2024-05-15T15:30:27-05:00 2023-06-30 135565207 KPMG LLP 301 MAIN STREET SUITE 2150 BATON ROUGE LA 70801 990 2022-07-01 640303091 ST DOMINIC - JACKSON MEMORIAL HOSPITAL STDO 6012006570 969 LAKELAND DRIVE JACKSON MS 392164699 SAM SCOTT REGIONAL CFO 6012006570 2024-05-14 1 SAM SCOTT 999009999 0 RYAN HOOKS P00746825 2253444000 2024-05-14 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z 969 LAKELAND DRIVE JACKSON MS 392164699 554438669 0 X WWW.STDOM.COM X 1946 MS TO PROVIDE FOR THE CARE OF THE ILL, INJURED, OR DISABLED PERSONS, AND TO PROVIDE FOR RESEARCH, EDUCATION, AND FOR THE ENHANCEMENT OF HEALTH OF THOSE IN THE COMMUNITY. 15 9 4062 259 457959 0 11779404 7167444 530365163 530787522 -2121726 2940635 9747841 4720867 549770682 545616468 2381455 526950 0 0 284102007 265022579 0 0 0 310240020 371660584 596723482 637210113 -46952800 -91593645 457480771 403117319 230428767 293375103 227052004 109742216 X INSPIRED BY THE VISION OF ST. FRANCIS OF ASSISI AND IN THE TRADITION OF THE ROMAN CATHOLIC CHURCH, WE EXTEND THE HEALING MINISTRY OF JESUS CHRIST TO GOD'S PEOPLE, ESPECIALLY THOSE MOST IN NEED. WE CALL FORTH ALL WHO SERVE IN THIS HEALTHCARE MINISTRY, TO SHARE THEIR GIFTS AND TALENTS TO CREATE A SPIRIT OF HEALING - WITH REVERENCE AND LOVE FOR ALL OF LIFE, WITH JOYFULNESS OF SPIRIT, AND WITH HUMILITY AND JUSTICE FOR ALL THOSE ENTRUSTED TO OUR CARE. WE ARE, WITH GOD'S HELP, A HEALING AND SPIRITUAL PRESENCE FOR EACH OTHER AND FOR THE COMMUNITIES WE ARE PRIVILEGED TO SERVE. 0 0 502257361 0 527597609 THE ST. DOMINIC - JACKSON MEMORIAL HOSPITAL PROVIDES QUALITY HOSPITAL AND MEDICAL SERVICES TO ITS PATIENTS. IN THE CURRENT YEAR, SERVICES WERE PROVIDED FOR 130,811 PATIENT DAYS, 45,619 EMERGENCY ROOM VISITS AND 21,455 INPATIENT DISCHARGES. THE MEDICAL CENTER IS AN ACTIVE, CARING MEMBER OF THE COMMUNITIES IT SERVES. IN CARRYING OUT ITS MISSION, THE MEDICAL CENTER HAS ESTABLISHED A POLICY UNDER WHICH IT PROVIDES CARE TO NEEDY MEMBERS OF ITS COMMUNITIES. ADDITIONAL COSTS WERE INCURRED FOR PARTICIPATION IN PROGRAMS WHICH, IN SOME CASES, PAY AMOUNTS LESS THAN THE COST OF PROVIDING SERVICES. 526950 526950 THE HOSPITAL SERVES THE COMMUNITY IN NUMEROUS WAYS. SOME EXAMPLES INCLUDE ASSISTING IN EDUCATING THE COMMUNITY REGARDING HEALTH-RELATED ISSUES. 502784311 1 1 0 0 0 0 0 0 0 0 1 1 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 1 1 1 0 0 0 1 0 0 4062 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 15 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 0 X SAM SCOTT 6012006570 969 LAKELAND DRIVE JACKSON MS 392164699 JOHNNY DONALDSON VICE CHAIR 0.75 0.00 X X 0 0 0 SISTER M TRINITA EDDINGTON OP SECRETARY 0.75 40.50 X X 0 0 0 JEFF FLETCHER CHAIR 0.75 0.00 X X 0 0 0 RICK GUYNES MD BOARD MEMBER 1.00 0.00 X 0 0 0 REGINALD MARTIN MD BOARD MEMBER/PHYSICIAN 40.00 0.00 X 337888 0 38100 REBEKAH MOULDER MD BOARD MEMBER/PHYSICIAN 40.00 0.00 X 772889 0 17360 SISTER ROSE MIRIAM SCHULTE OP BOARD MEMBER 0.75 1.00 X 0 0 0 D PAUL SEAGO MD BOARD MEMBER/PHYSICIAN 40.00 0.50 X 974725 0 34517 SISTER KARINA DICKEY OP BOARD MEMBER 0.75 0.00 X 0 0 0 SISTER DOROTHEA SONDGEROTH OP BOARD MEMBER 0.75 41.50 X 0 0 0 MONSIGNOR ELVIN SUNDS BOARD MEMBER 40.00 0.00 X 0 0 0 SISTER KATHLEEN ANNE TAIT OP BOARD MEMBER 0.75 0.00 X 0 0 0 STEVEN GREMILLION MD BD MEMBER/FMOLHS EVP CMO 0.75 40.00 X 0 929358 40368 SCOTT KASHMAN MARKET PRESIDENT (UNTIL 7/22) 40.00 2.50 X X 610569 0 97937 GENE LOPER MD BOARD MEMBER/PHYSICIAN 5.00 0.00 X 35825 0 0 BRYAN MILLER MD BD MEMBER/FMOLHS VP CHIEF CTO 0.75 41.00 X 0 421403 33362 KRISTIN WOLKART INTERIM MARKET PRESIDENT (START 7/22) 0.75 42.50 X X 0 575846 115578 SAMUEL SCOTT SVP, CFO 41.50 0.00 X 484817 0 32087 THU PHAN VP COO 40.00 0.00 X 287070 0 22259 JOHN LANCON PHYSICIAN 40.00 0.00 X 1301731 0 43100 BRYAN A GASPARD PHYSICIAN 40.00 0.00 X 979749 0 41008 PB KERR PHYSICIAN 40.00 0.00 X 1116047 0 40400 ZACHARY BALDWIN PHYSICIAN 40.00 0.00 X 757978 0 40400 DAVID THEODORO PHYSICIAN 40.00 0.00 X 1018412 0 33356 LESTER DIAMOND FORMER PRESIDENT 0.00 0.00 X 0 531654 0 ROBERT NELSON FORMER VP CHIEF NURSING OFFICER 0.00 0.00 X 287127 0 14410 WILLIAM MORGAN FORMER COO 0.00 0.00 X 171654 0 0 9136481 2458261 644242 470 1 1 0 PHYSICIANS ANESTHESIA GROUP PA PO BOX 3749 JACKSON MS 39207 PROFESSIONAL SERVICES 7289029 AYA HEALTHCARE INC 5930 CORNERSTONE COURT WEST SAN DIEGO CA 92121 AGENCY CONTRACT LABOR 6554852 TRIMEDX INC PO BOX 636129 CINCINNATI OH 45263 BIOMED SERVICES 6446797 SAVISTA LLC P O BOX 676188 DALLAS TX 75267 REVENUE CYCLE SERVICES 4018706 JACKSON HEART CLINIC PA PO BOX 5169 JACKSON MS 39296 PROFESSIONAL FEE SERVICES 3889941 96 5652761 250741 1263942 7167444 PATIENT SERVICE REVENU 621990 523509470 523509470 OTHER PROGRAM SERVICE 621990 4062466 3604507 457959 CAFETERIA 722514 2576368 2576368 LAB 621990 483632 483632 VENDING REVENUE 900099 82719 82719 72867 72867 530787522 2619825 2619825 4720867 0 4720867 4720867 4720867 9143011 8822201 320810 320810 320810 545616468 527597609 457959 10393456 526950 526950 3341570 3149805 191765 223163892 210356999 12806893 6837076 6428714 408362 17006749 15992289 1014460 14673292 13796893 876399 93837084 46348930 47488154 338412 31070 307342 91400 8392 83008 67701 67701 34655362 11079670 23575692 1002399 151221 851178 30259678 12911452 17348226 1956549 295164 1661385 16529460 13792951 2736509 288948 43590 245358 55303 8343 46960 865201 10779 854422 16488386 14015129 2473257 6242902 1130039 5112863 MEDICAL & OTHER SUPPLIE 130500333 117929733 12570600 PENSION RELATED ADJUSTM 29493590 26652585 2841005 OTHER EXPENSES 7554353 6828176 726177 REPAIRS & MAINTENANCE 1396233 1261739 134494 37290 33698 3592 637210113 502784311 134425802 0 42791227 15151818 36956160 726945 56209733 63883921 16612202 15839171 13159253 12952326 289525618 60421464 229916694 229104154 30314640 33594463 9260054 7257601 17257645 13410813 5003163 11196107 457480771 403117319 60671979 44387215 169756788 248987888 230428767 293375103 X 227052004 109742216 227052004 109742216 457480771 403117319 X -91593645 2682759 -28398902 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 14930000 14930000 212840642 29784123 183056519 57715522 30627656 27087866 4039454 9685 4029769 229104154 FND DEPR - FMOL PORTFOLIO 33594463 F 33594463 NET DUE TO/FROM AFFILIATES 132758408 OPERATING LEASE - LT 6343818 INTERCOMPANY AP 2125576 SELF INSURANCE LIABILITY LT 5543345 RETIREMENT PAYABLE LONG TERM 95368991 OBLIGATION OPERATING- ST 2339585 OTHER LIABILITIES 4508165 248987888 X PART X, LINE 2: FMOLHS RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. RECOGNIZED INCOME TAX POSITIONS ARE MEASURED AT THE LARGEST AMOUNT THAT IS GREATER THAN 50% LIKELY OF BEING REALIZED. CHANGES IN RECOGNITION OR MEASUREMENT ARE REFLECTED IN THE PERIOD IN WHICH THE CHANGE IN JUDGMENT OCCURS. NO RESERVE FOR UNCERTAIN TAX POSITIONS HAVE BEEN RECORDED. 1 1 1 X 250.000000000000 0 1 1 1 0 0 16086665 2574365 13512300 0.02120 66367934 66367934 82454599 68942299 13512300 0.02120 48654 165 48489 0.00010 43935 43935 0.00010 18232905 15493685 2739220 0.00430 484814 6587 478227 0.00080 18810308 15500437 3309871 0.00530 101264907 84442736 16822171 0.02650 186240 186240 0.00030 186240 186240 0.00030 1 13913630 161883684 134971866 26911818 X 1 1 1 ST DOMINIC ASC OUTPATIENT SURGERY CENTER 0.46300 0.53700 1 1 ST DOMINIC-JACKSON MEMORIAL HOSPITAL 969 LAKELAND DRIVE JACKSON MS 392164699 HTTP://WWW.STDOM.COM/14-031 14-031 X X X ST DOMINIC-JACKSON MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 21 1 0 0 1 X SEE SECTION C X 1 21 1 SEE SECTION C 0 1 X 250.000000000000 0.000000000000 X X X X X 1 1 X X X 1 X SEE PART V SECTION C X SEE PART V SECTION C X SEE PART V SECTION C X X X X X X X 1 X 0 X X X X 1 X 0 0 ST. DOMINIC-JACKSON MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: AS PART OF THE COMMUNITY NEEDS ASSESSMENT, ST. DOMINIC HOSPITAL REACHED OUT TO AN EXPANSIVE AND HIGHLY DIVERSE GROUP OF INDIVIDUALS TO PARTICIPATE IN ITS COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) LEADERSHIP TEAM AND TO CONTRIBUTE INSIGHT FROM COMMUNITY SERVICE ORGANIZATIONS. EACH MEMBER PROVIDED PROJECT INSIGHT, FEEDBACK REGARDING PERCEPTIONS OF AREA HEALTH NEEDS, DATA EVALUATION, AND OTHER GUIDANCE DURING THE CHNA DEVELOPMENT PROCESS. THESE INDIVIDUALS OFFERED A BREADTH OF COMMUNITY HEALTH VISION, KNOWLEDGE, AND POWER TO IMPACT THE WELL-BEING OF THE SERVICE AREA. INFORMATION WAS GATHERED ABOUT THE LARGER COMMUNITY USING SECONDARY RESEARCH, DISCUSSION GROUPS AND COMMUNITY SURVEYS. ST. DOMINIC-JACKSON MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: DURING THE CURRENT YEAR, ST. DOMINIC'S CONTINUED TO ADDRESS THE FOLLOWING SIGNIFICANT HEALTH NEEDS IDENTIFIED DURING THE PRIOR CHNA. THOSE NEEDS WERE: - HOMELESSNESS;- CRISIS CARE PROGRAMS FOR MENTAL HEALTH; - AFFORDABLE HEALTHCARE SERVICES FOR PEOPLE OR FAMILIES WITH LOW INCOME;- DOMESTIC VIOLENCE RESOURCES; - HOUSING FOR ALL INCOMES/AGES; - COUNSELING SERVICES FOR DEPRESSION OR ANXIETY; - JOB READINESS; - POST-ADDICTIONS TREATMENT SUPPORT PROGRAMS; - COUNSELING SERVICES FOR ADOLESCENTS AND - PRESCRIPTION ASSISTANCE.THE HOSPITAL WILL NOT ADDRESS HOMELESSNESS, HOUSING FOR ALL INCOMES/AGES, JOB READINESS, DOMESTIC VIOLENCE OR COUNSELING SERVICES FOR ADOLESCENTS/CHILDREN AS THOSE COMMUNITY NEEDS ARE OUTSIDE OF ITS SCOPE. THE HOSPITAL HAS DECIDED THAT IT WILL ADDRESS CRISIS CARE FOR MENTAL HEALTH, COUNSELING SERVICES FOR DEPRESSION OR ANXIETY, AND POST-ADDICTIONS TREATMENT SUPPORT PROGRAMS WITHIN THE NEXT 2-3 YEARS.DURING THE CURRENT YEAR, TO ADDRESS THE SIGNIFICANT COMMUNITY HEALTH NEEDS LISTED ABOVE, THE HOSPITAL DID THE FOLLOWING:A SIGNIFICANT INVESTMENT WAS MADE IN COMMUNITY-DRIVEN INITIATIVES THAT MET VULNERABLE POPULATIONS WHERE THEY ARE BEST SERVED IN THE COMMUNITY. THE CARE-A-VAN MOBILE MEDICAL UNIT PROVIDED APPROXIMATELY 2,500 SCREENINGS, ASSISTANCE, AND EDUCATION TO COMMUNITY MEMBERS. EXAMPLES OF ACTIVITIES INCLUDE THE BB KING MUSEUM CHILDRENS' SUMMER CAMP WHERE CHILDREN WERE SCREENED FOR THE SOCIAL DETERMINANTS OF HEALTH, VACCINATION CLINICS THAT PROVIDED FREE IMMUNIZATIONS (867 COVID-19 AND 63 FLU), PROJECT HOMELESS CONNECT IN WHICH ST. DOMINIC'S STAFF COLLABORATED WITH COMMUNITY PARTNERS TO PRESENT A ONE-STOP-SHOP FOR FAMILIES TO GET RESOURCES TO COMBAT HOMELESSNESS AND LEARN ABOUT ACCESS RESOURCES, AND HEALTH SCREENINGS THROUGHOUT THE AREA THAT PROVIDED FRONT LINE ACCESS TO CURRENT HEALTH DATA FOR 1,508 AREA RESIDENTS.ST. DOMINIC'S PROVIDED PROGRAMMING, WELLNESS OPPORTNITIES, AND EDUCAITON THROUGH ITS SENIOR-FOCUSED NEW DIRECTIONS. IN TOTAL, 2,228 LIVES WERE AFFECTED BY THE PROGRAM THROUGH OUTREACH EFFORTS, SUCH AS DIGITAL AND FISCAL LITERACY CLASSES, CLASSES FOCUSED ON ADDRESSING HEALTH AND WELLNESS, AND DANCE CLASSES TO ENCOURAGE SENIOR MOBILITY. ADDITIONALLY, ST. DOMINIC'S FOCUSED ITS COMMUNITIY BENEFIT FUNDING STRATEGIES IN AREAS THAT TARGETED ITS COMMUNITY HEALTH NEEDS ASSESSMENT GOALS. IN TOTAL, ST. DOMINIC'S INVESTED $485,850 IN THE JACKSON AREA COMMUNITY, WITH A FOCUS ON PROGRAMS SERVING VULNERABLE POPULATIONS AND ADDRESSING HEALTH ISSUES THAT WERE RELATED TO THE CHNA IDENTIFIED PRIORITY NEEDS. THE HOSPITAL ALSO CONTINUED TO ADDRESS BEHAVORIAL OR MENTAL HEALTH BY FOCUSING ON ACCESS, EARLY DETECTION AND INTERVENTION AS EVIDENCED BY STEERED SCREENING OR EDUCATION ACTIONS IN COMMUNITIES THROUGHOUT THE STATE, COMPLETED IN-PERSON AND THROUGH VIRTUAL MEANS. EARLY DETECTION WAS A FOCUS IN PROVIDING DEPRESSION SCREENING TOOLS TO SDMA AND MEA CLINICS, AS WELL AS OTHER CLINIC LOCATIONS FOR PATIENTS SEEN IN THE PHP SETTING. ST. DOMINIC'S ALSO CONTINUED THE TELEMEDICINE OFFERINGS TO ENCOMPASS BEHAVIORAL HEALTH AND ASSIST OUTLYING COMMUNITIES WITH LIMITED PERSONNEL AND RESOURCES TO CONDUCT PROPER ASSESSMENTS. ST. DOMINIC-JACKSON MEMORIAL HOSPITAL PART V, SECTION B, LINE 13H: PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES THAT MAY INCLUDE:1. THE PATIENT RECEIVING FREE CARE FROM A COMMUNITY CLINIC AND ISREFERRED TO THE HOSPITAL;2. STATE-FUNDED PRESCRIPTION PROGRAMS;3. HOMELESS, INDIGENT, OR HOMELESS CLINIC PATIENT;4. PATIENTS' CHILDREN WHO QUALIFY FOR OTHER FINANCIAL ASSISTANCEPROGRAMS;5. PATIENT ELIGIBLE FOR FOOD STAMPS;6. MEDICAID ELIGIBLE PATIENT;7. PATIENT IS DECEASED WITH NO KNOWN RESPONSIBLE PARTY;8. PATIENT IS INCARCERATED AND HAS NO OTHER RESPONSIBLE PARTY ST. DOMINIC-JACKSON MEMORIAL HOSPITAL PART V, SECTION B, LINE 16J: REGISTRATION PERSONNEL REFER UNINSURED AND/OR LOW-INCOME PATIENTS TO FINANCIAL COUNSELORS TO DISCUSS THE FINANCIAL ASSISTANCE POLICY. PART V, SECTION A, LINES 7A &10: HTTPS://WWW.FMOLHS.ORG/ABOUT-US/COMMUNITY-IMPACT PART V, SECTION B, LINE 16 A, B, C: THE FAP, FAP APPLICATION FORM, AND A PLAIN LANGUAGE SUMMARY OF THE FAP ARE AVAILABLE AT:HTTPS://WWW.FMOLHS.ORG/PATIENTS-GUESTS/PATIENTS-RESOURCES/FINANCIAL-ASSISTANCE-POLICY 35 1 - ST DOMINIC'S HOSPITAL MEDICINE 971 LAKELAND DRIVE SUITE 1453 JACKSON MS 39216 HOSPITALIST CLINIC 2 - ST DOMINIC'S NEUROSURGERY ASSOCIATES 971 LAKELAND DRIVE SUITE 657 JACKSON MS 39216 PHYSICIAN CLINIC 3 - ST DOMINIC'S NEUROCARE 971 LAKELAND DRIVE SUITE 557 JACKSON MS 39216 PHYSICIAN CLINIC 4 - ST DOMINIC'S VASCULAR AND ENDOVASCULAR 971 LAKELAND DRIVE SUITE 1250 JACKSON MS 39216 PHYSICIAN CLINIC 5 - ST DOMINIC'S EAR NOSE & THROAT SURGICA 970 LAKELAND DRIVE SUITE 40 JACKSON MS 39216 PHYSICIAN CLINIC 6 - ST DOMINIC'S INTERNAL MEDICINE GROUP 971 LAKELAND DRIVE SUITE 250 JACKSON MS 39216 PHYSICIAN CLINIC 7 - STDOMINIC'S FAMILY MEDICINE OF MADISON 106 HIGHLAND WAY 103 MADISON MS 39110 PHYSICIAN CLINIC 8 - ST DOMINIC'S INTERNAL MEDICINE MADISON 106 HIGHLAND WAY 200 MADISON MS 39110 PHYSICIAN CLINIC 9 - ST DOMINIC'S CARDIOVASCULAR SURGERY 971 LAKELAND DRIVE SUITE 657 JACKSON MS 39216 PHYSICIAN CLINIC 10 - ST DOMINIC'S PAIN MANAGEMENT CENTER 971 LAKELAND DRIVE SUITE 1159 JACKSON MS 39216 PHYSICIAN CLINIC 11 - ST DOMINIC'S GYNECOLOGIC ONCOLOGY 971 LAKELAND DRIVE SUITE 750 JACKSON MS 39216 PHYSICIAN CLINIC 12 - ST DOMINIC'S UROLOGY 971 LAKELAND DRIVE SUITE 360 JACKSON MS 39216 PHYSICIAN CLINIC 13 - ST DOMINIC'S INFECTIOUS DISEASE 971 LAKELAND DRIVE SUITE 954 JACKSON MS 39216 PHYSICIAN CLINIC 14 - ST DOMINIC'S PSYCHIATRIC ASSOCIATES 890 LAKELAND DRIVE JACKSON MS 39216 PHYSICIAN CLINIC 15 - ST DOMINIC'S RHEUMATOLOGY 106 HIGHLAND WAY SUITE 200 MADISON MS 39110 PHYSICIAN CLINIC 16 - ST DOMINIC'S FAMILY MEDICINE OF BRANDON 1297 WEST GOVERNMENT STREET BRANDON MS 39042 PHYSICIAN CLINIC 17 - ST DOMINIC'S FAMILY MEDICINE OF CLINTON 728 CLINTON PARKWAY SUITE B CLINTON MS 39056 PHYSICIAN CLINIC 18 - ST DOMINIC'S FAMILY MEDICINE OF FLOWOOD 1050 RIVER OAKS DRIVE FLOWOOD MS 39232 PHYSICIAN CLINIC 19 - ST DOMINIC'S FAMILY MEDICINE OF DOGWOOD 205A BELLE MEADE POINTE FLOWOOD MS 39232 PHYSICIAN CLINIC 20 - ST DOMINIC'S FAMILY MEDICINE OF MAGEE 360 SIMPSON HWY 149 SUITE 220 MAGEE MS 39111 PHYSICIAN CLINIC 21 - ST DOMINIC'S FAMILY MEDICINE OF JACKSON 890 LAKELAND DRIVE JACKSON MS 39056 PHYSICIAN CLINIC 22 - ST DOMINIC'S MARTIN SURGICAL ASSOCIATES 971 LAKELAND DRIVE SUITE 211 JACKSON MS 39216 PHYSICIAN CLINIC 23 - ST DOMINIC'S FAMILY MED OF PELAHATCHIE 610 2ND STREET PELAHATCHIE MS 39145 PHYSICIAN CLINIC 24 - ST DOMINIC'S FAMILY MEDICINE OF RALEIGH 342 MAGNOLIA DRIVE RALEIGH MS 39153 PHYSICIAN CLINIC 25 - ST DOMINIC'S FAMILY MEDICINE GLUCKSTADT 286 CALHOUN STATION PARKWAY MADISON MS 39110 PHYSICIAN CLINIC 26 - ST DOMINIC'S COUMADIN CLINIC 890 LAKELAND DRIVE JACKSON MS 39056 PHYSICIAN CLINIC 27 - ST DOMINIC'S CHRONIC CARE CLINIC 969 LAKELAND DRIVE JACKSON MS 39216 PHYSICIAN CLINIC 28 - ST DOMINIC'S OUTREACH PROGRAM-TELEMEDIC 969 LAKELAND DRIVE JACKSON MS 39216 PHYSICIAN CLINIC 29 - ST DOMINIC'S OUTREACH PROGRAM-MAGEE 360 SIMPSON HWY 149 SUITE 370 MAGEE MS 39111 PHYSICIAN CLINIC 30 - ST DOMINIC'S OUTREACH PROGRAM-CLEVELAND 810 E SUNFLOWER ROAD CLEVELAND MS 38732 PHYSICIAN CLINIC 31 - ST DOMINIC'S OUTREACH PROGRAM-KOSCIUSKO 332 HIGHWAY 12 WEST KOSCIUSKO MS 39090 PHYSICIAN CLINIC 32 - ST DOMINIC'S OUTREACH PROGRAM-PELAHATCH 610 2ND STREET PELAHATCHIE MS 39145 PHYSICIAN CLINIC 33 - ST DOMINIC'S OUTREACH PROGRAM-VICKSBURG 4204 CLAY STREET VICKSBURG MS 39180 PHYSICIAN CLINIC 34 - ST DOMINIC'S OUTREACH PROGRAM-BROOKHAVE 427 HWY 51 N BROOKHAVEN MS 39601 PHYSICIAN CLINIC 35 - ST DOMINIC'S INTERNAL MEDICINE CLINIC 112 SOUTH LAKE CIRCLE CANTON MS 39046 PHYSICIAN CLINIC PART I, LINE 3C: FINANCIAL ASSISTANCE IS AVAILABLE FOR INDIVIDUALS WHO ARE UNINSURED, UNDERINSURED, INELIGIBLE FOR ANY GOVERNMENT HEALTH CARE BENEFIT PROGRAM, AND WHO ARE UNABLE TO PAY FOR THEIR CARE. FULLY-DISCOUNTED CARE IS AVAILABLE IF INCOME AND ASSETS MEET CERTAIN FEDERAL POVERTY GUIDELINE LEVELS. FULLY-DISCOUNTED CARE IS ALSO AVAILABLE FOR THOSE PATIENTS WITH CATASTROPHIC MEDICAL BILLS IF MEDICAL BILLS EXCEED A CERTAIN PERCENTAGE OF INCOME AND ASSETS. FULLY DISCOUNTED CARE IS ALSOAVAILABLE WHERE THE PATIENT OR OTHER SOURCES CAN PROVIDE SUFFICIENT EVIDENCE OF PRESUMPTIVE ELIGIBILITY. PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES THAT MAY INCLUDE:1) PATIENT RECEIVING FREE CARE FROM A COMMUNITY CLINIC AND IS REFERREDTO THE HOPSITAL;2) STATE-FUNDED PRESCRIPTION PROGRAMS;3) HOMELESS, INDIGENT, OR HOMELESS CLINIC PATIENT;4) PATIENT'S CHILDREN WHO QUALIFY FOR OTHER FINANCIAL ASSISTANCEPROGRAMS;5) PATIENT ELIGIBLE FOR FOOD STAMPS;6) MEDICAID ELIGIBLE PATIENT;7) PATIENT IS DECEASED WITH NO KNOWN RESPONSIBLE PARTY;8) PATIENT IS INCARCERATED AND HAS NO OTHER RESPONSIBLE PARTY. PART I, LINE 7: A COST TO CHARGE RATIO WAS USED TO CALCULATE PART I, LINE 7A AND 7B. THE COST TO CHARGE RATIO WAS DERIVED FROM IRS WORKSHEET 2, RATIO OF PATIENT CARE COST TO CHARGES. THE COST TO CHARGE RATIO IS APPLIED TO GROSS CHARGES RELATED TO CHARITY CARE AND CARE COVERED BY MEDICAID AND OTHER GOVERNMENT PROGRAMS. FOR PART I, LINES 7E THROUGH 7I, DIRECT COSTS WERE CAPTURED FROM THE HOSPITAL'S AUDITED FINANCIAL STATEMENTS AND THE MEDICARE COST REPORT LESS DIRECT OFFSESTTING REVENUE, WHERE APPLICABLE. PART II, COMMUNITY BUILDING ACTIVITIES: ST. DOMINIC PROVIDES SIGNIFICANT SUPPORT TO ITS COMMUNITY THROUGH A VARIETY OF WAYS INCLUDING FREE HEALTH SCREENINGS AT LOCAL SCHOOLS, PARTICIPATION IN VARIOUS NON-PROFIT BOARDS AS WELL AS FINANCIAL SUPPORT THROUGH CASH DONATIONS. PART III, LINE 2: THE AMOUNT REPORTED IN PART III, LINE 2 AS BAD DEBT EXPENSE MATCHES THE AMOUNT OF BAD DEBT EXPENSE REPORTED ON THE HOSPITAL'S INTERNAL FINANCIAL STATEMENTS. PART III, LINE 3: ST. DOMINIC HOSPITAL FREQUENTLY HAS PATIENT ACCOUNTS THAT ARE INTITIALLY WRITTEN OFF AS A BAD DEBT EXPENSE, BUT LATER (THROUGH A SCREENING PROCESS) IT IS DETERMINED THAT THE PATIENT DOES QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. THE PERCENTAGE OF ACCOUNTS IS ESTIMATED TO BE 83 PERCENT. THE PERCENTAGE IS DETERMINED UTILIZING AN INTERNAL REPORT OF ACCOUNTS WRITTEN OFF AS A BAD DEBT EXPENSE IN ONE YEAR AND CLASSIFIED AS CHARITY IN A SUBSEQUENT YEAR. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND REPORTED AT NET REALIZABLE VALUE. IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS HISTORICAL EXPERIENCE AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR UNCOLLECTABLE ACCOUNTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR UNCOLLECTIBLE ACCOUNTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYER HAS NOT YET PAID, OR FOR PAYERS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A PROVISION FOR UNCOLLECTIBLE ACCOUNTS IN THE PERIOD OF SERVICE ON THE BASIS OF THEIR PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 8: THE COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COSTS REPORTED IN THE MEDICARE COST REPORT IS BASED ON REGULATORY REQUIREMENTS AND GUIDELINES. PART III, LINE 9B: ST. DOMINIC HOSPITAL HAS A BOARD APPROVED COLLECTION POLICY AND HAS WRITTEN CONTRACTS IN PLACE WITH ITS COLLECTION AGENCIES SO THE APPROPRIATE COLLECTION ACTIVITIES ARE FOLLOWED. THE COLLECTION AGENCIES THAT ST. DOMINIC USES ARE FULLY INFORMED ABOUT THE HOSPITAL'S FINANCIAL AID POLICY AND ASSIST IN EDUCATING ITS PATIENTS. THEY ROUTINELY SEND FINANCIAL AID APPLICATIONS TO PATIENTS AND REFER THOSE PATIENTS BACK TO THE HOSPITAL'S FINANCIAL COUNSELORS WHEN APPROPRIATE. PART VI, LINE 2: ST. DOMINIC HOSPITAL ASSESSES THE COMMUNITY IT SERVES THROUGH VARIOUS SOURCES WHICH INCLUDE:1) ANALYSIS OF THE PAYOR SOURCE AND DISEASE CATEGORIES OF PATIENTS TREATED AT ST. DOMINIC HOSPITAL WITH PARTICULAR ANALYSIS DONE ON PATIENTS PRESENTING TO ITS EMERGENCY DEPARTMENT;2) FEEDBACK FROM THE BOARD MEMBERS WHO REPRESENT THE COMMUNITY IT SERVES;3) REQUESTS MADE FROM THE COMMUNITY; AND4) PUBLIC HEALTH INFORMATION. PART VI, LINE 3: ST. DOMINIC HOSPITAL WORKS TO EDUCATE ITS PATIENTS AND COMMUNITY OF ASSISTANCE OPTIONS BY:1) POSTING SIGNAGE IN THE EMERGENCY ROOM AND OTHER REGISTRATION AREAS INFORMING PATIENTS THAT FINANCIAL ASSISTANCE IS AVAILABLE.2) PROVIDING BROCHURES IN THE WAITING ROOMS AND AT THE REGISTRATION DESKS THAT EXPLAIN THE BILLING AND COLLECTION PROCESS AS WELL AS INFORMATION ABOUT THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY AND PHONE NUMBERS TO CALL FOR ASSISTANCE.3) CONTRACTING AND PAYING AN AGENCY TO MEET WITH ALL UNINSURED PATIENTS TO ASSIST THEM IN APPLYING FOR FEDERAL AND STATE ASSISTANCE (I.E. MEDICAID, DISABILITY, ETC.).4) PROVIDING FINANCIAL COUNSELORS TO MEET WITH PATIENTS. THESE COUNSELORS FULLY UNDERSTAND THE HOSPITAL'S CHARITY POLICY AND ARE AVAILABLE TO ASSIST WITH THE APPLICATIONS, SET UP INTEREST FREE PAYMENT PLANS AND OFFER ADVICE ON PUBLIC ASSISTANCE THAT MAY BE AVAILABLE.5) STAFFING PATIENT REPRESENTATIVES TO ANSWER QUESTIONS AND ASSIST PATIENTS AS NEEDED.6) EDUCATING THE EARLY-OUT AND BAD DEBT COLLECTION AGENCIES ON THE HOSPITAL'S FINANCIAL ASSISTANCE POLICIES SO THEY CAN ASSIST PATIENTS WHOM THEY FIND MIGHT HAVE FINANCIAL NEED. PART VI, LINE 4: COMMUNITY INFORMATION:ST. DOMINIC HOSPITAL IS A COMMUNITY-BASED, NOT-FOR-PROFIT HOSPITAL LOCATED IN JACKSON, MISSISSIPPI, IN HINDS COUNTY. FOR PURPOSES OF THE CHNA, THE HOSPITAL DEFINES ITS PRIMARY SERVICE AREA AS THE MADISON, HINDS, AND RANKIN TRI-COUNTY REGION OF MISSISSIPPI. PURSUANT TO THE HOSPITAL'S LAST CHNA, ST. DOMINIC HOSPITAL'S PRIMARY SERVICE AREA HAS A POPULATION OF APPROXIMATELY 493,383 RESIDENTS. THE MEDIAN AGE FOR THE PRIMARY SERVICE AREA IS 37. THE MEDIAN INCOME OF THE PRIMARY SERVICE AREA IS $60,049 AND 13.1% OF RESIDENTS ARE LIVING IN POVERTY. PART VI, LINE 5: INSPIRED BY THE TEACHINGS OF JESUS CHRIST AND THE WITNESS OF OUR FOUNDING DOMINICAN SISTERS, WE PROVIDE COMPASSIONATE CARE AND HOPE AS A HEALING MINISTRY OF THE CATHOLIC CHURCH. ST. DOMINIC APPLIES THIS MISSION BY CONDUCTING NEEDS ASSESSMENTS, PUBLISHING THE RESULTS, ESTABLISHING GOALS AND STRATEGIES TO HELP RESOLVE IDENTIFIED ISSUES AND SEEKING OPPORTUNITIES TO WORK WITH THE COMMUNITY. ST. DOMINIC HOSPITAL IMPROVES THE HEALTH OF THE COMMUNITIES IT IS PRIVILEGED TO SERVE IN MANY WAYS THAT EXTEND FAR BEYOND THE HEALING MINISTRY OF BEDSIDE CARE. THROUGH APPROACHES SUCH AS OPEN MEDICAL STAFF POLICIES, UNIQUE TECHNOLOGY INNOVATIONS FOR BETTER OUTCOMES, AND DIVERSITY, EQUITY, AND INCLUSION STRATEGIES FOCUSED ON EVERY ASPECT OF HEALTH CARE FROM THE BEDSIDE TO THE PURCHASING DOCK TO EACH PATIENT WHO WALKS THROUGH OUR DOORS, THE HOSPITAL CONTINUOUSLY EXPANDS ITS DEFINITION OF WHAT IT MEANS TO HAVE A "COMMUNITY IMPACT." THE HOSPITAL ALSO INVOLVES MEMBERS OF ITS COMMUNITY IN ITS GOVERNANCE SO THAT IT MAINTAINS THE FOCUS ON THE NEEDS OF ITS COMMUNITY. ST. DOMINIC'S HEART FAILURE CLINIC IS A STAND-ALONE CLINIC OVERSEEN BY AN EXPERIENCED NURSE PRACTITIONER. THIS SPECIALIZED CLINIC OFFERS HEART FAILURE PATIENTS QUICK, EASY, ACCESSIBLE CARE AND PROVIDES DETAILED EDUCATION ABOUT THE DISEASE PROCESS., DIETARY RESTRICTIONS OF SODIUM AND FLUID, AND THERAPY OPTIONS. THE CLINIC ALSO OFFERS LABORATORY SERVICES, SUPPORT GROUPS, AND, IF WARRANTED, INTRAVENOUS OR INTRAMUSCULAR DIURETIC INJECTIONS. ST. DOMINIC'S IS THE FIRST HOSPITAL IN MISSISSIPPI TO RECEIVE THE JOINT COMMISSION'S GOLD SEAL OF APPROVAL AND THE AMERICAN HEART ASSOCIATION/AMERICAN STROKE ASSOCIATION'S HEART-CHECK MARK FOR ADVANCED CERTIFICATION FOR COMPREHENSIVE STROKE CENTERS. ST. DOMINIC'S COMPREHENSIVE STROKE CENTER OFFERS RAPID DIAGNOSIS, HIGH-TECH INTERVENTION, EXPERT CARE, AND INTENSE REHABILITATION IN A CARING, COMPASSIONATE SETTING. ST. DOMINIC'S CAN DELIVER THE FULL SPECTRUM OF CARE TO SERIOUSLY ILL PATIENTS WITH STROKE AND CEREBROVASCULAR DISEASE. THE CHIEF COMPONENT OF THE PROGRAM IS A HIGHLY COLLABORATIVE, EXPERTLY SKILLED TEAM OF CLINICAL PROFESSIONALS WHO DIRECT AND PROVIDE EVIDENCE-BASED CARE FOR EVERY STROKE PATIENT. SERVICES PROVIDED INCLUDE: EMERGENCY DEPARTMENT, HOSPITALIST MEDICAL, ADULT NEUROLOGY, NEUROSURGERY, INTERVENTIONAL RADIOLOGY, ACUTE REHABILITATION AND OUTPATIENT REHABILITATION, AND CRITICAL CARE. ST. DOMINIC'S TELE-STROKE PROGRAM CONNECTS ST. DOMINIC'S NEUROLOGISTS TO PATIENTS IN ST. DOMONIC'S EMERGENCY DEPARTMENT AND TO PATIENTS IN OUTLYING HOSPITALS' EMERGENCY DEPARTMENTS USING A TELEMEDICINE CART AND LAPTOP CONNECTIONS. NEUROLOGISTS CAN QUICKLY AND EFFICIENTLY PROVIDE A DIAGNOSIS AND BEST TREATMENT OPTIONS USING THE TECHNOLOGY. ST. DOMINIC'S IS CURRENTLY PARTNERED WITH SIX MISSISSIPPI HOSPITALS AS PART OF ITS TELE-STROKE PROGRAM: COPIAH COUNTY MEDICAL CENTER IN HAZELHURT, GREENWOOD LEFLORE HOSPITAL IN GREENWOOD, NESHOBA GENERAL IN PHILADELPHIA, MAGEE GENERAL HOSPITAL IN MAGEE, DELTA REGIONAL MEDICAL CENTER IN GREENVILLE, AND SOUTHWEST REGIONAL MEDICAL CENTER IN MCCOMB. PART VI, LINE 6: ST. DOMINIC HEALTH SERVICES, INC. IS THE PARENT ORGANIZATION OF A SYSTEM THAT INCLUDES ST. DOMINIC - JACKSON MEMORIAL HOSPITAL (A 571-BED ACUTE CARE FACILITY), ST. CATHERINE'S VILLAGE (A CONTINUING CARE RETIREMENT COMMUNITY), ST. DOMINIC HEALTH SERVICES FOUNDATION (A FUNDRAISING/GRANT FOCUSED ENTITY) AND ST. DOMINIC MADISON HEALTH SERVICES, INC. (A MEDICAL OFFICE BUILDING AND FITNESS CENTER). IN ADDITION, ST. DOMINIC HEALTH SERVICES OPERATES COMMUNITY HEALTH SERVICES - ST. DOMINIC, INC., WHICH INCORPORATES THE OUTREACH SERVICES OF THE CLUB AT ST. DOMINIC'S, NEW DIRECTIONS FOR OVER 55, ST. DOMINIC COMMUNITY HEALTH CLINIC, MADISON SCHOOL NURSE PROGRAM AND THE CARE-A-VAN SCREENING PROGRAM. AS A WHOLE, ALL OF THE SERVICES, ENTITIES AND HOSPITAL ARE COLLECTIVELY REFERRED TO AS ST. DOMINIC'S. ST DOMINIC'S SEEKS TO GIVE TIME, TALENTS, AND RESOURCES TO MAKE THE COMMUNITIES SERVED BY THE ORGANIZATION BETTER PLACES TO LIVE. THE ST. DOMINIC'S FAMILY OF CAREGIVERS NOT ONLY SERVES PATIENTS, BUT ALSO CONTRIBUTES TO AN ATMOSPHERE OF CARE AND COMPASSION FOR THOSE OUTSIDE THE HOSPITAL'S WALLS. ST. DOMINIC STRIVES TO NOT ONLY PROVIDE CARE FOR THE SICK BUT ALSO TO OFFER EDUCATION AND WELLNESS SERVICES TO IMPROVE THE HEALTH STATUS OF THE COMMUNITY AND HELP ELIMINATE RISK FACTORS FOR MORE SERIOUS HEALTH PROBLEMS. ADDITIONALLY ON JULY 1, 2019, ST. DOMINIC HEALTH SERVICES BECAME PART OF THE FRANCISCAN MISSIONARIES OF OUR LADY HEALTH SYSTEM (FMOLHS). AS SUCH, IT IS AFFILIATED WITH TAX-EXEMPT HOSPITALS THROUGHOUT THE STATE OF LOUISIANA INCLUDING:OUR LADY OF LOURDES REGIONAL MEDICAL CENTERST. FRANCIS MEDICAL CENTEROUR LADY OF THE LAKE ASSUMPTION HOSPITALOUR LADY OF THE ANGELS HOSPITALOUR LADY OF THE LAKE HOSPITAL 1 AMERICAN HEART ASSOCIATION 250 WILLIAMS STREET ATLANTA GA 30303 135613797 501 (C)(3) 50000 0 GENERAL SUPPORT 100 BLACK MEN OF JACKSON INC 5360 HIGHLAND DRIVE JACKSON MA 39286 640817928 501 (C)(3) 40000 0 GENERAL SUPPORT OPERATION SHOESTRING 1711 BAILY AVENUE JACKSON MA 39283 640471554 501 (C)(3) 40000 0 GENERAL SUPPORT REAL CHRISTIAN FOUNDATION PO BOX 180059 RICHLAND MA 39218 640885750 501 (C)(3) 32500 0 GENERAL SUPPORT CENTER FOR VIOLENCE PREVENTION THE PO BOX 6279 PEARL MA 39288 581959108 501 (C)(3) 30000 0 GENERAL SUPPORT NEWKS CARES 814 NORTH CONGRESS STREET JACKSON MA 39202 640765336 501 (C)(3) 25000 0 GENERAL SUPPORT CANOPY CHILDRENS SOLUTIONS 1465 LAKELAND DR JACKSON MA 39216 640303085 501 (C)(3) 25000 0 GENERAL SUPPORT MS SYMPHONY ORCHESTRA PO BOX 2052 JACKSON MA 39225 640273405 501 (C)(3) 25000 0 GENERAL SUPPORT JACKSON HEART FOUNDATION PO BOX 5021 JACKSON MA 39206 270723542 501 (C)(3) 20000 0 GENERAL SUPPORT REFILL CAFE 136 SOUTH ADAMS STREET JACKSON MA 39203 832814994 501 (C)(3) 20000 0 GENERAL SUPPORT DEVOTED DREAMERS FOUNDATION 454 OAK LAWN DRIVE PEARL MA 39208 276601178 501 (C)(3) 15000 0 GENERAL SUPPORT MISSION FIRST INC PO BOX 22655 JACKSON MA 39225 640824240 501 (C)(3) 15000 0 GENERAL SUPPORT CATHOLIC CHARITIES INC 850 EAST RIVER PLACE JACKSON MA 39201 640466850 501 (C)(3) 8000 0 GENERAL SUPPORT B B KING MUSEUM AND DELTA INTERPREPTIVE CENTER 400 SECOND STREET INDIANOLA MA 38751 460501512 501 (C)(3) 7500 0 GENERAL SUPPORT AMERICAN CANCER SOCIETY INC 250 WILLIAMS STREET ATLANTA GA 30303 131788491 501 (C)(3) 17500 0 CANCER SUPPORT ST JOSEPH CATHOLIC SCHOOL 308 NEW MANNSDALE ROAD MADISON MA 39110 640339825 501 (C)(3) 25000 0 GENERAL SUPPORT PLAYERS PHILANTHROPY FUND 454 OAK LAWN DRIVE PEARL MA 39208 276601178 501 (C)(3) 15000 0 GENERAL SUPPORT NATIONAL COALITION OF 100 BLACK WOMEN - CENT MS CHAPTER PO BOX 68412 JACKSON MA 39286 582063167 501 (C)(3) 15000 0 GENERAL SUPPORT CATHOLIC DIOCESE OF JACKSON PO BOX 22723 JACKSON MA 39225 640303073 501 (C)(3) 15000 0 GENERAL SUPPORT MISSION MISSISSIPPI PO BOX 22655 JACKSON MA 39225 640824240 501 (C)(3) 15000 0 GENERAL SUPPORT FONDREN RENAISSANCE FOUNDATION 4145 OLD CANTON ROAD JACKSON MA 39216 640873626 501 (C)(3) 11000 0 GENERAL SUPPORT JUNIOR LEAGUE OF JACKSON 805 RIVERSIDE DRIVE JACKSON MA 39202 646011106 501 (C)(3) 10750 0 GENERAL SUPPORT MISSISSIPPI HOUSING PARTNERSHIP PO BOX 22987 JACKSON MA 39225 640816305 501 (C)(3) 10000 0 GENERAL SUPPORT BRAIN INJURY ASSOCIATION OF MS 1640 LELIA DRIVE JACKSON MA 39216 570885672 501 (C)(3) 10000 0 GENERAL SUPPORT TUTWILER COMMUNITY EDUCATION CENTER INC PO BOX 448 TUTWILER MA 38963 581887449 501 (C)(3) 8000 0 GENERAL SUPPORT 25 PART I, LINE 2: THE HOSPITAL HAS A CONTRIBUTIONS COMMITTEE, WHICH IS A SUB-COMMITTEE OF THE BOARD, THAT OVERSEES THE HOSPITAL'S GIVING. THEY MONITOR THE REQUESTS AND OVERSEE ALL GIFTS. X X X X X 1 1 0 0 0 0 0 0 0 JOHN LANCON PHYSICIAN 1094837 0 203634 0 3260 0 15250 0 27850 0 1344831 0 0 0 PB KERR PHYSICIAN 966632 0 121043 0 28372 0 15250 0 25150 0 1156447 0 0 0 DAVID THEODORO PHYSICIAN 904504 0 110344 0 3564 0 14300 0 19056 0 1051768 0 0 0 BRYAN A GASPARD PHYSICIAN 824430 0 129097 0 26222 0 15250 0 25758 0 1020757 0 0 0 D PAUL SEAGO MD BOARD MEMBER/PHYSICIAN 773953 0 93597 0 107175 0 15250 0 19267 0 1009242 0 0 0 STEVEN GREMILLION MD BD MEMBER/FMOLHS EVP CMO 0 639829 0 277388 0 12141 0 15250 0 25118 0 969726 0 0 ZACHARY BALDWIN PHYSICIAN 616959 0 139777 0 1242 0 15250 0 25150 0 798378 0 0 0 REBEKAH MOULDER MD BOARD MEMBER/PHYSICIAN 441568 0 330269 0 1052 0 15250 0 2110 0 790249 0 0 0 SCOTT KASHMAN MARKET PRESIDENT (UNTIL 7/22) 499303 0 108077 0 3189 0 70852 0 27085 0 708506 0 0 0 KRISTIN WOLKART INTERIM MARKET PRESIDENT (START 7/22 0 440832 0 131783 0 3231 0 95636 0 19942 0 691424 0 0 LESTER DIAMOND FORMER PRESIDENT 0 0 0 0 0 531654 0 0 0 0 0 531654 0 0 SAMUEL SCOTT SVP, CFO 321567 0 157491 0 5759 0 14175 0 17912 0 516904 0 0 0 BRYAN MILLER MD BD MEMBER/FMOLHS VP CHIEF CTO 0 366022 0 52860 0 2521 0 15250 0 18112 0 454765 0 0 REGINALD MARTIN MD BOARD MEMBER/PHYSICIAN 316384 0 18940 0 2564 0 12950 0 25150 0 375988 0 0 0 THU PHAN VP COO 241578 0 44000 0 1492 0 14173 0 8086 0 309329 0 0 0 ROBERT NELSON FORMER VP CHIEF NURSING OFFICER 155774 0 0 0 131353 0 755 0 13655 0 301537 0 0 0 WILLIAM MORGAN FORMER COO 0 0 0 0 171654 0 0 0 0 0 171654 0 0 0 PART I, LINE 3 THE FMOL HEALTH SYSTEM BOARD OF DIRECTORS DESIGNATES A COMPENSATION COMMITTEE, MADE UP OF INDEPENDENT BOARD MEMBERS, TO REVIEW AND SET COMPENSATION ANNUALLY. THE COMPENSATION COMMITTEE OBTAINS AND RELIES UPON COMPARABLE DATA INCLUDING A COMPENSATION STUDY/SURVEY FROM AN INDEPENDENT COMPENSATION CONSULTANT. THE COMPENSATION COMMITTEE REIVEWS COMPENSATION PACKAGES AND APPRROPRIATE COMPENSATION IS DETERMINED AND APPROVED. THE BASIS FOR MAKING SUCH DETERMINATION IS DOCUMENTED BY THE COMPENSATION COMMITTEE. PART I, LINES 4A-B FMOLHS MAINTAINS THREE UNFUNDED DEFERRED COMPENSATION PLANS WHICH MEET THE REQUIREMENTS OF IRC SECTION 457(F) AND IRC SECTION 409A. THE PLANS PROVIDE FOR COMPENSATION TO BE DEFERRED AND PAID UPON THE OCCURRENCE OF CERTAIN EVENTS SUCH AS TERMINATION WITHOUT CAUSE, DISABILITY, DEATH OR ATTAINMENT OF A SPECIFIC PAYMENT DATE. PARTICIPATION IN THE PLANS IS LIMITED TO CERTAIN EXECUTIVES AND IS SUBJECT TO APPROVAL OF FMOLHS BOARD OF DIRECTORS OR A DESIGNATED COMMITTEE OF SUCH BOARD. NO ONE LISTED ON PART VII, SECTION A RECEIVED A PAYMENT FROM THE PLANS IN THE CURRENT YEAR. PART I, QUESTION 4A: TWO OFFICERS AND ONE BOARD MEMBER ARE ENTITLED TO A SEVERANCE BENEFIT. THE PAYOUT OF SUCH BENEFIT IS REMOTE AS IT IS EFFECTIVE ONLY FOR A TERMINATION OF EMPLOYMENT WITHOUT CAUSE, FOR GOOD REASON OR DUE TO CHANGE OF CONTROL. IF TRIGGERED, THE EMPLOYEE WOULD BE PAID HIS/HER BASE SALARY AND PROVIDED RETIREMENT AND WELFARE BENEFITS FOR AN ENTITLEMENT PERIOD. THE ENTITLEMENT PERIOD IS 18 MONTHS. NO PAYMENTS WERE MADE UNDER THE PLAN IN THE CURRENT YEAR. AN OFFICER IS ENTITLED TO A SEVERANCE BENEFIT. THE PAYOUT OF SUCH BENEFIT IS REMOTE AS IT IS EFFECTIVE ONLY FOR A TERMINATION OF EMPLOYMENT WITHOUT CAUSE, FOR GOOD REASON OR DUE TO CHANGE OF CONTROL. IF TRIGGERED, THE EMPLOYEE WOULD BE PAID HIS/HER BASE SALARY AND PROVIDED RETIREMENT AND WELFARE BENEFITS FOR AN ENTITLEMENT PERIOD. THE ENTITLEMENT PERIOD IS 12 MONTHS. NO PAYMENTS WERE MADE UNDER THE PLAN IN THE CURRENT YEAR. THE FOLLOWING INDIVIDUALS RECEIVED SEVERANCE PAYMENTS THIS YEAR - LESTER DIAMOND $531,654 WILLIAM MORGAN $171,654 ROBERT NELSON $129,466 FORM 990, PART VI, SECTION A, LINE 6 ST. DOMINIC HEALTH SERVICES, INC. IS THE SOLE MEMBER OF ST. DOMINIC JACKSON MEMORIAL HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF DIRECTORS OF ST. DOMINIC- JACKSON MEMORIAL HOSPITAL'S SOLE MEMBER, ST. DOMINIC HEALTH SERVICES, INC., HAS THE AUTHORITY TO APPROVE THE ELECTION OF THE PRESIDENT/CEO, THE CHAIR OF THE BOARD OF DIRECTORS AND THE VICE-CHAIR OF THE BOARD OF DIRECTORS OF THE HOSPITAL AND ALL OTHER DIRECTORS AND OFFICERS OF THE HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7B THE RESERVED POWER TO THE MEMBER, ST. DOMINIC HEALHT SERVICES, INC., ARE AS FOLLOWS: I. TO CHANGE PHILOSOPHY, OBJECTIVES AND PURPOSES OF CORPORATION. II. TO APPOINT OR REMOVE THE MEMBERS OF THE BOARD OF TRUSTEES AND OFFICERS OF THE CORPORATION. III. TO AMEND, ALTER, MODIFY, OR REPEAL THE ARTICLES OF INCORPORATION AND BYLAWS OF THE CORPORATION. IV. TO AUTHORIZE MERGER, CONSOLIDATION, OR AFFILIATION, OR PARTICIPATE IN JOINT VENTURES. V. TO DISSOLVE AND TO DISTRIBUTE ASSETS OF THE CORPORATION. VI. TO APPOINT AND/OR TERMINATE WITH OR WITHOUT CAUSE THE CHIEF EXECUTIVE OFFICER OF THE CORPORATION. VII. TO ACQUIRE, PURCHASE, SELL, LEAASE, TRANSFER, OR ENCUMBER ANY IMMOVABLE PROPERTY ON BEHALF OF THE CORPORATION. VIII. TO ADD TO OR INCUR LONG-TERM DEBT IN EXCESS OF $5 MILLION BY THE CORPORATION. IX. TO APPOINT THE FISCAL AUDITOR FOR THE CORPORATION. X. TO APPROVE ANY INCREMENT OR ADDITION TO THE CAPITAL DEBT OR EFFORTS TO RENEGOTIATE, MODIFY OR CHANGE THE EXISTING CAPITAL DEBT OBLIGATIONS OF THE CORPORATION. XI. TO APPROVE THE ANNUAL OPERATING AND CAPITAL BUDGETS OF THE CORPORATION. XII. TO APPROVE A STRATEGIC BUSINESS PLAN OF THE CORPORATION. FORM 990, PART VI, SECTION B, LINE 11B THE BOARD HAS DELEGATED REVIEW OF THE FORM 990 TO THE FINANCE COMMITTEE OF THE BOARD PRIOR TO FILING. A FULL COPY, AS APPROVED BY THE FINANCE COMMITTEE, IS PROVIDED TO THE BOARD. FORM 990, PART VI, SECTION B, LINE 12C ALL BOARD MEMBERS ARE REQUIRED TO COMPLETE AND SIGN A CONFLICT OF INTEREST FORM ANNUALLY. THE PRESIDENT REVIEWS THE FORMS, AND ANY CONFLICTS ARE DISCLOSED TO THE OTHER MEMBERS OF THE BOARD AND MADE A MATTER OF RECORD. PERSONS WITH CONFLICTS OF INTERESTS DO NOT VOTE OR USE HIS OR HER INFLUENCE ON THE MATTER AND ARE EXCLUDED FROM THE COUNT IN DETERMINING THE QUORUM FOR THE MEETING, EVEN WHERE PERMITTED BY LAW. FORM 990, PART VI, SECTION B, LINE 15 OUR BOARD OF DIRECTORS DESIGNATES AN EXECUTIVE COMMITTEE MADE UP OF INDEPENDENT BOARD MEMBERS TO REVIEW AND SET THE COMPENSATION ANNUALLY OF OUR OFFICERS AND KEY EMPLOYEES. THE EXECUTIVE COMMITTEE OBTAINS AND RELIES UPON COMPARABLE DATA INCLUDING INDUSTRY-WIDE COMPENSATION INFORMATION PROVIDED BY AN OUTSIDE CONSULTING FIRM. THE EXECUTIVE COMMITTEE REVIEWS COMPENSATION PACKAGES AND APPROPRIATE COMPENSATION IS DETERMINED AND APPROVED. THE BASIS FOR DETERMINATION IS THEN DOCUMENTED BY THE EXECUTIVE COMMITTEE. THE COMPENSATION FOR THE CEO OF ST. DOMINIC JACKSON MEMORIAL HOSPITAL IS SET BY THE COMPENSATION COMMITTEE OF ST. DOMINIC HEALTH SERVICES (A RELATED TAX-EXEMPT ORGANIZATION) ACCORDING TO THEIR PAY PRACTICES WHICH ARE SIMILAR TO THOSE DESCRIBED ABOVE. 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. SECTION 1.263(A)-3(N) - BOOK CONFORMITY ELECTION: ST. DOMINIC JACKSON MEMORIAL HOSPITAL IS MAKING THE ELECTION UNDER TREAS. REG. 1.263(A)-3(N) TO CAPITALIZE THE REPAIR AND MAINTENANCE COSTS THAT IT TREATS AS CAPITAL IMPROVEMENTS ON ITS BOOKS AND RECORDS FOR THE TAX YEAR ENDED JUNE 30, 2023. SECTION 1.263(A)-1(F) - DE MINIMIS SAFE HARBOR ELECTION: ST. DOMINIC JACKSON MEMORIAL HOSPITAL HEREBY MAKES THE DE MINIMIS SAFE HARBOR ELECTION UNDER SECTION 1.263(A)-1(F) OF THE TREASURY REGULATIONS, EFFECTIVE ONLY FOR THE TAX YEAR ENDED JUNE 30, 2023. TAXPAYER HAS AN APPLICABLE FINANCIAL STATEMENT FOR THE YEAR OF THE ELECTION. THIS ELECTION PERMITS THE TAXPAYER TO DEDUCT FOR TAX PURPOSES ANY ITEM DEDUCTED UNDER ITS BOOK POLICY THAT DOES NOT EXCEED $5,000 PER INVOICE (OR PER ITEM, AS SUBSTANTIATED BY THE INVOICE) OR ITEMS HAVING AN ECONOMIC USEFUL LIFE OF TWELVE MONTHS OR LESS AS DESCRIBED IN SECTION 1.263(A)-1(F)(1)(I). FORM 990, PART XI, LINE 9: CAPITAL TRANSFER -28,398,902. 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