2023-07-07T16:47:18-05:00 2022-09-30 420714325 RSM US LLP 30 South Wacker Dr Suite 3300 Chicago IL 606063392 990 2021-10-01 951656366 PIH Health Good Samaritan Hospital PIHH 2139772121 1225 Wilshire Blvd Los Angeles CA 900172395 Vid Shivaraman CFO 2139772121 2023-06-28 1 Vid Shivaraman XXX-XX-XXXX Rebekuh Eley P01247672 3126343400 2023-06-28 3 AAL1 IAL1 2021 2023-04-26 12:10:37Z James West 12401 Washington Blvd Whittier CA 90602 473668615 0 X www.PIHHealth.org X 1885 CA Provide high-quality healthcare, without discrimination, and contribute to the health and well-being of our communities in an ethical, safe and fiscally prudent manner, in recognition of our charitable purpose. 15 15 1977 326 137469 0 15082179 5256557 400932901 394173438 12384612 30119687 7637121 6371765 436036813 435921447 53083 238180 0 0 185710516 181281254 0 0 39053 268873341 254205924 454636940 435725358 -18600127 196089 663025397 607219911 193503519 171956806 469521878 435263105 X We provide high-quality healthcare, without discrimination, and contribute to the health and well-being of our communities in an ethical, safe and fiscally prudent manner, in recognition of our charitable purpose. 0 0 223608024 238180 279994580 Patient Care: Founded in 1885, PIH Health Good Samaritan Hospital became part of PIH Health in December 2019. As a 501(c) (3) nonprofit, 408-bed acute care hospital, the downtown Los Angeles campus serves the healthcare needs of a growing and diverse community. Patient Care in Fiscal Year 2021-2022Employees 1,977Volunteers 326Number of Emergency Department (ED) visits 47,761Number of Births 1,543Medical Staff 691 167876289 0 113430472 Financial Assistance and Means-Tested Government Programs: Financial Assistance, also known as charity care, is defined as free or discounted health services provided to individuals who cannot afford to pay and who meet the eligibility criteria of the organization's financial assistance policy. PIH Health Good Samaritan Hospital offers a generous Financial Assistance Program, providing charity care to those with family income(s) at or below 350% of Federal Poverty Level guidelines. The hospital has a policy to treat emergency and certain other patients regardless of their ability to pay. Under the charity care policy, charity care may be provided to people who are uninsured or underinsured and cannot afford to pay for their own medical care.In providing services to those patients participating in means-tested government health programs, such as Medi-Cal, PIH Health Good Samaritan Hospital realizes a collective net loss each fiscal year due to the shortfall created when the payments received from these programs are less than the cost of caring for public program beneficiaries. Number of persons served by financial assistance and means-tested government programs: 35,167 6180342 0 748386 Other Community Benefit Services: Community health improvement services and community benefit operations, health professions education, subsidized services, research, community building and cash and in-kind contributions for community benefit are comprised of the following: COMMUNITY HEALTH IMPROVEMENT SERVICES: Defined as community health improvement activities, which extend beyond patient care activities. This category includes community health education, community social service helpline, flu and COVID-19 vaccination clinics, Medi-Cal eligibility workers and transportation services.Snapshot of Outcomes:- 20,935 community members were reached through a variety of community health improvement activities.HEALTH PROFESSIONS EDUCATION: This category includes educational programs for physicians, nurses, chaplain and other health professional students when education is necessary or required by state law, accrediting body or health profession society. Snapshot of Outcomes:- 75 medical residents and ancillary professions students were provided with mentorship, internship and training opportunities.SUBSIDIZED HEALTH SERVICES: Subsidized services are clinical programs, which are provided despite a financial loss so significant that negative margins remain after removing the effects of financial assistance, bad debt and Medi-Cal shortfalls. Nevertheless, the service is provided because it meets an identified community need and, if no longer offered, would either be unavailable in the area or fall to the responsibility of government or another nonprofit organization to provide. PIH Health Good Samaritan Hospital subsidized Emergency Department On-Call Physicians and the Neonatal Intensive Care Unit (NICU).Snapshot of Outcomes:- $440,862 in expenses were incurred in subsidized services in Fiscal Year 2021-2022RESEARCH: Research that may be reported as community benefit includes clinical and community health research as well as studies on healthcare delivery that are generalizable and shared with the public. PIH Health Good Samaritan Hospital has been offering clinical trials and research studies aimed at improving health. Snapshot of Outcomes:- Over $193,559 in expenses have been incurred in research in Fiscal Year 2021-2022CASH & IN-KIND CONTRIBUTIONS: This category includes funds and in-kind services donated by PIH Health Good Samaritan Hospital to community organizations or to the community-at-large for a community benefit purpose. These donations include cash donations to community organizations, in-kind hours contributed by staff to the community while on PIH Health work time, the cost of office and meeting space provided to community groups, and the donations of equipment, medications, supplies and services. Snapshot of Outcomes:- 3,390 at-risk individuals were provided with in-kind durable medical equipment or services, such as skilled nursing or mental healthcare.Total number of persons served by other community benefit services: 21,253 For additional information, please refer to PIH Health's community benefit report at https://www.pihhealth.org/about-us/community-benefit/ 397664655 1 1 0 1 0 0 0 0 0 1 1 0 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 0 1 1 1 0 0 1 309 0 1 1977 1 1 1 0 0 0 0 1 1 0 0 0 0 0 0 X 15 15 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 1 0 CA X Mark Kawauchi 5626980811 12102 Washington Blvd Whittier CA 90606 X Patrick Monroe Trustee & Chair 1.50 6.00 X X 0 0 0 Charlotte Weaver PhD Trustee & Vice Chair 1.50 6.00 X X 0 0 0 Jeffrey Hamar Trustee & Treasurer 1.50 6.00 X X 0 0 0 Peter Greaney MD Trustee & Secretary 1.50 6.00 X X 0 0 0 Alex Alvarez Trustee 1.50 6.00 X 0 0 0 J Richard Atwood Trustee 1.50 7.50 X 0 0 0 Melanie Batiste Trustee 1.50 6.00 X 0 0 0 Paula Cowan Trustee 1.50 6.00 X 0 0 0 Blayne Cutler MD PhD Trustee 1.50 6.00 X 0 0 0 Jane Dicus Trustee 1.50 6.00 X 0 0 0 Marissa Goldberg Trustee 1.50 6.00 X 0 0 0 Wesley Heartfield MD Trustee 1.50 0.00 X 0 0 0 Robert Maloney MD Trustee 1.50 6.00 X 0 0 0 Paul Treinen Trustee 1.50 6.00 X 0 0 0 Kenton Woods Trustee 1.50 6.00 X 0 0 0 James West System President & CEO 10.00 43.20 X 0 2763938 340079 Rosalio Lopez MD Chief Strategy Officer 10.00 36.20 X 0 1573688 212248 Peggy Chulack System CAO & Asst. Secretary 10.00 43.20 X 0 1058662 164469 Vid Shivaraman System CFO & Assistant Treasurer 10.00 43.20 X 0 702914 118060 Irena Zuanic CNO & Co-Site Admin. 40.00 0.00 X 0 336137 94125 Jaime Diaz MD CMO & Co-Site Admin. (Until 9/2022) 40.00 0.00 X 378851 138688 24210 Brian Smolskis System COO 10.00 37.70 X 0 1029190 176975 Jean Meussner VP Human Resources (Until 9/2021) 0.00 0.00 X 554338 0 22774 Hilarion Castillo Controller 40.00 0.00 X 293812 0 18678 Ira Meiselman Director Managed Care 40.00 0.00 X 276206 0 27995 Noli Perillo Staff RN 40.00 0.00 X 271079 0 15995 Maria Chacon Staff RN 40.00 0.00 X 269516 0 17090 Jing Cheung Staff RN 40.00 0.00 X 263722 0 14180 Anita Chou Former CFO & Asst. Treasurer 0.00 0.00 X 0 1100156 21568 2307524 8703373 1268446 637 1 1 0 Cross Country Staffing PO Box 404674 Atlanta GA 30384 Nursing Registry Services 25567992 Morrison Management Specialists 5801 Peachtree Dunwoody Road Atlanta GA 30342 Dietary Services 4659401 RehabCare Group of California LLC PO Box 502096 St Louis MO 63150 Rehabilitation Services 3639606 Sodexo America LLC 9801 Washington Blvd Gaithersburg MD 20878 Dietary Services 2929558 Crothall Healthcare Inc 955 Chesterbrook Blvd Ste 300 Wayne PA 19087 Environmental Services 2870816 74 2225149 1319656 1711752 5256557 Patient Revenue 621990 341673275 341673275 Hospital Fee Program 900099 52411344 52411344 Rental Income 532000 88819 88819 394173438 20129801 20129801 47725022 12032 37747168 0 9977854 12032 9989886 9989886 Parking Lot 812930 2084999 74654 2010345 Physician Mngmt Svcs 621110 39150 39150 Child Care Center 624410 -641 -212 -429 4248257 23877 4224380 6371765 435921447 394173438 137469 36353983 X 238180 238180 451833 316283 135550 130986659 125250380 5736279 4773819 4594146 179673 33734729 32287128 1447601 11334214 10947217 386997 547696 547696 -202227 -202227 101014 101014 234523 234523 100633459 94031345 6686385 -84271 305873 43899 261974 2740480 2693381 47099 808 808 957 957 6510813 5265406 1245407 1819796 1819796 Supplies 77280935 77092527 188173 235 Hospital Fee Program 29670858 29670858 Bad Debt Expense 15723327 15723327 Utilities 6242891 6213697 29194 12594721 9018443 3453189 123089 435725358 397664655 38021650 39053 X 976293 2406617 1200000 1367000 69185535 92194351 0 0 6533573 5549268 4086698 6115499 336960898 24967391 293582346 311993507 105045419 84859495 182415533 102734174 663025397 607219911 92772461 95666268 100731058 76290538 193503519 171956806 X 400357909 361127939 69163969 74135166 469521878 435263105 663025397 607219911 X 196089 -35348135 893273 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 101014 101014 0 Part II-B, Line 1: Lobbying expenses represent a portion of the dues PIH Health Good Samaritan Hospital pays to the Hospital Association of Southern California and to American Hospital Association. PIH Health Good Samaritan Hospital does not participate in or intervene in (including the publishing or distributing of statements), any political campaign on behalf of (or in opposition to) any candidate for public office. 70136970 18931 3493226 2963822 753790 69931515 68288340 35438 5607660 3656122 138346 70136970 68269283 20070 1013 68288340 72033292 9678 -1950120 1648396 175171 68269283 73767150 108951 4068889 5875119 36579 72033292 0.16252 0.79385 0.04363 0 0 204149473 204149473 44751537 3819246 40932291 50354725 18765020 31589705 37705163 2383125 35322038 311993507 Intercompany Receivable 50026824 Right-of-Use Assets 293420 Hospital Fee Program Receivable 45019782 Self-Insurance receivable - current portion 2545300 Other notes and loan receivable 4848848 102734174 Advances from Third Party Payors 7030253 CARES Act Provider Relief Funds 5622435 Other Annuity Payment Liability 1578521 Hospital Fee Payable 29166044 Other Liabilities 263044 Other Long Term Reserves 8263787 Pension Plan 9069940 Reserve for Asset Retirement Obligation 12521955 Reserve for Self-Insured Programs 2518671 Right-of-Use Liability 255888 76290538 X Part V, Line 4: The organization's endowment consists of funds established for health care services, as specified by donors or the organization's board of directors. Part X, Line 2: The principal operations of the Company are exempt from income taxes pursuant to Internal Revenue Code (IRC) Section 501(c)(3) and the laws of the states in which it operates and, as such, is generally not subject to federal or state income taxes. However, the Company is subject to income taxes on net income derived from a trade or business regularly carried on that does not further the organization's exempt purpose. Further, the Company is also subject to federal excise taxes pursuant to the Tax Cuts and Jobs Act. No significant income tax provision has been recorded in the accompanying consolidated financial statements for net income derived from unrelated trade or business and excise taxes. The Company measures liabilities for unrecognized tax uncertainties in accordance with ASC 740, Income Taxes, which prescribes a comprehensive model for how a company should recognize, measure, present and disclose in its financial statements uncertain tax positions that a company has taken or expects to take on a tax return. The guidance is applicable to profit-oriented entities, pass-through entities and tax-exempt organizations. Management believes it has no significant uncertain tax positions and, as such, no tax liability, benefits, interest or penalties were accrued at September 30, 2022 or 2021. The Company is subject to routine audits by taxing jurisdictions; however, there are currently no audits for any tax periods in progress. The Company believes it is no longer subject to income tax examinations for years prior to 2018 for federal purposes and 2016 for California purposes. 1 1 X 1 X 1 X 1 1 0 1 1 7137 4869318 4869318 0.01160 28030 161093357 113430472 47662885 0.11350 35167 165962675 113430472 52532203 0.12510 9 20935 3075146 19124 3056022 0.00730 3 75 2350397 719167 1631230 0.00390 1 25 474390 474390 0.00110 1 209 203654 10095 193559 0.00050 2 9 76755 76755 0.00020 16 21253 6180342 748386 5431956 0.01300 16 56420 172143017 114178858 57964159 0.13810 1 761793 0 88992311 102291248 -13298937 X 1 0 1 1 PIH Health Good Samaritan Hospital 1225 Wilshire Blvd Los Angeles CA 90017 www.pihhealth.org 930000071 X X X X X PIH Health Good Samaritan Hospital 1 0 0 1 X X X X X X X X X X 21 1 1 0 1 X See Part V, Page 8 X 1 21 1 See Part V, Page 8 0 1 X 200.000000000000 350.000000000000 X X X X 1 1 X X X 1 X See Part V, Page 8 X See Part V, Page 8 X See Part V, Page 8 X X X X X X 1 X 0 X X X X 1 X 0 0 PIH Health Good Samaritan Hospital Part V, Section B, Line 3j: The community health needs assessment includes data, maps and information regarding social determinants of health, health status and life expectancy, access to healthcare, mental health, alcohol, substance and tobacco use, physical activity, nutrition and weight status, reproductive health, acute and chronic disease, leading causes of death, community perspectives gathered from focus groups and interviews, and progress on the implementation strategy. PIH Health Good Samaritan Hospital Part V, Section B, Line 5: PIH Health Good Samaritan Hospital conducted targeted interviews to gather information and opinions from persons who represent the broad interests of the community served by the medical center.Forty-three (43) telephone interviews were conducted during December 2021 and January 2022. Interview participants included a broad range of stakeholders concerned with health and wellbeing in the Los Angeles service area who spoke to issues and needs in the communities served by the hospital. The identified stakeholders were invited by email to participate in the phone interview. Appointments for the interviews were made on dates and times convenient to the stakeholders. At the beginning of each interview, the purpose of the interview in the context of the assessment was explained, the stakeholders were assured their responses would remain confidential, and consent to proceed was given. Interview questions focused on the following topics: - Biggest health issues in the community- Groups most impacted by community issues- Where people access routine healthcare services- Reasons for not having health coverage/insurance- Reasons for delaying needed healthcare- COVID-19 pandemic impact and the vaccine- Priority ranking of community needs- Whether they have received any cancer screenings and reasons for delaying- Barriers experienced while receiving cancer treatment- Additional comments and concerns A list of the stakeholder interview respondents, their titles and organizations can be found in Attachment 2.The full Community Health Needs Assessment, can be found athttps://www.pihhealth.org/app/files/public/7fb79b0d-deb2-42e7-a1b6-da7400c7f211/Community%20Health%20Improvement%20Plan%202022_PHGSH.pdf PIH Health Good Samaritan Hospital Part V, Section B, Line 6a: PIH Health Good Samaritan Hospital participated in a collaborative process for the Community Health Needs Assessment, in partnership with California Hospital Medical Center. PIH Health Good Samaritan Hospital Part V, Section B, Line 11: PIH Health's Community Health Implementation Strategy (CHIS) ensures alignment of CHNA findings, our community health improvement programs and PIH Health's organizational strategy. To view the 2023-2025 CHIS and the initiatives identified to address areas of focus (access to health care - primary care, dental care and mental health, cancer incidence/mortality, diabetes incidence/mortality, heart disease/stroke incidence/mortality, overweight/obesity, substance use and misuse, preventative screenings and immunizations with emphasis on flu and pneumonia vaccines and cancer screenings, food insecurity, housing/homelessness), visit https://www.pihhealth.org/app/files/public/7fb79b0d-deb2-42e7-a1b6-da7400c7f211/Community%20Health%20Improvement%20Plan%202022_PHGSH.pdf.Since PIH Health Good Samaritan Hospital cannot directly address all the health needs present in the community, we will concentrate on those health needs that can most effectively be addressed given our areas of focus and expertise. Taking existing hospital and community resources into consideration, PIH Health Good Samaritan Hospital will not directly address the remaining health needs identified in the CHNA, including: birth indicators, COVID-19, economic insecurity, education, and violence and injury prevention. While the hospital does not intend to emphasize community COVID-19 interventions at this point in the pandemic, PIH Health Good Samaritan Hospital will continue to deliver vaccines, testing and acute medical care to address COVID-19. PIH Health Good Samaritan Hospital Part V, Section B, Line 13b: Assistance is provided free or discounted for those patients eligible for FAP. The criteria for FAP is if the patient is uninsured and does not have the ability to pay, has restricted Medi-Cal benefits, or is uninsured. There are also considerations for patients where the FPG is not applicable and the patient is insured with inadequate coverage or excessive liability. Part V, Section B, Line 7, CHNA Policy Website: https://www.pihhealth.org/about-us/community-benefit/ Part V, Section B, Line 10, Implementation Strategy Website: https://www.pihhealth.org/wellness/community-benefit/ Part V, Section B, Line 16a, FAP website: https://www.pihhealth.org/patients-visitors/billing-financial-assistance/financial-assistance/ Part V, Section B, Line 16b, FAP Application website: https://www.pihhealth.org/patients-visitors/billing-financial-assistance/financial-assistance/ Part V, Section B, Line 16c, FAP Plain Language Summary website: https://www.pihhealth.org/patients-visitors/billing-financial-assistance/financial-assistance/ Part I, Line 6a: PIH Health's Community Benefit Report, prepared annually, accounts for the organization's programs and services that promote the health of the community. The report separates out community benefit investment figures for each hospital. The report was made widely available to the public via social media, our organization's website and a community e-newsletter. It will also be shared with certain internal and community stakeholders via presentation.To view the full report, visit https://www.pihhealth.org/app/files/public/ea2d53fa-d864-4c4f-aacf-39799409ebaf/PIH_Health_Good_Samaritan_Hospital_FY22_Community_Benefit_Annual_Report_and_Plan.pdf Part I, Line 7: Patient care cost to charge ratio derived from Worksheet 2 was used to calculate the financial assistance and Medi-Cal cost. Actual costs from general ledger or departments were used for all other Costs. Part I, Line 7, Column (f): The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 15,723,327. Part III, Line 2: Bad debt expense is determined by applying cost to charge ratio to bad debt transfers net of recoveries. This expense was not included in community benefit expense. Part III, Line 3: PIH Health Good Samaritan Hospital actively provides all patients the option to apply for financial assistance, therefore, no estimate is made for bad debt attributable to patients eligible under the financial assistance policy. Part III, Line 4: From the audited financial statements of PIH Health, Inc. and Subsidiaries for the year ended September 30, 2022: "Implicit price concessions are based upon management's assessment of historical and expected net collections, taking into consideration historical business and economic conditions, trends in healthcare coverage and other collection indicators. Management routinely assesses the adequacy of the implicit price concessions based upon historical write-off experience by payor category. Implicit price concessions are included as a deduction from patient services revenues since the Company generally accepts and treats all patients without regard to the ability to pay."The bad debt expense on line 2 is calculated using total cost to charge ratio applying to total bad debt transfers net of recoveries and none of the bad debt expense is included in community benefit expense. Part III, Line 8: The amounts on lines 5 and 6 are from the FY 2022 Medicare cost report and we believe do not qualify as community benefit. Part VI, Line 2: In addition to the hospital's CHNA, PIH Health utilizes the following methods to assess the health care needs of the communities it serves: Community Benefit Oversight Committee- In 2006, PIH Health's Board of Directors established the Community Benefit Oversight Committee (CBOC), which is comprised of community stakeholders and key public health and legislative representatives. This committee meets regularly and its members share healthcare-related needs/concerns experienced by the community members they represent as well as assets or potential partners for the hospital to engage in addressing the identified needs.Feedback from Community Organizations / Collaborative- Through participation in various community collaborative and networking meetings, PIH Health is able to assess the healthcare needs of the community and identify partnership opportunities. Part VI, Line 3: Uninsured patients are screened for Medi-Cal linkage and if they meet the criteria, the patient is referred to RISARC to assist with the application and eligibility process. If the patient does not have Medi-Cal linkage, they are screened for Queens Care which is a program for uninsured patients that reside within specific zip codes in Los Angeles County and meet income qualification. Financial Assistance Applications are provided to all patients who are unisured, underinsured, financial hardship, have catastrophic illness or have excessive medical expenses. The following hospital policies are available on our website; Charity Care / Discount Policy, Financial Assistance Application and Cash Price Policy. The statements mailed to patients provides information regarding Financial Assistance, Covered California Health Benefits, Medi-Cal and Medicare. Part VI, Line 4: PIH Health Good Samaritan Hospital (PHGSH) is located at 1225 Wilshire Blvd., Los Angeles, California 90017. The hospital service area includes 17 ZIP Codes in Los Angeles. The service area is served by the Los Angeles County 1st and 2nd Supervisorial Districts and falls within the Los Angeles County Service Planning Areas (SPAs) 4 and 6. PIH Health Good Samaritan Hospital tracks ZIP codes of origin for patient admissions. The service area was determined from the ZIP codes that reflect a majority (59%) of patient admissions from the local geographic area.Based on the 2022 Community Health Needs Assessment, the population for the PHGSH service area is 930,016. Children and youth, ages 0-17, make up 22.8% of the population, 67.7% are 18-64 years of age, and 9.6% are seniors, 65 years and older. In the service area, 62.4% of the population are Hispanic/Latino, 13.3% are Asian, 13.2% Black/African American, 9.0% are White, and the remaining 0.2% are Native Hawaiian/Pacific Islander. Among the service area population, ages five and older, 58.1% speak Spanish, 27.9% speak only English, 11.6% speak an Asian or Pacific Islander language, 1.7% speak other Indo-European languages, and 0.7% speak other languages in their home English is spoken in the home among 32.8% of the service area population. In the service area, 27.1% of the population is at or below 100% of the federal poverty level. Among service area adults, ages 25 and older, 22.3% have less than a 9th grade education. 36.8% of area adults are high school graduates, and 27.9% have an associate, bachelor's, or graduate/professional degree. Area residents have lower educational levels than adults in the county and state. Part VI, Line 5: Community BoardPIH Health's community Board of Directors works to advance the commitment to helping our communities get well and stay healthy.Open Medical StaffPIH Health extends medical staff privileges to all qualified physicians in its community for some or all of its departments or specialties.Donation of TimeMany PIH Health providers are living out their passion to serve people in need by donating their time and talents both in our community and overseas. Environmental and Recycling ProjectsPIH Health continues to implement "green" initiatives, including increased usage of LED lighting to decrease consumption of electricity and developing energy management projects.Volunteer Contributions Some 1,459 PIH Health volunteers collectively contributed 116,429 hours of service, supporting departments throughout the organization. Part VI, Line 6: Hospital affiliates include: 1) PIH Health, Inc., PIH Health's parent company; 2) PIH Health Downey Hospital; 3) PIH Health Whittier Hospital 4) PIH Health Physicians, a nonprofit medical foundation; 5) PIH Health Home Healthcare and 6) the PIH Health Foundation, a nonprofit organization that exists to raise philanthropic funds in support of PIH Health's charitable mission 1) PIH Health, Inc. provides technical, facility and support services for tax-exempt affiliates whose charitable purpose is to provide a broad range of healthcare services to their community by way of an integrated health care delivery system.2) PIH Health Downey Hospital officially became part of PIH Health in October 2013. As a 501 (c)(3) nonprofit, 199-bed hospital, the Downey campus has provided quality care in a welcoming environment for more than 100 years. As a nonnprofit hospital with a charitable mission, PIH Health Hospital Downey is a dedicated community health and wellness partner. This commitment and leadership gives back to the community through charity care, health professions education and more.3) PIH Health Whittier Hospital opened in 1959. As a 501 (c)(3) nonprofit, 523-bed hospital, the Whittier campus has developed into a health system offering a multitude of services. As a nonnprofit hospital with a charitable mission, PIH Health Hospital Whittier is a dedicated community health and wellness partner. This commitment and leadership gives back to the community through charity care, medical research, donations, health professions education and more.4) PIH Health Physicians (PHP) A 501(c)(3) nonprofit medical group that is exclusively affiliated with PIH Health, the group is comprised of more than 150 primary care physicians and over 250 specialists who coordinate care from diagnosis to recovery. PHP supports the local community through its financial assistance program, Whittier First Day Health & Wellness Center for the homeless and those at-risk for homelessness, health professions education, and other community health improvement services.5) PIH Health Home Healthcare provides around-the-clock, quality care for patients in their own home. PIH Health Home Healthcare is certified by the Centers for Medicare and Medicaid Services.6) The PIH Health Foundation is a 501(c)(3) nonprofit organization with the sole mission to raise funds through philanthrophy to benefit PIH Health and its affiliates. Dollars raised are reinvested into the communities we serve through quality healthcare, health-based programs and services offered through PIH Health.For detailed information regarding these PIH Health affiliates' additional activities to support and promote community health, please see each respective organization's IRS Form 990. Part VI, Line 7, Reports Filed With States CA 1 Good Samaritan Institute for Research Education 1225 Wilshire Blvd Los Angeles CA 90017 954077161 501(c)(3) 196738 0 Expenses paid by the Organization Rampart Pal 8726 S Sepulveda Blvd Suite D132 Los Angeles CA 90045 954675764 501(c)(3) 10392 0 To purchase first aid kits for Rampart Police Substation patrol vehicles Cultivala Inc 1723 James M Wood Blvd Los Angeles CA 90015 842062123 501(c)(3) 6700 0 To support the mission of Cultivala Inc Breastfeeding Task Force of Greater Los Angeles 2851 W 120th Street Suite E 335 Hawthorne CA 90250 954861413 501(c)(3) 6325 0 To support the mission of Breastfeed LA 4 0 Part I, Line 2: PIH Health provides financial assistance to both not-for-profit organizations and individuals. PIH Health provides financial support to nonprofit organizations in our service area cities through its Community Support and Sponsorships Program, with emphasis on community health needs/areas of concern as identified by PIH Health's most recent Community Health Needs Assessment findings. Financial support may be provided if the requesting organization addresses one or more of these areas and is responsive to the health and wellness needs of the communities we serve, allowing PIH Health to build upon the impact of existing community health improvement efforts. For contributions made to charitable organizations, PIH Health has adopted a policy which guides the process to ensure good stewardship of PIH Health's charitable resources as a federally registered nonprofit entity. To ensure accurate community benefit reporting, this policy sets forth that direct financial contributions made to community organizations must be appropriately classified as either a) Community Benefit or b) a Sponsorship (a Marketing Communications Department expense not reportable as community benefit). In compliance with this policy, information is gathered from the grantee regarding the intended use of funds and a restriction letter is sent, noting the intended use of funds. Organizations receiving Community Support funding in the amount of $2,500 or more are required to submit a summary report of program or service impact, within 90 days after event or receipt of program funding, unless an alternate date is designated. For contributions made to individuals, PIH Health has established a dedicated budget which subsidizes vital assistance such as purchase of durable medical equipment or non-acute care not covered by insurance upon hospital discharge, including paid placement in skilled nursing or mental health facilities. In these instances, a specific service is being purchased and receipt of proper service is ensured through follow-up by PIH Health discharge planners or social workers. 1 1 0 0 0 0 0 0 0 James West System President & CEO 0 1403776 0 1129582 0 230580 0 320688 0 19391 0 3104017 0 210464 Rosalio Lopez MD Chief Strategy Officer 0 848206 0 336481 0 389001 0 203006 0 9242 0 1785936 0 381303 Peggy Chulack System CAO & Asst. Secretary 0 701640 0 347513 0 9509 0 150342 0 14127 0 1223131 0 0 Brian Smolskis System COO 0 697337 0 323736 0 8117 0 155902 0 21073 0 1206165 0 0 Anita Chou Former CFO & Asst. Treasurer 0 113900 0 142450 0 843806 0 8041 0 13527 0 1121724 0 233343 Vid Shivaraman System CFO & Assistant Treasurer 0 516146 0 180469 0 6299 0 111770 0 6290 0 820974 0 0 Jean Meussner VP Human Resources (Until 9/2021) 238415 0 0 0 315923 0 9217 0 13557 0 577112 0 0 0 Jaime Diaz MD CMO & Co-Site Admin. (Until 9/2022) 378851 138615 0 0 0 73 2808 0 19629 1773 401288 140461 0 0 Irena Zuanic CNO & Co-Site Admin. 0 264750 0 65869 0 5518 0 80394 0 13731 0 430262 0 0 Hilarion Castillo Controller 286294 0 7241 0 277 0 9042 0 9636 0 312490 0 0 0 Ira Meiselman Director Managed Care 271098 0 5108 0 0 0 8898 0 19097 0 304201 0 0 0 Noli Perillo Staff RN 268979 0 2100 0 0 0 9100 0 6895 0 287074 0 0 0 Maria Chacon Staff RN 264716 0 4800 0 0 0 7445 0 9645 0 286606 0 0 0 Jing Cheung Staff RN 261322 0 2400 0 0 0 7875 0 6305 0 277902 0 0 0 Part I, Line 3 Compensation for the CEO was established and paid by PIH Health Whittier Hospital (PIH), a related organization. PIH used the following to establish the CEO's compensation: (1) Compensation Committee; (2) Independent Compensation Consultant; (3) Form 990 of other organizations; (4) Compensation Survey or Study; (5) Approval by the Board. Part I, Lines 4a-b Part I, Line 4A: Anita Chou and Jean Meussner received a severance payment during the calendar year. The payment is included in Part VII, Column D (E) and Schedule J, Part II, Column B(iii). The terms and conditions of the confidential severance agreement are available to the Internal Revenue Service upon request. Part I, Line 4B: PIH Health Inc. and its affiliates provides a supplemental executive retirement plan for certain executives. The following individuals participate in the plan: Anita Chou Brian Smolskis James West Peggy Chulack Rosalio Lopez Vid Shivaraman The following amounts became vested or were paid-out in 2021 and are included in Schedule J, Part II, Column (b)(iii): Anita Chou: $233,343 James West $210,464 Rosalio Lopez $381,303 Form 990, Part VI, Section A, line 2 The Organization is a member of an integrated healthcare system controlled by PIH Health, Inc. The following individuals have a business relationship by virtue of their positions as officers or directors of related entities within the system: J. Richard Atwood, Jeffrey Hamar, Paula Cowan, Alex Alvarez, Blayne Cutler, Jane Dicus, Patrick Monroe, Charlotte Weaver, Kenton Woods, Peter Greaney, Paul Treinen, James West, Peggy Chulack, Vid Shivaraman, Rosalio Lopez, Marissa Goldberg, Melanie Batiste, Robert Maloney, and Brian Smolskis. Form 990, Part VI, Section A, line 6 PIH Health, Inc. is the sole member of PIH Health Good Samaritan Hospital. Form 990, Part VI, Section A, line 7a PIH Health, Inc. has authority to elect all the members of the board of directors of PIH Health Good Samaritan Hospital. Form 990, Part VI, Section A, line 7b PIH Health, Inc. has all voting rights and the power to elect the board of directors of PIH Health Good Samaritan Hospital. Form 990, Part VI, Section B, line 11b The Organization works with an independent accountant, RSM US LLP, to prepare the Form 990. Once the return is prepared, the return is reviewed by the Chief Financial Officer and VP of Finance. Form 990 is then reviewed by the Audit Committee of PIH Health, Inc., which is made up of independent directors. RSM US LLP makes all changes necessary. The final Form 990 is provided to the board prior to filing. Form 990, Part VI, Section B, line 12c Each year, all management and board of directors members are required to complete a conflict of interest disclosure form. All positive responses are reviewed by the General Counsel and Chief Administrative Officer of PIH Health, Inc. Each positive response is considered in light of magnitude of ownership interest, financial transaction(s), etc. If deemed necessary, conflicts of interest could be resolved by insisting that the incumbent either divest their ownership interest, that the organization terminate the business relationship, or even that the director resign. Directors with potential conflicts of interest may recuse themselves from voting on certain matters and/or may excuse themselves from meetings during the discussion, deliberation, and voting on of matters. Form 990, Part VI, Section C, line 19 PIH Health Good Samaritan Hospital's organizing documents and the Conflict of Interest Policy are not made available to the public. The financial information from the financial statements is included in the Organization's Form 990, which is available for public inspection upon request. Form 990, Part VI, Section B, Line 16b: PIH Health Good Samaritan Hospital holds a 9.8% interest a joint venture arrangement that exists to further the charitable and community-based health care purposes, mission, vision, and values of its controlling tax exempt members. PIH Health Good Samaritan Hospital annually evaluates its participation in joint venture arrangements. Form 990, Part VII, Section A, Line 1: One of the filing organization's officers, Rosalio Lopez, is an employee of PIH Health Downey Medical Group, Inc. (DMG), which has a professional service agreement with PIH Health Physicians, an affiliate of the filing organization, to provide physician services. The individuals received compensation from DMG, as follows: Rosalio Lopez: Reportable Base Compensation - $72,736 Other Compensation - $0 Form 990, Part IX, line 11g Physician Fees: Program service expenses 13,961,854. Management and general expenses 0. Fundraising expenses 0. Total expenses 13,961,854. Consulting and Management Fees: Program service expenses 0. Management and general expenses 9,687. Fundraising expenses -90,000. Total expenses -80,313. Other Contracted Services: Program service expenses 3,814,794. Management and general expenses 8,468. Fundraising expenses 0. Total expenses 3,823,262. Other Professional Fees: Program service expenses 17,494. Management and general expenses 16,970. Fundraising expenses 0. Total expenses 34,464. Medical Purchased Services: Program service expenses 4,062,978. Management and general expenses 94,800. Fundraising expenses 0. Total expenses 4,157,778. Repairs and Maintenance: Program service expenses 4,388,384. Management and general expenses 239,808. Fundraising expenses 0. Total expenses 4,628,192. Software Maintenance : Program service expenses 3,676,318. Management and general expenses 0. Fundraising expenses 0. Total expenses 3,676,318. Collection Fees: Program service expenses 0. Management and general expenses 71,020. Fundraising expenses 0. Total expenses 71,020. Other Purchased Services: Program service expenses 22,711,806. Management and general expenses 6,245,632. Fundraising expenses 5,729. Total expenses 28,963,167. Outside Provider Cost : Program service expenses 18,708,276. Management and general expenses 0. Fundraising expenses 0. Total expenses 18,708,276. Purchased Labor: Program service expenses 22,689,441. Management and general expenses 0. Fundraising expenses 0. Total expenses 22,689,441. Form 990, Part X, Column A, Line 7: The FY21 amount in line 7 of $176,172,569 was moved to line 15 to match the FY22 presentation. The amounts in line 7 were all moved to line 15 as other assets with the detail being shown on Form 990, Schedule D, Part IX. Form 990, Part XI, line 9: Accrued Minimum Pension Liability 659,617. Intercompany Transfer 185,388. Grant Refund 41,442. Net Assets Released from Restrictions 6,826. Good Samaritan Institute for Research and Education 1225 Wilshire Blvd Los Angeles CA 90017 954077161 Heart Research CA 501(c)(3) Line 4 PIH Health Good Samaritan Hospital 1 Orthopedic Institute of the Good Samaritan Hospital 1225 Wilshire Blvd Los Angeles CA 90017 954346048 Orthopedic Research CA 501(c)(3) Line 12a, I PIH Health Good Samaritan Hospital 1 Samaritan Imaging Center 1225 Wilshire Blvd Los Angeles CA 90017 954252321 Outpatient Imaging Services CA 501(c)(3) Line 10 PIH Health Good Samaritan Hospital 1 Good Samaritan Medical Office Building Inc 1225 Wilshire Blvd Los Angeles CA 90017 953244046 Physicians Medical Offices CA 501(c)(3) Line 12a, I PIH Health Good Samaritan Hospital 1 Kate Van Nuys Page Foundation 1225 Wilshire Blvd Los Angeles CA 90017 956028032 Grants Income to Good Samaritan Hospital CA 501(c)(3) Line 12a, I PIH Health Good Samaritan Hospital 1 PIH Health Adult Day Healthcare 12401 Washington Boulevard Whittier CA 90602 953643829 Support of Tax-Exempt Affiliates CA 501(c)(3) Line 12b, II PIH Health Inc 1 PIH Health Foundation 12401 Washington Boulevard Whittier CA 90602 953761274 Fundraising CA 501(c)(3) Line 7 PIH Health Inc 1 PIH Health Home Healthcare 12401 Washington Boulevard Whittier CA 90602 953036281 Support of Tax-Exempt Affiliates CA 501(c)(3) Line 12b, II PIH Health Inc 1 PIH Health Downey Hospital 11500 Brookshire Avenue Downey CA 90241 951903935 Healthcare CA 501(c)(3) Line 3 PIH Health Inc 1 PIH Health Whittier Hospital 12401 Washington Boulevard Whittier CA 90602 951934652 Healthcare CA 501(c)(3) Line 3 PIH Health Inc 1 PIH Health Management Corp 12401 Washington Boulevard Whittier CA 90602 954016278 Support of Tax-Exempt Affiliates CA 501(c)(3) Line 12b, II PIH Health Inc 1 PIH Health Physicians 6557 Greenleaf Ave Whittier CA 90601 953942828 Healthcare CA 501(c)(3) Line 10 PIH Health Inc 1 PIH Health Inc 12401 Washington Boulevard Whittier CA 90602 953619388 Support of Tax-Exempt Affiliates CA 501(c)(3) Line 12b, II N/A 0 Auxiliary of the Hospital of the Good Samaritan 1225 Wilshire Blvd Los Angeles CA 90017 956051253 Welfare of the Good Samaritan Hospital CA 501(c)(3) Line 12c, III-FI N/A 0 DRMC Properties Inc 11500 Brookshire Avenue Downey CA 90241 954769768 Real Estate CA N/A C 1 HealthMed Services Inc 12401 Washington Boulevard Whittier CA 90602 300831225 Healthcare CA N/A C 1 PIH Health Care Solutions 6557 Greenleaf Avenue Whittier CA 90601 462072342 Healthcare CA N/A C 1 PIH Health Insurance Company 1003 Bishop Street Honolulu HI 96813 263760243 Captive Insurance HI N/A T 1 PIH Health RE 1003 Bishop Street Honolulu HI 96813 472501390 Captive Insurance HI N/A T 1 Pioneer Medical Group Inc 12401 Washington Boulevard Whittier CA 90602 330927283 Medical Services CA N/A C 1 Pioneer Provider Network A Medical Group Inc 12401 Washington Boulevard Whittier CA 90602 330922631 Management Services CA N/A C 1 1 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 Good Samaritan Hospital Medical Office Building Inc A 5368676 FMV Good Samaritan Hospital Medical Office Building Inc K 2682517 FMV Orthopedic Institute of the Good Samaritan Hospital C 1661372 FMV Good Samaritan Institute for Research and Education C 532428 FMV Good Samaritan Institute for Research and Education B 196738 FMV