2014-11-13T07:34:06-06:00 2013-12-31 381357951 PLANTE & MORAN PLLC 65 EAST STATE STREET COLUMBUS OH 43215 990 2013-01-01 340714535 SAMARITAN REGIONAL HEALTH SYSTEM SAMA 4192890491 1025 CENTER STREET ASHLAND OH 44805 DANNY L BOGGS PRESIDENT & CEO 4192890491 2014-11-06 1 BERNIE OSTROWSKI P00366367 6148493000 2013 2015-11-30 17:44:51Z SEE SCHEDULE O DANNY L BOGGS 1025 CENTER STREET ASHLAND OH 44805 80075108 0 X WWW.SAMARITANHOSPITAL.ORG X 1910 OH SAMARITAN REGIONAL HEALTH SYSTEM PROVIDES QUALITY MEDICAL HEALTHCARE SERVICES AND EDUCATION REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR ABILITY TO PAY. THE HOSPITAL PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS. SERVICES PROVIDED TO MEDICARE AND MEDICAID PATIENTS ARE SOMETIMES PROVIDED BELOW COST. TO THE EXTENT REIMBURSEMENT IS BELOW COST, THE HOSPITAL RECOGNIZES THESE AMOUNTS AS CHARITY CARE. CHARITY CARE IS ALSO PROVIDED THROUGHOUT THE YEAR BASED UPON ACTIVITIES AND SERVICES WHICH THE HOSPITAL BELIEVES WILL SERVE A BONA FIDE COMMUNITY HEALTH NEED. CHARITY CARE FOR 2013 WAS VALUED AT $2,426,000. DURING 2013, THE HOSPITAL ALSO PROVIDED NUMEROUS OUTREACH PROGRAMS WHICH SERVE AND EDUCATE THE COMMUNITY. 14 11 638 200 2711476 -466293 1298898 831596 73144624 73670305 -42545 -327702 4327352 5252637 78728329 79426836 40972 39650 0 0 35203568 33447735 0 0 0 42033574 42738788 77278114 76226173 1450215 3200663 72908236 73083240 28432281 27976873 44475955 45106367 X THE MISSION OF SAMARITAN REGIONAL HEALTH SYSTEM IS TO TAKE THE LEAD IN PROMOTING THE HEALTH AND WELLNESS OF PEOPLE IN THE COMMUNITIES WE SERVE. 0 0 67258850 39650 74717744 SAMARITAN REGIONAL HEALTH SYSTEM PROVIDES QUALITY MEDICAL HEALTHCARE SERVICES AND EDUCATION REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE OR ABILITY TO PAY. THE HOSPITAL PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS. SERVICES PROVIDED TO MEDICARE AND MEDICAID PATIENTS ARE SOMETIMES PROVIDED BELOW COST. TO THE EXTENT REIMBURSEMENT IS BELOW COST, THE HOSPITAL RECOGNIZES THESE AMOUNTS AS CHARITY CARE. CHARITY CARE IS ALSO PROVIDED THROUGHOUT THE YEAR BASED UPON ACTIVITIES AND SERVICES WHICH THE HOSPITAL BELIEVES WILL SERVE A BONA FIDE COMMUNITY HEALTH NEED.DURING 2013, THE HOSPITAL PROVIDED NUMEROUS OUTREACH PROGRAMS WHICH SERVE AND EDUCATE THE COMMUNITY. THESE INCLUDED:COMMUNITY HEALTH IMPROVEMENT SERVICES: $56,295 SERVING 1,298 PEOPLEHEALTH PROFESSIONS EDUCATION: $2,195, SERVING 1 PERSONSUBSIDIZED HEALTH SERVICES: $3,998,204 SERVING THE COMMUNITYFINANCIAL AND IN-KIND CONTRIBUTIONS: $39,666 SERVING 890 PEOPLECOMMUNITY BUILDING ACTIVITIES: $20,069 SERVING 67 PEOPLECOMMUNITY BENEFIT OPERATIONS: $23,237 SERVING THE COMMUNITY 67258850 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 0 1 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 0 0 1 52 0 1 638 1 1 1 0 0 0 0 0 0 0 0 0 X 14 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X MARY GRIEST CFO 4192077837 663 EAST MAIN STREET ASHLAND OH 44805 DANNY BOGGS PRESIDENT/CEO 35.00 10.00 X X 278968 0 34735 STEPHEN STUART PHD CHAIR 2.00 1.00 X X 0 0 0 HAROLD KEENER PHD VICE CHAIR 2.00 0.00 X X 0 0 0 ANNE BEER SECRETARY 2.00 1.00 X X 0 0 0 KIMBERLY ROYAL DO MEDICAL STAFF VP 2.00 0.00 X 0 148503 26284 MICHAEL MARTIN MD MEDICAL STAFF PRESIDENT 2.00 0.00 X 11000 0 0 PAUL MYERS BOARD MEMBER 2.00 1.00 X 0 0 0 MICHAEL STENCEL MD BOARD MEMBER 2.00 0.00 X 11000 0 0 ROGER KRAMER CPA BOARD MEMBER 2.00 1.00 X 0 0 0 POLLY CHANDLER BOARD MEMBER 2.00 0.00 X 0 0 0 RALPH KELSEY BOARD MEMBER 2.00 0.00 X 0 0 0 TIM COWEN BOARD MEMBER 2.00 1.00 X 0 0 0 TOM MCGEE START 42613 BOARD MEMBER 2.00 0.00 X 0 0 0 ANNETTE SHAW START 82713 BOARD MEMBER 2.00 0.00 X 0 0 0 SUE HEIMANN THRU 62513 BOARD MEMBER 2.00 0.00 X 0 0 0 JERRY SEITER THRU 426 13 BOARD MEMBER 2.00 0.00 X 0 0 0 MICHAEL BANDY 42613 - 103013 BOARD MEMBER 2.00 0.00 X 0 0 0 VICKY STEPHENSON THRU 42613 BOARD MEMBER 2.00 0.00 X 0 0 0 MARY GRIEST VP FINANCE/CFO 40.00 5.00 X 151905 0 22205 CHRISTOPHER HUNT VP CLINICAL SERVICES 40.00 0.00 X 124263 0 13243 ALYCE LEGG VP RESOURCE DEVELOPMENT 40.00 0.00 X 123771 0 16954 PHILIP MYERS MD VP MEDICAL AFFAIRS 40.00 0.00 X 120948 0 19869 JEFFREY COOK DIRECTOR PHARMACY SERVICES 40.00 0.00 X 119025 0 23359 KARIN SCHWAN CNO/VP PATIENT CARE 40.00 0.00 X 117245 0 23936 1058125 148503 180585 12 0 1 0 CERNER CORPORATION PO BOX 412702 KANSAS CITY MO 64141 IT SERVICES 1477110 CARETECH SOLUTIONS PO BOX 674271 DETROIT MI 48267 IT SERVICES 1050259 COMPREHENSIVE MEDICAL MANAGEMENT 1 RIVERFRONT PLACE 6TH FLOOR NEWPORT KY 41071 ANESTHESIA SERVICES 1034507 HMP OF ASHLAND PO BOX 645037 CINCINNATI OH 452645037 HOSPITALISTS 891241 SAMARITAN EMERGENCY PHYS LLP PO BOX 674579 DETROIT MI 482674271 ED PHYSICIANS 720908 15 679117 152479 93479 831596 PATIENT SERVICES 621110 73483519 73483519 RENTS FROM AFFILIATE 900099 186786 186786 73670305 377435 320570 56865 56865 56865 327702 -327702 -327702 -327702 PHARMACY RETAIL 446110 2252756 2252756 OTHER SERVICES- LAB 621500 1107256 115 1107141 ARRA INCENTIVE PAYMENTS 621110 1047439 1047439 788321 458605 329716 5195772 79426836 74717744 2711476 1166020 X 39650 39650 509813 22000 487813 23614490 18891592 4722898 1437885 1150308 287577 6162202 4929762 1232440 1723345 1378676 344669 115924 115924 109657 109657 9749831 9636428 113403 56227 56227 1363193 1097370 265823 233567 233567 3142434 3142434 132536 106029 26507 381011 381011 5801122 5801122 715015 572012 143003 MEDICAL SUPPLIES 14147515 14147515 PROVISION FOR BAD DEBTS 5504863 5504863 OHIO FRANCHISE FEE 1117609 1117609 EDUCATION PROGRAMS 128603 128603 39681 39681 76226173 67258850 8967323 0 14268323 18996271 9140377 6734252 1606139 1649655 1503288 1600291 1923211 1910621 104973138 65191883 42087563 39781255 59979 33488 2319356 2377407 72908236 73083240 7575230 8106103 16625246 15223367 170485 566101 4061320 4081302 28432281 27976873 X 44371927 45022476 104028 83891 44475955 45106367 72908236 73083240 X 3200663 363996 -2934247 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5738 5738 0 PART II-B, LINE 1: MEMBERSHIP DUES IN THE AMOUNT OF $20,259 AND $27,833 WERE PAID TO THE AMERICAN HOSPITAL ASSOCIATION AND THE OHIO HOSPITAL ASSOCIATION, RESPECTIVELY. $4,791 AND $947 OF THE DUES PAYMENTS WERE FOR LOBBYING EXPENSES. 2346208 2346208 17169160 8409755 8759405 2215971 1666899 549072 38676247 29786529 8889718 44565552 25328700 19236852 39781255 COST REPORT SETTLEMENT PAYABLE 3702353 INTEREST RATE SWAP 378949 4081302 X PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE SYSTEM AND RECOGNIZE A TAX LIABILITY IF THE SYSTEM HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS OR OTHER APPLICABLE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE SYSTEM AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2013, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILTIY OR DISCLOSURE IN THE CONSOLIDATED FINANCIAL STATEMENTS. THE SYSTEM FILES FEDERAL AND STATE TAX RETURNS AND IS NO LONGER SUBJECT TO FEDERAL, STATE, OR LOCAL INCOME TAX EXAMINATIONS BY TAX AUTHORITIES FOR THE YEARS BEFORE FISCAL YEAR 2010. 1 1 X 1 X 0 1 1 0 1 1 2331984 775679 1556305 0.02200 6835240 3834737 3000503 0.04240 9167224 4610416 4556808 0.06440 82342 2810 79532 0.00110 2195 2195 0.00000 39666 39666 0.00060 124203 2810 121393 0.00170 9291427 4613226 4678201 0.06610 1783 1783 0.00000 96 96 0.00000 1653 1653 0.00000 16537 16537 0.00020 20069 20069 0.00020 1 5504863 2811 11231287 15693934 -4462647 X 1 1 1 1 SAMARITAN HOSPITAL 1025 CENTER STREET ASHLAND OH 44805 X X X SAMARITAN REGIONAL HEALTH SYSTEM 1 1 X X X X X X X 12 1 0 1 X HTTP://WWW.SAMARITANHOSPITAL.ORG X X X X X X 0 0 1 1 200.000000000000 0 1 X X X X X 1 1 X X X X X 1 0 X X X X 1 X 0 0 SAMARITAN REGIONAL HEALTH SYSTEM PART V, SECTION B, LINE 3: THE FIRST SECTION OF THE CHNA IS A COMMUNITY HEALTH SURVEY OF ASHLAND COUNTY RESIDENTS. THE SURVEY CONSISTED OF FILL-IN-THE-BLANK QUESTIONS DESIGNED TO ELICIT RESPONSES FROM ASHLAND COUNTY RESIDENTS' OPINION OF HEALTHCARE NEEDS IN THE COUNTY. THE SECOND SECTION OF THE CHNA PRESENTS A FOCUS GROUP ASSESSMENT OF STAKEHOLDERS' OPINIONS OF HEALTHCARE NEEDS IN THE COUNTY. THE THREE FOCUS GROUPS INCLUDE MEMBERS OF REPRESENTING BUSINESS AND COMMUNITY LEADERS, MEDICAL PROFESSIONALS AND END USERS- PATIENTS. THE SURVEY AND FOCUS GROUP ASSESSMENTS WERE PERFORMED UNDER THE GUIDANCE AND COLLABORATION OF OSCAR MCKNIGHT, PH.D., A PROFESSOR AT ASHLAND UNIVERSITY AND STATISTICAL CONTRACTOR FOR BUSINESS IN OHIO AND SURROUNDING STATES. DR. MCKNIGHT WAS ALSO THE MODERATOR FOR THE FOCUS GROUPS. SAMARITAN REGIONAL HEALTH SYSTEM PART V, SECTION B, LINE 7: THE ORGANIZATION COMPLETED AN IMPLEMENTATION STRATEGY TO ADDRESS THE NEEDS FROM THE MOST RECENTLY CONDUCTED COMMUNITY HEALTH NEEDS ASSESSMENT AND IS INCLUDED IN THE REPORT UNDER NEXT STEPS. THE REPORT IS POSTED AT HTTP://WWW.SAMARITANHOSPITAL.ORG/ABOUT-US/COMMUNITY-HEALTH-NEEDS-ASSESSMENT. SAMARITAN REGIONAL HEALTH SYSTEM PART V, SECTION B, LINE 12I: INCOME VALIDATION INFORMATION, MONTHLY EXPENSES, AND BANK STATEMENTS ARE USED TO DETERMINE CHARGES TO PATIENTS. DISCOUNT IS DETERMINED BY THE PERCENTAGE OVER THE 200% FPL AND IS DECREASING THE GREATER THIS VARIANCE IS. SAMARITAN REGIONAL HEALTH SYSTEM PART V, SECTION B, LINE 20D: ALL SELF PAY PATIENTS ARE BILLED GROSS CHARGES UNTIL THEY INDICATE AN INABILITY TO PAY. THEY MAY THEN APPLY FOR FINANCIAL ASSISTANCE AND IF THEY MEET THE CRITERIA IN THE POLICY THEIR BILL IS DISCOUNTED OR WRITTEN OFF ENTIRELY.FAP-ELIGIBLE INDIVIDUALS CANNOT BE CHARGED MORE THAN AMOUNTS GENERALLY BILLED TO INDIVIDUALS WHO HAVE INSURANCE COVERING SUCH CARE. 7 SAMARITAN HEALTH & REHAB CENTER 2163 CLAREMONT AVENUE ASHLAND OH 44805 OUTPATIENT PHYS, OCC, SPEECH REHAB KETTERING SAMARITAN HEALTH CENTER 546 NORTH UNION STREET ASHLAND OH 44842 OUTPATIENT ANCILLARY SVC SAMARITAN PROFESSIONAL PARK 2212 MIFFLIN AVENUE ASHLAND OH 44805 OUTPATIENT ENDOSCOPY SAMARITAN PROFESSIONAL PARK 2212 MIFFLIN AVENUE ASHLAND OH 44805 WOMEN'S HEALTH, OCC MEDICINE SAMARITAN PROFESSIONAL PARK 2212 MIFFLIN AVENUE ASHLAND OH 44805 SLEEP LAB, PHYSICIAN OFFICES SAMARITAN BANEY RD OUTPATIENT FACILITY 1941 BANEY ROAD ASHLAND OH 44805 OUTPATIENT ANCILLARY SVCS SAMARITAN ADMINISTRATIVE BUILDING 663 EAST MAIN STREET ASHLAND OH 44805 ADMINISTRATIVE OFFICES PART I, LINE 3C: SAMARITAN'S POLICY INCLUDES FEDERAL POVERTY GUIDELINES ALONG WITH EVALUATION OF MONTHLY EXPENSES AND BANK STATEMENTS TO DETERMINE ELIGIBILITY FOR CHARITY CARE. IN SOME CIRCUMSTANCES WHEN A PATIENT DOES NOT MEET THE CRITERIA, FURTHER DOCUMENTATION MAY BE REQUESTED (RELATED TO INCOME AND EXPENSES), AND THE CFO MAY GRANT A DISCOUNT AS A SPECIAL CIRCUMSTANCE. PART I, LINE 7: CHARITY CARE AND MEDICAID COSTS WERE CALCULATED USING A COST TO CHARGE RATIO USING THE WORKSHEET 2 METHOD TO CALCULATE THE COST TO CHARGE RATIO. PART I, LINE 7G: NOT APPLICABLE PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 5,504,863. PART II, COMMUNITY BUILDING ACTIVITIES: SAMARITAN PROVIDES A NUMBER OF EDUCATIONAL SEMINARS RELATED TO VARIOUS HEALTHCARE TOPICS THAT ARE FREE TO THE PUBLIC. THROUGH THESE EFFORTS THE PUBLIC IN OUR SERVICE AREA RELY ON SAMARITAN FOR BOTH INFORMATION AND THEN TREATMENT. PART III, LINE 4: FINANCIAL STATEMENT FOOTNOTE: AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS ESTABLISHED ON AN AGGREGATE BASIS BY USING HISTORICAL WRITE-OFF RATE FACTORS APPLIED TO UNPAID ACCOUNTS BASED ON AGING. LOSS RATE FACTORS ARE BASED ON HISTORICAL LOSS EXPERIENCE AND ADJUSTED FOR ECONOMIC CONDITIONS AND OTHER TRENDS AFFECTING THE SYSTEM'S ABILITY TO COLLECT OUTSTANDING AMOUNTS. UNCOLLECTIBLE AMOUNTS ARE WRITTEN OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE.THE BAD DEBT ESTIMATE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE FINANCIAL ASSISTANCE POLICY WAS DETERMINED BY USING THE PERCENTAGE OF ACCOUNTS WRITTEN OFF TO BAD DEBT AND LATER REVERSED FROM BAD DEBT TO WRITE OFF AS A CHARITY ACCOUNT. THIS PERCENTAGE WAS APPLIED TO ALL BAD DEBT WRITE OFFS, THEN THE COST TO CHARGE RATIO APPLIED. PART III, LINE 8: MEDICARE REVENUE WAS 64% OF TOTAL REVENUE FOR SAMARITAN FOR 2013. BASED ON A COST TO CHARGE RATIO, THE COST OF PROVIDING CARE TO THE MEDICARE POPULATION IN 2013 WAS $15,693,934. THE PAYMENTS RELATED TO THESE SERVICES TOTALED $11,332,186. THIS LEAVES A MEDICARE SHORTFALL OF $4,361,748 FOR THE YEAR. THIS IS CONSIDERED A COMMUNITY BENEFIT BASED ON THE ELDERLY POPULATION. PART III, LINE 9B: PATIENTS RECEIVE 3 STATEMENTS FOR SELF PAY BALANCES. FOR BALANCES GREATER THAN $200, ONE ATTEMPT IS MADE TO CALL THE PATIENT TO MAKE PAYMENT ARRANGEMENTS. PART VI, LINE 2: FOCUS GROUPS FROM A CROSS SECTION OF COMMUNITY MEMBERS AND KEY STAKEHOLDERS WERE SURVEYED FOR THEIR INPUT. WE ALSO COLLABORATED WITH OTHER NON-PROFIT AGENCIES WHO CONDUCTED SIMILAR STUDIES AND VIEWED THEIR FINDINGS USEFUL AND PRACTICAL. OUR OCCUPATIONAL MEDICINE PROGRAM SERVES INDUSTRY AND FUNCTIONS AS A "LISTENING POST" TO GATHER INPUT FROM OUR BUSINESS COMMUNITY. PART VI, LINE 3: INFORMATION RELATED TO THE CHARITY PROGRAM AT SAMARITAN IS PROVIDED IN A NUMBER OF WAYS. BROCHURES ARE PROVIDED AT EACH POINT OF ADMISSION ALONG WITH THE PUBLICLY POSTED INFORMATION NOTICES. EACH STATEMENT SENT LISTS THE FEDERAL POVERTY GUIDELINES AND WHAT INFORMATION IS NEEDED TO QUALIFY. AN APPLICATION FOR FREE CARE IS ON THE BACK OF EACH STATEMENT SENT TO PATIENTS. PART VI, LINE 4: SAMARITAN REGIONAL HEALTH SYSTEM DEFINES ASHLAND COUNTY AND THE 10 ZIP CODES THAT COMPRISE IT AS OUR PRIMARY SERVICE AREA (PSA). FURTHER, WE INCLUDE AT LEAST ONE ZIP CODE FROM EACH OF THE 5 CONTIGUOUS COUNTIES WITHIN OUR PSA. OUR PSA IS PRIMARILY RURAL WITH GREATER THAN 50% OF THE POPULATION LIVING IN THE 44805 ZIP CODE AREA. AS A COMMUNITY HOSPITAL WE MEET A BROAD RANGE OF NEEDS FOR A COMMUNITY THAT IS DIVERSE IN AGE AND SOCIO ECONOMIC MAKE-UP. OUR COMMUNITY INCLUDES A LARGE AMISH POPULATION AND A DEMOGRAPHIC THAT HAS BEEN SEVERLY IMPACTED BY THE ECONOMIC DOWNTURN DUE TO THE DECLINE IN MANUFACTURING BASE OVER THE PAST SEVERAL YEARS. PART VI, LINE 5: SAMARITAN REGIONAL HEALTH SYSTEM IS VIEWED AS THE LEADER IN THE COMMUNITY FOR PROVIDING INFORMATION THAT LEADS TO EARLY TREATMENT AND BETTER OUTCOMES WITH LOWER ASSOCIATED COSTS. SAMARITAN HAS AN EFFECTIVE EDUCATIONAL PROGRAM (FREE OF CHARGE) THAT GATHERS DIRECT INPUT AS TO THE NEEDS AND CONCERNS OF THE COMMUNITY. PART VI, LINE 6: SAMARITAN REGIONAL HEALTH SYSTEM IS A GENERAL ACUTE-CARE FACILITY LOCATED IN ASHLAND, OHIO WHERE IT OPERATES FOUR MEDICAL OFFICE BUILDINGS, AN OUTPATIENT CLINIC, AN OFFSITE REHAB FACILITY, AND AN ADMINISTRATIVE OFFICE BUILDING. SRHS IS THE PARENT ORGANIZATION OF SAMARITAN PROFESSIONAL CORPORATION AND THE SOLE BENEFICIARY OF SAMARITAN HOSPITAL FOUNDATION.SAMARITAN PROFESSIONAL CORPORATION CONTINUED ITS MISSION TO RETAIN QUALITY PHYSICIANS AND EXPAND SERVICES IN THE COMMUNITY. THE STRUCTURE OF THE ORGANIZATION ENABLED THE PHYSICIANS TO CONTINUE THEIR OPERATIONS AND TO ENHANCE SERVICES PROVIDED BY THE LOCAL HEALTHCARE NETWORK.SAMARITAN HOSPITAL FOUNDATION PROVIDES A PROVISION OF FUNDRAISING AND ASSET MANAGEMENT IN SUPPORT OF SAMARITAN REGIONAL HEALTH SYSTEM. 1 MEDICAL FINANCIAL ASSISTANCE 8 39650 PART I, LINE 2: SAMARITAN REGIONAL HEALTH SYSTEM MAKES CONTRIBUTIONS IN SUPPORT OF ITS RELATED PARTIES AS WELL AS ORGANIZATIONS WITHIN THE COMMUNITY. WHEN A PATIENT APPLIES FOR FINANCIAL ASSISTANCE, THE FINANCIAL COUNSELOR FOLLOWS THE FINANCIAL ASSISTANCE POLICY. IF THE PATIENT IS OVER INCOME GUIDELINES AND MAY NOT BE ABLE TO RETURN TO WORK DUE TO THE ILLNESS, THE FINANCIAL COUNSELOR WRITES AN EXCEPTION LETTER EXPLAINING THE PATIENT'S CIRCUMSTANCES. THIS LETTER IS ATTACHED TO THE SUPPORTING PAPERWORK AND FORWARDED TO THE CFO FOR APPROVAL. AN E-MAIL IS SENT TO THE FOUNDATION OFFICE EXPLAINING THE PATIENT'S CIRCUMSTANCES WITHOUT GIVING PERSONAL INFORMATION. THE OFFICE MAINTAINS A LOG OF ACCOUNTS WRITTEN OFF USING FOUNDATION FUNDS. X 1 1 X X X X X 0 0 0 0 0 0 0 0 0 DANNY BOGGS PRESIDENT/CEO 275738 0 0 0 3230 0 28228 0 6507 0 313703 0 0 0 KIMBERLY ROYAL DO MEDICAL STAFF VP 0 146133 0 2100 0 270 0 16178 0 10106 0 174787 0 0 MARY GRIEST VP FINANCE/CFO 150242 0 0 0 1663 0 16858 0 5347 0 174110 0 0 0 PART I, LINE 1A THE PRESIDENT/CEO RECEIVES HEALTH/SOCIAL CLUB DUES WHICH ARE NON TAXABLE. THE HOSPITAL IS REIMBURSED FOR ANY PERSONAL USE. A COUNTY OF ASHLAND OHIO 346000122 2008-12-19 9500000 ED & OB BUILDING & STRUCTURE RENOVATION & IMPROVEMENTS; EQUIPMENT 1 0 0 B COUNTY OF ASHLAND OHIO 346000122 2009-01-09 4495023 REFUND PRIOR ISSUE 1 0 0 C COUNTY OF ASHLAND OHIO 346000122 2009-01-27 6004977 BUILDING & STRUCTURE RENOVATION; EQUIPMENT 1 0 0 A 2083155 9665616 119942 1744 9543930 2010 0 0 1 1 B 1371923 4495023 4495023 4495023 2006 1 0 1 1 C 1321555 6208273 41424 57 6166792 2011 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 C 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 1 1 FIFTH THIRD BANK 6.900000000000 0 0 0 0 0 B 0 0 1 1 1 1 FIFTH THIRD BANK 6.900000000000 0 0 0 0 0 C 0 0 0 1 1 1 FIFTH THIRD BANK 6.900000000000 0 0 0 0 0 A 0 B 0 C 0 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: COUNTY OF ASHLAND, OHIO DATE THE REBATE COMPUTATION WAS PERFORMED: 04/14/2014 X EQUIPMENT 4 93479 COST OF THE EQUIPMEN 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 THE CFO REVIEWS THE 990 PRIOR TO FILING. THE 990 IS REVIEWED AT THE BOARD OF DIRECTORS MEETING WITH SUFFICIENT TIME TO MAKE ANY AND ALL INQUIRIES REGARDING THE INFORMATION CONTAINED THEREIN. A COPY OF THE FORM 990 IS AVAILABLE TO EACH BOARD MEMBER BEFORE IT IS FILED. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS AND KEY EMPLOYEES ARE REQUIRED TO SIGN A DISCLOSURE OF POTENTIAL CONFLICT OF INTEREST & CONFIDENTIALITY OF INFORMATION AGREEMENT ANNUALLY OR WHEN THEY FIRST JOIN. THE FORMS ARE SENT FROM THE CEO'S OFFICE AND ARE MAINTAINED THERE UPON COMPLETION. SHOULD A CONFLICT OF INTEREST ARISE, A BOARD MEMBER MAY RESIGN FROM THE BOARD DEPENDING ON THE LEVEL OF CONFLICT. IN ADDITION, THE BOARD MEMBER WILL ABSTAIN FROM VOTING AND IF APPROPRIATE WILL BE EXCUSED FROM THE BOARD MEETING DURING THE DISCUSSION REGARDING A POTENTIAL CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 EVERY TWO YEARS, SINCE 2004, AN INDEPENDENT CONSULTANT PERFORMS A MARKET ANALYSIS OF THE SENIOR LEADERSHIP POSITIONS USING THE RESULTS OF AT LEAST THREE INDEPENDENT WAGE SURVEYS. THEIR REPORT IS USED TO DEVELOP/REVISE WAGE RANGES FOR ALL LEADERSHIP POSITIONS. THE INFORMATION IS THEN PRESENTED TO THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS FOR THEIR APPROVAL. DECISIONS REGARDING THE CEO'S COMPENSATION ARE DOCUMENTED IN THE BOARD OF DIRECTOR MINUTES WHEN IT IS APPROVED AS WELL AS A NOTIFICATION THAT IS KEPT IN THE CEO'S FILE. IN THE FALL OF 2010 THE SCOPE WAS EXPANDED AND ALL MANAGEMENT POSITIONS WERE REVIEWED. THE PROCESS FOR DETERMINING COMPENSATION OF THE ORGANIZATION'S CEO AND OFFICERS WAS LAST UNDERTAKEN DURING 2010. THE LAST FULL REVIEW OF SENIOR LEADERSHIP AND DEPARTMENT DIRECTORS WAS COMPLETED IN NOVEMBER 2010 FOR THE APRIL 2011 WAGE CYCLE. THE SAME DATA WAS USED FOR WAGE DECISIONS IN 2012. WAGE INCREASES FOR ALL POSITIONS WERE SUSPENDED FOR 2013; THEREFORE, NO CURRENT REVIEW WAS COMPLETED. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G CONTRACT SERVICES- MEDICAL: PROGRAM SERVICE EXPENSES 5,636,982. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,636,982. CONTRACT SERVICES- NON PATIENT: PROGRAM SERVICE EXPENSES 3,613,063. MANAGEMENT AND GENERAL EXPENSES 111,744. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,724,807. WASTE MANAGEMENT: PROGRAM SERVICE EXPENSES 53,647. MANAGEMENT AND GENERAL EXPENSES 1,659. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 55,306. COLLECTION FEES: PROGRAM SERVICE EXPENSES 332,736. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 332,736. FORM 990, PART XI, LINE 9: TRANSFER TO SAMARITAN PROFESSIONAL CORPORATION -2,874,217. NET ASSETS RELEASED FROM RESTRICTIONS -60,030. FORM 990, PAGE 12, PART XII, LINE 2C THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT AND SELECTION OF THE INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. FORM 990, PAGE 1, PART I, LINE C DOING BUSINESS AS: SAMARITAN HOSPITAL PEOPLES HOSPITAL FORM 990, PAGE 6, PART VI, LINE 16 THERE WAS A PROCEDURE IN PLACE THAT INVOLVED ATTORNEYS IN REVIEWING THE JOINT VENTURE ARRANGEMENT TO ENSURE TAX EXEMPT PROTECTION. SAMARITAN PROFESSIONAL CORPORATION 1025 CENTER STREET ASHLAND OH 44805 341856531 PHYSICIAN BASED HEALTH SERVICES OH 501(C)(3) 3 SAMARITAN REGIONAL HEALTH SYSTEM 1 SAMARITAN HOSPITAL FOUNDATION 663 EAST MAIN STREET ASHLAND OH 44805 341783215 FUNDRAISING AND ASSET MANAGEMENT OH 501(C)(3) 11A SAMARITAN REGIONAL HEALTH SYSTEM 1 SAMARITAN REGIONAL PAIN MANAGEMENT LLC 1025 CENTER STREET ASHLAND OH 44805 462286785 HOSPITAL SUPPORT-MEDICAL SERVICES OH SAMARITAN REGIONAL HEALTH SYSTEM RELATED -7213 101097 0 1 0.51000 1 0 1 0 0 0 0 0 0 0 1 1 0 0 1 0 0 1 1 SAMARITAN PROFESSIONAL CORP A 385260 ACTUAL RENT RECORDED SAMARITAN PROFESSIONAL CORP S 2874417 CASH VALUE SAMARITAN HOSPITAL FOUNDATION C 679117 ACTUAL CONTRIBUTIONS RECEIVED SAMARITAN HOSPITAL FOUNDATION K 228500 ACTUAL LEASE PAYMENT SAMARITAN PROFESSIONAL CORP L 303448 ACTUAL PAYROLL EXPENSE SAMARITAN PROFESSIONAL CORP O 120306 PAYROLL