289ATLANTAGA30368 DIETARY SERVS. 1,355,166
INTERNETWORK ENGINEERING INCPO BOX 636604CINCINNATIOH45263 WEB MGMT/LICEN. 371,017
CROTHALL SERVICES EAST TN995 CHESTERBROOK BLVD SUITE 300WAYNEPA19087 LINEN SERVICES 285,499
MCKESSON TECHNOLOGIES INCPO BOX 98347CHICAGOIL60693 HLTH S/W MGMT. 195,630
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet7
Form 990 (2012)
Form 990 (2012)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response to any question in this Part VIII ..............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d 82,545
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		24,388
g Noncash contributions included in lines
1a-1f:$ 		 
h Total. Add lines 1a-1f.......MediumBullet 106,933
Program Service Revenue Business Code
2a PATIENT SERVICES 622110 42,203,917 42,203,917    
b WELLNESS PROGRAMS 622110 2,098,505 2,098,505    
c LABORATORY 622110 155,640   155,640  
d P/S INCOME PREMIER & ISHN 561000 113,007 113,007    
e PREMIER PURCHASING K-1 561000 3,392   3,392  
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 44,574,461
Other Revenue 3 Investment income (including dividends, interest, and other similar amounts).......MediumBullet 677,241     677,241
4 Income from investment of tax-exempt bond proceeds..MediumBullet        
5 Royalties...........MediumBullet        
(i) Real (ii) Personal
6a Gross rents 276,568  
b Less: rental expenses    
c Rental income or (loss) 276,568  
d Net rental income or (loss).......MediumBullet 276,568     276,568
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory   8,636
b Less: cost or other basis and sales expenses 120,498  
c Gain or (loss) -120,498 8,636
d Net gain or (loss)..........MediumBullet -111,862 8,630   -120,492
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ..
a 2,819
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet 2,819   2,819
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...MediumBullet        
10a Gross sales of inventory, less
returns and allowances .
a 24,782
b Less: cost of goods sold ..b 9,183
c Net income or (loss) from sales of inventory..MediumBullet 15,599 15,599    
Miscellaneous Revenue Business Code
11a CAFETERIA SALES 900099 259,717     259,717
b MANAGEMENT FEES 900099 97,867     97,867
c OTHER REVENUE 900099 11,594     11,594
d All other revenue .... 11,139     11,139
e Total. Add lines 11a–11d ...... MediumBullet 380,317
12 Total revenue. See Instructions......MediumBullet 45,922,076 44,439,658 159,032 1,216,453
Form 990 (2012)
Form 990 (2012)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response to any question in this Part IX ...............
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 10,732 10,732
2 Grants and other assistance to individuals in the United States. See Part IV, line 22    
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16    
4 Benefits paid to or for members    
5 Compensation of current officers, directors, trustees, and key employees .... 414,330 20,644 393,686  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....        
7 Other salaries and wages 18,541,222 15,357,015 3,184,207  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 568,963 483,357 85,606  
9 Other employee benefits ....... 2,062,690 1,919,173 143,517  
10 Payroll taxes ........... 1,171,916 1,129,586 42,330  
11 Fees for services (non-employees):        
a Management ...... 34,114   34,114  
b Legal ......... 51,088   51,088  
c Accounting ...........        
d Lobbying ...........        
e Professional fundraising services. See Part IV, line 17    
f Investment management fees ...... 28,018   28,018  
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........ 8,172,414 8,153,142 19,272  
12 Advertising and promotion .... 82,914 64,643 18,271  
13 Office expenses ....... 432,536 374,194 58,342  
14 Information technology ...... 228,811 225,028 3,783  
15 Royalties ..        
16 Occupancy ........... 1,141,091 1,035,371 105,720  
17 Travel ............ 172,157 155,849 16,308  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ......        
19 Conferences, conventions, and meetings .... 3,557 3,262 295  
20 Interest ........... 173,767   173,767  
21 Payments to affiliates .......        
22 Depreciation, depletion, and amortization ..... 4,932,945 1,870,477 3,062,468  
23 Insurance .............. 149,572   149,572  
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a MEDICAL SUPPLIES & DRUGS 5,036,215 5,036,215    
b MANAGEMENT FEES 2,658,267 189,358 2,468,909  
c REPAIRS & MAINTENANCE 676,687 658,585 18,102  
d UBI TAXES 8,500   8,500  
e All other expenses 345,785 226,409 119,376  
25 Total functional expenses. Add lines 1 through 24e 47,098,291 36,913,040 10,185,251 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 MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2012)
Form 990 (2012)
Page 11
Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing ............. 812,382 1 2,388,481
2 Savings and temporary cash investments ......... 64,910 2  
3 Pledges and grants receivable, net ...........   3  
4 Accounts receivable, net ............. 8,655,192 4 7,640,675
5 Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..................
  5  
6 Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
  6  
7 Notes and loans receivable, net .............   7  
8 Inventories for sale or use .............. 953,670 8 915,788
9 Prepaid expenses and deferred charges .......... 314,696 9 351,420
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 127,433,476
b Less: accumulated depreciation ..... 10b 54,087,105 72,569,428 10c 73,346,371
11 Investments—publicly traded securities .......... 18,695,346 11 18,545,937
12 Investments—other securities. See Part IV, line 11 .....   12  
13 Investments—program-related. See Part IV, line 11 ..... 710,615 13 710,615
14 Intangible assets ...............   14  
15 Other assets. See Part IV, line 11 ........... 3,977,853 15 525,531
16 Total assets. Add lines 1 through 15 (must equal line 34)...... 106,754,092 16 104,424,818
Liabilities 17 Accounts payable and accrued expenses ......... 4,880,379 17 4,596,331
18 Grants payable .................   18  
19 Deferred revenue ................   19  
20 Tax-exempt bond liabilities ............. 16,464,093 20 16,208,215
21 Escrow or custodial account liability. Complete Part IV of Schedule D..   21  
22 Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L..........   22  
23 Secured mortgages and notes payable to unrelated third parties ..   23  
24 Unsecured notes and loans payable to unrelated third parties ....   24  
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.................... 3,507,741 25 1,829,288
26 Total liabilities. Add lines 17 through 25......... 24,852,213 26 22,633,834
Net Assets or Fund Balance Organizations that follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets .............. 81,866,036 27 81,755,141
28 Temporarily restricted net assets ........... 35,843 28 35,843
29 Permanently restricted net assets ...........   29  
Organizations that do not follow SFAS 117 (ASC 958), check here MediumBullet 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 ........... 81,901,879 33 81,790,984
34 Total liabilities and net assets/fund balances ........ 106,754,092 34 104,424,818
Form 990 (2012)
Form 990 (2012)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI ...............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
45,922,076
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
47,098,291
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
-1,176,215
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
81,901,879
5
Net unrealized gains (losses) on investments ...............
5
 
6
Donated services and use of facilities .................
6
 
7
Investment expenses .....................
7
 
8
Prior period adjustments .....................
8
 
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
1,065,320
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
81,790,984
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII ..............
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?
2a
 
No
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If “Yes,” to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits
3b
 
 
Form 990 (2012)
Form 990, Special Condition Description:
Special Condition Description
Additional Data


Software ID:  
Software Version:  
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.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
SMYTH COUNTY COMMUNITY HOSPITAL
 
Employer identification number

54-0794913
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the 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)
 
 
h
Provide the following information about the supported organization(s).
(i) Name of supported organization (ii) EIN (iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions)) (iv) Is the organization in col. (i) listed in your governing document? (v) Did you notify the organization in col. (i) of your support? (vi) Is the organization in col. (i) organized in the U.S.? (vii) Amount of monetary support
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 2
Part II
Support Schedule for Organizations Described in Sections 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) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (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) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (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. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..            
11 Total support (Add lines 7 through 10).            
12
12
 
13
First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization, check this box and stop here........................................right arrow
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 3
Part III
Support Schedule for Organizations Described in Section 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) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (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) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.            
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) ..            
13 Total support. (Add lines 9, 10c, 11, and 12.)..            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 4
Part IV
Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and 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) 2012

Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2012
Name of the organization
SMYTH COUNTY COMMUNITY HOSPITAL
 
Employer identification number

54-0794913
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule
Special Rules
......................... Arrow Bullet   $    
Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990; or check the box on line H of its
Form 990-EZ or on Part I, line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 2
Name of organization
SMYTH COUNTY COMMUNITY HOSPITAL
  		Employer identification number

54-0794913
Part I
Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 3
Name of organization
SMYTH COUNTY COMMUNITY HOSPITAL
  		Employer identification number

54-0794913
Part II
Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 4
Name of organization
SMYTH COUNTY COMMUNITY HOSPITAL
  		Employer identification number

54-0794913
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet$  
Use duplicate copies of Part III if additional space is needed.
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Additional Data


Software ID:  
Software Version:  
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
2012
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, Part V, line 35c (Proxy Tax), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
SMYTH COUNTY COMMUNITY HOSPITAL
 
Employer identification number

54-0794913
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization’s direct and indirect political campaign activities in Part IV.
2
Political expenditures ....................................SchCMd Bullet
$  
3
Volunteer hours ........................................
 

Part I-B
Complete if the organization is exempt under section 501(c)(3).
1
Enter the amount of any excise tax incurred by the organization under section 4955 .........SchCMd Bullet
$  
2
Enter the amount of any excise tax incurred by organization managers under section 4955 ......SchCMd Bullet
$  
3
If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............
4a
Was a correction made? .........................................
b
If "Yes," describe in Part IV.
Part I-C
Complete if the organization is exempt under section 501(c), except section 501(c)(3).
1
Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet
$  
2
Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ...................................SchCMd Bullet

$  
3
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b..SchCMd Bullet

$  
4
Did the filing organization file Form 1120-POL for this year? ..........................
5
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 Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.
Cat. No. 50084S
Schedule C (Form 990 or 990-EZ) 2012

Schedule C (Form 990 or 990-EZ) 2012
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 SchCMd Bulletexpenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
organization's
totals 		(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? ......................................

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) 2009 (b) 2010 (c) 2011 (d) 2012 (e) Total
             
2a Lobbying nontaxable 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) 2012


Schedule C (Form 990 or 990-EZ) 2012
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)
No
Yes
(b)
Amount
1
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:
a
Volunteers? .........................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
 
No
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
 
No
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
Yes
 
2,105
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
 
No
 
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
No
 
i
Other activities? ..........................
 
No
 
j
Total. Add lines 1c through 1i ...............................
2,105
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
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
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........
3
 
 
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."
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ............................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
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? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
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, line 5; Part II-A (affiliated group list); Part II-A, line 2; and Part ll-B, line 1. Also, complete this part for any additional information.
Identifier Return Reference Explanation
  SCHEDULE C, PART II-B, LINE 1 PORTION OF DUES PAID TO VIRGINIA HOSPITAL AND HEALTHCARE ASSOCIATION THAT ARE ATTRIBUTABLE TO DIRECT LOBBYING.
Schedule C (Form 990 or 990EZ) 2012

Additional Data


Software ID:  
Software Version:  

SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet 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
2012
Open to Public Inspection
Name of the organization
SMYTH COUNTY COMMUNITY HOSPITAL
 
Employer identification number

54-0794913
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 ........    
5
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? ............
6
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? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
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.
Held at the End of the 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  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................
9
In Part XIII, 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.
1a
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 XIII, the text of the footnote to its financial statements that describes these items.
b
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 $  
2
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:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 52283D
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.
5
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?........
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.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIII and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current year (b)Prior year b (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 ......          
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet  
c
Temporarily restricted endowment SchDMd Bullet  
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
 
(ii) related organizations ........................
3a(ii)
 
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIII 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 (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   1,842,711 1,842,711
b Buildings ................   65,964,188 14,912,807 51,051,381
c Leasehold improvements ............   65,442 64,850 592
d Equipment ................   56,586,390 37,823,784 18,762,606
e Other .................   2,974,745 1,285,664 1,689,081
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 73,346,371
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 3
Part VII
Investments—Other 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.)Small Bullet  
Part VIII
Investments—Program 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.)Small Bullet  
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.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of liability (b) Book value
Federal income taxes  
ASSET RETIREMENT OBLIGATION 752,000
DUE TO AFFILIATES 441,720
OTHER LONG-TERM LIABILITIES 360,275
DUE TO THIRD-PARTY 275,293





Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 1,829,288
2. Fin 48 (ASC 740) Footnote. In Part XIII, 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 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 4
Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIII.) ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
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 XIII.) ........... 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  
Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ........... 1  
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 XIII.) ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
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 XIII.) ............ 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  
Part XIII
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, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
LIABILITY UNDER FIN 48 FOOTNOTE SCHEDULE D, PAGE 3, PART X "THE HOSPITAL IS CLASSIFIED AS AN ORGANIZATION EXEMPT FROM INCOME TAXES PURSUANT TO SECTION 501(C)(3)OF THE INTERNAL REVENUE CODE. AS SUCH, NO PROVISION FOR INCOME TAXES HAS BEEN MADE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS FOR THE HOSPITAL. SOUTHWEST COMMUNITY HEALTH SERVICES (SWCH) IS A TAXABLE ENTITY AND ACCOUNTS FOR INCOME TAXES IN ACCORDANCE WITH FASB ASC 740, INCOME TAXES (NOTE K). AT JUNE 30, 2013, TAX RETURNS FOR FISCAL YEARS 2010 THROUGH 2012 ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. THE HOSPITAL HAS NO UNCERTAIN TAX POSITIONS AT JUNE 30, 2013 AND 2012. AS SUCH, NO INTEREST OR PENALTIES WERE RECOGNIZED IN THE CONSOLIDATED STATEMENTS OF OPERATIONS AND CHANGES IN NET ASSETS RELATED TO UNRECOGNIZED BENEFITS".
Schedule D (Form 990) 2012

Additional Data


Software ID:  
Software Version:  




SCHEDULE H (Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet 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
2012
Open to Public Inspection
Name of the organization
SMYTH COUNTY COMMUNITY HOSPITAL
 
Employer identification number

54-0794913
Part I
Financial Assistance and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a ...
1a
Yes
 
b
If "Yes," was it a written policy? .......................
1b
Yes
 
2
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.
3
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.
a
Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
%
b
Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate
which of the following was the family income limit for eligibility for discounted care: .........
3b
Yes
 
%
c
If the organization used factors other than FPG in determining 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, as a factor in determining eligibility for free or discounted care.
4
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"? ..............

4

Yes

 
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? ......
5b
 
No
c
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? ..............
5c
 
 
6a
Did the organization prepare a community benefit report during the tax year? ..........
6a
Yes
 
b
If "Yes," did the organization make it available to the public? ..............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance and
Means-Tested
Government Programs
 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) .. 		    797,530   797,530 1.690 %
b Medicaid (from Worksheet 3,
column a) .... 		    7,009,144 5,704,341 1,304,803 2.770 %
c Costs of other means-tested
government programs (from
Worksheet 3, column b) . 		           
d Total Financial Assistance
and Means-Tested
Government Programs . 		    7,806,674 5,704,341 2,102,333 4.460 %
Other Benefits
     164,999   164,999 0.350 %
e Community health
improvement services and
community benefit operations
(from Worksheet 4) ..
f Health professions education
(from Worksheet 5) .. 		    188,696   188,696 0.400 %
g Subsidized health services
(from Worksheet 6) .. 		    14,486   14,486 0.030 %
h Research (from Worksheet 7)            
i Cash and in-kind
contributions for community
benefit (from Worksheet 8) 		    12,742   12,742 0.030 %
j Total. Other Benefits ..     380,923   380,923 0.810 %
k Total. Add lines 7d and 7j .     8,187,597 5,704,341 2,483,256 5.270 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
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 (d) Direct offsetting
revenue 		(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            
6 Coalition building            
7 Community health improvement advocacy            
8 Workforce development            
9 Other     500   500  
10 Total     500   500  
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......
2
5,015,379
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......
3
3,410,458
4
Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
15,707,620
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
15,928,487
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-220,867
8
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:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
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.......................

9b

Yes

 
Part IV
Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—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) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest—see instructions)
How many hospital facilities did the organization operate during the tax year?1
Name, address, and primary website address 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe) Facility reporting group
1 SMYTH COUNTY COMMUNITY HOSPITAL
PO BOX 880
MARIN,VA24354 		X X         X      
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
SMYTH COUNTY COMMUNITY HOSPITAL
Name of hospital facility or facility reporting group  
For single facility filers only: line Number of Hospital Facility (from Schedule H, Part V, Section A) 1
Yes No
Community Health Needs Assessment (Lines 1 through 8c are optional for tax years begining on or before March 23, 2012)
1 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 9.................... 1 Yes  
If “Yes,” indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
2 Indicate the tax year the hospital facility last conducted a CHNA: 20 11
3 In conducting its most recent CHNA, did the hospital facility take into account input from representatives of the community served by the hospital facility, including those with special knowledge of or expertise in public health? 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 Yes  
4 Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI................................ 4 Yes  
5 Did the hospital facility make its CHNA report widely available to the public? ............. 5 Yes  
If “Yes,” indicate how the CHNA report was made widely available (check all that apply):
a
b
c
6 If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply to date):
a
b
c
d
e
f
g
h
i
7 Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs ........ 7   No
8a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)? ........................... 8a   No
b If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax? ...... 8b    
c If "Yes" to line 8b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $  

Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information (continued)

Financial Assistance Policy Yes No
9 Did the hospital facility have in place during the tax year a written financial assistance policy that:
Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 9 Yes  
10 Used federal poverty guidelines (FPG) to determine eligibility for providing free care?........... 10 Yes  
If "Yes," indicate the FPG family income limit for eligibility for free care: 200.0%
If "No," explain in Part VI the criteria the hospital facility used.
11 Used FPG to determine eligibility for providing discounted care?................. 11 Yes  
If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 400.0%
If "No," explain in Part VI the criteria the hospital facility used.
12 Explained the basis for calculating amounts charged to patients?................. 12 Yes  
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a
b
c
d
e
f
g
h
13 Explained the method for applying for financial assistance?................... 13 Yes  
14 Included measures to publicize the policy within the community served by the hospital facility?....... 14 Yes  
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a
b
c
d
e
f
g
Billing and Collections
15 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?....... 15 Yes  
16 Check all of the following 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
b
c
d
e
17 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?.......... 17   No
If “Yes,” check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information (continued)

18 Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):
a
b
c
d
e
Policy Relating to Emergency Medical Care
Yes No
19 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?.......... 19 Yes  
If “No,” indicate why:
a
b
c
d
Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)
20 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
b
c
d
21 During the tax year, did the hospital facility charge any FAP-eligible individuals 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? ............................ 21   No
If “Yes,” explain in Part VI.
22 During the tax year, did the hospital facility charge any FAP-eligible individuals an amount equal to the gross charge for any service provided to that individual? ......................... 22   No
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
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?1
Name and address Type of Facility (describe)
1 FRANCIS MARION MANOR HEALTH &
REHABILITATION
100 FRANCIS MARION LANE
MARION,VA24354 		NURSING HOME
2
3
4
5
6
7
8
9
10
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
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; Part V, Section A; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
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.
8 Facility reporting group(s). If applicable, for each hospital facility in a facility reporting group provide the descriptions required for Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
Identifier ReturnReference Explanation
RELATED ORGANIZATION INFORMATION PART I LINE 6A MOUNTAIN STATES HEALTH ALLIANCE PREPARED AND MADE PUBLIC A COMMUNITY BENEFIT REPORT TO INCLUDE INFORMATION FOR ALL OF THE HOSPITALS WITHIN THE HEALTH SYSTEM INCLUDING SCCH
COSTING METHODOLOGY EXPLANATION PART I LINE 7 A COST TO CHARGE RATIO WAS USED TO CALCULATE LINES 7A AND B UTILIZING THE SCHEDULE H APPLICABLE WORKSHEETS INCLUDING WORKSHEET 2 RATIO OF PATIENT CARE COST TO CHARGES LINES 7E F AND G USED THE DIRECT COST OF SPECIFIC PROGRAMS LINE 7I REFLECTS CHARITABLE CONTRIBUTIONS AT COST WE SUBTRACTED LINES 7EI COLUMNC EXPENSE FROM WORKSHEET 2 LINE 4 SO THAT THE EXPENSE WOULD NOT BE DUPLICATED
BAD DEBT EXPENSE EXPLANATION PART III LINE 4 OUR VICE PRESIDENT OF PATIENT FINANCIAL SERVICES AND OUR CFO ESTIMATE THAT 68 OF TOTAL BAD DEBT EXPENSE WAS ASSUMED ATTRIBUTABLE TO PATIENTS LIKELY ELIGIBLE FOR FINANCIAL ASSISTANCE WE HAVE MANY INSTANCES DURING THE YEAR OF PATIENTS WITH LARGE ACCOUNT BALANCES AND NO HEALTH INSURANCE COVERAGE THAT WE ARE SURE WOULD QUALIFY FOR CHARITY CARE ALTHOUGH HOSPITAL TEAM MEMBERS ENCOURAGE THESE INDIVIDUALS TO COMPLETE OUR FINANCIAL ASSISTANCE APPLICATION MANY WILL NOT DO SO EVEN WHEN THESE INDIVIDUALS ARE TOLD WE FEEL SURE THEY DO QUALIFY FOR FULL OR PARTIAL ASSISTANCE THEY STILL REFUSE TO COMPLETE OUR FINANCIAL ASSISTANCE APPLICATION REGARDING LINE 3 IT IS IMPLAUSIBLE TO DETERMINE THE AMOUNT OF SCCHS BAD DEBT ASSOCIATED WITH THOSE PATIENTS WHO MAY HAVE MET THE CRITERIA SET FORTH IN OUR FINANCIAL ASSISTANCE POLICY WITHOUT HAVING A COMPLETED FINANCIAL ASSESSMENT WE ARE UNABLE TO DETERMINE OUR PATIENTS FINANCIAL CIRCUMSTANCES UNLESS A COMPLETED FINANCIAL ASSESSMENT FORM IS VOLUNTARILY PROVIDED TO US WE CAN ASSERT THAT MORE THAN 97 OF OUR PATIENTS WHO HAVE PROVIDED COMPLETED FINANCIAL ASSESSMENT FORMS HAVE BEEN APPROVED FOR AT LEAST PARTIAL FINANCIAL ASSISTANCE THE FOLLOWING TEXT IS INCLUDED IN SCCHS FY13 AUDITED FINANCIAL STATEMENTS CURRENT OPERATIONS ARE CHARGED WITH AN ESTIMATED PROVISION FOR BAD DEBTS BASED UPON HISTORICAL EXPERIENCE KNOWN COLLECTION RISKS AND OTHER ENVIRONMENTAL FACTORS INCLUDING THE AGE OF THE RECEIVABLES ADDITIONS TO THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS RESULT FROM THE PROVISION FOR BAD DEBTS PATIENT ACCOUNTS WRITTEN OFF AS UNCOLLECTIBLE ARE DEDUCTED FROM THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS THE FOOTNOTES TO THE AUDITED FINANCIAL STATEMENTS REPORT THE AMOUNT OF ESTIMATED UNCOLLECTIBLE SELFPAY AND EXPLAINS THAT UNCOLLECTIBLE PATIENT ACCOUNTS RECEIVABLE ESTIMATED RESERVES ARE BASED UPON PRIOR COLLECTION HISTORY FOR GROUPS OF RECEIVABLES KNOWN COLLECTION RISKS AND OTHER ENVIRONMENTAL FACTORS INCLUDING THE AGE OF THE RECEIVABLES
MEDICARE EXPLANATION PART III LINE 8 MEDICARE ALLOWABLE COSTS WERE REPORTED USING SCCHS FILED MEDICARE COST REPORT CR THE CR USES A COST TO CHARGE RATIO BASED ON A STEPDOWN ALLOCATION METHODOLOGY IN CARING FOR THE PATIENT THERE ARE SEVERAL SERVICES THAT ARE CONSIDERED NONALLOWABLE SUCH AS TRANSPORTATION OF A PATIENT COMFORT ITEMS TO INCLUDE A TELEVISION MAGAZINES OR A TELEPHONE ADDITIONAL NONALLOWABLE COSTS INCLUDE THE RECRUITMENT OF PHYSICIANS PHYSICIAN GUARANTEES AND A PORTION OF THE BAD DEBT 12 ASSOCIATED WITH THE CARE OF THE PATIENT MEDICARE LOSSES INCLUDING SOME NONALLOWABLE COSTS SHOULD BE COUNTED AS A COMMUNITY BENEFIT AS THIS IS THE COST OF CARE FOR SERVING THE AGING POPULATION AS A PARTICIPATING PROVIDER IN THE MEDICARE PROGRAM SCCH IS REQUIRED TO PROVIDE THE FULL REGIMEN OF CARE FOR OUR MEDICARE POPULATION THERE ARE A NUMBER OF CARE REGIMENS THAT ARE COMPENSATED BY THE MEDICARE PROGRAM AT LEVELS BELOW OUR COST THEREFORE IT IS ONLY LOGICAL TO ALLOW JMH TO REPORT THESE UNCOMPENSATED SERVICES AS A COMMUNITY BENEFIT ON THIS DOCUMENT BY MAKING THIS CHANGE NONPROFIT PROVIDERS WILL BE ENCOURAGED TO SUSTAIN IMPORTANT CARE DELIVERY MODELS FOR OUR AGING POPULATION IN SPITE OF THE FACT IT IS SOMETIMES ECONOMICALLY INJURIOUS
COLLECTION PRACTICES EXPLANATION PART III LINE 9B SCCH PROVIDES A PATIENT FRIENDLY BILLING FLOW CHART ON ITS WEBSITE THAT GUIDES A PATIENT THROUGH THE PROCESS BEGINNING WITH ADMISSION AND ENDING WITH THE PATIENTS ACCOUNT BEING SUCCESSFULLY RESOLVED SCCH FOLLOWS A STRONG COLLECTION PROGRAM THAT COMMUNICATES FINANCIAL RESPONSIBILITY TO THE PATIENT COLLECTION PRACTICES APPLY TO ALL PATIENTS CHARITY AND NONCHARITY CARE IN ROUTINE CIRCUMSTANCES WHEN IT IS DETERMINED THAT A PATIENT HAS NOT RESPONDED TO REQUESTS FOR PAYMENT AND HAS NOT PROVIDED INFORMATION TO ASCERTAIN ABILITY TO PAY AN ACCOUNT CAN BE REFERRED TO AN OUTSIDE COLLECTION AGENCY FOR COLLECTION ASSISTANCE SCCH ENSURES THAT OUTSIDE COLLECTION AGENCIES FOLLOW HOSPITAL BILLING AND COLLECTION GUIDELINES ONCE A DELINQUENT PATIENT ACCOUNT HAS BEEN SUBMITTED TO AN OUTSIDE AGENCY IT CAN BE ADJUSTED TO CHARITY IF THE DETERMINATION IS LATER MADE THAT THE PATIENT IS ELIGIBLE FOR FINANCIAL ASSISTANCE ALL REQUESTS FOR FINANCIAL ASSISTANCE MUST BE ACCOMPANIED BY A COMPLETED FINANCIAL ASSESSMENT FORM AND SUPPORTING DOCUMENTATION
NEEDS ASSESSMENT PART VI PART VI LINE 2 MSHA INCLUDED AMERICAS HEALTH RANKINGS AHR IN ITS ASSESSMENT IN ORDER TO BETTER DEFINE THE HEALTH CARE NEEDS OF THE COMMUNITIES IT SERVES TENNESSEE RANKS 42ND AND VIRGINIA RANKS 26TH HOWEVER IT SHOULD BE NOTED THAT SOUTHWEST VIRGINIA WHERE MSHA FACILITIES ARE LOCATED CLOSELY RESEMBLES THE HEALTH RANKINGS FOR TENNESSEE AMERICAS HEALTH RANKINGS ARE BASED ON A SERIES OF MEASURES INCLUDING SEVERAL HEALTH OUTCOMES AND HEALTH FACTORS A SURVEY WAS GIVEN TO 67 INDIVIDUALS REPRESENTING THE NINE COUNTIES IN WHICH MSHA OWNS A FACILITY THESE INDIVIDUALS INCLUDED PHYSICIANS PUBLIC HEALTH LEADERS NONPROFIT DIRECTORS SCHOOL NURSES AND OFFICIALS AND BUSINESS LEADERS A SURVEY WAS GIVEN TO EACH INDIVIDUAL SEEKING FEEDBACK REGARDING AVAILABLE RESOURCES IN EACH AREA THE HEALTH STATUS HEALTH PRIORITIES AND SUGGESTIONS FOR IMPROVEMENT THE MAJORITY OF RESPONSES SUGGESTED FOCUSING ON EDUCATION IN ORDER TO PROMOTE HEALTHY HABITS OTHER RESPONSES INCLUDED MAKE PHYSICAL EDUCATION A REQUIREMENT AS PART OF SCHOOL CURRICULUM IMPROVE NATURAL TRAILS AND WALKWAYS INCREASE COMMUNITY SUPPORT FOR SMOKEFREE AREAS PARTNER WITH LOCAL FARMERS MARKETS SHARE HEALTH INFORMATION BETWEEN PHARMACIES NETWORK WITH SMALL BUSINESSES AND NONPROFITS IN ORDER TO AVOID DUPLICATING RESOURCES AND PROVIDE EARLY SCREENINGS FOR THE UNINSURED OR UNDERINSURED OVERALL THE COMMUNITY MEMBERS GAVE MSHAS CORE SERVICE AREA A HEALTH STATUS RANKING OF 424 OUT OF 10 1 BEING THE LOWEST 10 BEING THE HIGHEST ALSO ALL 67 PARTICIPANTS AGREED THAT OBESITY CANCER HEART DISEASE AND DIABETES WERE THE TOP HEALTH PRIORITIES IN EACH COUNTY AHR REPORTS THAT TENNESSEE AND VIRGINIA BOTH SAW AN INCREASE IN DIABETES AND OBESITY WITHIN THE PAST TEN YEARS TENNESSEE ALSO RANKS 44TH FOR CARDIOVASCULAR DEATHS 45TH FOR CANCER DEATHS AND 46TH FOR DIABETES VIRGINIA OVERALL HAS A BETTER RANKING IN THESE THREE CATEGORIES BUT AS STATED EARLIER SOUTHWEST VIRGINIA CLOSELY RESEMBLES TENNESSEE SINCE COMPLETION OF THE CHNA AND ITS IMPLEMENTATION PLAN MSHA HAS PARTNERED WITH SCHOOLS NONPROFIT AGENCIES AND OTHERS ON VARIOUS INITIATIVES TO ADDRESS HEALTH ISSUES CHILDHOOD OBESITY IN PARTICULAR
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE PART VI PART VI LINE 3 SCCH PROVIDES COMMUNICATION OF FINANCIAL ASSISTANCE ON ITS WEBSITE AND ON POSTERS LOCATED IN PROMINENT AREAS OF THE HOSPITAL SUCH AS ADMITTING AND THE EMERGENCY DEPARTMENT PRINTED EDUCATIONAL MATERIALS INCLUDING FINANCIAL ASSISTANCE CONTACT INFORMATION ARE ALSO PROVIDED IN EACH PATIENTS PAPERWORK POSTERS AND REFERENCE MATERIALS ARE WRITTEN IN BOTH ENGLISH AND SPANISH ADMITTING STAFF ARE TRAINED TO EDUCATE PATIENTS ON SCCHS FINANCIAL ASSISTANCE POLICY SCCH ALSO HAS FINANCIAL COUNSELORS TO PROVIDE FURTHER INFORMATION AND ASSISTANCE TO SCCH PATIENTS REGARDING SCCHS FINANCIAL ASSISTANCE POLICY THESE COUNSELORS ALSO HELP UNINSURED PATIENTS DETERMINE SOURCES OF PAYMENT FOR MEDICAL BILLS AND HELP PATIENTS DETERMINE ELIGIBILITY FOR PROGRAMS SUCH AS MEDICAID IN ADDITION SCCH CONTRACTS WITH THE COMPANY FIRSTSOURCE SOLUTIONS USA TO WORK WITH SELFPAYING PATIENTS WHO HAVE LIMITED FINANCIAL RESOURCES FIRSTSOURCE SOLUTIONS USA DETERMINES A PATIENTS ELIGIBILITY IN MEDICAL COVERAGE OPTIONS AND ASSISTS WITH THEIR ENROLLMENT SCCH BEARS THE COST FOR THE FIRSTSOURCE SOLUTIONS PROGRAM
COMMUNITY INFORMATION PART VI PART VI LINE 4 SCCH IS LOCATED IN MARION SMYTH COUNTY WHICH IS IN RURAL SOUTHWEST VIRGINIA BOTH NORTHEAST TENNESSEE AND SOUTHWEST VIRGINIA SWVA ARE LOCATED WITHIN THE APPALACHIAN MOUNTAINS SPECIFICALLY THE BLUE RIDGE MOUNTAIN REGION AND TENNESSEE VALLEY SWVA IS CONSIDERED RURAL AND MUCH DIFFERENT THAN THE REST OF THE STATE SWVA HAS BEEN AND REMAINS A MAJOR COAL MINING REGION SMYTH COUNTY IS A FEDERALLY DESIGNATED MEDICALLY UNDERSERVED AREA AND HAS A HIGH RATE OF INDIVIDUALS WHO ARE UNINSURED THE POPULATION OF SMYTH COUNTY IS JUST OVER 31100 AND ACCORDING TO THE US CENSUS BUREAU THE TOWN OF MARION HAS A POPULATION OF 5869 THE LATEST CENSUS BUREAU DATA ESTIMATES THE MEDIAN AGE OF RESIDENTS OF SMYTH COUNTY IS 431 WHICH IS OLDER THAN THE MEDIAN AFE OF 375 IN VIRGINIA THE BUREAU ESTIMATES SMYTH COUNTY MEDIAN HOUSEHOLD INCOME AT 34394 COMPARED TO 61741 FOR THE STATE OF VIRGINIA 28 OF SMYTH COUNTYS CHILDREN LIVE IN POVERTY COMPARED TO 16 STATEWIDE
HEALTH OF COMMUNITY IN RELATION TO EXEMPT PURPOSE PART VI PART VI LINE 5 SCCH IS DEDICATED TO OPERATING EFFICIENTLY SO THAT WASTE IS MINIMIZED AND SURPLUSES MAY BE APPLIED TO MAINTAINING ADEQUATE FACILITIES AND EQUIPMENT FOR THE CARE OF OUR PATIENTS VARIOUS CHECKS AND BALANCES ARE ESTABLISHED TO ENSURE THAT EXPENDITURES FOR OPERATING EXPENSES AND CAPITAL COSTS ARE REASONABLE AND NECESSARY THE MAJORITY OF SCCHS GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATIONS PRIMARY SERVICE AREAS PHYSICIANS THAT REQUEST PRIVILEGES WHO ARE QUALIFIED AND CREDENTIALED ARE EXTENDED PRIVILEGES BY SCCH
AFFILIATED HEALTH CARE INFORMATION PART VI PART VI LINE 6 SCCH IS A 44BED ACUTECARE FACILITY OPERATED UNDER THE DIRECTION OF A 13MEMBER BOARD OF DIRECTORS PRIMARILY COMPRISED OF LOCAL COMMUNITY RESIDENTS ADDITIONALLY SCCH HAS A 109BED NURSING CARE FACILITY THAT OFFERS BOTH SKILLED NURSING CARE AND NURSING CARE SCCH IS MAJORITY OWNED BY MOUNTAIN STATES HEALTH ALLIANCE MSHA BASED IN JOHNSON CITY TENNESSEE MSHA IS INTEGRATED BOTH VERTICALLY AND HORIZONTALLY AND IS THE LARGEST REGIONAL HEALTHCARE SYSTEM WITH 13 HOSPITALS MSHA PROVIDES CARE TO PEOPLE IN 29 COUNTIES IN TENNESSEE VIRGINIA KENTUCKY AND NORTH CAROLINA SCCH SERVES AS THE COUNTYS PRIMARY HEALTH SERVICE PROVIDER PATIENTS BENEFIT FROM SCCHS AFFILIATION WITH A HEALTHCARE SYSTEM WHERE THEY CAN BE EFFICIENTLY MOVED ALONG AN INTEGRATED COMPREHENSIVE CONTINUUM OF CARE AS THEIR HEALTH STATUS DICTATES PATIENTS CAN BE MOVED TO THE SYSTEMS FLAGSHIP FACILITY JOHNSON CITY MEDICAL CENTER WHICH IS A TERTIARY CARE FACILITY PROVIDING ADVANCED TREATMENT OPTIONS
LIST OF STATES WHERE COMMUNITY BENEFIT REPORT IS FILED PART VI VIRGINIA
SMYTH COUNTY COMMUNITY HOSPITAL LINE NUMBER 1 PART V LINE 3 PART V LINE 3 MSHA MET WITH TEN FOCUS GROUPS EACH REPRESENTING ONE OF THE TEN HOSPITAL FACILITIES INCLUDING SCCH LOCATED WITHIN THE CORE COUNTIES OF MSHA FACILITIES 16 COUNTIES EACH GROUP CONSISTED OF PUBLIC HEALTH LEADERS NURSES NONPROFIT DIRECTORS COMMUNITY DEVELOPERS FAITH BASED LEADERS PUBLIC OFFICIALS AND SCHOOL REPRESENTATIVES EACH GROUP RANGED IN ATTENDANCE FROM 6 TO 21 INDIVIDUALS PARTICIPANTS WERE GIVEN SURVEYS TO DETERMINE A COUNTYS HEALTH STATUS RATING AVAILABLE RESOURCES TOP HEALTH PRIORITIES AND SUGGESTIONS FOR IMPROVEMENT OPEN DISCUSSION FOLLOWED THE COLLECTED INFORMATION WAS THEN PAIRED WITH STATISTICAL DATA IN ORDER TO PRIORITIZE HEALTH NEEDS THE SPECIFIC NEEDS FOR EACH COUNTY WERE INCLUDED IN THE APPROPRIATE FACILITY IMPLEMENTATION PLAN
SMYTH COUNTY COMMUNITY HOSPITAL LINE NUMBER 1 PART V LINE 4 PART V LINE 4 EACH HOSPITAL WITHIN THE MSHA SYSTEM COMPLETED A CHNA FOR THOSE HOSPITALS THAT ARE LOCATED IN THE SAME COUNTY ONLY ONE COMMUNITY GROUP WAS SURVEYED FOR INSTANCE JOHNSON CITY MEDICAL CENTER AND FRANKLIN WOODS COMMUNITY HOSPITAL ARE BOTH LOCATED IN WASHINGTON COUNTY TENNESSEE WE SURVEYED 21 INDIVIDUALS FROM WASHINGTON COUNTY IN ORDER TO DETERMINE HEALTH PRIORITIES DICKENSON COMMUNITY HOSPITAL AND NORTON COMMUNITY HOSPITAL ALSO HAD ONE COMMUNITY GROUP SURVEYED THESE TWO COUNTIES SERVE SIMILAR COMMUNITIES AND HAVE SIMILAR HEALTH RANKINGS ACCORDING TO AMERICAS HEALTH RANKINGS EVEN THOUGH ONLY TWO COMMUNITY GROUPS SERVED ON BEHALF OF THE FOUR HOSPITALS LISTED STATISTICAL DATA WAS COLLECTED FOR EACH INDIVIDUALLY SCCHS CHNA WAS CONDUCTED WITH ALL MSHA HOSPITALS TO INCLUDE JOHNSON CITY MEDICAL CENTER FRANKLIN WOODS COMMUNITY HOSPITAL INDIAN PATH MEDICAL CENTER SYCAMORE SHOALS HOSPITAL JOHNSON COUNTY COMMUNITY HOSPITAL RUSSELL COUNTY MEDICAL CENTER JOHNSTON MEMORIAL HOSPITAL NORTON COMMUNITY HOSPITAL AND DICKENSON COMMUNITY HOSPITAL
SMYTH COUNTY COMMUNITY HOSPITAL LINE NUMBER 1 PART V LINE 7 PART V LINE 7 MSHA PUBLISHED ITS COMMUNITY HEALTH NEEDS ASSESSMENT ON JUNE 29 OF FY12 THE DATA INCLUDED WAS COLLECTED OVER THE COURSE OF 2011 AND 2012 AN IMPLEMENTATION PLAN WAS CREATED FOR EACH HOSPITAL AND EACH HOSPITALS BOARD APPROVED THE IMPLEMENTATION PLAN DURING THE MONTHS OF MAY AND JUNE 2012 MSHA ANNUALLY TRACKS PROGRESS OF IMPLEMENTATION STRATEGIES FOR EACH HOSPITAL DUE TO LACK OF RESOURCES SOME OF MSHA FACILITIES WERE UNABLE TO ADDRESS ISSUES THAT WERE IDENTIFIED
SMYTH COUNTY COMMUNITY HOSPITAL LINE NUMBER 1 PART V LINE 14G PART V LINE 14G THE MOUNTAIN STATES HEALTH ALLIANCE FINANCIAL ASSISTANCE POLICY HS BEEN APPROVED BY THE BOARD OF DIRECTORS AND APPLIES TO ALL MSHA HOSPITALS DURING THE ADMISSION PROCESS PATIENTS ARE TOLD THAT THE HOSPITAL HAS A FINANCIAL ASSISTANCE POLICY AND ADMISSION PAPERS GIVEN TO EACH PATIENT ADVISE THEM OF THE POLICY BILLING CORRESPONDENCE ALSO ADVISES THAT FINANCIAL ASSISTANCE MAY BE AVAILABLE A COMMUNITY RESOURCE GUIDE REPORTS THAT THE HOSPITAL HAS A FINANCIAL ASSISTANCE POLICY
SMYTH COUNTY COMMUNITY HOSPITAL LINE NUMBER 1 PART V LINE 20D PART V LINE 20D UNINSURED PATIENTS RECEIVE A 62 DISCOUNT AND BASED ON OTHER FACTORS SUCH AS INCOME OR MEDICAL INDIGENCY MAY QUALIFY FOR AN ADDITIONAL DISCOUNT
Schedule H (Form 990) 2012
Additional Data


Software ID:  
Software Version:  
Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
SMYTH COUNTY COMMUNITY HOSPITAL
 
Employer identification number
54-0794913
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21, for any recipient that received more than $5,000. Part II can be duplicated if additional space is needed.
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance






















2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................ Bullet Image
 
3
Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2012

Schedule I (Form 990) 2012
Page 2
Part III
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.
(a)Type of grant or assistance (b)Number of
recipients		 (c)Amount of
cash grant		 (d)Amount of
non-cash assistance		 (e)Method of valuation (book,
FMV, appraisal, other)		 (f)Description of non-cash assistance












Part IV
Supplemental Information.
Complete this part to provide the information required in Part I, line 2, Part III, column (b), and any other additional information.
Identifier Return Reference Explanation
PROCEDURES FOR MONITORING THE USE OF GRANT FUNDS INSIDE THE UNITED STATES SCHEDULE I, PAGE 1, PART I, LINE 2 FUNDING MAY BE PROVIDED TO LOCAL 501(C)(3)ORGANIZATIONS WHOSE FOCUS IS ON HEALTH AND EDUCATION. FOR MANY YEARS, SCCH HAS MADE DONATIONS OF MEDICATIONS TO AREA NON-PROFIT EMERGENCY MEDICAL SERVICE COMPANIES. THESE MEDICATION DONATIONS COMPRISE THE SIGNIFICANT MAJORITY OF OUR DONATIONS. ON OCCASION, WE MAKE A VERY SMALL NUMBER OF MODEST CASH DONATIONS TO AREA SCHOOLS AND OTHER NON-PROFIT HEALTH CARE ORGANIZATIONS. DURING FY13, WE MADE ONE DONATION TO A SCHOOL AND ONE DONATION TO A HEALTH CARE ORGANIZATION. DONATION REQUESTS ARE EVALUATED BASED ON COMMUNITY NEED AND HEALTH CARE BENEFIT (OTHER THAN THE OCCASIONAL SCHOOL DONATION).
ADDITIONAL INFORMATION SCHEDULE I, PAGE 4, PART IV PART III, LINE 1 DURING FY13, SCCH DID NOT CONTRIBUTE 5,000 TO ANY ONE ORGANIZATION.
Schedule I (Form 990) 2012


Additional Data


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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
2012
Open to Public Inspection
Name of the organization
SMYTH COUNTY COMMUNITY HOSPITAL
 
Employer identification number

54-0794913
Part I
Questions Regarding Compensation
Yes
No
1a
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.
b
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 of the expenses described above? If "No," complete Part III to explain....
1b
 
 
2
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? .......
2
 
 
3
Indicate which, if any, of the following the filing organization used 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.
4
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:
a
Receive a severance payment or change-of-control payment? ................
4a
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? .........
4c
 
No
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.
5
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:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
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:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
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 ............
7
 
No
8
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 .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012
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 (E) amounts for that individual.
(A) Name and Title (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
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1)ANN FLEMINGDIRECTOR (i)
(ii)		  
351,697 		 
51,836 		 
22,747 		 
48,425 		 
17,857 		 
492,562 		 
 
(2)JOHN SCHARIODIRECTOR (i)
(ii)		  
326,339 		 
68,681 		 
6,502 		 
6,630 		 
24,558 		 
432,710 		 
 
(3)LINDA WHITEVPCEO (i)
(ii)		  
184,990 		 
23,278 		 
8,995 		 
20,963 		 
22,519 		 
260,745 		 
 
(4)MATTHEW JUSTUS   (i)
(ii)		  
174,442 		 
  		 
180 		 
5,428 		 
501 		 
180,551 		 
 
(5)SAMUEL SMALL   (i)
(ii)		  
157,956 		 
  		 
2,638 		 
4,739 		 
77 		 
165,410 		 
 
(6)STEPHANIE POLLARD   (i)
(ii)		  
130,643 		 
  		 
5,733 		 
4,062 		 
17,814 		 
158,252 		 
 
(7)BELDON FLEMING   (i)
(ii)		  
135,321 		 
  		 
180 		 
7,658 		 
20,784 		 
163,943 		 
 
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.
Identifier Return Reference Explanation
RELATED ORG METHODS USED FOR COMPENSATION EXPLANATION SCHEDULE J, PAGE 1, PART I, LINE 3 SCCH'S CEO'S SALARY AND BENEFITS ARE SUBJECT TO THE MOUNTAIN STATES HEALTH ALLIANCE (MSHA) COMPENSATION COMMITTEE PROCESS, WHEREBY THE MSHA CEO RECOMMENDS THE SALARY AND IT IS REVIEWED AND APPROVED BY THE COMPENSATION COMMITTEE, BASED UPON MARKET DATA, MADE AVAILABLE BY THIRD PARTY CONSULTANTS. THE COMPENSATION COMMITTEE HAS FINAL APPROVAL OF MSHA'S CEO RECOMMENDATIONS FOR PAY AND BENEFITS FOR THE SCCH CEO AND ALL OTHER EXECUTIVES WITHIN MSHA. WE USE AN OUTSIDE, INDEPENDENT CONSULTING FIRM TO PROVIDE CONSULTATION ON EXECUTIVE PAY AS WELL AS OUR EXECUTIVE PAY AT RISK PLAN.
SEVERANCE, NONQUALIFIED, AND EQUITY-BASED PAYMENTS SCHEDULE J, PAGE 1, PART I, LINE 4 ANN FLEMING 0 35,925 0 LINDA WHITE 0 9,529 0
OTHER ADDITIONAL INFORMATION SCHEDULE J, PART III PART I, LINE 4B ANN FLEMING AND LINDA WHITE PARTICIPATED IN A 457(F) RETIREMENT PLAN PROVIDED BY MOUNTAIN STATES HEALTH ALLIANCE (MSHA). THE 457(F)PLAN IS A NONQUALIFIED TAX-DEFERRED COMPENSATION PLAN AVAILABLE TO A SELECT GROUP OF KEY EXECUTIVES FOR THE INTENT OF SUPPORTING RETENTION AND TO OFFER A COMPETITIVE TOTAL RETIREMENT PROGRAM. ACCOUNT BALANCES HAVE A "SUBSTANTIAL RISK OF FORFEITURE". IN ADDITION TO CREDITOR RISK, SUBSTANTIAL RISK OF FORFEITURE IS CREATED THROUGH DEFAULT RISK IF THE PARTICIPANT'S EMPLOYMENT WITH MSHA IS TERMINATED PRIOR TO AGE 65. HOWEVER, THE 457(F) PLAN CONTAINS A NON-COMPETE PROVISION THAT PROVIDES THE ACCOUNT BALANCE TO BE PAID IN A LUMP SUM AFTER THE EXECUTIVE SATISFIES THE TWO-YEAR NON-COMPETE PERIOD. THIS PROVISION APPLIES TO EMPLOYER CONTRIBUTIONS IF THE EXECUTIVE HAS PROVIDED ELIGIBLE SERVICE FOR SIX OR MORE YEARS. (ELIGIBLE SERVICE IS OFFICER SERVICE THAT PERMITTED THE EXECUTIVE TO PARTICIPATE IN THE PLAN.) THE EXECUTIVE WILL RECEIVE THE ENTIRE ACCOUNT BALANCE IF HE/SHE BECOMES DISABLED, DIES OR IF THE EXECUTIVE TERMINATES FOR "GOOD REASON" OR IS INVOLUNTARILY TERMINATED WITHOUT "GOOD CAUSE" WITHIN A 24 MONTH PERIOD AFTER A CHANGE-OF-CONTROL OCCURS. DISTRIBUTIONS FROM THIS PLAN ARE SUBJECT TO FEDERAL, STATE, AND LOCAL TAXES ON THE ENTIRE ACCOUNT BALANCE UPON DISTRIBUTION.
Schedule J (Form 990) 2012

Additional Data


Software ID:  
Software Version:  
Schedule L
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V, line 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ. MediumBullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
SMYTH COUNTY COMMUNITY HOSPITAL
 
Employer identification number

54-0794913
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501(c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Relationship between disqualified person and organization (c) Description of transaction (d) Corrected?
Yes No





2
Enter the amount of tax incurred by organization managers or disqualified persons during the year under section 4958. ........................... Bullet Image$
 
3
Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ....... Bullet Image$
 

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22
(a) Name of interested person (b) Relationship with organization (c) Purpose of loan (d) Loan to or from the organization? (e)Original principal amount (f)Balance due (g) In default? (h) Approved by board or committee? (i)Written agreement?
To From Yes No Yes No Yes No
Total ......Small Bullet $  
Part III
Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of assistance (d) Type of assistance (e) Purpose of assistance
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2012
Schedule L (Form 990 or 990-EZ) 2012
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) BETTY KIRK FAMILY MEMBER 75,192 SEE PART V   No
(2) REBECCA SPARGER FAMILY MEMBER 9,124 SEE PART V   No
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
Identifier Return Reference Explanation
ADDITIONAL INFORMATION SCHEDULE L PART V 1A NAME OF PERSON BETTY KIRK 1B RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION FAMILY MEMBER OF JIM BEAR 1D DESCRIPTION OF TRANSACTION JIM BEAR SCCH BOARD TREASURER IS A FAMILY MEMBER OF BETTY KIRK AN EMPLOYEE OF SMYTH COUNTY COMMUNITY HOSPITAL 2A NAME OF PERSON REBECCA SPARGER 2B RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION FAMILY MEMBER OF JAMES PATTERSON MD 2D DESCRIPTION OF TRANSACTION JAMES PATTERSON MD SCCH BOARD MEMBER IS A FAMILY MEMBER OF REBECCA SPARGER AN EMPLOYEE OF SMYTH COUNTY COMMUNITY HOSPITAL
Schedule L (Form 990 or 990-EZ) 2012

Additional Data


Software ID:  
Software Version:  




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
2012
Open to Public
Inspection
Name of the organization
SMYTH COUNTY COMMUNITY HOSPITAL
 
Employer identification number

54-0794913
Identifier Return Reference Explanation
ORGANIZATION'S MISSION FORM 990 - ORGANIZATION'S MISSION PART I, LINE I - ORGANIZATION'S MISSION: SMYTH COUNTY COMMUNITY HOSPITAL (SCCH) IS COMMITTED TO BRINGING LOVING CARE TO HEALTH CARE. WE EXIST TO IDENTIFY AND RESPOND TO THE HEALTH CARE NEEDS OF INDIVIDUALS AND COMMUNITIES IN OUR REGION AND TO ASSIST THEM IN ATTAINING THEIR HIGHEST POSSIBLE LEVEL OF HEALTH.
FIRST ACCOMPLISHMENT DESCRIPTION FORM 990, PAGE 2, PART III, LINE 4A AS A NOT-FOR-PROFIT HOSPITAL, ALL OF SCCH'S NET INCOME IS INVESTED IN IMPROVING HEALTHCARE IN THE COMMUNITY. WITH A STRONG COMMITMENT TO QUALITY PATIENT CARE AND A HERITAGE OF SERVICES, SCCH CONTINUES TO MEET THE HEALTHCARE NEEDS OF SMYTH AND THE ADJOINING COUNTIES. THROUGHOUT THE YEAR, SCCH PROVIDES A RANGE OF EVENTS AND PROGRAMS FOR THE COMMUNITY. A FEW EXAMPLES ARE: ADVANCED DIRECTIVES DAY: THIS WAS A DAY TO EDUCATE COMMUNITY MEMBERS ABOUT LEGAL DOCUMENTS THEY MAY WISH TO HAVE IN ORDER TO EXPRESS THE TYPE OF MEDICAL CARE WANTED WHEN ILL AND TO MAKE CLEAR THEIR DECISIONS FOR THEIR OWN END OF LIFE CARE. SINCE A MEDICAL CRISIS CAN OCCUR AT ANY AGE, THIS ADVANCED CARE PLANNING IS AN IMPORTANT STEP TOWARD ENSURING AN INDIVIDUAL'S WISHES ARE FOLLOWED IF HE/SHE IS TOO ILL TO MAKE HIS/HER OWN HEALTHCARE DECISIONS. TWELVE SCCH TEAM MEMBERS WERE INVOLVED WITH THIS EDUCATION DAY. MSHA FACILITIES, INCLUDING SCCH, SERVE AS CLINICAL TRAINING AREAS FOR HEALTH PROFESSIONAL EDUCATION STUDENTS. SCCH HAS DEDICATED STAFF TO WORK WITH REGIONAL COLLEGES AND UNIVERSITIES TO COORDINATE THE PLACEMENT OF HEALTHCARE PROFESSIONAL STUDENTS AS PART OF THEIR EDUCATIONAL CURRICULUM. IN ADDITION TO CLINICAL TRAINING, THE HEALTH CARE STUDENTS ENTERING OUR SYSTEM ARE REQUIRED TO HAVE ORIENTATION AND COMPUTER TRAINING. PARTICIPANTS RECEIVING CLINICAL EXPERIENCE AT SCCH DURING FY13 INCLUDED 50 NURSING STUDENTS FROM VARIOUS COLLEGES, UNIVERSITIES AND PROGRAMS. THIS NURSING CLINICAL EXPERIENCE REQUIRED EXTENSIVE SCCH NURSING STAFF INVOLVEMENT. THE CLINICAL SETTING AND HANDS-ON INSTRUCTION COST SCCH 100,328. SCCH PROVIDED A CLINICAL SETTING FOR ANOTHER 101 STUDENTS TRAINING IN HEALTH-RELATED PROGRAMS SUCH AS RADIOLOGY, PHARMACY, PHYSICAL THERAPY, EMT/PARAMEDIC AND OTHER ALLIED-HEALTH DISCIPLINES. THESE ADDITIONAL CLINICAL STUDENTS COST SCCH 88,368. SMYTH COUNTY LPN STUDENTS RECEIVE THEIR CLINICAL TRAINING AT SCCH. BECAUSE OF THE CLOSE TIE BETWEEN THE STUDENTS AND SCCH, THE STUDENTS ALWAYS ASK TO HAVE THEIR GRADUATION CEREMONY HELD AT THE HOSPITAL. THE HOSPITAL IS VERY PLEASED TO HOST THE CEREMONY FOR THE STUDENTS AND THEIR FAMILIES. REFRESHMENTS ARE PROVIDED AND SCCH'S CEO AND CNO ATTEND THE CEREMONY. SCCH OFFERS A SUPPORT GROUP FOR PEOPLE WITH DIABETES. TWO SCCH TEAM MEMBERS PROVIDE EDUCATION REGARDING SELF-CARE, INCLUDING NUTRITION COUNSELING. SCCH HAS PARTNERED WITH THE COMPANY, FIRSTSOURCE SOLUTIONS USA, TO WORK WITH SELF-PAYING PATIENTS WHO HAVE LIMITED FINANCIAL RESOURCES. FIRSTSOURCE REPRESENTATIVES WERE ABLE TO DETERMINE GOVERNMENTAL MEDICAL ASSISTANCE (MEDICAID) ELIGIBILITY, AND TO HELP WITH THE APPLICATION PROCESS AND FOLLOW-UP. ONCE A PERSON IS APPROVED FOR MEDICAID THROUGH THIS PROGRAM OFFERED THROUGH SCCH, THEY RETAIN COVERAGE FOR FUTURE MEDICAL CARE. FIRSTSOURCE IS COMPENSATED BY SCCH. DURING FY13, SCCH'S COST FOR THIS PROGRAM WAS 67,998. SCCH TEAM MEMBERS PARTICIPATE IN A LOCAL NUTRITION NETWORK, A COLLABORATION OF SPONSORS AND AGENCIES WHO GRAPPLE WITH THE ISSUES OF POVERTY, HUNGER, AND LACK OF KNOWLEDGE REGARDING HEALTH CONSEQUENCES OF POOR NUTRITION. THE NETWORK SERVES TO EDUCATE THE COMMUNITY ABOUT OBESITY RELATED HEALTH PROBLEMS SUCH AS DIABETES, HYPERTENSION, HIGH CHOLESTEROL, AND HEART DISEASE. THE NETWORK'S GOAL IS TO ADDRESS POVERTY AND THE WIDESPREAD USE OF INEXPENSIVE, PROCESSED FOODS WHICH CONTRIBUTE TO THE OBESITY RISK. SINCE THE SOLUTION TO OBESITY AND ITS RELATED DISEASES DOES NOT REQUIRE HIGH TECH TREATMENT OR CUTTING EDGE MEDICATIONS, REPRESENTATIVES FROM SCCH, VIRGINIA DEPARTMENT OF HEALTH, VIRGINIA TECH, FARMERS MARKETS AND GROCERY STORES, LOCAL SCHOOLS AND CHARITY ORGANIZATIONS ARE DEEMED TO BE THE BEST PLACE TO START THE PROCESS OF REDUCING OBESITY WITHIN THE COMMUNITY. A VARIETY OF SCREENINGS, SUPPORT GROUPS, HEALTH EDUCATION, AND HEALTH FAIRS WERE PROVIDED ON AN ONGOING BASIS THROUGHOUT THE YEAR. SOME OF THE SERVICES PROVIDED DURING THE YEAR INCLUDE: LAB SERVICES FOR A FREE PUBLIC CLINIC, CPR TRAINING TO THE PUBLIC, PHYSICALS FOR LOCAL SCHOOLS, AND FIRST AID CLASSES. THE COST OF PROVIDING THESE FREE SERVICES WAS MORE THAN 16,000. FOR MANY YEARS, SCCH HAS PROVIDED ASSISTANCE TO LOCAL LIFESAVING ORGANIZATIONS SUCH AS AMBULANCE SERVICES, FIRE DEPARTMENTS AND RESCUE SQUADS. SCCH DONATES FREE MEDICATIONS AND PHARMACEUTICAL SUPPLIES TO THESE NON-PROFIT ORGANIZATIONS. THE COST OF DONATED MEDICATIONS TO RESCUE ORGANIZATIONS DURING FY13 WAS 11,695. PLANS ARE UNDERWAY TO ESTABLISH AN AFTERHOURS URGENT CARE FOR COUNTY RESIDENTS SO THAT SCCH'S EMERGENCY DEPARTMENT IS NOT THE ONLY OPTION. THE SMYTH COUNTY HOSPITAL HEALTH TRUST WILL SOON BEGIN RAISING MONEY FOR THE MUCH NEEDED URGENT CARE CLINIC PROJECT. PATIENT CARE SERVICES INCLUDE, BUT ARE NOT LIMITED TO: 24-HOUR EMERGENCY DEPARTMENT: SCCH HAS A PHYSICIAN ON DUTY 24 HOURS A DAY, 7 DAYS A WEEK TO TAKE CARE OF MEDICAL NEEDS. IN ADDITION TO OUR PHYSICIANS, WE ALSO STAFF EITHER A FAMILY NURSE PRACTITIONER OR PHYSICIAN ASSISTANT 7 DAYS A WEEK FROM 11AM UNTIL 10PM TO EXPAND CARE BY TREATING EAR ACHES, SORE THROATS, BURNS, SIMPLE FRACTURES, AND MOST OTHER MINOR EMERGENCIES. TOTAL ER VISITS DURING THE YEAR EXCEEDED 18,000. SCCH HAS A HELIPAD FOR AIR EMERGENCY VEHICLES SUCH AS WINGS AIR RESCUE. INPATIENT CARE: THE MEDICAL/SURGICAL UNITS DELIVER COMPREHENSIVE CARE, INCLUDING TELEMETRY SERVICES. A CLINICAL NURSE SPECIALIST OVERSEES CLINICAL MANAGEMENT OF PATIENT CARE AND AN ENTEROSTOMAL NURSE ASSESSES PATIENTS FOR PREVENTION OF SKIN PROBLEMS AND COMPLICATED WOUNDS. SCCH ALSO PROVIDES INPATIENT REHABILITATION AND SKILLED NURSING CARE. INPATIENT ADMISSIONS WERE 1,712 DURING FY13, WHILE INPATIENT DAYS WERE 7,729. CARDIAC & PULMONARY: CARDIAC AND PULMONARY REHABILITATION IS A PROGRAM DESIGNED TO OFFER MORE REHABILITATIVE SERVICES AS WELL AS DIAGNOSTIC TESTING TO INDIVIDUALS SO THEY DO NOT HAVE TO TRAVEL TO LARGER MORE URBAN AREAS. UPON PHYSICIAN REFERRAL WITH HEART AND LUNG DISEASES THAT INCLUDE, BUT ARE NOT LIMITED TO, CORONARY ANGIOPLASTY, HEART ATTACK, CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) AND DYSPNEA (SHORTNESS OF BREATH). CARDIAC REHABILITATION, STRESS TESTING, AND RESPIRATORY THERAPY ARE FOR PATIENTS WHO HAVE EXPERIENCED CARDIAC ILLNESS. THE CARDIAC REHAB DEPARTMENT FOCUSES ON RISK FACTOR MODIFICATION AND LIFESTYLE CHANGES FOR THOSE WHO HAVE EXPERIENCED A HEART ATTACK, OR WHO HAVE HAD CARDIAC SURGERY, BALLOON ANGIOPLASTY OR CORONARY STENTS, KNOWN HEART DISEASE SUCH AS STABLE ANGINA OR CONGESTIVE HEART FAILURE. THIS YEAR, SCCH'S CARDIAC AND PULMONARY REHABILITATION PROGRAM RECEIVED CERTIFICATION FROM THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION (AACVPR) AFTER A TWO-YEAR DOCUMENTATION AND APPLICATION PROCESS. THE COVETED CERTIFICATION MEANS THAT THE OUPATIENT CARDIAC SERVICES OFFERED AT SCCH MEET AACVPR'S STRICT GUIDELINES FOR APPROPRIATE AND EFFECTIVE EARLY OUTPATIENT CARE OF CARDIAC PATIENTS. SINCE THE INCEPTION OF THIS PROGRAM 15 YEARS AGO, THE FACILITY'S SQUARE FOOTAGE HAS DOUBLED AND THE NUMBER OF REHABILITATION SESSIONS HAS GROWN MORE THAN 5 TIMES THE RATES SEEN IN EARLY YEARS. PHYSICIANS IN SEVERAL STATES NOW REFER PATIENTS TO SCCH'S CARDIAC REHABILITATION PROGRAM. LABORATORY SERVICES: LABORATORY SERVICES FOR SCCH ARE AVAILABLE TO MEET THE NEEDS OF OUR PATIENTS. LABORATORY SERVICES ARE INSPECTED AND ACCREDITED BY THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS AND THE VIRGINIA DEPARTMENT OF HEALTH. LABORATORY SERVICES ALSO PARTICIPATE IN THE COLLEGE OF AMERICAN PATHOLOGISTS' PROGRAMS FOR QUALITY CONTROL. TESTING IS PERFORMED AND SUPERVISED BY COLLEGE TRAINED AND DEGREED TECHNICIANS AND TECHNOLOGISTS CERTIFIED BY THE AMERICAN SOCIETY OF CLINICAL PATHOLOGISTS AND THE AMERICAN SOCIETY OF MEDICAL TECHNOLOGISTS. SATELLITE TESTING IS PROVIDED BY LICENSED NURSES TRAINED AND SUPERVISED BY LABORATORY STAFF. JUST UNDER 160,000 LAB TESTS WERE PERFORMED DURING THE YEAR. IN JANUARY 2013, AN UNANNOUNCED EXTERNAL INSPECTION OF THE LAB WAS CONDUCTED BY THE COLLEGE OF AMERICAN PATHOLOGISTS(CAP). THE INSPECTION WENT VERY WELL WITH SCCH'S LAB RECEIVING THE DESIGNATION OF EXCELLENCE. ONE OF THE INSPECTORS REMARKED THAT THE SCCH LAB INSPECTION WAS THE BEST HE HAS ENCOUNTERED OVER THE COURSE OF THE 12 YEARS HE HAS BEEN A LAB INSPECTOR. SURGICAL SERVICES: SURGICAL SERVICES PROVIDED BY SCCH INCLUDE: UROLOGY, SINUPLASTY AND OTHER ENT, OPTHALMOLOGY, ORTHOPEDICS, PLASTICS, GYN, PODIATRY, ORAL, AND GENERAL SURGERY, LASER OPTHALMOLOGY AND REFRACTORY PROCEDURES ARE PERFORMED IN THE OPERATING ROOM. 422 INPATIENT SURGERY CASES WERE PERFORMED DURING THE YEAR. SCCH HAS A 11-BED OUTPATIENT SURGERY DEPARTMENT DEVELOPED FOR PATIENTS WHO ARE HAVING A SHORT STAY SURGERY OR PROCEDURE AND ARE ABLE TO BE SENT HOME FOLLOWING A RECOVERY PERIOD AT THE HOSPITAL. 1,358 OUTPATIENT SURGERY CASES WERE PERFORMED DURING FY13. SPIRITUAL AND PASTORAL CARE: SCCH HAS A VOLUNTEER CHAPLAIN PROGRAM THAT IS ENHANCED BY A SPIRITUAL SUPPORT TEAM MADE UP OF SCCH TEAM MEMBERS. THEIR WORK CROSSES INSTITUT
CLASSES OF MEMBERS OR STOCKHOLDERS FORM 990, PAGE 6, PART VI, LINE 6 MOUNTAIN STATES HEALTH ALLIANCE IS THE 80% MEMBER OF SMYTH COUNTY COMMUNITY HOSPITAL. SMYTH COUNTY COMMUNITY HOSPITAL FOUNDATION IS THE 20% MEMBER OF SMYTH COUNTY COMMUNITY HOSPITAL.
ELECTION OF MEMBERS AND THEIR RIGHTS FORM 990, PAGE 6, PART VI, LINE 7A THERE ARE TWO CLASSES OF MEMBERS, AND EACH CLASS IS ENTITLED TO ELECT A SPECIFIED NUMBER OF DIRECTORS TO THE BOARD. THE MOUNTAIN STATES HEALTH ALLIANCE (MSHA) CLASS IS ELECTED BY THE MSHA BOARD OF DIRECTORS AND THE SMYTH COUNTY COMMUNITY HOSPITAL CLASS IS ELECTED BY THE SMYTH COUNTY COMMUNITY HOSPITAL FOUNDATION BOARD OF DIRECTORS. NEITHER SIDE CAN VETO AN APPOINTMENT.
DECISIONS SUBJECT TO APPROVAL OF MEMBERS FORM 990, PAGE 6, PART VI, LINE 7B CERTAIN DECISIONS OF THE BOARD ARE, PURSUANT TO CHARTER AND VIRGINIA STATUTE, SUBJECT TO APPROVAL OF THE MEMBERS. THESE DECISIONS INCLUDE: DISSOLUTION OF THE CORPORATION; MERGER OF THE CORPORATION; NON-ORDINARY COURSE OF BUSINESS SALE OF ASSETS; ETC. NO ORDINARY, DAY TO DAY DECISIONS ARE SUBJECT TO MEMBER APPROVAL.
ORGANIZATION'S PROCESS USED TO REVIEW FORM 990 FORM 990, PAGE 6, PART VI, LINE 11B THE CONTROLLER, ALLONG WITH THE CEO, REVIEWED THE FORM 990 WITH THE BOARD OF DIRECTORS PRIOR TO FILING WITH THE IRS AND THE RETURN WAS MADE AVAILABLE TO EACH BOARD MEMBER IN AN ELECTRONIC FORMAT PRIOR TO THE REVIEW.
ENFORCEMENT OF CONFLICTS POLICY FORM 990, PAGE 6, PART VI, LINE 12C ANNUALLY, THE CORPORATE AUDIT AND COMPLIANCE DEPARTMENT OF MSHA FORWARDS THE CONFLICT OF INTEREST POLICY AND DISCLOSURE FORM TO ALL MSHA MANAGEMENT TEAM MEMBERS AND BOARD MEMBERS. EMPLOYEES AND BOARD MEMBERS MUST NOTE ANY CONFLICTS OR ATTEST THEY HAVE "NONE", AND RETURN THE FORM TO THE AUDIT AND COMPLIANCE DEPARTMENT. ANY NOTED DISCLOSURES ARE FORWARDED TO THE APPROPRIATE MANAGEMENT OR BOARD PERSONNEL TO EVALUATE AND UTILIZE WHEN A TRANSACTION INVOLVING A CONFLICTED PERSON ARISES. ADDITIONALLY, PERSONNEL WHO HAVE A CONFLICT ARISE BETWEEN THE ANNUAL DISTRIBUTION OF THE POLICY AND FORMS ARE REQUIRED TO DISCLOSE THE CONFLICT AND WOULD BE DISCIPLINED IN ANY INSTANCE WHERE THEY HAVE NOT DISCLOSED AND ENGAGED IN A CONFLICTED TRANSACTION.
COMPENSATION PROCESS FOR TOP OFFICIAL FORM 990, PAGE 6, PART VI, LINE 15A THE CEO'S COMPENSATION AND BENEFITS ARE SUBJECT TO THE EXECUTIVE COMPENSATION POLICY OF MOUNTAIN STATES HEALTH ALLIANCE (MSHA). THE POLICY WAS ESTABLISHED BY MSHA'S BOARD OF DIRECTORS AND IS ALLIGNED WITH THE MSHA MISSION, VISION, AND VALUES, SUPPORTING THE ACHIEVEMENT OF THE HEALTH SYSTEM'S STRATEGIC PLANS AND ANNUAL GOALS AND OBJECTIVES. THE POLICY ENSURES THAT MSHA'S EXECUTIVE COMPENSATION IS COMPLIANT WITH THE LEGAL, REGULATORY, AND STATUTORY ENVIRONMENT AFFECTING COMPENSATION. MSHA'S PRESIDENT AND CEO MAKES RECOMMENDATIONS TO THE EXECUTIVE COMMITTEE OF THE MSHA BOARD FOR ALL ELEMENTS OF COMPENSATION FOR THE SENIOR MANAGEMENT TEAM, INCLUDING SMYTH COUNTY COMMUNITY HOSPITAL'S CEO, LINDA WHITE. THE BOARD OF DIRECTORS MONITORS THE PERFORMANCE OF THE SENIOR MANAGEMENT TEAM ON AN ONGOING BASIS, BUT AT LEAST ANNUALLY.
COMPENSATION PROCESS FOR OFFICERS FORM 990, PAGE 6, PART VI, LINE 15B SIMILAR TO THE CEO'S COMPENSATION, THE CFO RECEIVES COMPENSATION AND BENEFITS THAT COMPLY WITH MSHA'S SALARY POLICY. HIS PAY IS SET AT A MARKET PERCENTILE SPECIFIC TO HIS POSITION.
GOVERNING DOCUMENTS DISCLOSURE EXPLANATION FORM 990, PAGE 6, PART VI, LINE 19 GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE MADE AVAILABLE UPON REQUEST TO APPROPRIATE PARTIES REQUESTING THEM. FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THOSE PARTIES WHO OWN INDEBTEDNESS OF THE COMPANY ON A QUARTERLY BASIS.
RELATED ORGANIZATIONS FORM 990, PAGE 7, PART VII FORM 990, PART VII, SECTION A: TRUSTEE COMPENSATION: HOSPITAL BOARD OF TRUSTEES MEMBERS ANN FLEMING AND JOHN SCHARIO HAVE FORM 990 REPORTABLE COMPENSATION DERIVED FROM SERVICES THEY PROVIDED TO RELATED ORGANIZATIONS. THEY DO NOT RECEIVE COMPENSATION FOR SERVICES AS HOSPITAL BOARD TRUSTEES.
OTHER FEES FOR SERVICES FORM 990, PART IX, LINE 11G HOSPITAL SUPPORTED CLINIC 3,464,549 0 0 PHYSICIAN FEES 2,695,862 0 0 DIETARY FEES 1,360,071 0 0 OTHER FEES 632,660 19,272 0
OTHER CHANGES IN NET ASSETS EXPLANATION FORM 990, PART XI, LINE 9 NET UNREALIZED GAIN ON INVESTMENTS 1,535,593 PARTNERSHIP INCOME NOT ON BOOKS -116,399 PARTNERSHIP INTEREST INCOME NOT ON BOOKS -517 PARTNERSHIP CAPITAL GAINS NOT ON BOOKS -6 PARTNERSHIP CHARITABLE CONTRIBUTIONS NOT ON BOOKS 30 ELIMINATION OF INTERCOMPANY REC/PAY -353,381 TOTAL TO FORM 990, PART XI, LINE 5 1,065,320
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2012

Additional Data


Software ID:  
Software Version:  
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
SMYTH COUNTY COMMUNITY HOSPITAL
 
Employer identification number

54-0794913
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" to Form 990, Part IV, line 33.)
(a)
Name, address, and EIN (if applicable) 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" to 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 entity?
Yes No
(1) MOUNTAIN STATES HEALTH ALLIANCE

400 N STATE OF FRANKLIN ROAD

JOHNSON CITY,TN37604
62-0476282 		HOSPITAL TN 501C3 3 NA
 
 
No
(2) SMYTH COUNTY COMM FOUNDATION

1 HEALTH WAY

MARION,VA24354
31-1650055 		SUPPORT VA 501C3 11A NA
 
 
No
(3) NORTON COMMUNITY HOSPITAL

100 15TH STREET NORTHWEST

NORTON,VA24273
54-0566029 		HOSPITAL VA 501C3 3 NA
 
 
No
(4) DICKENSON COMMUNITY HOSPITAL

ONE HOSPITAL DRIVE

CLINTWOOD,VA24238
77-0599553 		HOSPITAL VA 501C3 3 NCH
 
 
No
(5) JOHNSTON MEMORIAL HOSPITAL

16000 JOHNSTON MEMORIAL DRIVE

ABINGDON,VA24211
54-0544705 		HOSPITAL VA 501C3 3 NA
 
 
No
(6) ABINGDON PHYSICIAN PARTNERS

16000 JOHNSTON MEMORIAL DRIVE

ABINGDON,VA24211
20-5485346 		MED. SERV. VA 501C3 11A JMH
 
 
No
(7) MOUNTAIN STATES FOUNDATION

2335 KNOB CREEK ROAD STE 101

JOHNSON CITY,TN37604
58-1418862 		FUNDRAISER TN 501C3 11A MSHA
 
 
No
(8) MSHA AUXILIARY

400 N STATE OF FRANKLIN ROAD

JOHNSON CITY,TN37604
58-1418345 		SUPPORT TN 501C3 11A NA
 
 
No
(9) APPALACHIAN EMERGENCY PHYSICIANS

1021 W OAKLAND AVENUE STE 207

JOHNSON CITY,TN37604
80-0592504 		MED. SERV VA 501C3 11A N/A
 
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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 V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No
(1) INTEGRATED SOLUTIONS HLTH NTWK LLC

400 N STATE OF FRANKLIN ROAD
JOHNSON CITY,TN37604
62-1711997 		INVESTMENT TN NA
  		EXCLUDED -10 -352   No     No 0.040 %
(2) EMMAUS COMMUNITY HEALTHCARE PLLC

6070 HWY 11E
PINEY FLATS,TN37686
20-0577483 		MED. SERV. TN NA
  		        No     No  
(3) MEDICAL SPECIALISTS OF J C LLC

2528 WESLEY STREET SUITE 2
JOHNSON CITY,TN37604
27-2199037 		MED. SERV. TN NA
  		        No     No  
(4) ANEWCARE COLLABORATIVE LLC

208 SUNSET DRIVE SUITE 403
JOHNSON CITY,TN37604
45-3232366 		ACO TN NA
  		        No     No  
(5) INTEGRATED SOLUTIONS HLTH NTWK LLC

400 N STATE OF FRANKLIN ROAD
JOHNSON CITY,TN37604
62-1711997 		INVESTMENT TN NA
  		EXCLUDED -10 -352   No     No 0.040 %
(6) EMMAUS COMMUNITY HEALTHCARE PLLC

6070 HWY 11E
PINEY FLATS,TN37686
20-0577483 		MED. SERV. TN NA
  		        No     No  
(7) MEDICAL SPECIALISTS OF J C LLC

2528 WESLEY STREET SUITE 2
JOHNSON CITY,TN37604
27-2199037 		MED. SERV. TN NA
  		        No     No  
(8) ANEWCARE COLLABORATIVE LLC

208 SUNSET DRIVE SUITE 403
JOHNSON CITY,TN37604
45-3232366 		ACO TN NA
  		        No     No  
Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" to 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
 		(i)
Section 512(b)(13) controlled entity?
Yes No
(1) SOUTHWEST COMMUNITY HEALTH SERVICES

P O BOX 880
MARION,VA24354
54-1460695 		MED. SERV. VA NA
  		C CORP 238,565 1,372,768 100.000 %   No
(2) BLUE RIDGE MEDICAL MANAGEMENT CORP

1021 W OAKLAND AVENUE SUITE 207
JOHNSON CITY,TN37604
62-1490616 		MED. SERV. TN NA
  		C CORP         No
(3) MEDISERVE MED EQUIP OF KINGSPORT

1021 W OAKLAND AVENUE SUITE 207
JOHNSON CITY,TN37604
62-1212286 		DME TN NA
  		C CORP         No
(4) MOUNTAIN STATES PROPERTIES

1021 W OAKLAND AVENUE SUITE 207
JOHNSON CITY,TN37604
62-1845895 		PROP MGMT TN NA
  		C CORP         No
(5) MOUNTAIN STATES PHYSICIANS GRP INC

1021 W OAKLAND AVENUE SUITE 207
JOHNSON CITY,TN37604
62-1700412 		HEALTHCARE TN NA
  		C CORP         No
(6) COMMUNITY HOME CARE INC

1460 PARK AVENUE
NORTON,VA24273
54-1453810 		MED. EQUIP TN NA
  		C CORP         No
(7) WILSON PHARMACY INC

PO BOX 5289
JOHNSON CITY,TN37602
62-0329587 		PHARMACY TN NA
  		C CORP         No
(8) CRESTPOINT HEALTH INSURANCE CO INC

208 SUNSET DRIVE SUITE 101
JOHNSON CITY,TN37604
62-0381170 		INSURANCE TN NA
  		C CORP         No
(9) SOUTHWEST COMMUNITY HEALTH SERVICES

P O BOX 880
MARION,VA24354
54-1460695 		MED. SERV. VA NA
  		C CORP 238,565 1,372,768 100.000 %   No
(10) BLUE RIDGE MEDICAL MANAGEMENT CORP

1021 W OAKLAND AVENUE SUITE 207
JOHNSON CITY,TN37604
62-1490616 		MED. SERV. TN NA
  		C CORP         No
(11) MEDISERVE MED EQUIP OF KINGSPORT

1021 W OAKLAND AVENUE SUITE 207
JOHNSON CITY,TN37604
62-1212286 		DME TN NA
  		C CORP         No
(12) MOUNTAIN STATES PROPERTIES

1021 W OAKLAND AVENUE SUITE 207
JOHNSON CITY,TN37604
62-1845895 		PROP MGMT TN NA
  		C CORP         No
(13) MOUNTAIN STATES PHYSICIANS GRP INC

1021 W OAKLAND AVENUE SUITE 207
JOHNSON CITY,TN37604
62-1700412 		HEALTHCARE TN NA
  		C CORP         No
(14) COMMUNITY HOME CARE INC

1460 PARK AVENUE
NORTON,VA24273
54-1453810 		MED. EQUIP TN NA
  		C CORP         No
(15) WILSON PHARMACY INC

PO BOX 5289
JOHNSON CITY,TN37602
62-0329587 		PHARMACY TN NA
  		C CORP         No
(16) CRESTPOINT HEALTH INSURANCE CO INC

208 SUNSET DRIVE SUITE 101
JOHNSON CITY,TN37604
62-0381170 		INSURANCE TN NA
  		C CORP         No
Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35b, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
Yes
No
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 or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
Yes
 
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
Yes
 
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
 
No
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
Yes
 
f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
Yes
 
k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1m
Yes
 
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1n
 
No
o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
Yes
 
p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1s
Yes
 
2
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-s) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1) SOUTHWEST COMMUNITY HEALTH SERVICES

 A 25,177  
(2) SOUTHWEST COMMUNITY HEALTH SERVICES

 B 358,645  




Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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) 		(d)
Predominant income (related, unrelated, excluded from tax under section 512-514)

(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 V—UBI
amount in box 20
of Schedule K-1
(Form 1065) 		(j)
General or
managing
partner? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
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


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