2018-07-09T13:13:27-05:00 2017-08-31 861065772 Deloitte Tax LLP 191 Peachtree St Suite 2000 Atlanta GA 303031749 990 2016-09-01 611356023 Our Lady of Bellefonte Hospital Inc OURL 6068333333 St Christopher Drive Ashland KY 41101 Kevin Halter Chief Executive Officer 6068333600 2018-07-09 1 John W Sadoff Jr P00540589 4042201500 2016 2022-09-23 18:48:47Z Kevin Halter St Christopher Drive Ashland KY 41101 174034835 0 0928 X bonsecours.com X 1999 KY Acute Care Hospital 19 16 1355 61 6486245 168856 367860 382574 170895730 169298843 640865 483753 3123969 3869665 175028424 174034835 601770 582381 0 0 63103862 70958001 0 0 0 100665935 103988754 164371567 175529136 10656857 -1494301 153602571 153618023 88441278 87483269 65161293 66134754 The mission is to bring compassion to health care and to be good help to those in need, especially those who are poor and dying. As a system of caregivers, we commit ourselves to help bring people and communities to health and wholeness. 0 0 162621305 582381 164019680 To bring compassion to healthcare and to be good help to those in need by providing healthcare services. Please see community benefit disclosures in Sch H. 162621305 1 1 0 1 0 0 0 0 0 0 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 1 0 0 0 0 0 0 1 0 0 0 1 121 0 1 1355 1 1 1 0 0 0 0 0 0 0 0 0 X 19 16 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 1 0 KY X Aaron Akers 6068334136 St Christopher Drive Ashland KY 41101 X Carol Allen Board Member 2.00 0.00 X 0 0 0 Gregory Bausch PhD Board Member 2.00 0.00 X 0 0 0 Lori Cooksey Board Member 2.00 0.00 X 0 0 0 Mary Flath PhD Board Member 2.00 0.00 X 0 0 0 Geoff Griffith Board Member (Jan-Aug) 2.00 0.00 X 0 0 0 Kevin Halter FACHE CEO - BSKY 37.00 13.00 X X 0 452561 56406 Kevin Howard Board Member (Jan-Aug) 50.00 0.00 X 183046 0 17424 Daniel Huffman Board Member 2.00 0.00 X 0 0 0 Gregory Jackson Chairman 3.00 0.00 X X 0 0 0 Connie Johnson Board Member (Sep-Dec) 2.00 0.00 X 0 0 0 Larry Jones Board Member (Sep-Dec) 2.00 0.00 X 0 0 0 James Martin Jr MD Board Member 2.00 0.00 X 2003 0 0 Andrea Mazzoccoli PhD Board Member 2.00 48.00 X 0 585415 83331 Jason McCloud OD Board Member 2.00 0.00 X 0 0 0 Stephen McGinnis Esq Board Member 2.00 0.00 X 0 0 0 Thomas Morris PhD President 3.50 46.50 X X 0 464396 82259 James Payne PhD Board Member 2.00 0.00 X 0 0 0 Pam Phillips Board Member 2.00 48.00 X 0 228445 27431 Laura Timberlake Board Member 2.00 0.00 X 0 0 0 Emily Watson Board Member 2.00 0.00 X 0 0 0 William Willan PhD Board Member 2.00 0.00 X 0 0 0 Joe Buchheit Treasurer/CFO-BSKY 37.00 13.00 X 307585 0 22742 Rodney Hieneman Secretary 50.00 0.00 X 164861 0 32718 John Darnell CMO 50.00 0.00 X 285348 0 17880 Michele Friday MD Cardiologist 49.50 0.50 X 857498 0 33705 Yogendra Prasad MD Cardiologist 50.00 0.00 X 608458 0 32814 Kurt Jaenicke MD Obstetrician 50.00 0.00 X 586008 0 24742 Phillip Lackey MD Plastic Surgeon 50.00 0.00 X 396559 0 31318 Jason Ford MD Pediatrician 50.00 0.00 X 340861 0 29694 John Wallenhorst Former Board Officer 0.00 50.00 X 0 454099 35488 3732227 2184916 527952 45 1 1 0 Morrison MGT Specialists PO Box 102289 Atlanta GA 303682289 Food Services 3009005 Ashland Anesthesia PSC PO Box 29 Ashland KY 411050029 Anesthesia Services 2806769 Aramark CTS Inc 12483 Collections CTR Dr Chicago IL 60693 Equipment Maintenance 2454825 Aramark 24863 Network Place Chicago IL 606731248 Housekeeping/Laundry 2008321 Jackson & Coker Locum Tenens 3000 Old Alabama Road Suite 119-608 Alpharetta GA 30022 Jobs Services 1867211 35 316640 65934 382574 Patient Service Rev. 622110 169298843 163685699 5613144 169298843 226555 226555 634363 0 634363 634363 634363 236963 20235 0 0 236963 20235 257198 257198 Retail Pharmacy Rev. 446110 2546793 873101 1673692 Comm. Health & Fitness 713940 333981 333981 Medical Records 900099 157695 157695 196833 196833 3235302 174034835 164019680 6486245 3146336 578381 578381 4000 4000 1096547 986893 109654 50983628 45885265 5098363 6635991 5972392 663599 8257681 7431913 825768 3984154 3585739 398415 213873 192486 21387 23404 21064 2340 13750 12375 1375 10147022 10147022 432176 388958 43218 1743452 1569107 174345 469110 422199 46911 6338520 5704668 633852 373189 335870 37319 41268 37141 4127 2112234 2112234 8709656 7838690 870966 692436 623192 69244 Medical Supplies 28794413 28794413 Purchased Services 15986064 14387458 1598606 Corporate Mgmt Dues 14775379 13297841 1477538 Unrelated Business Inco 455982 455982 12666826 12292004 374822 175529136 162621305 12907831 0 824 824 63982185 59570773 18667834 19909181 751291 1644278 4093040 4150922 1537028 1645273 143278698 95413496 45022308 47865202 9733063 10609579 419692 436396 252734 243053 9142572 7542542 153602571 153618023 13343620 16216566 4451748 4499531 70645910 66767172 88441278 87483269 X 65160733 66134194 560 560 65161293 66134754 153602571 153618023 X -1494301 551684 1916078 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 13750 13750 0 Part II-B, Line 1: The filing organization maintains memberships to various professional healthcare associations. Portions of their membership dues are used for lobbying activities. The lobbying portion of such dues is included on line 1i. 4509318 4509318 58825441 33028444 25796997 2563271 2545740 17531 72620470 56975044 15645426 4760198 2864268 1895930 47865202 LT Liab - Pension Liability 58922558 HPL/GL Liability 5786497 Medicare/Medicaid Settlements 1047769 Due to Affiliates 686725 Reserves from Medicare 254334 Unapplied Credit 41178 Unclaimed Prop Accrual 28111 66767172 X Part X, Line 2: Schedule D, Part X, Line 2 requires that the organization provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under ASC 740. ASC 740 addresses the accounting for uncertainty in income taxes recognized in an entity's financial statements and prescribes a threshold of more-likely-than-not for recognition and derecognition of tax positions taken or expected to be taken in a tax return. The adoption of ASC 740 by BSHSI on September 1, 2007 did not have a material impact on BSHSI's consolidated financial statements. As the organization does not conduct a separate audit of its financial statements, below is the related statement from the Bon Secours Health System, Inc. consolidated audited financial statements: The System and most of its subsidiaries (including certain joint venture entities) are exempt from federal income taxes under Section 501(c)(3) of the Internal Revenue Code of 1986, as amended. The System accounts for uncertain tax positions in accordance with ASC Topic 740, Income Taxes. Their related income is exempt from federal income tax under Section 501(A). The System accounts for uncertainty in income tax positions by applying a recognition threshold and measurement attribute for financial statement recognition and measurement of a tax position taken or expected to be taken in a tax return. The System has determined that no material unrecognized tax benefits or liabilities exist as of August 31, 2017 or 2016. Accounting for uncertainty in income taxes, ASC Topic 740-10 prescribes a comprehensive model for how an organization should measure, recognize, present, and disclose in its financial statements uncertain tax positions that an organization has taken or expects to take on a tax return. The System is subject to routine audits by taxing jurisdictions; however, there are currently no audits for any tax periods in progress. The System believes it is no longer subject to income tax examinations for years prior to 2013. As of August 31, 2017 and 2016, the System has no uncertain tax positions. The System's taxable subsidiaries had approximately $106,393 and $89,895 of net operating loss carryforwards as of August 31, 2017 and 2016, respectively, which expire in varying periods through 2037 and are available to offset future taxable income. The System accounts for income taxes under the asset and liability method. Under this method, deferred tax assets and liabilities are recognized for the estimated future tax consequences attributable to differences between the financial statement carrying amounts of existing assets and liabilities and their respective tax bases. Deferred tax assets and liabilities are measured using enacted tax rates expected to be in effect during the year in which those temporary differences are expected to be recovered or settled. The effect on deferred tax assets and liabilities of a change in tax rates is recognized in income in the period that includes the enactment date. Interest and penalties related to income taxes are accounted for as income tax expense. The System's deferred tax assets are fully reserved at August 31, 2017 and 2016 as the System considers it more likely than not that these amounts will not be recognized. 1 1 X 1 X 1 X 1 1 0 1 1 1443181 445930 997251 0.00600 39126387 24657329 14469058 0.08660 40569568 25103259 15466309 0.09260 30514 764228 764228 0.00460 313 381340 224167 157173 0.00090 340447 340447 0.00200 5317 75937 75937 0.00050 36144 1561952 224167 1337785 0.00800 36144 42131520 25327426 16804094 0.10060 1920 3481 3481 0.00000 126 1068 1068 0.00000 295 3867 3867 0.00000 1155 3196 3196 0.00000 5573 57043 57043 0.00030 9571 49895 49895 0.00030 1435 7871 7871 0.00000 20075 126421 126421 0.00060 1 8424472 0 42201682 43255756 -1054074 X 1 1 1 1 Our Lady of Bellefonte Hospital Inc St Christopher Drive Ashland KY 41101 https://bonsecours.com/kentucky 100154 X X X X Our Lady of Bellefonte Hospital Inc 1 0 0 1 X X X X X X X X X 15 1 1 0 1 X See Section C X X 1 15 0 1 0 1 X 200.000000000000 400.000000000000 1 1 X X X 1 X http://www.fa.bonsecours.com/ X http://www.fa.bonsecours.com/ X http://www.fa.bonsecours.com/ X X X X X X X 1 X 0 X X X X 1 X 0 0 Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 5: In preparing the OLBH CHNA, the hospital collaborated with community service organizations to provide feedback on the questions we included in the survey. Local health dept's, police and fire dept's, school districts, community based service organizations, local businesses, representatives from faith communities along with residents and organizations. Interviews were conducted with individuals with special knowledge and expertise in public health, along with representatives of individuals that are medically underserved and battling chronic diseases. Interviews were conducted with the following individuals: Chris Crum, Director of Greenup Co. Health Dept., Maria Hardy, Director Boyd Co. Health Dept., Laura Brown, Director Ironton OH Health Dept. , Debbie Fisher Director Lawrence Co. Ohio Health Dept., Kelli Prater, Director Boyd Co. Head Start, Mary Crowley, NEKCC Free clinic, Debbie Sivis, Director at Shelter of Hope, Alfreda Moore, Director Ashland Community Kitchen, Debbie Blevins, Director of Helping Hands of Greenup KY, Ann Perkins, Director of Safe Harbor, Trish Hall Director of CARES, Eve Greene Nurse at Greenup Co. Health Dept. Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 6a: King's Daughters Medical Center Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 7d: The CHNA is available to the public in the following locations: Hospital and coalition Web sites, printed copies were made available at the hospital in various departments including the emergency department, administration, marketing and mission departments. Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 11: The CHNA identified significant needs in several areas. Through collaboration with Healthy Choices/Healthy Communities coalition the following 4 areas are being addressed through team committees or sub-groups.1) Obesity- Festival of Fitness: A community event aimed to bring awareness to opportunities in the local area to increase individual and family fitness in daily lives. Several coalition agencies have funded walking tracks and trails in several local communities. This initiative aims to provide facilities in remote and rural areas. BSKY has increased financial support for school and community gardens, and funded two community bicycle safety programs, and assists with funding for three local farmers markets, support for safe routes to schools and continue work on policy changes through schools to support active recess and healthy eating in child care centers. Initiatives are in place to support completion of streets in several communities.2) Access to Care: Supports a van ministry program to transport patients to physician appointments and treatments. Sponsors community events to bring awareness to colon cancer through an event at the mall in collaboration with the American Cancer Society. We provide free screenings in the community for Blood Pressure, Blood sugar, A1C, Hemoglobin and Cholesterol.3) Substance abuse: Assists with a program in local schools- "2 good for drugs program" is currently in 4 local school systems in collaboration with Pathways, working on 24-7 smoke free policy in schools, and supports a program in the schools called "truth or consequences" in collaboration with UK extension office and law enforcement.4) Poverty/Socioeconomic challenges: This workgroup is working with the United Way to implement a 2-1-1 system for referrals to social service agencies. The group is working on a job fair to assist the homeless and most vulnerable to find employment which would assist them to move out of poverty. Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 16j: Information regarding the FAP is available on our websites, brochures are available at time of registration. We have on-site Financial Counselors who assist patients. We also have eligibility vendors who work with the patients and our statements indicate we have an FAP. We also provided local clinics in each market brochures regarding our FA program. Form 990, Schedule H, Part V, Section B, Line 14: Charges for patients who are eligible for financial assistance shall be limited to no more than amounts generally billed ("AGB") for such services. These charges are based on the average allowed amounts from Medicare and commercial payers for emergency and other medically necessary care. The allowed amounts include both the amount the insurer will pay and the amount, if any, the individual is personally responsible for paying. The AGB is calculated using a look back method. Because both Maryland law and Federal tax law limit the amounts that may be charged to patients, an FAP eligible individual or an uninsured individual will not be charged more than the lesser of the AGB or the regulated charge set by the Maryland Health Services Cost Review Commission for emergency or other medically necessary care. Form 990, Schedule H, Part V, Section B, Line 7a: https://bonsecours.com/kentucky/community-commitment/community-health-needs-assessment 14 1 - Med Plaza Pharmacy 700 St Christopher Drive Ashland KY 41101 Pharmacy 2 - Same Day Surgery Center 1101 St Christopher Drive Ashland KY 41101 Surgery Center 3 - Bellefonte Behavioral Health 1000 St Christopher Drive Ashland KY 41101 Behavioral Health 4 - Bellefonte Home Health Care Agency 700 St Christopher Drive Suite 105 Ashland KY 41101 Home Health 5 - Ironton MRI 1015 East Ring Road Ironton OH 45638 Imaging Center 6 - Ashland Imaging 1816 Carter Ave Ashland KY 41101 Imaging Center 7 - Ashland Lab 1816 Carter Ave Ashland KY 41101 Lab Services 8 - Bellefonte Center 1000 Ashland Drive Ashland KY 41101 Women's Health, Pre-testing, Various physician offices 9 - Ashland Infusion Center 2930 Carter Ave Ashland KY 41101 Infusion Therapy 10 - Wheelersburg PT 8985 Ohio River Road Wheelersburg OH 45638 Physical Therapy 11 - OLBH Pediatric Rehabilitation Clinic 1100 St Christopher Drive Ashland KY 41101 Pediatric Rehab 12 - Bellefonte Sleep Lab 118 St Christopher Drive Ashland KY 41101 Sleep Lab 13 - Vitality Center 1100 St Christopher Drive Ashland KY 41101 Cardio/Vascular Rehab 14 - Bellefonte Home Health Care Agency - Ohi 109 N 3rd St Ironton OH 45638 Home Health Part I, Line 6a: Annually, Bon Secours Kentucky Health System, through its Foundation, publishes a report for the community, explaining the various community benefit services and programs that exist. This report also includes the annual financial commitment of the local system to the community, detailing monetary contributions for government sponsored healthcare shortfall, community benefit programs and charity care at cost. This report is available to the public each year on or around March 15.This report is available online at https://www.olbhfoundation.org/annual-report. Part I, Line 7: Part I, line 7a: Charity Care at cost is computed by applying a cost-to-charge ratio to the aggregate charity adjustments recorded in the general ledger. Part I, line 7b: Unreimbursed Medicaid is computed by determining the cost of Medicaid services supplied less payments received for these services. To determine the cost of Medicaid services provided, a cost-to-charge ratio is applied to traditional and managed Medicaid gross charges captured in the patient accounting system and general ledger. Payments include payments for individual claims, payments from the Medicaid program paid outside the claim process (such as medical education payments) and expected or actual cost report settlements.Part I, line 7c: Unreimbursed costs from other means-tested government programs are computed by applying a cost-to-charge ratio to the total charges to patients covered under these programs. The charges are identified by the financial class assigned to the patient. For Part I, Line 7 a-c computations: The cost-to-charge ratio is derived using the suggested computation in Worksheet 2, Ratio of Patient Care Cost-to-Charges. Operating expenses and Gross patient charges are taken from the general ledger. Expenses for nonpatient care activities recorded in operating expenses are approximated as directly equaling other operating revenue, assuming these activities do not provide profit. Part I, line 7e: Community health improvement services and community benefit operations are accumulated throughout the year and reported at actual cost in a software program that specifically addresses this purpose.Part I, line 7f: Health professions education cost is determined as the direct and indirect cost of qualifying education activities as traditionally reported in columns 21-24 on Worksheet B of the Medicare cost report as a Medical Education program, nursing school or other allied health program. Part I, Ln 7 Col(f): Bad debt expense included in Part IX; line 25 and excluded from the "percent of total expense" calculation is: $8,424,472. Part II, Community Building Activities: The service area addressed in the recent CHNA covered 4 counties in 2 states; Boyd, Greenup, Carter in KY and Lawrence Co in Ohio. located in 2 states, Ky and OH. Our community building activites include School and community gardens, walking trails, farmers markets, after school and summer camps for low income students living in public housing in the Ironton Ohio community. The trails and gardens located in the Greenup county community of Argillite KY continue to be utilized and provide opportunities for education on how to grow fresh vegetables and provides a venue for the community and the school students and personal to walk in a safe atmospher in a rural community this project is aimed to to help fight obesity. BSKY continues to use First Book market place to purchase books to distribute free to students in the low income communities of Ashland, Greenup, Argillite, KY and Ironton, OH. Support of 94 student backpacks and weekend snack sack programs provides supplies and food to students most at risk of going hungry during the weekend and without needed school supplies when school resumes form the summer break. These programs are essential and continues to assist the high risk students in our service area. Healthy Community Services conducted 94 health fairs, providing approximately 7,650 health screenings in 2017 for chronic conditions such as heart disease, diabetes, osteoporosis, anemia, glaucoma, and peripheral vascular disease. All participants in our health fairs received personal health counseling and those with abnormal results 1,719 received educational materials and the offer of assistance in finding a medical home or care provider if they had none. Additionally Healthy Community services conducted 8 community CPR classes in 2017 resulting in 46 individuals being certified in adult, infant and child CPR. We offered 2 safe sitter classes and certified 13 young people as safe sitters. We offered bicycle safety camp with 75 children and their families in attendance. We currently have faith ministry or faith community nurse partnerships with 58 local churches. We have 4 churches offering exercise classes with 50 participants. We provided Flu shots at 16 locations providing 205 immunizations. . Our Healthy Community Services Van Ministry provided free non-emergency medical transportation for outpatient services on the OLBH campus and to patients who had appointments with campus or BPS-affiliated physicians. We operate four vans --two of which is equipped with a wheelchair lift we provided 358 wheelchair transports. In an area which has very limited public transportation, our van ministry provides an option for our patients who need treatment but have no means of affordable non-emergency medical transportation. Our van ministry provided over 3,907 round trips and traveled over 94,192 miles. We served over 493 individuals in transporting most of these individuals multiple times. Our Meals on Wheels programs serve 200 home-bound seniors in 10 communities for an average of 3,600 meals delivered each month. We provide approximately $32,000 in free or reduced price meals each year. Part III, Line 2: Bad debt expense on the general ledger includes: 1) actual write offs of discounted gross charges where it is determined an uninsured patient can pay and does not pay; and 2) the estimated write offs for uninsured patient accounts with outstanding balances after discount. Estimates are based on historical collection rates.When an uninsured patient is billed for patient care services, the charges are automatically discounted and the patient is requested to only pay the amount after discount. The discount is recorded as an adjustment to gross revenue and is not recorded in bad debt expense. If the balance after discount is not paid or not paid in full, the unpaid amount will be written off to bad debt expense. When a patient remits a payment on an account that has already been written off to bad debt expense, the payment is recorded as a recovery of bad debt, which reduces bad debt expense. Part III, Line 3: The organization does not report an estimate for the portion of bad debt expense that may have been likely to qualify for financial assistance under the hospital's charity care policy. The organization takes the position that ample opportunity and assistance is provided to the patient to qualify under the financial assistance policy. If sufficient information is not provided, the organization must assume the patient does not qualify. Part III, Line 4: Please see Footnote "(2d) Accounts Receivable, net" discussing "accounts receivable" on page 10 in the attached BSHSI consolidated audited financial statements ("AFS"). "Allowance for uncollectible accounts" is discussed in the second paragraph in Footnote "(10) Net Patient Service Revenue" on page 38-39 of the attached AFS. There is not a separate "bad debt expense" footnote in the AFS. Part III, Line 8: Medicare allowable costs reflected in Part III come directly from the facility's Medicare cost report. The cost report segregates the total facility actual expenses into costs for support departments, clinical departments (routine and ancillary) and nonreimburseable departments. The cost report uses appropriate statistical bases to "step down" support costs to allowable clinical and nonreimburseable departments. The charges for clinical departments are matched to the total cost for these departments for a cost-to-charge ratio. Medicare-specific allowable costs for in- and outpatient ancillary departments are computed by applying the department-specific cost-to-charge ratio to the Medicare program charges by department. For routine departments, a per diem total cost is computed and applied to Medicare program days for the Medicare routine program cost.In addition to the costs reported above, the organization incurred additional costs relating to Medicare support that are not includable in the Medicare Cost Report in the amount of: $388,339. Part III, Line 9b: The hospital has a written policy that describes collection practices applying to patients who qualify for financial assistance. If full assistance is approved, no collection efforts are pursued on that patient's account(s). If partial assistance is approved, the patient is responsible for the adjusted account balance and collection efforts will follow the established practices for all patients where a self-pay balance exists. Collection efforts are not pursued on any pending FAP account.Specific criteria exists for how much financial assistance, partial or total, will be provided to the patient based on the assessed need. Criteria is based on Federal Poverty Guidelines and is reviewed and updated annually. Once a patient has been deemed eligible for the Patient Financial Assistance Program (FAP), the patient is notified by letter within 60 days after receipt of the application and supporting documentation. The patient retains eligibility for a period of eight months from the date of the application. This eligibility is identified by hospital admissions, billing and collection staff by the assignment of a specific financial class with accompanying eligibility dates. At the end of the eight months, the patient is responsible for reapplying for FAP eligibility. Part VI, Line 2: Our Lady of Bellefonte Hospital (OLBH) uses multiple approaches to assess the health needs of the communities it serves. We have a community based Board of Directors that provides the hospital with guidance and input on services needed in the local community through contacts with local business and government leaders. Community health screening data is gathered through the year and analyzed for use in planning. Community need assessments are updated using a variety of informational sources including Kentucky Health Information for state-based performance data, Kentucky Hospital Association information for market and geographic data bases, third party data bases, US Census Bureau data and Thomson-Reuter's Market Expert is used to retrieve demographic information and trends for the primary and secondary service areas pertaining to Our Lady of Bellefonte Hospital. We have also developed regional alignment plans using this data and tying it to our underserved areas to plan for future growth in the communities we serve by providing more access points for patients in our service areas. The CHNA survey was open to the public through a web based survey and available in hard copies. We worked with local health departments, participated in health needs assessments, had conversations with local residents, health professionals, public forums, community meetings and coalitions. All these groups contributed to the assessment of the community's health care needs. Part VI, Line 3: The Patient Financial Assistance program is communicated to patients verbally upon scheduling, registration, visible postings of the program are in common areas throughout the hospital, along with brochures and the program is detailed on our Bon Secours website. In addition, patient billing statements and letters inform patients regarding our financial assistance program. Bon Secours proactively screens patients to identify individuals and their families who may qualify for federal, state or local health insurance programs or the Bon Secours Patient Financial Assistance Program ("FAP") and assist the potential eligible patients through the qualification process. Potentially eligible patients that do not qualify for a federal or state health insurance program are referred to the Financial Assistance Coordinator located in Patient Financial Services for assistance in completing the documentation required to establish FAP eligibility. Bon Secours is also dedicated to meeting the needs of non-English speaking patients by having on-site Spanish translators, and other language translation services. In addition, Bon Secours employs a telephone language service which assists in meeting any language needs that arise. The translation services are offered to non-English speaking patients from admission to discharge, including the financial assistance process. Based on market need, our financial assistance policy and application are translated into multiple languages and placed on our Bon Secours website for patients to access. Part VI, Line 4: Our Lady of Bellefonte Hospital and related entities serve a region of approximately 400,000 people in northeastern Kentucky, southern Ohio, and western West Virginia. The service areas include six counties in northern Kentucky (Greenup, Boyd, Lawrence, Carter, and Elliott) which comprises of the FIVCO Area Development District as well as Lewis County, two counties in southern Ohio (Lawrence, and Scioto) and Wayne and Cabell counties in western West Virginia. Due to our growing aging population, services for our community residents aged 55 and older are needed, particularly women's health, orthopedics, diabetes, cardiopulmonary services, cancer, drug rehab and wound care. According to the 2017 County Health rankings data, the counties in OLBH primary service area rank among the highest in the state at risk for poor health outcomes and poor health factors. Consistent with the state and national trends, five chronic diseases account for most of the spending on health care: diabetes, heart disease, hypertension, asthma and depression. Prescription drug abuse and addiction is a growing problem in the area, as is illegal drug use including heroine, methamphetamine and marijuana. Access to quality preventative care and disease management education is critical in minimizing future hospitalizations. Health insurance coverage is also a factor in determining whether patients will seek preventative care or wait for symptoms to become more severe, thus requiring more extensive treatments, including hospitalization. The area's growing drug addiction problems puts these individuals more at risk for depression, suicides and kidney failure. The area's population of drug abuse by all ages is growing at a relatively fast pace and will necessitate planning of and access to health care services unique to this population. There are few exceptions to our local community versus state averages with regard to health impacts. Our service area has higher overall cancer rates in lung cancer than the state average. Other cancers that are prevalent in our primary and secondary service areas are breast, colon, bladder, prostate and lymphoma. Part VI, Line 5: The organization has an open medical staff with privileges available to all qualified physicians in the area. Bon Secours Kentucky Health System is governed by a board of directors whose composition is representative of the community it serves. OLBH has been instrumental in developing and collaborating with other local agencies on programs to meet the needs of uninsured and low income families. OLBH also supports van ministry that provides free non-emergency medical transportation for outpatient services at our campus, primary care centers and other service areas. Our staff organizes and chairs the Greenup County Interagency Council. We have partnerships with 54 churches to conduct health ministry and/or faith community nursing programs.Healthy Choices Healthy Communities coalition: This coalition is tackling obesity, substance abuse, poverty, and access to care issues in our communities. OLBH Green Team: The OLBH Green Team has implemented recycling programs (plastic, aluminum, electronics, printer cartridges and toners, cardboard, batteries, etc.) that offer the opportunity for our community residents to be better stewards of our earth and live in a healthier environment. In 2016, the team took on the project of adding rain barrels to a walking trail on our campus that provides an opportunity for employees and community residents to walk, garden (adopt-a-flower-bed program) or just enjoy nature. The team also operates a clothing closet, has regular clean-up days for our campus and participates in Cell Phones for Soldiers by donating old cell phones to provide talk time for American military personnel around the world. We also have an E-recycling drop off site for the community and recycling for Christmas lights. Part VI, Line 6: Bon Secours Health System, Inc., a Maryland nonprofit, nonstock membership corporation (BSHSI), and all of the other entities that are controlled directly or indirectly by Bon Secours, Inc., a Maryland nonprofit, nonstock membership corporation (BSI) are described collectively as the System. BSI, which is the sole corporate member of BSHSI, has no healthcare operations. The System was organized in June 1983 to fulfill the healthcare mission of the United States Province of the Congregation of the Sisters of Bon Secours of Paris, a congregation of religious women of the Roman Catholic Church founded in France in 1824. The System's activities are in the states of New York, Pennsylvania, Maryland, Virginia, Kentucky, South Carolina, and Florida, each referred to as a local system. The Ministry of BSHSI aids those in need, particularly those who are sick and dying, by offering services that include but are not limited to acute inpatient, outpatient, pastoral, palliative, home health, nursing home, rehabilitative, primary and secondary care and assisted living without regard to race, religion, color, gender, age, marital status, national origin, sexual orientation, or disability. As a member of the Catholic health ministry and a member of Bon Secours Health System, Inc. (BSHSI), this organization and its related entities are called to continue the healing ministry of Jesus. We exist to benefit the people living in the communities it serves. Through all of the services offered to the community, the mission is "to bring compassion to health care and to be good help to those in need, especially those who are poor and dying. As a System of caregivers, we commit ourselves to help bring people and communities to health and wholeness as part of the healing ministry of Jesus Christ and the Catholic Church." This organization and related organizations share the BSHSI Vision. BSHSI's vision to partner with communities to create a more humane world, build social justice for all and provide exceptional value for those served is implemented through its Strategic Quality Plan which provides focus in four goal areas for the current three year period (2016-2018). - Co-Create Healthy Communities: We recognize that the factors which drive health outcomes extend well beyond the scope of traditional health care services. Thus, we commit to improve the health of communities through partnership and collaboration with a broad range of constituencies including committed community residents - Be Person Centric: We recognize that those whom we serve are increasingly engaged in their own care and are seeking convenience, affordability and reliability. Thus, we commit to anticipate and respond to the changing expectations of health care consumers, and to ensure that we engage each person in an individualized plan for health with a focus on prevention and wellness. - Serve Those Who Are Vulnerable: We recognize, by our Catholic identity, that the struggle for a more humane world is not an option, but an integral part of spreading the gospel. Thus, we commit to serve those who are vulnerable in many ways, addressing health disparities, sustaining global ministries, healing the environment and working to end violence and oppression.- Strengthen Our Culture and Capabilities: We recognize that the health care delivery system is undergoing rapid change with increasing complexity. Thus, we commit to liberate the potential of our people by strengthening individual and collective capabilities with respect to ministry leadership, knowledge, analytics, innovation and finances. Please see Schedule R for listings of the related organizations. Each of the reported entities play a role in achieving the vision of BSHSI and the SQP (Strategic Quality Plan). Part VI, Line 7, Reports Filed With States KY 1 Bon Secours Kentucky Health System Foundation Inc St Christopher Drive Ashland KY 41101 611381952 501(c)(3) 576581 General and Administrative Support 1 0 Part I, Line 2: The organization complies with Bon Secours Health System, Inc.'s system-wide financial and accounting policies. Contributions are generally made as reimbursements for funds spent. In such cases, the donee/grantee organization must provide documentation to the filing organization before funds are approved for disbursement. Grant administration is maintained within the Foundation arm and received by the hospital as reimbursement for spend. 0 1 0 0 0 0 0 0 0 Kevin Halter FACHE CEO - BSKY 0 358895 0 41539 0 52127 0 29714 0 26692 0 508967 0 8326 Kevin Howard Board Member (Jan-Aug) 175025 0 7866 0 155 0 0 0 17424 0 200470 0 0 0 Andrea Mazzoccoli PhD Board Member 0 407244 0 97555 0 80616 0 62355 0 20976 0 668746 0 36954 Thomas Morris PhD President 0 336400 0 81600 0 46396 0 61346 0 20913 0 546655 0 21104 Pam Phillips Board Member 0 160241 0 38357 0 29847 0 17282 0 10149 0 255876 0 0 Joe Buchheit Treasurer/CFO-BSKY 236843 0 28648 0 42094 0 4681 0 18061 0 330327 0 0 0 Rodney Hieneman Secretary 153807 0 10742 0 312 0 4738 0 27980 0 197579 0 0 0 John Darnell CMO 250884 0 32819 0 1645 0 6090 0 11790 0 303228 0 0 0 Michele Friday MD Cardiologist 683773 0 172144 0 1581 0 4745 0 28960 0 891203 0 0 0 Yogendra Prasad MD Cardiologist 440517 0 166809 0 1132 0 4622 0 28192 0 641272 0 0 0 Kurt Jaenicke MD Obstetrician 342733 0 240891 0 2384 0 4829 0 19913 0 610750 0 0 0 Phillip Lackey MD Plastic Surgeon 395060 0 500 0 999 0 4617 0 26701 0 427877 0 0 0 Jason Ford MD Pediatrician 142649 0 198080 0 132 0 4652 0 25042 0 370555 0 0 0 John Wallenhorst Former Board Officer 0 300576 0 72652 0 80871 0 24843 0 10645 0 489587 0 24034 Part I, Line 3 Bon Secours Health System, Inc., a related organization of the filing organization, uses the following to establish the compensation of the organization's CEO/Executive Director: Compensation Committee Independent Compensation Consultant Written Employment Contract Compensation Survey or Study Approval by the Board or Compensation Committee Part I, Line 4b The filing organization participates in a BSHSI sponsored executive retirement program that allows for deposits into additional retirement plans and available only to key employees. The 457F plan is a non-qualified plan and is subject to a minimum three-year service requirement before vesting on deposits made into this plan. Individuals that received a distribution include: Kevin Halter, FACHE, $ 9,610; Andrea Mazzoccoli, $37,070; Thomas Morris, PhD, $ 22,519; John Wallenhorst, PhD, $34,685. Judy Houston Sibling of BM, James Payne 84438 Employment 0 Teresa Baron Sibling of BM, James Payne 56960 Employment 0 Form 990, Part VI, Section A, line 6 Bon Secours Health System, Inc. is the sole member of Bon Secours Kentucky Health System, Inc. which in turn is the sole member of Our Lady of Bellefonte Hospital, Inc. Form 990, Part VI, Section A, line 7a The governing body of Our Lady of Bellefonte Hospital, Inc. is appointed by its Member, Bon Secours Kentucky Health System, Inc. and subject to approval by Bon Secours Health System, Inc. Form 990, Part VI, Section A, line 7b Certain authorities of Our Lady of Bellefonte Hospital, Inc. are reserved to its member or to Bon Secours Health System, Inc. Form 990, Part VI, Section B, line 11b The process the organization uses to review the Form 990 consists of a review by the local system's audit and compliance board-committee and providing the form to the local system board of directors to allow for a thorough review by both before the filing date. The local system's audit and compliance committee and board of directors have reviewed the Form 990, scheduled time on meeting agendas, and asked questions regarding the Form 990 before the return is filed. Form 990, Part VI, Section B, line 12c The organization regularly and consistently monitors compliance with the conflict of interest policy. On an annual basis, all persons subject to the policy, including all officers, directors and key employees are required to make certain disclosures. These include disclosures related to certain personal, financial and organizational relationships that may present a conflict, or the appearance of a conflict of interest with the organization. All disclosures go through a three-part review process: (1) disclosures are reviewed first by the corporate responsibility officer (CRO); (2) a governance team comprised of the CEO, board president, board chair, CRO, and the BSHSI CRO participate in a second review of all disclosures during which recommendations are made as to the resolution of any conflicts or potential conflicts. Depending on the facts and circumstances, resolutions may include ongoing disclosure, recusal or removal of the conflict; and (3) all disclosures and recommendations are reviewed by a board committee (audit and compliance committee reviews the disclosures of management and the governance committee reviews the disclosures of the board and board committee members. Form 990, Part VI, Section B, line 15b The compensation committee of the board of Bon Secours Health System, Inc. (BSHSI) engages in a comprehensive process for the oversight and management of remuneration for executive employees and disqualified parties of BSHSI. The compensation committee consists of a group of independent board members and engages an independent external compensation consultant to ensure they receive appropriate analysis of market and follow the practices necessary to obtain full compliance with the IRS's rebuttable presumption of reasonableness. The committee establishes and maintains a compensation philosophy; reviews pay practices against local, regional and national healthcare organizations and approves all remunerative decisions for this group of individuals. The committee reviews and receives assurances that all levels of pay within the organization are reasonable based on performance and validates incentives are met. These decisions are documented in the BSHSI board of directors and compensation committee minutes. Compensation Process Other Officers/Key Employees: For those key employees and highest paid employees that are not reviewed by the BSHSI compensation committee, the process included a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision. In the review, the other officers or key employees of the organization were compared to other hospitals' employees in the area that hold the same title. During the review and approval of the compensation, documentation of the decision was recorded in human resources. Form 990, Part VI, Section C, line 19 Our Lady of Bellefonte Hospital, Inc. provides any documents open to public inspection upon request. Form 990, Part VII - Additional Disclosure: Board Member positions are generally voluntary in nature. Compensated employees of the filing organization and other related organizations who also hold board positions are compensated only in relation to their employment and do not receive additional compensation for their board responsibilities. Form 990, Part XI, line 9: Minimum Pension Liability 3,382,757. Transfer to BSHSI for Swaps & Debt -1,170,982. Miscellaneous Changes in Net Assets -295,697. Eastern Kentucky Quality Alliance LLC 1 St Christopher Drive Ashland KY 41101 822832840 Clinically Integrated Network KY 0 0 Our Lady of Bellefonte Hospital Inc Bon Secours Health System Inc 1505 Marriottsville Road Marriottsville MD 21104 521301088 Parent Org. Management Services MD 501(c)(3) Line 12c, III-FI Bon Secours Inc 0 Bellefonte Physician Services Inc 1000 St Christopher Drive Ashland KY 41101 352320780 Physician Practices KY 501(c)(3) Line 10 Bon Secours Kentucky Health System Inc 0 Bon Secours Kentucky Health System Foundation Inc 1000 St Christopher Drive Ashland KY 41101 611381952 Grant Making Foundation KY 501(c)(3) Line 7 Bon Secours Kentucky Health System Inc 0 Bon Secours Kentucky Health System Inc 1000 St Christopher Drive Ashland KY 41101 611356024 Local System Parent Org. KY 501(c)(3) Line 12c, III-FI Bon Secours Health System Inc 0 Our Lady of Bellefonte Hospital Auxiliary 1000 St Christopher Drive Ashland KY 41101 610488859 Fundraising for Our Lady of Bellefonte Hospital KY 501(c)(3) N/A 0 0 1 1 0 1 0 0 0 0 0 0 0 1 0 0 1 1 1 0