2023-05-15T16:05:09-05:00 2022-06-30 135565207 KPMG LLP 301 MAIN STREET SUITE 2150 BATON ROUGE LA 70801 990 2021-07-01 640303091 ST DOMINIC - JACKSON MEMORIAL HOSPITAL STDO 6012006570 969 LAKELAND DRIVE JACKSON MS 392164699 SAM SCOTT REGIONAL CFO 6012006570 2023-05-15 1 SAM SCOTT 999009999 RYAN HOOKS P00746825 2253444000 2023-05-10 3 AAL1 IAL1 2021 2023-04-26 12:10:37Z SAMUEL T SCOTT 969 LAKELAND DRIVE JACKSON MS 392164699 557322632 0 X WWW.STDOM.COM X 1946 MS TO PROVIDE FOR THE CARE OF THE ILL, INJURED, OR DISABLED PERSONS, AND TO PROVIDE FOR RESEARCH, EDUCATION, AND FOR THE ENHANCEMENT OF HEALTH OF THOSE IN THE COMMUNITY. 16 11 4352 265 627827 0 49243178 11779404 525283460 530365163 8870762 -2121726 8633917 9747841 592031317 549770682 2523206 2381455 0 0 247519837 284102007 0 0 0 269299712 310240020 519342755 596723482 72688562 -46952800 502151354 457480771 213774579 230428767 288376775 227052004 X INSPIRED BY THE VISION OF ST. FRANCIS OF ASSISI AND IN THE TRADITION OF THE ROMAN CATHOLIC CHURCH, WE EXTEND THE HEALING MINISTRY OF JESUS CHRIST TO GOD'S PEOPLE, ESPECIALLY THOSE MOST IN NEED. WE CALL FORTH ALL WHO SERVE IN THIS HEALTHCARE MINISTRY, TO SHARE THEIR GIFTS AND TALENTS TO CREATE A SPIRIT OF HEALING - WITH REVERENCE AND LOVE FOR ALL OF LIFE, WITH JOYFULNESS OF SPIRIT, AND WITH HUMILITY AND JUSTICE FOR ALL THOSE ENTRUSTED TO OUR CARE. WE ARE, WITH GOD'S HELP, A HEALING AND SPIRITUAL PRESENCE FOR EACH OTHER AND FOR THE COMMUNITIES WE ARE PRIVILEGED TO SERVE. 0 0 455157867 0 533041592 THE ST. DOMINIC - JACKSON MEMORIAL HOSPITAL PROVIDES QUALITY HOSPITAL AND MEDICAL SERVICES TO ITS PATIENTS. IN THE CURRENT YEAR, SERVICES WERE PROVIDED FOR 119,976 PATIENT DAYS, 44,888 EMERGENCY ROOM VISITS AND 19,932 INPATIENT DISCHARGES. THE MEDICAL CENTER IS AN ACTIVE, CARING MEMBER OF THE COMMUNITIES IT SERVES. IN CARRYING OUT ITS MISSION, THE MEDICAL CENTER HAS ESTABLISHED A POLICY UNDER WHICH IT PROVIDES CARE TO NEEDY MEMBERS OF ITS COMMUNITIES. ADDITIONAL COSTS WERE INCURRED FOR PARTICIPATION IN PROGRAMS WHICH, IN SOME CASES, PAY AMOUNTS LESS THAN THE COST OF PROVIDING SERVICES. 2381455 2381455 0 THE HOSPITAL SERVES THE COMMUNITY IN NUMEROUS WAYS. SOME EXAMPLES INCLUDE ASSISTING IN EDUCATING THE COMMUNITY REGARDING HEALTH-RELATED ISSUES. 457539322 1 1 0 1 0 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 1 225 0 1 4352 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 16 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 0 X SAM SCOTT 6012006570 969 LAKELAND DRIVE JACKSON MS 392164699 JOHNNY DONALDSON VICE CHAIR 0.75 0.00 X X 0 0 0 SISTER M TRINITA EDDINGTON OP SECRETARY 0.75 40.50 X X 0 0 0 JEFF FLETCHER CHAIR 0.75 0.00 X X 0 0 0 RICK GUYNES MD BOARD MEMBER 40.00 0.00 X 40079 0 0 REGINALD MARTIN MD BOARD MEMBER/PHYSICIAN 40.00 0.00 X 351041 0 25571 REBEKAH MOULDER MD BOARD MEMBER/PHYSICIAN 40.00 0.00 X 614401 0 2676 SISTER ROSE MIRIAM SCHULTE OP BOARD MEMBER 0.75 1.00 X 0 0 0 D PAUL SEAGO MD BOARD MEMBER/PHYSICIAN 40.00 0.50 X 973306 0 20028 SISTER KARINA DICKEY OP BOARD MEMBER 0.75 0.00 X 0 0 0 SISTER DOROTHEA SONDGEROTH OP BOARD MEMBER 0.75 41.50 X 0 0 0 MONSIGNOR ELVIN SUNDS BOARD MEMBER 0.75 0.00 X 0 0 0 SISTER KATHLEEN ANNE TAIT OP BOARD MEMBER 0.75 0.00 X 0 0 0 STEVEN GREMILLION MD BOARD MEMBER 0.75 42.00 X 0 992768 39628 THOMAS K HUDSON BOARD MEMBER 0.75 0.00 X 0 0 0 SCOTT KASHMAN PRESIDENT - SD & JACKSON MARKET 0.75 42.00 X X 0 187062 2298 GENE LOPER MD BOARD MEMBER 0.75 0.00 X 0 0 0 SAMUEL SCOTT SVP, CFO 0.75 41.00 X 0 508382 33276 ROBERT NELSON VP CHIEF NURSING OFFICER 40.00 0.00 X 352493 0 40405 JOHN LANCON PHYSICIAN 40.00 0.00 X 1201707 0 28310 BRYAN A GASPARD PHYSICIAN 40.00 0.00 X 933692 0 25610 PB KERR PHYSICIAN 40.00 0.00 X 955798 0 25610 DAVID THEODORO PHYSICIAN 40.00 0.00 X 1083208 0 19532 RONALD KENNEDY PHYSICIAN 40.00 0.00 X 815869 0 12472 LESTER DIAMOND PRESIDENT (THRU 03/2021) 0.00 0.00 X 0 714339 6751 DAVID C HENRY VP OPERATIONS - THRU 5/2021 0.00 0.00 X 231083 0 9892 WILLIAM MORGAN COO - THRU 5/2021 0.00 0.00 X 420124 0 11020 7972801 2402551 303079 386 1 1 0 TRIMEDX PO BOX 636129 CINCINNATI OH 452636129 EQUIPMENT MAINTENANCE 8898714 ALLIED EMERGENCY SERVICES PC PO BOX 2120 RIDGELAND MS 39158 EMERGENCY ROOM SERVICES 6487553 PHYSICIANS ANESTHESIA GROUP PA 971 LAKELAND DRIVE JACKSON MS 39207 ANESTHESIA SERVICE 5623344 CERNER CORPORATION PO BOX 959156 ST LOUIS MO 63195 INFORMATION TECHNOLOGY 5082737 NTHRIVE INC PO BOX 676188 DALLAS TX 752676188 PATIENT FINANCIAL SVCS 4376229 61 1882386 8537371 1359647 11779404 PATIENT SERVICE REV 621990 512777660 512777660 OTHER PROGRAM SERVICE 621990 14525983 13898156 627827 CAFETERIA SALES 722514 2366528 2366528 RETAIL SALES 453000 598320 598320 LAB 621990 84190 84190 12482 12482 530365163 -3633160 -3633160 3466255 0 3466255 3466255 3466255 9053634 9750 7551950 0 1501684 9750 1511434 1511434 PENSION RELATED CHANGE 900099 6281586 6281586 6281586 549770682 533041592 627827 4321859 2381455 2381455 2262471 2034315 228156 228490930 205449037 23041893 16117341 14492007 1625334 22493380 20225062 2268318 14737885 13251661 1486224 57559396 37847806 19711590 239193 14703 224490 50400 3098 47302 33893 9726 24167 38231563 13485799 24745764 1141638 327604 814034 36609716 17024924 19584792 1109751 318454 791297 14584963 145850 14439113 272486 78193 194293 23545 6756 16789 3291256 20904 3270352 17289571 163215 17126356 7412298 3675413 3736885 MEDICAL & OTHER SUPPLIE 126119075 126119075 REPAIRS & MAINTENANCE 4845483 314884 4530599 MISCELLANEOUS EXPENSES 1425793 149381 1276412 596723482 457539322 139184160 0 117018469 79747387 75326090 56209733 15422662 16612202 22543161 13159253 273560957 43644263 214761603 229916694 31561936 30314640 7846405 9260054 7361321 17257645 10309707 5003163 502151354 457480771 58236879 60671979 12548941 142988759 169756788 213774579 230428767 X 288376775 227052004 0 0 288376775 227052004 502151354 457480771 X -46952800 -4542917 -9829054 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 23602 0 0 0 23602 0 PART II-B, LINE 1: ST. DOMINIC-JACKSON MEMORIAL HOSPITAL PAID DUES TO THE MISSISSIPPI HOSPITAL ASSOCIATION. THE MISSISSIPPI HOSPITAL ASSOCIATION REPORTS THAT 13.37% OF THE $176,533 OF DUES PAID WERE RELATED TO LOBBYING ACTIVITIES. 0 15142699 15142699 204024892 20628363 183396529 54351775 23008987 31342788 41591 6913 34678 229916694 FND DEPR - FMOL PORTFOLIO 30314640 F 30314640 CAPITAL LEASES 12765910 OTHER LONG TERM LIABILITIES 3121390 RETIREMENT PAYABLE LONG TERM 67369447 NET DUE TO/FROM AFFILIATES 69889389 CURR PORTION OF LT DEBT 12557908 SELF INSURANCE LIABILITY LT 4053703 MEDICARE ACCELERATED PAYMENTS -959 169756788 X PART X, LINE 2: FMOLHS RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. RECOGNIZED INCOME TAX POSITIONS ARE MEASURED AT THE LARGEST AMOUNT THAT IS GREATER THAN 50% LIKELY OF BEING REALIZED. CHANGES IN RECOGNITION OR MEASUREMENT ARE REFLECTED IN THE PERIOD IN WHICH THE CHANGE IN JUDGMENT OCCURS. NO RESERVE FOR UNCERTAIN TAX POSITIONS HAVE BEEN RECORDED. 1 1 1 X 250.000000000000 0 1 1 1 0 1 1 13926615 6405889 7520726 0.01260 64293631 63111767 1181864 0.00200 120365 73129 47236 0.00010 78340611 69590785 8749826 0.01470 1056337 1056337 0.00180 161280 161280 0.00030 17282386 14267255 3015131 0.00510 1789000 1789000 0.00300 20289003 14267255 6021748 0.01020 98629614 83858040 14771574 0.02490 601795 601795 0.00100 601795 601795 0.00100 1 35128648 10614667 136625297 139256937 -2631640 X 1 1 1 ST DOMINIC ASC OUTPATIENT SURGERY CENTER 0.46300 0.53700 1 1 ST DOMINIC-JACKSON MEMORIAL HOSPITAL 969 LAKELAND DRIVE JACKSON MS 392164699 HTTP://WWW.STDOM.COM/ 14-031 X X X ST DOMINIC-JACKSON MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 21 1 0 0 1 X SEE SECTION C X 1 21 1 SEE SECTION C 0 1 X 250.000000000000 0.000000000000 X X X X X 1 1 X X X 1 X SEE PART V SECTION C X SEE PART V SECTION C X SEE PART V SECTION C X X X X X X X 1 X 0 X X X X 1 X 0 0 ST. DOMINIC-JACKSON MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: AS PART OF THE COMMUNITY NEEDS ASSESSMENT, ST. DOMINIC HOSPITAL REACHED OUT TO AN EXPANSIVE AND HIGHLY DIVERSE GROUP OF INDIVIDUALS TO PARTICIPATE IN ITS COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) LEADERSHIP TEAM AND TO CONTRIBUTE INSIGHT FROM COMMUNITY SERVICE ORGANIZATIONS. EACH MEMBER PROVIDED PROJECT INSIGHT, FEEDBACK REGARDING PERCEPTIONS OF AREA HEALTH NEEDS, DATA EVALUATION, AND OTHER GUIDANCE DURING THE CHNA DEVELOPMENT PROCESS. THESE INDIVIDUALS OFFERED A BREADTH OF COMMUNITY HEALTH VISION, KNOWLEDGE, AND POWER TO IMPACT THE WELL-BEING OF THE SERVICE AREA. INFORMATION WAS GATHERED ABOUT THE LARGER COMMUNITY USING SECONDARY RESEARCH, DISCUSSION GROUPS AND COMMUNITY SURVEYS. ST. DOMINIC-JACKSON MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: ST. DOMINIC'S BUILT UPON WHAT IT LEARNED IN ITS PRECEDING CHNA'S AND USED THAT INFORMATION TO CONDUCT A NEW AND MORE EXTENSIVE NEEDS ASSESSMENTS. THE RESULTS OF THE NEW ASSESSMENT WERE LATER PUBLISHED WITHIN THE 2021-2024 COMMUNITY HEALTH NEEDS ASSESSMENT AND CAN BE FOUND ONLINE AT HTTPS://WWW.STDOM.COM/ABOUT-US/COMMUNITY-BENEFIT/COMMUNITY-HEALTH-NEEDS-ASSESSMENT.THE OVERARCHING GOAL OF THE ASSESSMENT WAS TO IDENTIFY AND RESPOND TO COMMUNITY HEALTH NEEDS, IMPROVE ACCESS AND IMPROVE HEALTH STATUS ESPECIALLY FOR THE MOST VULNERABLE AND UNDERSERVED IN THE COMMUNITY. IT IS INTEGRAL TO ST. DOMINIC'S FOCUS TO ESTABLISH COMMUNITY AND PROVIDE SERVICE, SETTING AN EXAMPLE TO OTHERS IN COMMUNITY SERVICE. ST. DOMINIC HOSPITAL'S OVERALL APPROACH TO COMMUNITY BENEFIT IS TO TARGET THE INTERSECTION OF DOCUMENTED UNMET COMMUNITY HEALTH NEEDS AND THE ORGANIZATION'S KEY STRENGTHS AND MISSION COMMITMENTS. SPECIFICALLY, MEMBERS OF THE TASK FORCE THAT LED THE DEVELOPMENT OF THE ASSESSMENT IDENTIFIED PRIORITY HEALTH ISSUES IN ST. DOMINIC'S SERVICE AREA BASED ON ITS REVIEW OF DEMOGRAPHIC INFORMATION, FOCUS GROUP FEEDBACK AND THE RESULTS OF COMMUNITY SURVEYS. THOSE IDENTIFIED PRESSING ISSUES FOR 2021-2024 ARE:- HOMELESSNESS;- CRISIS CARE FOR MENTAL HEALTH; - AFFORDABLE HEALTHCARE SERVICES FOR PEOPLE OR FAMILIES WITH LOW INCOME;- DOMESTIC VIOLENCE RESOURCES; - HOUSING FOR ALL INCOMES/AGES; - COUNSELING SERVICES FOR DEPRESSION OR ANXIETY; - JOB READINESS; - POST-ADDICTIONS TREATMENT SUPPORT PROGRAMS; - COUNSELING SERVICES FOR ADOLESCENTS/CHILDREN AND - PRESCRIPTION ASSISTANCE.THE HOSPITAL IS CURRENTLY ADDRESSING THE COMMUNITY NEEDS OF AFFORDABLE HEALTHCARE SERVICES FOR PEOPLE OR FAMILIES WITH LOW INCOME, DOMESTIC VIOLENCE RESOURCES, AND PRESCRIPTION ASSISTANCE AND IS PLANNING ON CONTINUING TO ADDRESS SUCH NEEDS. THE HOSPITAL HAS DECIDED THAT IT WILL ADDRESS CRISIS CARE FOR MENTAL HEALTH, COUNSELING SERVICES FOR DEPRESSION OR ANXIETY, AND POST-ADDICTIONS TREATMENT SUPPORT PROGRAMS WITHIN THE NEXT 2-3 YEARS. THE HOSPITAL WILL NOT ADDRESS HOMELESSNESS, HOUSING FOR ALL INCOMES/AGES, OR COUNSELING SERVICES FOR ADOLESCENTS/CHILDREN AS THOSE COMMUNITY NEEDS ARE OUTSIDE OF ITS SCOPE. IN 2022, AS IT DID IN PRIOR YEARS, ST. DOMINIC'S INTEGRATED ITS COMMITMENT TO COMMUNITY SERVICE INTO ITS MANAGEMENT AND GOVERNANCE STRUCTURES AS WELL AS ITS STRATEGIC AND OPERATIONAL PLANS. THE HOSPITAL'S STRATEGIC PLAN CONTAINED A GOAL AND STRATEGIES SPECIFICALLY DIRECTED AT ALLOCATING RESOURCES TO MEET THE NEEDS OF THE COMMUNITY IN RESPONSE TO THE IDENTIFIED FOCUS AREAS IN THE NEEDS ASSESSMENT. THE HOSPITAL ADDRESSED THE COMMUITY HEALTH NEEDS IDENTIFIED IN ITS PRIOR CHNA OF ACCESS TO AFFORDABLE HEALTH CARE AND MENTAL HEALTH AND SUBSTANCE ABUSE. IT DID NOT ADDRESS LIFESTYLE RELATED CONDITIONS AS THAT NEED IT OUTSIDE OF ITS SCOPE. ACCESS TO AFFORDABLE HEALTH CARE - SERVED VULNERABLE CHILDREN AND MATURE ADULTS THROUGHOUT THE STATE FROM JULY 2021 - JUNE 2022 THROUGH THE CARE-A-VAN PROGRAM. THE PROGRAM TAKES HEALTH SCREENING TO THE MOST VULNERABLE POPULATIONS SUCH AS SENIOR CENTERS, DAYCARE CENTERS, ELEMENTARY SCHOOLS, AS WELL AS COMMUNITY-WIDE WELLNESS FAIRS IN RURAL AND UNDERSERVED AREAS OF THE METRO JACKSON AREA. CARE-A-VAN PERFORMED 634 HEALTH SCREENINGS AND ADMINISTERED 1,269 COVID-19 VACCINATIONS.BEHAVIORAL OR MENTAL HEALTH - FOCUS ON ACCESS, EARLY DETECTION AND INTERVENTION AS EVIDENCED BY STEERED SCREENING OR EDUCATION ACTIONS IN COMMUNITIES THROUGHOUT THE STATE, COMPLETED IN-PERSON AND THROUGH VIRTUAL MEANS. THE NUMBER OF REFERRAL DEVELOPMENT CONTACTS RECORDED FROM JULY 2021 TO JUNE 2022 WAS APPROXIMATELY 3072, OR AN AVERAGE OF 256 PER MONTH. THIS NUMBER REFLECTS THE OUTREACH OF BEHAVIORAL HEALTH IN THE COMMUNITY TO PROMOTE ACCESS AND INTERVENTION. EARLY DETECTION WAS A FOCUS IN PROVIDING DEPRESSION SCREENING TOOLS TO SDMA AND MEA CLINICS, AS WELL AS OTHER CLINIC LOCATIONS FOR PATIENTS SEEN IN THE PHP SETTING. ST. DOMINIC'S ALSO CONTINUED THE TELEMEDICINE OFFERINGS TO ENCOMPASS BEHAVIORAL HEALTH AND ASSIST OUTLYING COMMUNITIES WITH LIMITED PERSONNEL AND RESOURCES TO CONDUCT PROPER ASSESSMENTS. ST. DOMINIC'S BEHAVIORAL HEALTH PARTNERED WITH OTHER SENIOR CARE AGENCIES TO PROMOTE SENIOR CARE SERVICES ACROSS THE STATE AND PARTICIPATED IN COMMUNITY OUTREACH PROGRAMS WHERE BHS CLINICAL STAFF SPOKE TO SMALLER AUDIENCES IN AGENCIES AND COMMUNITY SETTINGS, SOMETIMES VIRTUALLY TO ADHERE TO COVID GUIDELINES. BEHAVIORAL HEALTH IS THE SINGLE POINT OF ENTRY FOR THE HINDS COUNTY CRISIS INTERVENTION TEAM (CIT) AND IS PART OF THE COMMITTEE AND THE OFFICER TRAINING ASSOCIATED WITH THE CIT. ST. DOMINIC-JACKSON MEMORIAL HOSPITAL PART V, SECTION B, LINE 13H: PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES THAT MAY INCLUDE:1. THE PATIENT RECEIVING FREE CARE FROM A COMMUNITY CLINIC AND ISREFERRED TO THE HOSPITAL;2. STATE-FUNDED PRESCRIPTION PROGRAMS;3. HOMELESS, INDIGENT, OR HOMELESS CLINIC PATIENT;4. PATIENTS' CHILDREN WHO QUALIFY FOR OTHER FINANCIAL ASSISTANCEPROGRAMS;5. PATIENT ELIGIBLE FOR FOOD STAMPS;6. MEDICAID ELIGIBLE PATIENT;7. PATIENT IS DECEASED WITH NO KNOWN RESPONSIBLE PARTY;8. PATIENT IS INCARCERATED AND HAS NO OTHER RESPONSIBLE PARTY ST. DOMINIC-JACKSON MEMORIAL HOSPITAL PART V, SECTION B, LINE 16J: REGISTRATION PERSONNEL REFER UNINSURED AND/OR LOW-INCOME PATIENTS TO FINANCIAL COUNSELORS TO DISCUSS THE FINANCIAL ASSISTANCE POLICY. PART V, SECTION A, LINES 7A &10: HTTPS://WWW.STDOM.COM/ABOUT-US/COMMUNITY-BENEFIT/COMMUNITY-HEALTH-NEEDS-ASSESSMENT PART V, SECTION B, LINE 16 A, B, C: THE FAP, FAP APPLICATION FORM, AND A PLAIN LANGUAGE SUMMARY OF THE FAP ARE AVAILABLE AT:HTTPS://WWW.STDOM.COM/PATIENTS-AND-VISITORS/PATIENT-GUIDE/FINANCIAL-ASSISTANCE 35 1 - ST DOMINIC'S HOSPITAL MEDICINE 971 LAKELAND DRIVE SUITE 1453 JACKSON MS 39216 HOSPITALIST CLINIC 2 - ST DOMINIC'S NEUROSURGERY ASSOCIATES 971 LAKELAND DRIVE SUITE 657 JACKSON MS 39216 PHYSICIAN CLINIC 3 - ST DOMINIC'S NEUROCARE 971 LAKELAND DRIVE SUITE 557 JACKSON MS 39216 PHYSICIAN CLINIC 4 - ST DOMINIC'S VASCULAR AND ENDOVASCULAR 971 LAKELAND DRIVE SUITE 1250 JACKSON MS 39216 PHYSICIAN CLINIC 5 - ST DOMINIC'S EAR NOSE & THROAT SURGICA 970 LAKELAND DRIVE SUITE 40 JACKSON MS 39216 PHYSICIAN CLINIC 6 - ST DOMINIC'S INTERNAL MEDICINE GROUP 971 LAKELAND DRIVE SUITE 250 JACKSON MS 39216 PHYSICIAN CLINIC 7 - STDOMINIC'S FAMILY MEDICINE OF MADISON 106 HIGHLAND WAY 103 MADISON MS 39110 PHYSICIAN CLINIC 8 - ST DOMINIC'S INTERNAL MEDICINE MADISON 106 HIGHLAND WAY 200 MADISON MS 39110 PHYSICIAN CLINIC 9 - ST DOMINIC'S CARDIOVASCULAR SURGERY 971 LAKELAND DRIVE SUITE 657 JACKSON MS 39216 PHYSICIAN CLINIC 10 - ST DOMINIC'S PAIN MANAGEMENT CENTER 971 LAKELAND DRIVE SUITE 1159 JACKSON MS 39216 PHYSICIAN CLINIC 11 - ST DOMINIC'S GYNECOLOGIC ONCOLOGY 971 LAKELAND DRIVE SUITE 750 JACKSON MS 39216 PHYSICIAN CLINIC 12 - ST DOMINIC'S UROLOGY 971 LAKELAND DRIVE SUITE 360 JACKSON MS 39216 PHYSICIAN CLINIC 13 - ST DOMINIC'S INFECTIOUS DISEASE 971 LAKELAND DRIVE SUITE 954 JACKSON MS 39216 PHYSICIAN CLINIC 14 - ST DOMINIC'S PSYCHIATRIC ASSOCIATES 890 LAKELAND DRIVE JACKSON MS 39216 PHYSICIAN CLINIC 15 - ST DOMINIC'S RHEUMATOLOGY 106 HIGHLAND WAY SUITE 200 MADISON MS 39110 PHYSICIAN CLINIC 16 - ST DOMINIC'S FAMILY MEDICINE OF BRANDON 1297 WEST GOVERNMENT STREET BRANDON MS 39042 PHYSICIAN CLINIC 17 - ST DOMINIC'S FAMILY MEDICINE OF CLINTON 728 CLINTON PARKWAY SUITE B CLINTON MS 39056 PHYSICIAN CLINIC 18 - ST DOMINIC'S FAMILY MEDICINE OF FLOWOOD 1050 RIVER OAKS DRIVE FLOWOOD MS 39232 PHYSICIAN CLINIC 19 - ST DOMINIC'S FAMILY MEDICINE OF DOGWOOD 205A BELLE MEADE POINTE FLOWOOD MS 39232 PHYSICIAN CLINIC 20 - ST DOMINIC'S FAMILY MEDICINE OF MAGEE 360 SIMPSON HWY 149 SUITE 220 MAGEE MS 39111 PHYSICIAN CLINIC 21 - ST DOMINIC'S FAMILY MEDICINE OF JACKSON 890 LAKELAND DRIVE JACKSON MS 39056 PHYSICIAN CLINIC 22 - ST DOMINIC'S MARTIN SURGICAL ASSOCIATES 971 LAKELAND DRIVE SUITE 211 JACKSON MS 39216 PHYSICIAN CLINIC 23 - ST DOMINIC'S FAMILY MED OF PELAHATCHIE 610 2ND STREET PELAHATCHIE MS 39145 PHYSICIAN CLINIC 24 - ST DOMINIC'S FAMILY MEDICINE OF RALEIGH 342 MAGNOLIA DRIVE RALEIGH MS 39153 PHYSICIAN CLINIC 25 - ST DOMINIC'S FAMILY MEDICINE GLUCKSTADT 286 CALHOUN STATION PARKWAY MADISON MS 39110 PHYSICIAN CLINIC 26 - ST DOMINIC'S COUMADIN CLINIC 890 LAKELAND DRIVE JACKSON MS 39056 PHYSICIAN CLINIC 27 - ST DOMINIC'S CHRONIC CARE CLINIC 969 LAKELAND DRIVE JACKSON MS 39216 PHYSICIAN CLINIC 28 - ST DOMINIC'S OUTREACH PROGRAM-TELEMEDIC 969 LAKELAND DRIVE JACKSON MS 39216 PHYSICIAN CLINIC 29 - ST DOMINIC'S OUTREACH PROGRAM-MAGEE 360 SIMPSON HWY 149 SUITE 370 MAGEE MS 39111 PHYSICIAN CLINIC 30 - ST DOMINIC'S OUTREACH PROGRAM-CLEVELAND 810 E SUNFLOWER ROAD CLEVELAND MS 38732 PHYSICIAN CLINIC 31 - ST DOMINIC'S OUTREACH PROGRAM-KOSCIUSKO 332 HIGHWAY 12 WEST KOSCIUSKO MS 39090 PHYSICIAN CLINIC 32 - ST DOMINIC'S OUTREACH PROGRAM-PELAHATCH 610 2ND STREET PELAHATCHIE MS 39145 PHYSICIAN CLINIC 33 - ST DOMINIC'S OUTREACH PROGRAM-VICKSBURG 4204 CLAY STREET VICKSBURG MS 39180 PHYSICIAN CLINIC 34 - ST DOMINIC'S OUTREACH PROGRAM-BROOKHAVE 427 HWY 51 N BROOKHAVEN MS 39601 PHYSICIAN CLINIC 35 - ST DOMINIC'S INTERNAL MEDICINE CLINIC 112 SOUTH LAKE CIRCLE CANTON MS 39046 PHYSICIAN CLINIC PART I, LINE 3C: FINANCIAL ASSISTANCE IS AVAILABLE FOR INDIVIDUALS WHO ARE UNINSURED, UNDERINSURED, INELIGIBLE FOR ANY GOVERNMENT HEALTH CARE BENEFIT PROGRAM, AND WHO ARE UNABLE TO PAY FOR THEIR CARE. FULLY-DISCOUNTED CARE IS AVAILABLE IF INCOME AND ASSETS MEET CERTAIN FEDERAL POVERTY GUIDELINE LEVELS. FULLY-DISCOUNTED CARE IS ALSO AVAILABLE FOR THOSE PATIENTS WITH CATASTROPHIC MEDICAL BILLS IF MEDICAL BILLS EXCEED A CERTAIN PERCENTAGE OF INCOME AND ASSETS. FULLY DISCOUNTED CARE IS ALSOAVAILABLE WHERE THE PATIENT OR OTHER SOURCES CAN PROVIDE SUFFICIENT EVIDENCE OF PRESUMPTIVE ELIGIBILITY. PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES THAT MAY INCLUDE:1) PATIENT RECEIVING FREE CARE FROM A COMMUNITY CLINIC AND IS REFERREDTO THE HOPSITAL;2) STATE-FUNDED PRESCRIPTION PROGRAMS;3) HOMELESS, INDIGENT, OR HOMELESS CLINIC PATIENT;4) PATIENT'S CHILDREN WHO QUALIFY FOR OTHER FINANCIAL ASSISTANCEPROGRAMS;5) PATIENT ELIGIBLE FOR FOOD STAMPS;6) MEDICAID ELIGIBLE PATIENT;7) PATIENT IS DECEASED WITH NO KNOWN RESPONSIBLE PARTY;8) PATIENT IS INCARCERATED AND HAS NO OTHER RESPONSIBLE PARTY. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT FOR ST. DOMINIC HOSPITAL IS CONSOLIDATED WITH THE PARENT ORGANIZATION, ST. DOMINIC HEALTH SERVICES, INC. THE REPORT IS AVAILABLE AT HTTPS://WWW.STDOM.COM/ABOUT-US/COMMUNITY-BENEFIT-AND-NEEDS/. PART I, LINE 7: ST. DOMINIC HOSPITAL USED A COST-TO-CHARGE RATIO BASED ON WORKSHEET 2 PROVIDED IN THE FORM 990, SCHEDULE H INSTRUCTIONS. PART I, LINE 7G: ST. DOMINIC HOSPITAL DID NOT INCLUDE LOSSES ON ITS OWNED PHYSICIAN CLINICS AS SUBSIDIZED HEALTH SERVICES. IN ORDER TO MEET THE NEEDS OF THE COMMUNITY IT SERVES, ST. DOMINIC CONTINUES ITS MINISTRY IN VARIOUS SERVICE LINES THAT ARE NOT PROFITABLE TO THE ORGANIZATION. EXAMPLES OF THESE SERVICES INCLUDE BUT ARE NOT LIMITED TO THE EMERGENCY DEPARTMENT AND BEHAVIORAL HEALTH SERVICES. PART II, COMMUNITY BUILDING ACTIVITIES: ST. DOMINIC PROVIDES SIGNIFICANT SUPPORT TO ITS COMMUNITY THROUGH A VARIETY OF WAYS INCLUDING FREE HEALTH SCREENINGS AT LOCAL SCHOOLS, PARTICIPATION IN VARIOUS NON-PROFIT BOARDS AS WELL AS FINANCIAL SUPPORT THROUGH CASH DONATIONS. PART III, LINE 2: THE AMOUNT REPORTED IN PART III, LINE 2 AS BAD DEBT EXPENSE MATCHES THE AMOUNT OF BAD DEBT EXPENSE REPORTED ON THE HOSPITAL'S INTERNAL FINANCIAL STATEMENTS. PART III, LINE 3: ST. DOMINIC HOSPITAL FREQUENTLY HAS PATIENT ACCOUNTS THAT ARE INTITIALLY WRITTEN OFF AS A BAD DEBT EXPENSE, BUT LATER (THROUGH A SCREENING PROCESS) IT IS DETERMINED THAT THE PATIENT DOES QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. THE PERCENTAGE OF ACCOUNTS IS ESTIMATED TO BE 44 PERCENT. THE PERCENTAGE IS DETERMINED UTILIZING AN INTERNAL REPORT OF ACCOUNTS WRITTEN OFF AS A BAD DEBT EXPENSE IN ONE YEAR AND CLASSIFIED AS CHARITY IN A SUBSEQUENT YEAR. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND REPORTED AT NET REALIZABLE VALUE. IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS HISTORICAL EXPERIENCE AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR UNCOLLECTABLE ACCOUNTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR UNCOLLECTIBLE ACCOUNTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYER HAS NOT YET PAID, OR FOR PAYERS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A PROVISION FOR UNCOLLECTIBLE ACCOUNTS IN THE PERIOD OF SERVICE ON THE BASIS OF THEIR PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 8: THE COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COSTSREPORTED IN THE MEDICARE COST REPORT IS BASED ON REGULATORY REQUIREMENTSAND GUIDELINES. PART III, LINE 9B: ST. DOMINIC HOSPITAL HAS A BOARD APPROVED COLLECTION POLICY AND HAS WRITTEN CONTRACTS IN PLACE WITH ITS COLLECTION AGENCIES SO THE APPROPRIATE COLLECTION ACTIVITIES ARE FOLLOWED. THE COLLECTION AGENCIES THAT ST. DOMINIC USES ARE FULLY INFORMED ABOUT THE HOSPITAL'S FINANCIAL AID POLICY AND ASSIST IN EDUCATING ITS PATIENTS. THEY ROUTINELY SEND FINANCIAL AID APPLICATIONS TO PATIENTS AND REFER THOSE PATIENTS BACK TO THE HOSPITAL'S FINANCIAL COUNSELORS WHEN APPROPRIATE. PART VI, LINE 2: ST. DOMINIC HOSPITAL ASSESSES THE COMMUNITY IT SERVES THROUGH VARIOUS SOURCES WHICH INCLUDE:1) ANALYSIS OF THE PAYOR SOURCE AND DISEASE CATEGORIES OF PATIENTS TREATED AT ST. DOMINIC HOSPITAL WITH PARTICULAR ANALYSIS DONE ON PATIENTS PRESENTING TO ITS EMERGENCY DEPARTMENT;2) FEEDBACK FROM THE BOARD MEMBERS WHO REPRESENT THE COMMUNITY IT SERVES;3) REQUESTS MADE FROM THE COMMUNITY; AND4) PUBLIC HEALTH INFORMATION. PART VI, LINE 3: ST. DOMINIC HOSPITAL WORKS TO EDUCATE ITS PATIENTS AND COMMUNITY OF ASSISTANCE OPTIONS BY:1) POSTING SIGNAGE IN THE EMERGENCY ROOM AND OTHER REGISTRATION AREAS INFORMING PATIENTS THAT FINANCIAL ASSISTANCE IS AVAILABLE.2) PROVIDING BROCHURES IN THE WAITING ROOMS AND AT THE REGISTRATION DESKS THAT EXPLAIN THE BILLING AND COLLECTION PROCESS AS WELL AS INFORMATION ABOUT THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY AND PHONE NUMBERS TO CALL FOR ASSISTANCE.3) CONTRACTING AND PAYING AN AGENCY TO MEET WITH ALL UNINSURED PATIENTS TO ASSIST THEM IN APPLYING FOR FEDERAL AND STATE ASSISTANCE (I.E. MEDICAID, DISABILITY, ETC.).4) PROVIDING FINANCIAL COUNSELORS TO MEET WITH PATIENTS. THESE COUNSELORS FULLY UNDERSTAND THE HOSPITAL'S CHARITY POLICY AND ARE AVAILABLE TO ASSIST WITH THE APPLICATIONS, SET UP INTEREST FREE PAYMENT PLANS AND OFFER ADVICE ON PUBLIC ASSISTANCE THAT MAY BE AVAILABLE.5) STAFFING PATIENT REPRESENTATIVES TO ANSWER QUESTIONS AND ASSIST PATIENTS AS NEEDED.6) EDUCATION THE EARLY-OUT AND BAD DEBT COLLECTION AGENCIES ON THE HOSPITAL'S FINANCIAL ASSISTANCE POLICIES SO THEY CAN ASSIST PATIENTS WHOM THEY FIND MIGHT HAVE FINANCIAL NEED. PART VI, LINE 4: THE COMMUNITY SERVED BY THE HOSPITAL, INCLUDING GEOGRAPHIC AND DEMOGRAPHIC AREAS, IS ADDRESSED IN THE 2021-2024 COMMUNITY HEALTH NEEDS ASSESSMENT. THE CHNA CAN BE ACCESSED AT: HTTPS://WWW.STDOM.COM/ABOUT-US/COMMUNITY-BENEFIT/COMMUNITY-HEALTH-NEEDS-ASSESSMENT PART VI, LINE 5: INSPIRED BY THE TEACHINGS OF JESUS CHRIST AND THE WITNESS OF OUR FOUNDING DOMINICAN SISTERS, WE PROVIDE COMPASSIONATE CARE AND HOPE AS A HEALING MINISTRY OF THE CATHOLIC CHURCH. ST. DOMINIC APPLIES THIS MISSION BY CONDUCTING NEEDS ASSESSMENTS, PUBLISHING THE RESULTS, ESTABLISHING GOALS AND STRATEGIES TO HELP RESOLVE IDENTIFIED ISSUES AND SEEKING OPPORTUNITIES TO WORK WITH THE COMMUNITY. THE HOSPITAL INVOLVES MEMBERS OF ITS COMMUNITY IN ITS GOVERNANCE SO THAT IT MAINTAINS THE FOCUS ON THE NEEDS OF ITS COMMUNITY. THE HOSPITAL HAS AN OPEN MEDICAL STAFF. PART VI, LINE 6: ST. DOMINIC HEALTH SERVICES, INC. IS THE PARENT ORGANIZATION OF A SYSTEM THAT INCLUDES ST. DOMINIC - JACKSON MEMORIAL HOSPITAL (A 571-BED ACUTE CARE FACILITY), ST. CATHERINE'S VILLAGE (A CONTINUING CARE RETIREMENT COMMUNITY), ST. DOMINIC HEALTH SERVICES FOUNDATION (A FUNDRAISING/GRANT FOCUSED ENTITY) AND ST. DOMINIC MADISON HEALTH SERVICES, INC. (A MEDICAL OFFICE BUILDING AND FITNESS CENTER). IN ADDITION, ST. DOMINIC HEALTH SERVICES OPERATES COMMUNITY HEALTH SERVICES - ST. DOMINIC, INC., WHICH INCORPORATES THE OUTREACH SERVICES OF THE CLUB AT ST. DOMINIC'S, NEW DIRECTIONS FOR OVER 55, ST. DOMINIC COMMUNITY HEALTH CLINIC, MADISON SCHOOL NURSE PROGRAM AND THE CARE-A-VAN SCREENING PROGRAM. AS A WHOLE, ALL OF THE SERVICES, ENTITIES AND HOSPITAL ARE COLLECTIVELY REFERRED TO AS ST. DOMINIC'S. ST DOMINIC'S SEEKS TO GIVE TIME, TALENTS, AND RESOURCES TO MAKE THE COMMUNITIES SERVED BY THE ORGANIZATION BETTER PLACES TO LIVE. THE ST. DOMINIC'S FAMILY OF CAREGIVERS NOT ONLY SERVES PATIENTS, BUT ALSO CONTRIBUTES TO AN ATMOSPHERE OF CARE AND COMPASSION FOR THOSE OUTSIDE THE HOSPITAL'S WALLS. ST. DOMINIC STRIVES TO NOT ONLY PROVIDE CARE FOR THE SICK BUT ALSO TO OFFER EDUCATION AND WELLNESS SERVICES TO IMPROVE THE HEALTH STATUS OF THE COMMUNITY AND HELP ELIMINATE RISK FACTORS FOR MORE SERIOUS HEALTH PROBLEMS. ADDITIONALLY ON JULY 1, 2019, ST. DOMINIC HEALTH SERVICES BECAME PART OF THE FRANCISCAN MISSIONARIES OF OUR LADY HEALTH SYSTEM (FMOLHS). AS SUCH, IT IS AFFILIATED WITH TAX-EXEMPT HOSPITALS THROUGHOUT THE STATE OF LOUISIANA INCLUDING:OUR LADY OF LOURDES REGIONAL MEDICAL CENTERST. FRANCIS MEDICAL CENTEROUR LADY OF THE LAKE ASSUMPTION HOSPITALOUR LADY OF THE ANGELS HOSPITALOUR LADY OF THE LAKE HOSPITAL PART VI, LINE 7: STATE FILING OF COMMUNITY BENEFIT REPORTST. DOMINIC HOSPITAL (CONSOLIDATED WITH ST. DOMINIC HEALTH SERVICES, INC.) PREPARES ANNUALLY A COMMUNITY BENEFIT REPORT WHICH IS DISTRIBUTED TO KEY MEMBERS OF THE LOCAL COMMUNITY AND STATE GOVERNMENT. HOWEVER, THERE ARE CURRENTLY NO REQUIREMENTS TO DO SO IN THE STATE OF MISSISSIPPI. 1 100 BLACK MEN OF JACKSON 5360 HIGHLAND DRIVE JACKSON MS 39286 640817928 501 (C)(3) 22000 0 GENERAL SUPPORT AMERICAN CANCER SOCIETY 250 WILLIAMS STREET ATLANTA GA 30303 131788491 501 (C)(3) 10000 0 GENERAL SUPPORT AMERICAN HEART ASSOCIATION 4830 MCWILLIE CIRCLE JACKSON MS 39206 135613797 501 (C)(3) 50000 0 GENERAL SUPPORT BB KING MUSEUM 400 SECOND STREET INDIANOLA MS 38751 460501512 501 (C)(3) 15000 0 GENERAL SUPPORT CANOPY CHILDREN'S SOLUTION 1465 LAKELAND DRIVE JACKSON MS 39216 640303085 501 (C)(3) 25000 0 GENERAL SUPPORT CATHOLIC CHARITIES 850 EAST RIVER PLACE JACKSON MS 39201 640466850 501 (C)(3) 135000 0 GENERAL SUPPORT CATHOLIC DIOCESE OF JACKSON PO BOX 2248 JACKSON MS 392252248 640303073 501 (C)(3) 15000 0 GENERAL SUPPORT CENTER FOR VIOLENCE PREVENTION PO BOX 6279 PEARL MS 39288 581959108 501 (C)(3) 47500 0 GENERAL SUPPORT COMMUNITY HEALTH SERVICES 970 LAKELAND DR JACKSON MS 39216 640884870 501 (C)(3) 100000 0 GENERAL SUPPORT DEVOTED DREAMERS 454 OAK LAWN DRIVE PEARL MS 39208 276601178 501 (C)(3) 15000 0 GENERAL SUPPORT HOPE HOUSE OF HOSPITALITY 786 EAST NORTHSIDE DRIVE JACKSON MS 39206 640622022 501 (C)(3) 15000 0 GENERAL SUPPORT HOSPICE MINISTRIES 45 TOWNE CENTER BLVD RIDGELAND MS 39157 640789919 501 (C)(3) 50000 0 GENERAL SUPPORT JACKSON HEART FOUNDATION PO BOX 5021 JACKSON MS 39296 270723542 501 (C)(3) 20000 0 GENERAL SUPPORT LEXINGTON MEDICAL CLINIC 22741 HIGHWAY 12 LEXINGTON MS 39095 200378262 501 (C)(3) 18000 0 GENERAL SUPPORT MISSION FIRST INC PO BOX 250 JACKSON MS 39205 640797107 501 (C)(3) 15000 0 GENERAL SUPPORT MISSION MISSISSIPPI PO BOX 22655 JACKSON MS 39225 640824240 501 (C)(3) 37500 0 GENERAL SUPPORT MISSISSIPPI CHILDREN'S MUSEUM PO BOX 55409 JACKSON MS 392965409 640850010 501 (C)(3) 10000 0 GENERAL SUPPORT MISSISSIPPI SYMPHONY ORCHESTRA PO BOX 2052 JACKSON MS 39225 640273405 501 (C)(3) 20800 0 GENERAL SUPPORT NATIONAL COALITION OF 100 BLACK WOMEN PO BOX 68412 JACKSON MS 39286 582063167 501 (C)(3) 15000 0 GENERAL SUPPORT NEWKS CARES 814 NORTH CONGRESS STREET JACKSON MS 39202 640765336 501 (C)(3) 50000 0 GENERAL SUPPORT OPERATION SHOESTRING 1711 BAILEY AVENUE JACKSON MS 39283 640471554 501 (C)(3) 20000 0 GENERAL SUPPORT REAL CHRISTIAN FOUNDATION PO BOX 180059 RICHLAND MS 39218 640885750 501 (C)(3) 42500 0 GENERAL SUPPORT REFILL CAFE 136 SOUTH ADAMS STREET JACKSON MS 39203 832814994 501 (C)(3) 10000 0 GENERAL SUPPORT SISTERS IN BIRTH 5839 PEAR ORCHARD RD JACKSON MS 39211 812072883 501 (C)(3) 10000 0 GENERAL SUPPORT ST JOSEPH CATHOLIC SCHOOL PO BOX 2027 MADISON MS 391302027 640339825 501 (C)(3) 40000 0 GENERAL SUPPORT TUTWILER COMMUNITY EDUCATION CENTER INC PO BOX 448 TUTWILER MS 38963 581887449 501 (C)(3) 10000 0 GENERAL SUPPORT ST DOMINIC HEALTH SERVICES INC 969 LAKELAND DRIVE JACKSON MS 39216 640714999 501 (C)(3) 1500000 0 GENERAL SUPPORT 30 PART I, LINE 2: THE HOSPITAL HAS A CONTRIBUTIONS COMMITTEE, WHICH IS A SUB-COMMITTEE OF THE BOARD, THAT OVERSEES THE HOSPITAL'S GIVING. THEY MONITOR THE REQUESTS AND OVERSEE ALL GIFTS. X X X X X 1 1 0 0 0 0 0 0 0 JOHN LANCON PHYSICIAN 1201707 0 0 0 0 0 0 0 28310 0 1230017 0 0 0 DAVID THEODORO PHYSICIAN 1083208 0 0 0 0 0 0 0 19532 0 1102740 0 0 0 STEVEN GREMILLION MD BOARD MEMBER 0 599955 0 385164 0 7649 0 14500 0 25128 0 1032396 0 0 D PAUL SEAGO MD BOARD MEMBER/PHYSICIAN 956412 0 16894 0 0 0 0 0 20028 0 993334 0 0 0 PB KERR PHYSICIAN 955798 0 0 0 0 0 0 0 25610 0 981408 0 0 0 BRYAN A GASPARD PHYSICIAN 933692 0 0 0 0 0 0 0 25610 0 959302 0 0 0 RONALD KENNEDY PHYSICIAN 815869 0 0 0 0 0 0 0 12472 0 828341 0 0 0 LESTER DIAMOND PRESIDENT (THRU 03/2021) 0 116032 0 79177 0 519130 0 0 0 6751 0 721090 0 75873 REBEKAH MOULDER MD BOARD MEMBER/PHYSICIAN 614401 0 0 0 0 0 0 0 2676 0 617077 0 0 0 SAMUEL SCOTT SVP, CFO 0 334237 0 174145 0 0 0 14500 0 18776 0 541658 0 0 WILLIAM MORGAN COO - THRU 5/2021 145478 0 0 0 274646 0 0 0 11020 0 431144 0 0 0 ROBERT NELSON VP CHIEF NURSING OFFICER 263998 0 88495 0 0 0 14500 0 25905 0 392898 0 0 0 REGINALD MARTIN MD BOARD MEMBER/PHYSICIAN 351041 0 0 0 0 0 0 0 25571 0 376612 0 0 0 DAVID C HENRY VP OPERATIONS - THRU 5/2021 78468 0 0 0 152615 0 0 0 9892 0 240975 0 0 0 SCOTT KASHMAN PRESIDENT - SD & JACKSON MARKET 0 95448 0 75000 0 16614 0 0 0 2298 0 189360 0 0 PART I, LINE 3 THE FMOL HEALTH SYSTEM BOARD OF DIRECTORS DESIGNATES A COMPENSATION COMMITTEE, MADE UP OF INDEPENDENT BOARD MEMBERS, TO REVIEW AND SET COMPENSATION ANNUALLY. THE COMPENSATION COMMITTEE OBTAINS AND RELIES UPON COMPARABLE DATA INCLUDING A COMPENSATION STUDY/SURVEY FROM AN INDEPENDENT COMPENSATION CONSULTANT. THE COMPENSATION COMMITTEE REIVEWS COMPENSATION PACKAGES AND APPRROPRIATE COMPENSATION IS DETERMINED AND APPROVED. THE BASIS FOR MAKING SUCH DETERMINATION IS DOCUMENTED BY THE COMPENSATION COMMITTEE. PART I, LINES 4A-B FMOLHS MAINTAINS THREE UNFUNDED DEFERRED COMPENSATION PLANS WHICH MEET THE REQUIREMENTS OF IRC SECTION 457(F) AND IRC SECTION 409A. THE PLANS PROVIDE FOR COMPENSATION TO BE DEFERRED AND PAID UPON THE OCCURRENCE OF CERTAIN EVENTS SUCH AS TERMINATION WITHOUT CAUSE, DISABILITY, DEATH OR ATTAINMENT OF A SPECIFIC PAYMENT DATE. PARTICIPATION IN THE PLANS IS LIMITED TO CERTAIN EXECUTIVES AND IS SUBJECT TO APPROVAL OF FMOLHS BOARD OF DIRECTORS OR A DESIGNATED COMMITTEE OF SUCH BOARD. LESTER DIAMOND RECEIVED A PAYMENT IN THE CURRENT YEAR OF $78,347. PART I, QUESTION 4A: ONE DIRECTOR AND ONE OFFICER ARE ENTITLED TO A SEVERANCE BENEFIT. THE PAYOUT OF SUCH BENEFIT IS REMOTE AS IT IS EFFECTIVE ONLY FOR A TERMINATION OF EMPLOYMENT WITHOUT CAUSE, FOR GOOD REASON OR DUE TO CHANGE OF CONTROL. IF TRIGGERED, THE EMPLOYEE WOULD BE PAID HIS/HER BASE SALARY AND PROVIDED RETIREMENT AND WELFARE BENEFITS FOR AN ENTITLEMENT PERIOD. THE ENTITLEMENT PERIOD IS 18 MONTHS. NO PAYMENTS WERE MADE UNDER THE PLAN IN THE CURRENT YEAR. AN OFFICER IS ENTITLED TO A SEVERANCE BENEFIT. THE PAYOUT OF SUCH BENEFIT IS REMOTE AS IT IS EFFECTIVE ONLY FOR A TERMINATION OF EMPLOYMENT WITHOUT CAUSE, FOR GOOD REASON OR DUE TO CHANGE OF CONTROL. IF TRIGGERED, THE EMPLOYEE WOULD BE PAID HIS/HER BASE SALARY AND PROVIDED RETIREMENT AND WELFARE BENEFITS FOR AN ENTITLEMENT PERIOD. THE ENTITLEMENT PERIOD IS 12 MONTHS. NO PAYMENTS WERE MADE UNDER THE PLAN IN THE CURRENT YEAR. THE FOLLOWING INDIVIDUALS RECEIVED SEVERANCE PAYMENTS THIS YEAR - LESTER DIAMOND $519,130 DAVID HENRY $152,615 WILLIAM MORGAN $274,646 FORM 990, PART VI, SECTION A, LINE 6 ST. DOMINIC HEALTH SERVICES, INC. IS THE SOLE MEMBER OF ST. DOMINIC JACKSON MEMORIAL HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF DIRECTORS OF ST. DOMINIC- JACKSON MEMORIAL HOSPITAL'S SOLE MEMBER, ST. DOMINIC HEALTH SERVICES, INC., HAS THE AUTHORITY TO APPROVE THE ELECTION OF THE PRESIDENT/CEO, THE CHAIR OF THE BOARD OF DIRECTORS AND THE VICE-CHAIR OF THE BOARD OF DIRECTORS OF THE HOSPITAL AND ALL OTHER DIRECTORS AND OFFICERS OF THE HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7B THE RESERVED POWER TO THE MEMBER, ST. DOMINIC HEALHT SERVICES, INC., ARE AS FOLLOWS: I. TO CHANGE PHILOSOPHY, OBJECTIVES AND PURPOSES OF CORPORATION. II. TO APPOINT OR REMOVE THE MEMBERS OF THE BOARD OF TRUSTEES AND OFFICERS OF THE CORPORATION. III. TO AMEND, ALTER, MODIFY, OR REPEAL THE ARTICLES OF INCORPORATION AND BYLAWS OF THE CORPORATION. IV. TO AUTHORIZE MERGER, CONSOLIDATION, OR AFFILIATION, OR PARTICIPATE IN JOINT VENTURES. V. TO DISSOLVE AND TO DISTRIBUTE ASSETS OF THE CORPORATION. VI. TO APPOINT AND/OR TERMINATE WITH OR WITHOUT CAUSE THE CHIEF EXECUTIVE OFFICER OF THE CORPORATION. VII. TO ACQUIRE, PURCHASE, SELL, LEAASE, TRANSFER, OR ENCUMBER ANY IMMOVABLE PROPERTY ON BEHALF OF THE CORPORATION. VIII. TO ADD TO OR INCUR LONG-TERM DEBT IN EXCESS OF $5 MILLION BY THE CORPORATION. IX. TO APPOINT THE FISCAL AUDITOR FOR THE CORPORATION. X. TO APPROVE ANY INCREMENT OR ADDITION TO THE CAPITAL DEBT OR EFFORTS TO RENEGOTIATE, MODIFY OR CHANGE THE EXISTING CAPITAL DEBT OBLIGATIONS OF THE CORPORATION. XI. TO APPROVE THE ANNUAL OPERATING AND CAPITAL BUDGETS OF THE CORPORATION. XII. TO APPROVE A STRATEGIC BUSINESS PLAN OF THE CORPORATION. FORM 990, PART VI, SECTION B, LINE 11B THE BOARD HAS DELEGATED REVIEW OF THE FORM 990 TO THE FINANCE COMMITTEE OF THE BOARD PRIOR TO FILING. A FULL COPY, AS APPROVED BY THE FINANCE COMMITTEE, IS PROVIDED TO THE BOARD. FORM 990, PART VI, SECTION B, LINE 12C ALL BOARD MEMBERS ARE REQUIRED TO COMPLETE AND SIGN A CONFLICT OF INTEREST FORM ANNUALLY. THE PRESIDENT REVIEWS THE FORMS, AND ANY CONFLICTS ARE DISCLOSED TO THE OTHER MEMBERS OF THE BOARD AND MADE A MATTER OF RECORD. PERSONS WITH CONFLICTS OF INTERESTS DO NOT VOTE OR USE HIS OR HER INFLUENCE ON THE MATTER AND ARE EXCLUDED FROM THE COUNT IN DETERMINING THE QUORUM FOR THE MEETING, EVEN WHERE PERMITTED BY LAW. FORM 990, PART VI, SECTION B, LINE 15 OUR BOARD OF DIRECTORS DESIGNATES AN EXECUTIVE COMMITTEE MADE UP OF INDEPENDENT BOARD MEMBERS TO REVIEW AND SET THE COMPENSATION ANNUALLY OF OUR OFFICERS AND KEY EMPLOYEES. THE EXECUTIVE COMMITTEE OBTAINS AND RELIES UPON COMPARABLE DATA INCLUDING INDUSTRY-WIDE COMPENSATION INFORMATION PROVIDED BY AN OUTSIDE CONSULTING FIRM. THE EXECUTIVE COMMITTEE REVIEWS COMPENSATION PACKAGES AND APPROPRIATE COMPENSATION IS DETERMINED AND APPROVED. THE BASIS FOR DETERMINATION IS THEN DOCUMENTED BY THE EXECUTIVE COMMITTEE. THE COMPENSATION FOR THE CEO OF ST. DOMINIC JACKSON MEMORIAL HOSPITAL IS SET BY THE COMPENSATION COMMITTEE OF ST. DOMINIC HEALTH SERVICES (A RELATED TAX-EXEMPT ORGANIZATION) ACCORDING TO THEIR PAY PRACTICES WHICH ARE SIMILAR TO THOSE DESCRIBED ABOVE. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. SECTION 1.263(A)-3(N) - BOOK CONFORMITY ELECTION: ST. DOMINIC JACKSON MEMORIAL HOSPITAL IS MAKING THE ELECTION UNDER TREAS. REG. 1.263(A)-3(N) TO CAPITALIZE THE REPAIR AND MAINTENANCE COSTS THAT IT TREATS AS CAPITAL IMPROVEMENTS ON ITS BOOKS AND RECORDS FOR THE TAX YEAR ENDED JUNE 30, 2022. SECTION 1.263(A)-1(F) - DE MINIMIS SAFE HARBOR ELECTION: ST. DOMINIC JACKSON MEMORIAL HOSPITAL HEREBY MAKES THE DE MINIMIS SAFE HARBOR ELECTION UNDER SECTION 1.263(A)-1(F) OF THE TREASURY REGULATIONS, EFFECTIVE ONLY FOR THE TAX YEAR ENDED JUNE 30, 2022. TAXPAYER HAS AN APPLICABLE FINANCIAL STATEMENT FOR THE YEAR OF THE ELECTION. THIS ELECTION PERMITS THE TAXPAYER TO DEDUCT FOR TAX PURPOSES ANY ITEM DEDUCTED UNDER ITS BOOK POLICY THAT DOES NOT EXCEED $5,000 PER INVOICE (OR PER ITEM, AS SUBSTANTIATED BY THE INVOICE) OR ITEMS HAVING AN ECONOMIC USEFUL LIFE OF TWELVE MONTHS OR LESS AS DESCRIBED IN SECTION 1.263(A)-1(F)(1)(I). FORM 990, PART XI, LINE 9: PRIOR PERIOD ADJUSTMENTS -4,052,816. CAPITAL TRANSFERS -5,776,238. 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