2016-07-12T14:18:23-05:00 2015-08-31 861065772 Deloitte Tax LLP 191 Peachtree St Suite 2000 Atlanta GA 303031749 990 2014-09-01 540647482 Richmond Community Hospital Inc RICH 8042818413 8580 Magellan Parkway Building IV Richmond VA 23227 Stephan F Quiriconi Treasurer BSR-VP Finance 8047646102 2016-07-12 1 John W Sadoff Jr P00540589 4042201500 2014 2016-09-27 15:27:22Z Michael Robinson 8260 Atlee Road Mechanicsville VA 23116 127170128 0 X www.bonsecours.com X 1922 VA Acute Care Hospital 21 17 413 28 0 0 622460 2121457 103125636 124868919 0 9750 -219691 44298 103528405 127044424 11661 18283 0 0 22666523 22907351 0 0 0 57725967 63432375 80404151 86358009 23124254 40686415 26800194 61604998 14179063 8297452 12621131 53307546 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 81519725 18283 124868919 Richmond Community Hospital provides medical care to patients without regard to their ability to pay. As a community not-for-profit hospital in Richmond, Richmond Community Hospital is an access point for under insured and financially disadvantaged who will not be treated at the for profit hospitals. In addition, Richmond Community Hospital provides support for community services. Please refer to the Community Benefit Information on Schedule H. 81519725 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 32 0 1 413 1 0 0 0 0 0 0 0 0 0 0 X 21 17 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 1 0 VA X Laura Ellison 4433673835 8990 Old Annapolis Road Columbia MD 21045 X Toni Ardabell CEO-SMH / CEO-Richmond (Sep-Dec / Jan-Aug) 6.70 43.30 X X 0 734625 46332 Jean Bolling Board Member 2.00 0.00 X 0 0 0 John Bowman MD Board Member 2.00 0.00 X 0 0 0 Barry Case Board Member (Sep-Jun) 2.00 0.00 X 0 0 0 Chandrashekar Challa Board Member 2.00 0.00 X 0 0 0 John Daniel III MD Board Member 2.00 0.00 X 0 0 0 Anup Gokli MD Board Member 2.00 0.00 X 0 0 0 Mark Gordon Board Member 2.00 48.00 X 0 546935 53356 Pamela Hacker Board Member 2.00 0.00 X 0 0 0 James Holmes Board Member (Jan-Aug) 2.00 48.00 X 0 233879 29009 BH Hubbard Board Member (Jan-Aug) 2.00 0.00 X 0 0 0 Sr Anne Mack CBS President 3.00 47.00 X X 0 0 0 Joanne Nattrass Board Member 2.00 0.00 X 0 0 0 Fr Jack Podsiadlo Board Member (Jan-Aug) 2.00 0.00 X 0 0 0 Michael Robinson CEO - RCH & MRMC 24.00 26.00 X X 0 730851 25808 Sr Victoria Segura CBS Board Member 10.00 40.00 X X 0 0 0 William Shewmake Board Member 2.00 0.00 X 0 0 0 Shannon Sinclair Board Member 2.00 0.00 X 0 0 0 William Stallings MD Board Member 2.00 0.00 X 0 0 0 Nancy Thomas Chairman 3.00 0.00 X X 0 0 0 Michael Williams Board Member 2.00 0.00 X 0 0 0 Thomas Winfree Board Member 2.00 0.00 X 0 0 0 Peter Bernard CEO - Virginia 6.90 43.10 X 0 1489553 205165 Allen Goolsby III Secretary 2.00 2.00 X 0 0 0 Stephan Quiriconi Treasurer 9.00 41.00 X 0 307530 14228 Jim Godwin VP HR 2.00 48.00 X 0 254827 31651 Michelle Dickerson Nursing Admin. 50.00 0.00 X 204635 0 34257 Jill Kennedy VP-CNE 25.00 25.00 X 0 337797 31429 Bruce Stevens Psychiatrist 50.00 0.00 X 817435 0 40033 Sultan Lakhani MD Psychiatrist 50.00 0.00 X 331664 0 32376 Charles Welander Medical Director - Infusion Center 50.00 0.00 X 246018 0 21167 Virginia Stephens RN - WKD CC 50.00 0.00 X 169197 0 27973 Stacy Coleman RN 50.00 0.00 X 169905 0 17733 Kathleen Santini Former Key Employee 0.00 0.00 X 0 151246 15658 1938854 4787243 626175 20 1 1 0 One Hampton Medical LLC 3475 Monument Place Chicago IL 606895334 Physician Services 1641564 Morrison Mgt Specialists PO Box 102289 Atlanta GA 303682289 Dietary Services 1111212 Aramark Cts Inc 12483 Collections Ctr Dr Chicago IL 60693 Biomedical 894275 Emerald Construction Co 2219 Dabney Rd Richmond VA 23230 Construction 514584 Shiftwise LLC PO Box 70870 St Paul MN 551709705 Nursing Services 379475 22 2049714 71743 607141 2121457 Patient Service Rev. 622110 124868919 124868919 124868919 9750 9750 65061 125704 -60643 -60643 -60643 Health & Wellness 900099 65213 65213 Third Party Interest 900099 18614 18614 Vending 900099 18566 18566 2548 2548 104941 127044424 124868919 0 54048 5000 5000 13283 13283 226032 203429 22603 18219607 16397646 1821961 694580 625122 69458 2257726 2031953 225773 1509406 1358465 150941 121803 109623 12180 5924 5332 592 4148386 4148386 13387 12048 1339 118907 107016 11891 171096 153986 17110 2393402 2154062 239340 76836 69152 7684 19210 17289 1921 1661054 1494949 166105 294606 265145 29461 Medical Supplies 22405438 22405438 Purchased Services 17757932 15982139 1775793 Bad Debt Expense 11403082 11403082 Corporate Dues Alloc. 2026287 1823658 202629 815025 733522 81503 86358009 81519725 4838284 0 302 297 1883 27145274 16527 10897106 16738899 1436685 1982030 1081728 517506 46545401 34116713 10790302 12428688 2592188 2775777 26800194 61604998 3598892 2599480 695849 688230 9884322 5009742 14179063 8297452 X 12619248 53307546 1883 0 12621131 53307546 26800194 61604998 40686415 0 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5924 5924 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. 1323411 1323411 13253389 7585599 5667790 1846107 429139 1416968 28665098 25614286 3050812 1457396 487689 969707 12428688 Due to BSHSI 2795298 HPL/GL Liability 1840367 Due to Third Party Payors 232621 Deferred Lease Liability 141456 5009742 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. The System's taxable subsidiaries have approximately $84,748 and $61,513 of net operating loss carryforwards as of August 31, 2015 and 2014, respectively, which expire in varying periods through 2035 and are available to offset future taxable income. The System's deferred tax assets are fully reserved at August 31, 2015 and 2014 as the System considers it more likely than not that these amounts will not be recognized. Any changes to the valuation allowance on the deferred tax asset are reflected in the year of the change. 1 1 X 1 X 0 1 1 1 0 1 1 3508808 589637 2919171 0.03890 11412633 10574635 837998 0.01120 14921441 11164272 3757169 0.05010 3 2189 634169 16576 617593 0.00820 0 0 0 0 1 103 72701 0 72701 0.00100 0 0 0 0 1 0 174097 0 174097 0.00230 5 2292 880967 16576 864391 0.01150 5 2292 15802408 11180848 4621560 0.06160 1 0 417534 0 417534 0.00560 1 0 125000 0 125000 0.00170 1 0 172639 0 172639 0.00230 1 0 39500 0 39500 0.00050 4 754673 754673 0.01010 1 11403082 0 15807141 15644968 162173 X 1 1 1 1 Richmond Community Hospital Inc 1500 N 28th Street Richmond VA 23223 http://richmond.bonsecours.com H1832 X X X Richmond Community Hospital Inc 1 0 0 1 X X X X X X X X X 12 1 0 0 1 X http://richmond.bonsecours.com X 1 12 1 http://richmond.bonsecours.com 1 0 1 X 200.000000000000 X 1 1 X X X 1 X http://richmond.bonsecours.com X X X X X 1 X 1 X X X X X 1 X 0 0 Richmond Community Hospital, Inc. Part V, Section B, Line 5: Community SurveyAn electronic survey using Survey Monkey was developed and administered to 488 community members and partners by CHS. Individuals were invited to participate based on their ability to represent: underserved, low-income and minority population needs; needs of chronically ill patients; and awareness of healthcare needs in their respective communities. A total of 152 (31%) responded, though not all participants completed each question. Participants represented over 60 agencies from across the primary service area, including concerned citizens, faith community leaders, free clinics, physicians, elected officials and governmental servants. Participants were asked to share their viewpoints on:- Important health concerns in the community;- Significant service gaps in the community; - Ideas for addressing concerns and service gaps.To gauge the importance of various health concerns, respondents were asked to identify issues of community concern from a list modified from topics in Healthy People 2020. Respondents were able to enter additional concerns in an open-ended response item. Participants were also asked to review a list of services typically important to addressing health concerns. Respondents were then asked to indicate services that needed to be strengthened in terms of availability, access, or quality. Open-ended response items were provided for participants to indicate additional service gaps in the community and ideas for addressing concerns and service gaps. Priority Needs The Bon Secours Richmond CHNA Community Review session covered all four hospitals, and was facilitated by Becky Clay Christensen. This review included: Medical Directors and Associate Medical Directors covering Health Departments for four jurisdictions; Health Department Registered Nurses from two jurisdictions; Chief Operating Officer of a Free Clinic; Executive Director of a Federally Qualified Health Center; Executive Director for Community Health Services; Director of Richmond Promise Neighborhoods. In addition to these community health leaders, the following internal leaders also participated: Senior Vice President of Sponsorship for Bon Secours Richmond; Administrative Director for Community Health Services; Administrative Director for Advocacy; Manager for Evaluation and Sustainability; Manager for Community Nutrition; Two Healthy Community Liaisons. After hearing a presentation on initial findings, which included secondary and survey data, this group discussed and made "dot choices" to help prioritize issues by distributing dots on issues from the report and raised by the group. Richmond Community Hospital, Inc. Part V, Section B, Line 11: The Implementation Plan focuses on three broad areas including Health Prevention and Promotion, Access to Health Care and Support Services. A focus in the area of Health Prevention and Promotion is access to and preparation of healthy food. Multiple community partnerships advance this work including provision of fresh produce in identified food deserts, creation of community gardens in underserved neighborhoods and nutrition instruction in school and community settings. Over 11,500 community members were engaged in nutrition activities.Access to Health Care addresses the needs of the uninsured in the greater metropolitan Richmond area. The mobile health program, Care-A-Van, provides culturally competent primary care services to the uninsured in collaboration with 21 church partners. Over 19,000 patient visits were rendered in FY 2015. Bon Secours also supports the free clinic safety net by providing financial support, lab services and in-kind inpatient and outpatient services.Healthy Beginnings is an example of a Support Service focused on prenatal, postpartum and newborn care. Assistance is provided to women helping them identify and access resources to support their pregnancy. Services include Medicaid enrollment, parenting classes and nutritional support (WIC) among others.Dental Care/Oral HealthDental Care was identified in the CHNA community survey as a gap. Oral health is important because it can impact general health. Multiple community organizations are engaged in providing dental care services to the uninsured. They include Virginia Commonwealth University's School of Dentistry, Daily Planet, FQHC, Vernon J. Harris FQHC Dental Clinic, CrossOver Ministry and Goochland Free Clinic and Family Services. As such Bon Secours will not be addressing dental needs at this time.Transportation Other community organizations are better positioned to provide transportation. The Greater Richmond Transit Authority (GRTC) serves the City of Richmond and Henrico County. They have 186 buses and 40 routes. Each bus is equipped with a wheel chair lift. GRTC serves the Richmond Community Hospital campus.GRTC CARE service provides curb-to-curb public transportation to disabled individuals who may not be reasonably able to use the GRTC fixed route bus. It is also available for persons aged 80 or older. Richmond Community Hospital provides limited patient transportation. Patients who reside within a 10-mile radius of the hospital may utilize the patient transport van to reach the hospital campus. This service includes behavioral health patients.Lack of adequate transportation can be a barrier to accessing health care services. The Bon Secours Care-A-Van is a mobile health outreach program providing primary care services in local neighborhoods in the Richmond Community Hospital service area. The Care-A-Van contributes to the elimination of transportation as a barrier to care for uninsured patients. Richmond Community 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. Richmond Community Hospital, Inc. Part V, Section B, Line 16i: Information regarding the FAP is available on our websites and 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. Richmond Community 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 out 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. Part V, Section B, Line 16 Financial Assistance Policy Website Availability Richmond Community Hospital, Inc. Part V, Section B, line 16b website: http://richmond.bonsecours.com 7 Infusion Center - Bremo 5875 Bremo Road MOB South Suite G-2 Richmond VA 23226 Outpatient Drug Infusion Center Infusion Center - Hanover 8260 Atlee Road MOB III Suite 206 Mechanicsville VA 23116 Outpatient Drug Infusion Center Infusion Center - Chesterfield 13801 St Francis Blvd Ste 1300A Midlothian VA 23114 Outpatient Drug Infusion Center Laburnum Diagnostic Imaging 4630 S Laburnum Avenue Suite C Richmond VA 23231 Outpatient Imaging Center Richmond Community Hopital Infusion Cent 5855 Bremo Rod MOB North Suite 605585 Richmond VA 23226 Outpatient Drug Infusion Center Outpatient Infusion Center RCH 1510 N 28th Street Suite 110 Richmond VA 23223 Outpatient Drug Infusion Center Richmond Hope Therapy Center 4900 Dominion Boulevard Suite B Glen Allen VA 23060 Outpatient Physical Therapy Part I, Line 3c: The Community Service Adjustment was based on the average amounts paid by our insurance companies. Part I, Line 6a: Annually, Bon Secours Richmond Health System (BSRHS) publishes a report for the community on the community benefit services and programs that exist. This report also includes the annual financial commitment of the local system to the community, detailing monetary contributions for government sponsored healthcare shortfall, community benefit programs and charity care at cost. This report is available online at www.bonsecours.com/about-us-about-bon-secours.html. Part I, Line 7: Part I, line 7a: Charity Care at cost is computed by applying a cost-to-charge ratio to the aggregate charity adjustments recorded in the general ledger. Part I, line 7b: Unreimbursed Medicaid is computed by determining the cost of Medicaid services supplied less payments received for these services. To determine the cost of Medicaid services provided, a cost-to-charge ratio is applied to traditional and managed Medicaid gross charges captured in the patient accounting system and general ledger. Payments include payments for individual claims, payments from the Medicaid program paid outside the claim process (such as medical education payments) and expected or actual cost report settlements.Part I, line 7c: Unreimbursed costs from other means-tested government programs are computed by applying a cost-to-charge ratio to the total charges to patients covered under these programs. The charges are identified by the financial class assigned to the patient. For Part I, Line 7 a-c computations: The cost-to-charge ratio is derived using the suggested computation in Worksheet 2, Ratio of Patient Care Cost-to-Charges. Operating expenses and Gross patient charges are taken from the general ledger. Expenses for nonpatient care activities recorded in operating expenses are approximated as directly equaling other operating revenue, assuming these activities do not provide profit. Part I, line 7e: Community health improvement services and community benefit operations are accumulated throughout the year and reported at actual cost in a software program that specifically addresses this purpose.Part I, line 7f: Health professions education cost is determined as the direct and indirect cost of qualifying education activities as traditionally reported in columns 21-24 on Worksheet B of the Medicare cost report as a Medical Education program, nursing school or other allied health program. Part I, Ln 7 Col(f): Bad debt expense included in Part IX; line 25 and excluded from the "percent of total expense" calculation is: $11,403,082. Part II, Community Building Activities: Funding was provided to community partners working in Richmond's East End to renovate housing, create community gardens, stimulate economic development through seed funding, enhance children's educational experiences and provide recreational opportunities to children residing in public housing. Part III, Line 2: Bad debt expense on the general ledger includes: 1) actual write offs of discounted gross charges where it is determined an uninsured patient can pay and does not pay; and 2) the estimated write offs for uninsured patient accounts with outstanding balances after discount. Estimates are based on historical collection rates.When an uninsured patient is billed for patient care services, the charges are automatically discounted and the patient is requested to only pay the amount after discount. The discount is recorded as an adjustment to gross revenue and is not recorded in bad debt expense. If the balance after discount is not paid or not paid in full, the unpaid amount will be written off to bad debt expense. When a patient remits a payment on an account that has already been written off to bad debt expense, the payment is recorded as a recovery of bad debt, which reduces bad debt expense. Part III, Line 3: The organization does not report an estimate for the portion of bad debt expense that may have been likely to qualify for financial assistance under the hospital's charity care policy. The organization takes the position that ample opportunity and assistance is provided to the patient to qualify under the financial assistance policy. If sufficient information is not provided, the organization must assume the patient does not qualify. Part III, Line 4: Please see Footnote "(2d) Accounts Receivable, net" discussing "accounts receivable" on pages 11-12 in the attached BSHSI consolidated audited financial statements ("AFS"). "Allowance for uncollectible accounts" is discussed in the second paragraph in Footnote "(10) Net Patient Service Revenue" on page 45 of the attached AFS. There is not a separate "bad debt expense" footnote in the AFS. Part III, Line 8: Medicare allowable costs reflected in Part III come directly from the facility's Medicare cost report. The cost report segregates the total facility actual expenses into costs for support departments, clinical departments (routine and ancillary) and nonreimburseable departments. The cost report uses appropriate statistical bases to "step down" support costs to allowable clinical and nonreimburseable departments. The charges for clinical departments are matched to the total cost for these departments for a cost-to-charge ratio. Medicare-specific allowable costs for in- and outpatient ancillary departments are computed by applying the department-specific cost-to-charge ratio to the Medicare program charges by department. For routine departments, a per diem total cost is computed and applied to Medicare program days for the Medicare routine program cost. 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. 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: $37,717. Part VI, Line 2: BSR contracted with Community Health Solutions (CHS), a local Healthcare Consultant who was recommended by the Virginia Hospital and Healthcare Association (VHHA) to assist with data collection and analysis. Becky Clay Christenson, of The Clay Christensen Group, facilitated conversation to prioritize and vet findings from the initial data collection. Jason W. Smith, PhD, consulted on the CHNA and implementation strategy process, documenting method, analyzing data, and synthesizing components into a public document. The CHNA was conducted during Fiscal Year 2013 (September 1, 2012 to August 31, 2013.) in order to prepare documents by the end of the fiscal year. It was determined that existing secondary data, augmented by a key informant survey, would be used to identify and prioritize health indicators. An executive summary and report was then presented to system leadership from Mission and Business Development. Findings were then presented to the Memorial Regional/Richmond Community Senior Operations Team for further review and comment. Finally, a presentation was made to the Bon Secours Richmond Health System Board for final approval prior to being made available to the public.Secondary DataThe core of the secondary data analysis was conducted by CHS in order to develop a Community Health Indicator Profile. The analysis intentionally did not include every possible indicator, but instead focused on key metrics that provide a broad insight into community health. Availability of data sources was also considered in selection of content. In many cases, results can be considered in comparison to Virginia averages. Foundational source of data include: Alteryx, Inc.; Virginia Department of Health; hospital discharge data from Virginia Health Information, Inc.; Health Resources and Administration data. In other cases, data was only readily available at the state or national levels and synthetic estimates were created by CHS in order to further develop the community profile. CHS developed statistical models to produce estimates where local data was not available. This analysis was based on the CDC's Behavioral Risk Factor Surveillance Survey; the Virginia Foundation for Youth's Market Decisions' 2010 Obesity Survey; a report produced for Virginia Healthcare Foundation by Urban Institute; and local demographic characteristics obtained by Alteryx, Inc. Because the data is extrapolated, meaningful comparisons to state and national averages cannot be made. Community Input Input from community members was included in assessing health care needs as described in Part V, Line 5 below. 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: The Richmond Community Hospital service area consists of 34 zip codes that fall mostly in the counties of Chesterfield, Hanover, Henrico; and the cities of Petersburg and Richmond. The service area covers a large and diverse section of Virginia, so it is not surprising that the needs assessment bears out many state trends. The study region for Richmond Community Hospital contained 851,230 people as of 2010, of which 52% are female and 48% male--a population that is expected to grow to 890,905 by 2015. Compared to the Commonwealth of Virginia as a whole, this region is more densely populated (583.0 people per sq. mile) and is proportionately more Black/African American (32%). It is helpful to note that the service area for Richmond Community is expansive in part because it is one of the few facilities providing acute psychological treatment, constituting 40 dedicated beds within the acute care facility. The median household income of the community is $56,631, just under the median income in Virginia of $60,034. The study region also has lower income levels (29% are Low Income Households with income less than $35,000). Part VI, Line 5: Richmond Community Hospital has an open medical staff with privileges available to all qualified physicians in the area. Richmond Community Hospital through the Bon Secours Richmond Health System is governed by a board of directors whose composition is representative of the community.Richmond Community Hospital engages in medical research. Inpatient and outpatient research-related activities are conducted by Richmond Community with oversight from the Bon Secours Richmond Health System Institutional Review Board. The Care-A-Vans are mobile health care clinics, which travel throughout the Richmond Metro area to provide free primary, urgent and preventive care to patients. Patients on these vans speak many different languages. Approximately one-third of the Care-A-Van's staff are bilingual in English and Spanish. Each van is a self-contained mobile clinic with examining rooms, storage, bathroom, and waiting area. Services include health screenings, childhood immunizations, flu shots for adults, school physicals for uninsured children and examination and treatment of sick patients who are uninsured. Patients who need health care from specialists are referred to volunteer physicians within the community including Bon Secours Medical Group physicians. The vans make regular stops six days a week at churches providing 12,137 patient visits in FY 15. Bon Secours Richmond Health System partnered with the Daily Planet, a federally qualified health center and St. Joseph's Villa for Children, a not-for-profit organization serving children with special needs, at risk youth, and adults with disabilities to create St. Joseph's Outreach Clinic. The clinic provides primary care services to both the insured and the uninsured and serves a large Hispanic population. In FY 15, 6,997 patient visits were provided. Controlling Asthma in the Richmond Metropolitan Area (CARMA) works to improve the management of pediatric asthma through collaborative partnerships with multiple health care systems, schools, American Lung Association, community physicians and schools, case management organizations, and universities. In FY 15 over 2,794 children, parents, teachers and physicians were directly served through CARMA's services. Every Women's Life (EWL), Virginia Breast and Cervical Cancer Early Detection Program is a partnership with the Virginia Department of Health, with funding through the Centers for Disease Control and Prevention. This program provides breast and cervical cancer screenings and diagnostic testing if needed for low income, uninsured women who are 40 to 64 years old. If cancer is found, women are enrolled in Medicaid for treatment. BSRHS holds clinics in six facilities in the Richmond Metro area. Additionally, BSRHS provides case management, follow-up and patient education for these women. In FY 15, 799 screenings were provided. To address the issue of high infant mortality in the Richmond Community Hospital service area, Healthy Beginnings was initiated. Healthy Beginnings is a resource center located on the campus of Richmond Community Hospital. The program targets teenage and young adult women who are pregnant or considering pregnancy. BSRHS assists low to moderate-income families whose children may qualify for state-sponsored insurance programs (Medicaid and FAMIS). Partnerships have developed with other agencies that have enrollers to identify and refer uninsured children, avoid duplication of effort, and to share responsibilities for case managing to complete the enrollment process. Two BSRHS outreach specialists enrolled or re-enrolled over 140 children in FAMIS or Medicaid in FY 15.The nationally recognized Reach Out and Read (ROR) program provides books for young children when they visit the Care-A-Van. Volunteers transform the sites into literary rich areas for children and parents while helping families learn the joys and techniques of reading aloud. Volunteers distributed 482 books in FY 2013 to children at Care-A-Van sites. Part VI, Line 6: Bon Secours Health System, Inc., a Maryland nonprofit, nonstock membership corporation (BSHSI), and all of the other entities that are controlled directly or indirectly by Bon Secours, Inc, a Maryland nonprofit, nonstock membership corporation (BSI) are described collectively as the System. BSI, which is the sole corporate member of BSHSI, has no healthcare operations. The System was organized in June 1983 to fulfill the healthcare mission of the United States Province of the Congregation of the Sisters of Bon Secours of Paris, a congregation of religious women of the Roman Catholic Church founded in France in 1824. The System's activities are in the states of New York, Pennsylvania, Maryland, Virginia, Kentucky, South Carolina, and Florida, each referred to as a local system. The Ministry of BSHSI aids those in need, particularly those who are sick and dying, by offering services that include but are not limited to acute inpatient, outpatient, pastoral, palliative, home health, nursing home, rehabilitative, primary and secondary care and assisted living without regard to race, religion, color, gender, age, marital status, national origin, sexual orientation, or disability. BSHSI's vision to bring about the holistic health of the communities it serves is implemented through its Strategic Quality Plan which provides focus in five goal areas for the current three year period (2013-2015). One of those goals was to bring our communities to wholeness. To accomplish this, two key strategies are to: - Improve Health Locally and Globally- Build Partnerships for Population Health 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. "Inspired by the healing ministry of Jesus Christ and the charism of Bon Secours, Bon Secours Health System will be recognized for its leadership in justice, transforming the communities in which we serve and work into places of health and hope, and being a prophetic voice for systemic US health reform and a more humane world." Please see Schedule R for listings of the related organizations. Part VI, Line 7, Reports Filed With States VA 1 Junior Achievement of Central Virginia 7217 W Broad St Richmond VA 23294 540803325 501(C)(3) 5000 Youth Financial Education 1 0 Indigent Cab Fare 531 13283 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. Schedule I, Part III Cab fares are estimated based on $25/fare. 0 1 0 0 0 0 0 0 0 Toni Ardabell CEO-SMH / CEO-Richmond (Sep-Dec / Ja 0 493876 0 159372 0 81377 0 43832 0 2500 0 780957 0 25794 Mark Gordon Board Member 0 336416 0 144733 0 65786 0 25236 0 28120 0 600291 0 17280 James Holmes Board Member (Jan-Aug) 0 233879 0 0 0 0 0 7939 0 21070 0 262888 0 0 Michael Robinson CEO - RCH & MRMC 0 464732 0 154883 0 111236 0 15600 0 10208 0 756659 0 0 Peter Bernard CEO - Virginia 0 789743 0 326469 0 373341 0 174403 0 30762 0 1694718 0 186126 Stephan Quiriconi Treasurer 0 248452 0 57920 0 1158 0 3945 0 10283 0 321758 0 0 Jim Godwin VP HR 0 206334 0 47086 0 1407 0 9594 0 22057 0 286478 0 0 Michelle Dickerson Nursing Admin. 166453 0 37446 0 736 0 8442 0 25815 0 238892 0 0 0 Jill Kennedy VP-CNE 0 263447 0 73574 0 776 0 5056 0 26373 0 369226 0 0 Bruce Stevens Psychiatrist 247725 0 568644 0 1066 0 13000 0 27033 0 857468 0 0 0 Sultan Lakhani MD Psychiatrist 249283 0 80453 0 1928 0 13000 0 19376 0 364040 0 0 0 Charles Welander Medical Director - Infusion Center 204489 0 0 0 41529 0 11698 0 9469 0 267185 0 0 0 Virginia Stephens RN - WKD CC 162812 0 5870 0 515 0 6918 0 21055 0 197170 0 0 0 Stacy Coleman RN 168646 0 607 0 652 0 7964 0 9769 0 187638 0 0 0 Kathleen Santini Former Key Employee 0 132654 0 75 0 18517 0 3296 0 12362 0 166904 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: Toni Ardabell, $37,602; Peter Bernard, $241,741; Mark Gordon, $25,011. X 1 607141 Cost or selling price Other: 0 0 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 Richmond LLC which was formerly Bon Secours Richmond Health Corp, a nonprofit tax exempt organization prior to conversion. Bon Secours Richmond LLC holds the majority interest in Bon Secours - Richmond Health System, which in turn is the sole member of Richmond Community Hospital, Inc. Form 990, Part VI, Section A, line 7a The governing body of Richmond Community Hospital, Inc. is appointed by its member Bon Secours - Richmond Health System and subject to approval by Bon Secours Health System, Inc. Form 990, Part VI, Section A, line 7b Certain authorities of Richmond Community 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' 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 The filing organization makes all documents available to the general public 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. The governing bodies of the hospitals of Bon Secours Richmond Health System, including Bon Secours St. Mary's Hospital, Bon Secours St. Francis Medical Center, Bon Secours Memorial Regional Medical Center and Richmond Community Hospital are comprised of the same board members and board officers (Chairman, President, Secretary and Treasurer). These governing bodies are referred to as the Richmond Joint Board. Hours reported for these voluntary board positions represent total hours worked per week, which include responsibilities for all four hospitals. Sr. Anne Marie Mack and Sr. Victoria Segura do not receive payroll distributions as they have taken vows of poverty. 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 Bon Secours Richmond Health System 8580 Magellan Parkway Richmond VA 23227 521988421 Local System Parent Org. VA 501(c)(3) Line 9 Bon Secours Richmond LLC 0 Bon Secours Memorial Regional Medical Center 8580 Magellan Parkway Richmond VA 23227 541744931 Health Care VA 501(c)(3) Line 3 Bon Secours Richmond LLC 0 Bon Secours St Mary's Hospital Inc 8580 Magellan Parkway Richmond VA 23227 540793767 Health Care VA 501(c)(3) Line 3 Bon Secours Richmond Health System 0 Bon Secours St Francis Medical Center 8580 Magellan Parkway Richmond VA 23227 311716973 Health Care VA 501(c)(3) Line 3 Bon Secours Richmond Health System 0 Laburnum Properties 8580 Magellan Parkway Richmond VA 23227 521260700 Title Holding Company VA 501(c)(2) Bon Secours Richmond Health System 0 Bon Secours Richmond Healthcare Foundation 8580 Magellan Parkway Richmond VA 23227 541201346 Grant Making Foundation VA 501(c)(3) Line 7 Bon Secours Richmond LLC 0 Richmond Community Hospital Foundation 8580 Magellan Parkway Richmond VA 23227 541780854 Grant Making Foundation VA 501(c)(3) Line 11b, II N/A 0 Rappahanock General Hospital Foundation 101 Harris Road Kilmarnock VA 22482 541210450 Supporting Organization VA 501(c)(3) Line 7 Bon Secours Richmond Health System 0 Chesapeake Medical Group 101 Harris Road Kilmarnock VA 22482 541857174 Healthcare Services VA 501(c)(3) Line 9 Bon Secours Richmond Health System 0 Chesapeake Hospital Corporation PO Box 1449 Kilmarnock VA 22482 237424835 Health Care VA 501(c)(3) Line 3 Bon Secours Richmond Health System 0 St Mary's MRI LP 8580 Magellan Parkway Richmond VA 23227 541568022 Imaging Services VA N/A RI LP 8580 Magellan Parkway Richmond VA 23227 541708835 Imaging Services VA N/A Broad64 Imaging LLC 8580 Magellan Parkway Richmond VA 23227 205886018 Imaging Services VA N/A Richmond Radiation Oncology Center I LLC 8580 Magellan Parkway Richmond VA 23227 208444551 Radiation Oncology Services VA N/A Chesterfield Community Healthcare Center MOB I LLC 435 Southlake Blvd Richmond VA 23236 541745670 Rental - Medical Office Building VA N/A CCHC Inc 8580 Magellan Parkway Richmond VA 23227 541812738 Ambulatory Healthcare Services VA N/A C 0 RHS Management Corporation 8580 Magellan Parkway Richmond VA 23227 541313425 Independent Living Facility VA N/A C 0 Bon Secours - Virginia HealthSource Inc 8580 Magellan Parkway Richmond VA 23227 541417686 Ambulatory Healthcare Services VA N/A C 0 Richmond MRI Inc 8580 Magellan Parkway Richmond VA 23227 541568452 Imaging Services VA N/A C 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1