2017-11-14T12:43:36-06:00 2016-12-31 ERNST & YOUNG US LLP 800 YARD ST 200 GRANDVIEW HEIGHTS OH 43212 990 2016-01-01 310536981 GOOD SAMARITAN HOSPITAL % J MICHAEL SIMS GOOD 9374999942 110 N MAIN ST 500 DAYTON OH 45402 TIMOTHY D SNIDER TREASURER / CFO 9374999942 2017-11-08 true DIANE L BEAN P00104972 6142245678 108.206.163.59 31499120173185000005 2017-11-14 P 582F47EFACDD6166E52205D1FBFEA2601660FA18 582F47EFACDD6166E52205D1FBFEA2601660FA18 2016 2021-01-29 14:40:06Z Eloise Broner PresidentCEO 2222 PHILADELPHIA DR DAYTON OH 45406 482168921 false 0928 X WWW.PREMIERHEALTH.COM X 1932 OH WE WILL IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE WITH OTHERS WHO SHARE OUR COMMITMENT TO PROVIDE HIGH-QUALITY, COST-COMPETITIVE HEALTHCARE SERVICES. 8 4 3521 356 251146 -70584 959031 345570 338862036 358470414 9042783 17152792 5213465 4037714 354077315 380006490 2363870 3209492 0 0 154536874 166562040 0 0 0 181444700 208685726 338345444 378457258 15731871 1549232 493068205 374728116 145021154 59164200 348047051 315563916 WE WILL IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE WITH OTHERS WHO SHARE OUR COMMITMENT TO PROVIDE HIGH-QUALITY, COST-COMPETITIVE HEALTHCARE SERVICES. false false 351978453 3209492 358470414 SEE SCHEDULE H 351978453 true true false true false false false false false false true false false true true true false true false false true false false false false false true true true false true false false false false false false true false false false false false true true true true false false true 204 0 true 3521 true true true false false false false false false false false false X 8 4 false true true false true true true true true false false true true true true true true true true true true OH X J MICHAEL SIMS 9374999942 110 N MAIN ST SUITE 500 DAYTON OH 45402 X MARTIN FUJIMURA MD BOARD CHAIR 0.5 0.5 X X 0 0 0 ELOISE P BRONER PRESIDENT & CEO 38.5 1.5 X X 802556 0 36119 CAROL BAUER SC TRUSTEE 39.0 1.0 X 0 0 0 MARY H BOOSALIS TRUSTEE & PREMIER PRESIDENT 7.5 24.5 X 0 0 0 GEORGE T BRODERICK JR MD TRUSTEE 0.5 1.5 X 0 0 0 ANUJ GOYAL MD TRUSTEE & CHIEF OF STAFF 0.5 0.5 X 20000 1425 0 JAMES R PANCOAST TRUSTEE & PREMIER CEO 7.5 8.5 X 0 0 0 LASZLO TOTH MD TRUSTEE 0.5 0.0 X 0 0 0 DALE E CREECH BOARD SECRETARY/SYSTEM VP-CLO 7.5 32.5 X 0 708171 62021 TIMOTHY D SNIDER BOARD TREASURER / CFO 18.5 1.5 X 133804 0 20099 THOMAS R CURTIN SYSTEM VP - REVENUE CYCLE 8.0 31.0 X 0 293603 61061 MARY E GARMAN VP OPERATIONS & CNO 39.5 0.5 X 341896 0 23857 GARY G GINTER SYSTEM VP - CIO 8.0 32.0 X 0 537399 73245 KATHLEEN M HARPER VP HOSPITAL OPERATIONS 40.0 0.0 X 194234 0 27285 BARBARA A JOHNSON SYSTEM VP - HR OPERATIONS 8.0 32.0 X 0 523006 30879 TAMMY S LUNDSTROM MD SYSTEM VP - CMO 8.0 32.0 X 0 716856 59414 THOMAS R PARKER SYS VP-CHF EXPERIENCE OFFICER 7.5 32.5 X 0 496641 54594 CRAIG SELF SYS VP -CHIEF STRATEGY OFFICER 8.0 32.0 X 0 497273 39370 MARK W SHAW SYSTEM VP - MANAGED CARE 8.0 32.0 X 0 458030 61038 SCOTT A SHELTON SYSTEM VP - CPO 8.0 32.0 X 0 358074 32224 SYLVAIN TREPANIER DNP RN CENP SYSTEM VP - CNO 8.0 31.0 X 0 398678 35692 DENA L HELSINGER DEPARTMENT DIRECTOR 40.0 0.0 X 218214 0 24098 FRANK E SAWYER SYS VP - ONCOLOGY SERVICE LINE 39.5 0.5 X 303651 0 34708 LAURA F SITTLER VP - CNO 40.0 0.0 X 214296 0 58329 SHARON K THORNTON SYSTEM VP - ERP OPERATIONS 40.0 0.0 X 228035 0 18668 DARLENE WISEMAN VP FINANCE - SUPPORT SERVICES 40.0 0.0 X 212574 0 37048 RENEE P GEORGE FORMER KEY EMPLOYEE 0.0 40.0 X 0 324102 24786 J NICK LAIR FORMER KEY EMPLOYEE 0.0 40.0 X 0 324961 56822 DANIEL L SCHOULTIES MD FORMER KEY EMPLOYEE 0.0 40.0 X 0 460321 379110 2669260 6098540 1250467 116 true true false DAWSON HEALTHCARE 1114 DUBLIN RD COLUMBUS OH 43215 AGENCY STAFF 9390343 MESSER CONSTRUCTION CO 4801 HEMPSTEAD STATION DR DAYTON OH 45429 CONSTRUCTION 4656930 ANESTHESIA ASSOCIATION OF NW DAYTON 3180 KETTERING BLVD DAYTON OH 45439 MEDICAL SERVICES 4218416 EMERGENCY PROFESSIONAL SERVICES INC PO BOX 634850 CINCINNATI OH 45263 MEDICAL SERVICES 1773914 WENCO CONSTRUCTION CO LLC 1807 DALTON DR NEW CARLISLE OH 45344 CONSTRUCTION 1444419 66 235570 110000 345570 NET PATIENT REVENUE 621110 178334581 178098814 235767 MEDICARE/MEDICAID 621110 155625309 155625309 JOINT OPERATING AGREEMENT 423000 16151000 16151000 FRANCHISE TAX RECOVERIES 812930 8242464 8242464 HEALTH EDUCATION 561499 91006 91006 26054 26054 358470414 3331676 15379 3316297 0 0 5019561 4503611 515950 0 515950 515950 110552137 594608 96839147 486482 13712990 108126 13821116 13821116 0 0 0 0 0 0 426510 333191 93319 93319 CAFETERIA 721110 2377982 2377982 PARKING GARAGE 812930 300505 300505 DISCOUNTS / REBATES 900099 165562 165562 584396 584396 3428445 380006490 358234647 251146 21175127 3209492 3209492 0 0 0 1599850 1459064 140786 0 188695 172090 16605 127863672 116611669 11252003 8211083 7488508 722575 19487333 17772448 1714885 9211407 8400803 810604 4136665 3772638 364027 331947 302736 29211 154771 154771 25532 25532 0 459836 459836 33089895 30177984 2911911 3063758 3063758 1817220 1657305 159915 8332311 7599068 733243 0 5300146 4833733 466413 200617 182963 17654 0 621 566 55 2832039 2832039 0 27700614 25262960 2437654 905534 825847 79687 OPERATING SUPPLIES 69382146 69382146 PENSION SETTLEMENT 20670858 18851822 1819036 PURCHASED SERVICES 18359051 16743455 1615596 HOSPITAL FRANCHISE TAX 5418325 5418325 6503840 5931502 572338 378457258 351978453 26478805 0 17640 17538 11697230 17335268 0 0 54106496 50439667 0 0 0 0 1035262 783320 5959164 5175076 5993308 4003413 527985045 338019268 200946434 189965777 135998165 69239856 32773937 13773753 0 0 3376413 3376413 41164156 20618035 493068205 374728116 24472947 27985549 1408687 846443 1168573 348679 0 0 0 0 0 0 92605491 616899 0 0 25365456 29366630 145021154 59164200 X 348047051 315563916 0 0 0 0 348047051 315563916 493068205 374728116 X 1549232 -6755142 -27277225 X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false true 19322 false false true 6210 25532 false Part II-B, Lines 1F PAYMENTS FOR LOBBYING ACTIVITIES INCLUDE DUES PAID TO GREATER DAYTON AREA HOSPITAL ASSOCIATION, DAYTON DEVELOPMENT COALITION, AMERICAN HOSPITAL ASSOCIATION, AND OHIO HOSPITAL ASSOCIATION. PART II-B, LINE 1I: THE HOSPITAL CONTRACTS WITH A LOBBYIST FOR HEALTHCARE RELATED ISSUES. 7691110 7691110 310103669 190016089 120087580 3400186 3024149 376037 197676512 144979030 52697482 9113568 9113568 189965777 JOINT OPERATING AGREEMENT 16447000 OTHER A/R 2101229 HCAP ACCRUAL 1806408 DEFERRED COMPENSATION 233398 AFFILIATES INVESTMENT 30000 20618035 0 AFFILIATES PAYABLE 15981676 MALPRACTICE INSURANCE 8662283 PENSION OBLIGATION 1115410 SETTLEMENT-3RD PARTY PAYORS 944889 LOAN GUARANTEE & OTHER LTL 746037 WORKERS COMPENSATION RESERVE 658799 CONSTRUCTION RETAINAGE 375079 OTHER 882457 29366630 X PART X, LINE 2: THE FOLLOWING FOOTNOTE IS FROM THE AUDITED COMBINED FINANCIAL STATEMENTS FOR PREMIER HEALTH AND AFFILIATES. SAMARITAN HEALTH PARTNERS IS THE PARENT ORGANIZATION OF GOOD SAMARITAN HOSPITAL (GSH): PREMIER HEALTH (PREMIER), MEDAMERICA HEALTH SYSTEMS (MAHS), ATRIUM HEALTH SYSTEM (AHS), SAMARITAN HEALTH PARTNERS (SHP), AND UVMC have been determined by the Internal Revenue Service to be tax-exempt nonprofit corporations and public charities under Sections 501(c)(3) and 509(a), respectively, of the Internal Revenue Code. As tax-exempt organizations, their income is exempt from federal income tax except to the extent of any unrelated business activities. PREMIER, SHP, AND UVMC ALSO OWN OR CONTROL CERTAIN SUBSIDIARIES, WHICH ARE FOR-PROFIT CORPORATIONS SUBJECT TO FEDERAL INCOME TAXES. Taxes payable at December 31, 2016 and 2015, for such unrelated business activities are not significant. Management annually reviews the tax positions and has determined that there are no material uncertain tax positions. Central America and the Caribbean Investments 1184000 East Asia and the Pacific Investments 4041000 Europe (Including Iceland and Greenland) Investments 9336000 Middle East and North Africa Investments 139000 North America Investments 906000 Russia and the Newly Independent States Investments 348000 South America Investments 766000 South Asia Investments 418000 Sub-Saharan Africa Investments 139000 Central America and the Caribbean Program Services INSURANCE 25000 17302000 17302000 true false true false true false true true true X true X true true false true true 7887000 1806000 6081000 0.01610 72749464 54484464 18265000 0.04830 2952000 2099000 853000 0.00230 83588464 58389464 25199000 0.06670 898411 44411 854000 0.00230 11585000 11585000 0.03060 1921000 1921000 0.00510 14404411 44411 14360000 0.03800 97992875 58433875 39559000 0.10470 432000 432000 0.00110 575 575 34926 34926 0.00010 11500 11500 2300 2300 211795 211795 0.00060 693096 693096 0.00180 true 6267266 0 71625000 84571000 -12946000 X true true SAM NORTH SURG CTR SURGICAL SERVICES 0.8 0.2 1 1 GOOD SAMARITAN HOSPITAL 2222 PHILADELPHIA DR Dayton Ohio OH 45406 WWW.PREMIERHEALTH.COM SEE PART V SECT C X X X X Good Samaritan Hospital 1 false false true X X X X X X X X X 16 true true true true X SEE PART V, SECTION C X true 17 true SEE PART V, SECTION C false true X 200. 400. X X true true X X X true X SEE PART V, SEC C X SEE PART V, SEC C X SEE PART V, SEC C X X X X X X X true X false X X X X true X false false PART V, SECTION B, LINE 1: THE STATE OF OHIO DOES NOT LICENSE HOSPITALS, BUT THE OHIO DEPARTMENT OF HEALTH DOES REGISTER HOSPITALS. AS PART OF THIS REGISTRATION PROCESS, HOSPITALS IN THE STATE OF OHIO ARE REQUIRED TO COMPLETE AND SUBMIT THE ANNUAL HOSPITAL REGISTRATION AND PLANNING REPORT (AHR) EACH CALENDAR YEAR. Good Samaritan's REGISTRATION NUMBER IS 1245. PART V, SECTION B, LINE 5: PARTNERING IN THE DATA REVIEW PROCESS AND IN THE PROCESS FOR IDENTIFYING AND PRIORITIZING COMMUNITY HEALTH NEEDS AND SERVICES WERE THE BOARD OF TRUSTEES AND EXECUTIVE LEADERSHIP OF GOOD SAMARITAN HOSPITAL, The Health Collaborative in Cincinnati, Ohio, Dayton-Montgomery County Public Health Department, Darke County General Health District, Miami County Public Health, and the Greater Dayton Area Hospital Association with its member hospitals. The participating hospitals invited a broad range of nonprofit agencies and organizations, which serve the medically underserved, low-income and minority populations, to attend community meetings and complete surveys. Part V, Section B, LINE 6A & 6B: Good Samaritan Hospital partnered with member hospitals of the Greater Dayton Area Hospital Association, The Health Collaborative in Cincinnati, Ohio, Dayton-Montgomery County Public Health Department, Darke County General Health District, Miami County Public Health, The Greater Dayton Area Hospital Association, Xavier University and an independent consultant to prepare the community health needs assessment. PART V, Section B, LINE 7A & 10A: The website address where the 2016 CHNA and the 2017 Community Health Improvement Plan can be accessed is: http://www.premierhealth.com/Our-Community/Making-a-Difference/ Community-Health-Improvement/ Part V, Section B, Line 11: Good Samaritan Hospital (GSH), as a member of the Premier Health system, was part of a collaboration in 2016 with member hospitals of the Greater Dayton Area Hospital Association, The Health Collaborative in Cincinnati, Ohio, The Greater Dayton Area Hospital Association, Xavier University, Dayton-Montgomery County Public Health Department, Darke County General Health District, Miami County Public Health, and an independent consultant to prepare the community health needs assessment. Based on the results of this assessment, GSH has adopted an implementation strategy to address the following prioritized needs: * Birth Outcomes * Behavioral Health/Substance Abuse * Chronic diseases Health issue: Birth Outcomes -------------- GSH will improve the health and well-being of women and infants with the CenteringPregnancy program. This program is developed by Catholic Social Services and provides group prenatal care and home visits. Lifestages Samaritan Centers for Women operates CenteringPregnancy at GSH and Good Samaritan North Health Center (GSHN). Additional features include screening, brief intervention and referral to treatment (SBIRT), depression screening, and transportation and childcare vouchers. The program targets women who live in the ZIP Codes where the most infant deaths have occurred. This program leverages resources from Lifestages Samaritan Centers for Women, Catholic Social Services of the Miami Valley, Five Rivers Health Center for Womens Health, GSHN, Montgomery County Infant Mortality Coalition, and Ohio Perinatal Quality Collaborative. The Family Birthing Center and Lifestages Samaritan Centers for Woman at GSH work with a team of other community organizations to increase the number of women who breastfeed their babies. The objectives are 1) to increase the frequency of education about breastfeeding before birth, and 2) to provide lactation support after birth. Breastfed children have fewer illnesses and less risk of Sudden Infant Death Syndrome, childhood cancers, and diabetes. Mothers have less risk of breast cancer, ovarian cancer, anemia, and osteoporosis. The family saves money since breast milk is readily available and free. The mother and her significant other or person of choice (grandparent, friend) are encouraged to attend monthly breastfeeding classes. This is important to combat myths that surround breastfeeding. Mothers new to breastfeeding benefit from lactation consulting after birth and at home. GSH has completed 6 of the 10 steps required for recognition through the "Ten Steps for Successful Breasfeeding" promotion by Baby Friendly USA as part of the Ohio First Steps for Healthy Babies, a collaborative of the Ohio Hospital Association and the Ohio Department of Health. Other team members include Premier Community Health, Catholic Social Services of the Miami Valley, WIC, and Ohio First Steps for Healthy Babies. Health issue: Behavioral Health / Substance Abuse ----------------------------------- GSH will provide education that addiction is a disease, and as a result, change perceptions first of hospital personnel and medical professionals, and then of the community. The objectives are 1) to provide CEUs to front-line staff and physicians for education on this topic, with curriculum delivered by ADAMHS, and 2) to educate Health Ministries staff in a 'train the trainer' approach so they can provide training through a network of hundreds of churches. In addition to assistance from the ADAMHS Board, resources will be obtained from Health Ministries, Samaritan Behavioral Health, Inc., physician practices, and local churches. Health issue: Chronic Diseases ---------------- GSH will work with the American Heart Association and The Heart Institute of Dayton to train more people in how to provide CPR through installations of educational kiosks in certain public areas. An interactive kiosk features a touch screen with a video program that gives a brief "how-to" followed by a practice session and a 30-second CPR test. With the help of a rubber torso, the kiosk gives feedback about the depth and rate of compressions and proper hand placement factors that influence the effectiveness of CPR. The kiosk is an interactive training opportunity with no on-site staff. More widespread CPR training is important because only about 46 percent of people who experience an out-of-hospital cardiac arrest get the help they need before the ambulance arrives. Survival rates drop as much as 10 percent for each minute without intervention. The second chronic issue targeted by GSH is food hardships in the community. According to the Food Research & Action Center, Dayton ranked 11th out of 109 metropolitan areas for households experiencing food hardship. To address this need, the hospital will work with other community organizations to increase the amount of healthy food for people with health-related nutritional needs. The short-term objectives are 1) to ensure that all eligible patients are signed up for Supplemental Nutrition Assistance Program (SNAP) and/or Women Infant Children (WIC) food assistance benefits, and 2) to increase the availability of fresh produce in partnership with local food pantries and farmers. The hospital may begin screening for hunger to ascertain the scope of the problem. If determined feasible, GSH, along with its affiliates in Premier Health, would create a food pharmacy, or similar prescription for food program by 2019. A food pharmacy accepts people with a physician referral and offers two to three days worth of food per visit. Patients can return to the food pharmacy once per month for up to six months, at which time they can return to their physician for another referral if they are still in need. Other services may include nutrition counseling, cooking classes, and connection to community resources. GSH will collaborate with Dayton-Montgomery County Food & Hunger Coalition, Catholic Social Services of the Miami Valley Food Pantry, Grace Church, Sinclair College, SNAP, and WIC in this mission. Good Samaritan Hospital is one of five hospitals in the Premier Health system. All five hospitals participated with other health care organizations to create a collaborative Community Health Needs Assessment (CHNA). Based on the results of the Assessment, the five Premier hospitals jointly identified three shared health care need priorities that are critical throughout the Premier service area: Birth Outcomes, Chronic Diseases and Behavioral Health/Substance Abuse. The remaining health care needs identified in the Assessment are shared with many local health departments in our region, as well as state agencies. These include Access to Care, Social Determinants, Provider Shortages, Transportation, Care for Children / Child Health, Immunizations, and Accidents. The leadership of the Premier hospitals recognize no one entity can single-handedly effect dramatic change in all of these serious areas within the three-year timeframe of the CHNA process. Therefore, Premier will direct and focus its resources on the three priorities that are most prevalent in its surrounding communities. PART V, SECTION B, LINE 16 A, B, AND C: The direct website address where a copy of the financial assistance policy (FAP), FAP Applicatio 8 GOOD SAMARITAN NORTH HEALTH CENTER 9000 N MAIN ST DAYTON OH 45415 GENERAL MEDICAL AND SURGICAL GOOD SAMARITAN NORTH SURGERY CENTER 9000 N MAIN ST DAYTON OH 45415 GENERAL MEDICAL AND SURGICAL GOOD SAMARITAN HEALTH CTR-HUBER HEIGHTS 6521 GOOD SAMARITAN WAY BRANDT PIKE HUBER HEIGHTS OH 45424 GENERAL MEDICAL AND SURGICAL GSH Medical Imaging- N Main (closed Apr) 7271 North Main Street Dayton OH 45415 X-Ray GSH Medical Imaging - Needmore 1530 Needmore Road Suite 200 30 Dayton OH 45414 X-ray GSH Medical Imaging - Beavercreek 2619 Commons Blvd - Suite 102 Beavercreek OH 45431 X-Ray GSH Medical Imaging - Greenville 742 Sweitzer Street Suite 3 Greenville OH 45331 Echocardiograms & X-Rays Samaritan SleepDiabetes Center 80 East Woodbury Dayton OH 45415 Joint Sleep & Diabetes Center PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT FOR GOOD SAMARITAN HOSPITAL IS PART OF THE PREMIER HEALTH REPORT (EIN# 31-1446699). PART I, LINE 7: A cost to charge ratio was used to calculate this financial assistance at cost. This calculation takes total operating expenses less other operating revenues divided by total gross revenues. Unreimbursed Medicaid and other means-tested governmental programs were calculated using a cost accounting system. This system addresses all patient segments and includes fully loaded costs. For the remaining items, the organization used specific numbers for expense paid directly for these services. PART I, LINE 7G: Good Samaritan Hospital provides subsidized emergency services by operating a 24-hour emergency room 365 days per year. This emergency room is open to all individuals regardless of their ability to pay. The hospital incurs expenses related to call time and physician subsidies due to the large number of indigent patients coming through the emergency room. For 2016, the amount paid for call and subsidies was $11,585,000. PART II: Good Samaritan Hospital (GSH) is committed to improving the health of the communities it serves through a variety of prevention, health improvement and engagement programs. As part of its overall commitment to the community, GSH focuses on four areas of service: --Investing in the community --Prevention and wellness --Commitment to the under-served --Community engagement Some of the programs supported by GSH during 2016 include: 1) Ongoing efforts to improve the economic condition in Dayton and the Miami Valley. A total of $35,000 was contributed toward a capital campaign project to build and develop a new community center. The center will be located in an under-privileged community where approximately 30% of the families live below the poverty level. The community center will reinforce early learning, inter-generational and family engagement, population health and advocacy and workforce development. 2) Neighborhood revitalization and development through a contribution of $432,000 to the Phoenix Project. The goals of this project are to reduce and deter crime, revitalize the appearance of the neighborhood and activate linkages for physical, mental and social health services. This program also purchases properties in the surrounding area, rehabilitates them and sells them to those in need. 3) Funding of $12,000 towards the economic development and revitalization of an urban community within the hospitals service area. This project includes construction of a performing arts pavilion that will provide free concerts to the surrounding communities. 4) Funding of local charitable organizations through the hospitals Board Charitable Credit Fund. As part of GSH's community partnership activity, board members of the hospital are granted charitable credits to be donated in the name of the board member with priorities to not-for-profit, tax-exempt 501(c)(3) health and human services organizations, arts and culture organizations, as well as other community activities in the hospital systems area. Also suggested are organizations that focus on supporting youth, education, underserved groups, and safe neighborhoods. The amount of support provided in 2016 was $207,000. PART III, LINE 2 & 3: Bad debt expense is incurred when an account is taken out of accounts receivable and turned over to a collection agency. This action may occur if a patient refuses payment arrangements, refuses to apply for financial assistance, and there is not an insurance balance being contended. An account is written off to bad debt after 130 days if an attempt to collect from the patient is made within our collection policy. The collection agency attempts to collect the account in accordance with established guidelines. Collection attempts are ceased and the account returned back to the organization if the patient applies for financial assistance. Any amounts collected from these accounts are credited back against bad debt expense. The organization recognizes that there are accounts written off to bad debt that may have qualified for charity care if the patient had provided the necessary financial information. In order to resolve this, the organization has engaged a third-party vendor to analyze data based on credit scores to reallocate some of this expense to charity care. A representative sample of these accounts is then sent to our third-party vendor who gathers external credit data that presents the account as less than 100% federal poverty level or not enough information (typically indicative of indigent). These accounts are reclassed from bad debt expense to charity expense on our income statement. Any credit score that presents the accounts as greater than 100% federal poverty level remains in bad debt expense. Due to this process, the organization has used best efforts to not report bad debt expense for patients eligible under the organization's charity care policy. PART III, LINE 4: THE ORGANIZATION DOES NOT HAVE A FOOTNOTE IN THE AUDITED FINANCIAL STATEMENTS WHICH DISCUSSES THIS CALCULATION. PART III, SECTION B, LINES 5, 6, AND 7: THE AMOUNTS REPORTED ON LINES 5, 6, AND 7 DO NOT INCLUDE CERTAIN MEDICARE PROGRAM REVENUES AND COSTS, AND THUS DO NOT REFLECT ALL OF THE ORGANIZATION'S REVENUES AND COSTS ASSOCIATED WITH ITS PARTICIPATION IN MEDICARE PROGRAMS. IN ADDITION TO THE AMOUNTS REPORTED ON LINE 5, 6, AND 7, THE ORGANIZATION RECEIVED REVENUE OF $71,874,000 AND INCURRED COST OF $100,928,000, FOR AN ADDITIONAL NET SHORTFALL OF $29,054,000 ASSOCIATED WITH THESE PROGRAMS. BELOW IS A RECONCILIATION OF THE AMOUNTS ASSOCIATED WITH MEDICARE PROGRAMS. ALLOWABLE MEDICARE REVENUE PER MEDICARE COST REPORT IN PART III, SECTION B $71,625,000 MEDICARE REVENUE NOT REPORTED IN PART III, SECTION B $71,874,000 TOTAL MEDICARE ASSOCIATED REVENUE $143,499,000 ALLOWABLE MEDICARE COST PER MEDICARE COST REPORT IN PART III, SECTION B $84,571,000 MEDICARE COST NOT REPORTED IN PART III, SECTION B $100,928,000 TOTAL MEDICARE ASSOCIATED COST $185,499,000 MEDICARE SHORTFALL PER PART III, SECTION B $12,946,000 ADDITIONAL SHORTFALL NOT INCLUDED IN PART III, SECTION B $29,054,000 TOTAL MEDICARE SHORTFALL $42,000,000 PART III, LINE 8: THE ORGANIZATION'S SHORTFALL SHOULD BE CONSIDERED CHARITY CARE BECAUSE IT IS PROVIDING HIGH-QUALITY CARE IN EXCESS OF THE COST TO OUR COMMUNITY RESIDENTS THAT NEED CARE. THE MEDICARE POPULATION AT THE ORGANIZATION IS IN EXCESS OF 52% OF NET PATIENT REVENUE. THE ORGANIZATION USED A COST ACCOUNTING SYSTEM TO CALCULATE THE MEDICARE ALLOWABLE COSTS. PART III, LINE 9B: THE ORGANIZATION MAKES REASONABLE EFFORTS TO DETERMINE WHETHER OR NOT AN INDIVIDUAL IS ELIGIBLE FOR ASSISTANCE UNDER THE STATE OR HOSPITAL FINANCIAL ASSISTANCE POLICY BEFORE ENGAGING IN EXTRAORDINARY COLLECTIVE ACTIONS AGAINST THAT INDIVIDUAL. PATIENTS WHO ARE KNOWN TO QUALIFY FOR FINANCIAL ASSISTANCE ARE OFFERED REASONABLE PAYMENT PLAN ARRANGEMENTS FOR ANY REMAINING BALANCES. ANY THIRD PARTY COLLECTING SELF-PAY RECEIVABLES ON OUR BEHALF IS REQUIRED TO MAKE REASONABLE EFFORTS TO DETERMINE IF THE INDIVIDUAL MEETS THE QUALIFICATIONS OF THE STATE OR OF OUR HOSPITAL FINANCIAL ASSISTANCE PROGRAMS. REASONABLE EFFORTS INCLUDE: A. VALIDATING THAT THE PATIENT OWES THE UNPAID BILLS AND THAT ALL SOURCES OF THIRD PARTY PAYMENT HAVE BEEN IDENTIFIED AND BILLED BY THE HOSPITAL. B. DOCUMENTING THAT THE ORGANIZATION HAS OR HAS ATTEMPTED TO OFFER THE PATIENT THE OPPORTUNITY TO APPLY FOR CHARITY CARE UNDER ITS FINANCIAL ASSISTANCE POLICY. C. DOCUMENTED THAT THE PATIENT DOES NOT QUALIFY FOR FINANCIAL ASSISTANCE. D. DOCUMENT THAT THE PATIENT HAS BEEN OFFERED and accepted TERMS for a payment PLAN, but not honored the terms of that plan. THE FINANCIAL COUNSELORS MEET WITH INPATIENT, OUTPATIENT SELF-PAY, AND OTHER PATIENTS UPON REQUEST WHO MAY NEED FINANCIAL ASSISTANCE. IN ADDITION TO ASSISTING PATIENTS WHO WANT TO APPLY FOR ASSISTANCE THROUGH THE MEDICAID PROGRAM, THE FINANCIAL COUNSELOR WILL PROVIDE THE PATIENT WITH A FINANCIAL ASSISTANCE APPLICATION. PART VI, LINE 2: The organization works with the community on programs that address the underlying causes of persistent health problems as part of a comprehensive strategy to improve the health status and quality of life for identified members of the community who are economically disadvantaged, disenfranchised and/or who have disproportionate unmet health needs. The organization strives to work with Premier Health, the THE GOOD SAMARITAN HOSPITAL Board of Trustees, executive management, managers, staff members, community groups, and individuals to provide a collaborative approach to the governance and management of community benefit activities. PART VI, LINE 3: There are several ways in which our organization informs and educates patients who may be billed for services about eligibility for assistance under federal, state, or local government programs, or under the hospital's financial assistance policy. First, notification of true FIVE RIVERS HEALTH CENTERS 2261 PHILADELPHIA DR DAYTON OH 45406 450914398 501(C)(3) 1772196 SUPPORT CITYWIDE DEVELOPMENT CORP 8 N MAIN ST DAYTON OH 45402 310821189 501(C)(4) 432000 COMMUNITY DEVELOPMENT PREMIER COMMUNITY HEALTH co Fidelity Health Care 3170 KETTERING BLVD Dayton OH 45439 311122883 501(C)(3) 240148 COMMUNITY HEALTH MIAMI VALLEY HOSPITAL 110 N MAIN ST 500 DAYTON OH 45402 310537504 501(C)(3) 37483 AFRICAN AMERICAN WOMEN'S HEALTH PROGRAM OMEGA COMMUNITY DEVELOPMENT 1800 HARVARD BLVD DAYTON OH 45406 311561713 501(C)(3) 34500 CAPITAL RENOVATION CATHOLIC SOCIAL SERVICES 922 W RIVERVIEW AVE DAYTON OH 45402 310536968 501(C)(3) 31246 SUPPORT REACH OUT MONTGOMERY COUNTY 25 E FORAKER ST DAYTON OH 45409 311434282 501(C)(3) 32479 RX ASSISTANCE FOR INDIGENT GALA OF HOPE FOUNDATION - 3500 PENTAGON BLVD 500 BEAVERCREEK OH 45431 464277044 501(C)(3) 23000 SUPPORT GOODWILL EASTER SEALS MIAMI VALLEY 660 S MAIN ST DAYTON OH 45402 310537112 501(C)(3) 17710 SUPPORT THE DAYTON FOUNDATION 40 N MAIN ST 500 DAYTON OH 45423 316027287 501(C)(3) 11500 SUPPORT DAYBREAK 605 S PATTERSON BLVD DAYTON OH 45402 310864474 501(C)(3) 11373 SUPPORT DAYTON ART INSTITUTE 456 BELMONTE PARK N DAYTON OH 45405 310537480 501(C)(3) 11638 SUPPORT EQUITAS HEALTH 15 W FOURTH ST DAYTON OH 45402 311126780 501(C)(3) 11500 SUPPORT PROJECT HOPE 1510 N MAIN ST DAYTON OH 45405 341421548 501(C)(3) 11900 SUPPORT GOOD SAMARITAN HOSPITAL FOUNDATION - DAYTON 110 N MAIN ST 500 DAYTON OH 45402 237296923 501(C)(3) 16575 SUPPORT BIG BROTHERS BIG SISTERS 22 S JEFFERSON ST DAYTON OH 45402 310641306 501(C)(3) 5345 SUPPORT SAINT PETER CATHOLIC CHURCH 6161 CHAMBERSBURG RD HUBER HGHTS OH 45424 310626310 501(C)(3) 20250 SUPPORT 16 1 SCHEDULE I, PART I, LINE 2: 1) DISBURSEMENTS ARE ANALYZED MONTHLY THROUGH VARIOUS REPORTS AND COMMITTEE MEETINGS. 2) INVOICES ARE RECEIVED IN ACCOUNTS PAYABLE AND APPROVED AND DISBURSED PER ORGANIZATIONAL POLICY. 3) GRANT SPENDING IS MONITORED AGAINST BUDGETED AMOUNTS ON AN ONGOING BASIS. X X X X true true false false false false false false false ELOISE P BRONER PRESIDENT & CEO 429630 0 186519 0 186407 0 33264 0 2855 0 838675 0 0 0 DALE E CREECH BOARD SECRETARY/SYSTEM VP-CLO 0 384517 0 157999 0 165655 0 35724 0 26297 0 770192 0 0 TIMOTHY D SNIDER BOARD TREASURER / CFO 99202 0 34103 0 499 0 7116 0 12983 0 153903 0 0 0 THOMAS R CURTIN SYSTEM VP - REVENUE CYCLE 0 217200 0 73402 0 3001 0 31381 0 29680 0 354664 0 0 MARY E GARMAN VP OPERATIONS & CNO 275964 0 63306 0 2626 0 11676 0 12181 0 365753 0 0 0 GARY G GINTER SYSTEM VP - CIO 0 371557 0 162212 0 3630 0 47670 0 25575 0 610644 0 0 KATHLEEN M HARPER VP HOSPITAL OPERATIONS 173715 0 19643 0 876 0 4581 0 22704 0 221519 0 0 0 BARBARA A JOHNSON SYSTEM VP - HR OPERATIONS 0 358532 0 148857 0 15617 0 21090 0 9789 0 553885 0 0 TAMMY S LUNDSTROM MD SYSTEM VP - CMO 0 511262 0 200578 0 5016 0 57992 0 1422 0 776270 0 0 THOMAS R PARKER SYS VP-CHF EXPERIENCE OFFICER 0 369275 0 103016 0 24350 0 42604 0 11990 0 551235 0 0 CRAIG SELF SYS VP -CHIEF STRATEGY OFFICER 0 361101 0 134279 0 1893 0 12640 0 26730 0 536643 0 0 MARK W SHAW SYSTEM VP - MANAGED CARE 0 297362 0 94038 0 66630 0 35596 0 25442 0 519068 0 0 SCOTT A SHELTON SYSTEM VP - CPO 0 241172 0 85638 0 31264 0 28797 0 3427 0 390298 0 0 SYLVAIN TREPANIER DNP RN CENP SYSTEM VP - CNO 0 317525 0 78603 0 2550 0 9718 0 25974 0 434370 0 0 DENA L HELSINGER DEPARTMENT DIRECTOR 186246 0 27351 0 4617 0 20105 0 3993 0 242312 0 0 0 FRANK E SAWYER SYS VP - ONCOLOGY SERVICE LINE 232260 0 70795 0 596 0 9389 0 25319 0 338359 0 0 0 LAURA F SITTLER VP - CNO 42421 0 14532 0 157343 0 39288 0 19041 0 272625 0 0 0 SHARON K THORNTON SYSTEM VP - ERP OPERATIONS 162915 0 47539 0 17581 0 9525 0 9143 0 246703 0 0 0 DARLENE WISEMAN VP FINANCE - SUPPORT SERVICES 171709 0 39990 0 875 0 17736 0 19312 0 249622 0 0 0 RENEE P GEORGE FORMER KEY EMPLOYEE 0 248408 0 74875 0 819 0 12854 0 11932 0 348888 0 0 J NICK LAIR FORMER KEY EMPLOYEE 0 221875 0 74484 0 28602 0 25951 0 30871 0 381783 0 0 DANIEL L SCHOULTIES MD FORMER KEY EMPLOYEE 0 311772 0 53204 0 95345 0 351801 0 27309 0 839431 0 0 Part I, Line 4A: THE FOLLOWING INDIVIDUAL ELECTED TO PARTICIPATE IN A VOLUNTARY RETIREMENT PROGRAM, AND RECEIVED THE FOLLOWING PAYMENTS: DANIEL SCHOULTIES, M.D. $13,730 IN 2016 AND WILL RECEIVE $343,260 IN 2017; SEVERANCE PAYMENTS WERE MADE TO THE FOLLOWING INDIVIDUAL: LAURA SITTLER $157,152 IN 2016 AND WILL RECEIVE $39,288 IN 2017. PART I, LINE 4B: DUE TO RESTRICTIONS IMPOSED BY THE INTERNAL REVENUE CODE, CERTAIN PERSONS ARE LIMITED IN THE AMOUNT OF BENEFIT THAT CAN BE EARNED UNDER A QUALIFIED RETIREMENT PLAN. LIKE MANY EMPLOYERS, GOOD SAMARITAN HOSPITAL (GSH) AND ITS AFFILIATED ORGANIZATIONS COMPENSATE FOR THIS LIMITATION AND SUPPLEMENT THE AFFECTED EXECUTIVES' QUALIFIED PENSION THROUGH CERTAIN NONQUALIFIED PLANS. GSH SUPPLEMENTS THROUGH A PENSION RESTORATION PLAN AND A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). THE BENEFITS UNDER THESE SUPPLEMENTAL NONQUALIFIED PLANS ARE SUBJECT TO MULTI-YEAR VESTING AND A PARTICIPANT CAN FORFEIT BENEFITS EARNED IF VESTING REQUIREMENTS ARE NOT SATISFIED. UNDER THE TERMS OF THE SUPPLEMENTAL PLANS, AND BECAUSE OF TAX RULES PERTAINING TO TAXATION OF THE EARNED BENEFITS UPON VESTING, CERTAIN INDIVIDUALS RECEIVED A PAYOUT OF THE CUMULATIVE VESTED BENEFITS UNDER THEIR SUPPLEMENTAL PLAN DURING 2016. THE INDIVIDUALS LISTED BELOW HAVE MET THE MULTI-YEAR VESTING REQUIREMENT UNDER THE PENSION RESTORATION PLAN AND RECEIVED THE ASSOCIATED PAYMENT IN 2016: ELOISE BRONER $164,035; DALE CREECH $159,735; J. NICK LAIR $9,782; MARK SHAW $53,557; SCOTT SHELTON $28,038. THE INDIVIDUALS LISTED BELOW HAVE MET THE MULTI-YEAR VESTING REQUIREMENT UNDER THE SERP AND RECEIVED THE ASSOCIATED PAYMENTS IN 2016: BARBARA JOHNSON $10,303; DANIEL SCHOULTIES M.D. $19,953. In addition, the following SERP amounts were deferred on the participants behalf during the year and will be held until the incremental amounts are vested and paid to the SERP participants: Thomas Curtin $1,493; Mary Garman $1,275; Renee George $1,610; Gary Ginter $18,847; Barbara Johnson $10,811; Tammy Lundstrom, M.D. $49,100; Thomas Parker $14,575; Daniel Schoulties, M.D. $1,843; Craig Self $1,462. BASED ON THE GUIDANCE PROVIDED IN THE INSTRUCTIONS TO THE FORM 990, ANY PAYMENTS TO THE PARTICIPANTS RELATED TO THESE PLANS THAT WERE MADE WITHIN 2-1/2 MONTHS AFTER THE END OF THE ORGANIZATION'S TAX YEAR ARE NOT TREATED AS DEFERRED COMPENSATION FOR PURPOSES OF SCHEDULE J. SUCH AMOUNTS ARE PROPERLY REPORTED AS COMPENSATION FOR FORM 990 PURPOSES WHEN INCLUDED IN THE PARTICIPANTS' FORM W-2 WAGES. ANY PAYMENTS MADE AFTER THE 2-1/2 MONTHS WERE PROPERLY REPORTED ON PRIOR YEARS' FILED IRS FORM 990 RETURNS, DISCLOSING COMPENSATION EARNED BY THESE INDIVIDUALS UNDER THE PLANS FOR EACH SUCH YEAR. Thomas R Parker Wife 188695 Salary false FORM 990, PART VI, SECTION A, LINE 3: Premier Health (Premier), as the operator of Good Samaritan Hospital (GSH), develops and oversees the implementation of the strategic plan for GSH, which includes (but is not limited to) such matters as location of clinical and administrative expenses and the consolidation of such services. GSH shall comply with and implement this plan and shall not take any action that materially departs from this plan without Premier's approval. GSH shall implement any capital and operating budget so approved and/or revised for it by Premier. GSH shall implement the business plan approved by Premier. Premier is the sole agent to negotiate all relationships with payors on behalf of GSH with all third-party payors and alternative delivery systems including, but not limited to insurers. GSH must have approval from Premier to borrow in any fiscal year, guarantee in any year, or incur any lien or other encumbrance on any property in an amount equal to or greater than $1,000,000. GSH must seek Premier's approval for any acquisitions, sale or transfer of any material asset used in Premier's activities. FORM 990, PART VI, SECTION A, LINE 4: In 2016, Good Samaritan Hospitals (GSH) Code of Regulations were modified. Listed below are the significant changes: 1) The Board of Trustees will be comprised of the President & CEO of Premier Health (or designee), the President & CEO of GSH, and the President of the Medical Staff of GSH; all as Ex-Officio members with vote. In addition, at least one "At Large" executive from either Premier Health or GSH and at least two "At Large" physicians from the Medical Staff shall be nominated. There shall always be one more physician than executive on the Board of Trustees. 2) Officers of the Corporation shall be Chair of the Board of Trustees, President & CEO, Secretary, Treasurer, Assistant Secretary(ies) and Assistant Treasurer(s). 3) Committee members shall be appointed by the Chair of the Board of Trustees. 4) An attendance requirement was added for the Trustees, requiring at least 75% attendance of the Board meetings. If this requirement is not met, the Trustee is considered to have resigned. In addition, the Trustees must attend at least 75% of each meeting, with an exception for physicians addressing urgent patient care needs. In such an event, the physician must attend at least 50% of the meeting to be considered present. 5) The Executive Committee may exercise the full powers, duties, responsibilities and authority of the Board of Trustees, except where prohibited by law, and provide written reports to the Board of Trustees of all actions taken on the Boards behalf. All actions taken by the Executive Committee must be by unanimous vote. 6) Successors to Board vacancies are selected by the Nominating Committee of GSHs Board of Trustees and approved by Samaritan Health Partners (the parent of GSH). 7) The Board of Trustees may designate the formation of auxillary organization(s). 8) In the event of dissolution of GSH, the Board of Trustees shall distribute the assets of GSH first to Samaritan Health Partners, followed by other local charitable tax-exempt organizations. Any remaining assets shall be disposed of by a local court. Premier Health has no right as a Co-Member of GSH to receive any distribution of property upon dissolution of GSH. FORM 990, PART VI, SECTION A, LINE 6: GOOD SAMARITAN HOSPITAL HAS TWO CORPORATE MEMBERS. ONE MEMBER IS SAMARITAN HEALTH PARTNERS. THE SECOND MEMBER IS PREMIER HEALTH (PREMIER), AN OHIO NON-PROFIT CORPORATION FORMED PURSUANT TO THE JOINT OPERATING AGREEMENT. SAMARITAN HEALTH PARTNERS HAS THE SOLE AUTHORITY TO ELECT THE BOARD OF TRUSTEES OF THE CORPORATION. PREMIER HAS THE GENERAL AUTHORITY TO OPERATE AND MANAGE THE OPERATIONAL ACTIVITIES OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A & 7B: Samaritan Health Partners (SHP) has the sole authority to elect the Board of Trustees for Good Samaritan Hospital from among those recommended by the nominating committee set forth in the Joint Operating Agreement. SHP has the authority to remove such trustees at any regular or special meeting or by written consent. FORM 990, PART VI, SECTION B, LINE 11B: THIS 990 TAX RETURN AND ATTACHED SCHEDULES (THE RETURN) ARE PREPARED BY A STAFF MEMBER IN THE TAX DEPARTMENT OF PREMIER HEALTH (PREMIER), WITH WHICH GOOD SAMARITAN HOSPITAL IS AN AFFILIATE. THE RETURN IS REVIEWED BY THE TAX MANAGER AND THE DIRECTOR OF TAX COMPLIANCE OF PREMIER. THE RETURN IS CONCURRENTLY SENT TO ERNST & YOUNG U.S. LLP FOR THEIR REVIEW. AFTER ALL CHANGES FROM THE ABOVE GROUPS ARE MADE, THE RETURN IS REVIEWED BY THE VICE PRESIDENT/CONTROLLER OF PREMIER AND THE CHIEF FINANCIAL OFFICER OF THIS ENTITY. A FINAL VERSION OF THE RETURN IS SENT TO ERNST & YOUNG U.S. LLP FOR A FINAL REVIEW AND THEN PROVIDED TO THE BOARD OF TRUSTEES FOR REVIEW. AT THE BOARD OF TRUSTEES MEETING, THE VICE PRESIDENT/CONTROLLER OF PREMIER (OR DESIGNEE) SHARES DETAILED INFORMATION ON COMPENSATION AND OTHER KEY AREAS, AS WELL AS ADDRESS ANY OTHER QUESTIONS FROM THE BOARD OF TRUSTEES, PENDING THEIR REVIEW. THE 990 TAX RETURN IS ALSO SHARED WITH THE AUDIT COMMITTEE OF PREMIER. FORM 990, PART VI, SECTION B, LINE 12C: PREMIER HEALTH (PREMIER), OF WHICH GOOD SAMARITAN HOSPITAL IS AN AFFILIATE, REQUIRES ALL BOARD MEMBERS, OFFICERS, EXECUTIVE DIRECTORS, VICE PRESIDENTS, DIRECTORS, PURCHASING DEPARTMENT STAFF, AUTHORIZED PURCHASERS, MEDICAL DIRECTORS, DEPARTMENT AND SECTIONS CHAIRS, AND ALL EMPLOYED PHYSICIANS TO ANNUALLY REVIEW THE PREMIER COMPREHENSIVE CONFLICT OF INTEREST STATEMENT, AN EXPLANATORY MEMORANDUM, THE ANTITRUST COMPLIANCE POLICY, AND COMPLETE AN INDIVIDUAL QUESTIONNAIRE DISCLOSING ANY POTENTIAL CONFLICTS AS DEFINED IN THE CONFLICT OF INTEREST POLICY. THIS IS ACCOMPLISHED EITHER BY WAY OF AN ELECTRONIC COMMUNICATION SENT OUT DIRECTLY BY THE CORPORATE COMPLIANCE DEPARTMENT OR BY WAY OF A MEMO SENT OUT FROM THE CHAIRMAN OF THE BOARD AND CHIEF EXECUTIVE OFFICER OF PREMIER. IT ALSO INCLUDES AN EXPLANATORY MEMORANDUM OF SPECIFIC ACTIVITIES THAT MIGHT GIVE CAUSE TO A CONFLICT AND AN INDIVIDUAL QUESTIONNAIRE TO DISCLOSE ALL SUCH ACTIVITIES. THIS QUESTIONNAIRE MUST BE COMPLETED AND SIGNED BY THE INDIVIDUAL. THIS CORRESPONDENCE INCLUDES A COPY OF THE ANTITRUST COMPLIANCE POLICY THAT MUST BE SIGNED BY THE INDIVIDUAL. ALL OF THESE DOCUMENTS ARE SENT TO THE CORPORATE COMPLIANCE DEPARTMENT. THE CORPORATE COMPLIANCE DEPARTMENT ENSURES ALL FORMS ARE RETURNED AND RETAINS THE DOCUMENTS FOR FIVE YEARS. IN ADDITION, AT EACH MEETING OF THE BOARD OR ANY BOARD COMMITTEE, FOLLOWING APPROVAL OF THE PREVIOUS MEETING'S MINUTES, THE BOARD OR COMMITTEE CHAIR SHALL REQUEST ANY BOARD MEMBER WHO PERCEIVES A POTENTIAL CONFLICT OF INTEREST ON ANY OF THE MEETING'S AGENDA ITEMS TO DISCLOSE THE POTENTIAL CONFLICT. ADDITIONALLY, AT ANY BOARD OR BOARD COMMITTEE MEETING WHERE THE SUBJECT OF CONFLICT OF INTEREST IS DISCUSSED, THE MINUTES SHALL CONTAIN THE NAME OF THE PARTY DISCUSSING A POTENTIAL CONFLICT OF INTEREST, THE NATURE OF THE POTENTIAL CONFLICT OF INTEREST AND WHETHER A CONFLICT OF INTEREST WAS FOUND TO EXIST. IF A CONFLICT OF INTEREST IS DETERMINED BY THE BOARD TO EXIST, THE MEMBER WILL BE EXCUSED FROM PARTICIPATING IN ANY DISCUSSION OR VOTING ON THE PARTICULAR AGENDA ITEM. THE CHIEF COMPLIANCE AND ENTERPRISE RISK OFFICER REPORTS THE RESULTS OF THE PREMIER CONFLICT OF INTEREST QUESTIONNAIRES NO LESS THAN ANNUALLY TO THE BOARD OF TRUSTEES BY WAY OF THE COMPLIANCE AND AUDIT COMMITTEE. THIS REVIEW IS DOCUMENTED IN THE MINUTES OF THE MEETING. PERIODICALLY, THE INTERNAL AUDIT DEPARTMENT WILL REVIEW A SAMPLE OF COMPLETED CONFLICT OF INTEREST QUESTIONNAIRES AND REPORT THE RESULTS TO THE COMPLIANCE AND AUDIT COMMITTEE. THE ANNUAL CONFLICT OF INTEREST QUESTIONNAIRES ARE INDIVIDUALLY SUMMARIZED IN A DOCUMENT AND SENT ELECTRONICALLY TO THE FINANCE DEPARTMENT FOR ANY NECESSARY DISCLOSURES REQUIRED ON THE 990 TAX RETURN. FORM 990, PART VI, SECTION B, LINES 15A AND 15B: COMPENSATION FOR GOOD SAMARITAN HOSPITALS (GSH) CEO IS REVIEWED AND APPROVED BY PREMIER HEALTH (PREMIER), WITH WHICH GSH IS AN AFFILIATE, ON AN ANNUAL BASIS. THE REVIEW PROCESS PERFORMED BY PREMIER FOLLOWS A MARKET BASED COMPENSATION PHILOSOPHY DESIGNED TO ATTRACT AND RETAIN THE EXECUTIVE TALENT REQUIRED TO MEET THE HIGH-PERFORMANCE STANDARDS OF OUR BOARD AND OUR COMMUNITY. PREMIER ANNUALLY REVIEWS EXECUTIVE COMPENSATION SURVEY DATA FOR A REGIONAL PEER GROUP OF SYSTEMS AND HOSPITALS THAT ARE SIMILAR IN SIZE AND COMPLEXITY TO PREMIER AND ITS AFFILIATES. THE DATA FOR THE SURVEY IS PROVIDED BY A THIRD-PARTY CONSULTANT GROUP THAT IS INDEPENDENT OF PREMIER. THIS REPORT INCLUDES COMPARABILITY FOR KEY EXECUTIVES, VICE PRESIDENTS, AND DIRECTOR LEVEL POSITIONS. THE INDEPENDENT COMPARABILITY DATA IS REVIEWED BY THE EXECUTIVE COMPENSATION COMMITTEE ON AN ANNUAL BASIS. THIS COMMITTEE IS COMPRISED OF THREE MEMBERS, ALL OF WHOM ARE INDEPENDENT. THIS COMMITTEE REVIEWS IN DETAIL THE COMPENSATION FOR THE PREMIER CEO, COO, CFO, CHIEF STRATEGY OFFICER, CHIEF INTEGRATION OFFICER AND THE HOSPITAL CEOS. OTHER POSITIONS ARE REVIEWED AT A HIGH LEVEL FOR REASONABLENESS. ALL THE MEETING MINUTES ARE DOCUMENTED AND KEPT ON FILE ALONG WITH ANY COMPARABILITY DATA AND THE CONSULTANT REPORT. AFTER THE COMPENSATION COMMITTEE REVIEWS AND APPROVES THE COMPENSATION ACTIONS, THE PROCESS IS AUDITED BY THE INTERNAL AUDIT DEPARTMENT. THE EXECUTIVE COMPENSATION COMMITTEE PRESENTS THE COMPENSATION ACTIONS TO THE PREMIER BOARD ANNUALLY. FORM 990, Part VI, Section C, line 19: THE GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC WHEN REQUIRED BY LAW OR FOR ACCREDITATION PURPOSES. THE CONFLICT OF INTEREST POLICY IS AVAILABLE ON WWW.PREMIERHEALTH.COM. FORM 990, PART XI, LINE 9: EQUITY TRANSFERS $(19,319,718) PHIC EQUITY TRANSFER $(15,668,000) PHO EQUITY TRANSFER $(8,780,000) PHG EQUITY TRANSFER $(578,286) FOUNDATION ADJUSTMENT $(235,570) TRANSFER FROM AFFILIATE $130,758 JOA DIALYSIS CENTER SALE $296,000 MINORITY INTEREST DISTRIBUTION $487,040 DISTRIBUTIONS TO PARENT $5,080,000 PENSION FUND ADJUSTMENT $11,310,551 TOTAL $(27,277,225) SAMARITAN HEALTH PARTNERS (SHP) 110 N MAIN ST 500 DAYTON OH 45402 311107411 PARENT OH 501(c)(3) 12C III FI NA false PREMIER HEALTH 110 N MAIN ST 500 DAYTON OH 45402 311446699 SUPPRTG. ORG. OH 501(c)(3) 12A I NA false GOOD SAMARITAN HOSPITAL FOUNDATION-DAYTO 110 N MAIN ST 500 DAYTON OH 45402 237296923 FOUNDATION OH 501(c)(3) 7 SHP true CATHOLIC HEALTH INITIATIVES 198 INVERNESS DR W 500 ENGLEWOOD CO 80112 470617373 PARENT CO 501(c)(3) 10 NA false THE HEART INSTITUTE OF DAYTON 110 N MAIN ST 500 DAYTON OH 45402 300502367 EDUCATION OH 501(c)(3) 10 SHP true SAMARITAN BEHAVORIAL HEALTH INC 601 EDWIN C MOSES BLVD DAYTON OH 45417 020633634 Behavorial He OH 501(c)(3) 7 SHP true SAMARITAN NORTH SURGERY CENTER 9000 N MAIN ST DAYTON OH 45415 311618587 O/P SURGERY OH GSH RELATED 5028964 4104602 false 0 true 0.80000 true true true false false true false false false false false false false false false true true true false GOOD SAMARITAN HOSPITAL FOUNDATION - DAYTON C 366328 CASH GOOD SAMARITAN HOSPITAL FOUNDATION - DAYTON Q 613176 CASH SAMARITAN BEHAVIORAL HEALTH INC Q 198479 CASH CATHOLIC HEALTH INITIATIVES R 3701000 FMV PREMIER HEALTH B 277210 FMV SAMARITAN NORTH SURGERY CENTER A-IV 1045555 Cash SAMARITAN NORTH SURGERY CENTER F 5080000 Cash SAMARITAN NORTH SURGERY CENTER B 487040 Cash THE HEART INSTITUTE OF DAYTON Q 1021527 CASH