2020-07-15T17:43:05-05:00 2019-08-31 420714325 RSM US LLP 1 S Wacker Drive Ste 800 Chicago IL 60606 990 2018-09-01 951656366 Good Samaritan Hospital GOOD 2139772121 1225 WIlshire Blvd Los Angeles CA 900172395 Anita Chou CFO 2139772121 2020-07-15 1 Rebekuh Eley P01247672 3126343400 104.181.213.116 2020-07-15 14:41:53 CD P 2A28FA2E2A09A40AF4F0A751499BE74D16D20E85 2A28FA2E2A09A40AF4F0A751499BE74D16D20E85 2018 2021-01-29 14:40:06Z PIH Health Good Samaritan Hosp Anita Chou 1225 WIlshire Blvd Los Angeles CA 900172395 393632975 0 X www.goodsam.org X 1885 CA Provide accessible, quality, cost-effective healthcare services at 408-bed hospital in LA. 24 23 1679 327 584216 0 24995391 5646258 366837230 360346227 6686784 8450513 1603456 2790362 400122861 377233360 693029 552231 0 0 156088633 170456156 0 0 1547857 194328241 221196301 351109903 392204688 49012958 -14971328 498043556 485500294 176929852 173737014 321113704 311763280 X To provide accessible, quality, cost-effective community healthcare. The Hospital operates a 408-bed facility in inner-city Los Angeles. 0 0 205126259 552231 260783842 Patient Care: Good Samaritan Hospital was established in 1885 by Sister Mary Wood and has been helping the community for 130 years. As a 501(c)(3) nonprofit, 408-bed hospital, along with 32 Surgical Suites, Good Samarian Hospital is offering a multitude of services. The hospital's mission is to provide accessible, quality, cost-effective, and compassionate health care services that meet the needs of the patients, their families, the community, physicians and employees.Patient Care in Fiscal Year 2018-2019Employees ....... 1,601Volunteers ....... 304Number of Emergency Department (ED) visits ....... 44,054Number of Births ....... 2,667Medical Staff ....... 456 134362003 0 99516874 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. 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, 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: 32,735 668255 0 45511 Other Community Benefit Services: Community health improvement services and community benefit operations, Health professions education, Research 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. The annual Korean Health Fair is included in this category.Snapshot of Outcomes:- 780 community members were reached through a variety of community health improvement activities.HEALTH PROFESSIONS EDUCATION: This category includes educational programs for physicians, nurses, students and other health professionals when education is necessary or required by state law, accrediting body or health profession society. Good Samaritan Hospital's programs include the volunteer jobs training and lab student internship programs. Snapshot of Outcomes:- 306 volunteers and lab students were provided with mentorship, internship and training opportunities.RESEARCH: 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. Good Samaritan Hospital has been offering clinical trials and research studies aimed at improving health. Snapshot of Outcomes:- Over $390,000 expenses have been incurred in research in Fiscal Year 2018-2019.CASH & IN-KIND CONTRIBUTIONS: This category includes funds and in-kind services donated by Good Samaritan Hospital to community organizations or to the community-at-large for a community benefit purpose. Snapshot of Outcomes:- $5,000 in cash donations was given to an organization to address the significant health needs in our service area communities.Total number of persons served by all categories: 33,822For additional information, please refer to PIH Health's community benefit report at https://www.goodsam.org/About-Us/Community-Benefit-Plan.aspx 340156517 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 0 0 1 455 0 1 1679 1 1 1 0 0 0 0 1 1 0 0 0 0 0 0 X 24 23 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 0 CA X Ernalyn Baysac 2139772003 637 South Lucas Avenue 3rd Floor Los Angeles CA 90017 Andrew B Leeka President & CEO 50.00 8.00 X X 664710 0 29840 Charles T Munger Chairman 1.00 4.00 X X 0 0 0 Robert E Denham Vice President 1.00 4.00 X X 0 0 0 George A Bender Secretary 1.00 4.00 X X 0 0 0 Sushma Adarkar MD Trustee 1.00 4.00 X 0 0 0 Bruce Bennett Trustee 1.00 4.00 X 0 0 0 William M Bitting Trustee 1.00 0.00 X 0 0 0 Mrs Jack L Blumenthal Trustee 1.00 0.00 X 0 0 0 Mrs Maribeth A Borthwick Trustee 1.00 0.00 X 0 0 0 Victoria Seaver Dean Trustee 1.00 4.00 X 0 0 0 John B Frank Trustee 1.00 4.00 X 0 0 0 James H Gipson Trustee 1.00 4.00 X 0 0 0 Mimi Grant Trustee 1.00 0.00 X 0 0 0 Allison A Hill MD Trustee 1.00 4.00 X 0 0 0 Robert K Maloney MD Trustee 1.00 4.00 X 0 0 0 Charles P Meister Trustee 1.00 0.00 X 0 0 0 Glen H Mitchel Jr Trustee 1.00 4.00 X 0 0 0 Peter W Mullin Trustee 1.00 0.00 X 0 0 0 Bruce E Pherson Jr Trustee 1.00 0.00 X 0 0 0 Clark W Porter Trustee 1.00 0.00 X 0 0 0 Helen Lho Ryu Trustee 1.00 0.00 X 0 0 0 Stephen L Smith Trustee 1.00 0.00 X 0 0 0 The Rt Rev John Harvey Taylor Trustee 1.00 0.00 X 0 0 0 Edward A Wopschall Trustee 1.00 0.00 X 0 0 0 Alan M Ino CFO 50.00 8.00 X 520377 0 22630 Dean Campbell VP Info. Tech. Services 40.00 0.00 X 278753 0 0 Todd Goodall VP Business Development 40.00 0.00 X 290975 0 14559 Lexie Schuster VP Human Resources 40.00 0.00 X 253451 0 329 Brian Thorne VP Fund Development 40.00 0.00 X 281255 0 28517 Philip Wolfe VP Professional Services 40.00 0.00 X 283522 0 8574 Shauna Pearce VP Nursing Services 40.00 0.00 X 187230 0 22110 Ching Chen Chief Radiation Physicist 40.00 0.00 X 330589 0 22630 Elena Bochove Staff R.N. 40.00 0.00 X 267848 0 22769 Samir Nabulsi Director Worker's Comp 40.00 0.00 X 270818 0 17658 Ira Meiselman Director Managed Care 40.00 0.00 X 266967 0 31999 James Whitcomb Director Revenue Cycle 40.00 0.00 X 269150 0 26833 4165645 0 248448 572 0 1 0 Crothall Healthcare Inc 955 Chesterbrook Blvd 300 Wayne PA 19087 Environmental Services 6087515 Orange Commercial Credit Ref SecureNurs PO Box 25229 Anaheim CA 92825 Nursing Registry Services 4299521 Morrison Management Specialists Inc 5801 Peachtree Dunwoody Rd Atlanta GA 30342 Dietary Services 3555806 Millie and Severson Inc 3601 Serpentine Drive Los Alamitos CA 90720 Construction Services 3073711 Samaritan Hospitalists Medical Group In 898 N Pacific Coast Hwy Ste 600 El Segundo CA 90245 Professional Medical Services 2237000 109 146201 196902 57999 5245156 200660 5646258 Patient Revenue 621990 359284320 359284320 Child Care Center 624410 738178 398616 339562 Rental Income 532000 323729 323729 360346227 8228882 8228882 16490091 1030 16269490 0 220601 1030 221631 221631 98915 146201 130125 -31210 -31210 Parking Lot 812930 1065238 68803 996435 Non-Patient Lab Svcs 621500 60997 60997 Physician Mngmt Svcs 621110 55800 55800 1639537 1639537 2821572 377233360 359608049 584216 11394837 X 552231 552231 3044107 484699 2269903 289505 121386474 112000273 9137968 248233 7088508 6350906 737602 28954770 25218916 3670351 65503 9982297 9013765 925984 42548 1675620 1542429 133191 410000 410000 27424 27424 80426759 70671837 9707838 47084 899603 143138 756465 2476902 2429112 43970 3820 44426 21373 21951 1102 2105845 2105845 12117218 6506479 5610739 2665673 516318 2149223 132 Supplies 75259589 74689823 558119 11647 Hospital Fee Program 20713890 20713890 Bad Debt Expense 8699488 8699488 Utilities 5323967 4956788 366984 195 8349897 3781124 3863876 704897 392204688 340156517 50500314 1547857 21249311 29991092 939598 957000 53524004 57919039 194346404 177697339 1690024 1937434 6463369 5148279 470206390 358783965 109626924 111422425 105340234 95171348 4863688 5256338 498043556 485500294 74510263 74613845 52892925 52397957 49526664 46725212 176929852 173737014 X 253732359 246334946 9825997 10850409 57555348 54577925 321113704 311763280 498043556 485500294 X -14971328 5704697 -83793 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 27424 27424 0 Part II-B, Line 1: Lobbying expenses represent a portion of the dues Good Samaritan Hospital pays to the Hospital Association of Southern California. 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. 73767150 108951 4068889 5875119 36579 72033292 74567557 16756 5368619 6185782 73767150 72393290 1202722 8424663 7426842 26276 74567557 71589573 164742 4279465 3979499 -339009 72393290 63269200 10395868 2792152 4867647 71589573 0.15780 0.75770 0.08450 1 0 17195670 17195670 151460317 119073924 32386393 284927249 236464985 48462264 16623154 3245056 13378098 111422425 Reserve for Self-Insured Programs 4121772 Pension Plan 17168043 Advances from Third Party Payors 2437810 Reserve for Asset Retirement Obligation 11509109 Other Annuity Payment Liability 1738583 Other Long Term Reserves 9749895 46725212 X Part V, Line 4: For specific purposes listed by the donors. Part X, Line 2: The Hospital, SIC, and MOB are not-for-profit corporations as described in Section 501(c)(3) of the Internal Revenue Code (the "Code") and are exempt from federal income taxes pursuant to Section 501(a) of the Code. They are exempt from state franchise taxes under similar statutes. Accordingly, no provision for income taxes has been recorded in the accompanying consolidated financial statements. During the years ended August 31, 2019 and 2018, the Company did not record any liability for unrecognized tax contingencies. Golf Tournament 245116 146201 98915 71875 22534 35716 245116 146201 98915 71875 22534 35716 130125 -31210 1 1 X 1 X 1 X 1 1 0 1 1 7101 8615861 8615861 0.02200 25634 125746142 99516874 26229268 0.06690 32735 134362003 99516874 34845129 0.08890 780 44800 6000 38800 0.00010 306 186312 186312 0.00050 432143 38511 393632 0.00100 1 5000 5000 0.00000 1087 668255 44511 623744 0.00160 33822 135030258 99561385 35468873 0.09050 1 1126130 0 92340980 100292060 -7951080 X 1 1 1 1 Good Samaritan Hospital 1225 Wilshire Blvd Los Angeles CA 90017 www.goodsam.org 930000071 X X X X X Good Samaritan Hospital 1 0 0 1 X X X X X X X X X 18 1 1 0 1 X See Part V, Page 8 X 1 18 1 See Part V, Page 8 0 1 X 200.000000000000 350.000000000000 X X X 1 1 X X X 1 X www.goodsam.org/About-Us/Charity-Care-Discount-Policy/Policy.aspx X www.goodsam.org/documents/Financial-Assistance-Request-Form-English_Spanish X www.goodsam.org/About-Us/Charity-Care-Discount-Policy/Policy.aspx X X X X X X 1 X 0 X X X X 1 X 0 0 Good Samaritan Hospital Part V, Section B, Line 5: 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.Twenty-nine (29) interviews were completed from November 2018 to January 2019. Community stakeholders identified by the Metro Los Angeles Collaborative were contacted and asked to participate in the needs assessment. Interviewees included individuals who are leaders and/or representatives of medically underserved, low-income, and minority populations, local health or other departments or agencies that have current data or other information relevant to the health needs of the community. Input was obtained from the Los Angeles County Department of Public Health.The identified stakeholders were invited by email to participate in a 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 needs 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: - Health issues in the community - Challenges and barriers people face in addressing these issues - Socioeconomic, behavioral, or environmental factors contributing to poor health in the community - Potential resources to address the identified health needs, such as services, programs and/or community efforts - Additional comments and concerns A list of the stakeholder interview respondents, their titles and organizations can be found in Attachment 2. Good Samaritan Hospital Part V, Section B, Line 6a: Good Samaritan Hospital participated in a collaborative process for the Community Health Needs Assessment, in partnership with St. Vincent Medical Center and California Hospital Medical Center. Good Samaritan Hospital Part V, Section B, Line 11: The Needs Assessment for Good Samaritan Hospital was conducted in collaboration with California Hospital Medical Center and St. Vincent Medical Center.The Community Needs Assessment process identified the top broad health issues as:- Access to Care (health insurance, regular source of care, inappropriate use of the ER)- Care for Chronic Conditions (diabetes, heart disease)- Cancer Care- Disease Management and Preventative Care (patient education, cardiovascular disease, including stroke, breastfeeding, screenings, and vaccinations)- Community Social IssuesFor needs that are not addressed such as mental health services, education on sexually transmitted infections including HIV, alcohol and substance abuse, and Alzheimer's disease, Good Samaritan Hospital has partnered with several organizations that have this expertise.The initiatives included in this year's Community Benefit Implementation Plan will require collaboration with many public and private organizations including philanthropic foundations, disease support groups, and governmental programs for the uninsured, community service agencies, local elected officials, security agencies and schools. Part V, Section B, Line 7, CHNA Policy Website: https://www.goodsam.org/documents/Good-Samaritan-2019-CHNA-FINAL.pdf Part V, Section B, Line 10, Implementation Strategy Website: https://www.goodsam.org/About-Us/Community-Benefit-Plan.aspx Part V, Section B, Lines 9 and 12a: During tax year 2018, Good Samaritan Hospital (GSH), a single facility hospital, conducted a community health needs assessment in accordance with Section 501(r)(3). The CHNA report was adopted by the board of directors in July 2019. On December 23, 2019, Good Samaritan Hospital was acquired by PIH Health Inc. (PIH Health), EIN 95-3619388, at which time the GSH board of directors was dissolved and replaced by the PIH Health board of directors. Immediately upon acquisition, PIH Health began its due diligence to ensure GSH was in compliance with the requirements of Section 501(r). As of the date of acquisition, GSH became subject to PIH Health's existing Community Health Improvement Plan (CHIP), which was approved by the PIH Health board of directors in December 2019. At this time, PIH Health also began assessing whether and to what extent adjustments to its existing CHIP were necessary to fully incorporate Good Samaritan Hospital's community needs based on the most recently conducted GSH CHNA. Due to the transition arising from the acquisition, there were administrative delays which prevented Good Samaritan Hospital's newly appointed Board of Directors from being able to convene and formally adopt a written implementation strategy by the statutory deadline of January 15, 2020, as required by Treas. Reg. Section 501(r)-3(a)(2). However, Good Samaritan Hospital had a revised, written implementation strategy in place in January 2020 and was acting upon the PIH Health CHIP, which already incorporated several needs identified by the GSH CHNA. PIH Health's revised 2020-2022 CHIP, which includes PIH Health Good Samaritan Hospital, was formally approved by the Board on April 8, 2020. PIH Health's Board meets on a quarterly basis.Except for the formal adoption of the written implementation strategy by the January 15, 2020 deadline, GSH acted in a manner to meet the needs of the community served by GSH based on the 2019 Community Health Needs Assessment (CHNA). Beginning in January 2020, the PIH Health Community Benefit department incorporated the GSH service areas into the work to support the 2019 CHNA, while the GSH CHNA IP was being developed. These programs have continued through the 2020 fiscal year. PIH Health Good Samaritan Hospital has implemented new policies and procedures to minimize the likelihood of further Section 501(r)(3) compliance errors and to facilitate the prompt identification and correction of any such future failures that do occur. Changes include hiring a consultant to assist with assessment of the organization's Section 501(r) compliance, appointing new employees to oversee the community benefit process, and subjecting Good Samaritan Hospital to the policies and procedures established by PIH Health Inc., the organization's newly controlling related entity. For these reasons, Good Samaritan Hospital's error with respect to the implementation policy is not considered a failure to meet a requirement of Section 501(r) because the error was minor and due to reasonable cause. However, Good Samaritan Hospital corrected the error promptly upon discovery and is including this disclosure pursuant to Revenue Procedure 2015-21 Sections 6 and 7. Part I, Line 7: Charity cost: Hospital RCC from internal financial statements applied to charity write offs. Medi-Cal cost: From hospital's Harris costing system. Health Fair: Cost provided by Public Relations Department. Job Training for Volunteers: From general ledger expense for Volunteer Department. Research Cost: Provided by Accounting Department. Part III, Line 2: Bad debt expense is determined by applying RCC from Hospital financial statements to bad debt transfers net of recoveries. This expense was not included in community benefit expense. Part III, Line 3: Good Samaritan Hospital has a very robust financial assistance program, 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 Good Samaritan Hospital and its affiliates for the year ended August 31, 2019: The Company has agreements with third-party payors that provide for payments to the Company at amounts different from its established rates. Payment arrangements include prospectively determined rates per discharge, reimbursed costs, discounted charges, and per diem payments. Net patient service revenue is reported at the estimated net realizable amounts from patients, third-party payors, and others for services rendered, including estimated retroactive adjustments under reimbursement agreements with third-party payors. Retroactive adjustments are accrued on an estimated basis in the period the related services are rendered and adjusted in future periods as final settlements are determined. The Company presents its provision for bad debts as a reduction of patient service revenue on a separate line item in its consolidated statements of operations.The bad debt expense reported on Part III, 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 2019 Medicare cost report and we believe do not qualify as community benefit. Part III, Line 9b: Patients are advised that they have the opportunity to submit a charity application or apply for a discount under the Hospital's Charity Care Policy or Cash Price Policy. Part VI, Line 2: Good Samaritan Hospital addresses the healthcare needs of the communities it serves through participation in various community collaboratives and networking meetings, including it's annual Korean Health Fair. Good Samaritan Hospital is able to assess the healthcare needs of the community and identify partnership opportunities. Part VI, Line 3: Signage describing the Hospital's charity programs is posted at all points of registration in three languages. Also, all uninsured patients are sent a letter with their first bill informing them of the Hospital's available charity care programs and personnel to contact for information and application. 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 uninsured, 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: Good Samaritan Hospital is located at 1225 Wilshire Blvd., Los Angeles, California 90017. The hospital service area includes 18 ZIP Codes in Los Angeles City Council District 1. The service area is comprised of portions of Service Planning Areas (SPAs) 4 and 6. The hospital service area is detailed below by community and ZIP Code and was determined from the ZIP Codes that reflect a majority of patient admissions from the local geographic area.The population for the GSH service area is 516,340. Children and youth, ages 0-17, make up 15.6% of the population, 74% are 18-64 years of age, and 10.4% are seniors, 65 years and older. In the service area, 53.1% of the population are Hispanic/Latino, 22.5% are Asian, 13.2% are White, 8.9% are Black/African American; and the remaining 2.3% are American Indian/Alaskan Native, Native Hawaiian/Pacific Islander, other or multiple races. English is spoken in the home among 32.8% of the service area population. Spanish is spoken at home among 42.3% of the population, and 21.1% of the population speaks an Asian language in the home. In the service area, 30% of the population is at or below 100% of the federal poverty level. Among area adults, ages 25 and older, 30.2% lack a high school diploma, 19% are high school graduates and 35.6% are college graduates. Part VI, Line 5: Community BoardGood Samaritan Hospital's community Board of Directors works to advance the commitment to helping our communities get well and stay healthy.Open Medical StaffGood Samaritan Hospital extends medical staff privileges to all qualified physicians in its community for some or all of its departments or specialties.Use of Company Campaign FundsGood Samaritan Hospital's employees donate back to the hospital during Good Company Campaign each year and the money raised applies toward improvements in patient care, technology, medical education and areas with greatest needs.Donation of TimeMany Good Samaritan Hospital Health providers are living out their passion to serve people in need by donating their time and talents both in our community and overseas. Volunteer Contributions Some 304 Good Samaritan Hospital volunteers collectively contributed 36,886 hours of service, supporting departments throughout the organization. Part VI, Line 6: Good Samaritan Hospital (the "Hospital") is a not-for-profit and tax-exempt corporation that operates a 408-bed tertiary hospital in Los Angeles, California. The Hospital's mission is to provide accessible, quality, cost-effective, and compassionate health care services that meet the needs of the patients, their families, the community, physicians, and employees.Good Samaritan Medical Office Building, Inc. (MOB), a not-for-profit corporation consisting of a medical office building adjacent to the Hospital, was formed to provide and lease office space to physicians on staff at the Hospital.Samaritan Imaging Center (SIC), a not-for-profit corporation, was formed as an outpatient imaging center, dedicated to the advancement of the care of the sick, injured, and disabled individuals requiring radiological imaging services.The Hospital, MOB, and SIC are consolidated in these financial statements because the Hospital is the sole corporate member of MOB and SIC, and are referred to collectively as the "Company."As part of its clinical mission, the Company created Good Samaritan Institute for Research and Education and the Orthopedic Institute (collectively, the "Institutes"). The Institutes conduct clinical research in their specialized areas and provide education to the medical community and the general public. The Institutes are included in these consolidated financial statements. Part VI, Line 7, Reports Filed With States CA 1 Good Samaritan Institute for Research and Education 1225 Wilshire Blvd Los Angeles CA 90017 954077161 501(c)(3) 432161 0 Expenses paid by the Organization California Health Foundation and Trust 1215 K Street Suite 800 Sacramento CA 95814 941498687 501(c)(3) 108970 0 Support charitable activities at Hospitals and Health Systems in California Orthopedic Institute of the Good Samaritan Hospital 1225 Wilshire Blvd Los Angeles CA 90017 954346048 501(c)(3) 11100 0 Expenses paid by the Organization 3 0 Part I, Line 2: The Institutes (Good Samaritan Institute for Research and Education and Ortho) do not have their own checking accounts, so all of their expenses (including salaries, wages and benefits) are paid for by the Hospital and are all recorded in each of the Institutes' accounts in the general ledger, through intercompany due to and from accounts on both sides (Institutes and Hospital's). Grants will only be made to 501(c)(3) organizations to ensure the funds will be used properly. X X X X 0 0 0 0 0 0 0 0 0 Andrew B Leeka President & CEO 664710 0 0 0 0 0 8250 0 21590 0 694550 0 0 0 Alan M Ino CFO 520377 0 0 0 0 0 8250 0 14380 0 543007 0 0 0 Dean Campbell VP Info. Tech. Services 278753 0 0 0 0 0 0 0 0 0 278753 0 0 0 Todd Goodall VP Business Development 290975 0 0 0 0 0 8250 0 6309 0 305534 0 0 0 Lexie Schuster VP Human Resources 253451 0 0 0 0 0 0 0 329 0 253780 0 0 0 Brian Thorne VP Fund Development 281255 0 0 0 0 0 8250 0 20267 0 309772 0 0 0 Philip Wolfe VP Professional Services 283522 0 0 0 0 0 8250 0 324 0 292096 0 0 0 Shauna Pearce VP Nursing Services 187230 0 0 0 0 0 5697 0 16413 0 209340 0 0 0 Ching Chen Chief Radiation Physicist 330589 0 0 0 0 0 8250 0 14380 0 353219 0 0 0 Elena Bochove Staff R.N. 267848 0 0 0 0 0 16071 0 6698 0 290617 0 0 0 Samir Nabulsi Director Worker's Comp 270818 0 0 0 0 0 8218 0 9440 0 288476 0 0 0 Ira Meiselman Director Managed Care 246967 0 20000 0 0 0 8173 0 23826 0 298966 0 0 0 James Whitcomb Director Revenue Cycle 269150 0 0 0 0 0 7339 0 19494 0 295983 0 0 0 X 1 200660 FMV 0 0 0 0 Part I, Column (b): Is the number of contributions. Form 990, Part VI, Section A, line 2 Mrs. Maribeth Borthwick, a Board Member of Good Samaritan Hospital, has a family relationship with Mr. Charles Munger, Chairman of the Board. Mr. Clark W. Porter has a family relationship with Mr. Glen H. Mitchel, Jr., who are both board members. 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 the Controller, who will provide any final comments to RSM US LLP. RSM US LLP makes all changes necessary and a final Form 990 is made available to all Board Members prior to filing. Form 990, Part VI, Section B, line 12c All Board Members and officers are required to complete a conflict of interest disclosure statement each year. The Policy requires each governing body member to disclose any conflict on a particular matter that may arise, and recuse him or herself from deliberations and votes on such matters. The Policies are monitored by the Director of Risk Management of the Good Samaritan Hospital and are enforced by the Audit Committee Chairperson. Form 990, Part VI, Section B, line 15 A subcommittee of the Governing Board's Executive Committee is responsible for determining the Chief Executive Officer's compensation. This Subcommittee is given comparison data on CEO salaries and benefits from comparable hospitals in the local area, prepared by human resources from 990s; and salary surveys completed by the local association. The decision of the Subcommittee on the CEO's salary is documented by the Subcommittee in writing. The compensation of the Organization's Vice Presidents are reviewed and approved by the Organization's CEO. Their salaries and benefits are determined using comparable hospitals in the local area, prepared by human resources from 990s; and salary surveys completed by the local hospital association. Form 990, Part VI, Section C, line 19 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: Good Samaritan Hospital holds a 12.5% 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. Good Samaritan Hospital annually evaluates its participation in joint venture arrangements. Form 990, Part IX, line 11g Physician Fees: Program service expenses 9,208,225. Management and general expenses 0. Fundraising expenses 0. Total expenses 9,208,225. Consulting and Management Fees: Program service expenses 2,311,069. Management and general expenses 2,425,365. Fundraising expenses 15,074. Total expenses 4,751,508. Medical Purchased Services: Program service expenses 2,276,030. Management and general expenses 350. Fundraising expenses 0. Total expenses 2,276,380. Repairs and Maintenance: Program service expenses 6,454,595. Management and general expenses 888,341. Fundraising expenses 0. Total expenses 7,342,936. Software Maintenance: Program service expenses 1,833,675. Management and general expenses 1,762,426. Fundraising expenses 3,540. Total expenses 3,599,641. Other Purchased Services: Program service expenses 16,207,338. Management and general expenses 4,213,072. Fundraising expenses 28,470. Total expenses 20,448,880. Outside Provider Cost: Program service expenses 7,840,835. Management and general expenses 0. Fundraising expenses 0. Total expenses 7,840,835. Purchased Labor: Program service expenses 24,540,070. Management and general expenses 418,284. Fundraising expenses 0. Total expenses 24,958,354. Form 990, Part XI, line 9: Net assets released from restrictions -78,716. Pension related changes -8,456. Change in value of split-interest agreements -132,598. TRF Transfer 135,977. Good Samaritan Institute for Research and Education 1225 Wilshire Blvd Los Angeles CA 90017 954077161 Heart Research CA 501(c)(3) Line 4 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 Good Samaritan Hospital 1 Samaritan Imaging Center 1225 Wilshire Blvd Los Angeles CA 90017 954252321 Outpatient Imaging Services CA 501(c)(3) Line 10 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 Good Samaritan Hospital 1 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 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 Good Samaritan Hospital 1 1 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 Good Samaritan Institute for Research and Education B 432161 FMV Orthopedic Institute of the Good Samaritan Hospital C 120121 FMV Good Samaritan Medical Office Building Inc J 2422427 FMV Good Samaritan Medical Office Building Inc A 4750631 FMV