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 990-EZ or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
MediumBullet Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2016
Open to Public
Inspection
Name of the organization
UPSON COUNTY HOSPITAL INC
 
Employer identification number

58-1734026
Return Reference Explanation
Form 990, Part VI, Section A, line 3 THE ORGANIZATION HIRED HEALTHTECH MANAGMENT SERVICES TO PROVIDE THE INTERIM CEO. THE ORGANIZATION PAID $160,417 TO HEALTHTECH.
Form 990, Part VI, Section B, line 11b FORM 990 WAS EMAILED TO EACH BOARD OF TRUSTEE MEMBER PRIOR TO THE IRS FILING DUE DATE FOR THEIR REVIEW. FORM 990 REVIEW WAS PLACED ON THE BOARD AGENDA FOR DISCUSSIONS SHOULD ANY QUESTIONS OCCUR. THE 990 IS REVIEWED BY THE CFO IN DETAIL PRIOR TO FILING WITH THE IRS.
Form 990, Part VI, Section B, line 12c THE POLICY COVERS ALL DIRECTORS, OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION. SHOULD A MATTER COME BEFORE THE BOARD OF DIRECTORS WHICH CONSTITUTES A CONFLICT OF INTEREST, THE INDIVIDUAL INVOLVED WILL MAKE KNOWN THE POTENTIAL CONFLICT AND WITHDRAW FROM THE MEETING SO LONG AS THE MATTER SHALL CONTINUE UNDER DISCUSSION AND SHALL NOT EITHER VOTE ON THE MATTER UNDER DISCUSSION OR ATTEMPT TO INFLUENCE A DECISION OF THE GOVERNING AUTHORITY WITH RESPECT TO SUCH MATTERS, UPON WHICH THERE COULD POSSIBLY BE A CONFLICT OF INTEREST.
Form 990, Part VI, Section B, line 15 IN DETERMINING COMPENSATION FOR TOP OFFICIALS, HUMAN RESOURCES OBTAINS THE COMPARABLE SALARY SURVEY AND PRESENTS IT TO THE BOARD OF DIRECTORS WHO MAKE A FINAL DECISION. THE CEO IS NOT PRESENT DURING THE DISCUSSION AND DECISION-MAKING PROCESS. DELIBERATIONS AND DECISIONS ARE DOCUMENTED IN THE MINUTES OF THE MEETING. ANNUAL MERIT ADJUSTMENT: SALARY ADJUSTMENT IS DETERMINED BY ORGANIZATIONAL PERFORMANCE AS REFLECTED IN THE SCORE OF THE ESTABLISHED PERFORMANCE MEASUREMENT INSTRUMENT. (LEM/LEADERSHIP EVALUATION MANAGEMENT). PERIODIC MARKET ADJUSTMENT: SALARY IS REVIEWED PERIODICALLY BY THE CURRENT MANAGEMENT GROUP (HEALTH TECH) AND COMPARED TO CEO SALARIES OF COMPARABLE ORGANIZATIONS TO ENSURE THAT THE CURRENT RATE IS COMPETITIVE. IN DETERMINING COMPENSATION FOR THE CFO, OTHER OFFICERS OR KEY EMPLOYEES, THE ORGANIZATION'S HUMAN RESOURCES DEPARTMENT OBTAINS COMPARABLE SALARY DATA AND PRESENTS IT TO THE GOVERNING BODY WHO MAKES THE FINAL DECISION. THE INDIVIDUAL IN THE CONSIDERATION PROCESS IS NOT PRESENT DURING THE DISCUSSION AND DECISION-MAKING PROCESS. DELIBERATIONS AND DECISIONS ARE DOCUMENTED IN THE MINUTES OF THE MEETING. ANNUAL MERIT ADJUSTMENT: SALARY ADJUSTMENT IS DETERMINED BY ORGANIZATIONAL PERFORMANCE AS REFLECTED IN THE SCORE OF THE ESTABLISHED PERFORMANCE MEASUREMENT INSTRUMENT. (LEM/LEADERSHIP EVALUATION MANAGEMENT). PERIODIC MARKET ADJUSTMENT: SALARY OF EACH OFFICER IS REVIEWED PERIODICALLY BY HUMAN RESOURCES AND APPROPRIATE OFFICER AND COMPARED TO SALARIES OF COMPARABLE ORGANIZATIONS TO ENSURE THAT THE CURRENT RATE IS COMPETITIVE.
Form 990, Part VI, Section C, line 18 THE FORM 900 AND 990T IS MADE AVAILABLE UPON REQUEST.
Form 990, Part VI, Section C, line 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE FOR INSPECTION, WITH NOTICE, IN THE OFFICE OF THE ORGANIZATION.
Form 990, Part IX, line 11g Contract Labor: Program service expenses 2,096,257. Management and general expenses 813,457. Fundraising expenses 0. Total expenses 2,909,714. Other Fees: Program service expenses 2,167,692. Management and general expenses 3,384,096. Fundraising expenses 0. Total expenses 5,551,788. Physician Fees: Program service expenses 2,054,036. Management and general expenses 0. Fundraising expenses 0. Total expenses 2,054,036. Consulting Fees: Program service expenses 2,186. Management and general expenses 849,550. Fundraising expenses 0. Total expenses 851,736. Collections and Billing: Program service expenses 0. Management and general expenses 428,636. Fundraising expenses 0. Total expenses 428,636.
Form 990, Part XII, Line 2c: THIS PROCESS HAS NOT CHANGED FROM PRIOR YEAR.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2016


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