Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
BARREN RIVER REGIONAL CANCER CENTER INC
Employer identification number
26-0058987
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the 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)
(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)
(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
Gross receipts from related activities, etc. (see instructions)
..................
12
13
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here........................................
Section C. Computation of Public Support Percentage
14
Public support percentage for 2012 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2011 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2012.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
.......................
b
33 1/3% support test—2011.
If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2012.
If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization
.....................................................
b
10%-facts-and-circumstances test—2011.
If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported organization
................................................
18
Private foundation.
If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions
.....................................................
Schedule A (Form 990 or 990-EZ) 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)
(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)
(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
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public support percentage for 2012 (line 8, column (f) divided by line 13, column (f))
.........
15
16
Public support percentage from 2011 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f))
......
17
18
Investment income percentage from 2011 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2012.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
........
b
33 1/3% support tests—2011.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
.....
20
Private foundation.
If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 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:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
BARREN RIVER REGIONAL CANCER CENTER INC
Employer identification number
26-0058987
Identifier
Return Reference
Explanation
DELEGATION OF MANAGEMENT DUTIES
FORM 990, PART VI, LINE 3
------------------------ THE BOARD HAS ENTERED INTO A MANAGEMENT AND TECHNICAL SERVICES SUPPORT SERVICES AGREEMENT WHEREBY DAY TO DAY OPERATIONS OF THE OUTPATIENT RADIATION THERAPY CENTER ARE PROVIDED BY OR MANAGED BY CLINICAL, SUPPORT AND MANAGEMENT STAFF OF THE BOWLING GREEN WARREN COUNTY COMMUNITY HOSPITAL CORPORATION, DBA THE MEDICAL CENTER. THE MEDICAL CENTER IS AN ACUTE CARE HOSPITAL THAT HAS OPERATED A HOSPITAL-BASED RADIATION THERAPY CENTER SINCE APRIL, 1983. THE HOSPITAL HAS HIGHLY SKILLED NURSES, THERAPISTS, DOSIMETRISTS, PHYSICISTS, ASSISTANTS, SUPPORT STAFF AND MANAGEMENT WHO SERVE THE BARREN RIVER REGIONAL CANCER CENTER, INC. PATIENTS AND THEIR FAMILIES.
MEMBERS OR STOCKHOLDERS
FORM 990, PART VI, SECTION A, LINE 6
------------------------ THE CORPORATION IS EQUALLY OWNED BY TWO NON-PROFIT ACUTE CARE HOSPITAL CORPORATIONS WHO EACH SERVE AS A MEMBER OF THE ENTITY.
MEMBERS/STOCKHOLDERS WHO MAY ELECT GOVERNING BODY MEMBERS
FORM 990, PART VI, SECTION A, LINE 7A
------------------------ EACH MEMBER OF THE CORPORATION MAY DESIGNATE THREE DIRECTORS AND SHALL HAVE THE EXCLUSIVE RIGHT TO DESIGNATE THE SUCCESSOR FOR THE DIRECTOR OR DIRECTORS THEY DESIGNATED.
REVIEW OF FORM 990 BY THE GOVERNING BODY
FORM 990, PART VI, SECTION B, LINE 11
------------------------ FORM 990 IS PLACED ELECTRONICALLY ON A COMPANY WEBSITE USED TO SHARE INFORMATION WITH BOARD MEMBERS. EACH BOARD MEMBER IS PROVIDED ACCESS TO THIS WEBSITE AND IS ASKED TO REVIEW FORM 990 PRIOR TO A DESIGNATED DATE ON WHICH THE RETURN WILL BE FILED. AT LEAST TWO WEEKS OF ADVANCE NOTICE IS GIVEN TO BOARD MEMBERS SO THEY MAY REVIEW THE RETURN.
MONITORING AND ENFORCEMENT OF CONFLICT OF INTEREST POLICY
FORM 990, PART VI, SECTION B, LINE 12C
------------------------ BOWLING GREEN WARREN COUNTY COMMUNITY HOSPITAL CORPORATION, INC. IS A 50% EQUITY HOLDER IN THE CORPORATION AND ALSO MANAGES THE CORPORATION'S DAILY ACTIVITIES. BOWLING GREEN WARREN COUNTY COMMUNITY HOSPITAL CORPORATION, INC. USES THE POLICIES OF ITS PARENT, NOT-FOR-PROFIT COMMONWEALTH HEALTH CORPORATION, AS A BASIS FOR POLICIES APPLIED TO THE CORPORATION. THE COMMONWEALTH HEALTH CORPORATION (CHC) (APPLICABLE TO THE CORPORATION AND/OR ITS AFFILIATES) CODE OF CONDUCT EXPLICITLY STATES MEMBERS OF THE BOARD, ADMINISTRATION, THE MEDICAL STAFF AND ALL EMPLOYEES ARE EXPECTED TO AVOID CONFLICTS OF INTEREST IN A TIMELY MANNER. ALL INDIVIDUALS SIGN AN ACKNOWLEDGEMENT UPON EMPLOYMENT THAT THEY HAVE RECEIVED A COPY OF THE CODE OF CONDUCT, ARE FAMILIAR WITH ITS CONTENT AND UNDERSTAND THEIR RESPONSIBILITIES TO AVOID NON-COMPLIANT ACTIVITY. CHC'S REGULATORY COMPLIANCE COMMITTEE (RCC) REVIEWS AND APPROVES ALL CONTRACTS FOR CHC AND/OR AFFILIATES. THE REVIEW IS DESIGNED TO IDENTIFY POTENTIAL CONFLICTS OF INTEREST BY BOARD MEMBERS AND/OR OFFICERS. RCC MEMBERS ARE PROHIBITED FROM TAKING PART IN DECISIONS REGARDING TRANSACTIONS WITH WHICH HE/SHE HAS A CONFLICT OF INTEREST. ANNUALLY, WRITTEN INQUIRY IS MADE-BY QUESTIONNAIRE- OF BOARD MEMBERS AND OFFICERS SEEKING DISCLOSURE OF CONFLICTS OF INTEREST OR INFORMATION THAT RELATES TO FAMILY MEMBERS. TRANSACTIONS ARISING ARE REVIEWED BY MANAGEMENT AS THEY OCCUR.
MAKING DOCUMENTS AVAILABLE TO THE PUBLIC
FORM 990, PART VI, SECTION C, LINE 19
------------------------ Governing Documents, Conflict of Interest Policy and financial statements are only made available if required, and in the manner required, by a governing agency.
PROGRAM SERVICE ACCOMPLISHMENTS
FORM 990, PART III, LINE 4A
------------------------ THE BARREN RIVER REGIONAL CANCER CENTER, INC. ("CANCER CENTER") WAS ESTABLISHED AND OPENED APRIL 1, 2003 TO ACT AND OPERATE EXCLUSIVELY FOR CHARITABLE PURPOSES BECAUSE OF AN INCREASING NEED FOR RADIATION THERAPY SERVICES IN SOUTH-CENTRAL KENTUCKY. ONCE A SPECIFIC PLAN FOR TREATING THE PATIENT'S CANCER IS DEVELOPED, WE GO TO WORK. ADVANCED EQUIPMENT SENDS CANCER-FIGHTING RADIATION TO THE TUMOR. CAREFUL FOLLOW-UP AND CLOSE PHYSICIAN SUPERVISION ENSURE THE BEST POSSIBLE OUTCOME. RADIATION THERAPY IS A PRIMARY THERAPY FOR BASAL CELL CARCINOMAS OF THE SKIN, EARLY STAGE LARYNGEAL CANCERS, OTHER HEAD AND NECK CANCERS, EARLY STAGE HODGKIN'S DISEASE, NON-HODGKIN'S LYMPHOMAS, EARLY STAGE BREAST CANCER FOLLOWING LUMPECTOMY, CERTAIN LUNG CANCERS, SEMINOMAS, CARCINOMAS OF THE CERVIX, PROSTRATE CANCERS, BLADDER CANCERS, ANAL CANCERS, CERTAIN PEDIATRIC TUMORS, AND SOME BRAIN TUMORS. RADIATION THERAPY MAY BE PERFORMED FOR CURATIVE, CANCER ELIMINATION, OR PALLIATIVE REASONS. IT MAY BE USED TO SUPPLEMENT OTHER PRIMARY TREATMENT MODALITIES. PREOPERATIVE RADIATION IS USED TO SHRINK THE SIZE OF A TUMOR TO ALLOW A LESS RADICAL OR DISFIGURING SURGICAL PROCEDURE. POSTOPERATIVE RADIATION THERAPY IS FREQUENTLY USED TO DECREASE THE RISK OF LOCAL RECURRENCES FOLLOWING SURGERY TO THE BREAST, LUNG, RECTAL CANCERS, HEAD AND NECK TUMORS, AND BRAIN TUMORS. RADIATION THERAPY MAY ALSO BE USED TO PROPHYLACTICALLY TREAT TISSUES OR ORGANS BEFORE DISEASE IS CLINICALLY EVIDENT. RADIATION THERAPY USES HIGH-ENERGY IONIZING RADIATION TO KILL CANCER CELLS BY DELIVERING A LETHAL DOSE OF RADIATION TO TUMOR TISSUE, WHILE DELIVERING AN ACCEPTABLE DOSE TO HEALTHY TISSUE. IT IS TYPICALLY DELIVERED IN A SERIES OF FIFTEEN-MINUTE TREATMENT SESSIONS FIVE DAYS A WEEK OVER A SIX-TO-EIGHT WEEK PERIOD. RADIATION TREATMENTS ARE PROVIDED TO AN ADULT AND GERIATRIC POPULATION. ALL TREATMENTS ARE ORDERED BY RADIATION ONCOLOGISTS, A PHYSICIAN WHO HAS SPECIALIZED IN THE MANAGEMENT AND TREATMENT OF CANCER CASES UTILIZING IONIZING RADIATION. TREATMENTS ARE ADMINISTERED BY LICENSED RADIATION THERAPISTS WHO HAVE HAD TRAINING IN BOTH DIAGNOSTIC AND THERAPEUTIC RADIOLOGY PROGRAMS. QUALITY CONTROL OVERSIGHT IS PROVIDED BY A MASTER'S DEGREE PHYSICIST WHO HAS SPECIFIC TRAINING IN MEDICAL PHYSICS. THE PHYSICIST IS ASSISTED IN QUALITY CONTROL AND DOSE CALCULATION AND MANAGEMENT BY A CERTIFIED MEDICAL DOSIMETRIST. A RADIATION ONCOLOGY NURSE IS ALSO AVAILABLE FOR PATIENT ASSESSMENT, EDUCATION, AND NUTRITIONAL ASSESSMENT AND TO MEET THE VARIOUS NEEDS OF THE PATIENT. THE SCOPE OF THIS FACILITY IS SOLELY TO PROVIDE EXTERNAL BEAM RADIATION TREATMENTS. THIS SIMPLY MEANS TREATMENTS ARE DELIVERED FROM AN EXTERNAL SOURCE. THE SOURCE OF RADIATION IS FROM A LINEAR ACCELERATOR WHICH CREATES HIGH ENERGY X-RAYS IN THE THERAPEUTIC DOSAGE RANGE FOR THE TREATMENT OF CANCER. DURING THE BARREN RIVER REGIONAL CANCER CENTER'S LATEST FISCAL YEAR ENDING MARCH 31, 2013, 196 NEW PATIENTS PRESENTED FOR CONSULTATION. THIS WAS A DECREASE OF 15% FROM THE PREVIOUS YEAR WHEN 225 PATIENTS RECEIVED CONSULTATION. THE CANCER CENTER DELIVERED 4,774 EXTERNAL BEAM TREATMENTS DURING FISCAL 2013 AND 5,628 TREATMENTS IN FISCAL 2012. IN ADDITION, 970 PREVIOUSLY TREATED PATIENTS WERE SEEN FOR FOLLOW-UP.
RECONCILIATION OF NET ASSETS
FORM 990, PART XI, LINE 9
------------------------ OTHER RECONCILING ITEMS: DISTRIBUTIONS TO PARTNERS ($2,000,000)
PUBLIC CHARITY STATUS
SCHEDULE A, PART I, LINE 3
Barren River Regional Cancer Center, Inc.'s public charity classification has been designated as a hospital described in section 170(b)(1)(A)(ii) by the IRS. Schedule H has not been completed by Barren River REgional Cancer Center as it does not operate a state licensed hospital facility.
OTHER FEES FOR SERVICES FOR NON-EMPLOYEES
FORM 990 PART IX LINE 11G
DESCRIPTION:COLLECTION AGENCY FEES TOTAL FEES:8767
OTHER FEES FOR SERVICES FOR NON-EMPLOYEES
FORM 990 PART IX LINE 11G
DESCRIPTION:MEDICAL CONSULTING FEES TOTAL FEES:18000
OTHER FEES FOR SERVICES FOR NON-EMPLOYEES
FORM 990 PART IX LINE 11G
DESCRIPTION:CONTRACT FEES TOTAL FEES:27508
OTHER FEES FOR SERVICES FOR NON-EMPLOYEES
FORM 990 PART IX LINE 11G
DESCRIPTION:BILLING FEES TOTAL FEES:62880
OTHER FEES FOR SERVICES FOR NON-EMPLOYEES
FORM 990 PART IX LINE 11G
DESCRIPTION:EMPLOYEE SUPPORT FEES TOTAL FEES:813823
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.