2012-07-13T11:00:32-05:00 2011-08-31 DELOITTE TAX LLP 1750 TYSONS BLVD MCLEAN VA 221024219 990 2010-09-01 611356023 Our Lady of Bellefonte Hospital Inc OURL 6068333333 St Christopher Drive Ashland KY 41101 Joe Buchheit 6068333600 2012-07-13 1 Laura L Catlett 7032511000 2010 2016-02-24 21:20:13Z Kevin Halter St Christopher Drive Ashland KY 41101 155655404 0 0928 X www.olbh.com X 1999 KY Acute Care Hospital 19 14 1635 150 1574546 -93238 0 941431 148921164 150022362 325050 426499 4297822 4064403 153544036 155454695 0 372800 0 0 56546781 59461273 0 0 0 89177766 87228960 145724547 147063033 7819489 8391662 91664809 98205634 55485081 50715835 36179728 47489799 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 133793625 372800 150286493 To bring compassion to healthcare and to be good help to those in need by providing healthcare services. Please see community benefit disclosures in Sch H. 133793625 1 1 0 1 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 105 0 1 1635 1 1 1 0 0 0 0 0 0 0 0 0 X 19 14 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X Aaron Akers 6068334136 OLBH St Christopher Drive Ashland KY 41101 X Gregory Bausch 4.00 X 0 0 0 Danny BentleyPharmD FACA 4.00 X 0 0 0 Mary Carolyn Carter 4.00 X 0 0 0 William Dickens 4.00 X 0 0 0 Larry Fields MD 4.00 X 9066 0 0 Mary Catherine Flath PhD 4.00 X 0 0 0 John Gross III 4.00 X 0 0 0 Daniel Huffman 4.00 X 0 0 0 Connie Johnson 4.00 X 0 0 0 Larry Jones 4.00 X 0 0 0 Phillip Bruce Leslie Esq 4.00 X 0 0 0 James Martin MD 4.00 X 0 0 0 EW Unnikrishnan MD 4.00 X 0 0 0 William Willan 4.00 X 0 0 0 Elizabeth Keith 50.00 X 0 219843 25709 Lawrence Skip Hubbard CHCIO 50.00 X 0 474728 118294 Kevin Halter 50.00 X X 0 413436 47041 John Wallenhorst 50.00 X X 0 294258 25314 Frank Warnock Esq 4.00 X X 0 0 0 Joe Buchheit 50.00 X 292884 0 41939 Jennifer Moore 50.00 X 250001 0 16810 Emilio A Punzal MD 50.00 X 257526 0 28740 Kevin D Howard MD 50.00 X 229400 0 19493 Chuck D Charles 50.00 X 183337 0 2856 Rodney N Hieneman 50.00 X 153603 0 7704 Thomas G Lyons 50.00 X 147675 0 2518 Mark Gordon 50.00 X 0 459644 57923 Charles Rhodes MD X 0 0 0 Mark Neff X 0 0 0 Thomas Wolf X 0 0 0 Angela Foltz X 0 0 0 1523492 1861909 394341 28 1 1 0 Morrison Management Specialists Inc PO Box 102289 Atlanta GA 303682289 Cafeteria/Food Services 3248200 Ashland Anesthesia PSC PO Box 1377 Ashland KY 411051377 Anesthesia 2829169 Aramark CTS Inc 12483 Collections Center Dr Chicago IL 60693 Equipment maintenance 1703451 Aramark Refreshment Services 1301 Oliver Hill Way Richmond VA 23219 Lift Team Services 1399454 Medical Doctor Association PO Box 277185 Atlanta GA 303847185 Hospitalists Services 1089334 35 256354 685077 941431 Patient Service Rev. 622110 150022362 149630462 391900 150022362 239418 239418 416613 416613 416613 416613 387790 200709 187081 187081 187081 Retail Pharmacy Rev. 446110 2439523 1182646 1256877 Cafeteria/Vending 531120 753611 753611 Comm. Health & Fitness 621610 281841 281841 172815 172815 3647790 155454695 150286493 1574546 2652225 372800 372800 596328 536695 59633 42519092 38267183 4251909 5291874 4762687 529187 7998776 7198898 799878 3055203 2749683 305520 568402 511562 56840 12423 11181 1242 10281704 9253534 1028170 1373871 1236484 137387 1783504 1605154 178350 5950213 5355192 595021 443524 399172 44352 4268174 4268174 7470544 6723490 747054 1544536 1390082 154454 Medical Supplies 20110323 18099291 2011032 Purchased Services 13185867 11867280 1318587 Bad Debt 9727959 9727959 Corporate Dues 3563989 3207590 356399 Taxes & Bus. Licenses 2591070 2331963 259107 4352857 3917571 435286 147063033 133793625 13269408 0 4894049 9071874 14879379 17698609 802885 1290667 3535658 3669259 966986 453826 119375204 64005141 57748486 55370063 7030076 6686874 388320 2150492 3232940 91664809 98205634 12878637 14344504 4114833 3999967 38491611 32371364 55485081 50715835 X 36179728 47489799 36179728 47489799 91664809 98205634 X 8391662 2918408 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 14892 14892 0 Explanation of Other Lobbying Activities: Part II-B, Line 1i: Our Lady of Bellefonte Hospital paid dues to the Kentucky Hospital Association (KHA), Catholic Health Association (CHA), and American Hospital Association (AHA) a portion of which is used for lobbying activities. The portion of dues allocated to lobbying activities for each of these organizations is as follows: 16.2% ($8468) to the KHA, 4.7% ($1367) CHA, and 24.4%($5057) AHA. 4533456 4533456 56918738 21431983 35486755 2528936 1303317 1225619 50927155 38095457 12831698 4466919 3174384 1292535 55370063 Pension Liability 30017514 Mcare/Mcaid Liability 1851165 Other Miscellaneous 502350 Unclaimed Properties 160 Due to Affiliates 175 32371364 Description of Uncertain Tax Positions Under FIN 48: Part X: 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 FIN 48. FIN 48 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 FIN 48 by BSHSI on September 1, 2007 did not have a material impact on BSHSI's consolidated financial statements. As the organization does not conduct a separate audit of its financial statements, below is the related statement from the Bon Secours Health System' Inc. consolidated audited financial statements: The System and most of its subsidiaries (including certain joint venture entities) are exempt from federal income taxes under Section 501(c)(3) of the Internal Revenue Code of 1986, as amended. The system accounts for uncertain tax positions in accordance with ASC Topic 740. Income taxes of the System's for-profit subsidiaries are not material to the accompanying consolidated financial statements. The System's taxable subsidiaries have approximately $89,500 and $98,300 of net operating loss carryforwards as of August 31, 2011 and 2010, respectively, which expire in varying periods through 2031 and are available to offset future taxable income. The System's deferred tax assets are fully reserved at August 31, 2011 and 2010. Any changes to the valuation allowance on the deferred tax asset are reflected in the year of the change. 1 1 X 1 X 1 X 1 1 1 0 1 1 2963463 742250 2221213 0.02150 22563414 18495047 4068367 0.04160 25526877 19237297 6289580 0.06310 32 141120 786478 11581 774897 0.00360 4 254 1403228 166520 1236708 0.00750 1 787337 787337 0.00690 10 5702 19416 19416 0.00030 47 147076 2996459 178101 2818358 0.01830 47 147076 28523336 19415398 9107938 0.08140 3 1270 9299 9299 0.00010 3 205 231143 231143 0.00170 2 1222 6265 6265 0.00000 7 21382 202499 202499 0.00150 3 13722 69345 69345 0.00050 1 250 1427 1427 0.00000 1 603 603 0.00000 20 38051 520581 520581 0.00380 1 2460981 41032642 42666709 -1634067 X 1 1 1 1 Our Lady of Bellefonte Hospital Inc

St Christopher Dr Ashland KY 41101

X X X NA 1 10 Bellefonte Home Health Care Agency

1819 Ashland Road Greenup KY 41144

Home Health OLBH Pediatric Rehabilitation Clinic

1629 Ashland Road Unit 2 Greenup KY 41144

Pediatric Rehab Sleep Lab

118 St Christopher Drive Ashland KY 41101

Sleep Lab Bellefonte Behavioral Health

St Christopher Drive Ashland KY 41101

Behavioral Health Bellefonte Center

1000 Ashland Drive Ashland KY 41101

Holds Med. Records, Registration, Billing, Finance, HR, Physician Prac. Admi Renaissance Sleep Lab

2920 Winchester Avenue Ashland KY 41101

Sleep Lab Ironton MRI

1015 East Ring Road Ironton OH 45638

Imaging Center Vitality Center

St Christopher Drive Ashland KY 41101

Cardio/Vascular Rehab Same Day Surgery Center

1101 St Christopher Drive Ashland KY 41101

Surgery Center Med Plaza Pharmacy

700 St Christopher Drive Ashland KY 41101

Pharmacy Part I, Line 6a: Bon Secours Kentucky Health System annually develops a report to the community, explaining the various community benefit services and programs that exist. This report also includes the annual financial commitment of the local system to the community, detailing monetary contributions for government sponsored healthcare shortfall, community benefit programs and charity care at cost. This report is published each year and posted on the web at http://www.olbhfoundation.com. Part I, Line 7: 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 recorded in the 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, Line 7g: Primary Care Clinic Subsidy: Bellefonte Physician Services, Inc. ("BPS"), in conjunction with Our Lady of Bellefonte Hospital, employs 49 providers in order to offer quality healthcare to the residents of Eastern Kentucky, more specifically Boyd, Greenup, and Carter Counties. BPS providers offer healthcare services to patients who are either uninsured or are covered by Medicaid, which equals approximately 12% and 23% of our overall patient population, respectively. Part I, L7 Col(f): The bad debt expense included in Part IX; line 25 and excluded from the "percent of total expense" calculation is: $9,727,959 Part II: Healthy Community Initiative: BSKHS commitment to social and economic justice is integrated into the fabric of the organization through its Strategic Quality Plan and its common vision of a healthy community. Our vision of a healthy community is embodied in the following statements. A healthy community is a good place to live for all residents. The rich diversity of cultures and capacities of the community are celebrated and mobilized, with a particular concern for the poor, marginalized and dying, to create physical and social environments that promote families, nurture youth and support senior citizens. Individuals have the opportunity to fully participate in defining holistic well-being and assuming responsibility for the development of their innate potential.BSKHS is working to engage and empower the members of the Argillite community located in Greenup County to support them in improving their quality of life and holistic health. The Director of Healthy Community Initiatives is coordinating efforts to unite the communities and aid in health and social issues. The Director is assessing the needs and assets of the communities through resident interviews, community forums, surveys and focus groups. With this data, the community members will choose the priority improvement initiatives that residents and supporting organizations want to address.Argillite is a rural community with approximately 1,000 residents. Single-family homes and trailers prevail. 47% of the households make less than $25,000 per year with 17% of that number making less than $15,000 annually. Forty-three percent of residents have no high school diploma; 16% of that number have less than a 9th grade education. Argillite Elementary has 68% of students receiving free and reduced lunch. One of the first initiatives was a summer feeding and reading program for children in collaboration with the Greenup County Schools Family Resource and Youth Service Center. Other community projects include distribution of free dictionaries and books to students and Thanksgiving food baskets to needy families; a Back pack program to assist low income students with school supplies and clothes and funding for a weekend snack sack program that provides students most at risk of going hungry with food during the weekend. A walking track was built in the community to provide a safe area for residents to exercise in close proximity to where they live.The Ironton, Ohio community is a small urban area of approximately 25,000 residents. The once thriving city with abundant jobs in the steel and industrial areas is now in a situation of high unemployment, low job opportunities and a strapped city budget with an aging infrastructure. The 9th street community is home to subsidize housing for seniors and families; high crime rates and drug abuse are taking a toll on the residents. One of the first initiatives was the purchase of computers for senior housing recreation rooms and a community center used by students and families. Financial support for a cash strapped after school program allowed services to be provided three days a week to low income students needing assistance with homework and providing a safe environment for students. Students participating in summer youth activities at the community center will have the opportunity to go on fieldtrips, safe summer day camp activities and mentors to work with on various topics. Part III, Line 4: Part III, line 2: Bad Debt Expense at cost is computed by applying the cost-to-charge ratio computed on Worksheet 2 to the aggregate bad debt expense for patient accounts recorded in the general ledger. 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 hospitals 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 8: Part III, Line 6: 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 8: The organization feels the total shortfall of Medicare reimbursement compared to computed Medicare allowable costs should be treated as community benefit. The hospital improves access to patient care by providing services regardless of a patients ability to pay or the hospitals ability to receive full cost reimbursement for services. The hospital also relieves the government of a financial burden when it provides care to publically insured patients where reimbursement is less than cost of providing the service. 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 patients account(s). If partial assistance is provided, the patient is responsible for the adjusted account balance and collection efforts will follow the established practices for all patients where a self-pay balance exists. Collection efforts are not pursued on any pending FAP account.Specific criteria exist for how much financial assistance, partial or total, will be provided to the patient based on the assessed need. Criteria is based on Federal Poverty Guidelines and is reviewed and updated annually. Once a patient has been deemed eligible for the Patient Financial Assistance Program (FAP), the patient is notified by letter within 60 days after receipt of the application and supporting documentation. The patient retains eligibility for a period of twelve months from the date of the application. This eligibility is signaled to hospital admissions, billing and collection staff by the assignment of a specific financial class with accompanying eligibility dates. At the end of those twelve months, the patient is responsible for reapplying for FAP eligibility. Part VI, Line 2: Bon Secours Kentucky, Our Lady of Bellefonte Hospital (OLBH) uses multiple approaches to assess the health needs of the communities it serves. We have a community based Board of Directors that provides the hospital with guidance and input on services needed in the local community through contacts with local business and government leaders. Community health screening data is gathered through the year and analyzed for use in planning. Community need assessments are updated using a variety of informational sources including Kentucky Health Information for state-based performance data, Kentucky Hospital Association info site for market and geographic data bases, third party data bases, US Census Bureau data and Thomson-Reuters Market Expert is used to retrieve demographic information and trends for the primary and secondary service areas pertaining to Our Lady of Bellefonte Hospital. We have also developed regional alignment plans using this data and tying it to our underserved areas to plan for future growth in the communities we serve by providing more access points for patients in our service areas.Our primary service area consists of Boyd, Greenup, and Carter Counties in Kentucky and Lawrence County in Ohio. Our secondary service area consists of Lewis County, Kentucky and Scioto County, Ohio. We continually update our information for our market share and physician planning to offer services in underserved areas of our region utilizing hospital data including emergency department visits for our uninsured adult population that needs primary care services. OLBH has been instrumental in developing programs to meet the needs of uninsured and low income families. A free health care clinic Northeast Kentucky Care Center (NEKCC), serves uninsured adult residents of Boyd and Greenup Counties. OLBH has provided the clinic with financial support, volunteer personnel, and supplies. A van ministry that provides free non-emergency medical transportation for outpatient services at our campus and primary care centers; developing the Greenup County Interagency Council; a county drug task force, Greenup Residents Ending Addiction Together (GREAT); church partnerships with 52 churches to develop health ministry and/or faith community nursing programs; and our support of the previously mentioned Northeast Kentucky Care Center and Greenup County Health Department MAPP project. The most recent comprehensive community needs assessment for our tri-state area was a collaborative effort by the Lewis College of Business at Marshall University in Huntington, WV, and the River Cities Community Health Coalition. Conducted in 2002, a survey questionnaire of 88 questions was jointly developed and then administered by telephone to a random sample of households in the 12-county, tri-state area that comprises the River Cities (Ashland, KY; Huntington, WV; and Portsmouth, OH). Significant findings include:-Nearly 30% of respondents did not participate in any kind of physical activity.-Nearly 50% of respondents were trying to lose weight.-It had been more than one year since 20% of respondents had had their blood pressure checked.-Slightly over 25% of the survey respondents smoked cigarettes and over 80% of these respondents said they would like to quit smoking if they could.-33% of male respondents had not had prostate or testicular cancer screening.-36% of female respondents over the age of 40 had never had a mammogram.-52% of respondents had not had a tetanus shot in the past 10 years.-Nearly 24% of respondents said they had never had their cholesterol checked by a health professional.-Almost 43% of the overall survey respondents said they had needed medical care but did not seek it because of a lack of money, lack of insurance or lack of transportation.OLBH is currently partners with the Greenup County Health Department in its MAPP (Mobilize for Action through Planning & Partnerships) project which is a state mandated program that will result in a comprehensive community health plan for each county in Kentucky. OLBH is conducting a community needs assessment conducted on Survey Monkey is being distributed to local organizations, business leaders, non-profit organizations and other community organizations. OLBH staff members are being ask to participate as community members and the survey will be offered to local community residents in the spring by internet or through a paper version by mail, plans to reach local residents is an ongoing effort to receive feedback from a wide range of individuals in our local service area. 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), as adjusted by the Medicare geographic wage index for each community served to reflect that community's relative cost of living (Adjusted FPG). Adjustments to these guidelines are made in certain States, where applicable. 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 patients 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. The standard sliding scale is adjusted by the Medicare geographic wage index of each community served to reflect that community's relative cost of living. All patients are also eligible for a Prompt Pay Discount. In addition, a variety of other potential payment options are available. Bon Secours is dedicated to meeting the needs of non-English speaking patients by having on-site Spanish translators, and other language translation services. In addition, Bon Secours employs a telephone language service which assists in meeting any language needs that arise. The translation services are offered to non-English speaking patients from admission to discharge, including the financial process. Part VI, Line 4: Bon Secours Kentucky Health System (BSKHS) serves a region of approximately to 400,000 people in northeastern Kentucky, southern Ohio, and western West Virginia. The service areas includes six counties in northeastern Kentucky (Greenup, Boyd, Lawrence, Carter and Elliott which comprise the FIVCO Area Development District as well as Lewis County); two counties in southern Ohio (Lawrence and Scioto counties); and Wayne and Cabell counties in western West Virginia. Due to our growing aging population, services for our community residents aged 55 and older are needed, particularly womens health, orthopedics, diabetes, cardiopulmonary services and wound care. Major trends in the service area indicate a stable population that is aging. The 55 and older population is expected to increase by 14% over the next five years. The younger population tends to leave the area to find jobs. The high poverty and high unemployment rate in the area result in a low socioeconomic status. It is a very industrialized region which creates carcinogens and unhealthy life styles especially in eastern Kentucky which has some of the highest incidences in the country of smoking, diabetes, obesity and carcinogens. These demographic characteristics create a high demand for chronic disease health care including diabetes, cancer and heart disease among others. Part VI, Line 6: BSKHS' hospital, Our Lady of Bellefonte Hospital, operates an emergency room that is open 24 hours 7 days a week to all persons regardless of ability to pay. Three years ago, the hospital implemented the 30-minute guarantee that patients will be evaluated within 30 minutes of their arrival. This access to care guarantee continues to be the benchmark of performance. Our Lady of Bellefonte Hospital has an open medical staff with privileges available to all qualified physicians in the area.In FY11, Healthy Community Services conducted 94 health fairs and screenings. All participants in our health fairs received personal health counseling and those with abnormal results received appropriate educational materials and the offer of assistance in finding a health care provider if they had none. Participants were given a copy of their screening results and encouraged to share these results with their health care provider. Additionally, the services of our Diabetes Center, Firm Fitness and the Human Motion Vitality Center, and nutrition services were recommended when appropriate. Information about the Northeast Kentucky Care Center, our local "free" clinic was also given to participants who were uninsured or couldn't afford a health care provider.Faith Community Health Ministry: We currently partner with 50 local churches in health ministry and about 19 additional congregations are on our mailing list. A significant number of our health fairs and community flu shot clinics were held in our partnering congregations. Additionally, our congregational partners receive a monthly mailing that provides an article suitable for their church newsletter that blends scripture with timely health education. Information about health issues and events at the local, state and national levels is also included in the mailing. This includes information about advocacy and resources that might benefit members of the congregation. We also provide weekly Wellness Tips for Body, Mind and Spirit that can be used in church bulletins. Our mailing is also shared with the Kentucky Parish Nurse Network and the BSHI Parish Nurse Network which significantly increases the number of congregations we reach. We are planning our first Basic Parish Nurse Education course for summer of 2012. This will consist of three 1 1/2 day sessions scheduled one month apart. Transportation Services: Our Healthy Community Services Van Ministry provides free non-emergency medical transportation to patients who are receiving outpatient services at our campus or who have appointments with campus or Bellefonte Physician Services-affiliated physicians. We also provide transportation to our primary care centers. The program is staffed with one full-time and two part-time drivers. We have two vans including one that is equipped with a wheelchair lift. This has been an invaluable service to our community as there is severely limited public transportation to our campus. There are virtually no options, other than ambulance transport, for patients who require transport in a wheelchair. In FY11, the number of "round trips" we provided increased from 1,704 in FY10 to 2,013 and we traveled nearly 9,000 more miles in FY11 than in FY10.Community Health Education programs: Healthy Community Services provides our community CPR classes. In FY11 we provided 14 classes and certified 91 individuals in CPR. We provided one Safe Sitter class in FY11 resulting in 15 certified Safe Sitters. We also offered a parish nurse conference and retreat with 13 nurses in attendance and a diabetes education program to the Salvation Army's Home League. The Salvation Army is one of our health ministry partners and 15 ladies attended this program.BSKHS provides a Women's Services mobile clinic that offers mammography screening Additionally, Healthy Community Services provides bone density screening monthly at the Greenup County Health Department. In FY2011, we served 74 women at the health department identifying 16 in the pre-osteoporosis or osteoporosis range. One of our primary care physicians volunteered two times a month at Northeast Kentucky Care Center, our local free clinic, throughout FY2011. He supervises our medical students and they were also involved in the clinic experience. Our Healthy Community Services director also volunteers monthly at the clinic and serves on their board.Children and Youth Services: Healthy Community Services participated in our 13th Annual Bicycle Safety Camp in FY 2011 serving 50 children. We also provided educational programs at both end-of-school activities and back-to-school events such as Ready fest in both Greenup and Boyd Counties. We trained 15 young people to be Safe Sitters in FY2011. Primary Care Clinic Subsidy: Bellefonte Physician Services, Inc. ("BPS"), in conjunction with Our Lady of Bellefonte Hospital, employs 49 providers in order to offer quality healthcare to the residents of Eastern Kentucky, more specifically Boyd, Greenup, and Carter Counties. BPS providers offer healthcare services to patients who are either uninsured or are covered by Medicaid, which equals approximately 12% and 23% of our overall patient population, respectively. Part VI, Line 7: 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 four goal areas for the current three year period (2010-2012). One of those goals is to partner with communities to co-create a more humane world, improve health and model social justice. To accomplish this, two key strategies are to: - Engage communities to identify needs and assets and building partnerships to improve health and quality of life of a specific population.- Demonstrate sustainable stewardship for healing the earth as a way to improve health and life quality.As a member of the Catholic health ministry and a member of Bon Secours Health System, Inc. (BSHSI), Bon Secours Kentucky Health System (BSKHS) is called to continue the healing ministry of Jesus. BSKHS exists 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." BSKHS shares 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 within BSKHS. Reports Filed With States Part VI, Line 7 KY 1 OLBH Foundation St Christopher Drive Ashland KY 41101 521301088 501(c)(3) 372800 General and Administrative Support 1 0 X X X X X 0 1 0 0 0 0 0 0 0 Elizabeth Keith 0 158496 0 59911 0 1436 0 17705 0 8004 0 245552 0 0 Lawrence Skip Hubbard CHCIO 0 365557 0 102880 0 6291 0 96117 0 22177 0 593022 0 0 Kevin Halter 0 299973 0 90885 0 22578 0 18675 0 28366 0 460477 0 0 John Wallenhorst 0 222021 0 49904 0 22333 0 15504 0 9810 0 319572 0 0 Joe Buchheit 229525 0 41221 0 22138 0 19617 0 22322 0 334823 0 0 0 Jennifer Moore 184313 0 42734 0 22954 0 7380 0 9430 0 266811 0 0 0 Emilio A Punzal MD 193302 0 63968 0 256 0 3972 0 24768 0 286266 0 0 0 Kevin D Howard MD 154232 0 37570 0 37598 0 4296 0 15197 0 248893 0 0 0 Chuck D Charles 154647 0 26543 0 2147 0 2856 0 0 0 186193 0 0 0 Rodney N Hieneman 130348 0 23159 0 96 0 7704 0 0 0 161307 0 0 0 Thomas G Lyons 137250 0 9732 0 693 0 2304 0 214 0 150193 0 0 0 Mark Gordon 0 334541 0 101237 0 23866 0 30227 0 27696 0 517567 0 0 Part I, Line 4b The filing organization participates in a BSHSI sponsored executive retirement program that allows for deposits into additional retirement plans and is available only to officers and key employees. The 457F plan is a non-qualified plan and is subject to a minimum three-year service requirement before vesting on deposits are made into this plan. Supplemental Information Part III Part I, Line 3: Bon Secours Health System, Inc., a related organization of Our Lady of Bellefonte Hospital, Inc., uses the following to establish the compensation of the organization's CEO/Executive Director: Compensation Committee Independent compensation consultant Written employment contracts Compensation survey or study Approval by the board/compensation committee Form 990, Part VI, Section A, line 2 Board members Philip B. Leslie and Frank Warnock have a business relationship. Form 990, Part VI, Section A, line 6 Bon Secours Health System, Inc. is the sole member of Bon Secours Kentucky Health System, which in turn is the sole member of Our Lady of Bellefonte Hospital, Inc. Form 990, Part VI, Section A, line 7a The governing body of Our Lady of Bellefonte Hospital, Inc. is appointed by its Member, Bon Secours Kentucky Health System, Inc. and subject to approval by Bon Secours Health System, Inc. Form 990, Part VI, Section A, line 7b Certain authorities of Our Lady of Bellefonte Hospital, Inc. are reserved to its member or to Bon Secours Health System, Inc. Form 990, Part VI, Section B, line 11 The process the organization uses to review the Form 990 consists of a review by the local system's audit and compliance board committee and providing the form to the local system board of directors to allow for a thorough review by both before the filing date of July 16, 2012. 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 July 16, 2012. 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 15 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 the BSHSI. The compensation committee consists of a group of independent board members and engages 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. Form 990, Part VI, Section B, Line 15b - 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 positions of other officers or key employees of the organization were compared to similar position market data in comparably situated organizations taking into consideration geographic location and organization size where appropriate. During the review and approval of the compensation, documentation of the decision was recorded in human resources. Form 990, Part VI, Section C, line 19 Our Lady of Bellefonte Hospital, Inc. provides any documents open to public inspection upon request. Form 990, Part VII: Hours worked are not tracked on an entity by entity basis. All officers' and directors' hours reported on Form 990, Part VII, Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors represent aggregate hours worked per week. Volunteer Board Members are not compensated for their time. Voluntary Board Members are not compensated for their time. Kevin Halter's compensation is paid by Bon Secours Health System, Inc., a related organization. The compensation he receives is for his role as the CEO of Bon Secours Kentucky Health System, which includes direct management, monitoring and oversight of Bon Secours Kentucky Health System and its related organizations. John Wallenhorst's compensation is paid by Bon Secours Health Systems, Inc., a related organization. The compensation he receives is for his role as the VP of Mission & Ethics at Bon Secours Health Systems, Inc. Elizabeth Keith's compensation is paid by SFH, Inc., a related organization of Bon Secours Health System, Inc. The compensation she receives is for her role as the SVP, Mission Services at SFH, Inc. Lawrence "Skip" Hubbard's compensation is paid by Bon Secours Health System, Inc., a related organization. The compensation he receives is for his role as the Chief Information Officer of Bon Secours Health System, Inc. Mark Gordon's compensation is paid by Bon Secours Health System, Inc., a related organization. The compensation he receives is for his role as the Chief Executive Officer of St. Francis Medical Center, a related organization. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized gains on investments: 316,112. Minimum Pension Liability 6,748,545. Other Changes in Unrestricted Net Assets -84,081. Transfers to affiliates -4,062,168. Total to Form 990, Part XI, Line 5: 2,918,408. Bon Secours Health Systems Inc 1505 Marriottsville Rd Marriottsville MD 21104 521301088 Parent Org. Management Services MD 501(c)(3) 11b Bon Secours Inc 0 Bellefonte Physician Services Inc 1000 St Christopher Drive Ashland KY 41101 352320780 Physician Practices KY 501(c)(3) 3 Bon Secours Kentucky Health System 0 Our Lady of Bellefonte Hospital Foundation 1000 St Christopher Drive Ashland KY 41101 611381952 Grant Making Foundation KY 501(c)(3) 9 Bon Secours Kentucky Health System 0 Bon Secours Kentucky Health System 1000 St Christopher Drive Ashland KY 41101 611356024 Local System Parent Org. KY 501(c)(3) 11b Bon Secours Health System Inc 0 Our Lady of Bellefonte Hospital Auxiliary 1000 St Christopher Drive Ashland KY 41101 610488859 Fundraising for Our Lady of Bellefonte Hospital KY 501(c)(3) N/A 0 0 1 1 0 0 0 0 0 1 0 0 1 0 0 1 0 1 0