2016-11-12T12:15:10-06:00 2015-12-31 ERNST & YOUNG US LLP 800 YARD ST 200 GRANDVIEW HEIGHTS OH 43212 990 2015-01-01 310536981 GOOD SAMARITAN HOSPITAL % J MICHAEL SIMS GOOD 9374999942 110 N Main St 500 Dayton OH 45402 TIMOTHY D SNYDER TREASURER / CFO 9374999942 2016-11-08 true DIANE L BEAN P00104972 6142245678 2015 2017-02-10 21:41:12Z Eloise Broner PresidentCEO 2222 PHILADELPHIA DR DAYTON OH 45406 394232122 false 0928 X www.premierhealth.com X 1932 OH Good Samaritan Hospital is committed to building a healthier Dayton, Ohio community through high quality, cost COMPETITVE HEALTH CARE. 7 4 3490 315 410907 -112378 1515417 959031 319870778 338862036 14745364 9042783 4004497 5213465 340136056 354077315 2812407 2363870 0 0 154067507 154536874 0 0 0 171815869 181444700 328695783 338345444 11440273 15731871 528583518 493068205 156852216 145021154 371731302 348047051 GOOD SAMARITAN HOSPITAL IS COMMITTED TO BUILDING A HEALTHIER DAYTON, OHIO COMMUNITY THROUGH HIGH QUALITY, COST COMPETITVE HEALTH CARE. false false 312900537 2363870 338862036 SEE SCHEDULE H 312900537 true true false true false false false false false false true true 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 false true true true false false true 207 0 true 3490 true true true false false false false false false false false false X 7 4 false true false false true true true true true false false true true true true true true true true true true X J MICHAEL SIMS 9374999942 110 N MAIN ST SUITE 500 DAYTON OH 45402 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 686548 0 13990 CAROL BAUER SC TRUSTEE 39.0 1.0 X 0 0 0 GEORGE BRODERICK JR MD TRUSTEE 0.5 1.5 X 0 0 0 JAMES R PANCOAST PREMIER PRESIDENT & CEO 7.5 8.5 X 0 0 0 RAJESH PATEL MD TRUSTEE/CHIEF OF STAFF 0.5 0.5 X 46667 900 0 LASZLO TOTH MD TRUSTEE 0.5 0.0 X 0 0 0 TIMOTHY D SNIDER BOARD TREASURER/CFO 18.5 1.5 X 119664 0 17481 DALE E CREECH BOARD SECRETARY/SYSTEM VP-CLO 7.5 8.5 X 0 0 0 ANITA ADAMS VP - OPERATIONS 40.0 0.0 X 185216 0 23163 THOMAS R CURTIN SYSTEM VP - REVENUE CYCLE 7.5 8.5 X 276277 0 37323 MARY E GARMAN VP OPS & CNO 39.5 0.5 X 319501 0 22611 GARY G GINTER SYSTEM VP - CIO 8.0 32.0 X 0 493377 53719 BARBARA A JOHNSON SYSTEM VP- HR OPERATIONS 8.0 32.0 X 0 491255 17489 TAMMY S LUNDSTROM SYSTEM VP - CMO 8.0 32.0 X 0 656668 10493 THOMAS R PARKER SYSTEM VP - CHF EXPERIENCE OFF 8.0 32.0 X 0 481498 38310 FRANK E SAWYER VP-HOSPITAL OPERATIONS 39.5 0.5 X 226322 0 34501 CRAIG SELF VP-CHIEF STRATEGIC OFFICER 8.0 32.0 X 380470 0 37955 MARK W SHAW SYSTEM VP - MANAGED CARE 8.0 32.0 X 0 393525 61180 SCOTT A SHELTON SYSTEM VP - CPO 8.0 32.0 X 0 313527 29282 SYLVAIN TREPANIER DNP RN CENP SYSTEM VP - CNO 8.0 32.0 X 0 386458 17725 DENA L HELSINGER DEPARTMENT DIRECTOR 40.0 0.0 X 212081 0 25290 WANDA J KIMBROUGH SYSTEM VP-ICM-COMP 40.0 0.0 X 184523 0 30379 KIM K STRAHL SYSTEM VP STRATEGIC SOURCING 40.0 0.0 X 182275 0 29838 SHARON K THORNTON SYSTEM VP - ERP OPERATIONS 40.0 0.0 X 223475 0 18625 DARLENE WISEMAN VP FINANCE - SUPPORT SERVICES 40.0 0.0 X 191046 0 38859 RENEE P GEORGE FORMER KEY EMPLOYEE 0.0 40.0 X 0 300232 21000 J NICK LAIR FORMER KEY EMPLOYEE 0.0 40.0 X 0 294314 46572 DANIEL L SCHOULTIES MD FORMER KEY EMPLOYEE 0.0 40.0 X 0 419770 46591 3234065 4231524 672376 112 true true false ANESTHESIA ASSOC OF NW DAYTON 3180 KETTERING BVD DAYTON OH 45439 MEDICAL SERVICES 4191408 MEDICAL RADIOLOGISTS 1563 EAST DOROTHY SUITE 101 KETTERING OH 45429 MEDICAL SERVICES 2353076 DAWSON HEALTHCARE 3650 OLENTAGY RIVER RD STE 450 COLUMBUS OH 43214 AGENCY STAFF 4560636 KETTERING COLLEGE MEDICAL ARTS 3737 SOUTHERN BLVD KETTERING OH 45429 STAFFING 1051599 CITYWIDE DEVELOPMENT CORP 8 N MAIN ST DAYTON OH 45402 COMMUNITY DVLPMNT 818902 75 1479 157525 799161 866 959031 NET PATIENT REVENUE 621110 168305678 167894771 410907 MEDICARE/MEDICAID 621110 153991118 153991118 FRANCHISE TAX RECOVERIES 423000 10491970 10491970 JOINT OPERATING AGREEMENT 812930 5963000 5963000 HEALTH EDUCATION 561499 76469 76469 33801 33801 338862036 4735579 4735579 0 0 4758146 2733383 2024763 0 2024763 2024763 35090019 674145 30837022 619938 4252997 54207 4307204 4307204 0 0 6115895 5964464 151431 151431 CAFETERIA 721110 2161440 2161440 PARKING GARAGE 812930 277647 277647 LAUNDRY 900099 61196 61196 536988 536988 3037271 354077315 338451129 410907 14256248 2363870 2363870 0 0 0 2427689 2195602 232087 0 190775 172537 18238 118507719 107178381 11329338 5234460 4734046 500414 19373507 17521400 1852107 8802724 7961184 841540 3836200 3469459 366741 298663 270111 28552 193607 193607 22646 22646 0 660422 660422 27694519 25046923 2647596 2881886 2881886 1848362 1671659 176703 7650712 6919304 731408 0 6493194 5872445 620749 247954 224250 23704 0 1840 1664 176 4067502 4067502 0 26308381 23793300 2515081 0 OPERATING SUPPLIES 69862623 69862623 PURCHASED SERVICES 17869383 16161070 1708313 HOSPITAL FRANCHISE TAX 5658887 5117897 540990 EQUIPMENTAL RENTAL 1066106 1066106 4781813 4324672 457141 338345444 312900537 25444907 0 18140 17640 21376399 11697230 119677 0 43065183 54106496 0 0 0 0 1130259 1035262 6616349 5959164 6245750 5993308 553622139 352675705 182365619 200946434 168226970 135998165 37374420 32773937 0 0 3376413 3376413 58668339 41164156 528583518 493068205 30818200 24472947 1862472 1408687 1017478 1168573 0 0 0 0 0 0 103105477 92605491 0 0 20048589 25365456 156852216 145021154 X 371731302 348047051 0 0 0 0 371731302 348047051 528583518 493068205 X 15731871 -8522374 -30893748 X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false true 62436 false false true 6210 68646 false Part II-B, Lines 1F PAYMENTS FOR LOBBYING ACTIVITIES INCLUDE DUES PAID TO GREATER DAYTON AREA HOSPITAL ASSOCIATION, DAYTON DEVELOPMENT COALITION, AND OHIO HOSPITAL ASSOCIATION. FUNDS WERE ALSO GRANTED TO CITIZENS FOR SINCLAIR IN SUPPORT OF THE SINCLAIR COMMUNITY COLLEGE LEVY CAMPAIGN. PART II-B, LINE 1I: THE HOSPITAL CONTRACTS WITH A LOBBYIST FOR HEALTHCARE RELATED ISSUES. 7493563 7493563 272113104 180584950 91528154 4268764 3466521 802243 219601770 168624234 50977536 50144938 50144938 200946434 ALTERNATIVE INVESTMENTS 32773937 F 32773937 PENSION 25816869 JOINT OPERATING AGREEMENT 5963000 HCAP ACCRUAL 3172426 AFFILIATES RECEIVABLE 2925960 OTHER A/R 2555574 SETTLEMENT - 3RD PARTY PAYORS 481412 DEFERRED COMPENSATION 218915 AFFILIATES INVESTMENT 30000 41164156 0 PENSION 10226839 MALPRACTICE INSURANCE 7913182 CONSTRUCTION RETAINAGE 2749437 HOSPITAL FRANCHISE TAX PAYABLE 1361799 LOAN GUARANTEE & OTHER LTL 1334487 WORKERS COMPENSATION RESERVE 1262252 DEFERRED COMPENSATION 218915 OTHER 298545 25365456 X Form 990, Schedule D, Part X, Line 2: The following footnote is from the audited combined financial statements for Premier Health and affiliates. Samaritan Health Partners (SHP) is the parent organization of Good Samaritan Hospital (GSH): PREMIER HEALTH (PREMIER), MEDAMERICA HEALTH SYSTEMS (MAHS), ATRIUM HEALTH SYSTEM (AHS), 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. SAMARITAN HEALTH PARTNERS (SHP) IS TAX-EXEMPT UNDER SECTION 501(C)(3) AND IS A PUBLIC CHARITY BY REASON OF BEING INCLUDED IN THE GROUP RULING ISSUED TO THE U.S. CATHOLIC CHURCH. AS TAX-EXEMPT ORGANIZATIONS, THEIR INCOME IS EXEMPT FROM FEDERAL INCOME TAX EXCEPT TO THE EXTENT OF ANY UNRELATED BUSINESS ACTIVITIES. PREMIER, MAHS, SHP, AHS, AND UVMC ALSO OWN OR CONTROL CERTAIN SUBSIDIARIES, WHICH ARE FOR PROFIT CORPORATIONS SUBJECT TO FEDERAL INCOME TAXES. TAXES PAYABLE AT DECEMBER 31, 2015 AND 2014, 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 1967000 East Asia and the Pacific Investments 8776000 Europe (Including Iceland and Greenland) Investments 21033000 Middle East and North Africa Investments 454000 North America Investments 2118000 Russia and the Newly Independent States Investments 454000 South America Investments 1513000 South Asia Investments 757000 Sub-Saharan Africa Investments 303000 Central America and the Caribbean Program Services INSURANCE 25000 37400000 37400000 false false false false false false true true true X true X true true false true true 7206000 3134000 4072000 0.01200 72547000 52986000 19561000 0.05750 795000 439000 356000 0.00100 80548000 56559000 23989000 0.07050 908000 908000 0.00270 12696000 12337000 359000 0.00110 14234000 14234000 0.04180 1207000 1207000 0.00350 29045000 12337000 16708000 0.04910 109593000 68896000 40697000 0.11960 42000 42000 0.00010 4000 4000 0.00000 31000 31000 0.00010 6000 6000 0.00040 83000 83000 0.00060 true 6527000 0 66669000 75927000 -9258000 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 OHIO REG # 1245 X X X X Good Samaritan Hospital 1 false false true X X X X X X X X X 13 true true true true X SEE PART V, SECTION C X true 14 true SEE PART V, SECTION C false false true X 200. 400. X X true true X X X true X www.premierhealth.com X www.premierhealth.com X www.premierhealth.com 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, Question 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, community health collaboratives featuring community, health, and business stakeholders/advocates organized by both Good Samaritan Hospital, and the greater Dayton Area Hospital Association with its member hospitals. Part V, Section B, Question 6A & 6B: Good Samaritan Hospital partnered with member hospitals of the Greater Dayton Area Hospital Association and Wright State University to prepare their Community Health Needs Assessment. PART V, Section B, QUESTION 7A: THE DIRECT WEBSITE ADDRESS WHERE THE CHNA CAN BE ACCESSED IS: http://www.goodsamdayton.org/WorkArea/DownloadAsset.aspx?id=76900 PART V, Section B, QUESTION 10A: The direct website address where the implementation strategy can be accessed is: http://www.premierhealth.com/our-community/mking-a-difference/community-he alth-improvement-plan/gsh/ Part V, Section B, Line 11: Premier Health was part of a collaboration in 2013 with the Greater Dayton Area Hospital Association and hospitals throughout Southwestern Ohio to conduct a regional Community Health Needs Assessment. Identified Priorities: ---------------------- In the Community Health Assessment, researchers identified priority areas for community health improvement using a variety of criteria. The priorities that are included and excluded in the plan are outlined here. Priorities that are included in the plan are not listed in order of importance. Priorities Included in the Plan: -------------------------------- Through the Community Health Risk Assessment, the identified priorities with an improvement plan for Good Samaritan Hospital are: Primary and Chronic Diseases: 1. Hypertension-Hypertension rates are higher in the service area than in the State and nation. It is the leading inpatient discharge diagnosis and the 3rd leading ED discharge diagnosis. 2. Breast cancer-The breast cancer rate is 195.3 per 100,000, and the rate is increasing as opposed to historically prevalent cancers. 3. Diabetes- Widespread behavioral risk factors such as obesity and physical activity and the increasing rate of hospital inpatient diabetes diagnoses are cause for concern. Priorities Addressed Through Collaboration: ------------------------------------------- All identified priorities are important elements of improving the health of our community. In some instances priorities are already being targeted by collaborative groups of which Good Samaritan Hospital is a part. Additional strategies will not be developed independent of these efforts. Because of the importance of these community-wide efforts, the following identified priorities are not included in the Community Health Improvement Plan. Maternal and Infant Priorities: 1. First trimester prenatal care 2. Low birth weight 3. Infant mortality rate Good Samaritan Hospital is involved in several state-wide initiatives addressing these issues. As part of these collaborations, Good Samaritan Hospital will share the goals and objectives developed by those groups for program implementation and measurement. Ohio Perinatal Quality Collaborative. Good Samaritan Hospital is a non-charter member of this organization as a maternity hospital. The mission of the Collaborative is, "Through collaborative use of improvement science methods, reduce preterm births and improve outcomes of pre-term newborns in Ohio as quickly as possible." Projects of the collaborative include: * 39 Weeks Delivery Charter Project - To reduce elective unnecessary scheduled births before 39 weeks gestational age. (Reduce infant mortality and low birth weights.) * 39 Weeks Dissemination and Birth Registry Accuracy Project - This project was to address inaccuracies in birth certificate data within the Quality Improvement framework. * Obstetrics Antenatal Corticosteroids Project- This project focuses on increasing the use of antenatal corticosteroids to reduce mortality and morbidity among preterm infants. (Reduce infant mortality.) * Progesterone Project - This project intends to help raise awareness about the need for screening and intervention for progesterone, provide support to teams to implement screening, identification and treatment, develop the capacity and capability of skilled ultrasound technicians and remove administrative barriers to the administration of progesterone. (Reduce infant mortality and low birth weights.) Ohio Hospital Association (OHA). OHA has developed a plan to reduce infant mortality (which also addresses low infant birth weight and first trimester care) in Ohio which includes: * Safe sleep (infant mortality) * Eliminating elective deliveries before 39 weeks (infant mortality) * Progesterone for high risk mothers (infant mortality) * Eliminating health disparities * Safe spacing (infant mortality and low birth weight) * Access to prenatal care (First trimester care, infant mortality and low birth weight) * Promote breast milk * These program areas also then address increasing first trimester care, improving low birth weight and decreasing infant mortality. Primary and Chronic Diseases: 4. Alcohol and drug discharge diagnosis 5. Mental health disorders Good Samaritan Hospital is deeply involved in improving these areas. Samaritan Behavior Health (SBH), a subsidiary of the hospital, provides mental health and substance abuse services for all ages in Southwest Ohio. SBH collaborates with the National Alliance on Mental Illness of Montgomery County, Ohio. It also receives funding from the ADAMHS Board to provide Crisis Care for Montgomery County. In Montgomery County, alcohol, drug abuse and mental health services are coordinated by the ADAMHS Board (Alcohol, Drug Addiction and Mental Health Services.) The ADAMHS Board administers the planning, development, funding and evaluation of behavioral health services delivered by a network of nearly 30 community-based organizations. The ADAMHS Collaborative Coalition to Improve Alcohol and Other Drug Abuse and Addiction Services in Montgomery County, Ohio. This plan includes recommendations for: * Building infrastructure and capacity * Prevention * Building linkages * Treatment * Data sharing James Pancoast, Premier Health President and CEO is the Co-Chair of the Alcohol and Other Drug Abuse Implementation Advisory Team. Key Health Priorities by Objective Priority Area 1: Reduce the incidence and complications from adult hypertension. Blood pressure is how hard blood pushes against the walls of our arteries when our heart pumps blood. When someone has high blood pressure, which is also called hypertension, the increased pressure against the arteries causes damage. Hypertension is called the silent killer because usually those who have it do not feel anything. High blood pressure increases risk for heart disease, stroke, heart failure, kidney disease and blindness. In many cases hypertension can be prevented by maintaining a healthy weight, being active, eating healthy, not using tobacco and limiting alcohol. Most people who are diagnosed with high blood pressure can be controlled. Those with high blood pressure should take the same steps that may prevent high blood pressure. If medication is needed, it is imperative to take it every day. Hypertension rates are higher in the service area than in the State and nation. It is the leading inpatient discharge diagnosis and the 3rd leading ED discharge diagnosis. Because of the significant health threat posed by hypertension, a community-focused, population health improvement strategy would benefit all parts of the community. Priority Area 1: Reduce the proportion of adults with hypertension. Objective 1.1: Increase the proportion of adults with hypertension whose blood pressure is under control. Evidence-based Strategies: * Coordinate a hypertension education health communications campaign that will include communications tactics; free, community-based screenings and free online education. * Promote lectures about high blood pressure prevention and control in worksites, congregations, senior centers and other community based venues. * Identify or develop an educational brochure targeted to those who already have high blood pressure about the importance of medication adherence and healthy lifestyle. Make collateral available through system websites, Facebook pages, at employer and community events and other outlets to be identified. These will include how to get more information by telephone and/or online. Outcome Indicators Short and Intermediate Te 9 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 SAMARITAN HOMELESS CLINIC (SOLD AUG) 921 S Edwin C Moses Blvd DAYTON OH 45417 HOMELESS CLINIC GSH Medical Imaging - North Main 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. 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 the following subsidized services: 1. Good Samaritan Homeless Clinic: This Clinic is the only health clinic in the surrounding area specifically for the homeless. The clinic takes an integrated approach toward primary and preventative services. With the mission of serving the total well-being of the homeless, the Clinic aims to deliver quality, compassionate care and to get our patients back on their feet. The Clinic is staffed with a full-time physician and a dedicated nursing team. The Clinic provides a number of services to the homeless, including (but not limited to) respite care, dental services, mental health and substance abuse treatment and counseling, pharmacy services, vision screenings, podiatry, case management, health education, outreach services, transportation, life skills training, cancer prevention services, diabetes services and blood pressure monitoring. The clinic was sold to a Dayton area Federal Qualified Health Clinic look-alike organization in August 2015. 2. Lifestages, LLC: This limited liability company provides healthcare to women of all ages that includes Obstetric services, gynecology services and heart, bone and breast health. Lifestages is built around the core beliefs that each woman is unique and that all women deserve the best care available. This company serves a large population of Medicaid and uninsured patients. Good Samaritan Hospital provides support through funding for Lifestages' indigent patients and medical education. The funding for 2015 was $2,264,000. 3. Emergency Services: Good Samaritan Hospital operates 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 2015, the amounts paid for call time and subsidies were $11,970,000. PART II, LINES 9: Good Samaritan Hospital (GSH) PARTICIPATES IN THE FOLLOWING COMMUNITY Building ACTIVITIES: (1) GSH contributed $485,000 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. GSH has recognized $631,000 from the sale and rental of these facilities. (2) 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 DAYTON AREA. ALSO SUGGESTED ARE ORGANIZATIONS THAT FOCUS ON SUPPORTING YOUTH, EDUCATION, UNDERSERVED GROUPS, AND SAFE NEIGHBORHOODS. THE AMOUNT OF SUPPORT PROVIDED IN 2015 WAS $149,000. 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 $70,240,000 AND INCURRED COST OF $98,517,000, FOR AN ADDITIONAL NET SHORTFALL OF $28,277,000 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 $66,669,000 MEDICARE REVENUE NOT REPORTED IN PART III, SECTION B $70,240,000 TOTAL MEDICARE ASSOCIATED REVENUE $136,909,000 ALLOWABLE MEDICARE COST PER MEDICARE COST REPORT in PART III, SECTION B $75,927,000 MEDICARE COST NOT REPORTED IN PART III, SECTION B $98,517,000 TOTAL MEDICARE ASSOCIATED COST $174,444,000 MEDICARE SHORTFALL PER PART III, SECTION B $9,258,000 ADDITIONAL SHORTFALL NOT INCLUDED IN PART III, SECTION B $28,277,000 TOTAL MEDICARE SHORTFALL $37,535,000 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 53% 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 A PAYMENT PLAN, and HAS 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 programs 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 Good Samaritan Hospital Board of Directors, executive management, managers, staff members, community true PREMIER COMMUNITY HEALTH co FIDELITY HEALTH 3170 Kettering Blvd DAYTON OH 45439 311122883 501(c)(3) 240714 N/A N/A HEALTH EDUCATION VICTORIA THEATRE 138 N MAIN 45402 DAYTON OH 45402 310897638 501(c)(3) 104305 N/A N/A PERFORMING ARTS UNITED WAY 33 W First St 45406 DAYTON OH 45402 310536658 501(c)(3) 7935 N/A N/A COMMUNITY SUPPORT Dayton Foundation 500 Kettering Tower Dayton OH 45402 316027287 501(c)(3) 1014968 N/A N/A Community Support DayBreak 605 S Patterson Blvd Dayton OH 45402 310864474 501(c)(3) 7073 N/A N/A Community Support American Heart Association 5455 N High St Columbus OH 43214 135613797 501(c)(3) 64170 N/A N/A Education Good Samaritan Hospital Foundation - Dayton 110 N Main St500 Dayton OH 45402 237296923 501(c)(3) 14433 N/A N/A Community Develop Dayton Area Chamber of Commerce 22 E 5th Dayton OH 45402 310257370 501(c)(6) 18600 N/A N/A MINORITY SUPPORT Reach Out Montgomery County 25 East Foraker St Dayton OH 45409 311434282 501(c)(3) 56908 N/A N/A RX ASSISTANCE FOR INDIGENT PATIENTS AIDS Resource Center 15 West 4th St Suite 200 Dayton OH 45402 311126780 501(c)(3) 66147 N/A N/A Community Support Project Hope Inc 1508 North Main Street Dayton OH 45405 341421548 501(c)(3) 8050 N/A N/A Community Support SINCLAIR COMMUNITY COLLEGE FOUNDATION 444 W 3RD ST DAYTON OH 45402 310723444 501(C)(3) 186070 CAPITAL RENOVATION & EXPANSION UNIVERSITY OF DAYTON 300 COLLEGE PARK DAYTON OH 45469 310536715 501(C)(3) 115000 CYBERSECURITY & DATA INTELLIGENCE MIAMI VALLEY HOSPITAL 110 N MAIN ST 500 DAYTON OH 45402 310537504 501(C)(3) 64280 MAHOGANY CHILD & INDIGENT PATIENTS CITIZENS FOR SINCLAIR 120 W SECOND ST 614 DAYTON OH 45402 611529465 None 46000 SUPPORT MIAMI VALLEY HOSPITAL FOUNDAITON 110 N MAIN ST 500 DAYTON OH 45402 311040231 501(C)(3) 23736 SUPPORT OMEGA COMMUNITY DEVELOPMENT 1810 HARVARD BLVD DAYTON OH 45406 311561713 501(C)(3) 23575 SUPPORT DAYTON CONTEMPORARY DANCE COMPANY 840 GERMANTOWN STREET DAYTON OH 45402 237220259 501(C)(3) 7360 SUPPORT ATRIUM MEDICAL CENTER FOUNDATION 110 N MAIN ST 500 DAYTON OH 45402 311079213 501(C)(3) 13823 SUPPORT MIDDLETOWN COMMUNITY FOUNDATION 300 NORTH MAIN STREET 300 MIDDLETOWN OH 45042 310898380 501(C)(3) 8855 SUPPORT UVMC FOUNDATION 110 N MAIN ST 500 DAYTON OH 45402 311581859 501(C)(3) 7389 SUPPORT OHIO HOSPITAL ASSOCIATION 155 E BROAD ST 301 COLUMBUS OH 43215 314270340 501(C)(6) 5750 SUPPORT The Heart Institute of Dayton 110 N MAIN ST 500 DAYTON OH 45402 300502367 501(C)(3) 297225 HEART EDUCATION 20 3 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 false true false false false false false false false ELOISE P BRONER PRESIDENT & CEO 433215 0 113857 0 139476 0 11050 0 2940 0 700538 0 0 0 ANITA ADAMS VP - OPERATIONS 153836 0 28823 0 2557 0 13388 0 9775 0 208379 0 0 0 THOMAS R CURTIN SYSTEM VP - REVENUE CYCLE 217857 0 55160 0 3260 0 8232 0 29091 0 313600 0 0 0 MARY E GARMAN VP OPS & CNO 277596 0 40351 0 1554 0 10480 0 12131 0 342112 0 0 0 GARY G GINTER SYSTEM VP - CIO 0 351975 0 139106 0 2296 0 26339 0 27380 0 547096 0 0 BARBARA A JOHNSON SYSTEM VP- HR OPERATIONS 0 372517 0 106120 0 12618 0 7701 0 9788 0 508744 0 0 TAMMY S LUNDSTROM SYSTEM VP - CMO 0 519002 0 131441 0 6225 0 8908 0 1585 0 667161 0 0 THOMAS R PARKER SYSTEM VP - CHF EXPERIENCE OFF 0 369184 0 87253 0 25061 0 26354 0 11956 0 519808 0 0 FRANK E SAWYER VP-HOSPITAL OPERATIONS 192254 0 33469 0 599 0 9640 0 24861 0 260823 0 0 0 CRAIG SELF VP-CHIEF STRATEGIC OFFICER 314509 0 64068 0 1893 0 11333 0 26622 0 418425 0 0 0 MARK W SHAW SYSTEM VP - MANAGED CARE 0 282789 0 65769 0 44967 0 35804 0 25376 0 454705 0 0 SCOTT A SHELTON SYSTEM VP - CPO 0 250217 0 50865 0 12445 0 25280 0 4002 0 342809 0 0 SYLVAIN TREPANIER DNP RN CENP SYSTEM VP - CNO 0 329769 0 55449 0 1240 0 7971 0 9754 0 404183 0 0 DENA L HELSINGER DEPARTMENT DIRECTOR 186856 0 22668 0 2557 0 21248 0 4042 0 237371 0 0 0 WANDA J KIMBROUGH SYSTEM VP-ICM-COMP 140105 0 38152 0 6266 0 17276 0 13103 0 214902 0 0 0 KIM K STRAHL SYSTEM VP STRATEGIC SOURCING 150750 0 29175 0 2350 0 20328 0 9510 212113 0 0 0 SHARON K THORNTON SYSTEM VP - ERP OPERATIONS 168219 0 36858 0 18398 0 9448 0 9177 242100 0 0 0 DARLENE WISEMAN VP FINANCE - SUPPORT SERVICES 167882 0 21591 0 1573 0 18271 0 20588 0 229905 0 0 0 RENEE P GEORGE FORMER KEY EMPLOYEE 0 253960 0 45640 0 632 0 9526 0 11474 0 321232 0 0 J NICK LAIR FORMER KEY EMPLOYEE 0 224436 0 41191 0 28687 0 21914 0 24658 0 340886 0 0 DANIEL L SCHOULTIES MD FORMER KEY EMPLOYEE 0 309086 0 35979 0 74705 0 21123 0 25468 0 466361 0 0 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 SUPPLEMENTS 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 2015. The individuals listed below have met the multi-year vesting requirement under the Pension Restoration Plan and received the associated payment in 2015: Eloise Broner $118,605; BARBARA JOHNSON $5,674; Nick Lair $9,733; Mark Shaw $37,161; Scott Shelton $8,625. There were no individuals who met the multi-year vesting requirement under the SERP and received the associated payments in 2015. 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 190775 Salary false Form 990, Part VI, Section A, Question 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. 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 Question 6: Good Samaritan Hospital has two corporate members. One member is Samaritan Health Partners, the parent company of the hospital. 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, Question 7a: Samaritan Health Partners (SHP) has the sole authority to elect the Board of Trustees of Good Samaritan Hospital (GSH). SHP has the authority to remove trustees at any regular or special meeting or by written consent. Premier Health (Premier) has the right to request that SHP remove a trustee of GSH if Premier has determined that such trustee is frustrating the goals and purposes of Premier's network. Such removal shall not be unreasonably refused by SHP. Form 990, Part VI, Section A, Question 7b: See the response above for Form 990, Part VI, Section A, question 3. Form 990, Part VI, Section B, Question 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, Question 12c: PREMIER HEALTH (PREMIER), WITH 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, Question 15A and 15B: COMPENSATION TO 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, 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, Question 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. Part VII, Section A, System Key Employees: The System Key Employees' total compensation amount is accurately reported on the various entities they serve. If the System Key Employee's compensation is paid by an unrelated organization, their compensation is being reported as related compensation to avoid the erroneous perception that these individuals are being paid identical amounts by multiple parties. Form 990, Part XI, Question 9: PENSION FASB 158 ADJUSTMENT $(19,626,997) EQUITY TRANSFERS $(15,010,767) PHG EQUITY TRANSFER $(460,393) MINORITY INTEREST DISTRIBUTION $(365,280) FOUNDATION ADJUSTMENT $(157,525) PSS EQUITY TRANSFER $87,630 TRANSFER FROM AFFILIATE $143,142 LIFESTAGES ACQUISITION $256,442 DIVIDENDS RECEIVED FROM SNSC $4,240,000 TOTAL $(30,893,748) SAMARITAN HEALTH PARTNERS 110 N Main St Suite 500 DAYTON OH 45402 311107411 PARENT OH 501(c)(3) 11C III FI NA false PREMIER HEALTH 110 N Main St Suite 500 DAYTON OH 45402 311446699 SUPPRTG. ORG. OH 501(c)(3) 11A I NA false Good SAMARITAN HOSPITAL FOUNDATION-Dayto 110 N Main St Suite 500 DAYTON OH 45402 237296923 FOUNDATION OH 501(c)(3) 7 SHP true CATHOLIC HEALTH INITIATIVES 198 INVERNESS DR W SUITE 500 ENGLEWOOD CO 80112 470617373 PARENT CO 501(c)(3) 9 NA false THE HEART INSTITUTE OF DAYTON 110 N MAIN ST SUITE 500 DAYTON OH 45402 300502367 EDUCATION OH 501(c)(3) 9 SHP true Samaritan Behavorial Health 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 5053852 5056141 false 0 true 0.80000 SAMARITAN FAMILY CARE 110 N Main St DAYTON OH 45402 311299450 PHYSICIANS OH SHP C CORP 0 0 0.00000 true true true true false false true false false false false false false false false false true true true false Samaritan Behavioral Health Inc Q 236928 CASH Samaritan Family Care A-IV 935976 CASH Samaritan Family Care P 1817730 CASH Samaritan Family Care Q 21422992 FMV Samaritan Family Care R 3521871 FMV Samaritan North Surgery Center A-IV 715258 Cash Samaritan North Surgery Center C 365280 Cash Samaritan North Surgery Center F 4240000 Cash The Heart Institute of Dayton Q 297225 FMV Catholic Health Initiatives R 3787000 FMV Premier Health B 460393 Cash Good Samaritan Hospital Foundation - Dayton P 52004 Cash Good Samaritan Hospital Foundation - Dayton Q 702766 Cash Good Samaritan Hospital Foundation - Dayton C 268941 FMV