2021-07-22T14:18:11-05:00 2020-08-31 420714325 RSM US LLP 30 South Wacker Dr Suite 3300 Chicago IL 606063392 990 2019-09-01 951656366 Good Samaritan Hospital GOOD 2139772121 1225 Wilshire Blvd Los Angeles CA 900172395 Vid Shivaraman CFO 2139772121 2021-07-22 1 Rebekuh Eley P01247672 3126343400 2021-07-06 2019 2022-09-23 18:48:47Z PIH Health Good Samaritan Hospital Vid Shivaraman 1225 Wilshire Blvd Los Angeles CA 900172395 436394400 0 X www.PIHHealth.org X 1885 CA Provide accessible, quality, cost-effective healthcare services at 408-bed hospital in LA. 13 12 1762 157 320222 0 5646258 42473194 360346227 381349361 8450513 8892166 2790362 3679679 377233360 436394400 552231 171834 0 0 170456156 184367853 0 0 1270146 221196301 242755924 392204688 427295611 -14971328 9098789 485500294 754664509 173737014 265337961 311763280 489326548 X To provide accessible, quality, cost-effective community healthcare. The Hospital operates a 408-bed facility in inner-city Los Angeles. 0 0 207153066 171834 263482769 Founded in 1885, PIH Health Good Samaritan Hospital became part of PIH Health in December 2019. As a 501(c) (3) nonprofit, 408-bed acute care hospital, the downtown Los Angeles campus serves the healthcare needs of a growing and diverse community.Patient Care in Fiscal Year 2019-2020Employees ....... 1,689Volunteers ....... 198Number of Emergency Department (ED) visits ....... 43,813Number of Births ....... 2,119Medical Staff ....... 714 169036474 0 116852159 Financial Assistance and Means-Tested Government Programs: Financial Assistance, also known as charity care, is defined as free or discounted health services provided to individuals who cannot afford to pay and who meet the eligibility criteria of the organization's financial assistance policy. PIH Health Good Samaritan Hospital offers a generous Financial Assistance Program, providing charity care to those with family income(s) at or below 350% of Federal Poverty Level guidelines. The hospital has a policy to treat emergency and certain other patients regardless of their ability to pay. Under the charity care policy, charity care may be provided to people who are uninsured or underinsured and cannot afford to pay for their own medical care.In providing services to those patients participating in means-tested government health programs, such as Medi-Cal, PIH Health Good Samaritan Hospital realizes a collective net loss each fiscal year due to the shortfall created when the payments received from these programs are less than the cost of caring for public program beneficiaries. Number of persons served by financial assistance and means-tested government programs: 33,758 4544047 0 522163 Other Community Benefit Services: Community health improvement services and community benefit operations, health professions education, subsidized services, research and cash and in-kind contributions for community benefit are comprised of the following: COMMUNITY HEALTH IMPROVEMENT SERVICES: Defined as community health improvement activities, which extend beyond patient care activities. The annual Korean Health Fair is included in this category as well as community health education, community social service helpline, Medi-Cal eligibility workers and transportation services.Snapshot of Outcomes:- 18,873 community members were reached through a variety of community health improvement activities.HEALTH PROFESSIONS EDUCATION: This category includes educational programs for physicians, nurses, chaplains and other health professional students when education is necessary or required by state law, accrediting body or health profession society. Snapshot of Outcomes:- 22 chaplain students and lab interns were provided with mentorship, internship and training opportunities.SUBSIDIZED HEALTH SERVICES: Subsidized services are clinical programs, which are provided despite a financial loss so significant that negative margins remain after removing the effects of financial assistance, bad debt and Medi-Cal shortfalls. Nevertheless, the service is provided because it meets an identified community need and, if no longer offered, would either be unavailable in the area or fall to the responsibility of government or another nonprofit organization to provide. PIH Health Good Samaritan Hospital provided Emergency Department On-Call Physicians.RESEARCH: Research that may be reported as community benefit includes clinical and community health research as well as studies on healthcare delivery that are generalizable and shared with the public. PIH Health Good Samaritan Hospital has been offering clinical trials and research studies aimed at improving health. Snapshot of Outcomes:- Over $164,951 expenses have been incurred in research in Fiscal Year 2019-2020.CASH & IN-KIND CONTRIBUTIONS: This category includes funds and in-kind services donated by PIH Health Good Samaritan Hospital to community organizations or to the community-at-large for a community benefit purpose. These donations include cash donations to community organizations, hours contributed by staff to the community while on PIH Health work time, the cost of meeting space provided to community groups, and the donations of equipment, medications, supplies and services. Snapshot of Outcomes:- 3,817 at-risk individuals were provided with in-kind durable medical equipment or services, such as skilled nursing or mental healthcare.Total number of persons served by other community benefit services: 22,723For additional information, please refer to PIH Health's community benefit report at https://www.pihhealth.org/about-us/community-benefit/ 380733587 1 1 0 1 0 0 0 0 0 1 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 1 1 0 0 1 398 0 1 1762 1 1 1 0 0 0 0 1 1 0 0 0 0 0 0 X 13 12 1 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 0 CA X Vid Shivaraman 2139772003 637 South Lucas Avenue 3rd Floor Los Angeles CA 90017 James West President & CEO 10.00 43.20 X 0 1789200 290278 Rosalio Lopez Chief Strategy & Medical Officer 10.00 33.00 X 0 1118285 11067 Peggy Chulack Chief Admin. Officer & Asst. Secy. 10.00 43.20 X 0 833977 137822 Andrew B Leeka President & CEO (Until 3/2020) 50.00 8.00 X X 723855 0 11470 Alan M Ino CFO (Until 4/2020) 50.00 8.00 X 539942 0 10229 Philip Wolfe VP Professional Services 40.00 0.00 X 314995 0 8789 Todd Goodall VP Business Development 40.00 0.00 X 313622 0 10162 Adnan Hamid VP Info. Tech. Services 40.00 0.00 X 297123 0 11259 Brian Thorne VP Fund Development 40.00 0.00 X 291856 0 10300 Samir Nabulsi Director Worker's Comp. 40.00 0.00 X 277312 0 9119 Shauna Pearce VP Nursing Services 40.00 0.00 X 283599 0 2310 Ira Meiselman Director Managed Care 40.00 0.00 X 274643 0 11259 Hilarion Castillo Controller 40.00 0.00 X 269532 0 8507 James Whitcomb Director Revenue Cycle 40.00 0.00 X 251949 0 7611 Sammy Feuerlicht Chief Strategy Officer 40.00 0.00 X 247038 0 10639 Tai Kang Staff R.N. 40.00 0.00 X 249761 0 0 Jean Meussner VP Human Resources 40.00 0.00 X 227331 0 7661 Irena Zuanic VP Nursing Services 40.00 0.00 X 188137 0 4548 Anita Chou CFO & Assistant Treasurer 10.00 43.10 X 0 117808 8 Charles T Munger Chairman (Until 12/31/19) 1.00 4.00 X X 0 0 0 J Richard Atwood Chairman 1.50 7.50 X X 0 0 0 Robert E Denham Vice Chairman (Until 12/31/19) 1.00 4.00 X X 0 0 0 Jeffrey Hamar Vice Chairman 1.50 6.00 X X 0 0 0 George A Bender Secretary (Until 12/31/19) 1.00 4.00 X X 0 0 0 Charlotte Weaver RN PhD Secretary 1.50 6.00 X X 0 0 0 Edward Dunlap Treasurer 1.50 6.00 X X 0 0 0 Sushma Adarkar MD Trustee (Until 12/31/19) 1.00 0.00 X 0 0 0 Alex Alvarez Trustee 1.50 6.00 X 0 0 0 Bruce Bennett Trustee (Until 12/31/19) 1.00 4.00 X 0 0 0 William M Bitting Trustee (Until 12/31/19) 1.00 0.00 X 0 0 0 Mrs Jack L Blumenthal Trustee (Until 12/31/19) 1.00 0.00 X 0 0 0 Mrs Maribeth A Borthwick Trustee (Until 12/31/19) 1.00 0.00 X 0 0 0 Paula Cowan Trustee 1.50 6.00 X 0 0 0 Blayne Cutler MD PhD Trustee 1.50 6.00 X 0 0 0 Victoria Seaver Dean Trustee (Until 12/31/19) 1.00 4.00 X 0 0 0 Jane Dicus Trustee 1.50 6.00 X 0 0 0 John B Frank Trustee (Until 12/31/19) 1.00 4.00 X 0 0 0 James H Gipson Trustee (Until 12/31/19) 1.00 4.00 X 0 0 0 Mimi Grant Trustee (Until 12/31/19) 1.00 0.00 X 0 0 0 Peter Greaney MD Trustee 1.50 6.00 X 0 0 0 Allison A Hill MD Trustee (Until 12/31/19) 1.00 4.00 X 0 0 0 Robert K Maloney MD Trustee (Until 12/31/19) 1.00 4.00 X 0 0 0 Charles P Meister Trustee (Until 12/31/19) 1.00 0.00 X 0 0 0 Glen H Mitchel Jr Trustee (Until 12/31/19) 1.00 4.00 X 0 0 0 Peter W Mullin Trustee (Until 12/31/19) 1.00 0.00 X 0 0 0 Patrick Monroe Trustee 1.50 6.00 X 0 0 0 Bruce E Pherson Jr Trustee (Until 12/31/19) 1.00 0.00 X 0 0 0 Clark W Porter Trustee (Until 12/31/19) 1.00 0.00 X 0 0 0 Helen Lho Ryu Trustee (Until 12/31/19) 1.00 0.00 X 0 0 0 Stephen L Smith Trustee (Until 12/31/19) 1.00 0.00 X 0 0 0 The Rt Rev John Harvey Taylor Trustee (Until 12/31/19) 1.00 0.00 X 0 0 0 Paul Treinen Trustee 1.50 6.00 X 0 0 0 Kenton Woods Trustee 1.50 6.00 X 0 0 0 Edward A Wopschall Trustee (Until 12/31/19) 1.00 0.00 X 0 0 0 4750695 3859270 563038 617 0 1 0 Orange Commercial Credit Ref SecureNurs PO Box 25229 Anaheim CA 92825 Nursing Registry Services 6234230 Crothall Healthcare Inc 955 Chesterbrook Blvd 300 Wayne PA 19087 Environmental Services 4982206 Morrison Management Specialists 5801 Peachtree Dunwoody Rd Atlanta GA 30342 Dietary Services 3466750 Samaritan Hospitalists Medical Group In 898 N Pacific Coast Hwy Ste 600 El Segundo CA 90245 Professional Medical Services 2966900 California Commercial Real Estate Servic 1800 Quail St Ste 100 Newport Beach CA 92660 Property Management 2746204 95 204136 38242036 4027022 42473194 Patient Revenue 621990 380707492 380707492 Child Care Center 624410 492270 162449 329821 Rental Income 532000 149599 149599 381349361 8875513 8875513 16653 0 16653 16653 16653 Parking Lot 812930 1112914 67282 1045632 Physician Mngmt Svcs 621110 51150 51150 Non-Patient Lab Svcs 621500 39341 39341 2476274 2476274 3679679 436394400 380857091 320222 12743893 X 171834 171834 3514864 802377 2410331 302156 132833635 121623882 11008830 200923 6161063 5778880 382183 30798836 28610156 2132320 56360 11059455 10236427 783018 40010 1091256 1254 978541 111461 526315 526315 22075 22075 93766993 85382409 8379340 5244 724960 123471 601489 2603962 2567269 35653 1040 16401 8278 7657 466 1927913 1927913 10135677 5586546 4549131 6473725 4034543 2438580 602 Supplies 76665636 76205341 438539 21756 Hospital Fee Program 27471627 27471627 Bad Debt Expense 8827730 8827730 Utilities 5566793 5462205 104355 233 6934861 4739175 1665791 529895 427295611 380733587 45291878 1270146 29991092 125386182 957000 1100000 57919039 65380738 177697339 173622862 1937434 5553434 5148279 4781603 282433780 8237592 111422425 274196188 95171348 99219109 5256338 5424393 485500294 754664509 74613845 164948786 52397957 50000000 46725212 50389175 173737014 265337961 X 246334946 421864682 65428334 67461866 311763280 489326548 485500294 754664509 X 9098789 3569921 163414000 1480558 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 22075 22075 0 Part II-B, Line 1: Lobbying expenses represent a portion of the dues Good Samaritan Hospital pays to the Hospital Association of Southern California. Good Samaritan Hospital does not participate in or intervene in (including the publishing or distributing of statements), any political campaign on behalf of (or in opposition to) any candidate for public office. 72033292 915671 3449811 3979311 175171 72244292 73767150 108951 4068889 5875119 36579 72033292 74567557 16756 5368619 6185782 73767150 72393290 1202722 8424663 7426842 26276 74567557 71589573 164742 4279465 3979499 -339009 72393290 0.15360 0.75000 0.09640 1 0 204149473 204149473 42352772 867579 41485193 26266203 5160916 21105287 9665332 2209097 7456235 274196188 Reserve for Self-Insured Programs 4478257 Pension Plan 14319328 Advances from Third Party Payors 5479468 Reserve for Asset Retirement Obligation 11341079 Other Annuity Payment Liability 1896192 Other Long Term Reserves 12874851 50389175 X Part V, Line 4: For specific purposes listed by the donors. Part X, Line 2: The principal operations of the Company are exempt from income taxes pursuant to Internal Revenue Code (IRC) Section 501(c)(3) and the laws of the states in which it operates and, as such, is generally not subject to federal or state income taxes. However, the Company is subject to income taxes on net income derived from a trade or business regularly carried on that does not further the organization's exempt purpose. Further, the Company is also subject to federal excise taxes pursuant to the Tax Cuts and Jobs Act. No significant income tax provision has been recorded in the accompanying consolidated financial statements for net income derived from unrelated trade or business and excise taxes. The Company measures liabilities for unrecognized tax uncertainties in accordance with ASC 740, Income Taxes, which prescribes a comprehensive model for how a company should recognize, measure, present and disclose in its financial statements uncertain tax positions that a company has taken or expects to take on a tax return. The guidance is applicable to profit-oriented entities, pass-through entities and tax-exempt organizations. Management believes it has no significant uncertain tax positions and, as such, no tax liability, benefits, interest or penalties were accrued at August 31, 2020 or 2019. The Company is subject to routine audits by taxing jurisdictions; however, there are currently no audits for any tax periods in progress. The Company believes it is no longer subject to income tax examinations for years prior to 2016 for federal purposes and 2014 for California purposes. 1 1 X 1 X 1 X 1 1 1 0 1 1 7828 8634634 8634634 0.02060 25930 160401840 116852159 43549681 0.10410 33758 169036474 116852159 52184315 0.12470 10 18873 1406049 6000 1400049 0.00330 2 22 1347795 513073 834722 0.00200 1 9 111596 111596 0.00030 1 168041 3090 164951 0.00040 3 3819 1510566 1510566 0.00360 17 22723 4544047 522163 4021884 0.00960 17 56481 173580521 117374322 56206199 0.13430 1 1358408 0 91898673 103779471 -11880798 X 1 1 1 1 PIH Health Good Samaritan Hospital 1225 Wilshire Blvd Los Angeles CA 90017 www.pihhealth.org 930000071 X X X X X PIH Health Good Samaritan Hospital 1 0 1 1 X X X X X X X X X 18 1 1 0 1 X See Part V, Page 8 X 1 19 1 See Part V, Page 8 0 1 X 200.000000000000 350.000000000000 X X X 1 1 X X X 1 X See Part V, Page 8 X See Part V, Page 8 X See Part V, Page 8 X X X X X X 1 X 0 X X X X 1 X 0 0 PIH Health Good Samaritan Hospital Part V, Section B, Line 2: On December 18, 2019, the State of California Attorney General provided consent to a proposed change in control and governance of Good Samaritan Hospital (GSH), a 408-bed facility based in Los Angeles, whereby PIH Health Inc. (PIH) would effect a membership transfer of GSH to PIH. On December 23, 2019, the amended articles of incorporation for GSH were successfully filed with the California Secretary of State, and PIH became the sole corporate member of GSH. On December 31, 2019, all of the members of GSH's board of directors were removed and replaced with the same individuals comprising PIH's board of directors. The purpose of the affiliation of PIH and GSH is to further the goal of expanding the integrated healthcare delivery system to improve the quality of healthcare within their communities and to further their mission of advancing the quality of care and furthering charitable service. PIH Health Good Samaritan Hospital Part V, Section B, Line 5: Good Samaritan Hospital conducted targeted interviews to gather information and opinions from persons who represent the broad interests of the community served by the medical center.Twenty-nine (29) interviews were completed from November 2018 to January 2019. Community stakeholders identified by the Metro Los Angeles Collaborative were contacted and asked to participate in the needs assessment. Interviewees included individuals who are leaders and/or representatives of medically underserved, low-income, and minority populations, local health or other departments or agencies that have current data or other information relevant to the health needs of the community. Input was obtained from the Los Angeles County Department of Public Health.The identified stakeholders were invited by email to participate in a phone interview. Appointments for the interviews were made on dates and times convenient to the stakeholders. At the beginning of each interview, the purpose of the interview in the context of the needs assessment was explained, the stakeholders were assured their responses would remain confidential, and consent to proceed was given. Interview questions focused on the following topics: - Health issues in the community - Challenges and barriers people face in addressing these issues - Socioeconomic, behavioral, or environmental factors contributing to poor health in the community - Potential resources to address the identified health needs, such as services, programs and/or community efforts - Additional comments and concerns A list of the stakeholder interview respondents, their titles and organizations can be found in Attachment 2.The full Community Health Needs Assessment can be found at: https://www.pihhealth.org/about-us/community-benefit/ PIH Health Good Samaritan Hospital Part V, Section B, Line 6a: Good Samaritan Hospital participated in a collaborative process for the Community Health Needs Assessment, in partnership with St. Vincent Medical Center and California Hospital Medical Center. PIH Health Good Samaritan Hospital Part V, Section B, Line 11: PIH Health, Inc. acquired Good Samaritan Hospital on December 23, 2019. As a result, during tax year 2019, Good Samaritan Hospital updated its existing Community Health Improvement Plan, as adopted July 25, 2019, to align with its new affiliates, PIH Health Whittier Hospital and PIH Health Downey Hospital. PIH Health Good Samaritan Hospital's board approved the 2020-2022 Community Health Improvement Plan on April 8, 2020.PIH Health's Community Health Improvement Plan (CHIP) ensures alignment of CHNA findings, our community health improvement programs and PIH Health's organizational strategy. To view the 2020-2022 CHIP and the initiatives identified to address areas of focus (cancer incidence/mortality, diabetes incidence/mortality, heart disease/stroke incidence/mortality, overweight/obesity, substance use and misuse, preventative screenings and immunizations with emphasis on flu and pneumonia vaccines and cancer screenings, food insecurity, housing/homelessness, dental care and mental health), visit https://www.pihhealth.org/app/files/public/a8f558ef-640a-446c-875b-b273453fa4ce/2020-2022-pih-health-community-health-improvement-plan.pdfFor the health needs not prioritized as areas of focus - access to healthcare, asthma incidence, birth indicators, economic insecurity, education, kidney disease mortality, liver disease mortality, sexually transmitted infections, violence and injury - it was determined that PIH Health has neither the expertise nor the infrastructure to lead efforts in these areas. As these health needs are still very important to PIH Health and the community it serves, emphasis will be placed on referral relationships with community-based agencies already working in these areas. Part V, Section B, Line 7, CHNA Policy Website: https://www.pihhealth.org/about-us/community-benefit/ Part V, Section B, Line 10, Implementation Strategy Website: https://www.pihhealth.org/wellness/community-benefit/ Part V, Section B, Line 16a, FAP website: https://www.pihhealth.org/patients-visitors/billing-financial-assistance/financial-assistance/ Part V, Section B, Line 16b, FAP Application website: https://www.pihhealth.org/patients-visitors/billing-financial-assistance/financial-assistance/ Part V, Section B, Line 16c, FAP Plain Language Summary website: https://www.pihhealth.org/patients-visitors/billing-financial-assistance/financial-assistance/ Part I, Line 6a: Good Samaritan Hospital's community benefit report is contained in the report prepared by PIH Health, Inc., a related organization. Part I, Line 7: Patient care cost to charge ratio derived from Worksheet 2 was used to calculate the financial assistance and Medi-Cal cost. Actual costs from general ledger or departments were used for health fair, research and all other costs. Part I, Line 7, Column (f): The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 8,827,730. Part III, Line 2: Bad debt expense is determined by applying cost to charge ratio to bad debt transfers net of recoveries. This expense was not included in community benefit expense. Part III, Line 3: PIH Health Good Samaritan Hospital actively provides all patients the option to apply for financial assistance, therefore, no estimate is made for bad debt attributable to patients eligible under the financial assistance policy. Part III, Line 4: In order to align with the PIH Health system, PIH Health Good Samaritan Hospital is changing its fiscal year-end in 2020 from August 31 to September 30. As a result of this change, Good Samaritan Hospital did not obtain a separate financial statement audit for the period ending August 31, 2020, but rather was included in the consolidated audit report of PIH Health Inc. as of September 30, 2020. However, our bad debt policy has not changed. From the audited financial statements of Good Samaritan Hospital and its affiliates for the year ended August 31, 2019: "The Company has agreements with third-party payors that provide for payments to the determined rates per discharge, reimbursed costs, discounted charges, and per diem payments. Net patient service revenue is reported at the estimated net realizable amounts from patients, third-party payors, and others for services rendered, including estimated retroactive adjustments under basis in the period the related services are rendered and adjusted in future periods as final settlements are determined. The Company presents its provision for bad debts as a reduction of patient service revenue on a separate line item in its consolidated statements of operations." The bad debt expense on Part III, Line 2 is calculated using total cost to charge ratio applying to total bad debt transfers net of recoveries and none of the bad debt expense is included in community benefit expense. Part III, Line 8: The amounts on Lines 5 and 6 are annualized amounts from the Terminating Medicare Cost Report (9/1/2019 to 12/22/2019). This is the latest cost report available. We believe these amounts do not qualify as community benefit. Part III, Line 9b: Patients are advised that they have the opportunity to submit a charity application or apply for a discount under the Hospital's Charity Care Policy or Cash Price Policy. Part VI, Line 2: PIH Health Good Samaritan Hospital addresses the healthcare needs of the communities it serves through participation in various community collaboratives and networking meetings. Good Samaritan Hospital is able to assess the healthcare needs of the community and identify partnership opportunities. Part VI, Line 3: Uninsured patients are screened for Medi-Cal linkage and if they meet the criteria, the patient is referred to RISARC to assist with the application and eligibility process. If the patient does not have Medi-Cal linkage, they are screened for Queens Care which is a program for uninsured patients that reside within specific zip codes in Los Angeles County and meet income qualification. Financial Assistance Applications are provided to all patients who are uninsured, underinsured, financial hardship, have catastrophic illness or have excessive medical expenses. The following hospital policies are available on our website; Charity Care / Discount Policy, Financial Assistance Application and Cash Price Policy. The statements mailed to patients provides information regarding Financial Assistance, Covered California Health Benefits, Medi-Cal and Medicare. Part VI, Line 4: PIH Health Good Samaritan Hospital is located at 1225 Wilshire Blvd., Los Angeles, California 90017. The hospital service area includes 18 ZIP Codes in Los Angeles City Council District 1. The service area is comprised of portions of Service Planning Areas (SPAs) 4 and 6. The hospital service area is detailed below by community and ZIP Code and was determined from the ZIP Codes that reflect a majority of patient admissions from the local geographic area.The population for the PHGSH service area is 516,340. Children and youth, ages 0-17, make up 15.6% of the population, 74% are 18-64 years of age, and 10.4% are seniors, 65 years and older. In the service area, 53.1% of the population are Hispanic/Latino, 22.5% are Asian, 13.2% are White, 8.9% are Black/African American; and the remaining 2.3% are American Indian/Alaskan Native, Native Hawaiian/Pacific Islander, other or multiple races. English is spoken in the home among 32.8% of the service area population. Spanish is spoken at home among 42.3% of the population, and 21.1% of the population speaks an Asian language in the home. In the service area, 30% of the population is at or below 100% of the federal poverty level. Among area adults, ages 25 and older, 30.2% lack a high school diploma, 19% are high school graduates and 35.6% are college graduates. Part VI, Line 5: Community BoardPIH Health Good Samaritan Hospital's community Board of Directors works to advance the commitment to helping our communities get well and stay healthy.Open Medical StaffPIH Health extends medical staff privileges to all qualified physicians in its community for some or all of its departments or specialties.Donation of TimeMany PIH Health providers are living out their passion to serve people in need by donating their time and talents both in our community and overseas. Environmental and Recycling ProjectsPIH Health continues to implement "green" initiatives, including increased usage of LED lighting to decrease consumption of electricity and developing energy management projects. Part VI, Line 6: PIH Health Good Samaritan Hospital is a member of an integrated healthcare system controlled by PIH Health, Inc. As such, the hospital has several affiliates, as outlined in Schedule R, which conduct, support, and promote the health of the community within the meaning of Section 501(c)(3) of the code. Key affiliates include: 1) PIH Health Downey Hospital; 2) PIH Health Whittier Hospital; 3)PIH Health Physicians, a nonprofit medical foundation; 4) PIH Health Home Healthcare and 5) the PIH Health Foundation, a nonprofit organization that exists to raise philanthropic funds in support of PIH's charitable mission.1) PIH Health, Inc. provides technical, facility and support services for tax-exempt affiliates whose charitable purpose is to provide a broad range of healthcare services to their community by way of an integrated health care delivery system.2) PIH Health Downey Hospital officially became part of PIH Health in October 2013. As a 501(c)(3) nonprofit, 199-bed hospital, the Downey campus has provided quality care in a welcoming environment for more than 100 years. As a nonprofit hospital with a charitable mission, PIH Health Hospital Downey is a dedicated community health and wellness partner. This commitment and leadership gives back to the community through charity care, health professions education and more.3) PIH Health Whittier Hospital opened in 1959. As a 501(c)(3) nonprofit, 523-bed hospital, the Whittier campus has developed into a health system offering a multitude of services. As a nonprofit hospital with a charitable mission, PIH Health Hospital Whittier is a dedicated community health and wellness partner. This commitment and leadership gives back to the community through charity care, medical research, donations, health professions education and more.4) PIH Health Physicians (PHP) A 501(c)(3) nonprofit medical group that is exclusively affiliated with PIH Health, the group is comprised of more than 121 primary care physicians and over 186 specialists who coordinate care from diagnosis to recovery. PHP supports the local community through its financial assistance program, Whittier First Day Health & Wellness Center for the homeless and those at-risk for homelessness, health professions education, and other community health improvement services.5) PIH Health Home Healthcare provides around-the-clock, quality care for patients in their own home. PIH Health Home Healthcare is certified by the Centers for Medicare and Medicaid Services.6) The PIH Health Foundation raises funds in support of PIH Health to ensure the health and well-being of our communities for years to come through supporting programs that directly impact the community, including PIH Health's community benefit programs. Healthy Living - Healthy Giving is an opportunity for everyone to play a role in the overall health of their friends, family, neighbors and everyone who lives, works, learns and plays in our community. Gifts - big, small and all will support PIH Health's work to provide access to quality healthcare, screenings, preventative care, prevention-focused education and other important initiatives.For detailed information regarding these PIH Health affiliates' additional activities to support and promote community health, please see each respective organization's IRS Form 990. Part VI, Line 7, Reports Filed With States CA 1 Good Samaritan Institute for Research and Education 1225 Wilshire Blvd Los Angeles CA 90017 954077161 501(c)(3) 169034 Expenses paid by the Organization 1 0 Part I, Line 2: The Institutes (Good Samaritan Institute for Research and Education and Orthopedic Institute of the Good Samaritan Hospital) do not have their own checking accounts, so all of their expenses (including salaries, wages and benefits) are paid for by the Hospital and are all recorded in each of the Institutes' accounts in the general ledger, through intercompany due to and from accounts on both sides (Institutes and Hospital's). Grants will only be made to 501(c)(3) organizations to ensure the funds will be used properly. X X X X 0 1 0 0 0 0 0 0 0 James West President & CEO 0 1257134 0 342262 0 189804 0 272003 0 18275 0 2079478 0 177030 Rosalio Lopez Chief Strategy & Medical Officer 0 859313 0 160631 0 98341 0 2800 0 8267 0 1129352 0 90055 Peggy Chulack Chief Admin. Officer & Asst. Secy. 0 599226 0 126276 0 108475 0 124412 0 13410 0 971799 0 101287 Andrew B Leeka President & CEO (Until 3/2020) 723855 0 0 0 0 0 8400 0 3070 0 735325 0 0 0 Alan M Ino CFO (Until 4/2020) 539942 0 0 0 0 0 8400 0 1829 0 550171 0 0 0 Philip Wolfe VP Professional Services 314995 0 0 0 0 0 8400 0 389 0 323784 0 0 0 Todd Goodall VP Business Development 313622 0 0 0 0 0 8400 0 1762 0 323784 0 0 0 Adnan Hamid VP Info. Tech. Services 297123 0 0 0 0 0 8400 0 2859 0 308382 0 0 0 Brian Thorne VP Fund Development 291856 0 0 0 0 0 8400 0 1900 0 302156 0 0 0 Samir Nabulsi Director Worker's Comp. 277312 0 0 0 0 0 8400 0 719 0 286431 0 0 0 Shauna Pearce VP Nursing Services 283599 0 0 0 0 0 0 0 2310 0 285909 0 0 0 Ira Meiselman Director Managed Care 254643 0 20000 0 0 0 8400 0 2859 0 285902 0 0 0 Hilarion Castillo Controller 269532 0 0 0 0 0 8118 0 389 0 278039 0 0 0 James Whitcomb Director Revenue Cycle 251949 0 0 0 0 0 7611 0 0 0 259560 0 0 0 Sammy Feuerlicht Chief Strategy Officer 247038 0 0 0 0 0 8400 0 2239 0 257677 0 0 0 Tai Kang Staff R.N. 249761 0 0 0 0 0 0 0 0 0 249761 0 0 0 Jean Meussner VP Human Resources 227331 0 0 0 0 0 6923 0 738 0 234992 0 0 0 Irena Zuanic VP Nursing Services 184804 0 3333 0 0 0 4548 0 0 0 192685 0 0 0 Part I, Line 4b A related organization, PIH Health, Inc., provides a supplemental executive retirement plan for certain executives. The following individuals participate in the plan: James West Peggy Chulack Anita Chou Rosalio Lopez The following amounts became vested or were paid-out in 2019 and are included in Schedule J, Part II, Column (b)(iii): James West $177,030 Peggy Chulack $101,287 Rosalio Lopez $90,055 Form 990, Part VI, Section A, line 2 The Organization is a member of an integrated healthcare system controlled by PIH Health, Inc. The following individuals have a business relationship by virtue of their positions as officers or directors of related entities within the system: J. Richard Atwood, Jeffrey Hamar, Paula Cowan, Alex Alvarez, Blayne Cutler, Jane Dicus, Patrick Monroe, Charlotte Weaver, Kenton Woods, Peter Greaney, Paul Treinen, James West, Peggy Chulack, Anita Chou, and Rosalio Lopez. Mrs. Maribeth Borthwick, a Board Member of Good Samaritan Hospital, has a family relationship with Mr. Charles Munger, Chairman of the Board. Mr. Clark W. Porter has a family relationship with Mr. Glen H. Mitchel, Jr., who are both board members. Form 990, Part VI, Section A, line 4 Good Samaritan Hospital amended its Bylaws to show PIH Health, Inc. as the sole member. Form 990, Part VI, Section A, line 6 PIH Health, Inc. is the sole member of Good Samaritan Hospital. Form 990, Part VI, Section A, line 7a PIH Health, Inc. has authority to elect all the members of the board of directors of Good Samaritan Hospital. Form 990, Part VI, Section A, line 7b PIH Health, Inc. has all voting rights and the power to elect the board of directors of Good Samaritan Hospital. Form 990, Part VI, Section B, line 11b The Organization works with an independent accountant, RSM US LLP, to prepare the Form 990. Once the return is prepared, the return is reviewed by the Chief Financial Officer and the Controller, who will provide any final comments to RSM US LLP. RSM US LLP makes all changes necessary and a final Form 990 is made available to all Board Members prior to filing. Form 990, Part VI, Section B, line 12c Each year, all management and board of directors members are required to complete a conflict of interest disclosure form. All positive responses are reviewed by the General Counsel and Chief Administrative Officer of PIH Health, Inc. Each positive response is considered in light of magnitude of ownership interest, financial transaction(s), etc. If deemed necessary, conflicts of interest could be resolved by insisting that the incumbent either divest their ownership interest, that the organization terminate the business relationship, or even that the director resign. Directors with potential conflicts of interest may recuse themselves from voting on certain matters and/or may excuse themselves from meetings during the discussion, deliberation, and voting on of matters. Form 990, Part VI, Section B, line 15 A subcommittee of the Governing Board's Executive Committee is responsible for determining the Chief Executive Officer's compensation. This Subcommittee is given comparison data on CEO salaries and benefits from comparable hospitals in the local area, prepared by human resources from 990s; and salary surveys completed by the local association. The decision of the Subcommittee on the CEO's salary is documented by the Subcommittee in writing. The compensation of the Organization's Vice Presidents are reviewed and approved by the Organization's CEO. Their salaries and benefits are determined using comparable hospitals in the local area, prepared by human resources from 990s; and salary surveys completed by the local hospital association. Form 990, Part VI, Section C, line 19 Good Samaritan Hospital's organizing documents and the Conflict of Interest Policy are not made available to the public. The financial information from the financial statements is included in the Organization's Form 990, which is available for public inspection upon request. Form 990, Part VI, Section B, Line 16b: Good Samaritan Hospital holds a 12.5% interest a joint venture arrangement that exists to further the charitable and community-based health care purposes, mission, vision, and values of its controlling tax exempt members. Good Samaritan Hospital annually evaluates its participation in joint venture arrangements. Form 990, Part IX, line 11g Physician Fees: Program service expenses 11,649,488. Management and general expenses 0. Fundraising expenses 0. Total expenses 11,649,488. Consulting and Management Fees: Program service expenses 421,876. Management and general expenses 1,227,616. Fundraising expenses 0. Total expenses 1,649,492. Medical Purchased Services: Program service expenses 2,544,953. Management and general expenses 0. Fundraising expenses 0. Total expenses 2,544,953. Repairs and Maintenance: Program service expenses 9,195,425. Management and general expenses 538,287. Fundraising expenses 2,413. Total expenses 9,736,125. Software Maintenance: Program service expenses 3,490,330. Management and general expenses 0. Fundraising expenses 0. Total expenses 3,490,330. Other Purchased Services: Program service expenses 21,116,376. Management and general expenses 6,333,053. Fundraising expenses 2,831. Total expenses 27,452,260. Outside Provider Cost: Program service expenses 16,785,873. Management and general expenses 0. Fundraising expenses 0. Total expenses 16,785,873. Purchased Labor: Program service expenses 20,178,088. Management and general expenses 280,384. Fundraising expenses 0. Total expenses 20,458,472. Form 990, Part XI, line 9: Pension related changes 1,353,192. Change in value of split-interest agreements -7,000. TRF Transfer 57,044. Net assets released from restrictions -94,514. Intercompany Transfer 171,836. Form 990, Part XI, Line 8: This line reflects a prior period adjustment for the organization's fair market valuation of assets, primarily fixed assets. This adjustment was identified during the opening balance sheet audit conducted during the tax year in connection with the acquisition of Good Samaritan Hospital and its affiliates by PIH Health, Inc. Schedule D Part VI similarly reflects changes resulting from this revaluation. Good Samaritan Institute for Research and Education 1225 Wilshire Blvd Los Angeles CA 90017 954077161 Heart Research CA 501(c)(3) Line 4 Good Samaritan Hospital 1 Orthopedic Institute of the Good Samaritan Hospital 1225 Wilshire Blvd Los Angeles CA 90017 954346048 Orthopedic Research CA 501(c)(3) Line 12a, I Good Samaritan Hospital 1 Samaritan Imaging Center 1225 Wilshire Blvd Los Angeles CA 90017 954252321 Outpatient Imaging Services CA 501(c)(3) Line 10 Good Samaritan Hospital 1 Good Samaritan Medical Office Building Inc 1225 Wilshire Blvd Los Angeles CA 90017 953244046 Physicians Medical Offices CA 501(c)(3) Line 12a, I Good Samaritan Hospital 1 Kate Van Nuys Page Foundation 1225 Wilshire Blvd Los Angeles CA 90017 956028032 Grants Income to Good Samaritan Hospital CA 501(c)(3) Line 12a, I Good Samaritan Hospital 1 PIH Health Adult Day Healthcare 12401 Washington Boulevard Whittier CA 90602 953643829 Support of Tax-Exempt Affiliates CA 501(c)(3) Line 12b, II PIH Health Inc 1 PIH Health Foundation 12401 Washington Boulevard Whittier CA 90602 953761274 Fundraising CA 501(c)(3) Line 7 PIH Health Inc 1 PIH Health Home Healthcare 12401 Washington Boulevard Whittier CA 90602 953036281 Support of Tax-Exempt Affiliates CA 501(c)(3) Line 12b, II PIH Health Inc 1 PIH Health Hospital - Downey 11500 Brookshire Avenue Downey CA 90241 951903935 Healthcare CA 501(c)(3) Line 3 PIH Health Inc 1 PIH Health Hospital - Whittier 12401 Washington Boulevard Whittier CA 90602 951934652 Healthcare CA 501(c)(3) Line 3 PIH Health Inc 1 PIH Health Management Corp 12401 Washington Boulevard Whittier CA 90602 954016278 Support of Tax-Exempt Affiliates CA 501(c)(3) Line 12b, II PIH Health Inc 1 PIH Health Physicians 6557 Greenleaf Ave Whittier CA 90601 953942828 Healthcare CA 501(c)(3) Line 10 PIH Health Inc 1 PIH Health Inc 12401 Washington Boulevard Whittier CA 90602 953619388 Support of Tax-Exempt Affiliates CA 501(c)(3) Line 12b, II N/A 0 Auxiliary of the Hospital of the Good Samaritan 1225 Wilshire Blvd Los Angeles CA 90017 956051253 Welfare of the Good Samaritan Hospital CA 501(c)(3) Line 12c, III-FI N/A 0 PIH Health Insurance Company 1003 Bishop Street Honolulu HI 96813 263760243 Captive Insurance HI N/A T 1 PIH Health Care Solutions 6557 Greenleaf Avenue Whittier CA 90601 462072342 Healthcare CA N/A C 1 DRMC Properties Inc 11500 Brookshire Avenue Downey CA 90241 954769768 Real Estate CA N/A C 1 PIH Health RE 1003 Bishop Street Honolulu HI 96813 472501390 Captive Insurance HI N/A T 1 HealthMed Services Inc 12401 Washington Boulevard Whittier CA 90602 300831225 Healthcare CA N/A C 1 Pioneer Medical Group Inc 12401 Washington Boulevard Whittier CA 90602 330927283 Medical Services CA N/A C 1 Pioneer Provider Network A Medical Group Inc 12401 Washington Boulevard Whittier CA 90602 330922631 Management Services CA N/A C 1 1 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 Good Samaritan Institute for Research and Education S 57044 FMV Good Samaritan Institute for Research and Education B 169034 FMV Good Samaritan Medical Office Building Inc S 570270 FMV Good Samaritan Medical Office Building Inc J 2214657 FMV Good Samaritan Medical Office Building Inc A 4881784 FMV Kate Van Nuys Page Foundation C 192181 FMV