2018-11-15T08:04:11-06:00 2017-12-31 ERNST & YOUNG US LLP 1900 Scripps Center 312 Walnut St Cincinnati OH 45202 990 2017-01-01 310536981 GOOD SAMARITAN HOSPITAL % J MICHAEL SIMS GOOD 9374999942 110 N MAIN ST 500 DAYTON OH 45402 TIMOTHY D SNIDER TREASURER / CFO 9374999942 2018-11-08 true JULIE L SPARKS P01268401 5136121400 108.206.163.59 31499120183195000008 2018-11-15 P E75E4AF8E999B2DA84673B904CC4ABFA422FD78A 770194AAF055F9EA87E64CA02E08FE540289067F 2017 2019-02-21 02:37:17Z Eloise Broner PresidentCEO 2222 PHILADELPHIA DR DAYTON OH 45406 421917658 false 0928 X WWW.PREMIERHEALTH.COM X 1932 OH WE WILL IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE WITH OTHERS WHO SHARE OUR COMMITMENT TO PROVIDE HIGH-QUALITY, COST-COMPETITIVE HEALTHCARE SERVICES. 7 5 3594 295 233211 -176237 345570 370968 358470414 382542402 17152792 7043536 4037714 3455170 380006490 393412076 3209492 3144614 0 0 166562040 155097700 0 0 0 208685726 250320350 378457258 408562664 1549232 -15150588 374728116 324444512 59164200 45607690 315563916 278836822 WE WILL IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE WITH OTHERS WHO SHARE OUR COMMITMENT TO PROVIDE HIGH-QUALITY, COST-COMPETITIVE HEALTHCARE SERVICES. false false 380436520 3144614 383042822 SEE SCHEDULE H 380436520 true true false true false false false false false false true false false true true true false true false false true false false false false false true true true false true false false false false false false true false false false false false true true true true false false true 185 0 true 3594 true true true false false false false false false false false false X 7 5 false true false false true true true true true false false true true true true true true true true true true OH X J MICHAEL SIMS 9374999942 110 N MAIN ST SUITE 500 DAYTON OH 45402 X MARTIN FUJIMURA MD BOARD CHAIR 0.5 0.5 X X 0 0 0 ELOISE P BRONER PRESIDENT & CEO 38.5 1.5 X X 828631 0 31880 CAROL BAUER SC TRUSTEE & VP MISSION EFFECTIVE 39.0 1.0 X 0 0 0 MARY H BOOSALIS TRUSTEE/PREMIER PRESIDENT &CEO 7.5 8.5 X 0 0 0 GEORGE T BRODERICK JR MD TRUSTEE 0.5 1.5 X 0 0 0 ANUJ GOYAL MD TRUSTEE &PRES OF MEDICAL STAFF 0.5 0.5 X 0 0 0 LASZLO TOTH MD TRUSTEE 0.5 0.0 X 0 0 0 DALE E CREECH JR BOARD SECRETARY/SYSTEM VP-CLO 7.5 30.0 X 0 631976 62931 MARY E GARMAN CHIEF OPERATING OFFICER 39.5 0.5 X 360881 0 25782 TIMOTHY D SNIDER BOARD TREASURER / CFO 18.5 1.5 X 141274 0 15106 THOMAS R CURTIN SYSTEM VP - REVENUE CYCLE 8.0 31.0 X 0 306577 58768 GARY G GINTER SYSTEM VP - CIO 8.0 32.0 X 0 525006 87150 KATHLEEN M HARPER VP NORTH HOSPITAL OPERATIONS 40.0 0.0 X 264037 0 31979 JENNIFER J HAULER MD SYSTEM VP - CMO (FROM OCT) 8.0 32.0 X 0 366374 1542 BARBARA A JOHNSON SYSTEM VP - HR OPERATIONS 8.0 32.0 X 0 508775 38453 TAMMY S LUNDSTROM MD SYSTEM VP - CMO (TO AUG) / CCO 8.0 32.0 X 0 722423 83950 MARGARET W MARK SYSTEM VP - CNO (FROM JUN) 8.0 32.0 X 0 345867 35411 THOMAS R PARKER SYS VP -CHF EXPERIENCE OFFICER 7.5 32.5 X 0 526374 67212 CRAIG SELF SYS VP -CHIEF STRATEGY OFFICER 8.0 32.0 X 0 536933 50456 MARK W SHAW SYSTEM VP - MANAGED CARE 8.0 32.0 X 0 514343 61788 SCOTT A SHELTON SYSTEM VP - CPO 8.0 32.0 X 0 380597 29234 SYLVAIN TREPANIER DNP RN CENP SYSTEM VP - CNO (TO APR) 8.0 31.0 X 0 215751 28526 FRANK E SAWYER SYS VP - ONCOLOGY SERVICE LINE 40.0 0.0 X 319306 0 34030 CHRISTIE GRAY VP - CNO 40.0 0.0 X 289376 0 32356 KIM K STRAHL SYSTEM VP STRATEGIC SOURCING 40.0 0.0 X 228460 0 28226 SHARON K THORNTON ERP OPERATIONS LEADER 40.0 0.0 X 223147 0 17151 DARLENE WISEMAN VP FINANCE - SUPPORT SERVICES 40.0 0.0 X 214689 0 38621 RENEE P GEORGE FORMER KEY EMPLOYEE 0.0 40.0 X 0 396472 28198 2869801 5977468 888750 93 true true false DAWSON HEALTHCARE 1114 DUBLIN RD COLUMBUS OH 43215 AGENCY STAFF 10063535 CATHOLIC HEALTH INITIATIVES 3900 OLYMPIC BLVD 400 ERLANGER KY 41018 CLINICAL ENGINEERING 8771687 SHOOK CONSTRUCTION 4977 NORTHCUTT PLACE DAYTON OH 45414 CONSTRUCTION 3354996 WENCO CONSTRUCTION CO LLC 1807 DALTON DR NEW CARLISLE OH 45344 CONSTRUCTION 2838150 ANESTHESIOLOGY SERVICES 1 WYOMING ST 3SW TOWER DAYTON OH 45409 MEDICAL SERVICES 2495998 57 250968 120000 370968 NET PATIENT REVENUE 621110 159176979 158952911 224068 MEDICARE/MEDICAID 621110 157278247 157278247 JOINT OPERATING AGREEMENT 900099 59331000 59331000 FRANCHISE TAX RECOVERIES 621110 6643571 6643571 HEALTH EDUCATION 561499 88008 88008 24597 24597 382542402 1942083 9143 1932940 0 0 4985053 4951887 33166 0 33166 33166 28259124 143500 23034238 266933 5224886 -123433 5101453 5101453 0 0 0 0 0 0 430981 252524 178457 178457 CAFETERIA 721100 2252145 2252145 ELECTRONIC MEDICAL RECORD MGMT SVC 518210 500420 500420 PARKING GARAGE 812930 265044 265044 225938 225938 3243547 393412076 382818754 233211 9989143 3144614 3144614 0 0 0 1699570 1522814 176756 0 187587 168078 19509 121233019 108624785 12608234 6312385 5655897 656488 16762549 15019244 1743305 8902590 7976721 925869 4242775 3801526 441249 1248983 1119089 129894 182297 182297 29794 29794 0 253876 253876 32063067 28728508 3334559 3712997 3712997 1834698 1643889 190809 9369839 8395376 974463 0 4758905 4263979 494926 162842 145906 16936 0 1306 1170 136 13467 13467 0 27149839 24326256 2823583 4782332 4284969 497363 ASSET IMPAIRMENT 66036000 66036000 OPERATING SUPPLIES 63517231 63517231 PURCHASED SERVICES 20585813 18444888 2140925 HOSPITAL FRANCHISE TAX 5422687 5422687 4951602 4436635 514967 408562664 380436520 28126144 0 17538 17690 17335268 7684524 0 0 50439667 45398455 0 0 0 0 783320 1309081 5175076 4571313 4003413 3303000 522640368 404313013 189965777 118327355 69239856 64250782 13773753 11344123 0 0 3376413 3376413 20618035 64861776 374728116 324444512 27985549 23668348 846443 1059334 348679 428016 0 0 0 0 0 0 616899 3855352 0 0 29366630 16596640 59164200 45607690 X 315563916 278836822 0 0 0 0 315563916 278836822 374728116 324444512 X -15150588 3172549 -24749055 X false true X true true true X false false false false false true 23314 false false true 6480 29794 false PART II-B, LINE 1F: PAYMENTS FOR LOBBYING ACTIVITIES INCLUDE DUES PAID TO GREATER DAYTON AREA HOSPITAL ASSOCIATION, DAYTON DEVELOPMENT COALITION, AMERICAN HOSPITAL ASSOCIATION, AND OHIO HOSPITAL ASSOCIATION. PART II-B, LINE 1I: THE HOSPITAL CONTRACTS WITH A LOBBYIST FOR HEALTHCARE RELATED ISSUES. 12245269 12245269 315182117 263173880 52008237 825589 822395 3194 184079685 138137738 45941947 10307708 2179000 8128708 118327355 JOINT OPERATING AGREEMENT 59331000 PENSION 2875415 OTHER A/R 1607145 AFFILIATES RECEIVABLE 753390 DEFERRED COMPENSATION 264826 AFFILIATES INVESTMENT 30000 64861776 0 MALPRACTICE INSURANCE 13449190 LOAN GUARANTEE & OTHER LTL 775102 WORKERS COMPENSATION RESERVE 563403 NOTES PAYABLE 459872 CONSTRUCTION RETAINAGE 367573 SETTLEMENT-3RD PARTY PAYORS 328786 DEFERRED COMPENSATION 297826 OTHER 354888 16596640 X PART X, LINE 2: THE FOLLOWING FOOTNOTE IS FROM THE AUDITED COMBINED FINANCIAL STATEMENTS FOR PREMIER HEALTH AND AFFILIATES. SAMARITAN HEALTH PARTNERS IS THE PARENT ORGANIZATION OF GOOD SAMARITAN HOSPITAL (GSH): PREMIER HEALTH (PREMIER), MEDAMERICA HEALTH SYSTEMS (MAHS), ATRIUM HEALTH SYSTEM (AHS), SAMARITAN HEALTH PARTNERS (SHP), AND UVMC HAVE BEEN DETERMINED BY THE INTERNAL REVENUE SERVICE TO BE TAX-EXEMPT NONPROFIT CORPORATIONS AND PUBLIC CHARITIES UNDER SECTIONS 501(C)(3) AND 509(A), RESPECTIVELY, OF THE INTERNAL REVENUE CODE. AS TAX-EXEMPT ORGANIZATIONS, THEIR INCOME IS EXEMPT FROM FEDERAL INCOME TAX EXCEPT TO THE EXTENT OF ANY UNRELATED BUSINESS ACTIVITIES. PREMIER, SHP, AND UVMC ALSO OWN OR CONTROL CERTAIN SUBSIDIARIES, WHICH ARE FOR-PROFIT CORPORATIONS SUBJECT TO FEDERAL INCOME TAXES. TAXES PAYABLE AT DECEMBER 31, 2017 AND 2016, FOR SUCH UNRELATED BUSINESS ACTIVITIES ARE NOT SIGNIFICANT. MANAGEMENT ANNUALLY REVIEWS THE TAX POSITIONS AND HAS DETERMINED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS. Central America and the Caribbean Investments 1101000 East Asia and the Pacific Investments 3424000 Europe (Including Iceland and Greenland) Investments 8011000 Middle East and North Africa Investments 183000 North America Investments 856000 Russia and the Newly Independent States Investments 245000 South America Investments 550000 South Asia Investments 245000 Sub-Saharan Africa Investments 122000 Central America and the Caribbean Program Services INSURANCE 27000 14764000 14764000 true false true false true false true true X true X true X true true true false true true 8111000 3242000 4869000 0.01190 74406571 52694571 21712000 0.05310 3016000 2228000 788000 0.00190 85533571 58164571 27369000 0.06690 834916 79916 755000 0.00180 9131000 9131000 0.02230 1697000 1697000 0.00420 11662916 79916 11583000 0.02830 97196487 58244487 38952000 0.09520 548200 548200 0.00130 367822 367822 0.00090 3480 3480 0.00000 3600 3600 0.00000 923102 923102 0.00220 true 9444269 0 72314000 84673000 -12359000 X true true SAM NORTH SURG CTR SURGICAL SERVICES 0.8 0.2 1 1 GOOD SAMARITAN HOSPITAL 2222 PHILADELPHIA DR Dayton Ohio OH 45406 WWW.PREMIERHEALTH.COM SEE PART V SECT C X X X X Good Samaritan Hospital 1 false false true X X X X X X X X X 16 true true true true X SEE PART V, SECTION C X true 17 true SEE PART V, SECTION C false true X 200. 300. X X true true X X X true X SEE PART V, SEC C X SEE PART V, SEC C X SEE PART V, SEC C X X X X X X X true X false X X X X true X false false PART V, SECTION B, LINE 1: THE STATE OF OHIO DOES NOT LICENSE HOSPITALS, BUT THE OHIO DEPARTMENT OF HEALTH DOES REGISTER HOSPITALS. AS PART OF THIS REGISTRATION PROCESS, HOSPITALS IN THE STATE OF OHIO ARE REQUIRED TO COMPLETE AND SUBMIT THE ANNUAL HOSPITAL REGISTRATION AND PLANNING REPORT (AHR) EACH CALENDAR YEAR. GOOD SAMARITAN'S REGISTRATION NUMBER IS 1245. PART V, SECTION B, LINE 5: PARTNERING IN THE DATA REVIEW PROCESS AND IN THE PROCESS FOR IDENTIFYING AND PRIORITIZING COMMUNITY HEALTH NEEDS AND SERVICES WERE THE BOARD OF TRUSTEES AND EXECUTIVE LEADERSHIP OF GOOD SAMARITAN HOSPITAL, THE HEALTH COLLABORATIVE IN CINCINNATI, OHIO, DAYTON-MONTGOMERY COUNTY PUBLIC HEALTH DEPARTMENT, DARKE COUNTY GENERAL HEALTH DISTRICT, MIAMI COUNTY PUBLIC HEALTH, AND THE GREATER DAYTON AREA HOSPITAL ASSOCIATION WITH ITS MEMBER HOSPITALS. THE PARTICIPATING HOSPITALS INVITED A BROAD RANGE OF NONPROFIT AGENCIES AND ORGANIZATIONS, WHICH ASSIST THE MEDICALLY UNDERSERVED, LOW-INCOME AND MINORITY POPULATIONS, TO ATTEND COMMUNITY MEETINGS AND COMPLETE SURVEYS. PART V, SECTION B, LINES 6A & 6B: GOOD SAMARITAN HOSPITAL PARTNERED WITH MEMBER HOSPITALS OF THE GREATER DAYTON AREA HOSPITAL ASSOCIATION, THE HEALTH COLLABORATIVE IN CINCINNATI, OHIO, DAYTON-MONTGOMERY COUNTY PUBLIC HEALTH DEPARTMENT, DARKE COUNTY GENERAL HEALTH DISTRICT, MIAMI COUNTY PUBLIC HEALTH, THE GREATER DAYTON AREA HOSPITAL ASSOCIATION, XAVIER UNIVERSITY AND AN INDEPENDENT CONSULTANT TO PREPARE THE COMMUNITY HEALTH NEEDS ASSESSMENT. PART V, SECTION B, LINES 7A & 10A: THE DIRECT WEBSITE ADDRESS WHERE THE 2016 CHNA AND THE 2017 COMMUNITY HEALTH IMPLEMENTATION PLAN CAN BE ACCESSED IS: HTTP://WWW.PREMIERHEALTH.COM/OUR-COMMUNITY/MAKING-A-DIFFERENCE/ COMMUNITY-HEALTH-IMPROVEMENT/ PART V, SECTION B, LINE 11: GOOD SAMARITAN HOSPITAL (GSH), AS A MEMBER OF THE PREMIER HEALTH SYSTEM, WAS PART OF A COLLABORATION IN 2016 WITH MEMBER HOSPITALS OF THE GREATER DAYTON AREA HOSPITAL ASSOCIATION, THE HEALTH COLLABORATIVE IN CINCINNATI, OHIO, THE GREATER DAYTON AREA HOSPITAL ASSOCIATION, XAVIER UNIVERSITY, DAYTON-MONTGOMERY COUNTY PUBLIC HEALTH, DARKE COUNTY GENERAL HEALTH DISTRICT, MIAMI COUNTY PUBLIC HEALTH, AND AN INDEPENDENT CONSULTANT TO PREPARE THE COMMUNITY HEALTH NEEDS ASSESSMENT. BASED ON THE RESULTS OF THIS ASSESSMENT, GSH ADOPTED AN IMPLEMENTATION STRATEGY TO ADDRESS THE FOLLOWING PRIORITIZED NEEDS: * BIRTH OUTCOMES * BEHAVIORAL HEALTH/SUBSTANCE ABUSE * CHRONIC DISEASES HEALTH ISSUE: BIRTH OUTCOMES -------------- GSH WILL IMPROVE THE HEALTH AND WELL-BEING OF WOMEN AND INFANTS WITH THE "CENTERINGPREGNANCY" PROGRAM. THIS PROGRAM IS DEVELOPED BY THE CATHOLIC SOCIAL SERVICES AND PROVIDES GROUP PRENATAL CARE AND HOME VISITS. LIFESTAGES SAMARITAN CENTERS FOR WOMEN OPERATES "CENTERINGPREGNANCY" AT GSH AND GOOD SAMARITAN NORTH HEALTH CENTER (GSHN). ADDITIONAL FEATURES INCLUDE SCREENING, BRIEF INTERVENTION AND REFERRAL TO TREATMENT (SBIRT), DEPRESSION SCREENING, AND TRANSPORTATION AND CHILDCARE VOUCHERS. THE PROGRAM TARGETS WOMEN WHO LIVE IN THE ZIP CODES WHERE THE MOST INFANT DEATHS HAVE OCCURRED. THIS PROGRAM LEVERAGES RESOURCES FROM LIFESTAGES SAMARITAN CENTERS FOR WOMEN, CATHOLIC SOCIAL SERVICES OF THE MIAMI VALLEY, FIVE RIVERS HEALTH CENTER FOR WOMEN'S HEALTH, GSHN, MONTGOMERY COUNTY INFANT MORTALITY COALITION, AND OHIO PERINATAL QUALITY COLLABORATIVE. THE FAMILY BIRTHING CENTER AND LIFESTAGES SAMARITAN CENTERS FOR WOMAN AT GSH WORK WITH A TEAM OF OTHER COMMUNITY ORGANIZATIONS TO INCREASE THE NUMBER OF WOMEN WHO BREASTFEED THEIR BABIES. THE OBJECTIVES ARE 1) TO INCREASE THE FREQUENCY OF EDUCATION ABOUT BREASTFEEDING BEFORE BIRTH, AND 2) TO PROVIDE LACTATION SUPPORT AFTER BIRTH. BREASTFED CHILDREN HAVE FEWER ILLNESSES AND LESS RISK OF SUDDEN INFANT DEATH SYNDROME, CHILDHOOD CANCERS, AND DIABETES. MOTHERS HAVE LESS RISK OF BREAST CANCER, OVARIAN CANCER, ANEMIA, AND OSTEOPOROSIS. THE FAMILY SAVES MONEY SINCE BREAST MILK IS READILY AVAILABLE AND FREE. THE MOTHER AND HER SIGNIFICANT OTHER OR PERSON OF CHOICE (GRANDPARENT, FRIEND) ARE ENCOURAGED TO ATTEND MONTHLY BREASTFEEDING CLASSES. THIS IS IMPORTANT TO COMBAT MYTHS THAT SURROUND BREASTFEEDING. MOTHERS NEW TO BREASTFEEDING BENEFIT FROM LACTATION CONSULTING AFTER BIRTH AND AT HOME. GSH HAS BEEN RECOGNIZED AS A FIVE-STAR HOSPITAL THROUGH THE "TEN STEPS FOR SUCCESSFUL BREASTFEEDING" PROMOTION BY BABY FRIENDLY USA AS PART OF THE OHIO FIRST STEPS FOR HEALTHY BABIES, A COLLABORATIVE OF THE OHIO HOSPITAL ASSOCIATION AND THE OHIO DEPARTMENT OF HEALTH. OTHER TEAM MEMBERS INCLUDE PREMIER COMMUNITY HEALTH, CATHOLIC SOCIAL SERVICES OF THE MIAMI VALLEY, WIC, AND OHIO FIRST STEPS FOR HEALTHY BABIES. HEALTH ISSUE: BEHAVIORAL HEALTH / SUBSTANCE ABUSE ----------------------------------- GSH WILL PROVIDE EDUCATION THAT ADDICTION IS A DISEASE, AND AS A RESULT, CHANGE PERCEPTIONS FIRST OF HOSPITAL PERSONNEL AND MEDICAL PROFESSIONALS, AND THEN OF THE COMMUNITY. THE OBJECTIVES ARE 1) TO PROVIDE CEU'S TO FRONT-LINE STAFF AND PHYSICIANS FOR EDUCATION ON THIS TOPIC, WITH CURRICULUM DELIVERED BY ADAMHS, AND 2) TO EDUCATE HEALTH MINISTRIES STAFF IN A 'TRAIN THE TRAINER' APPROACH SO THEY CAN PROVIDE TRAINING THROUGH A NETWORK OF HUNDREDS OF CHURCHES. IN ADDITION TO ASSISTANCE FROM THE ADAMHS BOARD, RESOURCES WILL BE OBTAINED FROM HEALTH MINISTRIES, SAMARITAN BEHAVIORAL HEALTH, INC., PHYSICIAN PRACTICES, AND LOCAL CHURCHES. HEALTH ISSUE: CHRONIC DISEASES ---------------- GSH WILL WORK WITH THE AMERICAN HEART ASSOCIATION AND THE HEART INSTITUTE OF DAYTON TO TRAIN MORE PEOPLE IN HOW TO PROVIDE CPR THROUGH INSTALLATIONS OF EDUCATIONAL KIOSKS IN CERTAIN PUBLIC AREAS. AN INTERACTIVE KIOSK FEATURES A TOUCH SCREEN WITH A VIDEO PROGRAM THAT GIVES A BRIEF "HOW-TO" FOLLOWED BY A PRACTICE SESSION AND A 30-SECOND CPR TEST. WITH THE HELP OF A RUBBER TORSO, THE KIOSK GIVES FEEDBACK ABOUT THE DEPTH AND RATE OF COMPRESSIONS AND PROPER HAND PLACEMENT - FACTORS THAT INFLUENCE THE EFFECTIVENESS OF CPR. THE KIOSK IS AN INTERACTIVE TRAINING OPPORTUNITY WITH NO ON-SITE STAFF. MORE WIDESPREAD CPR TRAINING IS IMPORTANT BECAUSE ONLY ABOUT 46 PERCENT OF PEOPLE WHO EXPERIENCE AN OUT-OF-HOSPITAL CARDIAC ARREST GET THE HELP THEY NEED BEFORE THE AMBULANCE ARRIVES. SURVIVAL RATES DROP AS MUCH AS 10 PERCENT FOR EACH MINUTE WITHOUT INTERVENTION. THE SECOND CHRONIC ISSUE TARGETED BY GSH IS FOOD HARDSHIPS IN THE COMMUNITY. ACCORDING TO THE FOOD RESEARCH & ACTION CENTER, DAYTON RANKED 11TH OUT OF 109 METROPOLITAN AREAS FOR HOUSEHOLDS EXPERIENCING FOOD HARDSHIP. TO ADDRESS THIS NEED, THE HOSPITAL WILL WORK WITH OTHER COMMUNITY ORGANIZATIONS TO INCREASE THE AMOUNT OF HEALTHY FOOD FOR PEOPLE WITH HEALTH-RELATED NUTRITIONAL NEEDS. THE SHORT-TERM OBJECTIVES ARE 1) TO ENSURE THAT ALL ELIGIBLE PATIENTS ARE SIGNED UP FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) AND/OR WOMEN INFANT CHILDREN (WIC) FOOD ASSISTANCE BENEFITS, AND 2) TO INCREASE THE AVAILABILITY OF FRESH PRODUCE IN PARTNERSHIP WITH LOCAL FOOD PANTRIES AND FARMERS. THE HOSPITAL MAY BEGIN SCREENING FOR HUNGER TO ASCERTAIN THE SCOPE OF THE PROBLEM. IF DETERMINED FEASIBLE, GSH, ALONG WITH ITS AFFILIATES IN PREMIER HEALTH, WOULD CREATE A FOOD PHARMACY, OR SIMILAR PRESCRIPTION FOR FOOD PROGRAM BY 2019. A FOOD PHARMACY ACCEPTS PEOPLE WITH A PHYSICIAN REFERRAL AND OFFERS TWO TO THREE DAYS' WORTH OF FOOD PER VISIT. PATIENTS CAN RETURN TO THE FOOD PHARMACY ONCE PER MONTH FOR UP TO SIX MONTHS, AT WHICH TIME THEY CAN RETURN TO THEIR PHYSICIAN FOR ANOTHER REFERRAL IF THEY ARE STILL IN NEED. OTHER SERVICES MAY INCLUDE NUTRITION COUNSELING, COOKING CLASSES, AND CONNECTION TO COMMUNITY RESOURCES. GSH WILL COLLABORATE WITH DAYTON-MONTGOMERY COUNTY FOOD & HUNGER COALITION, CATHOLIC SOCIAL SERVICES OF THE MIAMI VALLEY FOOD PANTRY, GRACE CHURCH, SINCLAIR COLLEGE, SNAP, AND WIC IN THIS MISSION. GOOD SAMARITAN HOSPITAL IS ONE OF FIVE HOSPITALS IN THE PREMIER HEALTH SYSTEM. ALL FIVE HOSPITALS PARTICIPATED WITH OTHER HEALTH CARE ORGANIZATIONS TO CREATE A COLLABORATIVE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA). BASED ON THE RESULTS OF THE ASSESSMENT, THE FIVE PREMIER HOSPITALS JOINTLY IDENTIFIED THE THREE SHARED HEALTH CARE NEED PRIORITIES THAT ARE CRITICAL THROUGHOUT THE PREMIER SERVICE AREA: BIRTH OUTCOMES, CHRONIC DISEASES AND BEHAVIORAL HEALTH / SUBSTANCE ABUSE. THE REMAINING HEALTH CARE NEEDS IDENTIFIED IN THE ASSESSMENT ARE SHARED WITH MANY LOCAL HEALTH DEPARTMENTS IN OUR REGION, AS WELL AS STATE AGENCIES. THESE INCLUDE ACCESS TO CARE, SOCIAL DETERMINANTS, PROVIDER SHORTAGES, TRANSPORTATION, CARE FOR CHILDREN / CHILD HEALTH, IMMUNIZATIONS, AND ACCIDENTS. THE LEADERSHIP OF THE PREMIER HOSPITALS RECOGNIZE NO ONE ENTITY CAN SINGLE-HANDEDLY EFFECT DRAMATIC CHANGE IN ALL OF THESE SERIOUS AREAS WITHIN THE THREE-YEAR TIMEFRAME OF THE CHNA PROCESS. THEREFORE, PREMIER WILL DIRECT AND FOCUS ITS RESOURCES ON THE THREE PRIORITIES THAT ARE MOST PREVALENT IN ITS SURROUNDING COMMUNITIES. PART V, SECTION B, LINES 16 A, B, AND C: THE DIRECT WEBSITE ADDRESS WHERE A COPY OF THE FINANCIAL ASSISTANCE POLICY (FAP), FAP APPL 7 GOOD SAMARITAN NORTH HEALTH CENTER 9000 N MAIN ST DAYTON OH 45415 GENERAL MEDICAL AND SURGICAL GOOD SAMARITAN NORTH SURGERY CENTER 9000 N MAIN ST DAYTON OH 45415 GENERAL MEDICAL AND SURGICAL GOOD SAMARITAN HEALTH CTR-HUBER HEIGHTS 6521 GOOD SAMARITAN WAY BRANDT PIKE HUBER HEIGHTS OH 45424 GENERAL MEDICAL AND SURGICAL GSH Medical Imaging - Needmore 1530 Needmore Road Suite 200 30 Dayton OH 45414 X-ray GSH Medical Imaging - Beavercreek 2619 Commons Blvd - Suite 102 Beavercreek OH 45431 X-Ray GSH Medical Imaging - Greenville 742 Sweitzer Street Suite 3 Greenville OH 45331 Echocardiograms & X-Rays Samaritan SleepDiabetes Center 80 East Woodbury Dayton OH 45415 Joint Sleep & Diabetes Center PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT FOR GOOD SAMARITAN HOSPITAL IS PART OF THE PREMIER HEALTH REPORT (EIN# 31-1446699). PART I, LINE 7: A COST TO CHARGE RATIO WAS USED TO CALCULATE THIS FINANCIAL ASSISTANCE AT COST. THIS CALCULATION TAKES TOTAL OPERATING EXPENSES LESS OTHER OPERATING REVENUES DIVIDED BY TOTAL GROSS REVENUES. UNREIMBURSED MEDICAID AND OTHER MEANS-TESTED GOVERNMENTAL PROGRAMS WERE CALCULATED USING A COST ACCOUNTING SYSTEM. THIS SYSTEM ADDRESSES ALL PATIENT SEGMENTS AND INCLUDES FULLY LOADED COSTS. FOR THE REMAINING ITEMS THE ORGANIZATION USED SPECIFIC NUMBERS FOR EXPENSE PAID DIRECTLY FOR THESE SERVICES. PART I, LINE 7G: GOOD SAMARITAN HOSPITAL PROVIDES SUBSIDIZED EMERGENCY SERVICES BY OPERATING A 24-HOUR EMERGENCY ROOM 365 DAYS PER YEAR. THIS EMERGENCY ROOM IS OPEN TO ALL INDIVIDUALS REGARDLESS OF THEIR ABILITY TO PAY. THE HOSPITAL INCURS EXPENSES RELATED TO CALL TIME AND PHYSICIAN SUBSIDIES DUE TO THE LARGE NUMBER OF INDIGENT PATIENTS COMING THROUGH THE EMERGENCY ROOM. FOR 2017, THE AMOUNT PAID FOR CALL AND SUBSIDIES WAS $9,131,000. PART II: GOOD SAMARITAN HOSPITAL (GSH) IS COMMITTED TO IMPROVING THE HEALTH OF THE COMMUNITIES IT SERVES THROUGH A VARIETY OF PREVENTION, HEALTH IMPROVEMENT AND ENGAGEMENT PROGRAMS. AS PART OF ITS OVERALL COMMITMENT TO THE COMMUNITY, GSH FOCUSES ON FOUR AREAS OF SERVICE: --INVESTING IN THE COMMUNITY --PREVENTION AND WELLNESS --COMMITMENT TO THE UNDER-SERVED --COMMUNITY ENGAGEMENT SOME OF THE PROGRAMS SUPPORTED BY GSH DURING 2017 INCLUDE: 1) NEIGHBORHOOD REVITALIZATION AND DEVELOPMENT THROUGH A CONTRIBUTION OF $505,000 TO THE PHOENIX PROJECT. THE GOALS OF THIS PROJECT ARE TO REDUCE AND DETER CRIME, REVITALIZE THE APPEARANCE OF THE NEIGHBORHOOD AND ACTIVATE LINKAGES FOR PHYSICAL, MENTAL AND SOCIAL HEALTH SERVICES. THIS PROGRAM ALSO PURCHASES PROPERTIES IN THE SURROUNDING AREA, REHABILITATES THEM AND SELLS THEM TO THOSE IN NEED. 2) PARTNERING WITH A LOCAL NON-PROFIT ECONOMIC DEVELOPMENT COMPANY AND THE LOCAL GOVERNMENT TO REVITALIZE SURROUNDING NEIGHBORHOODS. EFFORTS INCLUDED FUNDING ADDITIONAL COMMUNITY-BASED POLICE OFFICERS IN THE NEIGHBORHOOD, REDUCING CRIME BY MORE THAN 60%. THE AMOUNT CONTRIBUTED IN 2017 FOR THIS PROGRAM WAS $364,000. 3) FUNDING OF $24,000 TO SUPPORT A NON-PROFIT MINORITY-OWNED HEALTH CARE FACILITY THAT ACCOMMODATES RESIDENTS NEEDING SHORT-TERM REHAB, RESPITE CARE FOR A LOVED ONE, OR POST-OPERATIVE CARE. 4) ONGOING EFFORTS TO IMPROVE THE ECONOMIC CONDITION IN DAYTON AND THE MIAMI VALLEY. A TOTAL OF $19,000 WAS CONTRIBUTED TOWARD A CAPITAL CAMPAIGN PROJECT TO SUPPORT THE RENOVATION OF A 100-YEAR-OLD BUILDING OFFERING SINGLE ROOM OCCUPANCY HOUSING UNITS TO A DIVERSE POPULATION OF WOMEN FROM ALL DIFFERENT BACKGROUNDS THAT PROVIDES CRISIS INTERVENTION, SUPPORTIVE LISTENING, LINKAGE TO RESOURCES, SUPPORT GROUPS, LIFE COACHING, AND FINANCIAL EMPOWERMENT PROGRAMS. THE SUPPORT WILL GO TO UPDATE THE COMMUNAL SPACES WITH MODERN DAY AMENITIES; INCREASING ADA ACCESSIBILITY AND BASIC IMPROVEMENTS, INCLUDING NEW WINDOWS AND HVAC SYSTEMS. PART III, LINES 2 & 3: BAD DEBT EXPENSE IS INCURRED WHEN AN ACCOUNT IS TAKEN OUT OF ACCOUNTS RECEIVABLE AND TURNED OVER TO A COLLECTION AGENCY. THIS ACTION MAY OCCUR IF A PATIENT REFUSES PAYMENT ARRANGEMENTS, REFUSES TO APPLY FOR FINANCIAL ASSISTANCE, AND THERE IS NOT AN INSURANCE BALANCE BEING CONTENDED. AN ACCOUNT IS WRITTEN OFF TO BAD DEBT AFTER 130 DAYS IF AN ATTEMPT TO COLLECT FROM THE PATIENT IS MADE WITHIN OUR COLLECTION POLICY. THE COLLECTION AGENCY ATTEMPTS TO COLLECT THE ACCOUNT IN ACCORDANCE WITH ESTABLISHED GUIDELINES. COLLECTION ATTEMPTS ARE CEASED AND THE ACCOUNT RETURNED TO THE ORGANIZATION IF THE PATIENT APPLIES FOR FINANCIAL ASSISTANCE. ANY AMOUNTS COLLECTED FROM THESE ACCOUNTS ARE CREDITED BACK AGAINST BAD DEBT EXPENSE. THE ORGANIZATION RECOGNIZES THERE ARE ACCOUNTS WRITTEN OFF TO BAD DEBT THAT MAY HAVE QUALIFIED FOR CHARITY CARE IF THE PATIENT HAD PROVIDED THE NECESSARY FINANCIAL INFORMATION. TO RESOLVE THIS, THE ORGANIZATION HAS ENGAGED A THIRD-PARTY VENDOR TO ANALYZE DATA BASED ON CREDIT SCORES TO REALLOCATE SOME OF THIS EXPENSE TO CHARITY CARE. A REPRESENTATIVE SAMPLE OF THESE ACCOUNTS IS THEN SENT TO OUR THIRD-PARTY VENDOR WHO GATHERS EXTERNAL CREDIT DATA THAT PRESENTS THE ACCOUNT AS LESS THAN 100% FEDERAL POVERTY LEVEL OR NOT ENOUGH INFORMATION (TYPICALLY INDICATIVE OF INDIGENT). THESE ACCOUNTS ARE RECLASSED FROM BAD DEBT EXPENSE TO CHARITY EXPENSE ON OUR INCOME STATEMENT. ANY CREDIT SCORE THAT PRESENTS THE ACCOUNTS AS GREATER THAN 100% FEDERAL POVERTY LEVEL REMAINS IN BAD DEBT EXPENSE. DUE TO THIS PROCESS, THE ORGANIZATION HAS USED BEST EFFORTS TO NOT REPORT BAD DEBT EXPENSE FOR PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY. PART III, LINE 4: THE ORGANIZATION DOES NOT HAVE A FOOTNOTE IN THE AUDITED FINANCIAL STATEMENTS WHICH DISCUSSES THIS CALCULATION. PART III, SECTION B, LINES 5, 6, AND 7: THE AMOUNTS REPORTED ON LINES 5, 6, AND 7 DO NOT INCLUDE CERTAIN MEDICARE PROGRAM REVENUES AND COSTS, AND THUS DO NOT REFLECT ALL OF THE ORGANIZATION'S REVENUES AND COSTS ASSOCIATED WITH ITS PARTICIPATION IN MEDICARE PROGRAMS. IN ADDITION TO THE AMOUNTS REPORTED ON LINE 5, 6, AND 7, THE ORGANIZATION RECEIVED REVENUE OF $74,274,000 AND INCURRED COST OF $101,089,000, FOR AN ADDITIONAL NET SHORTFALL OF $26,815,000 ASSOCIATED WITH THESE PROGRAMS. BELOW IS A RECONCILIATION OF THE AMOUNTS ASSOCIATED WITH MEDICARE PROGRAMS. ALLOWABLE MEDICARE REVENUE PER MEDICARE COST REPORT IN PART III, SECTION B $72,314,000 MEDICARE REVENUE NOT REPORTED IN PART III, SECTION B $74,274,000 TOTAL MEDICARE ASSOCIATED REVENUE $146,588,000 ALLOWABLE MEDICARE COST PER MEDICARE COST REPORT IN PART III, SECTION B $84,673,000 MEDICARE COST NOT REPORTED IN PART III, SECTION B $101,089,000 TOTAL MEDICARE ASSOCIATED COST $185,762,000 MEDICARE SHORTFALL PER PART III, SECTION B $12,359,000 ADDITIONAL SHORTFALL NOT INCLUDED IN PART III, SECTION B $26,815,000 TOTAL MEDICARE SHORTFALL $39,174,000 PART III, LINE 8: THE ORGANIZATION'S SHORTFALL SHOULD BE CONSIDERED CHARITY CARE BECAUSE IT IS PROVIDING HIGH-QUALITY CARE IN EXCESS OF THE COST TO OUR COMMUNITY RESIDENTS THAT NEED CARE. THE MEDICARE POPULATION AT THE ORGANIZATION IS IN EXCESS OF 54% OF NET PATIENT REVENUE. THE ORGANIZATION USED A COST ACCOUNTING SYSTEM TO CALCULATE THE MEDICARE ALLOWABLE COSTS. PART III, LINE 9B: THE ORGANIZATION MAKES REASONABLE EFFORTS TO DETERMINE WHETHER OR NOT AN INDIVIDUAL IS ELIGIBLE FOR ASSISTANCE UNDER THE STATE OR HOSPITAL FINANCIAL ASSISTANCE POLICY BEFORE ENGAGING IN EXTRAORDINARY COLLECTIVE ACTIONS AGAINST THAT INDIVIDUAL. PATIENTS WHO ARE KNOWN TO QUALIFY FOR FINANCIAL ASSISTANCE ARE OFFERED REASONABLE PAYMENT PLAN ARRANGEMENTS FOR ANY REMAINING BALANCES. ANY THIRD-PARTY COLLECTING SELF-PAY RECEIVABLES ON OUR BEHALF IS REQUIRED TO MAKE REASONABLE EFFORTS TO DETERMINE IF THE INDIVIDUAL MEETS THE QUALIFICATIONS OF THE STATE OR OF OUR HOSPITAL FINANCIAL ASSISTANCE PROGRAMS. REASONABLE EFFORTS INCLUDE: A. VALIDATING THAT THE PATIENT OWES THE UNPAID BILLS AND THAT ALL SOURCES OF THIRD-PARTY PAYMENT HAVE BEEN IDENTIFIED AND BILLED BY THE HOSPITAL. B. DOCUMENTING THAT THE ORGANIZATION HAS OR HAS ATTEMPTED TO OFFER THE PATIENT THE OPPORTUNITY TO APPLY FOR CHARITY CARE UNDER ITS FINANCIAL ASSISTANCE POLICY. C. DOCUMENT THAT THE PATIENT DOES NOT QUALIFY FOR FINANCIAL ASSISTANCE. D. DOCUMENT THAT THE PATIENT HAS BEEN OFFERED AND ACCEPTED TERMS FOR A PAYMENT PLAN, BUT HAS NOT HONORED THE TERMS OF THAT PLAN. THE FINANCIAL COUNSELORS MEET WITH INPATIENT, OUTPATIENT, SELF-PAY, AND OTHER PATIENTS UPON REQUEST WHO MAY NEED FINANCIAL ASSISTANCE. IN ADDITION TO ASSISTING PATIENTS WHO WANT TO APPLY FOR ASSISTANCE THROUGH THE MEDICAID PROGRAM, THE FINANCIAL COUNSELOR WILL PROVIDE THE PATIENT WITH A FINANCIAL ASSISTANCE APPLICATION. PART VI, LINE 2: THE ORGANIZATION WORKS WITH THE COMMUNITY ON PROGRAMS THAT ADDRESS THE UNDERLYING CAUSES OF PERSISTENT HEALTH PROBLEMS AS PART OF A COMPREHENSIVE STRATEGY TO IMPROVE THE HEALTH STATUS AND QUALITY OF LIFE FOR IDENTIFIED MEMBERS OF THE COMMUNITY WHO ARE ECONOMICALLY DISADVANTAGED, DISENFRANCHISED AND/OR WHO HAVE DISPROPORTIONATE UNMET HEALTH NEEDS. THE ORGANIZATION STRIVES TO WORK WITH PREMIER HEALTH, THE HOSPITAL BOARD OF TRUSTEES, EXECUTIVE MANAGEMENT, MANAGERS, STAFF MEMBERS, COMMUNITY GROUPS, AND INDIVIDUALS TO PROVIDE A COLLABORATIVE APPROACH TO THE GOVERNANCE AND MANAGEMENT OF COMMUNITY BENEFIT ACTIVITIES. PART VI, LINE 3: THERE ARE SEVERAL WAYS IN WHICH OUR ORGANIZATION INFORMS AND EDUCATES PATIENTS WHO MAY BE BILLED FOR SERVICES ABOUT ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE, OR LOCAL GOVERNMENT PROGRAMS, OR UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. FIRST, NOTIFICATION OF SUCH AVAILABLE ASSISTANCE IS CLEARLY POSTED IN REGISTRATION AREAS, AS WELL AS MATERNITY AND EMERGENCY DEPARTMENTS. NEXT, PATIENT ADVOCATES, PATIENT ACCESS STAFF MEMBERS, AND FINANCIAL COUNSELORS IN THE INPATIENT AND EMERGENCY DEPARTMENTS MEET WITH UNINSURED AN true FIVE RIVERS HEALTH CENTERS 2261 PHILADELPHIA DR DAYTON OH 45406 450914398 501(C)(3) 1359287 SUPPORT CITYWIDE DEVELOPMENT CORP 8 N MAIN ST DAYTON OH 45402 310821189 501(C)(4) 869262 COMMUNITY DEVELOPMENT DAYTON FOUNDATION DEPOSITORY 40 N MAIN ST 500 DAYTON OH 45423 311044298 501(C)(3) 60600 SUPPORT MIAMI VALLEY HOSPITAL 110 N MAIN ST 500 DAYTON OH 45402 310537504 501(C)(3) 46908 AFRICAN AMERICAN WOMEN'S HEALTH PROGRAM REACH OUT MONTGOMERY COUNTY 25 E FORAKER ST DAYTON OH 45409 311434282 501(C)(3) 38941 RX ASSIST FOR INDIGENT YWCA OF DAYTON 141 W THIRD ST DAYTON OH 45402 310537168 501(C)(3) 27140 SUPPORT MARY SCOTT NURSING CENTER INC 3109 CAMPUS DR DAYTON OH 45406 316010222 501(C)(3) 24480 SUPPORT BRIGIDS PATH INC 3601 S DIXIE DR KETTERING OH 45439 471200761 501(C)(3) 24240 SUPPORT GOOD SAMARITAN HOSPITAL FOUNDATION - DAYTON 110 N MAIN ST 500 DAYTON OH 45402 237296923 501(C)(3) 12500 SUPPORT WRIGHT STATE UNIVERSITY 3640 COLONEL GLENN HWY DAYTON OH 45435 310732831 501(C)(3) 11700 SUPPORT EQUITAS HEALTH 15 W FOURTH ST DAYTON OH 45402 311126780 501(C)(3) 10500 SUPPORT MIAMI VALLEY HOSPITAL FOUNDATION 110 N MAIN ST 500 DAYTON OH 45402 311040231 501(C)(3) 10404 SUPPORT ADVOCATES FOR BASIC LEGAL EQUALITY INC 130 W 2ND ST 700 E DAYTON OH 45402 237376131 501(C)(3) 8000 SUPPORT DAYTON ART INSTITUTE 456 BELMONTE PARK N DAYTON OH 45405 310537480 501(C)(3) 7920 SUPPORT BIG BROTHERS BIG SISTERS 22 S JEFFERSON ST DAYTON OH 45402 310641306 501(C)(3) 6800 SUPPORT DAYTON CONTEMPORARY DANCE CO 840 GERMANTOWN ST DAYTON OH 45402 237220259 501(C)(3) 6260 SUPPORT ATRIUM MEDICAL CENTER FOUNDATION 110 N MAIN ST 500 DAYTON OH 45402 311079213 501(C)(3) 6060 SUPPORT HOUSE OF BREAD 9 ORTH AVE DAYTON OH 45402 311076425 501(C)(3) 6000 SUPPORT DAYBREAK 605 PATTERSON BLVD DAYTON OH 45402 310864474 501(C)(3) 5580 SUPPORT SOUTHBROOK CHRISTIAN CHURCH - 9095 WASHINGTON CHURCH RD MIAMISBURG OH 45342 311170733 501(C)(3) 5280 SUPPORT UNITED WAY GREATER DAYTON AREA 33 W 1ST ST DAYTON OH 45402 310536658 501(C)(3) 5180 SUPPORT ST PETER CATHOLIC CHURCH - 6161 CHAMBERSBURG RD HUBER HEIGHTS OH 45424 310626310 501(C)(3) 5100 SUPPORT 21 1 SCHEDULE I, PART I, LINE 2: 1) DISBURSEMENTS ARE ANALYZED MONTHLY THROUGH VARIOUS REPORTS AND COMMITTEE MEETINGS. 2) INVOICES ARE RECEIVED IN ACCOUNTS PAYABLE AND APPROVED AND DISBURSED PER ORGANIZATIONAL POLICY. 3) GRANT SPENDING IS MONITORED AGAINST BUDGETED AMOUNTS ON AN ONGOING BASIS. X X X X false true false false false false false false false ELOISE P BRONER PRESIDENT & CEO 444075 0 198154 0 186402 0 28963 0 2917 0 860511 0 0 0 DALE E CREECH JR BOARD SECRETARY/SYSTEM VP-CLO 0 398677 0 146709 0 86590 0 37157 0 25774 0 694907 0 0 MARY E GARMAN CHIEF OPERATING OFFICER 285072 0 73091 0 2718 0 14072 0 11710 0 386663 0 0 0 TIMOTHY D SNIDER BOARD TREASURER / CFO 101567 0 39194 0 513 0 3019 0 12087 0 156380 0 0 0 THOMAS R CURTIN SYSTEM VP - REVENUE CYCLE 0 231960 0 68571 0 6046 0 28926 0 29842 0 365345 0 0 GARY G GINTER SYSTEM VP - CIO 0 385251 0 135949 0 3806 0 61801 0 25349 0 612156 0 0 KATHLEEN M HARPER VP NORTH HOSPITAL OPERATIONS 187352 0 75722 0 963 0 7508 0 24471 0 296016 0 0 0 JENNIFER J HAULER MD SYSTEM VP - CMO (FROM OCT) 0 337058 0 28191 0 1125 0 0 0 1542 0 367916 0 0 BARBARA A JOHNSON SYSTEM VP - HR OPERATIONS 0 363394 0 124821 0 20560 0 28293 0 10160 0 547228 0 0 TAMMY S LUNDSTROM MD SYSTEM VP - CMO (TO AUG) / CCO 0 524280 0 192978 0 5165 0 81162 0 2788 0 806373 0 0 MARGARET W MARK SYSTEM VP - CNO (FROM JUN) 0 267121 0 70931 0 7815 0 9544 0 25867 0 381278 0 0 THOMAS R PARKER SYS VP -CHF EXPERIENCE OFFICER 0 378787 0 121190 0 26397 0 52371 0 14841 0 593586 0 0 CRAIG SELF SYS VP -CHIEF STRATEGY OFFICER 0 389413 0 144360 0 3160 0 23805 0 26651 0 587389 0 0 MARK W SHAW SYSTEM VP - MANAGED CARE 0 307295 0 118673 0 88375 0 36068 0 25720 0 576131 0 0 SCOTT A SHELTON SYSTEM VP - CPO 0 252664 0 116419 0 11514 0 24804 0 4430 0 409831 0 0 SYLVAIN TREPANIER DNP RN CENP SYSTEM VP - CNO (TO APR) 0 111026 0 103825 0 900 0 19789 0 8737 0 244277 0 0 FRANK E SAWYER SYS VP - ONCOLOGY SERVICE LINE 240653 0 77904 0 749 0 9559 0 24471 0 353336 0 0 0 CHRISTIE GRAY VP - CNO 221721 0 66121 0 1534 0 21251 0 11105 0 321732 0 0 0 KIM K STRAHL SYSTEM VP STRATEGIC SOURCING 154965 0 71402 0 2093 0 18744 0 9482 0 256686 0 0 0 SHARON K THORNTON ERP OPERATIONS LEADER 163009 0 41263 0 18875 0 7371 0 9780 0 240298 0 0 0 DARLENE WISEMAN VP FINANCE - SUPPORT SERVICES 185572 0 28169 0 948 0 20249 0 18372 0 253310 0 0 0 RENEE P GEORGE FORMER KEY EMPLOYEE 0 323626 0 71751 0 1095 0 15853 0 12345 0 424670 0 0 Part I, Line 4B: DUE TO RESTRICTIONS IMPOSED BY THE INTERNAL REVENUE CODE, CERTAIN PERSONS ARE LIMITED IN THE AMOUNT OF BENEFIT THAT CAN BE EARNED UNDER A QUALIFIED RETIREMENT PLAN. LIKE MANY EMPLOYERS, GOOD SAMARITAN HOSPITAL (GSH) AND ITS AFFILIATED ORGANIZATIONS COMPENSATE FOR THIS LIMITATION AND SUPPLEMENT THE AFFECTED EXECUTIVES' QUALIFIED PENSION THROUGH CERTAIN NONQUALIFIED PLANS. GSH SUPPLEMENTS THE AFFECTED EXECUTIVES THROUGH A PENSION RESTORATION PLAN AND A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). THE BENEFITS UNDER THESE SUPPLEMENTAL NONQUALIFIED PLANS ARE SUBJECT TO MULTI-YEAR VESTING AND A PARTICIPANT CAN FORFEIT BENEFITS EARNED IF VESTING REQUIREMENTS ARE NOT SATISFIED. UNDER THE TERMS OF THE SUPPLEMENTAL PLANS, AND BECAUSE OF TAX RULES PERTAINING TO TAXATION OF THE EARNED BENEFITS UPON VESTING, CERTAIN INDIVIDUALS RECEIVED A PAYOUT OF THE CUMULATIVE VESTED BENEFITS UNDER THEIR SUPPLEMENTAL PLAN DURING 2017. THE INDIVIDUALS LISTED BELOW HAVE MET THE MULTI-YEAR VESTING REQUIREMENT UNDER THE PENSION RESTORATION PLAN AND RECEIVED THE ASSOCIATED PAYMENT IN 2017: ELOISE BRONER $163,875; DALE CREECH JR. $80,472; BARBARA JOHNSON $15,163; MARK SHAW $79,734; SCOTT SHELTON $8,114. THERE WERE NO INDIVIDUALS WHO MET THE MULTI-YEAR VESTING REQUIREMENT UNDER THE SERP. IN ADDITION, THE FOLLOWING SERP AMOUNTS WERE DEFERRED ON THE PARTICIPANTS' BEHALF DURING THE YEAR AND WILL BE HELD UNTIL THE INCREMENTAL AMOUNTS ARE VESTED AND PAID TO THE SERP PARTICIPANTS: THOMAS CURTIN $3,311; MARY GARMAN $4,842; RENEE GEORGE $4,842; GARY GINTER $35,597; BARBARA JOHNSON $9,636; TAMMY LUNDSTROM, M.D. $71,860; MARGARET MARK $986; THOMAS PARKER $24,658; CRAIG SELF $14,135; TIMOTHY SNIDER $328; SYLVAIN TREPANIER $11,028. BASED ON THE GUIDANCE PROVIDED IN THE INSTRUCTIONS TO THE FORM 990, ANY PAYMENTS TO THE PARTICIPANTS RELATED TO THESE PLANS THAT WERE MADE WITHIN 2-1/2 MONTHS AFTER THE END OF THE ORGANIZATION'S TAX YEAR ARE NOT TREATED AS DEFERRED COMPENSATION FOR PURPOSES OF SCHEDULE J. SUCH AMOUNTS ARE PROPERLY REPORTED AS COMPENSATION FOR FORM 990 PURPOSES WHEN INCLUDED IN THE PARTICIPANTS' FORM W-2 WAGES. ANY PAYMENTS MADE AFTER THE 2-1/2 MONTHS WERE PROPERLY REPORTED ON PRIOR YEARS' FILED IRS FORM 990 RETURNS, DISCLOSING COMPENSATION EARNED BY THESE INDIVIDUALS UNDER THE PLANS FOR EACH SUCH YEAR. Thomas R Parker WIFE 187587 Salary false FORM 990, PART VI, SECTION A, LINE 3: PREMIER HEALTH (PREMIER), AS THE OPERATOR OF GOOD SAMARITAN HOSPITAL (GSH), DEVELOPS AND OVERSEES THE IMPLEMENTATION OF THE STRATEGIC PLAN FOR GSH, WHICH INCLUDES (BUT IS NOT LIMITED TO) SUCH MATTERS AS LOCATION OF CLINICAL AND ADMINISTRATIVE EXPENSES AND THE CONSOLIDATION OF SUCH SERVICES. GSH SHALL COMPLY WITH AND IMPLEMENT THIS PLAN AND SHALL NOT TAKE ANY ACTION THAT MATERIALLY DEPARTS FROM THIS PLAN WITHOUT PREMIER'S APPROVAL. GSH SHALL IMPLEMENT ANY CAPITAL AND OPERATING BUDGET SO APPROVED AND/OR REVISED FOR IT BY PREMIER. GSH SHALL IMPLEMENT THE BUSINESS PLAN APPROVED BY PREMIER. PREMIER IS THE SOLE AGENT TO NEGOTIATE ALL RELATIONSHIPS WITH PAYORS ON BEHALF OF GSH WITH ALL THIRD-PARTY PAYORS AND ALTERNATIVE DELIVERY SYSTEMS INCLUDING, BUT NOT LIMITED TO INSURERS. GSH MUST HAVE APPROVAL FROM PREMIER TO BORROW IN ANY FISCAL YEAR, GUARANTEE IN ANY YEAR, OR INCUR ANY LIEN OR OTHER ENCUMBRANCE ON ANY PROPERTY IN AN AMOUNT EQUAL TO OR GREATER THAN $1,000,000. GSH MUST SEEK PREMIER'S APPROVAL FOR ANY ACQUISITIONS, SALE OR TRANSFER OF ANY MATERIAL ASSET USED IN PREMIER'S ACTIVITIES. FORM 990, PART VI, SECTION A, LINE 6: GOOD SAMARITAN HOSPITAL HAS TWO CORPORATE MEMBERS. ONE MEMBER IS SAMARITAN HEALTH PARTNERS. THE SECOND MEMBER IS PREMIER HEALTH (PREMIER), AN OHIO NON-PROFIT CORPORATION FORMED PURSUANT TO THE JOINT OPERATING AGREEMENT. SAMARITAN HEALTH PARTNERS HAS THE SOLE AUTHORITY TO ELECT THE BOARD OF TRUSTEES OF THE CORPORATION. PREMIER HAS THE GENERAL AUTHORITY TO OPERATE AND MANAGE THE OPERATIONAL ACTIVITIES OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINES 7A & 7B: SAMARITAN HEALTH PARTNERS (SHP) HAS THE SOLE AUTHORITY TO ELECT THE BOARD OF TRUSTEES FOR GOOD SAMARITAN HOSPITAL FROM AMONG THOSE RECOMMENDED BY THE NOMINATING COMMITTEE SET FORTH IN THE JOINT OPERATING AGREEMENT. SHP HAS THE AUTHORITY TO REMOVE SUCH TRUSTEES AT ANY REGULAR OR SPECIAL MEETING OR BY WRITTEN CONSENT. FORM 990, PART VI, SECTION B, LINE 11B: THIS 990 TAX RETURN AND ATTACHED SCHEDULES (THE RETURN) ARE PREPARED BY A STAFF MEMBER IN THE TAX DEPARTMENT OF PREMIER HEALTH (PREMIER), WITH WHICH GOOD SAMARITAN HOSPITAL IS AN AFFILIATE. THE RETURN IS REVIEWED BY THE TAX MANAGER AND THE DIRECTOR OF TAX COMPLIANCE OF PREMIER. THE RETURN IS CONCURRENTLY SENT TO ERNST & YOUNG U.S. LLP FOR THEIR REVIEW. AFTER ALL CHANGES FROM THE ABOVE GROUPS ARE MADE, THE RETURN IS REVIEWED BY THE VICE PRESIDENT/CONTROLLER OF PREMIER AND THE CHIEF FINANCIAL OFFICER OF THIS ENTITY. A FINAL VERSION OF THE RETURN IS SENT TO ERNST & YOUNG U.S. LLP FOR A FINAL REVIEW AND THEN PROVIDED TO THE BOARD OF TRUSTEES FOR REVIEW. AT THE BOARD OF TRUSTEES MEETING, THE VICE PRESIDENT/CONTROLLER OF PREMIER (OR DESIGNEE) SHARES DETAILED INFORMATION ON COMPENSATION AND OTHER KEY AREAS, AS WELL AS ADDRESS ANY OTHER QUESTIONS FROM THE BOARD OF TRUSTEES, PENDING THEIR REVIEW. THE 990 TAX RETURN IS ALSO SHARED WITH THE AUDIT COMMITTEE OF PREMIER. FORM 990, PART VI, SECTION B, LINE 12C: PREMIER HEALTH (PREMIER), WITH WHICH GOOD SAMARITAN HOSPITAL IS AN AFFILIATE, REQUIRES ALL BOARD MEMBERS, BOARD COMMITTEE MEMBERS, MEDICAL DIRECTORS, SUPPLY CHAIN DIVISION MEMBERS, AUTHORIZED SIGNERS, DIRECTORS, EXECUTIVES, MEDICAL EXECUTIVE COMMITTEE MEMBERS, MEDICAL DEPARTMENT AND SECTION CHAIRS, PHYSICIAN PARTNERSHIP COMMITTEE MEMBERS, PHYSICIAN GUIDANCE GROUP MEMBERS, AND ALL EMPLOYED PHYSICIANS TO ANNUALLY REVIEW THE PREMIER COMPREHENSIVE CONFLICT OF INTEREST STATEMENT, AN EXPLANATORY MEMORANDUM, THE ANTITRUST COMPLIANCE POLICY, AND COMPLETE AN INDIVIDUAL QUESTIONNAIRE DISCLOSING ANY POTENTIAL CONFLICTS AS DEFINED IN THE CONFLICT OF INTEREST POLICY. THIS IS ACCOMPLISHED EITHER BY WAY OF AN ELECTRONIC COMMUNICATION SENT OUT DIRECTLY BY THE CORPORATE COMPLIANCE DEPARTMENT OR BY WAY OF A MEMO SENT OUT FROM THE CHAIRMAN OF THE BOARD AND CHIEF EXECUTIVE OFFICER OF PREMIER. IT ALSO INCLUDES AN EXPLANATORY MEMORANDUM OF SPECIFIC ACTIVITIES THAT MIGHT GIVE CAUSE TO A CONFLICT AND AN INDIVIDUAL QUESTIONNAIRE TO DISCLOSE ALL SUCH ACTIVITIES. THIS QUESTIONNAIRE MUST BE COMPLETED AND SIGNED BY THE INDIVIDUAL. THIS CORRESPONDENCE INCLUDES A COPY OF THE ANTITRUST COMPLIANCE POLICY THAT MUST BE SIGNED BY THE INDIVIDUAL. ALL OF THESE DOCUMENTS ARE SENT TO THE CORPORATE COMPLIANCE DEPARTMENT. THE CORPORATE COMPLIANCE DEPARTMENT ENSURES ALL FORMS ARE RETURNED AND RETAINS THE DOCUMENTS FOR FIVE YEARS. IN ADDITION, AT EACH MEETING OF THE BOARD OR ANY BOARD COMMITTEE, FOLLOWING APPROVAL OF THE PREVIOUS MEETING'S MINUTES, THE BOARD OR COMMITTEE CHAIR SHALL REQUEST ANY BOARD MEMBER WHO PERCEIVES A POTENTIAL CONFLICT OF INTEREST ON ANY OF THE MEETING'S AGENDA ITEMS TO DISCLOSE THE POTENTIAL CONFLICT. ADDITIONALLY, AT ANY BOARD OR BOARD COMMITTEE MEETING WHERE THE SUBJECT OF CONFLICT OF INTEREST IS DISCUSSED, THE MINUTES SHALL CONTAIN THE NAME OF THE PARTY DISCUSSING A POTENTIAL CONFLICT OF INTEREST, THE NATURE OF THE POTENTIAL CONFLICT OF INTEREST AND WHETHER A CONFLICT OF INTEREST WAS FOUND TO EXIST. IF A CONFLICT OF INTEREST IS DETERMINED BY THE BOARD TO EXIST, THE MEMBER WILL BE EXCUSED FROM PARTICIPATING IN ANY DISCUSSION OR VOTING ON THE PARTICULAR AGENDA ITEM. THE CHIEF COMPLIANCE AND ENTERPRISE RISK OFFICER REPORTS THE RESULTS OF THE PREMIER CONFLICT OF INTEREST QUESTIONNAIRES NO LESS THAN ANNUALLY TO THE BOARD OF TRUSTEES BY WAY OF THE COMPLIANCE AND AUDIT COMMITTEE. THIS REVIEW IS DOCUMENTED IN THE MINUTES OF THE MEETING. PERIODICALLY, THE INTERNAL AUDIT DEPARTMENT WILL REVIEW A SAMPLE OF COMPLETED CONFLICT OF INTEREST QUESTIONNAIRES AND REPORT THE RESULTS TO THE COMPLIANCE AND AUDIT COMMITTEE. THE ANNUAL CONFLICT OF INTEREST QUESTIONNAIRES ARE INDIVIDUALLY SUMMARIZED IN A DOCUMENT AND SENT ELECTRONICALLY TO THE FINANCE DEPARTMENT FOR ANY NECESSARY DISCLOSURES REQUIRED ON THE 990 TAX RETURN. FORM 990, PART VI, SECTION B, LINES 15A AND 15B: COMPENSATION FOR GOOD SAMARITAN HOSPITAL'S (GSH) CEO IS REVIEWED AND APPROVED BY PREMIER HEALTH (PREMIER), WITH WHICH GSH IS AN AFFILIATE, ON AN ANNUAL BASIS. THE REVIEW PROCESS PERFORMED BY PREMIER FOLLOWS A MARKET BASED COMPENSATION PHILOSOPHY DESIGNED TO ATTRACT AND RETAIN THE EXECUTIVE TALENT REQUIRED TO MEET THE HIGH-PERFORMANCE STANDARDS OF OUR BOARD AND OUR COMMUNITY. PREMIER ANNUALLY REVIEWS EXECUTIVE COMPENSATION SURVEY DATA FOR A REGIONAL PEER GROUP OF SYSTEMS AND HOSPITALS THAT ARE SIMILAR IN SIZE AND COMPLEXITY TO PREMIER AND ITS AFFILIATES. THE DATA FOR THE SURVEY IS PROVIDED BY A THIRD-PARTY CONSULTANT GROUP THAT IS INDEPENDENT OF PREMIER. THIS REPORT INCLUDES COMPARABILITY FOR KEY EXECUTIVES, VICE PRESIDENTS, AND DIRECTOR LEVEL POSITIONS. THE INDEPENDENT COMPARABILITY DATA IS REVIEWED BY THE EXECUTIVE COMPENSATION COMMITTEE ON AN ANNUAL BASIS. THIS COMMITTEE IS COMPRISED OF THREE MEMBERS, ALL OF WHOM ARE INDEPENDENT. THIS COMMITTEE REVIEWS IN DETAIL THE COMPENSATION FOR THE PREMIER CEO, COO, CFO, CHIEF INTEGRATION OFFICER, CHIEF STRATEGY OFFICER, AND THE HOSPITAL CEOS. OTHER POSITIONS ARE REVIEWED AT A HIGH LEVEL FOR REASONABLENESS. ALL THE MEETING MINUTES ARE DOCUMENTED AND KEPT ON FILE ALONG WITH ANY COMPARABILITY DATA AND THE CONSULTANT REPORT. AFTER THE COMPENSATION COMMITTEE REVIEWS AND APPROVES THE COMPENSATION ACTIONS, THE PROCESS IS AUDITED BY THE INTERNAL AUDIT DEPARTMENT. THE EXECUTIVE COMPENSATION COMMITTEE PRESENTS THE COMPENSATION ACTIONS TO THE PREMIER BOARD ANNUALLY. FORM 990, PART VI, SECTION C, LINE 19: THE GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC WHEN REQUIRED BY LAW OR FOR ACCREDITATION PURPOSES. THE CONFLICT OF INTEREST POLICY IS AVAILABLE ON WWW.PREMIERHEALTH.COM. FORM 990, PART XI, LINE 9: EQUITY TRANSFERS $(28,220,753) FOUNDATION ADJUSTMENT $(250,968) PENSION FUND ADJUSTMENT $(138,780) TRANSFERS FROM AFFILIATES $153,126 DISTRIBUTIONS / LIQUIDATIONS $3,708,320 TOTAL $(24,749,055) SAMARITAN HEALTH PARTNERS (SHP) 110 N MAIN ST 500 DAYTON OH 45402 311107411 PARENT OH 501(c)(3) 12C III FI NA false PREMIER HEALTH 110 N MAIN ST 500 DAYTON OH 45402 311446699 SUPPRTG. ORG. OH 501(c)(3) 12A I NA false GOOD SAMARITAN HOSPITAL FOUNDATION-DAYTO 110 N MAIN ST 500 DAYTON OH 45402 237296923 FOUNDATION OH 501(c)(3) 7 SHP true CATHOLIC HEALTH INITIATIVES 198 INVERNESS DR W 500 ENGLEWOOD CO 80112 470617373 PARENT CO 501(c)(3) 10 NA false THE HEART INSTITUTE OF DAYTON 110 N MAIN ST 500 DAYTON OH 45402 300502367 EDUCATION OH 501(c)(3) 10 SHP true SAMARITAN BEHAVORIAL HEALTH INC 601 EDWIN C MOSES BLVD DAYTON OH 45417 020633634 Behavorial He OH 501(c)(3) 7 SHP true SAMARITAN NORTH SURGERY CENTER 9000 N MAIN DAYTON OH 45415 311618587 O/P SURGERY OH GSH RELATED 3038313 3071691 false 0 true 0.80000 true true true false false true false false false false false false true false false true true true false GOOD SAMARITAN HOSPITAL FOUNDATION - DAYTON C 404094 CASH SAMARITAN BEHAVIORAL HEALTH INC Q 236930 CASH CATHOLIC HEALTH INITIATIVES R 3795000 FMV PREMIER HEALTH B 381189 FMV SAMARITAN NORTH SURGERY CENTER A-IV 715258 Cash SAMARITAN NORTH SURGERY CENTER B 748320 Cash SAMARITAN NORTH SURGERY CENTER F 2960000 Cash