Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for instructions and the latest information.
| (i) Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 10 above (see instructions)) | (iv) Is the organization listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
|
Total |
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Calendar year (or fiscal year beginning in) ![]() |
(a) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") .. | ||||||
| 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. | ||||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (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 VI.).. | ||||||
| 11 | Total support. Add lines 7 through 10 | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (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.) | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (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 VI.) .. | ||||||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | ||||||
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e |
Discount claimed for blockage or other factors (explain in detail in Part VI): |
|||||
| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 0.015 of line 3 (for greater amount, see instructions). | 4 | ||||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | ||||
| 6 | Multiply line 5 by 0.035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | 1 | |
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
2 | |
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | 3 | |
| 4 Amounts paid to acquire exempt-use assets | 4 | |
| 5 Qualified set-aside amounts (prior IRS approval required - provide details in Part VI) | 5 | |
| 6 Other distributions (describe in Part VI). See instructions | 6 | |
| 7Total annual distributions. Add lines 1 through 6. | 7 | |
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
8 | |
| 9 Distributable amount for 2020 from Section C, line 6 | 9 | |
| 10 Line 8 amount divided by Line 9 amount | 10 | |
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2020 |
(iii) Distributable Amount for 2020 |
|
|---|---|---|---|---|
| 1 Distributable amount for 2020 from Section C, line 6 | ||||
|
2
Underdistributions, if any, for years prior to 2019 (reasonable cause required-- explain in Part VI). See instructions. |
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| 3 Excess distributions carryover, if any, to 2020: | ||||
| a From 2015....... | ||||
| b From 2016....... | ||||
| c From 2017....... | ||||
| d From 2018....... | ||||
| e From 2019....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2020 distributable amount | ||||
|
i
Carryover from 2015 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from line 3f. | ||||
| 4Distributions for 2020 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2020 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from line 4. | ||||
|
5
Remaining underdistributions for years prior to 2020, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
6
Remaining underdistributions for 2020. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
7 Excess distributions carryover to 2021. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2016..... | ||||
| b Excess from 2017..... | ||||
| c Excess from 2018..... | ||||
| d Excess from 2019..... | ||||
| e Excess from 2020..... | ||||
| Facts And Circumstances Test |
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| Return Reference | Explanation |
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| Software ID: | |
| Software Version: |
Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| FORM 990, PART III, LINE 4A & 4B | PROGRAM SERVICE ACCOMPLISHMENTS --------------------------------- MCF HAS BEEN PROVIDING OUTSTANDING HEALTHCARE SERVICES FOR RESIDENTS IN FRANKLIN AND SIMPSON COUNTIES SINCE 2000. THE HOSPITAL'S PROFESSIONAL STAFF INCLUDES PHYSICIANS WHO ARE ENGAGED IN THE PRACTICE OF MEDICINE AND WHO REPRESENT MULTIPLE SPECIALTIES, INCLUDING FAMILY PRACTICE AND EMERGENCY CARE. THE STAFF ALSO INCLUDES NURSES, PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPISTS, RESPIRATORY THERAPISTS, DIETICIANS AND OTHERS USING AN INTERDISCIPLINARY TEAM APPROACH, THE STAFF WORKS COLLABORATIVELY TO PROVIDE PRIMARY OUTPATIENT CARE, RENDERED IN AN EMERGENCY ROOM AND OUTPATIENT SETTING, AND SECONDARY CARE CONSISTING OF INPATIENT SERVICES OF A GENERAL AND SPECIALIZED NATURE. MCF FEATURES A FULL-SERVICE EMERGENCY ROOM THAT IS AVAILABLE AND STAFFED WITH PHYSICIANS AND REGISTERED NURSES 24 HOURS A DAY, 7 DAYS A WEEK. WE OFFER CT, MRI, DIGITAL MAMMOGRAPHY, ULTRASOUND, OUTPATIENT CHEMOTHERAPY, AND NUCLEAR MEDICINE SERVICES. RADIOLOGISTS ARE AVAILABLE TO READ EXAMS IN REAL TIME VIA VIRTUAL OR ON-SITE. THE LABORATORY AND RESPIRATORY THERAPY DEPARTMENTS ARE STAFFED DAILY 24 HOURS PER DAY. OUR FACILITY ALSO PROVIDES PHYSICAL REHABILITATION SERVICES, INCLUDING PHYSICAL THERAPY, SPEECH THERAPY, AND OCCUPATIONAL THERAPY. OTHER SERVICES OFFERED INCLUDE OUPATIENT CARDIOPULMONARY REHABILITATION AND AN OUTPATIENT BEHAVIORAL HEALTH PROGRAM. TELEMEDICINE SERVICES ARE ALSO UTILIZED TO PROVIDE ACCESS TO CARE TO VARIOUS SPECIALTY PHYSICIANS. THE HOSPITAL HAS A SURGERY DEPARTMENT WITH TWO OPERATING SUITES, ONE ENDOSCOPY SUITE AND A SIX BED RECOVERY UNIT. SERVICES INCLUDE GENERAL SURGERY, PODIATRY SURGERY, OTOLARYNGOLOGY SURGERY, CATARACT SURGERY AND REFRACTIVE SURGERY. DURING FISCAL YEAR 2021 THE HOSPITAL ADMITTED 258 ACUTE PATIENTS WHO RECEIVED 997 PATIENT DAYS OF CARE AND 256 SWING BED PATIENTS WHO RECEIVED 5,182 DAYS OF CARE. |
| FORM 990, PART V, LINE 2A | MANAGEMENT SERVICES AGREEMENT -------------------------------- COMMONWEALTH HEALTH CORPORATION HAS A MANAGEMENT SERVICES AGREEMENT FOR THE FOLLOWING RELATED ORGANIZATIONS: BOWLING GREEN-WARREN COUNTY COMMUNITY HOSPITAL CORPORATION, THE MEDICAL CENTER AT FRANKLIN, INC., THE MEDICAL CENTER AT CLINTON COUNTY, INC., AND COMMONWEALTH REGIONAL SPECIALTY HOSPITAL. ALL SALARIES AND PAYROLL TAXES ARE REPORTED ON A CONSOLIDATED FORM 941. THE EIN ON THE FORM 941 IS 31-1118087. |
| FORM 990, PART VI, SECTION A, LINE 6 | MEMBERS ------------ THE CORPORATION'S ARTICLES OF INCORPORATION SPECIFY THE CORPORATION SHALL HAVE ONE (1) MEMBER. THE MEMBER SHALL BE COMMONWEALTH HEALTH CORPORATION, INC. |
| FORM 990, PART VI, SECTION A, LINE 7A & 7B | POWER OF MEMBERS --------------------- LINE 7A: BYLAWS OF THE CORPORATION SPECIFY THAT THE SOLE MEMBER SHALL APPOINT A NOMINATING COMMITTEE WHICH SHALL MEET AND DESIGNATE NOMINEES FOR BOARD DIRECTORSHIPS. LINE 7B: THE BYLAWS MAY BE REVISED OR AMENDED BY AFFIRMATIVE VOTE OF TWO-THIRDS (2/3) OF THE BOARD, SUBJECT TO APPROVAL OF THE MEMBER. |
| FORM 990, PART VI, SECTION B, LINE 11B | PROCESS TO REVIEW FORM 990 ---------------------------- FORM 990 IS PLACED ELECTRONICALLY ON A COMPANY WEBSITE USED TO SHARE INFORMATION WITH BOARD MEMBERS. EACH BOARD MEMBER IS PROVIDED ACCESS TO THE WEBSITE AND IS ASKED TO REVIEW FORM 990 PRIOR TO A DESIGNATED DATE ON WHICH THE RETURN WILL BE FILED. AT LEAST TWO WEEKS OF ADVANCE NOTICE IS GIVEN TO BOARD MEMBERS SO THEY MAY REVIEW THE RETURN. |
| FORM 990, PART VI, SECTION B, LINE 12C: | MONITORING THE CONFLICT OF INTEREST POLICY -------------------------------------------- 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 POLICY INTEREST. FURTHER, IT REQUIRES DISCLOSURE OF ANY POTENTIAL 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 BETWEEN CHC AND/OR ITS AFFILIATES AND DISQUALIFIED ENTITIES. 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. |
| FORM 990, PART VI, SECTION B, LINE 15A & 15B: | DETERMINING COMPENSATION --------------------------- OFFICERS OF THIS ENTITY ARE EMPLOYEES OF COMMONWEALTH HEALTH CORPORATION. CHC USES INDEPENDENT CONSULTANTS TO ANNUALLY REVIEW COMPENSATION. COMPENSATION-RELATED DETERMINATIONS ARE CONDUCTED IN ACCORDANCE WITH APPLICABLE REQUIREMENTS OF THE INTERNAL REVENUE CODE AND REGULATIONS TO QUALIFY FOR THE PRESUMPTION THAT THE COMPENSATION IS REASONABLE, INCLUDING BUT NOT LIMITED TO APPROVAL BY AN AUTHORIZED COMMITTEE OF THE BOARD OF DIRECTORS WHO DO NOT HAVE A CONFLICT OF INTEREST, OBTAINING AND RELYING ON APPROPRIATE DATA AS TO COMPARABILITY, AND CONCURRENT DOCUMENTATION OF THE BASES FOR THE COMPENSATION DETERMINATIONS. |
| FORM 990, PART VI, SECTION C, LINE 19 | MAKING DOCUMENTS AVAILABLE TO THE PUBLIC ---------------------------------------- GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE ONLY MADE AVAILABLE IF REQUESTED, AND IN THE MANNER REQUIRED, BY A GOVERNING AGENCY. |
| FORM 990, PART XI, LINE 9 | OTHER ADJUSTMENTS --------------------------- TRANSFER OF INVESTMENTS TO COMMONWEALTH HEALTH CORPORATION (AFFILIATE) ( $3,000,000 ) |
| FORM 990, PART XII, LINE 2C | OVERSIGHT PROCESS -------------------- THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTION OF THE INDEPENDENT ACCOUNTANT. NO PROCESSES HAVE CHANGED FROM PRIOR YEAR. |
| FORM 990 PART IX LINE 11G | DESCRIPTION:COLLECTION AGENCY FEES TOTAL FEES:296820 |
| FORM 990 PART IX LINE 11G | DESCRIPTION:MEDICAL CONSULTING FEES TOTAL FEES:732777 |
| FORM 990 PART IX LINE 11G | DESCRIPTION:OTHER PROFESSIONAL FEES TOTAL FEES:1232602 |
| FORM 990 PART IX LINE 11G | DESCRIPTION:LAB FEES TOTAL FEES:2010 |
| FORM 990 PART IX LINE 11G | DESCRIPTION:CONTRACT FEES TOTAL FEES:663760 |
| FORM 990 PART IX LINE 11G | DESCRIPTION:BILLING FEES TOTAL FEES:381627 |
| FORM 990 PART IX LINE 11G | DESCRIPTION:EMPLOYEE SUPPORT FEES TOTAL FEES:41052 |
| FORM 990 PART IX LINE 11G | DESCRIPTION:AGENCY NURSING FEES TOTAL FEES:341929 |
| Software ID: | |
| Software Version: |