2022-05-12T15:32:38-05:00 2021-06-30 ERNST & YOUNG US LLP 4365 EXECUTIVE DR STE 1600 SAN DIEGO CA 92121 990 2020-07-01 990246364 Kapi'olani Health Foundation % CHENWEI LI KAPI 8085357100 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 CARRIE ANN TSUTSUI ASSISTANT TREASURER 8085357100 2022-05-10 true CARRIE ANN TSUTSUI 999009999 JOCELYNE C MILLER P00634378 8585357200 2022-05-05 2 2020 2022-09-23 18:48:47Z DAWN DUNBAR 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 28673583 false X https://giving.hawaiipacifichealth.org X 1986 HI THE MISSION OF KAPI'OLANI HEALTH FOUNDATION IS TO CREATE A HEALTHIER HAWAI'I. 24 22 0 40 0 0 7829532 7846866 0 0 -1074716 1473914 674 1080 6755490 9321860 3031378 2286504 0 0 0 0 0 0 850572 4356793 1996179 7388171 4282683 -632681 5039177 92196378 117427566 1754095 2026824 90442283 115400742 X THE MISSION OF KAPI'OLANI HEALTH FOUNDATION IS TO CREATE A HEALTHIER HAWAI'I. false false 2795437 1058025 0 SEE SCHEDULE O 2795437 true true false false false false false 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0.2 0.0 X X 0 0 0 NATALIE BANACH Board of Director (PART YEAR) 0.2 0.0 X 0 0 0 KATHY CARR Board of Director 0.2 0.0 X 0 0 0 MEREDITH CHING Board of Director 0.2 0.0 X 0 0 0 SHELLEY CRAMER Board of Director 0.2 0.0 X 0 0 0 SARA DUDGEON Board of Director 0.2 0.0 X 0 0 0 MATTHEW EMERSON Board of Director 0.2 0.0 X 0 0 0 STEPHANIE GAMBETTA Board of Director 0.2 0.0 X 0 0 0 KIM HEHIR Board of Director (PART YEAR) 0.2 0.3 X 0 0 0 THOMAS KOSASA MD Board of Director 0.2 0.0 X 0 0 0 HOWARD LEE Board of Director 0.2 0.0 X 0 0 0 NEDRA MANSON Board of Director 0.2 0.0 X 0 0 0 PAUL MARX Board of Director, Chair 0.2 0.0 X X 0 0 0 MARCUS MERNER Board of Director 0.2 0.0 X 0 0 0 RALPH MESICK Board of Director 0.2 0.0 X 0 0 0 RUTH MILLS Board of Director 0.2 0.0 X 0 0 0 BRAD NICOLAI Board of Director, Vice Chair 0.2 0.0 X X 0 0 0 PAIGE PAHLMEYER Board of Director 0.2 0.0 X 0 0 0 KAREN T POLIVKA Board of Director 0.2 0.0 X 0 0 0 PATRICIA W SHEEHAN Board of Director 0.2 0.0 X 0 0 0 CHYNNA STONE Board of Director 0.2 0.0 X 0 0 0 KELLY SUEDA Board of Director 0.2 0.0 X 0 0 0 EILEEN WACKER Board of Director 0.2 0.0 X 0 0 0 SHELLEY WILSON Board of Director 0.2 0.0 X 0 0 0 LINDA WOO Board of Director 0.2 0.0 X 0 0 0 0 5023752 3512872 0 true true false 0 7846866 605605 7846866 0 1242952 1242952 0 0 0 0 0 19582685 19351723 230962 230962 230962 0 0 0 0 0 0 0 0 0 ALL OTHER REVENUE 900099 1080 1080 1080 9321860 1474994 X 2286504 2286504 0 0 0 0 0 0 0 0 0 0 0 14949 14949 0 0 269271 269271 856044 0 244119 611925 6821 6821 56355 26935 29420 103 103 0 37365 37365 2278 2278 0 634 634 0 0 1205 1205 13970 13970 PROGRAM EXPENDITURES 508933 508933 PRINTING & DESIGN SVCS. 122099 122099 CORPORATE ALLOCATION 67430 67430 ANNUAL GIVING GIFTS 9543 9543 29179 29179 4282683 2795437 636674 850572 0 0 2946840 8274910 2240767 2489858 1995884 1760903 0 0 0 0 0 0 0 0 79093 0 193211 193211 1205 0 33564303 40855090 48573557 61173516 2407496 2407496 0 0 387233 465793 92196378 117427566 38133 95037 0 0 0 0 0 0 145936 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CENTER 16080 DUE TO HPH RSRCH INSTITUTE 1506 DUE TO WILCOX MEMORIAL HOSPITAL 134 1790310 X FORM 990, SCHEDULE D, PART IV, LINE 2B ESCROW OR CUSTODIAL ACCOUNT LIABILITY ESCROW LIABILITIES REPRESENT AMOUNTS DUE TO INDIVIDUALS UNDER CHARITABLE REMAINDER TRUST AGREEMENTS. FORM 990, SCHEDULE D, PART V, LINE 4 DESCRIPTION OF INTENDED USES OF THE ORGANIZATION'S ENDOWMENT FUNDS ENDOWMENT FUNDS ARE MANAGED TO ENSURE THAT THE RETURNS SUPPORT THE MEDICAL CENTER'S OPERATIONS; HIRING OF STAFF; IMPLEMENTATION OF PROGRAMS; RESEARCH AND EDUCATION; AND PROVIDE QUALITY CARE FOR PATIENTS, ALL IN ACCORDANCE WITH THE DONOR'S INTENT AND THE ORGANIZATION'S MISSION. SCHEDULE D, PART X, LINE 2 Uncertain Tax Positions Audited Financial Statement Footnote THE COMPANY HAS NOT RECORDED ANY EXPENSE OR ACCRUED FOR ANY RELATED EXPENSE FOR ANY UNCERTAIN TAX POSITIONS. THE COMPANY'S 2017 THROUGH 2020 TAX YEARS REMAIN SUBJECT TO EXAMINATION FOR FEDERAL INCOME TAX PURPOSES, WHEREAS THE 2016 THROUGH 2020 TAX YEARS REMAIN SUBJECT TO EXAMINATION FOR STATE TAXING JURISDICTIONS IN WHICH THE COMPANY OPERATES. true KAPI'OLANI MED CENTER FOR WOMEN & CHILDREN 55 MERCHANT ST 24TH FL HONOLULU HI 96813 990177350 501(c)(3) 2197146 69624 FMV GIFT IN KIND GENERAL SUPPORT 1 FORM 990, SCHEDULE I, part I, line 2 DESCRIPTION OF ORGANIZATION'S PROCEDURES FOR MONITORING THE USE OF GRANTS TEMPORARILY RESTRICTED FUNDS RELEASED (& GRANTED) TO THE AFFILIATED ORGANIZATION ARE RELEASED AFTER THE SPECIFIC PURPOSE OF THE FUND HAS BEEN MET. ONCE THE AFFILIATED ORGANIZATION COMMUNICATES THE EXPENSE AND SATISFIES THE SUBSTANTIATION OF THE EXPENSE FOR THE PURPOSE THAT THE FUNDS WERE CONTRIBUTED FOR, THE FOUNDATION RELEASES THE RESTRICTION AND RECORDS THE GRANT TO THE AFFILIATED ORGANIZATION. NO FURTHER MONITORING OF THE FUNDS AFTER DISTRIBUTION IS NECESSARY. false true false false false false false false false RAYMOND P VARA JR Board of Director 0 1110173 0 372487 0 719150 0 2558309 0 26194 0 4786313 0 593274 DAVID OKABE Treasurer 0 553990 0 132543 0 259799 0 362800 0 15096 0 1324228 0 224487 CHARLES R CHING Secretary 0 436925 0 104835 0 229141 0 262171 0 20008 0 1053080 0 164297 DAWN DUNBAR President 0 299741 0 57822 0 35875 0 81124 0 23823 0 498385 0 65358 EARL INOUYE Former Officer 0 201366 0 40705 0 43074 0 67586 0 1944 0 354675 0 46925 CARRIE ANN TSUTSUI Assistant Treasurer 0 195857 0 17756 0 17265 0 41055 0 12358 0 284291 0 0 JESSICA LEWIS Assistant Secretary 0 170876 0 0 0 0 0 15118 0 25286 0 211280 0 0 FORM 990, SCHEDULE J, PART I, LINE 3 SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN THE RESTORATION PLAN WAS DESIGNED TO RESTORE BENEFITS THAT ARE LOST DUE TO LIMITS IMPOSED BY SECTIONS 401 AND 415 OF THE INTERNAL REVENUE CODE ON COMPENSATION CONSIDERED UNDER SUCH PLANS. AMOUNT PAID OUT DURING THE YEAR BY RELATED ORGANIZATIONS: RAYMOND P. VARA JR. - $443,030 DAVID OKABE - $156,411 CHARLES R. CHING - $84,461 ANNUAL INCENTIVE PLAN THE ANNUAL INCENTIVE PLANS ARE AFFORDED TO EXECUTIVES BASED ON ANNUAL SYSTEM GOALS THAT ARE NOT BASED ON A PERCENTAGE OF NET EARNINGS. AMOUNT PAID OUT DURING THE YEAR BY RELATED ORGANIZATIONS: RAYMOND P. VARA JR. - $372,488 DAVID OKABE - $132,543 CHARLES R. CHING - $104,835 EARL INOUYE - $40,705 DAWN DUNBAR - $57,822 CARRIE ANN TSUTSUI - $17,756 Retention incentive plan The retention incentive plan was designed to encourage continued interest in the success of the organization and provide competitive retirement benefits. The sole plan participant is Hawai'i Pacific health's chief executive officer, Raymond P. Vara Jr. The plan does not replace the annual and long-term incentive plan nor serp restoration plan. Amounts paid out during the year by a related organization: Raymond P. Vara JR - $1,015,000 FORM 990, SCHEDULE J, PART I, LINE 4B SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN THE RESTORATION PLAN WAS DESIGNED TO RESTORE BENEFITS THAT ARE LOST DUE TO LIMITS IMPOSED BY SECTIONS 401 AND 415 OF THE INTERNAL REVENUE CODE ON COMPENSATION CONSIDERED UNDER SUCH PLANS. AMOUNT PAID OUT DURING THE YEAR BY RELATED ORGANIZATIONS: RAYMOND P. VARA JR. - $443,030 DAVID OKABE - $156,411 CHARLES R. CHING - $84,461 ANNUAL INCENTIVE PLAN THE ANNUAL INCENTIVE PLANS ARE AFFORDED TO EXECUTIVES BASED ON ANNUAL SYSTEM GOALS THAT ARE NOT BASED ON A PERCENTAGE OF NET EARNINGS. AMOUNT PAID OUT DURING THE YEAR BY RELATED ORGANIZATIONS: RAYMOND P. VARA JR. - $372,488 DAVID OKABE - $132,543 CHARLES R. CHING - $104,835 EARL INOUYE - $40,705 DAWN DUNBAR - $57,822 CARRIE ANN TSUTSUI - $17,756 Retention incentive plan The retention incentive plan was designed to encourage continued interest in the success of the organization and provide competitive retirement benefits. The sole plan participant is Hawai'i Pacific health's chief executive officer, Raymond P. Vara Jr. The plan does not replace the annual and long-term incentive plan nor the serp restoration plan. Amounts paid out during the year by a related organization: Raymond P. Vara JR - $1,015,000 X 16641 COST/SELLING X 6 535980 FMV X 4 4060 COST/SELLING X 6 30381 COST/SELLING X PREPAID GIFT CARD 5 6980 COST/SELLING X MISC.-TOYS 10 11563 COST/SELLING false true false Schedule M, Part I, COLUMN B COLUMN B REPRESENTS THE NUMBER OF CONTRIBUTIONS RECEIVED. FORM 990, PART III, LINE 4 PROGRAM SERVICE ACCOMPLISHMENTS THE MISSION OF KAPI'OLANI HEALTH FOUNDATION (THE FOUNDATION) IS TO CREATE A HEALTHIER HAWAI'I. KAPI'OLANI MEDICAL CENTER FOR WOMEN & CHILDREN (KAPI'OLANI) IS A NOT-FOR-PROFIT MEDICAL CENTER LOCATED IN HONOLULU THAT IS DEDICATED TO THE HEALTH AND WELL BEING OF ALL HAWAI'I RESIDENTS. KAPI'OLANI IS HAWAI'I'S ONLY MATERNITY, NEWBORN AND PEDIATRIC SPECIALTY HOSPITAL. KAPI'OLANI IS PART OF THE HAWAI'I PACIFIC HEALTH SYSTEM, ONE OF THE STATE'S LARGEST HEALTH CARE SYSTEMS. AS A NOT-FOR-PROFIT MEDICAL CENTER, KAPI'OLANI RELIES ON PHILANTHROPIC SUPPORT FROM THE COMMUNITY TO FULFILL ITS MISSION AND CARE FOR ITS PATIENTS, REGARDLESS OF THEIR ABILITY TO PAY. CONTRIBUTIONS, BOTH UNRESTRICTED AND DESIGNATED, HELP THE MEDICAL CENTER PROVIDE EXCEPTIONAL MEDICAL CARE IN HAWAI'I. GENEROUS DONATIONS ASSIST, BUT ARE NOT LIMITED TO, THESE AREAS: PATIENT AND SPECIALITY CARE, CAPITAL IMPROVEMENTS, EDUCATION AND RESEARCH, COMMUNITY HEALTH AND UNCOMPENSATED CARE. SERVICES INCLUDE: PATIENT AND SPECIALITY CARE PEDIATRIC HEART CENTER KAPI'OLANI HEALTH FOUNDATION SUCCESSFULLY COMPLETED ITS FUNDRAISING CAMPAIGN FOR PEDIATRIC HEART CARE. THE MONEY RAISED WILL BUILD HAWAI'I'S FIRST AND ONLY PEDIATRIC HEART CENTER. THE CENTER WILL PROVIDE CARDIC CARE FOR CHILDREN THROUGHOUT HAWAI'I AND THE PACIFIC REGION. THE CONSTRUCTION OF THE CARDIAC CATHETERIZATION LAB BEGAN IN OCTOBER 2021 AND IS EXPECTED TO BE COMPLETED IN 2022. AS PART OF THIS PROGRAM DEVELOPMENT, HAWAI'I'S FIRST LOCALLY BASED PEDIATRIC CARDIOTHORACIC SURGEON WAS HIRED TO REDUCE THE NEED FOR PATIENTS TO TRAVEL TO THE MAINLAND FOR CARE. THE NEW PEDIATRIC HEART CENTER WILL PROVIDE STATE-OF-THE-ART SPECIALIZED CARE AND HELP TO REDUCE THE RISK AND EXPENSE OF TRAVEL. CAPITAL IMPROVEMENTS THE CONSTRUCTION OF THE NEW CATHETERIZATION LAB FOR THE PEDIATRIC HEART CENTER WILL LEAD TO ADDITIONAL STATE-OF-THE-ART TECHNOLOGY AND EQUIPMENT THAT WILL SERVE HUNDREDS OF CHILDREN WHO NEED SPECAILIZED CARDIAC CARE. COMMUNITY HEALTH AND UNCOMPENSATED CARE CHILD LIFE SERVICES: KAPI'OLANI'S CHILD LIFE PROGRAM WAS ESTABLISHED TO HELP PEDIATRIC PATIENTS AND THEIR FAMILIES COPE WITH HOSPITALIZATION TREATMENT. DONATIONS SUPPORT THE FINANCIAL NEEDS OF THE CHILD LIFE PROGRAM INCLUDING THE SALARIES OF CHILD LIFE SPECIALISTS, CLASSROOM ACTIVITIES AND SUPPLIES NEEDED BY THE EDUCATION LIAISON, AROMATHERAPY STAFFING AND PROGRAMS COSTS, AND THE MEDICAL CENTER'S THERAPY DOG VISITS. PATIENT ASSISTANCE FUND: FAMILY FUND THE PURPOSE OF THE PATIENT ASSISTANCE FUND IS TO ASSIST MEDICAL CENTER PATIENTS AND/OR THEIR SUPPORT SYSTEM RECEIVING SERVICES, INCLUDING EMERGENCY ROOM AND OUTPATIENT SERVICES AT THIS FACILITY. THE MANAGEMENT AND DISBURSEMENT OF THE PATIENT ASSISTANCE FUND OR FAMILY FUND IS LEFT TO THE DISCRETION OF THIS FACILITY TO MEET SPECIFIC PATIENT CARE NEEDS. THE FUNDS MAY BE USED FOR PATIENTS AND/OR THEIR SUPPORT SYSTEM THAT HAVE FINANCIAL BARRIERS AND NEED CONTINUED MEDICAL OR PSYCHOSOCIAL SUPPORT OR TO FACILITATE DISCHARGE. NEARLY HALF OF KAPI'OLANI'S PATIENTS COME FROM UNINSURED OR UNDERINSURED FAMILIES. FORM 990, PART V, LINE 1A FORM 1096 REPORTING HAWAI'I PACIFIC HEALTH (HPH), THE ORGANIZATION'S TAX EXEMPT PARENT, PAYS ALL VENDORS. THEREFORE, HPH ISSUES FORMS 1099 UNDER ITS TAX ID. FORM 990, PART VI, SECTION A, LINE 2 DESCRIPTION OF BUSINESS RELATIONSHIPS JEFFREY A. ARCE (Board of Director, Chair - partial) AND RAYMOND P. VARA JR. (Board of Director) HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 6 MEMBERS AND RIGHTS HAWAI'I PACIFIC HEALTH IS THE SOLE MEMBER WHO HAS THE RIGHT TO PARTICIPATE IN THE ORGANIZATION'S GOVERNANCE WITH THE RIGHT TO ELECT THE MEMBERS OF THE GOVERNING BODY AND/OR APPROVE SIGNIFICANT DECISIONS OF THE GOVERNING BOARD. FORM 990, PART VI, SECTION A, LINE 7A DESCRIPTION OF CLASSES OF PERSON AND THE NATURE OF THEIR RIGHTS HAWAI'I PACIFIC HEALTH IS THE SOLE MEMBER, AND HAS THE POWER TO APPROVETHE ELECTION OF MEMBERS OF THE GOVERNING BODY. HAWAI'I PACIFIC HEALTH, AS MEMBER, ALSO HAS THE POWER TO ELECT ONE OR MORE EX-OFFICIO VOTING MEMBERS OF THE GOVERNING BODY. FORM 990, PART VI, SECTION A, LINE 7B DESCRIPTION OF CLASSES OF PERSONS, DECISIONS REQUIRING APPROVAL & TYPE OF VOTING RIGHTS HAWAI'I PACIFIC HEALTH, AS MEMBER, HAS EXCLUSIVE POWER TO TAKE AND DIRECT THE FOLLOWING ACTIONS OF THE CORPORATION: (I) NOMINATE CANDIDATES TO THE BOARD FOR THE FOLLOWING POSITIONS: PRESIDENT, VICE-PRESIDENT(S), TREASURER, SECRETARY, ASSISTANT TREASURERS AND SECRETARIES, AND ANY OTHER OFFICER, EXCEPT THE CHAIR AND VICE-CHAIR OF THE BOARD; (II) AFTER CONSULTATION WITH THE BOARD, REMOVE THE PRESIDENT, VICE-PRESIDENT(S), TREASURER, SECRETARY, ASSISTANT TREASURERS AND SECRETARIES, AND ANY OTHER OFFICER, EXCEPT THE CHAIR AND VICE-CHAIR; (III) REMOVE A DIRECTOR FROM THE BOARD; (IV) DELEGATE MANAGEMENT AUTHORITIES FROM THE BOARD TO OFFICERS OR COMMITTEES OF THE CORPORATION IN ACCORDANCE WITH A DELEGATED AUTHORITIES MATRIX ADOPTED BY THE MEMBER; (V) AMEND THESE BYLAWS; (VI) CAUSE THE CORPORATION'S PARTICIPATION IN ALL LONG TERM FINANCING TRANSACTIONS WHICH ARE IN EXCESS OF ONE (1) YEAR AND/OR ONE MILLION DOLLARS ($1,000,000) OR MORE; (VII) SELECT BANKS, TRUST COMPANIES, OR OTHER DEPOSITORIES TO WHICH THE CORPORATION'S FUNDS SHALL BE DEPOSITED; (VIII) DIRECT, MANAGE AND CONTROL THE CUSTODY, ADVISORY SERVICE, AND ASSET MANAGEMENT OF THE FINANCIAL ASSETS OF THE CORPORATION; (IX) DETERMINE AND EFFECT INTER-CORPORATE FUND TRANSFERS BY AND BETWEEN THE CORPORATION AND ANY AFFILIATE; (X) DEVELOP AND IMPLEMENT THE GENERAL POLICIES REGARDING THE CORPORATION'S EXECUTIVE COMPENSATION AND BENEFIT PLANS; (XI) FORM A NEW CORPORATION, LIMITED LIABILITY COMPANY, PARTNERSHIP, OR OTHER ORGANIZATION THAT IS OWNED SOLELY BY THE CORPORATION; (XII) DEVELOP AND PROMULGATE OVERALL CORPORATE GOALS AND THE LONG-RANGE AND STRATEGIC PLAN OF THE CORPORATION; AND (XIII) DEVELOP AND IMPLEMENT THE ANNUAL CAPITAL, OPERATING, AND CASH FLOW BUDGETS. THE CORPORATION SHALL NOT TAKE THE FOLLOWING ACTIONS WITHOUT FIRST OBTAINING MEMBER APPROVAL: (I) ELECT ANY DIRECTOR TO THE BOARD; (II) AMEND THE ARTICLES; (III) MERGE THE CORPORATION WITH ANY ENTITY; (IV) DISSOLVE THE CORPORATION; (V) ENTER INTO ANY UNBUDGETED CONTRACTS ON BEHALF OF THE CORPORATION WHICH REQUIRE ANNUAL PAYMENTS BY OR ON BEHALF OF THE CORPORATION EXCEEDING ONE MILLION DOLLARS ($1,000,000) IN VALUE; (VI) ENTER INTO ANY UNBUDGETED CONTRACTS ON BEHALF OF THE CORPORATION WHICH REQUIRE ANNUAL PAYMENTS BY OR ON BEHALF OF THE CORPORATION EXCEEDING ONE MILLION DOLLARS ($1,000,000) IN VALUE; (VII) ACQUIRE ASSETS WORTH OVER ONE MILLION DOLLARS ($1,000,000) EXCEPT FOR THOSE ASSETS ACQUIRED BY GIFTS, GRANT, OR DONATION; (VIII) ACQUIRE SHARES IN ANOTHER CORPORATION; (IX) SELL, LEASE, EXCHANGE, ENCUMBER OR DISPOSE OF TWENTY-FIVE PERCENT (25%) OR MORE OF THE PROPERTY AND ASSETS HELD BY THE CORPORATION TO ANY ENTITY THAT IS NOT AN AFFILIATE; (X) ISSUE THE CORPORATION'S MEMBERSHIP TO ANYONE OTHER THAN THE MEMBER; (XI) FORM A JOINT VENTURE OR OTHER BUSINESS RELATIONSHIP (OTHER THAN THE ORDINARY COURSE OF BUSINESS CONTRACTS) BETWEEN THE CORPORATION AND ANY PERSON OR ENTITY; AND (XII) DEVELOP A NEW LINE OF BUSINESS OR A NEW SERVICE. FORM 990, PART VI, SECTION A, LINE 11B REVIEW OF THE FORM 990 BY THE ORGANIZATION'S GOVERNING BODY VARIOUS SCHEDULES OF THE FORM 990 ARE PREPARED PRIMARILY BY STAFF WITHIN THE ACCOUNTING AREA OF THE ORGANIZATION WORKING WITH VARIOUS OTHER AREAS OF THE ORGANIZATION SUCH AS MANAGEMENT OF OPERATING UNITS, HR, LEGAL, ETC. DISCLOSURE NARRATIVES ARE WRITTEN AND COMPLETED INTERNALLY BASED ON INPUT AND DISCUSSION WITH FINANCIAL ANALYSTS AND THE CHIEF OPERATING OFFICER/EXECUTIVE DIRECTOR OF THE REPORTING ENTITY. THE CHIEF OPERATING OFFICER/EXECUTIVE DIRECTOR OF EACH REPORTING ENTITY REVIEWS AND APPROVES THE DISCLOSURE NARRATIVES WHICH DESCRIBE THE MISSION/PURPOSE AND PROGRAM ACCOMPLISHMENTS OF THEIR ORGANIZATION. SENIOR MANAGEMENT OF THE HEALTH CARE SYSTEM REVIEWS THE FORM 990 OF EACH FILING ORGANIZATION WITHIN THE HEALTH CARE SYSTEM. ONCE SENIOR MANAGEMENT HAS COMPLETED ITS REVIEW, THE FORMS 990 ARE THEN PROVIDED TO THE GOVERNANCE AND NOMINATING COMMITTEE OF THE HEALTH CARE SYSTEM'S BOARD OF DIRECTORS FOR THEIR REVIEW. THE GOVERNANCE AND NOMINATING COMMITTEE OF THE PARENT ENTITY'S (HAWAI'I PACIFIC HEALTH "HPH") BOARD PROVIDES OVERSIGHT FOR THE FORM 990 REPORTING AND REVIEWS THE FORM 990 FOR EACH ENTITY PRIOR TO FILING. IN ADDITION, THE FORM 990 FOR EACH ENTITY IS MADE AVAILABLE TO THE BOARD MEMBERS OF EACH SUBSIDIARY UNIT OF HPH AND THE HPH BOARD OF DIRECTORS THROUGH A BOARD MEMBER PORTAL FOR REVIEW PRIOR TO THE FILING OF THE FORM 990. THE FORMS 990 WILL BE POSTED TO HPH'S WEBSITE FOR PUBLIC ACCESS AFTER THE FILING OF THE RETURN WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C monitoring and enforcement of conflict of interest policy ANNUALLY, EACH DIRECTOR, OFFICER, KEY EMPLOYEE AND MEMBER OF A COMMITTEE WITH BOARD DELEGATED POWERS SHALL ANNUALLY SIGN A STATEMENT WHICH AFFIRMS THAT SUCH PERSON: 1) RECEIVED A COPY OF THE CONFLICT OF INTEREST ("COI") POLICY; 2) HAS READ AND UNDERSTANDS THE POLICY; 3) AGREES TO COMPLY WITH THE POLICY; 4) HAS DISCLOSED ANY CONFLICTS OR POTENTIAL CONFLICTS OR ECONOMIC INTERESTS AS REQUIRED; AND 5) UNDERSTANDS THAT THE ORGANIZATION IS A CHARITABLE ORGANIZATION, AND THAT IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION, THE ORGANIZATION MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. THE IN-HOUSE LEGAL DEPARTMENT DISTRIBUTES THE STATEMENT REQUEST AND REVIEWS THE COI STATEMENTS RETURNED. IDENTIFIED CONFLICTS OF INTEREST ARE PRESENTED TO THE BOARD FOR REVIEW, DELIBERATION AND CONFIRMATION/REFUTATION THAT A CONFLICT OF INTEREST EXISTS. IF A CONFLICT OF INTEREST HAS BEEN FOUND, THE INDIVIDUAL MAY ADDRESS THE BOARD AND EXPLAIN THE TRANSACTION OR ARRANGEMENT CAUSING THE CONFLICT. AFTER THE PRESENTATION, THE INDIVIDUAL IS EXCUSED FROM THE MEETING AND SHALL NOT PARTICIPATE WITH ANY DISCUSSION OR VOTE ON MATTERS PERTAINING TO THE TRANSACTION OR ARRANGEMENT. IN MEETINGS WHERE APPLICATION OF THE COI POLICY OCCURS, THE MEETING MINUTES INCLUDE NATURE OF THE FINANCIAL INTEREST/CONFLICT, NAME(S) OF THE PERSON(S) WITH THE POTENTIAL OR ACTUAL CONFLICT, ANY ACTION TAKEN TO ASSIST IN THE DETERMINATION OF WHETHER A CONFLICT EXISTED, INCLUDING ANY DISCUSSION OF ALTERNATIVE ARRANGEMENTS, THE BOARD'S DECISION(S) REGARDING THE CONFLICT AND NAMES OF PERSON PRESENT IN THE DISCUSSION AND VOTES RELATING TO THE TRANSACTION OR ARRANGEMENT. BOARD'S DECISION(S) REGARDING THE CONFLICT AND NAMES OF PERSON PRESENT IN THE DISCUSSION AND VOTES RELATING TO THE TRANSACTION OR ARRANGEMENT. FORM 990, PART VI, SECTION B, LINES 15A & 15B PROCESS OF DETERMINING COMPENSATION THE PRESIDENT, OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION ARE NOT COMPENSATED BY THE FILING ORGANIZATION, BUT RATHER BY THE TAX EXEMPT PARENT HAWAI'I PACIFIC HEALTH ("HPH"). FOLLOWING IS THE PROCESS THAT THE PARENT ORGANIZATION UNDERTAKES TO APPROVE THE PRESIDENT, OFFICERS AND KEY EMPLOYEES' COMPENSATION. COMPENSATION FOR HAWAI'I PACIFIC HEALTH ("HPH") EXECUTIVES (VICE PRESIDENT AND ABOVE) IS SET BY THE HPH COMPENSATION COMMITTEE, WHICH IS COMPOSED SOLELY OF INDEPENDENT, COMMUNITY-BASED MEMBERS OF THE HPH BOARD OF DIRECTORS. ON AN ANNUAL BASIS THE HPH BOARD CHAIRPERSON (WHO IS INDEPENDENT) SELECTS A NEUTRAL THIRD PARTY EXECUTIVE COMPENSATION CONSULTANT TO REVIEW THE EXECUTIVES' COMPENSATION AND BENEFITS. THE CONSULTANT PROVIDES A WRITTEN REPORT TO THE COMPENSATION COMMITTEE AT ITS ANNUAL MEETING. INCLUDED IN THE REPORT IS MARKET BASED DATA FROM LIKE ORGANIZATIONS. THE COMPENSATION COMMITTEE MAKES FINAL DECISIONS REGARDING COMPENSATION AND BENEFITS AT THE MEETING AFTER REVIEW AND DISCUSSION OF THE CONSULTANT'S REPORT, AND SUCH DECISIONS ARE DOCUMENTED IN THE COMPENSATION COMMITTEE MEETING MINUTES. COMMUNITY BASED DIRECTORS OF THE ORGANIZATION ARE NOT COMPENSATED. CERTAIN EMPLOYED PHYSICIANS MAY BE OFFICERS OR AN IDENTIFIED KEY EMPLOYEE OF THE REPORTING OR RELATED ORGANIZATION. PHYSICIAN COMPENSATION IS ALSO HANDLED IN THE SAME MANNER AS EXECUTIVE COMPENSATION, WITH THE HPH COMPENSATION COMMITTEE RECEIVING A REPORT FROM A NEUTRAL CONSULTANT AND FOLLOWING THE SAME PROCESS AS DESCRIBED ABOVE ON AN ANNUAL BASIS. THIS PROCESS WAS LAST COMPLETED ON MARCH 09, 2021 TO REVIEW PHYSICIAN COMPENSATION AND ON JULY 28, 2021 TO REVIEW EXECUTIVE COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 DISCLOSURE OF GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS DISCLOSURE OF GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, FINANCIAL STATEMENTS AND STANDARDS OF CONDUCT ARE AVAILABLE ON THE HAWAI'I PACIFIC HEALTH WEBSITE. THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC VIA THE HAWAI'I PACIFIC HEALTH WEBSITE. FORM 990, PART XI, LINE 9 OTHER CHANGES IN NET ASSETS EQUITY TRANSFERS FROM HPH $ (54,717) OTHER CHANGES IN NET ASSETS $ (14,027) INTERCOMPANY TRANSFERS WITH FOUNDATIONS $ (89,912) ROUNDING $ (3) ------------- TOTAL $ (158,659) FORM 990 PART IX LINE 11G DESCRIPTION:INTERNAL SVC. PROVIDER EXPENSE TOTAL FEES:788668 FORM 990 PART IX LINE 11G DESCRIPTION:MANAGER/DIRECTOR BONUS TOTAL FEES:67376 HAWAI'I PACIFIC HEALTH 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 990246363 ADMIN. SVCS. HI 501(c)(3) 12C, III-FI NA false KAPI'OLANI MED CTR FOR WOMEN & CHILDREN 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 990177350 HOSPITAL HI 501(c)(3) 3 HPH true KAPI'OLANI MEDICAL SPECIALISTS 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 990322406 HEALTHCARE HI 501(c)(3) 3 HPH true KAUA'I MEDICAL CLINIC 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 990326099 HOSPITAL HI 501(c)(3) 3 HPH true PALI MOMI FOUNDATION 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 383840327 FUNDRAISING HI 501(c)(3) 7 HPH true PALI MOMI MEDICAL CENTER 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 990274038 HOSPITAL HI 501(c)(3) 3 HPH true PROVIDERS INSURANCE COMPANY 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 710893000 INSURANCE HI 501(c)(3) 12B, II HPH true STRAUB CLINIC & HOSPITAL 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 912151670 HOSPITAL HI 501(c)(3) 3 HPH true STRAUB FOUNDATION 55 MERCHANT STREET 26TH FLOOR HONOLULU HI 96813 990109350 FUNDRAISING HI 501(c)(3) 7 HPH true WILCOX HEALTH FOUNDATION 3-3420 KUHIO HIGHWAY LIHUE HI 96766 990204242 FUNDRAISING HI 501(c)(3) 7 HPH true WILCOX MEMORIAL HOSPITAL 3-3420 KUHIO HIGHWAY LIHUE HI 96766 990074365 HOSPITAL HI 501(c)(3) 3 HPH true ASC PACIFIC VENTURES LLC 55 Merchant St 27th floor Honolulu HI 96813 270540034 AMBU. SURG. CTR. AL NA N/A HAWAI'I PACIFIC HEALTH PARTNERS INC 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 990318588 HOLDING COMPANY HI NA C CORP STRAUB PHARMACY INC 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 990145107 INACTIVE HI NA C CORP HICORD INC 55 MERCHANT STREET 24TH FLOOR HONOLULU HI 96813 990251496 INVESTMENT HI NA C CORP false true false false false false false false false false false false false false true true true true true KAPI'OLANI MEDICAL CTR FOR WOMEN & CHILDREN b 1963750 FMV KAPI'OLANI MEDICAL CTR FOR WOMEN & CHILDREN p 266348 FMV KAPI'OLANI MEDICAL CTR FOR WOMEN & CHILDREN r 376739 FMV PALI MOMI FOUNDATION p 77006 FMV STRAUB FOUNDATION p 102747 FMV WILCOX HEALTH FOUNDATION p 82594 FMV SCHEDULE R, PART III RELATED ORG. TAXABLE AS PARTNERSHIP: ASC PACIFIC VENTURES, LLC EIN: 27-0540034 ADDRESS: 55 MERCHANT ST., 27TH FLOOR HONOLULU, HI 96813