2017-07-10T09:44:13-05:00 2016-08-31 861065772 Deloitte Tax LLP 191 Peachtree St Suite 2000 Atlanta GA 303031749 990 2015-09-01 611356023 Our Lady of Bellefonte Hospital Inc OURL 6068333333 St Christopher Drive Ashland KY 41101 Joe Buchheit CFO - BSKHS 6068333600 2017-07-10 1 John W Sadoff Jr P00540589 4042201500 2015 2021-01-29 14:40:06Z Kevin Halter St Christopher Drive Ashland KY 41101 175077177 0 0928 X bonsecours.com X 1999 KY Acute Care Hospital 19 16 1319 65 3744637 662151 2386354 367860 163534004 170895730 563011 640865 3070588 3123969 169553957 175028424 582583 601770 0 0 61271825 63103862 0 0 0 92115449 100665935 153969857 164371567 15584100 10656857 147223745 153602571 72376697 88441278 74847048 65161293 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 152738813 601770 169200434 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. 152738813 1 1 0 1 0 0 0 0 0 0 1 0 0 1 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 1 0 0 0 0 1 0 0 0 1 90 0 1 1319 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 Kevin Halter FACHE CEO - BSKY 20.00 30.00 X X 0 620478 57080 Lawrence Hubbard CHCIO Board Member (Sep-Dec) 2.00 5.00 X 0 697288 32216 Daniel Huffman Chair (Sep-Dec)/BM (Jan-Aug) 2.00 0.00 X X 0 0 0 Gregory Jackson BM (Sep-Dec)/Chair (Jan-Aug) 3.00 0.00 X 0 0 0 Mary Jasper Board Member (Sep-Dec) 2.00 0.00 X 0 0 0 Connie Johnson Board Member 2.00 0.00 X 0 0 0 Larry Jones Board Member 2.00 0.00 X 0 0 0 Elizabeth Keith Board Member (Sep-Dec) 2.00 48.00 X 0 250903 26395 Phillip Leslie Esq Board Member (Sep-Dec) 2.00 0.00 X 0 0 0 James Martin Jr MD Board Member 2.00 0.00 X 0 0 0 Andrea Mazzoccoli PhD Board Member (Jan-Aug) 2.00 48.00 X 0 765982 76642 Jason McCloud OD Board Member 2.00 0.00 X 0 0 0 Stephen McGinnis Esq Board Member (Jan-Aug) 2.00 0.50 X 0 0 0 Thomas Morris PhD President 3.00 47.00 X X 0 667551 61530 James Payne PhD Board Member (Jan-Aug) 2.00 0.50 X 0 0 0 Pam Phillips Board Member (Jan-Aug) 2.00 48.00 X 0 0 0 Laura Timberlake Board Member 2.00 0.00 X 0 0 0 EW Unnikrishnan MD Board Member (Sep-Dec) 2.00 0.00 X 0 0 0 Emily Watson Board Member (Jan-Aug) 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 338797 0 24261 Rodney Hieneman Secretary 50.00 0.00 X 182296 0 33450 Daniel Goulson CMO (Sep-Oct) 50.00 0.00 X 344692 0 37004 Michele Friday MD Cardiologist 49.50 0.50 X 688178 0 34440 Yogendra Prasad MD Cardiologist 50.00 0.00 X 680231 0 33515 Kurt Jaenicke MD Obstetrician 50.00 0.00 X 595503 0 31365 Phillip Lackey MD Plastic Surgeon 50.00 0.00 X 409242 0 35077 Jason Ford MD Pediatrician 50.00 0.00 X 348060 0 30909 John Wallenhorst Former Board Officer 0.00 50.00 X 0 454099 31025 3586999 3456301 544909 48 1 1 0 Owens & Minor INC Dept 79171 Baltimore MD 212790171 Delivery Services 2960410 Ashland Anesthesia PSC PO Box 29 Ashland KY 411050029 Anesthesia Services 2858196 Morrison MGT Specialists PO Box 102289 Atlanta GA 303682289 Food Services 2725396 Aramark Healthcare 24863 Network Place Chicago IL 606731248 Housekeeping/Laundry and Linen/Lift Team 2301111 Aramark CTS INC 12483 Collections CTR Dr Chicago IL 60693 Equipment Maintenance 2274893 42 322180 45680 37598 367860 Patient Service Rev. 622110 170895730 168885389 2010341 170895730 279340 279340 636712 0 636712 636712 636712 51150 359128 0 48753 51150 310375 361525 361525 Retail Pharmacy Rev. 446110 1900367 1734296 166071 Comm. Health & Fitness 713940 315045 315045 Infusion Solution JV I 900099 110752 110752 161093 161093 2487257 175028424 169200434 3744637 1715493 601770 601770 689304 620373 68931 46931443 42238299 4693144 4505412 4054871 450541 7303414 6573073 730341 3674289 3306860 367429 258069 232262 25807 33529 30176 3353 13120 11808 1312 7647784 7647784 622744 560470 62274 2196657 1976990 219667 4297833 3868050 429783 5799349 5219414 579935 538521 484669 53852 45061 40555 4506 2643107 2643107 8435522 7591970 843552 278732 250859 27873 Medical Supplies 28753437 28753437 Purchased Services 15772861 14195575 1577286 Professional Dues 10246728 9222055 1024673 Unrelated Business Inco 28500 28500 13054381 12614386 439995 164371567 152738813 11632754 0 927 824 57063295 63982185 17850837 18667834 642685 751291 3796375 4093040 502212 1537028 135526178 90503870 46280323 45022308 9453513 9733063 358940 419692 252734 252734 11021904 9142572 147223745 153602571 12985219 13343620 4719377 4451748 54672101 70645910 72376697 88441278 X 74846488 65160733 560 560 74847048 65161293 147223745 153602571 X 10656857 151463 -20494075 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 13120 13120 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 57778400 30983915 26794485 2563271 2505809 57462 67540789 54173430 13367359 3134400 2840716 293684 45022308 HPL/GL 6253981 Due From BSHSI 1150641 Other Pat and 3rd Party Payers 930171 Medicare/Medicaid Settlements 576844 Due From Affiliates 135217 Pharmacy AR 84950 Miscellaneous A/R 10768 9142572 LT Liab - Pension Liability 62343015 HPL/GL Liability 6253981 Medicare/Medicaid Settlements 886911 Due to BSHSI 836350 Reserves from Medicare 292685 Unclaimed Prop Accrual 28111 Other Third Party Reserves 4857 70645910 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. The System's taxable subsidiaries had approximately $89,895 and $84,748 of net operating loss carryforwards as of August 31, 2016 and 2015, respectively, which expire in varying periods through 2036 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. Income tax liabilities are recorded for the impact of positions taken on income tax returns, which management believes are not more likely than not to be sustained on tax audit. 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, 2016 and 2015 as the System considers it more likely than not that these amounts will not be recognized. 1 1 X 1 X 0 1 1 0 1 1 875481 503667 371814 0.00240 37790413 24263552 13526861 0.08730 38665894 24767219 13898675 0.08970 31 15708 429615 429615 0.00280 3 439 755082 203578 551504 0.00360 1 0 398121 0 398121 0.00260 0 0 0 0 11 4110 114833 0 114833 0.00070 46 20257 1697651 203578 1494073 0.00970 46 20257 40363545 24970797 15392748 0.09940 0 0 0 0 4 1912 5104 0 5104 0.00000 2 159 1965 0 1965 0.00000 1 45 3436 0 3436 0.00000 2 955 2197 0 2197 0.00000 15 4835 53970 0 53970 0.00030 7 11831 83687 0 83687 0.00050 1 200 634 0 634 0.00000 0 0 0 0 32 19937 150993 150993 0.00080 1 9374037 0 42676243 47063705 -4387462 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 X 1 1 X X X 1 X http://www.fa.bonsecours.com/ X X X X X 1 X 1 X 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 to be included in the survey. Local Health Dept., local police officers, fire dept., school districts, community based service org, local businesses and representatives from local faith communities, local residents and organizations. Interviews were conducted with several individuals with special knowledge and expertise in public health, representatives of medically underserved and those with chronic disease - 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: Kings Daughters Medical Center Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 7d: The CHNA is available through the OLBH Foundation and is also made available by the Foundation upon request. Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 11: The CHNA idenified 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 - A community event, "Festival of Fitness," aims 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 for several local communities, particularly in remote and rural areas. BSKY has increased financial support for school and community gardens, funded two community bicycle safety programs, and assists with funding for three local farmers markets. BSKY continues to support "Safe Routes to Schools and continues to work for policy changes in schools to support active recess and healthy eating in child care centers. Initiatives are in place to support "Complete Streets" work in several communities.2) Access to Care - BSKY operates a van ministry to transport patients to physician appointments and treatments. The hospital also sponsored community events to bring awareness about colon cancer through an event at the mall in collaboration with the American Cancer Society. Free screenings are offered in the community for blood pressure, blood sugar, A1C, Hemoglobin and cholesterol measurement.3) Substance abouse - "2 Good for Drugs" program is currently offered in 3 local school systems, and will be offered in another school in the fall of 2017. We are in collaboration with "Pathways", a 24-7 smoke free policy in schools, as well as "Truth or Consequences", a collaboration with UK extension office and law enforcement.4) Poverty/Socio-economic challenges - the workgroup is working with the United Way to implement a 2-1-1 system for referrals to agencies. Remote Access Medicines is planning a clinic for 2018 to serve individuals needing assistance with dental, vision and medical needs. The workgroup is also working on a job fair at the neignborhood level to assist the homeless and most vulnerable in the community with job opportunities for community members needing entry level jobs to assist them to find employment. Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 13h: The facility approved free care for patients at or below 200% of the FPL. For patients above 200% of the FPL we utilize a sliding scale with no cap. Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 16i: Information regarding the FAP is available on our websites; brochures are available at the time of registration. We have on site Counselors who can assist the patients. We have eligibility vendors who work with the patients and our statements indicate we have an FAP. Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 22d: Bon Secours offers 75% discounts to all self-pay patients in the following markets: Virginia, South Carolina and Kentucky. We also offer an 80% discount to our patients in our New York Market. Form 990, Schedule H, Part V, Section B, Line 14: The Community Service Adjustment was based on the average amounts paid by our insurance companies. Form 990, Schedule H, Part V, Section B, Line 7a: https://bonsecours.com/kentucky/community-commitment/community-health-needs-assessment 14 1 - Same Day Surgery Center 1101 St Christopher Drive Ashland KY 41101 Surgery Center 2 - Bellefonte Center 1000 Ashland Drive Ashland KY 41101 Women's Health, Pre-testing, Various physician Offices 3 - Bellefonte Sleep Lab 118 St Christopher Drive Ashland KY 41101 Sleep Lab 4 - Bellefonte Behavioral Health 1000 St Christopher Drive Ashland KY 41101 Behavioral Health 5 - Ashland Imaging 1816 Carter Ave Ashland KY 41101 Imaging Center 6 - Ironton MRI 1015 East Ring Road Ironton OH 45638 Imaging Center 7 - Ashland Infusion Center 2930 Carter Ave Ashland KY 41101 Infusion Therapy 8 - Wheelersburg PT 8985 Ohio River Road Wheelersburg OH 45694 Physical Therapy 9 - Med Plaza Pharmacy 700 St Christopher Drive Ashland KY 41101 Pharmacy 10 - OLBH Pediatric Rehabilitation Clinic 1100 St Christopher Drive Ashland KY 41101 Pediatric Rehab 11 - Vitality Center 1100 St Christopher Drive Ashland KY 41101 Cardio/Vascular Rehab 12 - Bellefonte Home Health Care Agency -Ohio 109 N 3rd St Ironton OH 45638 Home Health 13 - Ashland Lab 1816 Carter Ave Ashland KY 41101 Lab Services 14 - Bellefonte Home Health Care Agency 700 St Christopher Drive Suite 105 Ashland KY 41101 Home Health Part I, Line 3c: For patients with income above 200% of the FPG, the organization utilizes a sliding scale with no cap. Part I, Line 6a: Annually, Bon Secours KY/Our Lady of Bellefonte Hospital 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. The report relating to this fiscal year is generally made available online at https://bonsecours.com/kentucky the following spring. 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 non-patient 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: $9,374,037. 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 County in Ohio. Our community building activites include school and community gardens, walking trails, farmers markets, and 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 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 personnel to walk in a safe atmosphere in a rural community. This project is aimed to help fight obesity. BSKY continues to use First Book marketplace to purchase books to distribute free to students in the low income communities of Ashland, Greenup & Argillite, KY and Ironton, OH. Support of student backpack and weekend snack programs provide supplies and food to students most at risk of going hungry during the weekend and without needed school supplies when school resumes from the summer break. These programs are essential and continues to assist the high risk students in our service area. Healthy Community Services conducted 126 health fairs, providing approximately 8,511 health screenings in 2016 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 for those with abnormal results. 1,719 individuals 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 15 community CPR classes in 2016 resulting in 65 individuals being certified in adult, infant and child CPR. We offered 3 safe sitter classes and certified 40 young people as safe sitters. We offered bicycle safety camp with 65 children and their families in attendance. We currently have faith ministry or faith community nurse partnerships with 56 local churches, with 25 additional congregations on our mailing list. We have 4 churches offering exercise classes with 50 participants. In 2016, we provided flu shots at 17 locations and administered 226 immunizations. We provided 15 health education presentations to 585 participants. 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 are equipped with a wheelchair lift. In an area which has very limited public transportation, our van ministry provides an option for patients who need treatment but have no means of affordable non-emergency medical transportation. The van ministry provided over 2,883 round trips. We served over 360 individuals, transporting most of these individuals multiple times. Our Meals on Wheels programs served 200 home-bound seniors in 10 communities for an average of 3,600 meals delivered each month. We provide approximately $24,000 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 "accountsreceivable" on pages 12-13 in the attached BSHSI consolidated auditedfinancial statements ("AFS"). "Allowance for uncollectible accounts" isdiscussed in the second paragraph in Footnote "(10) Net Patient ServiceRevenue" on pages 42-43 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 non-reimbursable departments. The cost report uses appropriate statistical bases to "step down" support costs to allowable clinical and non-reimbursable 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.The organization feels the total shortfall of Medicare reimbursement compared to computed Medicare allowable costs should be treated as community benefit. The hospital improves access to patient care by providing services regardless of a patient's ability to pay or the hospital's ability to receive full cost reimbursement for services. The hospital also relieves the government of a financial burden when it provides care to publically insured patients where reimbursement is less than cost of providing the service.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: $440,245. Part III, Line 9b: The hospital has a written policy that describes collection practices applying to patients that qualify for charity care or financial assistance. If full assistance is approved, no collection efforts are pursued on that patient's account(s). If partial assistance is provided, 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 exist 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 twelve months from the date of the application. This eligibility is signaled to hospital admissions, billing and collection staff by the assignment of a specific financial class with accompanying eligibility dates. At the end of those twelve months, the patient is responsible for reapplying for FAP eligibility. Part VI, Line 2: Bon Secours Kentucky, 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 info site 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 community health care needs assessment was open to the public through a web based survey and available as a print copy. Working with local health departments we participated in health needs assessments through these organizations, conversations with local residents and health professionals, public forums and community meetings and coalitions. All of these sources contribute to the assessment of the community health care needs. Part VI, Line 3: Patient financial assistance policy is communicated to patients verbally upon scheduling, registration, visible postings of the policy in common areas throughout the hospital, brochures and on Bon Secours website. In addition, patient statements request that patients apply for financial assistance, if needed, once any patient financial obligation is determined.Bon Secours is committed to ensuring access to health care services for all. As a health care provider, Bon Secours treats all patients, whether insured, underinsured or uninsured, with dignity, respect and compassion throughout admission, delivery of services, discharge and billing and collection processes. Bon Secours addresses the needs of the uninsured by providing free or reduced fees on hospital services, community outreach efforts to assist with enrollment in Medicaid and other medical coverage programs, including free community-based preventive and primary care services. Bon Secours proactively screens 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. Patients are responsible for providing the information necessary to complete the documentation. The FAP aids uninsured and underinsured patients who do not qualify for government-sponsored health insurance and who communicate their inability to pay for their medical care. The FAP provides 100% financial assistance to uninsured patients with annual family incomes at or below 200% of the Federal Poverty Guidelines ("FPG"), A sliding scale assistance policy is afforded patients that exceed the income guidelines for 100% assistance. Sliding scale assistance is provided to patients and progressively declines in proportion to the patient's higher income level. Additionally, all uninsured (i.e. self-pay) patients are given a reduction to the amount of the full charges for medically necessary services through a community service adjustment ("CSA"). The CSA is market adjusted and based on the payment discount received by other health care payers doing business in the community. For these patients, the FAP also sets a maximum annual family payment liability to ensure that no family suffers a catastrophic financial burden to receive necessary health care services. Based on research conducted by the Tax Foundation, a non-partisan tax research group based in Washington DC, the maximum annual family liability is based on a sliding scale determined by the family income and size. In addition, a variety of other potential payment options are available. Bon Secours is 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 process. Part VI, Line 4: Bon Secours Kentucky Health System (BSKHS), Our Lady of Bellefonte Hospital (OLBH) serves 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 the FIVCO Area Development District as well as Lewis County, two counties in southern Ohio (Lawrence, Scioto) and Wayne and Cabell counties in western West Virginia. Due to a growing older aged population, increasing services for residents 55 and older are needed, particularly in the areas of women's health, orthopedics, diabetes, cardiopulmonary services, cancer, drug rehabilitation, and wound care. According to the County Health Rankings data 2015, the counties in the 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 heroin, methamphetamine, cocaine and marijuana. Access to quality preventative care and disease management education is critical in minimizing future hospitalizations as well as the seriousness of these diseases. 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 problem puts these individuals more at risk for depression, suicide 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: OLBH has been instrumental in developing and collaborating with other local agencies on programs to meet the needs of uninsured and low income families. A van ministry provides free non-emergency medical transportation for outpatient services to our campus and primary care centers. Our staff organize and chair the Greenup County Interagency Council. We have partnerships with 54 churches to conduct health ministry and/or faith community nursing programs. In response to the 2016 CHNA, the Healthy Choices Healthy Communities coalition is addressing obesity, substance abuse, poverty, and access to care issues in our communities. OLBH Homeless Care Initiative: This coalition of nurses and other OLBH personnel has provided health screening and flu shots to the homeless population of our community. Many of them volunteer at Church Without Walls, a worship service in Central Park on Saturday mornings that also provides breakfast. This initiative has collected coats, toiletries and food throughout the year to meet the needs of the homeless population.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. Greenup County Interagency Council: OLBH provides leadership for this council that provides an opportunity for service agencies in Greenup County to meet monthly for networking and collaboration.The Diabetes Today Coalition partnered with Greenup County Extension and the local Farmers' Markets to provide cooking classes in July 2016 and food preservation classes in August 2016. These classes had capacity attendance.The 2 Good 4 Drugs curriculum is now in all schools in the Greenup County system. Plans are to implement it in the Russell and Raceland Independent systems during the current 2017 school year. Part VI, Line 6: Bon Secours Health System, Inc., a Maryland nonprofit, non-stock membership corporation (BSHSI), and all of the other entities that are controlled directly or indirectly by Bon Secours, Inc., a Maryland nonprofit, non-stock 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) 600770 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 335998 0 238589 0 45891 0 28778 0 28302 0 677558 0 3006 Lawrence Hubbard CHCIO Board Member (Sep-Dec) 0 285123 0 319403 0 92762 0 15900 0 16316 0 729504 0 0 Elizabeth Keith Board Member (Sep-Dec) 0 144506 0 56247 0 50150 0 10008 0 16387 0 277298 0 0 Andrea Mazzoccoli PhD Board Member (Jan-Aug) 0 394357 0 297139 0 74486 0 54878 0 21764 0 842624 0 36954 Thomas Morris PhD President 0 319173 0 241261 0 107117 0 40598 0 20932 0 729081 0 18904 Joe Buchheit Treasurer/CFO-BSKY 239994 0 57425 0 41378 0 4533 0 19728 0 363058 0 0 0 Rodney Hieneman Secretary 155774 0 26273 0 249 0 4669 0 28781 0 215746 0 0 0 Daniel Goulson CMO (Sep-Oct) 288116 0 55863 0 713 0 11925 0 25079 0 381696 0 0 0 Michele Friday MD Cardiologist 509146 0 177717 0 1315 0 4585 0 29855 0 722618 0 0 0 Yogendra Prasad MD Cardiologist 472167 0 205454 0 2610 0 4465 0 29050 0 713746 0 0 0 Kurt Jaenicke MD Obstetrician 354367 0 238667 0 2469 0 4679 0 26686 0 626868 0 0 0 Phillip Lackey MD Plastic Surgeon 408057 0 500 0 685 0 4459 0 30618 0 444319 0 0 0 Jason Ford MD Pediatrician 148345 0 199579 0 136 0 4479 0 26430 0 378969 0 0 0 John Wallenhorst Former Board Officer 0 318576 0 72652 0 62871 0 20380 0 10645 0 485124 0 0 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, $3,669; Thomas Morris, PhD, $24,711; Andrea Mazzoccoli, $30,744. Judy Houston Sibling of BM, James Payne 88981 Employment 0 Teresa Baron Sibling of BM, James Payne 87239 Employment 0 X 1 37598 Cost or selling price 0 0 1 0 Part I, Column (b): The amount reported in Column (b) refers to the number of contributions. 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 11 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 -18,719,460. Transfer to BSHSI for Swaps & Debt -1,774,615. Bon Secours Health System Inc 1505 Marriottsville Road Marriottsville MD 21104 521301088 Parent Org. Management Services MD 501(c)(3) Line 11c, 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 9 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 11c, 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 0 0 0 0 0 1 0 0 1 0 0 1 1 1 0