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. Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
EPHRAIM MCDOWELL HEALTH INC
Employer identification number
61-1324736
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the supported organization?
................
11g(i)
No
(ii)
A family member of a person described in (i) above?
......................
11g(ii)
No
(iii)
A 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
No
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of monetary support
Yes
No
Yes
No
Yes
No
(A)
EPHRAIM MCDOWELL REGIONAL MEDICAL CENTER
610492356
03
Yes
Yes
Yes
0
Total
0
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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 2013 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2013.
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—2012.
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—2013.
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—2012.
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) 2013
Schedule A (Form 990 or 990-EZ) 2013
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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2013.
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—2012.
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) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 4
Part IV
Supplemental Information.
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) 2013
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.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
EPHRAIM MCDOWELL HEALTH INC
Employer identification number
61-1324736
Return Reference
Explanation
form 990, PART VI, SECTION B, LINE 11
PROCESS TO REVIEW FORM 990 -------------------------- COPIES OF THE FORM 990 ARE SUBMITTED TO THE FULL BOARD VIA EMAIL PRIOR TO FILING.
FORM 990, PART VI, SECTION B, LINE 12B AND 12C
MONITORING THE CONFLICT OF INTEREST POLICY ------------------------------------------ ANNUALLY, BOARD OF DIRECTORS, SENIOR LEADERSHIP AND MEDICAL STAFF LEADERS COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE. COMPLETION OF THE ANNUAL QUESTIONNAIRE IS COORDINATED BY GENERAL COUNSEL AND EPHRAIM MCDOWELL'S CORPORATE COMPLIANCE OFFICER. THE COMPLETED QUESTIONNAIRES ARE REVIEWED BY THE SENIOR LEADERSHIP AND THE CORPORATE COMPLIANCE OFFICER. THE CHAIRMAN OF THE BOARD OF DIRECTORS IS MADE AWARE OF CONFLICTS WHICH HAVE BEEN DISCLOSED ON ANNUAL STATEMENTS. IF CONFLICTS EXIST, THE CONFLICT IS DISCLOSED AND THE INDIVIDUAL WITH THE CONFLICT DOES NOT PARTICIPATE OR VOTE ON ACTIVITIES WHERE A CONFLICT OF INTEREST IS PRESENT.
FORM 990, PART VI, SECTION B, LINE 15A AND 15B
PROCESS FOR DETERMINING COMPENSATION ------------------------------------ THE MERCER GROUP, INDEPENDENT CONSULTANTS, CONDUCTED A REVIEW IN 2012 FOR ESTABLISHING REASONABLE COMPENSATION OF OFFICERS AND KEY EMPLOYEES. THE ORGANIZATION ALSO UTILIZED COMPENSATION STUDIES. THE COMPENSATION IS APPROVED BY THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS. THE DECISION AND PROCESS IS DOCUMENTED BY THE COMMITTEE.
FORM 990, PART VI, SECTION C, LINE 19
MAKING FORMS AVAILABLE TO THE PUBLIC ------------------------------------ The organization makes its governing documents, conflict of interest policy and financial statements available to the public upon request.
FORM 990, PART V, LINE 2A
COMMON PAYMASTER ---------------- EPHRAIM MCDOWELL REGIONAL MEDICAL CENTER IS THE COMMON PAYMASTER FOR EPHRAIM MCDOWELL HEALTH, INC. ALL SALARIES AND PAYROLL TAXES ARE REPORTED ON A CONSOLIDATED FORM 941. THE EIN ON THE FORM 941 IS 61-0492356.
FORM 990, PART III, LINE 4
PROGRAM SERVICE ACCOMPLISHMENTS ------------------------------- The top community health priorities for Ephraim McDowell Health (EMH) have been based on the 2011 Community Health Assessment conducted by Professional Research Consultants of Omaha, Nebraska. The top three priorities are: 1. Cardiovascular disease and related risk factors 2. Cancer and related risk factors 3. Childhood obesity and related risk factors. Other identified needs were deferred due to resource limitations and the fact that addressing health behaviors and risks associated with the top three would improve overall health and well-being. Targeted populations were the uninsured, underinsured and at-risk groups based on age, gender, ethnicity or socio-economic factors. All screenings were free of charge to the client. A logic chain model was used to plan events with our community partners and to evaluate the effectiveness of each event. Senior Leadership serves in many capacities within the larger community to improve the lives of those we serve. The recorded community benefit cost for the senior leadership team totaled $43,610, A 28 PERCENT INCREASE FROM $31,393 IN fy 2013. Not reported are the many hours spent as a volunteer manning the booths at the Annual Kentucky BBQ Festival, Brass Band Festival or Re-enactment of the Battle of Perryville to increase tourism in Danville/Boyle County. This does not reflect the time and efforts in advocacy and giving testimony at the local, state and national level to improve access to care or environmental impact and/or economic improvement. Senior leadership participated either as a volunteer or leading a community benefit activity in 86 venues. This includes local, regional, state and national events. Community Health Improvement Services ------------------------------------- EMH also sponsored Ambassadors for Early Heart AttacK Care (EHAC) in an effort in improve community health outcomes. This was a component of the Chest Pain Center Accreditation work within the health system. Bookmarks with signs and symptoms of heart attacK for men and women have been distributed to primary care provider, OB/gyn, orthopaedic, and general surgery offices for public distribution. EHAC information is also on the website and trifold educational materials are provided for the public. Community CPR was provided to schools and health ministries upon request. Community Health Education -------------------------- Parish Nurse Program - Journey Church in Lincoln County was the only new church added to the Faith Community Nursing/Health Ministries service of the organization in FY 2014. Eleven newsletters were sent to the associated churches and FCNs in FY 2014. An advanced educational program, "The Art of Resilience" was planned and communicated for a regional audience for early FY 2015. The Faith Community Nursing Foundation Course was provided in the Spring of FY 2014 with attendees from Kentucky and Tennessee. School Based Program - Safe Swim Program for Elementary School students served 119 children in FY 2014. Speakers Bureau (Health Topics) - Centenary United Methodist end of life series and stroke risk program. Financial Donations for the Community - In-Kind ----------------------------------------------- Cash or in -Kind Donations to the Community - two hundred seventeen turkeys were donated toward providing a holiday dinner for those served by the food baskets from The Salvation Army. The turkeys were an average of 13 pounds and valued at $2,839. Personnel/Administrative Support - included board membership of the YMCA, Heart of Danville, Heart of Kentucky United Way, Midway College Nursing Advisory Board, Chamber of Commerce, Heart of Danville Main Street Program, McDowell House, Kentucky Hospital Association, Kentucky Organization of Nurse Leaders, Premier, and The Salvation Army. Community Building Activities ----------------------------- Senior leadership serves with local and regional Big Brother/Big Sister programs. Services include board membership, fund raising activities, speaking engagement to raise public awareness and support of the potentially life changing services of Big Brother/Big Sister for clients. Senior leaders assisted in the Salvation Army Kettle drive fund raiser for those in need during a time of economic challenge in the region due to increased unemployment and under employment. Coalition Building - included serving on Heart of Danville Board, Chamber of Commerce, Economic Development Council, assisted with the Heart of Danville Lawn Chair Theatre for the community, board member of Kentucky Organization of Nurse Leaders, member of Rotary with committee responsibilities, board member of The Salvation Army, Heart of Kentucky United Way Investment committee member, board member of YMCA and board member of McDowell House. The marketing department also helped with the logistics of the United Way Day of Action, and The Salvation Army Annual Banquet. Senior leaders of the organization also participate in the Annual EMRMC Auxiliary Membership Event and annual volunteer recognition dinner. Community Health Improvement Advocacy - Senior leaders gave testimony at the City Commissioners meeting, served on the KHA legislative committee, conducted forums with Congressional members related to healthcare issues in rural south central Kentucky. The time spent in the various community benefit activities by senior leaders is valued at $43,610. Based upon community need feedback from town hall meetings, medical staff and governing board the following providers were recruited for the service area in FY 2014: Dr Gary Wortz-Opthalmology Dr. Nicola Jabbour-Oncology Dr Douglas Stein-Pediatric Dr John Merryman-General Surgeon Alana Leavell, APRNUrgent Care/SMP Dr John Allaham-Psychiatry Dr Yair Litvin- Endoscopy Vicki Chapman-APRN FMP Dr Stephen Meese-OB/GYN Leadership Development/Training for Community Members - mentoring by the senior leaders included resume building, interview practice, and individual coaching sessions for young professionals. Community Benefit Operation --------------------------- 2014 a repeat Community Health Need Assessment(CHNA) conducted by Professional Research Consultants (PRC) of Omaha, Nebraska for the EMH six county service area at a cost of $84,537 and a 95 per cent confidence level. A community focus group from the six counties was convened by PRC. The group included health department, governmental, first responders, educators and social agency leaders from each of the counties. Senior leadership reviews and approves both the community health assessment and the implementation plan to address the priority health risks for the population served and presents to the governing board for approval. They also allocate resources, both financially and personnel to address the implementation plan. Annually there is a budget approved by senior leadership and presented for governing board approval for community benefit. The senior leadership receives an annual update related the work plan objectives and outcomes. The 2011 health risk assessment showed improvement trends related to cardiovascular risk in Boyle County from the 2008 assessment. The focused community benefit efforts began in Boyle County in FY 2008. The Ephraim McDowell Health System provided $6,726,426 in financial assistance and means-tested programs within the two hospitals to improve the health of the community we serve.
FORM 990, PART XI, LINE 9
RECONCILIATION OF NET ASSETS ---------------------------- OTHER CHANGES IN NET ASSETS: ROUNDING $2
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.