2013 Open to Public Inspection

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1 SCHEDULE H (Form 990) Dprtmnt of th Trsury Intrnl Rvnu Srvi If "Ys," ws it writtn poliy? If th orgniztion h multipl hospitl filitis, init whih of th following st sris pplition of th finnil ssistn poliy to its vrious hospitl filitis uring th tx yr. Appli uniformly to ll hospitl filitis Appli uniformly to most hospitl filitis Answr th following s on th finnil ssistn ligiility ritri tht ppli to th lrgst numr of th orgniztion's ptints uring th tx yr. If th orgniztion us ftors othr thn FPG in trmining ligiility, sri in Prt VI th inom s ritri for trmining ligiility for fr or isount r. Inlu in th sription whthr th orgniztion us n sst tst or othr thrshol, rgrlss of inom, s ftor in trmining ligiility for fr or isount r. 4 Di th orgniztion's finnil ssistn poliy tht ppli to th lrgst numr of its ptints uring th tx yr provi for fr or isount r to th "milly inignt"? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 5 Di th orgniztion ugt mounts for fr or isount r provi unr its finnil ssistn poliy uring th tx yr? ~~~~ Complt th following tl using th workshts provi in th Shul H instrutions. Do not sumit ths workshts with th Shul H. OMB No Finnil Assistn n Crtin Othr Community Bnfits t Cost Numr of Prsons Totl Dirt Nt Prnt of Finnil Assistn n () () () () () (f) tivitis or srv ommunity offstting ommunity totl xpns progrms (optionl) (optionl) nfit xpns rvnu nfit xpns Mns-Tst Govrnmnt Progrms Totl Finnil Assistn n Mns-Tst Govrnmnt Progrms f g h i k Othr Bnfits Totl. A lins 7 n 7j Complt if th orgniztion nswr "Ys" to Form 990, Prt IV, qustion 0. Atth to Form 990. S sprt instrutions. Informtion out Shul H (Form 990) n its instrutions is t Di th orgniztion hv finnil ssistn poliy uring th tx yr? If "No," skip to qustion 6 ~~~~~~~~~~~ Gnrlly tilor to iniviul hospitl filitis Di th orgniztion us Frl Povrty Guilins (FPG) s ftor in trmining ligiility for proviing fr r? If "Ys," init whih of th following ws th FPG fmily inom limit for ligiility for fr r: ~~~~~~~~~~~~~ 00% 50% 00% Othr 0 % Di th orgniztion us FPG s ftor in trmining ligiility for proviing isount r? If "Ys," init whih of th following ws th fmily inom limit for ligiility for isount r: ~~~~~~~~~~~~~~~~~~~~~~~~ 00% 50% 00% 50% 400% Othr % If "Ys," i th orgniztion's finnil ssistn xpnss x th ugt mount? ~~~~~~~~~~~~~~~~ If "Ys" to lin 5, s rsult of ugt onsirtions, ws th orgniztion unl to provi fr or isount r to ptint who ws ligil for fr or isount r? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 6 Di th orgniztion prpr ommunity nfit rport uring th tx yr? ~~~~~~~~~~~~~~~~~~~~~~~ If "Ys," i th orgniztion mk it vill to th puli? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Finnil Assistn t ost (from Worksht ) ~~~~~~~~~~ Mii (from Worksht, olumn ) ~~~~~~~~~~~ Costs of othr mns-tst govrnmnt progrms (from Worksht, olumn ) ~~~~~ Community hlth improvmnt srvis n ommunity nfit oprtions (from Worksht 4) ~~~~~~~ Hlth profssions ution (from Worksht 5) ~~~~~~~ Susiiz hlth srvis (from Worksht 6) ~~~~~~~ Rsrh (from Worksht 7) Csh n in-kin ontriutions for ommunity nfit (from Worksht 8) ~~ ~~~~~~~~~ j Totl. Othr Bnfits ~~~~~~ Hospitls Nm of th orgniztion BLUE RIDGE HEALTHCARE HOSPITALS, INC. Prt I Finnil Assistn n Crtin Othr Community Bnfits t Cost , , ,649. 5, Opn to Puli Insption Employr intifition numr , , , LHA For Pprwork Rution At Noti, s th Instrutions for Form 990. Shul H (Form 990) Ys.70%.44%.5% 4.9%.%.64%.07%.8% 5.% No

2 Shul H (Form 990) 0 BLUE RIDGE HEALTHCARE HOSPITALS, INC Pg Prt II Community Builing Ativitis Complt this tl if th orgniztion onut ny ommunity uiling tivitis uring th tx yr, n sri in Prt VI how its ommunity uiling tivitis promot th hlth of th ommunitis it srvs. () Numr of tivitis or progrms (optionl) () Prsons srv (optionl) () Totl ommunity uiling xpns () Dirt offstting rvnu () Nt ommunity uiling xpns (f) Prnt of totl xpns Stion A. B Dt Expns 4 Stion B. Mir Stion C. Colltion Prtis 9 Physil improvmnts n housing Eonomi vlopmnt Community support Environmntl improvmnts Lrship vlopmnt n trining for ommunity mmrs Colition uiling Community hlth improvmnt voy Workfor vlopmnt Othr 0 Totl Prt III B Dt, Mir, & Colltion Prtis Di th orgniztion rport t xpns in orn with Hlthr Finnil Mngmnt Assoition Sttmnt No. 5? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Entr th mount of th orgniztion's t xpns. Explin in Prt VI th mthoology us y th orgniztion to stimt this mount Entr th stimt mount of th orgniztion's t xpns ttriutl to ptints ligil unr th orgniztion's finnil ssistn poliy. Explin in Prt VI th mthoology us y th orgniztion to stimt this mount n th rtionl, if ny, for inluing this portion of t s ommunity nfit ~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~ Provi in Prt VI th txt of th footnot to th orgniztion's finnil sttmnts tht sris t xpns or th pg numr on whih this footnot is ontin in th tth finnil sttmnts. Entr totl rvnu riv from Mir (inluing DSH n IME) Entr Mir llowl osts of r rlting to pymnts on lin 5 Sutrt lin 6 from lin 5. This is th surplus (or shortfll) ~~~~~~~~~~~~ ~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~ Dsri in Prt VI th xtnt to whih ny shortfll rport in lin 7 shoul trt s ommunity nfit. Also sri in Prt VI th osting mthoology or sour us to trmin th mount rport on lin 6. Chk th ox tht sris th mtho us: Cost ounting systm Cost to hrg rtio Othr Di th orgniztion hv writtn t olltion poliy uring th tx yr? ~~~~~~~~~~~~~~~~~~~~~~~ If "Ys," i th orgniztion's olltion poliy tht ppli to th lrgst numr of its ptints uring th tx yr ontin provisions on th olltion prtis to follow for ptints who r known to qulify for finnil ssistn? Dsri in Prt VI 9 Prt IV Mngmnt Compnis n Joint Vnturs (own 0% or mor y offirs, irtors, trusts, ky mploys, n physiins - s instrutions) BLUE RIDGE CARDIOLOGY CAROLINAS HEALTHCARE SYSTEM HEART CATH SVCS MANAGEMENT SERVICES 4,504. 4, %.00% 4,504. 4,504. 6,75,575.,55,90. 4,7,8. 48,6,88. -7,495,447. () Nm of ntity () Dsription of primry () Orgniztion's () Offirs, irt- () Physiins' tivity of ntity profit % or stok ownrship % ors, trusts, or ky mploys' profit % or stok ownrship %.00%.00% 9.4%.4% Ys profit % or stok ownrship %.00%.00% No Shul H (Form 990) 0

3 Shul H (Form 990) 0 BLUE RIDGE HEALTHCARE HOSPITALS, INC Prt V Fility Informtion Stion A. Hospitl Filitis (list in orr of siz, from lrgst to smllst) How mny hospitl filitis i th orgniztion oprt uring th tx yr? Nm, rss, primry wsit rss, n stt lins numr CMC-BR MORGANTON 0 SOUTH STERLING STREET MORGANTON, NC 8655 Lins hospitl Gn. mil & surgil Chilrn's hospitl Thing hospitl Critil ss hospitl Rsrh fility ER-4 hours ER-othr Othr (sri) Pg Fility rporting group CMC-BR VALDESE 70 MALCOM BLVD RUTHERFORD COLLEGE, NC Shul H (Form 990) 0

4 Shul H (Form 990) 0 BLUE RIDGE HEALTHCARE HOSPITALS, INC Prt V Fility Informtion (ontinu) Stion B. Fility Poliis n Prtis (Complt sprt Stion B for h of th hospitl filitis or fility rporting groups list in Prt V, Stion A) Pg 4 Nm of hospitl fility or fility rporting group CMC - BR MORGANTON If rporting on Prt V, Stion B for singl hospitl fility only: lin numr of hospitl fility (from Shul H, Prt V, Stion A) Community Hlth Ns Assssmnt (Lins through 8 r optionl for tx yrs ginning on or for Mrh, 0) f g h i j f g h i During th tx yr or ithr of th two immitly pring tx yrs, i th hospitl fility onut ommunity hlth ns ssssmnt (CHNA)? If "No," skip to lin 9 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "Ys," init wht th CHNA rport sris (hk ll tht pply): A finition of th ommunity srv y th hospitl fility Dmogrphis of th ommunity Existing hlth r filitis n rsours within th ommunity tht r vill to rspon to th hlth ns 8 Di th orgniztion inur n xis tx unr stion 4959 for th hospitl fility's filur to onut CHNA If "Ys" to lin 8, i th orgniztion fil Form 470 to rport th stion 4959 xis tx? If "Ys" to lin 8, wht is th totl mount of stion 4959 xis tx th orgniztion rport on Form of th ommunity How t ws otin Th hlth ns of th ommunity Primry n hroni iss ns n othr hlth issus of uninsur prsons, low-inom prsons, n minority groups Th pross for intifying n prioritizing ommunity hlth ns n srvis to mt th ommunity hlth ns Th pross for onsulting with prsons rprsnting th ommunity's intrsts Informtion gps tht limit th hospitl fility's ility to ssss th ommunity's hlth ns Othr (sri in Stion C) Init th tx yr th hospitl fility lst onut CHNA: 0 In onuting its most rnt CHNA, i th hospitl fility tk into ount input from prsons who rprsnt th ro intrsts of th ommunity srv y th hospitl fility, inluing thos with spil knowlg of or xprtis in puli hlth? If "Ys," sri in Stion C how th hospitl fility took into ount input from prsons who rprsnt th ommunity, n intify th prsons th hospitl fility onsult ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Ws th hospitl fility's CHNA onut with on or mor othr hospitl filitis? If "Ys," list th othr hospitl filitis in Stion C ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Di th hospitl fility mk its CHNA rport wily vill to th puli? If "Ys," init how th CHNA rport ws m wily vill (hk ll tht pply): Hospitl fility's wsit (list url): Othr wsit (list url): Avill upon rqust from th hospitl fility Othr (sri in Stion C) $ ~~~~~~~~~~~~~~~~~~~~~~~~ If th hospitl fility rss ns intifi in its most rntly onut CHNA, init how (hk ll tht pply s of th n of th tx yr): Aoption of n implmnttion strtgy tht rsss h of th ommunity hlth ns intifi through th CHNA Exution of th implmnttion strtgy Prtiiption in th vlopmnt of ommunity-wi pln Prtiiption in th xution of ommunity-wi pln Inlusion of ommunity nfit stion in oprtionl plns Aoption of ugt for provision of srvis tht rss th ns intifi in th CHNA Prioritiztion of hlth ns in its ommunity Prioritiztion of srvis tht th hospitl fility will unrtk to mt hlth ns in its ommunity Othr (sri in Stion C) Di th hospitl fility rss ll of th ns intifi in its most rntly onut CHNA? If "No," xplin in Stion C whih ns it hs not rss n th rsons why it hs not rss suh ns ~~~~~~~~~~~ s rquir y stion 50(r)()? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ for ll of its hospitl filitis? ~~~~~~~~~~~~~~~~ Ys No Shul H (Form 990) 0 4

5 Shul H (Form 990) 0 BLUE RIDGE HEALTHCARE HOSPITALS, INC Prt V Fility Informtion (ontinu) CMC - BR MORGANTON Pg 5 Finnil Assistn Poliy Ys No f g h i f g Billing n Colltions Di th hospitl fility hv in pl uring th tx yr writtn finnil ssistn poliy tht: Explin ligiility ritri for finnil ssistn, n whthr suh ssistn inlus fr or isount r? ~~~~~ Us frl povrty guilins (FPG) to trmin ligiility for proviing fr r? ~~~~~~~~~~~~~~~~~~~~ If "Ys," init th FPG fmily inom limit for ligiility for fr r: 0 % If "No," xplin in Stion C th ritri th hospitl fility us. Us FPG to trmin ligiility for proviing isount r? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "Ys," init th FPG fmily inom limit for ligiility for isount r: 50 % If "No," xplin in Stion C th ritri th hospitl fility us. Explin th sis for lulting mounts hrg to ptints? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "Ys," init th ftors us in trmining suh mounts (hk ll tht pply): Inom lvl Asst lvl Mil inigny Insurn sttus Uninsur isount Mii/Mir Stt rgultion Rsiny Othr (sri in Stion C) Explin th mtho for pplying for finnil ssistn? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Inlu msurs to puliiz th poliy within th ommunity srv y th hospitl fility? If "Ys," init how th hospitl fility puliiz th poliy (hk ll tht pply): Th poliy ws post on th hospitl fility's wsit Th poliy ws tth to illing invois Th poliy ws post in th hospitl fility's mrgny rooms or witing rooms Th poliy ws post in th hospitl fility's missions offis Th poliy ws provi, in writing, to ptints on mission to th hospitl fility Th poliy ws vill on rqust Othr (sri in Stion C) ~~~~~~~~~~~~~~~ Di th hospitl fility hv in pl uring th tx yr sprt illing n olltions poliy, or writtn finnil ssistn poliy (FAP) tht xplin tions th hospitl fility my tk upon non-pymnt? Chk ll of th following tions ginst n iniviul tht wr prmitt unr th hospitl fility's poliis uring th tx yr for mking rsonl fforts to trmin th iniviul's ligiility unr th fility's FAP: Rporting to rit gny Lwsuits Lins on rsins Boy tthmnts Othr similr tions (sri in Stion C) ~~~~~~~~~~~~~~ Di th hospitl fility or n uthoriz thir prty prform ny of th following tions uring th tx yr for mking rsonl fforts to trmin th iniviul's ligiility unr th fility's FAP? ~~~~~~~~~~~~~~~~~~~~~~ If "Ys," hk ll tions in whih th hospitl fility or thir prty ngg: Rporting to rit gny Lwsuits Lins on rsins Boy tthmnts Othr similr tions (sri in Stion C) Shul H (Form 990)

6 Shul H (Form 990) 0 BLUE RIDGE HEALTHCARE HOSPITALS, INC Prt V Fility Informtion (ontinu) CMC - BR MORGANTON 8 9 Init whih fforts th hospitl fility m for inititing ny of th tions list in lin 7 (hk ll tht pply): ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Notifi iniviuls of th finnil ssistn poliy on mission Notifi iniviuls of th finnil ssistn poliy prior to ishrg Notifi iniviuls of th finnil ssistn poliy in ommunitions with th iniviuls rgring th iniviuls' ills Doumnt its trmintion of whthr iniviuls wr ligil for finnil ssistn unr th hospitl fility's finnil ssistn poliy Othr (sri in Stion C) Poliy Rlting to Emrgny Mil Cr Di th hospitl fility hv in pl uring th tx yr writtn poliy rlting to mrgny mil r tht rquirs th hospitl fility to provi, without isrimintion, r for mrgny mil onitions to iniviuls rgrlss of thir ligiility unr th hospitl fility's finnil ssistn poliy? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 9 Ys Pg 6 No If "No," init why: Th hospitl fility i not provi r for ny mrgny mil onitions Th hospitl fility's poliy ws not in writing Th hospitl fility limit who ws ligil to riv r for mrgny mil onitions (sri in Stion C) Othr (sri in Stion C) Chrgs to Iniviuls Eligil for Assistn unr th FAP (FAP-Eligil Iniviuls) 0 Init how th hospitl fility trmin, uring th tx yr, th mximum mounts tht n hrg to FAP-ligil iniviuls for mrgny or othr milly nssry r. Th hospitl fility us its lowst ngotit ommril insurn rt whn lulting th mximum mounts tht n hrg Th hospitl fility us th vrg of its thr lowst ngotit ommril insurn rts whn lulting th mximum mounts tht n hrg Th hospitl fility us th Mir rts whn lulting th mximum mounts tht n hrg Othr (sri in Stion C) During th tx yr, i th hospitl fility hrg ny FAP-ligil iniviul to whom th hospitl fility provi mrgny or othr milly nssry srvis mor thn th mounts gnrlly ill to iniviuls who h insurn ovring suh r? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "Ys," xplin in Stion C. During th tx yr, i th hospitl fility hrg ny FAP-ligil iniviul n mount qul to th gross hrg for ny srvi provi to tht iniviul? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "Ys," xplin in Stion C. Shul H (Form 990)

7 Shul H (Form 990) 0 BLUE RIDGE HEALTHCARE HOSPITALS, INC Prt V Fility Informtion (ontinu) Stion B. Fility Poliis n Prtis (Complt sprt Stion B for h of th hospitl filitis or fility rporting groups list in Prt V, Stion A) Pg 4 Nm of hospitl fility or fility rporting group CMC-BR VALDESE If rporting on Prt V, Stion B for singl hospitl fility only: lin numr of hospitl fility (from Shul H, Prt V, Stion A) Community Hlth Ns Assssmnt (Lins through 8 r optionl for tx yrs ginning on or for Mrh, 0) f g h i j f g h i During th tx yr or ithr of th two immitly pring tx yrs, i th hospitl fility onut ommunity hlth ns ssssmnt (CHNA)? If "No," skip to lin 9 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "Ys," init wht th CHNA rport sris (hk ll tht pply): A finition of th ommunity srv y th hospitl fility Dmogrphis of th ommunity Existing hlth r filitis n rsours within th ommunity tht r vill to rspon to th hlth ns 8 Di th orgniztion inur n xis tx unr stion 4959 for th hospitl fility's filur to onut CHNA If "Ys" to lin 8, i th orgniztion fil Form 470 to rport th stion 4959 xis tx? If "Ys" to lin 8, wht is th totl mount of stion 4959 xis tx th orgniztion rport on Form of th ommunity How t ws otin Th hlth ns of th ommunity Primry n hroni iss ns n othr hlth issus of uninsur prsons, low-inom prsons, n minority groups Th pross for intifying n prioritizing ommunity hlth ns n srvis to mt th ommunity hlth ns Th pross for onsulting with prsons rprsnting th ommunity's intrsts Informtion gps tht limit th hospitl fility's ility to ssss th ommunity's hlth ns Othr (sri in Stion C) Init th tx yr th hospitl fility lst onut CHNA: 0 In onuting its most rnt CHNA, i th hospitl fility tk into ount input from prsons who rprsnt th ro intrsts of th ommunity srv y th hospitl fility, inluing thos with spil knowlg of or xprtis in puli hlth? If "Ys," sri in Stion C how th hospitl fility took into ount input from prsons who rprsnt th ommunity, n intify th prsons th hospitl fility onsult ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Ws th hospitl fility's CHNA onut with on or mor othr hospitl filitis? If "Ys," list th othr hospitl filitis in Stion C ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Di th hospitl fility mk its CHNA rport wily vill to th puli? If "Ys," init how th CHNA rport ws m wily vill (hk ll tht pply): Hospitl fility's wsit (list url): Othr wsit (list url): Avill upon rqust from th hospitl fility Othr (sri in Stion C) $ ~~~~~~~~~~~~~~~~~~~~~~~~ If th hospitl fility rss ns intifi in its most rntly onut CHNA, init how (hk ll tht pply s of th n of th tx yr): Aoption of n implmnttion strtgy tht rsss h of th ommunity hlth ns intifi through th CHNA Exution of th implmnttion strtgy Prtiiption in th vlopmnt of ommunity-wi pln Prtiiption in th xution of ommunity-wi pln Inlusion of ommunity nfit stion in oprtionl plns Aoption of ugt for provision of srvis tht rss th ns intifi in th CHNA Prioritiztion of hlth ns in its ommunity Prioritiztion of srvis tht th hospitl fility will unrtk to mt hlth ns in its ommunity Othr (sri in Stion C) Di th hospitl fility rss ll of th ns intifi in its most rntly onut CHNA? If "No," xplin in Stion C whih ns it hs not rss n th rsons why it hs not rss suh ns ~~~~~~~~~~~ s rquir y stion 50(r)()? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ for ll of its hospitl filitis? ~~~~~~~~~~~~~~~~ Ys No Shul H (Form 990) 0 7

8 Shul H (Form 990) 0 BLUE RIDGE HEALTHCARE HOSPITALS, INC Prt V Fility Informtion (ontinu) CMC-BR VALDESE Pg 5 Finnil Assistn Poliy Ys No f g h i f g Billing n Colltions Di th hospitl fility hv in pl uring th tx yr writtn finnil ssistn poliy tht: Explin ligiility ritri for finnil ssistn, n whthr suh ssistn inlus fr or isount r? ~~~~~ Us frl povrty guilins (FPG) to trmin ligiility for proviing fr r? ~~~~~~~~~~~~~~~~~~~~ If "Ys," init th FPG fmily inom limit for ligiility for fr r: 0 % If "No," xplin in Stion C th ritri th hospitl fility us. Us FPG to trmin ligiility for proviing isount r? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "Ys," init th FPG fmily inom limit for ligiility for isount r: 50 % If "No," xplin in Stion C th ritri th hospitl fility us. Explin th sis for lulting mounts hrg to ptints? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "Ys," init th ftors us in trmining suh mounts (hk ll tht pply): Inom lvl Asst lvl Mil inigny Insurn sttus Uninsur isount Mii/Mir Stt rgultion Rsiny Othr (sri in Stion C) Explin th mtho for pplying for finnil ssistn? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Inlu msurs to puliiz th poliy within th ommunity srv y th hospitl fility? If "Ys," init how th hospitl fility puliiz th poliy (hk ll tht pply): Th poliy ws post on th hospitl fility's wsit Th poliy ws tth to illing invois Th poliy ws post in th hospitl fility's mrgny rooms or witing rooms Th poliy ws post in th hospitl fility's missions offis Th poliy ws provi, in writing, to ptints on mission to th hospitl fility Th poliy ws vill on rqust Othr (sri in Stion C) ~~~~~~~~~~~~~~~ Di th hospitl fility hv in pl uring th tx yr sprt illing n olltions poliy, or writtn finnil ssistn poliy (FAP) tht xplin tions th hospitl fility my tk upon non-pymnt? Chk ll of th following tions ginst n iniviul tht wr prmitt unr th hospitl fility's poliis uring th tx yr for mking rsonl fforts to trmin th iniviul's ligiility unr th fility's FAP: Rporting to rit gny Lwsuits Lins on rsins Boy tthmnts Othr similr tions (sri in Stion C) ~~~~~~~~~~~~~~ Di th hospitl fility or n uthoriz thir prty prform ny of th following tions uring th tx yr for mking rsonl fforts to trmin th iniviul's ligiility unr th fility's FAP? ~~~~~~~~~~~~~~~~~~~~~~ If "Ys," hk ll tions in whih th hospitl fility or thir prty ngg: Rporting to rit gny Lwsuits Lins on rsins Boy tthmnts Othr similr tions (sri in Stion C) Shul H (Form 990)

9 Shul H (Form 990) 0 BLUE RIDGE HEALTHCARE HOSPITALS, INC Prt V Fility Informtion (ontinu) CMC-BR VALDESE 8 9 Init whih fforts th hospitl fility m for inititing ny of th tions list in lin 7 (hk ll tht pply): ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Notifi iniviuls of th finnil ssistn poliy on mission Notifi iniviuls of th finnil ssistn poliy prior to ishrg Notifi iniviuls of th finnil ssistn poliy in ommunitions with th iniviuls rgring th iniviuls' ills Doumnt its trmintion of whthr iniviuls wr ligil for finnil ssistn unr th hospitl fility's finnil ssistn poliy Othr (sri in Stion C) Poliy Rlting to Emrgny Mil Cr Di th hospitl fility hv in pl uring th tx yr writtn poliy rlting to mrgny mil r tht rquirs th hospitl fility to provi, without isrimintion, r for mrgny mil onitions to iniviuls rgrlss of thir ligiility unr th hospitl fility's finnil ssistn poliy? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 9 Ys Pg 6 No If "No," init why: Th hospitl fility i not provi r for ny mrgny mil onitions Th hospitl fility's poliy ws not in writing Th hospitl fility limit who ws ligil to riv r for mrgny mil onitions (sri in Stion C) Othr (sri in Stion C) Chrgs to Iniviuls Eligil for Assistn unr th FAP (FAP-Eligil Iniviuls) 0 Init how th hospitl fility trmin, uring th tx yr, th mximum mounts tht n hrg to FAP-ligil iniviuls for mrgny or othr milly nssry r. Th hospitl fility us its lowst ngotit ommril insurn rt whn lulting th mximum mounts tht n hrg Th hospitl fility us th vrg of its thr lowst ngotit ommril insurn rts whn lulting th mximum mounts tht n hrg Th hospitl fility us th Mir rts whn lulting th mximum mounts tht n hrg Othr (sri in Stion C) During th tx yr, i th hospitl fility hrg ny FAP-ligil iniviul to whom th hospitl fility provi mrgny or othr milly nssry srvis mor thn th mounts gnrlly ill to iniviuls who h insurn ovring suh r? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "Ys," xplin in Stion C. During th tx yr, i th hospitl fility hrg ny FAP-ligil iniviul n mount qul to th gross hrg for ny srvi provi to tht iniviul? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "Ys," xplin in Stion C. Shul H (Form 990)

10 Shul H (Form 990) 0 BLUE RIDGE HEALTHCARE HOSPITALS, INC Prt V Fility Informtion (ontinu) Stion C. Supplmntl Informtion for Prt V, Stion B. Provi sriptions rquir for Prt V, Stion B, lins j,, 4, 5, 6i, 7, 0,, i, 4g, 6, 7, 8, 9, 9, 0,, n. If pplil, provi sprt sriptions for h fility in fility rporting group, signt y "Fility A, " "Fility B," t. Pg 7 CMC - BR MORGANTON: PART V, SECTION B, LINE : BRHC CONDUCTED A SURVEY WHICH WAS DISTRIBUTED TO PATIENTS AND THE GENERAL PUBLIC VIA THE LOCAL HEALTH DEPARTMENT, FESTIVALS, MAILINGS, ETC. CMC-BR VALDESE: PART V, SECTION B, LINE : BRHC CONDUCTED A SURVEY WHICH WAS DISTRIBUTED TO PATIENTS AND THE GENERAL PUBLIC VIA THE LOCAL HEALTH DEPARTMENT, FESTIVALS, MAILINGS, ETC. CMC - BR MORGANTON: PART V, SECTION B, LINE 7: THE SURVEY EMPLOYED IN BRHC HOSPITAL'S CHNA PROCESS PRESENTED RESPONDENTS WITH A LIST OF 0 DISEASES AND HEALTH CONDITIONS. FROM THIS LIST, THEY WERE ASKED TO SELECT WHICH ONES THEY CONSIDERED TO BE THE TOP FIVE IN BURKE COUNTY. THERE WAS A SIGNIFICANT GAP BETWEEN THE FIFTH MOST SELECTED ITEM AND THOSE FOLLOWING. BASED ON THE PERCENTAGE OF RESPONDENTS WHO CHOSE DRUG ABUSE, CANCER, MENTAL HEALTH AND HEART DISEASE AMONG THE TOP FIVE, THESE ARE PROBLEMS THAT NEED ATTENTION. OBESITY/DIABETES WAS THE TOP CHOICE AND WILL BE THE CENTRAL FOCUS OF COMMUNITY HEALTH IMPROVEMENT BY BRHC HOSPITALS FOR THE NET THREE YEARS. THIS SHOULD NOT BE INTERPRETED TO MEAN THAT THE ORGANIZATION IS NOT ACTIVELY INVOLVED IN THE REMAINING FOUR ISSUES IN THE TOP FIVE. THEY ARE SIMPLY NOT THE FOCUS OF THE CHNA AND ITS IMPLEMENTATION STRATEGY. CMC-BR VALDESE: Shul H (Form 990) 0 0

11 Shul H (Form 990) 0 BLUE RIDGE HEALTHCARE HOSPITALS, INC Prt V Fility Informtion (ontinu) Stion C. Supplmntl Informtion for Prt V, Stion B. Provi sriptions rquir for Prt V, Stion B, lins j,, 4, 5, 6i, 7, 0,, i, 4g, 6, 7, 8, 9, 9, 0,, n. If pplil, provi sprt sriptions for h fility in fility rporting group, signt y "Fility A, " "Fility B," t. PART V, SECTION B, LINE 7: THE SURVEY EMPLOYED IN BRHC HOSPITAL'S CHNA PROCESS PRESENTED RESPONDENTS WITH A LIST OF 0 DISEASES AND HEALTH CONDITIONS. FROM THIS LIST, THEY WERE ASKED TO SELECT WHICH ONES THEY CONSIDERED TO BE THE TOP FIVE IN BURKE COUNTY. THERE WAS A SIGNIFICANT GAP BETWEEN THE FIFTH MOST SELECTED ITEM AND THOSE FOLLOWING. BASED ON THE PERCENTAGE OF RESPONDENTS WHO CHOSE DRUG ABUSE, CANCER, MENTAL HEALTH AND HEART DISEASE AMONG THE TOP FIVE, THESE ARE PROBLEMS THAT NEED ATTENTION. OBESITY/DIABETES WAS THE TOP CHOICE AND WILL BE THE CENTRAL FOCUS OF COMMUNITY HEALTH IMPROVEMENT BY BRHC HOSPITALS FOR THE NET THREE YEARS. THIS SHOULD NOT BE INTERPRETED TO MEAN THAT THE ORGANIZATION IS NOT ACTIVELY INVOLVED IN THE REMAINING FOUR ISSUES IN THE TOP FIVE. THEY ARE SIMPLY NOT THE FOCUS OF THE CHNA AND ITS IMPLEMENTATION STRATEGY. Pg 7 CMC - BR MORGANTON: PART V, SECTION B, LINE 4G: PATIENT ROOM VISIT FROM FINANCIAL COUNSELOR AND SOCIAL WORKER, OVERVIEW OF FINANCIAL ASSISTANCE POLICY, AND CONTACT INFORMATION ON WEBSITE AND PATIENT STATEMENTS. CMC-BR VALDESE: PART V, SECTION B, LINE 4G: PATIENT ROOM VISIT FROM FINANCIAL COUNSELOR AND SOCIAL WORKER, OVERVIEW OF FINANCIAL ASSISTANCE POLICY, AND CONTACT INFORMATION ON WEBSITE AND PATIENT STATEMENTS. CMC - BR MORGANTON: PART V, SECTION B, LINE 8E: ALL SELF PAY E.D. PATIENTS ARE SCREENED FOR Shul H (Form 990) 0

12 Shul H (Form 990) 0 BLUE RIDGE HEALTHCARE HOSPITALS, INC Prt V Fility Informtion (ontinu) Stion C. Supplmntl Informtion for Prt V, Stion B. Provi sriptions rquir for Prt V, Stion B, lins j,, 4, 5, 6i, 7, 0,, i, 4g, 6, 7, 8, 9, 9, 0,, n. If pplil, provi sprt sriptions for h fility in fility rporting group, signt y "Fility A, " "Fility B," t. CHARITY AND-OR FINANCIAL ASSISTANCE IN THE E.D. AREA. MONTHLY STATEMENTS REFERENCE THE PHONE NUMBERS TO CALL FOR FINANCIAL ASSISTANCE. Pg 7 CMC-BR VALDESE: PART V, SECTION B, LINE 8E: ALL SELF PAY E.D. PATIENTS ARE SCREENED FOR CHARITY AND-OR FINANCIAL ASSISTANCE IN THE E.D. AREA. MONTHLY STATEMENTS REFERENCE THE PHONE NUMBERS TO CALL FOR FINANCIAL ASSISTANCE. CMC - BR MORGANTON: PART V, SECTION B, LINE 0D: ALL PATIENTS RECEIVE SAME DISCOUNT. EFFECTIVE 9//0 THE UNINSURED DISCOUNT INCREASED FROM 0% TO 50%. CMC-BR VALDESE: PART V, SECTION B, LINE 0D: ALL PATIENTS RECEIVE SAME DISCOUNT. EFFECTIVE 9//0 THE UNINSURED DISCOUNT INCREASED FROM 0% TO 50% Shul H (Form 990) 0

13 Shul H (Form 990) 0 BLUE RIDGE HEALTHCARE HOSPITALS, INC Prt V Fility Informtion (ontinu) Stion D. Othr Hlth Cr Filitis Tht Ar Not Lins, Rgistr, or Similrly Rogniz s Hospitl Fility Pg 8 (list in orr of siz, from lrgst to smllst) How mny non-hospitl hlth r filitis i th orgniztion oprt uring th tx yr? Nm n rss CHS-BR SOUTHEAST PAIN CARE 4 4TH AVENUE CIRCLE NW HICKORY, NC 860 CHS-BR REHABILITATION & PHYSICAL MED. 7 W PARKER RD MORGANTON, NC 8655 Typ of Fility (sri) PROVIDER-BASED PAIN CARE CENTER OUTPATIENT REHAB CENTER (PT, OT, AND ST SERVICES) Shul H (Form 990)

14 Shul H (Form 990) 0 BLUE RIDGE HEALTHCARE HOSPITALS, INC Prt VI Supplmntl Informtion Pg 9 Provi th following informtion Rquir sriptions. Provi th sriptions rquir for Prt I, lins, 6, n 7; Prt II n Prt III, lins,, 4, 8 n 9. Ns ssssmnt. Dsri how th orgniztion sssss th hlth r ns of th ommunitis it srvs, in ition to ny CHNAs rport in Prt V, Stion B. Ptint ution of ligiility for ssistn. Dsri how th orgniztion informs n uts ptints n prsons who my ill for ptint r out thir ligiility for ssistn unr frl, stt, or lol govrnmnt progrms or unr th orgniztion's finnil ssistn poliy. Community informtion. Dsri th ommunity th orgniztion srvs, tking into ount th gogrphi r n mogrphi onstitunts it srvs. Promotion of ommunity hlth. Provi ny othr informtion importnt to sriing how th orgniztion's hospitl filitis or othr hlth r filitis furthr its xmpt purpos y promoting th hlth of th ommunity (.g., opn mil stff, ommunity or, us of surplus funs, t.). Affilit hlth r systm. If th orgniztion is prt of n ffilit hlth r systm, sri th rsptiv rols of th orgniztion n its ffilits in promoting th hlth of th ommunitis srv. Stt filing of ommunity nfit rport. If pplil, intify ll stts with whih th orgniztion, or rlt orgniztion, fils ommunity nfit rport. PART I, LINE C: EPLANATION: BLUE RIDGE HEALTHCARE HOSPITALS USES THE SLIDING SCALE PROVIDED IN THE FEDERAL POVERTY INCOME GUIDELINES PUBLISHED ANNUALLY BY THE DEPARTMENT OF HEALTH AND HUMAN SERVICES TO DETERMINE ELIGIBILITY. AN ASSET TEST IS USED TO DETERMINE ELIGIBILITY FOR FREE OR DISCOUNTED CARE. PART I, LINE 6A: COMMUNITY BENEFIT REPORT IS PREPARED FOR BLUE RIDGE HEALTHCARE SYSTEM (BRHS) WHICH INCLUDES CHS BLUE RIDGE MORGANTON (FORMERLY GRACE HOSPITAL) AND CHS BLUE RIDGE VALDESE (FORMERLY VALDESE GENERAL HOSPITAL). PART II, COMMUNITY BUILDING ACTIVITIES: EPLANATION: BRHC PROVIDES SUPERVISION AND STAFF FOR THE SCHOOL NURSE PROGRAM IN BURKE COUNTY. PART III, LINE : EPLANATION: BAD DEBT COST FROM LINE IS BASED ON TOTAL BAD DEBT EPENSE MULTIPLIED BY THE COST-TO-CHARGE RATIO Shul H (Form 990) 0 4

15 Shul H (Form 990) BLUE RIDGE HEALTHCARE HOSPITALS, INC. Prt VI Supplmntl Informtion (Continution) Pg 9 PART III, LINE : EPLANATION: CHARITY INCLUDED ON LINE IS CALCULATED BASED ON A STATISTICAL SAMPLE OF SELF PAY PATIENTS THAT QUALIFY FOR CHARITY CARE FROM THE OUTPATIENT SETTING. PART III, LINE 4: EPLANATION: UNINSURED DISCOUNTS AND BAD DEBTS INCLUDED THE COST OF SERVICES PROVIDED TO UNINSURED OR UNDERINSURED PATIENTS AND TO PATIENTS WHO OTHERWISE DO NOT PAY FOR THEIR HEALTHCARE SERVICES. THE MISSION OF BRHS IS TO CREATE AND OPERATE A HEALTH SYSTEM TO PROVIDE HOSPITAL, ACUTE AND EMERGENCY CARE, INPATIENT PSYCHIATRIC SERVICES, PHYSICIAN SERVICES, AND LONG-TERM CARE FOR THE BENEFIT OF THE COMMUNITY IT SERVES. COMMITMENT TO THIS MISSION REQUIRES BOTH AN INVESTMENT IN AND A PARTNERSHIP WITH THE COMMUNITY WITHIN WHICH BRHS OPERATES. PART III, LINE 8: EPLANATION: THE MEDICARE COST REPORT IS PREPARED USING THE AUDITED TRIAL BALANCE FOR BLUE RIDGE HEALTHCARE HOSPITALS, INC. THE COST REPORT IS PREPARED IN ACCORDANCE WITH ALL APPLICABLE RULES AND REGULATIONS. AS A 50(C)() ORGANIZATION, BLUE RIDGE HEALTHCARE HOSPITALS ACCEPTS ALL PATIENTS WITHOUT REGARD TO THE INSURANCE OR LACK OF INSURANCE. PART III, LINE 9B: EPLANATION: BLUE RIDGE HEALTHCARE FACILITIES OFFER FINANCIAL ASSISTANCE THROUGH OUR CHARITY POLICY, BASED ON THE CURRENT FEDERAL POVERTY GUIDELINES (FPG), TO PATIENTS AND GUARANTORS. THOSE APPROVED FOR FINANCIAL ASSISTANCE ARE ELIGIBLE FOR DISCOUNTS APPLIED TO BALANCES OWED AFTER Shul H (Form 990) 5

16 Shul H (Form 990) BLUE RIDGE HEALTHCARE HOSPITALS, INC. Prt VI Supplmntl Informtion (Continution) Pg 9 INSURANCE, AS WELL AS SELF-PAY BALANCES REMAINING AFTER OUR UNINSURED DISCOUNT IS APPLIED. PATIENTS WHOSE HOUSEHOLD INCOME IS LESS THAN 0% OF FEDERAL POVERTY GUIDELINES ARE ELIGIBLE FOR 00% ADJUSTMENT OF REMAINING BALANCES. THE DISCOUNTS ARE AVAILABLE IN A GRADUATED SCALE WHERE INCOMES OF UP TO 50% OF FPG QUALIFY FOR SOME ADJUSTMENTS OFF REMAINING BALANCES. THIS POLICY IS PUBLICIZED IN PATIENT REGISTRATION AREAS, ON BILLING STATEMENTS, AND IS AVAILABLE ON OUR WEB SITE. PATIENTS NOT ELIGIBLE FOR CHARITY OR WHO HAVE A BALANCE OWED AFTER THE APPLICATION OF CHARITY OR UNINSURED DISCOUNT ARE SENT STATEMENTS AND/OR COLLECTION LETTERS AT LEAST EVERY 0 DAYS UNTIL THE BALANCE OWED IS PAID OR SUITABLE, LONGER-TERM PAYMENT ARRANGEMENTS ARE MADE. ACCOUNTS THAT DO NOT HAVE SUITABLE PAYMENT ARRANGEMENTS ESTABLISHED, THAT ARE OLDER THAN 0 DAY FROM THE FIRST PATIENT STATEMENT ARE ELIGIBLE FOR OUTSIDE COLLECTION ACTIVITY. ALL PATIENTS ARE NOTIFIED OF POSSIBLE COLLECTION ASSIGNMENT AT LEAST 0 DAYS BEFORE AN ASSIGNMENT IS MADE. IF A PATIENT REQUESTS FINANCIAL ASSISTANCE AFTER THE STATEMENT PROCESS BEGINS, THE ACCOUNT IS PLACED ON HOLD UNTIL A DETERMINATION OF ELIGIBILITY IS MADE. PART VI, LINE : EPLANATION: BLUE RIDGE HEALTHCARE HOSPITALS PERFORMS OUTREACH SERVICES AND HEALTH EDUCATION OPPORTUNITIES FOR THE COMMUNITY SERVED. FEEDBACK FROM THESE EFFORTS ALONG WITH THE EVALUATION OF THE PATIENTS SERVED ARE CONSIDERED IN ASSESSING THE COMMUNITIES HEALTH CARE NEEDS. IN ADDITION, THE ORGANIZATION HAS CONDUCTED ETENSIVE RESEARCH INTO THE AREAS MOST SERIOUS HEALTH THREATS AND DEVELOPED A PLAN TO FOCUS ATTENTION ON THESE ISSUES. PART VI, LINE : Shul H (Form 990) 6

17 Shul H (Form 990) BLUE RIDGE HEALTHCARE HOSPITALS, INC. Prt VI Supplmntl Informtion (Continution) Pg 9 EPLANATION: ALL SELF PAY ED PATIENTS ARE SCREENED FOR CHARITY AND-OR FINANCIAL ASSISTANCE IN THE ED AREA. ALL SELF PAY INPATIENTS ARE SCREENED FOR FINANCIAL ASSISTANCE BY THE FINANCIAL COUNSELORS DURING THEIR STAY. DIAGNOSTIC AND THERAPEUTIC OUTPATIENT SERVICES ARE ALSO ELIGIBLE FOR FINANCIAL ASSISTANCE AND-OR CHARITY UPON APPLICATION BY THE PATIENT OR RESPONSIBLE PARTY. MONTHLY STATEMENTS AND WEBSITE REFERENCE THE PHONE NUMBERS TO CALL FOR FINANCIAL ASSISTANCE. PART VI, LINE 4: EPLANATION: BRHCS PRIMARY SERVICE AREA INCLUDES BURKE COUNTY; PATIENTS FROM A NUMBER OF OTHER OUTLYING COUNTIES ARE ALSO SERVED BY BRHC. THE POPULATION IS PREDOMINANTLY CAUCASIAN. SIGNIFICANT MINORITIES INCLUDE HMONG, AFRICAN-AMERICAN AND HISPANIC RESIDENTS. THE AREA IS ECONOMICALLY DEPRESSED DUE TO THE LOSS OF TRADITIONAL FURNITURE AND TETILE INDUSTRIES. PART VI, LINE 5: EPLANATION: BRHC IS GOVERNED BY A VOLUNTEER COMMUNITY BOARD OF DIRECTORS. BRHC SYSTEM IS SERVED BY OPEN MEDICAL STAFFS. THE SYSTEM IS ALSO SUPPORTED BY A GROWING BRHC VOLUNTEERS CORPS WHO CONTRIBUTE THOUSANDS OF HOURS IN SERVICE ANNUALLY. BRHC ACTIVELY RECRUITS PRIMARY CARE PHYSICIANS AND PHYSICIAN SPECIALISTS TO MEET SPECIFIC MEDICAL NEEDS IN THE COMMUNITY. PART VI, LINE 6: EPLANATION: BLUE RIDGE HEALTHCARE HOSPITALS IS PART OF BLUE RIDGE HEALTHCARE SYSTEM. BLUE RIDGE SERVES BURKE COUNTY, NC AND SURROUNDING COUNTIES. BLUE RIDGE IS AFFILIATED WITH CAROLINAS HEALTHCARE SYSTEM BASED IN CHARLOTTE, NC Shul H (Form 990) 7

18 Shul H (Form 990) BLUE RIDGE HEALTHCARE HOSPITALS, INC. Prt VI Supplmntl Informtion (Continution) Pg 9 PART VI, LINE 7, LIST OF STATES RECEIVING COMMUNITY BENEFIT REPORT: NC Shul H (Form 990) 8