2011-07-12T20:08:10-05:00 2010-08-31 DELOITTE TAX LLP 1750 TYSONS BLVD MCLEAN VA 221024219 990 2009-09-01 540548200 Mary Immaculate Hospital MARY 7578866758 7007 Harbour View Blvd No 108 Suffolk VA 23435 Gregory Simia 7578866768 2011-07-12 1 Yvette L Woods 7032511000 2009 2016-02-24 21:20:13Z X Patricia Robertson 2 Bernardine Drive Newport News VA 23602 159494017 0 0928 X www.bonsecourshamptonroads.org X 1956 VA Acute Care Hospital 16 14 978 186 284328 -38812 154958 121054 136089866 156084321 -998605 422867 2905717 2619937 138151936 159248179 0 0 42658680 41767384 0 0 82890550 101253767 125549230 143021151 12602706 16227028 119859921 135665655 32401029 31440939 87458892 104224716 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 48174505 55569720 Orthopedics is center of choice for orthopedic care in the Virginia Peninsula and beyond. It includes a continuum of care from pre-operative education through post-op recovery, and is supported by state-if-the-art technology and expert physicians, as well as a comprehensive rehab network. 18802867 15300599 Women and children services provided added capacity and resources so that the needs of the community for OB care would continue to be met. Mary Immaculate also offers advanced nursery services, caring for "specialty" neonates. Bon Secours also offers the largest curriculum of family and parenting classes through its Love & Learn program. 10721460 12907750 Cardiovascular services - a comprehensive Early Detection Center, aimed at identifying cardiac disease early and referring patients to physicians as necessary for prompt and effective treatment, strong relationships with other Bon Secours hospitals for the delivery of advanced cardiac interventions, such as cardiac surgery. 52505551 72021924 Other major services offered by Mary Immaculate include the Hernia Center which is a comprehensive program dedicated to treating hernias. The program specializes in developing treatments based on each patient's individual needs. The program uses the latest innovations and performs many of its procedures using state-of-the-art, minimally invasive techniques. In addition, Mary Immaculate offers Neuroscience, Gastroenterology and Pulmonary services as well a full service 24 hour Emergency Room. 52505551 72021924 130204383 1 1 0 1 0 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 100 0 1 978 1 1 1 0 0 0 0 0 0 0 0 16 14 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 0 1 1 1 1 VA X James Pirtle 7578895717 150 Kingsley Lane Norfolk VA 23505 John H Garrett 4.00 X 0 0 0 Steven B Hopson 4.00 X 0 0 0 Matthew James 4.00 X 0 0 0 Sr M Margaret Jackson 4.00 X 0 0 0 Robert M Yacobi 4.00 X 0 0 0 Susan B Anthony 4.00 X 0 0 0 Sr Lynn Rachelle Pascoe 4.00 X 0 0 0 Timothy J Davis 50.00 X 0 1223989 129362 Sr Pat Heath 50.00 X 0 0 0 Sr Ann M Lutz 50.00 X 0 0 0 Sr Elaine Davia 4.00 X 0 0 0 Paul W Garman 6.00 X X 0 0 0 Jon A Nystrom 6.00 X X 0 0 0 Sister David Ann Niski 6.00 X X 0 0 0 Kasia Grzelkowski 6.00 X X 0 0 0 Patricia Robertson 50.00 X X 0 441620 42145 Gregory Simia 50.00 X 0 404075 51557 Michael Kerner 50.00 X 0 940681 126469 Darlene Stephenson 50.00 X 167784 0 0 Curtis H Smith 50.00 X 121833 0 31947 Karen B Lewis 50.00 X 128792 0 17941 Deborah E Boone 50.00 X 125554 0 28202 Roberta E Nichols-Covin 50.00 X 119090 0 19401 Bonnie Togna 50.00 X 117824 0 31716 Richard Hanson 50.00 X 0 772746 108243 Joseph Buchheit 50.00 X 0 354134 44775 Melinda J Miller 50.00 X 169491 0 5087 950368 4137245 636845 7 1 1 0 Rehabcare Group Inc PO Box 502096 St Louis MO 631502096 Rehab Services 2282022 Tidewater Physicians Multispecialty Grou 860 Omni Blvd Newport News VA 23606 Physician Services 1842316 Anesthesia Associates of Hampton 110 Three Point Ct Yorktown VA 23692 Physician Services 1500000 Wellspring Valuation Partners 123 North Wacker Drive Suite 900 Chicago IL 60606 Operations Consulting 1468486 Aramark CTS Inc 12483 Collections Ctr Dr Chicago IL 60693 Biomedical Engineering 802351 22 24983 96071 121054 Patient Service Rev. 621500 156084321 155799993 284328 156084321 635486 635486 52772 6410 909 52772 5501 58273 58273 32310 244254 675 -244254 31635 -212619 -212619 Joint venture income 900099 1219574 1219574 Cafe/Vending/Dietary 900099 811520 811520 Rehab Services 900099 167148 167148 363422 363422 2561664 159248179 155799993 284328 3042804 409516 368564 40952 32878399 29590559 3287840 1272311 1145080 127231 4781806 4303626 478180 2425352 2182817 242535 77320 69588 7732 61696 55526 6170 21611 19450 2161 4995859 4496273 499586 325484 292936 32548 384947 346452 38495 2081035 1872932 208103 145351 130816 14535 8802 7922 880 2124857 2124857 2876798 2589118 287680 1226542 1103888 122654 Supplies 41813786 37632407 4181379 0 Purchased Services 27897792 25108013 2789779 0 Bad Debt 12728612 12728612 0 0 Equipment Rental 1867872 1681085 186787 0 Repairs 1787666 1608899 178767 0 827737 744963 82774 143021151 130204383 12816768 0 46618514 59109545 15490178 17454271 2772423 3208655 221327 292831 74961199 46578412 29080424 28382787 21877775 23553227 3799280 3664339 119859921 135665655 9573969 9037136 1342425 1311029 13910000 13130000 7574635 7962774 32401029 31440939 X 87000534 103768348 429784 406019 28574 50349 87458892 104224716 119859921 135665655 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 1 0 0 0 0 1 11037 0 1 10574 21611 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: The organization paid dues to the Virginia Healthcare and Hospital Association (VHHA) 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: These organizations disclosed that 23.07% ($6,433) and 23.76% ($4,141) respectively, of their dues were used for lobbying purposes. 28574 22025 250 50349 112350 -83276 500 28574 1.00000 0 0 3352921 3352921 33367240 15373142 17994098 243211 71950 171261 36289873 30244462 6045411 1707954 888858 819096 28382787 Accr Salaries, Wages & Benefits 1040654 LT Liab-Pension Liability 5125758 LT Deferred Rent 208788 Fin 47 LT Asbestos Liab 1587574 7962774 Part V, Line 4: Description of Intended Use of Endowment Funds: Earnings are to used to assist the needy. Part X: Description of Uncertain Tax Positions Under FIN 48: 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. As the organization does not conduct a separate audit of its financial statement, 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 $98,300 and $117,200 of net operating loss carryforwards as of August 31, 2010 and 2009, respectively, which expire in varying periods through 2030 and are available to offset future taxable income. The System's deferred tax assets are fully reserved at August 31, 2010 and 2009. Any changes to the valuation allowance on the deferred tax asset are reflected in the year of the change. 1 1 1 X 1 X 1 1 1 0 1 1 1002513 1002513 0.00770 11286878 8340023 2946855 0.02260 12289391 8340023 3949368 0.03030 283341 5365 277976 0.00210 136698 136698 0.00100 420039 5365 414674 0.00310 12709430 8345388 4364042 0.03340 4628 4628 0.00000 618 618 0.00000 363 363 0.00000 5609 5609 1 3042729 40414680 43167907 -2753227 X 1 1 Mary Immaculate ASC LLC Outpatient Surgery 0.34140 0.49340 Mary Immaculate Hospital

2 Bernardine Dr Newport News VA 23602

X X X X Mary Immaculate Physical therapy Denbigh

14703 Warwick Blvd Suite B Newport News VA 23608

Physical Therapy, Occupational Med In-Motion Boo Williams Sportsplex

5 Armistead Pointe Parkway Hampton VA 23666

Physical Therapy, Occupational Med Mary Immaculate Physical Therapy Victory

101-A Long Green Blvd Yorktown VA 23693

Physical Therapy, Occupational Med Cardiovascular Specialists - McManus

12720 McManus Blvd Ste 201 Newport News VA 23602

Physician Practice Part I, Line 6a: Community benefit information is included in the Bon Secours Hampton Roads Health System newsletter which is published and mailed out three times each year. The report contains a summary of outreach activities, community benefits, uncompensated care, and accomplishments. The newsletters are distributed to approximately 90,000 households. 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 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 7f: The bad debt expense included in Part IX, line 25 and excluded from the "percent of total expense" calculation is $12,728,612. 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 non reimburseable departments. The cost report uses appropriate statistical bases to "step down" support costs to allowable clinical and non reimburseable 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 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 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 approval. 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. Family Focus is a program of MIH, which targets at-risk families for child abuse and helps teach positive parenting skills. MIH employs the director for the program and provides operating funds for two locations. Family Focus, founded by BSHSI and the Bernardine Sisters of the Third Order of St. Francis, is a broad coalition of private and public organizations that provide a continuum of education, prevention and support programming for over 500 families to encourage healthy child development and nurturing environments in the home and community. Faith Community Health Ministries builds on the skills of the registered nurse through additional training in holistic (body, mind and spirit) health services; the faith community nurse partners with the congregational leadership to promote good health by serving as an educator, counselor, referral agent and advocate. Specialized training has also been developed to prepare non-licensed persons to serve in congregational health ministry. Additionally, the Influenza Vaccination Administration program provided 500-750 vaccines for select covenanted partners to host annual vaccine clinics. BSHRHS employs a Director and Coordinator to provide education and support to more than 108 faith communities and 208 registered nurses and lay health promoters. The Let's Get Real (LGR) Program was created by BSHRHS in response to alarming data revealing an excessively high death rate from heart disease among African Americans in Hampton Roads. LGR is a heart health community outreach and education campaign specifically designed to bring valuable information to African-American women and their families. The goal is to raise awareness and lower risk factors for heart disease through culturally sensitive education, healthy cooking demonstrations, baseline and follow-up health screenings & risk-factor assessments and physical activity with an ethnic flair. Program components are centered on Cooking Light nutrition seminars and Tree of Life family history/genealogy research. Part VI, Line 2: Bon Secours Hampton Roads Health System (BSHR) utilizes multiple approaches when assessing community health needs. Typically, BSHR conducts a comprehensive needs assessment every three to five years, looking at the needs for residents of the greater Hampton Roads area, and more specifically for our three hospitals' distinct service areas. Most recently, a comprehensive meta analysis was conducted in partnership with Old Dominion University's School of Community Health Sciences, utilizing national data (Health People 2010, Thomson Reuters Health Status surveys, etc.), state-wide data (infant mortality, etc), local/county data, as well as discussions with leaders of community services organizations such as Consortium for the Immunization on Norfolk's Children (CINCH), Peninsula Institute for Community Health (PICH), Catholic Charities of Eastern Virginia, etc. The compilation identified geographic communities that performed poorly on the majority of health status indicators. Further analysis was then conducted to narrow to some demographic group. As a result, children and adolescents, especially African American, were identified as those with the most health disparity. Combining with the geographic areas of need helped narrow services BSHR could offer to improve the health needs of the communities it serves. Community need assessments are updated using a variety of informational sources including Virginia Health Information (VHI) for state-based performance data, Hammes Company for market and geographic data, Thomson-Reuters Market Expert to retrieve demographic information and trends for the service areas of the various entities within BSHR, patient statistics from our own facilities, etc. While needs may vary by service areas, BSHR always looks for ways to synergize existing services and best practices and deploying them as appropriate to other markets if the identified need is present in another community. This was successfully achieved recently with the Care-a-Van service serving on the Peninsula with plans of expansion to sections of Norfolk and Portsmouth, and the Life Coach program expanding from DePaul to Maryview, thanks to a partnership with Catholic Charities. Part VI, Line 3: BSHRHS is committed to ensuring access to health care services for all. As a health care provider, BSHRHS treats all patients, whether insured, underinsured or uninsured, with dignity, respect and compassion throughout admission, delivery of services, discharge and billing and collection processes. BSHRHS addresses the needs of the uninsured by providing free or reduced fees on hospital services, community outreach efforts to assist with Medicaid and State Child Health Insurance Program enrollment, and free community-based preventive and primary care services. BSHRHS 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). Potentially eligible patients are referred to the Patient Financial Assistance Department for assistance in completing the documentation required to establish eligibility in, and apply for, government insurance programs or the FAP. 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 communitys relative cost of living (Adjusted FPG).For uninsured and underinsured patients with annual family incomes greater than 200% of the Adjusted FPG, the FAP offers 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 communitys relative cost of living. All patients are eligible for a Prompt Pay Discount. In addition, a variety of other potential payment options are available. This patient financial assistance policy is communicated to patients verbally upon registration, visible postings of the policy and brochures in common areas throughout the hospital. The information is also made available in writing to all patients and is promoted on the BSHRHS website at http://bonsecourshamptonroads.com/about/payment_assistance.html. Part VI, Line 4: Bon Secours Mary Immaculate Hospital's primary service area has a population of 372,029 in 2010. The population is expected to grow by 1.9 percent to a total of 378,966 by 2015. Demographic data indicates that 54.3 percent of the population is white, 35.5 percent black, and a Hispanic population of 16,055, or 4.3 percent. The largest ethnic population growth is expected to be among the Hispanic population which will increase by 16.6% percent by 2015. [Data Source: Census data for the state of Virginia for 1990. New projections will be released later this year.] Among age cohorts, the largest growth is expected to be in the 55 - 64 age group, which is expected to increase by 6,396 people, or 12.4 percent of the population by 2015. [Data Source: 2010 Claritas, 2010 Thomson Reuters/Market Expert.]The median household income in 2010 was $54,910, compared to the Virginia average of $61,210 (CY 2008) and the national average of $52,029 (CY 2008). 19.52 percent of the population has a household income of less than $25,000, compared to the Virginia average of 17.47 percent and the national average of 22.28 percent. [Data Sources: Census and 2010 Claritas/SiteReports.com.]Health Conditions - the most prevalent health conditions impacting the primary service area are hypertension, pain/aching of joints and low back pain. The incidence rate for hypertension is 22.46 per 1,000 population, which is 4.5 percent greater than the state wide rate of 22.48 per 1,000. As for pain/aching of joints, the incidence rate is 21.98 per 1,000 which is 314.26 per 100,000 greater than the state wide rate of 22.29. [Data Source: 2010 Thomson Reuters/Market Expert.] In addition, the top five DRGs based on actual inpatient discharges from the defined service area are for major joint replacement, chest pain, severe sepsis, digestive disorders, and heart failure. [Data Source: 2009 & 2010 VA inpatient data.] For minority populations, incidence and death rates are even greater. For example, "In 2006 the death rates per 100,000 population from high blood pressure were 15.6 for white males, 51.1 for black males, 14.3 for white females and 37.7 for black females." [Data Source: American Heart Association.]In addition, the service area's incidence for these diseases is impacted by risk factors, among them smoking and being overweight. 18.1 percent of residents living in Virginia smoke, and 31.7 percent of residents living in eastern Virginia are considered obese.In fiscal year 2010, Mary Immaculate Hospital cared for 8,479 inpatients, and treated 44,695 patients through the Emergency Department. The Emergency Department is open 24 hours a day and available to all persons regardless of ability to pay. Bon Secours Mary Immaculate Hospital participates in Medicare, Medicaid, CHAMPUS, and other government sponsored health care programs including the state SCHIP/FAMIS program for children. Part VI, Line 5: BSHRHS is working to engage and empower the members of the East Ocean View neighborhood to support them in improving their quality of life and holistic health. East Ocean View has historically been one of the roughest neighborhoods in the community. Among the 6,000 residents, more than 25% of the households are at or below the poverty level and over 20% are single parent households. Family violence, gangs, addictions, housing affordability, access to healthcare, and a lack of educational opportunities affect the health of the individuals living in the neighborhood. In FY 10, the BSHRHS Administrative Director of Building Healthy Communities worked to coordinate efforts and to unite the community. The Director has assessed the needs of the community by conducting resident interviews, and community forums. Through this process, working with East Ocean View residents, businesses and faith communities along with other interested organizations, several priority improvement initiatives have been identified. The local food pantry has been renovated and expanded. BSHRHS and the City implemented an Earn-and-Learn program where BSHRHS provided employment to four teens and the City paid their wages via stimulus money. BSHRHS and the City are also pursuing the development of an Intel Computer Clubhouse to provide computer-training and technology opportunities for the community. Habitat for Humanity has been approved to build a Habitat home in the neighborhood with a tentative build time the Summer of 2011. Habitat and the community are considering opportunities for a building blitz in East Ocean View in 2011 where 10-20 homes would be built in improved the neigh neighborhood. As a start to the desired community beautification efforts, a BSHRHS Board member donated over 1,200 bushes that were planted by residents and BSHRHS volunteers last summer. In addition, the groundwork has been laid for the BSHRHS to bring the Care-A-Van program to provide primary care to the uninsured and underinsured of the community. On a longer term basis, discussions are underway with a local organization who is interested in building a health center in the neighborhood. Talks are underway for the development of a playground and park system as well. Part VI, Line 6: BSHRHS operates an emergency room at BSMMC, the Bon Secours Health Center at Harbour View, BSDMC, and MIH that are open 24 hours per day, 7 days per week. In accordance with the bylaws of each of the medical staffs, BSHRHS has an open medical staff with privileges available to all qualified physicians in the region. Board of Directors - The BSHRHS Board of Directors governs facilities located on the Southside of the service area. The BSHRHS Board of Directors is comprised of 17 members. One member, the president of the board, is appointed by Bon Secours Ministries, the Catholic Church sponsor of the health system. The board membership represent expertise in various areas, including finance, real estate, clinical quality, human resources, community outreach, management, representatives from BSHSI and administration. MIH's Board of Directors is comprised of 15 members. Three members are appointed by BSHSI, two are members appointed by the Bernardine Franciscan Sisters, and the others represent expertise in various areas, including finance, real estate, clinical quality, human resources, management, representatives from BSHSI and administration. BSHRHS participates in select investigational research studies by external IRB's that are in compliance with the Catholic Health Care Ethical and Religious Directives. Training and Education of Health Care Professionals is provided through regular CME teaching sessions are provided and open to the entire medical staff. BSHRHS hospitals are training sites for Eastern Virginia Medical School residents in Family Practice. In addition, training for residents specializing in Internal Medicine, Diagnostic Radiology, OB GYN (GYN Surgery), Surgery, Ophthalmology and Emergency Medicine are provided in collaboration with area universities without reimbursement to BSHRHS. BSHRHS sponsors a Certified Nurse Aide training program at BSDMC. Nursing students from area schools as well as North Carolina are provided clinical experience as are EVMS/ODU Physician Assistant students, Surgical Assistant students, Radiology and Respiratory Therapy Students. Pharmacy students from Hampton University students also receive clinical experiences. Our Wound and Skin Nurse precepts RN's going through college sponsored programs to qualify to sit for the National exams. All BSHRHS facilities participate in Medicaid, Medicare, Champus, Tricare, and/or other government-sponsored health care programs to also include the Medallion (Medicaid HMO), Medicare Advantage, and the State and Local Hospitalization (SLH) programs. 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. Activities directly associated with this purpose are considered operating activities. Operating activities also include other incidental services that are closely related to healthcare. VA X X X X X 1 1 0 0 0 0 0 0 0 Timothy J Davis 0 536658 0 665880 0 21451 0 110185 0 19177 0 1353351 0 0 Patricia Robertson 0 277753 0 141790 0 22077 0 32266 0 9879 0 483765 0 0 Gregory Simia 0 287470 0 69599 0 47006 0 24464 0 27093 0 455632 0 0 Michael Kerner 0 467646 0 290947 0 182088 0 99435 0 27034 0 1067150 0 0 Darlene Stephenson 141453 0 25837 0 494 0 0 0 0 0 167784 0 0 0 Curtis H Smith 116448 0 5000 0 385 0 5717 0 26230 0 153780 0 0 0 Deborah E Boone 114125 0 10978 0 451 0 10891 0 17311 0 153756 0 0 0 Richard Hanson 0 407990 0 335679 0 29077 0 80844 0 27399 0 880989 0 0 Joseph Buchheit 0 224034 0 47590 0 82510 0 28800 0 15975 0 398909 0 0 Melinda J Miller 45552 0 10000 0 113939 0 0 0 5087 0 174578 0 0 0 Part I, Lines 4a-b: Melinda Miller received a severance payment of $131,500. Part I, Line 4b: Mary Immaculate Hospital, Inc. participates in a BSHSI sponsored executive retirement program that allows for deposits into additional retirement plans and 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 deposits are made into this plan. Supplemental Information Part III Part I, Line 3: Bon Secours Health System, Inc., a related organization of Maryview Hospital, 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 6 The General Minister and General Council of the Bernardine Sisters of the Third order of St. Francis and Bon Secours Health System, Inc. are the members of Mary Immaculate Hospital. Form 990, Part VI, Section A, line 7a The governing body of Mary Immaculate Hospital is appointed by both members, with Bon Secours Health System, Inc. having the majority vote. Form 990, Part VI, Section A, line 7b Certain authorities of Mary Immaculate Hospital are reserved to its members. Form 990, Part VI, Section B, line 11 The process the organization uses to review the Form 990 consists of a review by Mary Immaculate Hospital's audit and compliance board committee and providing the form to the Mary Immaculate Hospital's board of directors to allow for a thorough review by both before the filing date of July 15, 2011. Mary Immaculate Hospital's audit and compliance board committee and Mary Immaculate Hospital's board of directors will review the Form 990 and ask any additional questions regarding the Form 990 before the return is filed July 15, 2011. Form 990, Part VI, Section B, line 12c Mary Immaculate Hospital 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 Mary Immaculate Hospital. 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 participates 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). Part VI, Section B, Line 14: Document Retention and Destruction Policy While Bon Secours Health System, Inc. does not have a written organization-wide document retention and destruction policy, individual department policies and practices are in place to ensure that each department of the organization maintains their documentation in compliance with state and federal requirements. In addition, any areas responsible for medical records have department policies in compliance with Medicare and HIPAA requirements. An organization-wide policy is currently in place for fiscal year ending August 31, 2011. Form 990, Part VI, Section B, line 15 The compensation committee of the board of Bon Secours Health System, Inc. engages in a comprehensive process for the oversight and management of remuneration for executive employees and disqualified parties of Mary Immaculate Hospital as well as other officers, key employees and highest paid employees. The compensation committee consists of a group of independent board members and engages external counsel to ensure they receive appropriate analysis of market and follow the practices necessary to obtain full compliance with the IRS's rebuttable presumption of reasonableness. The committee establishes and maintains a compensation philosophy, reviews pay practices against local, regional and national healthcare organizations and approves all remunerative decisions for this group of individuals. In addition, the committee receives assurances of the fair market value of all levels of compensation within the organization. The committee validates that incentives and performance based levels 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 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 key employees or highest paid employees 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 Mary Immaculate Hospital 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 officer's and director's 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. Timothy J. Davis' compensation is paid by Bon Secours Health System, Inc., a related organization. The compensation he receives is for his role as Executive Vice President and Chief Administrative Officer of Bon Secours Health System, Inc. Michael Kerner'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 Bon Secours Hampton Roads Health System. Greg Simia's compensation is paid by Maryview Hospital, a related organization. The compensation he receives is for his role as the Chief Financial Officer of Bon Secours Hampton Roads Health System. Patricia Robertson's compensation is paid by Bon Secours Health System, Inc., a related organization. The compensation she receives is for her role as the Executive Vice President of Mary Immaculate Hospital. Sr. Pat Heath and Sr. Anne Lutz do not receive payroll distributions as they have taken vows of poverty. Mary Immaculate Hospital Auxiliary 7007 Harvour View Blvd Ste 108 Suffolk VA 23435 546040266 Auxiliary VA 501(c)(3) Line 11b, Type III-F N/A Mary Immaculate Nursing Center Inc 7007 Harvour View Blvd Ste 108 Suffolk VA 23435 541516476 Nursing Care Center VA 501(c)(3) Line 9: 509(a)(2) N/A Bon Secours Hampton Roads Health System Inc 5818 Harbourview Blvd Suffolk VA 23435 521538513 Local System Parent Org. VA 501(c)(3) Line 11b, Type II: 5 N/A Bon Secours Maryview Nursing Care Center 7007 Harvour View Blvd Ste 108 Suffolk VA 23435 521578169 Nursing Care Center VA 501(c)(3) Line 9: 509(a)(2) N/A Maryview Hospital 7007 Harvour View Blvd Ste 108 Suffolk VA 23707 540506463 Healthcare VA 501(c)(3) Line 3: 170(b)(1)(A) N/A Bayley Properties 150 Kingsley Lane Norfolk VA 23505 541424748 Rental VA 501(c)(2) N/A N/A Bon Secours Health System Inc 1505 Marriottsville Road Marriottsville MD 23707 521301088 Parent Org. Management Services MD 501(c)(3) Line 11b, Type II: 5 N/A Bon Secours DePaul Health Foundation 7007 Harvour View Blvd Ste 108 Suffolk VA 23435 541843876 Fundraising VA 501(c)(3) Line 11b, Type III-F N/A Bon Secours Maryview Foundation 7007 Harvour View Blvd Ste 108 Suffolk VA 23435 521694731 Fundraising VA 501(c)(3) Line 11b, Type III-F N/A Mary Immaculate Foundation 2 Bernadine Drive Newport News VA 23602 311644734 Fundraising VA 501(c)(3) Line 11b, Type III-F N/A Province Place of Maryview LLC One Bon Secours Way Portsmouth VA 23703 541842697 Assisted Living VA N/A Related 0 0 Province Place of DePaul LLC 6403 Granby Street Norfolk VA 23505 541950880 Assisted Living VA N/A Related 0 0 Western Tidewater Diagnostic Imaging LLC c/o Roberts Dean PLC 150 Bousch St Norfolk VA 23510 383655545 Healthcare VA N/A Related 0 0 Professional Health Care Mgmt Inc 150 Kingsley Lane Norfolk VA 23505 541241031 Administrative VA N/A C Tidewater Diversified Inc 160 Kingsley Lane Norfolk VA 23505 541431826 Pharmacy VA N/A C OSF Inc 2 Bernadine Drive Newport News VA 23602 541369919 Rental VA N/A C 1.00000 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0