Smyth County Community Hospital

“Mountain States Health Alliance is the sole member of Smyth County Community Hospital.”

“There is a single class of member, Mountain States Health Alliance.”

“Certain decisions of the board are, pursuant to charter and Virginia statute, subject to approval of the member. These decisions include: dissolution of the corporation; merger of the corporation; non-ordinary course of business sale of assets, etc. No ordinary, day-to-day decisions are subject to member approval.”

“The Ballad Health Tax Department prepares and reviews the Form 990. During preparation other functional areas within the organization provide information and support to complete an accurate return. The return is reviewed by the organization's EVP/CFO and is provided in electronic form to all members of the Board of Directors prior to being filed with the IRS.”

“Ballad Health policy requires Board of Directors and Board Committee members, the Executive Chair/President, and Executive Vice Presidents to complete a conflict of interest disclosure statement on an annual basis. Ballad Health policy also requires team members to complete an annual acknowledgement that they have read and understand the conflict of interest policy and they will complete a conflict of interest disclosure statement if they have a conflict of interest. Should a conflict arise, it is the responsibility of the conflicted individual to update his or her disclosure immediately. All meetings of the board or board committees have a standing agenda item first on the agenda titled "Conflicts of Interest". If a member of the board or board committee has a conflict of interest involving any issue on the board agenda, he or she must declare the conflict of interest during the period allotted for disclosure. If any issue arises during a meeting in which the board member has a conflict of interest, he or she must immediately declare the conflict. While each member of the board or board committee is responsible for disclosing conflicts of interest, it is also the responsibility of any board member aware of a conflict which has not been disclosed to ensure the board is made aware. The presiding officer of a board or board committee meeting may ask a conflicted member to excuse themselves from the meeting during the discussion related to the issue with which the conflict of interest applies. Under no circumstances shall a member vote on a matter that gives rise to a potential conflict. This applies to all Ballad Health organizations.”

“Line 15a - Compensation Process for Top Officials The executive compensation committee serves as the compensation oversight committee of Ballad Health's Board of Directors. The executive compensation committee is comprised of members who are determined to be independent and whom are not reliant upon any business relationship with Ballad Health for income or compensation. The compensation plan for Alan Levine, Ballad Health's Chairman, President and CEO, was reviewed and approved by the executive compensation committee and then by the Ballad Health Board of Directors in accordance with the Board's compensation policy and practice. The Board of Directors relies upon the advice of an independent and experienced compensation consultant with knowledge about pay practices for comparable positions within the industry, and who has access to broad data, studies and surveys in order to ensure the compensation falls within competitive and appropriate ranges for the position. Line 15b - Compensation Process for Top Officers On an annual basis, Ballad Health's Human Resources (H/R) Department evaluates compensation for all executives at a position level of Assistant Vice President and above. H/R's evaluation is based on market data obtained from independent third-party consultants for positions with similar responsibilities at similarly situated organizations. Based on this comparable data, Ballad Health's CEO evaluates the data and, if appropriate, makes necessary adjustments. Any adjustments to Senior Vice Presidents or above are reviewed by the Board of Directors Executive Compensation Committee. In addition, Ballad Health offers an incentive plan to executives based on targeted achievement metrics categorized by; Quality, Service and Safety; Access to Care; Financial Stewardship, and any other metrics approved from time to time by the Board of Directors.”

“Governing documents and conflict of interest policy are made available upon request to the appropriate parties requesting them. Financial statements are made available upon request to appropriate parties requesting them, and they are made available to those parties who own indebtedness of the company on a quarterly basis.”

“Line 2 does not include W-2's processed by our parent organization, Ballad Health, on behalf of SCCH. Team members' reportable compensation, if included in Part VII, Section A, is reported as compensation from related organizations.”

“Smyth County Community Hospital's (SCCH) membership consists of Mountain States Health Alliance. SCCH is also a member of the Ballad Health network. Ballad Health (Ballad) is an integrated healthcare delivery system consisting of 20 hospitals in Northeast Tennessee and Southwest Virginia, including a Level 1 Trauma Center, dedicated children's hospital, several community hospitals, four critical access hospitals, a behavioral health hospital, an addiction treatment facility, long-term care facilities, home care and hospice services, retail pharmacies, outpatient services and a comprehensive medical management corporation. Ballad works closely with an active independent medical community and community stakeholders to improve the health and well-being of over one million people in 29 counties of the Appalachian Highlands in Northeast Tennessee, Southwest Virginia, Northwest North Carolina, and Southeast Kentucky. Ballad is a Tennessee non-profit corporation and is the main provider of healthcare services in Northeast Tennessee and Southwest Virginia. Ballad Health is a tax-exempt entity and the parent corporation of both Mountain States Health Alliance (MSHA) and Wellmont Health System (WHS). On February 1, 2018, Ballad was formed through a merger of two legacy systems, Mountain States Health Alliance and Wellmont Health System. Ballad was formed under state-action immunity in compliance with federal antitrust law, to create a healthier region and keep healthcare local. The action approving the merger was officially taken through the agreements made between Ballad and the State of Tennessee in the Certificate of Public Advantage (the "COPA") and the Letter Authorizing the Cooperative Agreement (the "CA") in Virginia. Pursuant to the COPA and CA, Ballad must fulfill certain obligations, commitments, and covenants. Tennessee and Virginia, through their respective health departments, supervise specific aspects of Ballad's operations under certain conditions of the COPA and the CA. The COPA and amendments are publicly available on the website of the Tennessee Department of Health, at https://www.tn.gov/health/health-program -areas/health-planning/certificate-of-public-advantage.html. The Cooperative Agreement is available on the website of the Virginia Department of Health, at https://www.vdh.virginia.gov/licensure- and-certification/cooperative-agreement/. Located in Marion, Virginia, Smyth County Community Hospital (SCCH) is a 44-bed hospital dedicated to bringing quality healthcare to Southwest Virginia. As a community hospital, SCCH offers a wide range of services including surgery, rehabilitation, home health, skilled nursing, long-term care, orthopedics and more. The hospital has achieved a "Five Star" overall rating by the Centers for Medicare & Medicaid Services, one of only 8 hospitals in Virginia, as well as a "Five Star" patient experience rating - one of 266 nationwide, and the only hospital in Virginia to receive this rating. Specific to the hospitals included in this Form 990, services were provided to: 1,162 hospital inpatients 62,466 outpatient visits 17,083 emergency visits 28 nursing home admissions SCCH subsidizes the Glade Springs Family Medicine Rural Health Clinic and the Family Medicine Practice in Rural Retreat, Virginia. These practices are located in rural, medically underserved areas and allow residents to receive quality care without having to travel outside of their home area. This is especially important for elderly residents and others that require family or friends to provide transportation to physician appointments. In FY24, Ballad Health continued to demonstrate its commitment to improving the health of the Appalachian Highlands region through investments in its people, COPA Plan spending commitments, and capital. These investments include: - Over $67 million in new investments for rural health, behavioral health, children's health, population health, health research and graduate medical education,”

“Ballad Health maintained increased patient eligibility for charity care at 225% of the federal poverty guidelines (up from 200% before the merger in 2018). Ballad Health spent over $106 million in FY24 for Charity and Unreimbursed TennCare and Medicaid, the most ever as a merged entity. Notably, the weighted average median household income in the region is approximately $46,800 (lower in some communities), while Ballad Health's threshold for free charity care for a family of 2.5 people is approximately $52,000 (225% of the Federal Poverty Level) - indicating one of the most generous charity care policies in the nation. Additionally, continued efforts by Ballad Health to provide care to chronic uninsured and underinsured patients had the desired result in reducing the cost of care, lowering charity care costs, and savings to employers, payers, and individuals who help subsidize the cost of charity care through state and federal programs. Reducing the number of preventable hospitalizations and emergency room visits results in lower costs of charity care and improves patient safety. This is a benefit of efforts by Ballad Health to initiate value-based initiatives, such as the Appalachian Highlands Care Network (AHCN). The AHCN connects uninsured patients and their families with free or low-cost clinics, dental services, financial counseling, and preventative care services. The AHCN is a national model for partnership programs between a health system and local organizations, outpatient clinics and providers that are working together to deliver a better, more supportive system of care for the uninsured population. These efforts reduce the cost of charity care - which benefits taxpayers, patients, and hospitals. The AHCN had over 8,500 uninsured enrollees by the end of the reporting period. Expanding Access to Care and Population Health: - Access to Care Metrics: Ballad Health achieved results over the pre-merger baseline for 21 of 25 access measures. Notable areas of improvement included appropriate emergency department wait times, asthma emergency department visits, antidepressant medication management for both acute and continuation phase, engagement of alcohol or drug treatment and rate of SBIRT administration during emergency department visits. Notably, while officially rolled out in FY24, with the FY23 investment in technology, anyone with access to a smart phone or the internet can now access Ballad Health's urgent care from anywhere in the region or world. Ballad Health is the only provider in the region which currently provides this service. - Population Health Measures: Ballad Health achieved all Process Measures (15 out of 15) for FY24. Ballad Health also exceeded its FY24 Population Health Plan Spend commitment of $11 million with an additional $7 million investment over its required spend. Improving Quality of Care, Patient Experience & Staff Experience: Quality data in almost every hospital in the nation declined during the pandemic. According to Premier - the nation's largest aggregator of quality data for hospitals - "Ballad Health's quality has recovered faster than any of the thousands of hospitals in its database." Quality of Care Metrics: Ballad Health publishes its quality data in accordance with the COPA requirements on its website. Notable highlights include the following: - Ballad Health improved results in 11 of the 17 target measures for FY24 compared to FY23. - Ballad Health improved in 8 out of the 10 patient experience monitoring measures for FY24 compared to FY23. - Among the hospital infection indicators, Ballad Health is performing better than expected or meeting the measure in all but one measure when using the Centers for Disease Control and Prevention's recommended adjustment methodology accounting for differences in patient population. Clinical Council: The Clinical Council (the Council) is aligned with the Ballad Health Board of Directors and the Board's Quality Service and Safety Committee (QSSC”

“Ballad Health is committed to being a responsible and concerned citizen of the communities of the service area where it operates and is driven by its mission: "honor those we serve by delivering the best possible care." Ballad continues to deploy initiatives intended to improve the overall health and well-being of the over one million people living in its service area. ENVIRONMENTAL - Environmental stewardship and preserving the environment is important to Ballad and is demonstrated in the following practices: - Environmentally responsible supply chain - Encourage the recycling of materials and minimization of waste - Encourage the reduction of energy usage - Incorporate environmentally preferable alternatives when designing new construction SOCIAL - Social commitments are an integral part of Ballad's mission, vision, and values. By working and collaborating with others in the communities in which it serves, Ballad works "to build a legacy of superior health by listening to and caring for those we serve." Ballad provides direct and in-kind support to improve access to care and deliver healthy lifestyle services, education, and activities. The community health programs are designed to improve access and quality of care, strengthen community outreach and partnerships, decrease healthcare costs, and assist in the reduction of health care disparities in the region. Ballad has opened two new rural hospitals in the past five years. Ballad offers extensive education and outreach programs throughout the community at little or no cost to participants. Program areas include: - Community events, such as health fairs, screenings, flu shots, health and safety education, support groups, stroke education, baby and child health, and medical libraries. - Children's resources, such as the Morning Mile Program, B.E.A.R. Buddies, car seat safety, and Families Thrive. - Heart and Soul, senior health, and well-being programs. - General health resources, individual health, nutrition, and safety education. - Regular health education speakers covering a wide range of topics. The following are some of the programs designed to improve healthcare equity and availability: Ballad as a Community Health Improvement Organization: Ballad's goal is to ensure the sustainability of rural healthcare services while improving the health and well-being of the region as a whole. In the short-term, Ballad will address health related social needs to improve access to care, reduce inequity, and empower individuals to adopt healthy behaviors and manage health conditions. In the long-term, Ballad will address social drivers of health to provide a community level foundation for permanent regional health improvement through multi-sector collective impact. Ballad is taking an intergenerational approach to focus on children's health initiatives to give kids a strong start in life, as well as assisting adults with overcoming obstacles to health and self-sufficiency. Ballad is on a journey to universalize social needs screening and prioritized navigation resources throughout the system using embedded Epic tools combined with the UniteUs referral management platform. These efforts are informed and supported by a multi-departmental team called the Social Needs Council which has accountability to the system Population Health Council, the Chief Population Health Officer, and ultimately the board of Population Health and Social Responsibility Committee. STRONG Accountable Care Community: Driving Community Level Action and Change: The STRONG Accountable Care Community is a regional collective impact model focusing on community level strategies across a life course model that includes a multi-generation approach to parenting support and family self-sufficiency. Established in 2018, the STRONG Accountable Care Community (STRONG ACC), sponsored by Ballad, is a 350 organization, multi-sector model serving the same geographic footprint as Ballad and additional contiguous counties. The STRO”

“for children are essential to optimal early development and later success in life. Started in 2021, STRONG Starts is aimed at improving birth outcomes and reducing the negative impact of chronic stress for mothers, babies and families. The birth of a new baby is a pivotal time for a mother and her family. No one should feel alone or unsupported during this time. Ballad seeks to connect with every expectant mother as early in her pregnancy as possible to ensure access to early prenatal care - all in partnership with the region's obstetric providers. As the life situation and pregnancy experience for every woman is different, Ballad will build supportive relationships aligned with the unique circumstances of every woman and family. With embedded staff in the region's obstetric practices and hospital birthing centers, these relationships begin early. Staff will help families connect with community resources for issues from food/housing insecurity to parenting resources to education/job training. The program continues into the post-natal and early stage of life. Ballad staff assist those in the program through kindergarten entry with a whole-family approach. This ongoing relationship will help with evolving needs and the transition in healthcare from the obstetric environment to the pediatric environment. Ballad works with regional pediatricians to ensure they can refer children and families into the program. The developmental milestones of children will be assessed so early supports can be provided, and Ballad can assist with connections to community resources as children grow, including programs which support resiliency and early learning environments. Ballad seeks to further support the safety, stability, and self-sufficiency of families and to help ensure children enter kindergarten developmentally, socially, and emotionally ready to learn. This first experience with the educational system is foundational, as it sets the tone for later success with grade level reading, math proficiency, and the academic discipline needed to ensure high school graduation and college and career readiness. These benchmarks are predictors of later economic and health outcomes which can reshape the life trajectory, health, and well-being for children and families for generations to come. In addition to these programs, Ballad invests significant funding annually to support partnering organizations, Community Health Improvement Sites, who provide aligned services and mutually serve the populations mentioned above. These services include free health services, care coordination, housing supports, substance use and recovery, social needs support, maternal/child supports, early learning and literacy improvement initiatives, and women's health services. Ballad also provides a host of other services to vulnerable populations including free cancer screenings, mobile health services, health fairs, children's resources, and health education programs notably through a network of faith community nurses. GOVERNANCE - Governance is overseen by the Ballad Board of Directors and ongoing ESG work through the following committees: - Audit and Compliance - environmental and sustainability performance - Community Benefit & Population Health - social and community goals and performance - Executive Compensation - human capital; diversity, equity, and inclusion; and pay equity goals and performance - Governance - governance goals and performance - Quality - equity of care, patient safety and quality of care goals and performance Ballad has a conflict-of-interest policy and plans to align reporting with the Sustainability Accounting Standards Board's topics for disclosure and other reporting frameworks in the coming years. Ballad has leader diversity with 30% of CEOs being females and 33% of Executive Vice Presidents being females. CHARITABLE CONTRIBUTIONS - From its inception in February of 2018, Ballad Health made significant contributions to the community it serves tota”

“- Ballad has invested significantly across the region specifically in academic and community institutions that serve the people in the service area. Examples of this investment are shown through the continuum of service from the offering of observation opportunities to students of all ages within our clinical facilities, to providing experts to lecture to school children on a broad variety of healthcare topics. The commitment to giving back extends to direct investment in regional educational partners. Some key examples of this include the Appalachian Highlands Center for Nursing Advancement, The Center for Rural Health Research, the STRONG BRAIN Institute, and the Gatton College of Pharmacy Center for Pharmacy, Education, Outreach, and Advocacy. The work of these centers at ETSU focuses on some of the leading issues facing the service area, from the development and support of the next evolution of nursing as a profession, to understanding the unique challenges facing our public health, to the scourge of adverse childhood experiences, to access and intervention at the community pharmacy, Ballad is committed to understanding and addressing the significant issues facing the service area. - Ballad is also engaged in funding the development of new and expanded healthcare training programs across the region. Ballad has granted support of programs in Nursing and Allied Health. From a new BSN program in Southwest Virginia at Emory & Henry College, to a new program in Ultrasonography at Southwest Virginia Community College, we are supporting programs large and small. We have expanded the medical-legal partnership we have in the Appalachian Highlands to include all of the Ballad facilities as well as many of the outpatient clinics. This one-of-a-kind program partners Ballad with Virginia Tech and the Appalachian School of Law together to address the challenges of access to social supports for the poorest members of the service area. Ballad is a sponsor of a residency in Advanced Education Graduate Dentistry in Southwest Virginia. The endemic problem of poor oral hygiene across service area accounts for loss of economic opportunity, loss of self-esteem, and profound impacts on the health of individuals suffering from missing or diseased teeth. - Ballad's research department serves as the central office for multi-specialty research oversight in the System. In addition to providing full spectrum support for studies generated and managed by the research department, the department provides oversight for studies generated by external groups. The research department has participated in several large-scale, multi-center trials with subject retention at nearly 100%. Oversight services include administrative, legal, regulatory support, internal service arrangement and financial management. Ballad is a world leader in cardiovascular clinical trials. - Received its Accreditation/Department of Distinction from the International Association for Healthcare Security & Safety (IAHSS). - Recognized by Harvard University and United Healthcare as one of four healthcare organizations leading the way towards a 3D model for value-based care. - Earned the College of Healthcare Information Management Executives (CHIME) Digital Health Most Wired. - After the creation of a regional and coordinated system of trauma care nearly two years prior, in July 2021, a Tennessee Department of Health survey concluded the trauma program serving the Appalachian Highlands provides "outstanding commitment to care for the injured patient and found zero deficiencies at the Level I Trauma Center at Johnson City Medical Center, a first for trauma care in the region. As a result of the regional and coordinated system of trauma care, Ballad decreased mortality by 40% and reduced the cost of care by approximately $3 million.”

“The tax exempt bond liability reflects the portion of bonds issued by Mountain States Health Alliance, SCCH's sole member, on behalf of SCCH for capital needs. SCCH pays all costs related to this portion of the bond issue.”

“Ballad Health (BH), SCCH's parent organization, files Form 1096 on a consolidated basis for all subsidiaries that are required to file Forms 1099-MISC/NEC. SCCH reimburses BH for all expenses related to vendor payments and the expenses are recorded on SCCH's books.”

“Ballad Health (BH), SCCH's parent organization, processes payroll for SCCH. SCCH reimburses BH for all salary and benefits related to our team members and the expense is recorded on SCCH's books. SCCH operates a rural health clinic. Under current Centers for Medicare and Medicaid Services (CMS) regulations governing staffing at a rural health clinic, at least one mid-level provider (nurse practitioner, physician assistant, etc.) must be a W-2 employee of the clinic. Therefore, SCCH pays several mid-level providers directly (rather than BH paying these team members' salary with SCCH reimbursing Ballad Health).”

“Collection Services: Program service expenses 0. Management and general expenses 1,861,784. Fundraising expenses 0. Total expenses 1,861,784. Consulting Fees: Program service expenses 0. Management and general expenses 28,413. Fundraising expenses 0. Total expenses 28,413. Contract Labor: Program service expenses 1,026,448. Management and general expenses 374,382. Fundraising expenses 0. Total expenses 1,400,830. Dietary Services: Program service expenses 789,494. Management and general expenses 0. Fundraising expenses 0. Total expenses 789,494. Environmental Services: Program service expenses 628,274. Management and general expenses 0. Fundraising expenses 0. Total expenses 628,274. Hospital Supported Clinics: Program service expenses 3,034,123. Management and general expenses 0. Fundraising expenses 0. Total expenses 3,034,123. Laboratory Services: Program service expenses 108,081. Management and general expenses 0. Fundraising expenses 0. Total expenses 108,081. Laundry Services: Program service expenses 137,524. Management and general expenses 0. Fundraising expenses 0. Total expenses 137,524. Long-Term Care Services: Program service expenses 1,473,017. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,473,017. Other: Program service expenses 362,655. Management and general expenses 73,799. Fundraising expenses 0. Total expenses 436,454. Physician Fees: Program service expenses 1,632,986. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,632,986. Rehabilitation Services: Program service expenses 30,854. Management and general expenses 0. Fundraising expenses 0. Total expenses 30,854.”

“Temporarily Restricted Grants -2,500.”