2017-11-15T11:48:09-06:00 2016-12-31 570381582 ELLIOTT DAVIS LLC PLLC ONE 10TH STREET SUITE 400 AUGUSTA GA 30901 990 2016-01-01 581581103 UNIVERSITY HEALTH SERVICES INC UNIV 7068282406 1350 WALTON WAY AUGUSTA GA 30901 DAVID A BELKOSKI CFO 7068282406 2017-11-14 1 JESSICA C CAIN CPA P01276209 7067229090 165.225.34.66 2017-11-14 17:05:15 ES P FA911B7747AA32E893665EE7CE6220A1088A557E FA911B7747AA32E893665EE7CE6220A1088A557E 2016 2017-02-10 21:41:12Z JAMES R DAVIS 1350 WALTON WAY AUGUSTA GA 30901 871063091 0 X WWW.UNIVERSITYHEALTH.ORG X 1984 GA THE MISSION OF UNIVERSITY HEALTH CARE SERVICES IS TO OPERATE AN ACUTE AND SUBACUTE CARE HOSPITAL PROVIDING HEALTH CARE SERVICES WHICH HELP THE CITIZENS OF OUR COMMUNITIES ACHIEVE AND MAINTAIN OPTIMAL HEALTH. 15 13 4012 278 3974509 115053 1512240 1765563 465432229 491032119 8077749 12537652 8816964 11371452 483839182 516706786 1305452 1255521 0 0 185567571 194658829 0 0 0 259899379 268559382 446772402 464473732 37066780 52233054 836906321 810233580 404074492 375086387 432831829 435147193 X THE MISSION OF UNIVERSITY HEALTH CARE SERVICES IS TO OPERATE AN ACUTE AND SUBACUTE CARE HOSPITAL PROVIDING HEALTH CARE SERVICES WHICH HELP THE CITIZENS OF OUR COMMUNITIES ACHIEVE AND MAINTAIN OPTIMAL HEALTH. 0 0 441296801 1255521 494532313 OPERATION OF A GENERAL ACUTE CARE AND SUB-ACUTE CARE HOSPITAL WITH 551 LICENSED BEDS, TOTAL (551 ACUTE AND 0 SUB-ACUTE). PATIENT DAYS FOR ADULTS AND PEDIATRICS FOR 2016 WERE 118,092, NEWBORN DAYS WERE 13,304 (FOR BOTH TERM & ICU NURSERY), AND OUTPATIENT VISITS WERE 535,844. EMERGENCY ROOM REGISTRATIONS WERE 82,892, OBSERVATION STAYS WERE 13,842, CARDIOVASCULAR INTERVENTIONAL PROCEDURES WERE 10,254 AND RADIOLOGY PROCEDURES WERE 257,343, OCCUPATIONAL MEDICINE VISITS WERE 27,672 AND HOME HEALTH VISITS FOR 2016 WERE 54,939.WITHIN ALL THESE INDICATORS ARE THE EFFORTS OF UNIVERSITY HEALTH SERVICES, INC TO SERVICE THE NEEDS OF THE COMMUNITY, WHICH INCLUDE THE INDIGENT. IN 2016 THE COST OF INDIGENT AND CHARITY CARE PROVIDED, WITH NO LOCAL FUNDING, WAS $36,369,270. HOWEVER, THE HOSPITAL DID RECEIVE DISPROPORTIONATE SHARE (DSH) PAYMENTS TO HELP WITH THIS SERVICE OF $2,435,552 (NET) AND UPPER PAYMENT LIMITS (UPL) FUNDS OF $991,327 (NET). THE $36,369,270 INCLUDES THE COST FOR PROVIDING INPATIENT AND OUTPATIENT SERVICES FOR INDIGENT AND CHARITY CARE PATIENTS OF $18,976,724. ALSO $1,483,518 TO HELP SUPPORT COMMUNITY BASED CLINICS, $15,909,028 FOR UNCOMPENSATED PHYSICIAN SERVICES FOR INDIGENT AND CHARITY CARE PATIENTS.ALSO PROVIDED ARE PROGRAMS FOR CONGESTIVE HEART FAILURE AND ASTHMA/COPD, WHICH HELPED INDIGENT PATIENTS MANAGE THEIR CONDITION AND IMPROVE THE QUALITY OF THEIR LIVES. OTHER COMMUNITY OUTREACH SERVICES FOR 2016 INCLUDE DIABETES TESTING AND EDUCATION, PROSTATE SPECIFIC ANTIGEN (PSA) TESTING, SKIN CANCER SCREENINGS, FREE COUNSELING AND EDUCATION FOR WOMEN AND THEIR FAMILY MEMBERS THROUGH ALL THE STAGES OF BREAST CANCER, FREE MAMMOGRAMS, HEART HEALTH EDUCATION, AND SUPPORT GROUPS FOR CANCER, HEART ATTACK, AND STROKE. IN 2016 UNIVERSITY HOSPITAL REACHED MORE THAN 8,810 PEOPLE AND INVESTED MORE THAN $143,280 IN FREE SCREENINGS, COMMUNITY EDUCATION, PUBLICATIONS, AND MORE. ADDITIONALLY, IN 2016 OVER $1.3 MILLION WAS PROVIDED FOR HEALTH PROFESSIONAL EDUCATION FOR CARDIOVASCULAR AND RADIOLOGY SCHOOLS, AND INTERNS AND RESIDENTS, IN SUPPORT OF TOMORROW'S CARE GIVERS. 441296801 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 1 1 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 1 225 0 4012 1 1 1 1 CJ 0 0 0 0 0 0 0 0 X 15 13 0 0 0 0 0 0 0 1 1 0 1 1 1 1 1 1 1 1 1 1 0 GA SC X X DAVID A BELKOSKI 7068282406 1350 WALTON WAY AUGUSTA GA 30901 LEVI W HILL IV BOARD CHAIRMAN 2.00 1.00 X X 0 0 0 TERRY D ELAM BOARD MEMBER 2.00 1.00 X 0 0 0 W CRAIG SMITH BOARD MEMBER 2.00 1.00 X 0 0 0 NATALIE D SCHWEERS BOARD MEMBER 2.00 1.00 X 0 0 0 SANFORD LOYD BOARD MEMBER 2.00 1.00 X 0 0 0 BRIAN J MARKS BOARD SECRETARY 2.00 1.00 X X 0 0 0 EUGENE F MCMANUS BOARD MEMBER 2.00 1.00 X 0 0 0 HUGH L HAMILTON BOARD MEMBER 2.00 1.00 X 0 0 0 JEFFREY L FOREMAN BOARD MEMBER 2.00 1.00 X 0 0 0 JAMES W BENNETT JR BOARD MEMBER 2.00 1.00 X 0 0 0 DANIEL H BOONE MD BOARD MEMBER 2.00 50.00 X 0 266619 13247 CHARLES G PETE CAYE JR BOARD MEMBER 2.00 1.00 X 0 0 0 CATHERINE D KNOX BOARD MEMBER 2.00 1.00 X 0 0 0 WILLIAM P DOUPE BOARD MEMBER 2.00 1.00 X 0 0 0 JAMES C SHERMAN MD BOARD MEMBER 2.00 50.00 X 0 118621 593 DAVID A BELKOSKI UHS CFO 50.00 5.00 X 605375 0 14858 JAMES R DAVIS UHS PRESIDENT & CEO 50.00 5.00 X 965846 0 304207 MARILYN A BOWCUTT PRESIDENT OF UNIVERSITY HO 50.00 5.00 X 659973 0 16704 WILLIAM L FARR CMO 50.00 5.00 X 537022 0 21601 EDWARD L BURR SR. VP LEGAL & REGULATORY 50.00 X 553470 0 23705 SANDRA MCVICKER CEO UNIVERSITY HOSPITAL MC 50.00 X 214836 0 4382 LAURIE OTT SMITH UHCF-VP HR & COMM SVC 50.00 X 358079 0 13613 THOMAS E LOWENCAMP VP - CONTINUING CARE 25.00 25.00 X 270408 0 26551 SHIRLEY K GABRIEL VP CHIEF INFORMATION OFFIC 50.00 X 381580 0 18788 TERESA BUSCHBACHER VP -HVI 50.00 X 206633 0 14461 LYNDA JONES WATTS VP PATIENT CARE SVCS/CNO 50.00 X 364614 0 25166 SCOTT ANSEDE VP PROFESSIONAL SERVICES 50.00 X 396709 0 24895 ELIZABETH R GALLUP VP CLINICAL OPERATIONS 50.00 X 219150 0 17209 ROBERT J KEPSHIRE ADMINISTRATIVE CNO - MCDUFFIE 50.00 X 184831 0 10337 JOHN C POPE PA ECHO CLINICAL PROG COOR 50.00 X 192778 0 9708 LISA RITCH CORPORATE CONTROLLER 50.00 X 176689 0 12388 JACKIE KENDINGER EMPLOYEE 50.00 X 182363 0 5474 DOUGLAS D PUGH II RN 50.00 X 187784 0 17465 6658140 385240 595352 182 0 1 0 CROTHALL HEALTHCARE 13028 COLLECTION CENTER DRIVE CHICAGO IL 60693 PLANT & HOUSEKEEPING 9509929 MORRISON MANAGEMENT HEALTHCARE INC 5353 REYNOLDS STREET SAVANNAH GA 31405 FOOD SERVICES 6738991 NOVANT HEALTH INC 2085 FRONTIS PLAZA WINSTON SALEM NC 27103 SYSTEM SUPPORT 6280302 CONVERGEONE NW 5806 PO BOX 1450 MINNEAPOLIS MN 55485 IT SERVICES 3222517 EPIC SYSTEMS CORPORATION PO BOX 88314 MILWAUKEE WI 53288 SYSTEM SUPPORT 2172162 84 171993 8739 1584831 1765563 PATIENT SERVICE REVENUE 900099 481387588 481387588 HOME HEALTH SERVICES 621610 8661307 8661307 PHYSICIAN ANSWERING SERVICE 541900 419078 419078 OTHER PROGRAM SERVICES 900099 325440 325440 ASK-A-NURSE 541900 210999 210999 27707 27707 491032119 8165623 8165623 4492918 3185582 1307336 1307336 48357 1258979 355530607 12145 351030157 140566 4500450 -128421 4372029 4372029 OUTREACH LAB 900099 3914439 3914439 EMPLOYEE PHARMACY 446110 2634580 2634580 EHR INCENTIVE PROGRAM 900099 2209637 2209637 1305460 1290557 11713 3190 10064116 516706786 494532313 3974509 16434401 1255521 1255521 6658914 5007119 1651795 135761357 134735651 1025706 3062417 3004844 57573 36585865 35898051 687814 12590276 12353579 236697 14103647 13838498 265149 454280 454280 258106 258106 225583 225583 1934491 1934491 30554447 29980023 574424 1101651 1080940 20711 1064175 1044169 20006 8364799 8207541 157258 5944073 5832324 111749 1084442 1064054 20388 15472 15472 9027793 9027793 30555912 29981461 574451 3997503 3922350 75153 MED SURG SUPPLIES 112205057 112205057 BAD DEBT EXPENSE 24805821 24805821 REPAIRS AND MAINTENANCE 9719750 9537019 182731 GA DCH HOSPITAL TAX 5378580 5378580 7763800 7542779 221021 464473732 441296801 23176931 0 33324776 9161680 66446953 75562510 7823797 11147991 8660308 9797976 7928753 8572532 620402812 383199763 241778986 237203049 419342333 409893486 51600415 48894356 836906321 810233580 28932539 24937852 137205000 149527198 120182006 98863133 117754947 101758204 404074492 375086387 X 432796829 435112193 35000 35000 432831829 435147193 836906321 810233580 X 52233054 18013627 -67931317 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 225583 225583 0 PART II-B, LINE 1: A PART OF THE VARIOUS ASSOCIATION DUES INCLUDE A PERCENTAGE ALLOCATION FOR EXPENDITURES ON LOBBYING ACTIVITIES. DUES PAID TO THE GEORGIA HOSPITAL ASSOCIATION, THE GEORGIA ALLIANCE OF COMMUNITY HOSPITALS, THE GEORGIA INITIATIVE, THE GEORGIA SAFETY NET COALITION, AND THE GEORGIA CHAMBER OF COMMERCE, ALL HAVE A LOBBYING COMPONENT. FOR 2016, THESE FEES AMOUNTED TO $172,514. ADDITIONALLY, OGLETHORPE CONSULTING GROUP WAS CONTRACTED DURING 2016 TO REVIEW AND ADVISE THE HOSPITAL ON LEGISLATIVE ISSUES. DURING 2016, $53,069 WAS PAID TO OGLETHORPE CONSULTING GROUP. 18075268 18075268 280136829 143186633 136950196 3610817 2783607 827210 306928690 237229523 69699167 11651208 11651208 237203049 457(B) DEFERRED COMP ASSET 830679 AMOUNTS DUE FROM AFFILIATES 36106117 BOND START UP COST 1669666 CVS LIFE INSURANCE 624693 LEASEHOLD RIGHTS 388180 PHOENIX HEALTH CARE MGMT SVCS 84169 PHYSICAN GUARANTEE ASSET 935488 PHYSICIANS LIFE INSURACE COLI 5305403 SOFTWARE LICENSE 1192474 VHA STOCK INVESTMENT 138416 WORK FORCE IN PLACE 1102165 WC ESCROW - SANFORD 73956 PL GI ESCROW - SANFORD 442950 48894356 ACCRUED COMPENSATION, BENEFITS, & WITHOLDINGS 23046273 ACCRUED POSTRETIREMENT BENEFIT COST 32601129 ASSET RETIREMENT OBLIGATION 3441155 EST THIRD PARTY PAYOR SETTLEMENTS 20966187 OTHER CURRENT LIABILITIES 3515938 RESERVE FOR SELF INSURED LOSSES 14868936 DUE TO AFFILIATES 3318586 101758204 X PART X, LINE 2: UNIVERSITY HEALTH SERVICES, INC. IS EXEMPT FROM FEDERAL INCOME TAX UNDER SECTION 501(A) AS ORGANIZATIONS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE OF 1986, AS AMENDED. ACCORDINGLY, THE FINANCIAL STATEMENTS DO NOT REFLECT A PROVISION OR LIABILITY FOR FEDERAL OR STATE INCOME TAXES. THE CORPORATION HAS EVALUATED ITS TAX POSITIONS AND HAS DETERMINED THAT IT DOES NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF DECEMBER 31, 2016. FISCAL YEARS ENDED ON OR AFTER DECEMBER 31, 2013 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. THERE IS PRESENTLY NO TAXATION IMPOSED BY THE GOVERNMENT OF THE CAYMAN ISLANDS ON INCOME OR PREMIUMS OF WWI. AS A RESULT, NO TAX LIABILITY OR EXPENSE HAS BEEN RECORDED. CENTRAL AMERICA AND THE CARIBBEAN - ANTIGUA & BARBUDA, ARUBA, BAHAMAS, 1 2 INSURANCE CAPTIVE 1 2 0 0 1 2 0 0 0 1 0 1 1 1 0 PART 1 - ADDITIONAL SUPPLEMENTAL INFORMATION PLEASE SEE FORM 5471 FILING FOR DETAILS RELATED TO OFFSHORE CAPTIVE INSURANCE 1 1 1 X 1 X 1 1 1 0 1 1 18227585 1777953 16449632 0.03540 47526817 38088393 9438424 0.02030 65754402 39866346 25888056 0.05570 18438471 9519538 8918933 0.01920 1066349 660788 405561 0.00090 1364783 1364783 0.00290 20869603 10180326 10689277 0.02300 86624005 50046672 36577333 0.07870 76886 0 76886 0.00020 9095 0 9095 0.00000 85981 85981 0.00020 1 24805721 133455 113935612 156708632 -42773020 X 1 1 1 1 UNIVERSITY HEALTH SERVICES INC 1350 WALTON WAY AUGUSTA GA 30901 WWW.UNIVERSITYHEALTH.ORG 121-375 X X X X 3 HOME HEALTH AGENCIES UNIVERSITY HEALTH SERVICES INC 1 0 0 1 X X X X X X X X X 16 1 0 0 1 X WWW.UNIVERSITYHEALTH.ORG X 1 16 1 WWW.UNIVERSITYHEALTH.ORG 1 0 1 X 200.000000000000 400.000000000000 X X X 1 1 X X 1 X WWW.UNIVERSITYHEALTH.ORG X X X X X 1 0 X X X 1 X 0 0 UNIVERSITY HEALTH SERVICES INC PART V, SECTION B, LINE 5: PAIGE MILLER, DEVELOPMENT DIRECTOR - HOPE HOUSEREV CHARLES E GOODMAN, PASTOR - TABERNACLE BAPTIST CHURCHLATOYA HARDMAN, DIRECTOR - FAMILY PROMISEJUANITA MCDANIEL, 2-1-1 COORDINATOR - UNITED WAY 2-1-1JONATHAN ADRIANO, DISTRICT PROGRAM MANAGER - GA DEPT OF PUBLIC HEALTH, ECHD IVKELLY BUSHEY, RN, COUNTY NURSE MANAGER - GA DEPT OF PUBLIC HEALTH, RCHDJOY MILLER, EPIDEMIOLOGIST - GA DEPT OF PUBLIC HEALTH , ECHD IVROBERT CAMPBELL, MD, MEDICAL DIRECTOR - CHIRST COMMUNITY HEALTH SERVICESTHOSE WHO WERE INVITED BUT DID NOT ATTEND WERE FROM THE FOLLOWING ORGANIZATIONS: AREA AGENCY ON AGING, AUGUSTA HOUSING & COMMUNITY DEVELOPMENT, AUGUSTA RESCUE MISSION, AUGUSTA PARTNERSHIP FOR CHILDREN, COORDINATED HEALTH SERVICES INC., GARDEN CITY RESCUE MISSION, SAVANNAH RIVER REMEDIATION, GOLDEN HARVEST FOOD BANK, AUGUSTA-RICHMOND COUNTY PUBLIC LIBRARY, MERCY MINISTRIES, WALTON OPTIONS FOR INDEPENDENT LIVING, SAFE HOMES AND SENIOR CITIZEN COUNCIL. REPRESENTATIVES FROM THESE ORGANIZATIONS WERE SENT AN EMAIL WITH THE LIST OF QUESTIONS FROM THE LISTENING SESSION AND INVITED TO PROVIDE FEEDBACK.IN ADDITION ON PAGE 53, UHS REACHED OUT TO 3257 PROVIDERS.WE INVITED PROVIDERS IN OUR COMMUNITY TO, "PLEASE TELL US ABOUT A RESOURCE YOU WISH WAS MORE ACCESSIBLE TO YOUR PATIENTS THAT WOULD HELP THEM ADDRESS THEIR HEALTH NEEDS." THE SURVEY WAS MADE ACCESSIBLE BY AN ONLINE SURVEY VENDOR. WE ACCESSED THE NAME, ADDRESS, AND TYPE OF PROVIDERS IN OUR COMMUNITY THROUGH THE CENTERS FOR MEDICARE AND MEDICAID SERVICES' NATIONAL PLAN AND PROVIDER ENUMERATION SYSTEM (NPPES). WE RESTRICTED THE SURVEY TO PHYSICIANS, MENTAL HEALTH PROVIDERS, AND PHARMACISTS. WE THEN MAILED AN INVITATION (FIGURE 38 ON PG 53) TO 3257 PROVIDERS THAT INCLUDED THE WEB ADDRESS OF THE SURVEY AND THE PROMISE OF A GIFT TO A RANDOMLY SELECTED RESPONDENT. UNIVERSITY HEALTH SERVICES INC PART V, SECTION B, LINE 6A: N/A UNIVERSITY HEALTH SERVICES INC PART V, SECTION B, LINE 6B: N/A UNIVERSITY HEALTH SERVICES INC PART V, SECTION B, LINE 11: SEE PAGE 4 OF IMPLEMENTATION STRATEGY HEART DISEASE & STROKE - EXPAND ADVANCED HEALTH FAILURE PROGRAM WITH OPERATIONAL IMPROVEMENTS AND NEW PROVIDERS: CONTINUE FREE HEART ATTACK AND STROKE CLASSESCANCER - OPEN NODULE CLINIC AND THORACIC SURGERY PROGRAM; CONTINUE CANCER GROUPS ; PHYSICIAN LEAD EDUCATION PRESENTATION & COMMUNITY SCREENINGS ARTHRITIS, OSTEOPOROSIS AND CHRONIC BACK CONDITIONS - EDUCATION ON BACK INJURY PREVENTION DIABETES - CONTINUE MONTHLY GROUPS AND EDUCATION SESSIONS NUTRITION AND WEIGHT STATUS - CONTINUE EATING WELL WITH KIM PROGRAM ON LOCAL TV AND EMAILACCESS TO HEALTH SERVICES - EXPAND PROMPT AND PRIMARY CARE AREAS; HEALTH U CALENDAR HEALTH LITERACY - HEALTHY U; EDUCATIONAL CLASSES, ETCAREAS THAT UHS WILL NOT FOCUS ON ARE:CHRONIC KIDNEY DISEASE - WHILE UH WILL CONTINUE TO TREAT KIDNEY DISEASE, WE COULD SUPPORT THIS AREA BETTER BY PLACING OUR EMPHASIS ON DIABETES, OBESITY, AND EDUCATION. RESPIRATORY DISEASE - UH WILL EMPHASIS EDUCATION; HOWEVER, THERE ARE OTHER PROVIDERS TO OFFER ASSISTANCE SUCH AS KOHL'S CARES AS WELL AS CHILDREN'S HOSPITAL OF GEORGIA MENTAL HEALTH - OTHER PROVIDERS HAVE MORE EXPERTISE IN THIS AREA; SUCH AS, AU'S PSYCHIATRY, SERENITY BEHAVIORAL HEALTH, LIGHTHOUSE CARE CENTER, AIKEN-BARNWELL MENTAL HEALTH CENTER, ETC. UNIVERSITY HEALTH SERVICES INC PART V, SECTION B, LINE 13B: ALSO USES ASSET TEST, REGARDLESS OF INCOME, TO DETERMINE ELIGIBILITY FOR FREE AND DISCOUNTED CARE. IN ADDITION THE HOSPITAL TAKES INTO CONSIDERATION BANKRUPCY AND FINANCIAL STANDING WHEN OFFERING DISCOUNTS ON PATIENT LIABILITY. USE ELECTRONIC ELIGIBILITY SYSTEM TO DETERMINE INDIGENT CARE. PART I, LINE 3C: IN ADDITION TO THE FPG, HOSPITAL MAY ALSO USE ASSET TEST, REGARDLESS OF INCOME, TO DETERMINE ELIGIBILITY FOR FREE AND DISCOUNTED CARE FOR THOSE INDIVIDUALS THAT DO NOT QUALIFY UNDER THE ELECTRONIC ELIGIBILITY SYSTEM OR THOSE WHO HAVE INSURANCE BUT HOSPITAL BILL IS CATASTROPHIC. IN ADDITION THE HOSPITAL TAKES INTO CONSIDERATION BANKRUPCY AND FINANCIAL STANDING WHEN OFFERING DISCOUNTS ON PATIENT LIABILITY. PART I, LINE 7: EXPLANATION OF COSTING METHODOLOGYUSED COST TO CHARGE RATIO CALCULATED USING WORKSHEET 2 --THE OPTIONAL WORKSHEETS PROVIDED TO ASSIST IN PREPARATION OF SCHEDULE H. PART II, COMMUNITY BUILDING ACTIVITIES: COLLABORATION WITH/SUPPORT OF COMMUNITY ORGANIZATIONS THROUGH SEVERAL SURROUNDING CHAMBERS OF COMMERCE.--- SEE PART II ABOVE. SEE PAGE 12 OF THE CHNA FOR THE LIST OF AGENCIES THAT UNIVERSITY WORKS WITH TO SUPPORT AND PROMOTE HEALTH IN OUR COMMUNITY. PART III, LINE 2: FOR RECEIVABLES ASSOCIATED WITH SELFPAY 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), UHS RECORDS PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS 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) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. RECOVERIES OF ACCOUNTS PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION TO THE PROVISION FOR BAD DEBT EXPENSE WHEN RECEIVED. PART III, LINE 3: UNIVERSITY PROVIDES ALL UNINSURED PATIENTS A DISCOUNT TO MATCH THE UNWEIGHTED AVERAGE OF DISCOUNT GIVEN TO COMMERCIAL AND MEDICARE PATIENTS . IN ADDITION UH USES ELECTRONIC ELIGIBILITY SYSTEM TO DETERMINE IF PATIENTS COULD QUALITY FOR INDIGENT STATUS AND THEN COMPARES DENIED PATIENTS WITH APPLICATIONS THE STATE DFCS SYSTEM. PLUS THE COLLECTIONS PERSONNEL WHEN CONTACTING PATIENTS WILL SEND PATIENT APPLICATIONS TO COMPLETE FOR A PERSONNAL REVIEW. HOWEVER, EVEN WITH THE ABOVE SOME PATIENTS MAY SLIP THROUGH---- THE ESTIMATED ASSUMES THE SAME % OF BAD DEBT EXPENSE TO TOTAL CHARGES IS THE SAME % OF PATIENTS THAT MAY SLIP THROUGH OUR PROCESSES AND NOT GET CLAIMED AS INDIGENT.BAD DEBT SHOULD BE INCLUDED AS A COMMUNITY BENEFIT SINCE THE SERVICES THAT INCUR BAD DEBT ARE PROVIDED BY THE HOSPITAL TO PROMOTE THE WELL-BEING OF THE COMMUNITY. THESE SERVICES ARE RENDERED IN CONJUNCTION WITH THE HOSPITAL'S CHARITABLE TAX-EXEMPT PURPOSES. THERE IS NO LOCAL SUPPORT FOR UNINSURED PATIENTS; THEREFORE, THE SERVICES PROVIDED BY THE HOSPITAL RELIEVE THE HEALTH CARE BURDENS OF THE LOCAL GOVERNMENTS. PART III, LINE 4: PAGE 9 OF THE AUDITED FINANCIAL STATEMENTSALLOWANCE FOR UNCOLLECTIBLE ACCOUNTSTHE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS, CONSIDERING BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTION INDICATORS. PERIODICALLY, MANAGEMENT ASSESSES THE ADEQUACY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON HISTORICAL WRITE-OFF EXPERIENCE BY PAYOR CATEGORY. THE RESULTS OF THIS REVIEW ARE THEN USED TO MAKE ANY MODIFICATIONS TO THE PROVISION FOR BAD DEBTS TO ESTABLISH AN APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. THE CORPORATION'S ALLOWANCE FOR DOUBTFUL ACCOUNTS WAS 81% AND 78% OF SELF-PAY ACCOUNTS RECEIVABLE AND PATIENT LIABILITY PORTION OF OTHER ACCOUNTS AT DECEMBER 31, 2016 AND 2015, RESPECTIVELY. PART III, LINE 8: EXPLANATION OF SHORTFALL AS COMMUNITY BENEFITTHE SERVICES PROVIDED TO THE MEDICARE BENEFICIARIES ARE TO PROMOTE THE WELL-BEING OF THE COMMUNITY WHICH IS PART OF THE HOSPITAL'S CHARITABLE TAX-EXEMPT PURPOSE. THE MEDICARE DIFFERENCE BETWEEN COST AND MEDICARE REIMBURSEMENT SHOULD BE ALLOWED AS COMMUNITY BENEFIT SINCE PROVIDERS CANNOT NEGOTIATE RATES WITH CENTERS FOR MEDICARE/MEDICAID SERVICES (CMS). CMS REGULATES THAT THE REIMBURSEMENT BE FEDERAL BUDGET NEUTRAL THUS PLACING THE COST OF THE CARING FOR MEDICARE BENEFICIARIES AS A COST TO THE HOSPITALS. PART III, LINE 9B: PROVISIONS ON COLLECTION PRACTICES FOR QUALIFIED PATIENTSAS OUTSTANDING BALANCES AGE, STATEMENT MESSAGES, COLLECTION LETTERS AND/OR TELEPHONE CALLS MAY BE USED AT APPROPRIATE INTERVALS DETERMINED BY THE PATIENT ACCOUNTING/COLLECTION DEPARTMENT. THE PATIENT ACCOUNTING/COLLECTION DEPARTMENT RECOGNIZES THAT THERE ARE OCCASIONS WHEN A PATIENT IS NOT FINANCIALLY ABLE TO PAY HIS OR HER MEDICAL BILL IN FULL AND/OR THE PATIENT IS EXPERIENCING FINANCIAL HARDSHIP. THE HOSPITAL HAS ESTABLISHED A CATASTROPHIC POLICY WHICH ALLOWS FOR THE COLLECTION DEPARTMENT TO APPLY THE INDIGENT CRITERIA AND WRITE-OFF AS MEDICALLY INDIGENT. AND AT ANY POINT DURING THE COLLECTION PROCESS IF A PATIENT STATES OR PATIENT ACCOUNTING/COLLECTIONS BELIEVES THAT THE PATIENT CANNOT AFFORD TO PAY, THEN AN INDIGENT/CHARITY CARE APPLICATION IS BEGUN BY THE COLLECTION DEPARTMENT WHERE DISCOUNTS MAY BE GIVEN. PART VI, LINE 2: NEEDS ASSESSMENTIN ADDITION TO THE CHNA PERFORMED IN 2016, UH WORKS WITH ER PERSONNEL TO IDENTIFY NEEDS BASED ON PATIENTS SEEKING HELP THROUGH THE EMERGENCY ROOM. THIS PROCESS STILL SHOWS THAT PATIENTS NEED A MEDICAL HOME, ASTHMA, CHF & DIABETES ASSISTANCE. THE PROGRAMS THAT UH HAS INITIATED AND CONTINUE TO SUPPORT. UH ALSO USED THE HEALTHY PEOPLE 2020 FRAMEWORK TO GUIDE DATA GATHERING FOR LEADING HEALTH INDICATORS. PART VI, LINE 3: UH HAS THE FOLLOWING INFORMATION AVAILABLE TO PATIENTS AND VISITORS ON THE ELIGIBILITY FOR ASSISTANCE. INFORMATION IS AVAILABLE ON THE UNIVERSITY HOSPITAL WEB SITE, PATIENT/VISITOR INFORMATION BOOKLET, AND UH HAS SIGNAGE AT REGISTRATION AND BILLING AREAS THAT ASK "... HELP WITH YOUR HOSPITAL BILL?" IN ADDITION, WHEN A REGISTERING PATIENT INDICATES THAT HE/SHE CAN NOT AFFORD TO PAY, UH WILL OFFER THE INDIGENT AND CHARITY CARE APPLICATION (ICCP) AND SET UP PATIENT TO SPEAK WITH THE FINANCIAL ASSISTANCE OFFICE (FAO). FAO WILL DIRECT PATIENTS TO A DEPARTMENT OF FAMILY AND CHILDREN (DFCS) CASE MANAGER LOCATED AT THE HOSPITAL TO SEE IF PATIENT QUALIFIES FOR STATE MEDICAID OR THE UH ICCP PROGRAM. THE PATIENT MAY BE DEEMED TO QUALIFY FOR OTHER STATE/FEDERAL ASSISTANCE IN WHICH THE FAO STAFF WILL HELP DIRECT THE PATIENT TO ANOTHER GROUP OPERATED OUT OF THE HOSPITAL, RESOURCE CORPORATION OF AMERICA (RCA), TO ASSIST WITH GETTING THE PATIENT QUALIFIED FOR SSI, ETC. PART VI, LINE 4: SEE PAGE 6-13 OF THE CHNAUNIVERSITY HEALTH CARE SYSTEM SERVES A DIVERSE COMMUNITY. AIKEN COUNTY HAS MORE RESIDENTS 65 AND OLDER; COLUMBIA COUNTY HAS MORE RESIDENTS BETWEEN 5 AND 17; RICHMOND COUNTY HAS MORE RESIDENTS UNDER 5 YEARS OLD. RICHMOND COUNTY IS VERY DIFFERENT RACIALLY AND ETHNICALLY FROM AIKEN COUNTY AND COLUMBIA COUNTY. WHILE AIKEN AND COLUMBIA COUNTIES HAVE SOME SIMILARITIES IN RACE AND ETHNIC ORIGINS, AIKEN COUNTY HAS FEWER COLLEGE GRADUATES AND HAS MORE POVERTY. RICHMOND COUNTY HAS EVEN FEWER GRADUATES AND AN EVEN HIGHER LEVEL OF POVERTY.RICHMOND COUNTY HAS MORE CHILDREN UNDER 5 YEARS OLD THAN ITS NEIGHBORS AND MORE THAN THE AVERAGE IN GEORGIA, SOUTH CAROLINA, AND THE UNITED STATES. AIKEN COUNTY HAS MORE PERSONS 65 YEARS AND OLDER THAN ALL OTHER GROUPS IN OUR COMPARISON. COLUMBIA COUNTY HAS MORE PERSONS BETWEEN 5 AND 17 YEARS OLD. THIS IS AN ESTIMATE OF THE POPULATION IN 2014.RICHMOND COUNTY HAS FEWER FOREIGN-BORN RESIDENTS AND SPEAKERS OF A LANGUAGE OTHER THAN ENGLISH AT HOME THAN THE REST OF THE NATION, GEORGIA, OR SOUTH CAROLINA IN GENERAL. IT HAS FEWER COLLEGE GRADUATES AND A HIGH DEGREE OF POVERTY. AIKEN COUNTY IS SIMILAR TO RICHMOND COUNTY IN THE PERCENTAGE OF FOREIGN-BORN RESIDENTS AND SPEAKERS OF A LANGUAGE OTHER THAN ENGLISH AT HOME. HOWEVER, IT HAS A HIGHER PERCENTAGE OF COLLEGE GRADUATES AND A LOWER LEVEL OF POVERTY. COLUMBIA COUNTY IS MORE DIVERSE, HAVING A HIGHER PERCENTAGE OF FOREIGN-BORN RESIDENTS AND SPEAKERS OF A LANGUAGE OTHER THAN ENGLISH AT HOME. IT ALSO HAS A HIGHER PERCENTAGE OF COLLEGE GRADUATES AND A LOWER LEVEL OF POVERTY.UNIVERSITY HEALTH CARE SYSTEM SERVES A DIVERSE COMMUNITY. AIKEN COUNTY HAS MORE RESIDENTS 65 AND OLDER; COLUMBIA COUNTY HAS MORE RESIDENTS BETWEEN 5 AND 17; RICHMOND COUNTY HAS MORE RESIDENTS UNDER 5 YEARS OLD. RICHMOND COUNTY IS VERY DIFFERENT RACIALLY AND ETHNICALLY FROM AIKEN COUNTY AND COLUMBIA COUNTY. WHILE AIKEN AND COLUMBIA COUNTIES HAVE SOME SIMILARITIES IN RACE AND ETHNIC ORIGINS, AIKEN COUNTY HAS FEWER COLLEGE GRADUATES AND HAS MORE POVERTY. RICHMOND COUNTY HAS EVEN FEWER GRADUATES AND AN EVEN HIGHER LEVEL OF POVERTY. PART VI, LINE 5: UH GOVERNING BOARD MEMBERS ARE COMPRISED OF CITIZENS WHO RESIDE IN THE UH'S PRIMARY SERVICE AREA AND ARE NEITHER EMPLOYEES NOR CONTRACTORS OF UH. UH BOARD MEMBERS ARE ACTIVE IN THE COMMUNITY AND ARE EAGER TO IMPROVE THE HEALTH AND WELFARE OF THE COMMUNITY. SEVERAL OF UH BOARD MEMBERS WORKED WITH THE LOCAL STATE MEDICAL SCHOOL TO GET INTERNS & RESIDENTS AT THE HOSPITAL SINCE UH IS AMONG SEVERAL COUNTIES THAT HAVE BEEN DEEMED AS A HEALTH PROFESSIONAL SHORTAGE AREA (HPSA). UH EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN OUR COMMUNITY FOR ALL OF THE UH DEPARTMENTS.UH WORKS WITH THE GREATER AUGUSTA HEALTHCARE NETWORK (GAHN) WHICH IS MADE UP OF AREA HOSPITALS AND THE LOCAL MEDICAL COLLEGES SCHOOL OF NURSING AND AREA PRIMARY CARE CLINICS. THIS GROUP ADDRESSES THE PRIMARY AND SPECIALTY CARE NEEDS IN THE COMMUNITY. UH SUPPORTS THE PROJECT ACCESS PROGRAM (PJA) IN RICHMOND AND COLUMBIA COUNTY. PJA IS A PROGRAM WHEREBY THE LOCAL MEDICAL SOCIETY PHYSICIANS AGREE TO TREAT A NUMBER OF INDIGENT COUNTY RESIDENTS WITHOUT PAYMENT. UH PROVIDES ALL OF THE INPATIENT HOSPITALIZATION FOR THE INDIGENT POPULATION THAT IS APPROVED FOR PROJECT ACCESS. THROUGH BOTH OF THESE GROUPS UH IS RESPONSIVE TO SUPPORT THEM IN THEIR NEEDS. PART VI, LINE 7, REPORTS FILED WITH STATES GA 1 CHRIST COMMUNITY HEALTH SERVICES 519 SCOTTS WAY AUGUSTA GA 30909 205404353 501(C)(3) 553800 229307 MEDICARE COST REPORT DONATED FACILITIES CLINIC FINANCIAL SUPPORT NEIGHBORHOOD IMPROVEMENT PROJECT 2467 GOLDEN CAMP ROAD AUGUSTA GA 30906 311491242 501(C)(3) 180000 CLINIC FINANCIAL SUPPORT COORDINATED HEALTH SERVICES 2110 BROAD STREET AUGUSTA GA 30904 582060572 501(C)(3) 140000 9558 COST OF LAB TESTS LAB TESTS CLINIC FINANCIAL SUPPORT MIRACLE MAKING MINISTRIES 1127 DRUID PARK AVE AUGUSTA GA 30904 582358627 501(C)(3) 40000 CLINIC FINANCIAL SUPPORT BEULAH GROVE COMMUNITY RESOURCE 1446 LEE BEARD WAY AUGUSTA GA 30904 582159621 501(C)(3) 40000 30981 COST EPIC CLINICAL SYSTEM & LAB TESTS CLINIC FINANCIAL SUPPORT AMERICAN CANCER SOCIETY 250 WILLIAMS STREET NW ATLANTA GA 30303 131788491 501(C)(3) 5000 FINANCIAL SUPPORT THE FAMILY Y 3570 WHEELER ROAD AUGUSTA GA 30909 580566254 501(C)(3) 10000 FINANCIAL SUPPORT UNITED WAY 1765 BROAD STREET AUGUSTA GA 30904 580566155 501(C)(3) 5000 FINANCIAL SUPPORT 8 0 PART I, LINE 2: UNIVERSITY HEALTH CARE SYSTEM DOES NOT PROVIDE "GRANTS" TO ASSIST OTHER ORGANIZATIONS, BUT DOES DONATE FUNDS BASED ON THE FOLLOWING POLICY AND PROCEDURES: POLICY: UNIVERSITY HEALTH CARE SYSTEM IS COMMITTED TO THE OVERALL HEALTH AND WELL-BEING OF THE COMMUNITIES IT SERVES AND RECOGNIZES THE NEED TO SUPPORT OTHER NON-PROFIT ORGANIZATIONS WHO SHARE THIS COMMITMENT. CORPORATE CONTRIBUTIONS AND SPONSORSHIPS ARE SOMETIMES AN APPROPRIATE VEHICLE FOR BUILDING PARTNERSHIPS WITH THESE NON-PROFIT ORGANIZATIONS AND MAXIMIZING OUR OVERALL POSITIVE IMPACT ON THE COMMUNITY. PROCEDURE 1. ALL CONTRIBUTION/SPONSORSHIP REQUESTS SHOULD BE SUBMITTED IN WRITING TO THE CORPORATE COMMUNICATIONS DEPARTMENT FOR CONSIDERATION. EVERY EFFORT SHOULD BE MADE TO PROCESS THESE REQUESTS AND NOTIFY THE REQUESTER WITHIN TWO WEEKS OF RECEIVING THE WRITTEN INFORMATION REQUIRED TO EVALUATE THE OPPORTUNITY. 2. IN CONSULTATION WITH THE CEO, THE DIRECTOR OF CORPORATE COMMUNICATIONS WILL PREPARE THE ANNUAL BUDGET FOR CORPORATE CONTRIBUTIONS/SPONSORSHIPS AND PROCESS/MANAGE ACTUAL DISBURSEMENTS DURING THE YEAR. 3. REQUESTS WILL BE EVALUATED BASED ON THE FOLLOWING CRITERIA: A. DOES THE ORGANIZATION, EVENT OR PUBLICATION PROMOTE THE OVERALL HEALTH AND WELL-BEING OF THE COMMUNITIES WE SERVE? SPECIAL CONSIDERATION WILL BE GIVEN TO REQUESTS THAT DIRECTLY IMPACT HEALTH AND WELLNESS EVEN THOUGH SUPPORT MAY BE AVAILABLE FOR ORGANIZATIONS, EVENTS AND/OR PUBLICATIONS THAT HAVE A POSITIVE IMPACT ON THE CSRA BY: "ASSISTING IN ATTRACTING AND RETAINING A VIABLE WORK-FORCE" "ASSISTING IN ATTRACTING AND RETAINING VIABLE BUSINESSES AND EMPLOYERS IN THE CSRA" "PROMOTING THE CONTINUED GROWTH AND ECONOMIC WELL-BEING OF THE COMMUNITY" "ENHANCING THE QUALITY OF LIFE IN THE CSRA" B. DOES THE PROPOSED CONTRIBUTION/SPONSORSHIP PRIMARILY ASSIST PEOPLE LIVING LOCALLY RATHER THAN A NATIONAL EFFORT/INITIATIVE? C. DOES THE REQUESTING ORGANIZATION HAVE AN APPROVED TAX-EXEMPT STATUS? D. WILL THE PROPOSED CONTRIBUTION/SPONSORSHIP ENHANCE THE OVERALL IMAGE/REPUTATION OF UNIVERSITY HEALTH CARE SYSTEM? E. WILL THE PROPOSED CONTRIBUTION/SPONSORSHIP HEIGHTEN AWARENESS OF A SIGNIFICANT HEALTH ISSUE OR DISEASE THAT HAS A NEGATIVE IMPACT ON THE CITIZENS IN THE COMMUNITIES WE SERVE? 4. UNDER NO CIRCUMSTANCES WILL CONTRIBUTIONS BE MADE TO POLITICAL CAMPAIGNS. 5. BECAUSE OF THE LARGE NUMBER OF PUBLIC AND PRIVATE SCHOOLS IN THE CSRA, UNIVERSITY WILL LIMIT FINANCIAL SUPPORT/CONTRIBUTIONS TO THE VARIOUS BOARDS OF EDUCATION RATHER THAN INDIVIDUAL SCHOOLS (ELEMENTARY, MIDDLE, AND HIGH SCHOOLS). 6. BECAUSE OF THE LARGE NUMBER OF CHURCHES IN THE CSRA, UNIVERSITY WILL LIMIT FINANCIAL SUPPORT/CONTRIBUTIONS TO PROGRAMS THAT INCLUDE HEALTH-RELATED SERVICES FOR UNDERSERVED RESIDENTS SUCH AS COMMUNITY CLINICS. 7. EXCEPTION: FINANCIAL SUPPORT AND PARTNERSHIPS WITH AREA COLLEGES AND TECHNICAL SCHOOLS DO NOT FALL UNDER THIS POLICY. X 1 1 X X X X X 0 1 0 0 0 1 0 0 0 DANIEL H BOONE MD BOARD MEMBER 0 239073 0 16500 0 11046 0 5984 0 7263 0 279866 0 0 DAVID A BELKOSKI UHS CFO 408205 0 117635 0 79535 0 1357 0 13501 0 620233 0 0 0 JAMES R DAVIS UHS PRESIDENT & CEO 701188 0 202708 0 61950 0 290011 0 14196 0 1270053 0 0 0 MARILYN A BOWCUTT PRESIDENT OF UNIVERSITY HO 423429 0 124180 0 112364 0 7516 0 9188 0 676677 0 0 0 WILLIAM L FARR CMO 376203 0 109053 0 51766 0 7930 0 13671 0 558623 0 0 0 EDWARD L BURR SR. VP LEGAL & REGULATORY 366310 0 107824 0 79336 0 7981 0 15724 0 577175 0 0 0 SANDRA MCVICKER CEO UNIVERSITY HOSPITAL MC 6629 0 65000 0 143207 0 0 0 4382 0 219218 0 0 0 LAURIE OTT SMITH UHCF-VP HR & COMM SVC 234144 0 70844 0 53091 0 5972 0 7641 0 371692 0 0 0 THOMAS E LOWENCAMP VP - CONTINUING CARE 237138 0 0 0 33270 0 7322 0 19229 0 296959 0 0 0 SHIRLEY K GABRIEL VP CHIEF INFORMATION OFFIC 271819 0 75115 0 34646 0 6648 0 12140 0 400368 0 0 0 TERESA BUSCHBACHER VP -HVI 165712 0 40297 0 624 0 5514 0 8947 0 221094 0 0 0 LYNDA JONES WATTS VP PATIENT CARE SVCS/CNO 243943 0 71468 0 49203 0 7165 0 18001 0 389780 0 0 0 SCOTT ANSEDE VP PROFESSIONAL SERVICES 279641 0 79059 0 38009 0 7995 0 16900 0 421604 0 0 0 ELIZABETH R GALLUP VP CLINICAL OPERATIONS 181034 0 36319 0 1797 0 5638 0 11571 0 236359 0 0 0 ROBERT J KEPSHIRE ADMINISTRATIVE CNO - MCDUFFIE 174911 0 8075 0 1845 0 5296 0 5041 0 195168 0 0 0 JOHN C POPE PA ECHO CLINICAL PROG COOR 177030 0 4328 0 11420 0 761 0 8947 0 202486 0 0 0 LISA RITCH CORPORATE CONTROLLER 153492 0 15850 0 7347 0 4800 0 7588 0 189077 0 0 0 JACKIE KENDINGER EMPLOYEE 173715 0 8013 0 635 0 5474 0 0 0 187837 0 0 0 DOUGLAS D PUGH II RN 178581 0 4140 0 5063 0 3095 0 14370 0 205249 0 0 0 PART I, LINE 1A SOCIAL CLUB DUES- THE RELATED ORGANIZATION PAYS MEMBERSHIP FEES FOR THE CEO (JAMES DAVIS) TO SAGE VALLEY AND THE AUGUSTA COUNTRY CLUB. THESE MEMBERSHIP FEES ARE PAID SO THE ORGANIZATION CAN HAVE ACCESS TO THE MEETING FACILITIES AND CATERING SERVICES THESE ORGANIZATIONS PROVIDE FOR MEETINGS THAT ARE HELD OFF CAMPUS. ANY PERSONAL USE, RELATED TO THESE MEMBERSHIPS, IS INCLUDED IN THE WAGES OF THE CEO. PART I, LINE 4B JAMES R DAVIS - SERP - $282,006 DAVID A BELKOSKI - ROTH IUL - $76,447 MARILYN A BOWCUTT - CAA BENEFITS - $71,570 WILLIAM L FARR - CAA BENEFITS - $42,656 EDWARD L BURR - CAA REDEMPTION - $75,554 SANDRA MCVICKER - ROTH IUL - $12,500 LAURIE OTT SMITH - ROTH IUL - $29,409 - SECT 162 - $2,541 SHIRLEY K GABRIEL - ROTH IUL - $27,000 - SECT 162 - $7,036 LYNDA JONES WATTS - ROTH IUL - $24,228 - SECT 162 - $4,779 SCOTT ANSEDE - ROTH IUL - $28,500 - SECT 162 - $6,626 TOM LOWENCAMP - ROTH IUL - $20,416 - SECT 162 - $3,964 PLEASE NOTE THAT ALL OF THE BENEFITS LISTED ABOVE ARE INCLUDED IN THE TOTALS REPORTED ON FORM 990, SCHEDULE VII AS REPORTABLE COMPENSATION OR OTHER COMPENSATION AND HAVE BEEN INCLUDED IN THE INDIVIDUALS W-2, WITH THE EXCEPTION OF THE SERP FOR JAMES R DAVIS. PART I, LINE 6 THE BONUS PLAN FOR MANAGEMENT IS CALCULATED BASED ON STRATEGIC INITIATIVES AS DETERMINED BY THE COMPENSATION COMMITTEE. THESE INITIATIVES ARE GOALS THAT MUST BE ACHIEVED DURING THE YEAR IN ORDER FOR BONUS PAYOUT. FOR 2016 THESE INITIATIVES WERE WEIGHTED AS DISPLAYED IN THE FOLLOWING SCHEDULE: UNIVERSITY HEALTH SERVICES, INC 2016 STRATEGIC INITIATIVES WEIGHT QUALITY 15% ACHIEVE NRC OVERALL RATING OF CARE SCORE 15% ACHIEVE AGGREGATE COMPOSITE CORE MEASURE SCORE FOR THE 2016 CORE MEASURE SET GROWTH 10% INCREASE ADMISSIONS FROM AIKEN AND COLUMBIA COUNTIES OVER 2015 LEVELS SAFETY 15% MINIMIZE THE NUMBER OF HOSPITAL ACQUIRED CONDITIONS PER 1000 DISCHARGES PEOPLE 15% ACHIEVE EMPLOYEE TURNOVER RATE FOR UHS AFFORDABILITY 25% ACHIEVE OPERATING MARGIN FOR UNIVERSITY HEALTH, INC SERVICE 5% INCREASE THE NUMBER OF ACTIVE MYCHART ACCOUNTS 100% EACH GOAL THAT WAS ACHIEVED REPRESENTED THAT PERCENTAGE OF BONUS PAYOUT OUT OF A POSSIBLE 100% BASED ON A THRESHOLD LEVEL, TARGET LEVEL, OR AN EXCEED LEVEL. A THE RICHMOND COUNTY HOSPITAL AUTHORITY 586001901 764603BV7 2016-10-25 154488348 REFUND BOND CERTIFICATES (SERIES 2009) 0 0 0 A 154488348 1658616 152829732 2016 0 1 1 1 A 0 1 1 1 1 1 0.02700 0.00200 0.02900 0 0 0 A 1 0 0 0 0 0 A 0 NATALIE H THOMPSON DAUGHTER OF BOARD MEMBER 13507 EMPLOYEE COMP AS RN 0 FORM 990, PART VI, SECTION A, LINE 1 IN JANUARY 1985, THE FULL BOARD APPROVED THE FORMATION OF AN EXECUTIVE BOARD BY PASSING THE FOLLOWING RESOLUTION: BE IT RESOLVED THAT AN EXECUTIVE COMMITTEE OF UNIVERSITY HEALTH SERVICES, INC. BE CREATED TO MEET ON A ROUTINE BASIS, SUCH COMMITTEE BEING COMPOSED OF SEVEN MEMBERS. THE SIZE OF THE COMMITTEE MAY BE CHANGED FROM TIME TO TIME BY THE CHAIRMAN OF THE BOARD BUT MUST ALWAYS CONFORM TO THE BYLAWS. THE TASKS OF THE COMMITTEE SHALL CONSIST OF PLANNING, CAPITAL EXPENDITURE REVIEW, AND FINANCIAL REVIEW OF THE ACTIVITIES OF UNIVERSITY HEALTH SERVICES, INC. THE EXECUTIVE COMMITTEE MAY ACT ON BEHALF OF UNIVERSITY HEALTH SERVICES, INC AND ON BUDGETED CAPITAL REQUESTS; HOWEVER, ALL CAPITAL REQUESTS IN EXCESS OF $500,000 MUST BE ACTED ON BY THE FULL BOARD OF TRUSTEES. FORM 990, PART VI, SECTION B, LINE 11B A COPY OF FORM 990 AND ALL RELATED SCHEDULES WAS PROVIDED TO THE GOVERNING BOARD BEFORE FILING IN ELECTRONIC FORM. AN EMAIL WAS SENT TO ALL MEMBERS OF THE GOVERNING BODY CONTAINING A LINK TO A PASSWORD-PROTECTED WEBSITE ON WHICH THE ENTIRE 990 COULD BE VIEWED. THE EMAIL EXPLAINED THAT THE FORM 990 WAS AVAILABLE FOR REVIEW ON THE WEBSITE. FORM 990, PART VI, SECTION B, LINE 12C THE STEPS IN THE CONFLICT OF INTEREST POLICY ARE OUTLINED BELOW: 1. SENIOR MANAGEMENT (VICE PRESIDENTS AND ABOVE) SHALL COMPLETE A POTENTIAL CONFLICT OF INTEREST QUESTIONNAIRE PERIODICALLY. EACH SYSTEM ORGANIZATION'S CEO, COO, CFO AND WITHIN THEIR DIVISION'S VICE PRESIDENTS MAY REQUIRE ANY EMPLOYEE TO COMPLETE A POTENTIAL CONFLICT OF INTEREST QUESTIONNAIRE. 2.EACH EMPLOYEE IS EXPECTED TO REPORT A POTENTIAL CONFLICT OF INTEREST WHEN IT ARISES. 3. A. AN EMPLOYEE WILL REPORT A POTENTIAL CONFLICT OF INTEREST BY INITIATING A POTENTIAL CONFLICT OF INTEREST DISCLOSURE FORM AND DELIVERING IT TO HIS/HER VICE PRESIDENT. ALL EMPLOYEE POTENTIAL CONFLICTS WILL BE SCREENED BY TWO LEVELS OF SENIOR MANAGEMENT TO IDENTIFY CONFLICT OR DUALITY OF INTEREST SITUATIONS. (A DUALITY OF INTEREST EXISTS WHEN AN INDIVIDUAL HAS PERSONAL OR OUTSIDE INTERESTS THAT CAN BE AFFECTED BY DECISIONS OF THE SYSTEM. SUCH A DUALITY OR EVEN MULTIPLICITY OF INTEREST CAN BE BENEFICIAL TO AND CONSISTENT WITH THE PRIMARY GOALS OF THE INSTITUTIONS. DUALITY OF INTEREST CAN RAISE THE POTENTIAL FOR CONFLICT OF INTEREST WHEN THE PERSONAL INTERESTS OF INDIVIDUALS COME INTO CONFLICT WITH THE INTERESTS OF THE SYSTEM.) B. WHEN A DIVISION VICE PRESIDENT IS NOTIFIED OF A POTENTIAL CONFLICT/DUALITY OF INTEREST, THE VICE PRESIDENT SHALL INVESTIGATE THE SITUATION AND MAKE A REPORT OF HIS OR HER FINDINGS ALONG WITH A RECOMMENDATION TO THE EXECUTIVE VICE PRESIDENT (COO) OR CEO OF THE INVOLVED SYSTEM ORGANIZATION. C. THE EXECUTIVE VICE PRESIDENT OR CEO WHO RECEIVED THE 3.B REPORT SHALL MAKE A DECISION CONCERNING A POTENTIAL CONFLICT OF INTEREST AND ANY RESOLUTION MEASURES TO BE TAKEN. IN THE EVENT THE POTENTIAL CONFLICT INVOLVES A VICE PRESIDENT, THE PRESIDENT OF UNIVERSITY HEALTH SHALL INVESTIGATE THE SITUATION AND MAKE A DECISION CONCERNING A POTENTIAL CONFLICT OF INTEREST AND ANY RESOLUTION MEASURES TO BE TAKEN. THIS INFORMATION SHALL BE COMMUNICATED DIRECTLY TO THE CONCERNED EMPLOYEE. D. THE EMPLOYEE MAY APPEAL THE CONFLICT OF INTEREST DETERMINATION TO THE PRESIDENT OF UNIVERSITY HEALTH. THE PRESIDENT'S DECISION ABOUT A POTENTIAL CONFLICT OF INTEREST AND ANY RESOLUTION MEASURES IS FINAL AND NOT COGNIZABLE UNDER THE EMPLOYEE GRIEVANCE POLICY A-30. E. IN THE EVENT THE POTENTIAL CONFLICT INVOLVES THE CEO OF A SYSTEM ORGANIZATION, THE MATTER SHALL BE REPORTED TO THE CHAIRMAN OF THE INVOLVED SYSTEM ORGANIZATION BOARD, WHO SHALL DETERMINE IF A CONFLICT EXISTS AND WHAT, IF ANY, RESOLUTION MEASURES ARE NECESSARY IN ACCORDANCE WITH THE CORPORATION'S CONFLICT OF INTEREST POLICY. 4. FILING OF FORMS A. CONFLICT OF INTEREST QUESTIONNAIRES OF THOSE WHO ARE REQUIRED BY THIS POLICY TO COMPLETE ONE PERIODICALLY SHALL BE FILED IN THE APPLICABLE CORPORATION'S CEO'S OFFICE AND RETAINED FOR NO LESS THAN SEVEN YEARS. OPTIONAL CONFLICT OF INTEREST QUESTIONNAIRES SHALL BE FILED IN THE OFFICE OF THE VICE PRESIDENT WHO REQUESTED COMPLETION OF THE FORM. B. COMPLETED POTENTIAL CONFLICT OF INTEREST DISCLOSURE FORMS SHALL BE FILED IN THE APPLICABLE CORPORATION'S CEO'S OFFICE FOR THE CEO, COO, AND VICE PRESIDENTS AND FOR ALL OTHERS IN THE APPROPRIATE VICE PRESIDENT'S OFFICE. THE FORMS SHOULD BE RETAINED FOR NO LESS THAN SEVEN YEARS. 5. THE VICE PRESIDENT FOR LEGAL AFFAIRS WILL BE AVAILABLE TO ADVISE ON POTENTIAL CONFLICT OF INTEREST MATTERS. BOARD MEMBERS: BOARD MEMBERS ARE ALSO REQUIRED TO COMPLETE A POTENTIAL CONFLICT OF INTEREST QUESTIONNAIRE ANNUALLY. THIS QUESTIONNAIRE ASKS FOR DISCLOSURES RELATED TO ANY FAMILY RELATIONSHIPS OR BUSINESS RELATIONSHIPS WITH OTHER BOARD MEMBERS, OR BUSINESS RELATIONSHIPS WITH THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION FOLLOWS THE PROCESS DESCRIBED IN TREASURY REGULATION 53.4958-6(C) FOR ESTABLISHING THE REBUTTABLE PRESUMPTION OF REASONABLENESS IN THE REVIEW, APPROVAL, AND DOCUMENTATION OF ANY OFFICER, KEY MANAGEMENT, AND DIRECTOR COMPENSATION. ANNUALLY, A COMPENSATION COMMITTEE OF THE UNIVERSITY HEALTH SERVICES (UHS) BOARD COMPRISED OF THREE INDEPENDENT BOARD MEMBERS, REVIEWS THE COMPENSATION OF THE CEO AND OTHER SENIOR MANAGEMENT MEMBERS. THE REVIEW IS CONDUCTED IN THE CONTEXT OF A BOARD APPROVED EXECUTIVE COMPENSATION PHILOSOPHY. BOTH THE DEVELOPMENT OF THE COMPENSATION PHILOSOPHY AND THE REVIEWS INVOLVE THE ADVICE AND ASSISTANCE OF AN INDEPENDENT COMPENSATION CONSULTING FIRM. MINUTES OF THE COMPENSATION ARE RECORDED. THE COMPENSATION COMMITTEE REPORTS TO THE UHS BOARD EXECUTIVE COMMITTEE. FORM 990, PART VI, SECTION C, LINE 19 ALL GOVERNING DOCUMENTS, POLICIES, FINANCIAL STATEMENTS, AND INFORMATIONAL RETURNS ARE AVAILABLE UPON REQUEST FROM THE ADMINISTRATION OFFICE. FORM 990, PART XI, LINE 9: CHANGE IN UNFUNDED PENSION GAINS 78,990,769. OTHER CUMULATIVE EFFECT ON ASSET RETIREMENT OBLIGATIONS -1,858,093. TRANSFER TO AFFILIATE -27,986,141. PTP INVESTMENT - UBTI NOT ON BOOKS -11,713. LOSS ON EARLY EXTINGUISHMENT OF DEBT -16,385,954. LOSS ON PENSION TERMINATION -100,680,185. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. WALTON WAY INDEMNITY SPC 2ND FL GOVERNORS SQ 23 LIME TREE WEST BAY GRAND CAYMAN CJ INSURANCE CAPTIVE CJ 2211442 28423294 UNIVERSITY HEALTH SERVICES INC UNIVERSITY EXTENDED CARE INC 1350 WALTON WAY AUGUSTA GA 30901 581581105 SKILLED NURSING HOMES GA 501(C)(3) 3 UNIVERSITY HEALTH INC 0 RICHMOND COUNTY HOSPITAL AUTHORITY 1350 WALTON WAY AUGUSTA GA 30901 586001901 LEASED FACILITIES GA 501(C)(3) 3 N/A 0 AUGUSTA RESOURCE CENTER ON AGING I 4275 OWENS ROAD EVANS GA 30809 581728812 NON PROFIT LIFE CARE COMMUNITY GA 501(C)(3) 9 UNIVERSITY HEALTH INC 0 UNIVERSITY HEALTH CARE FOUNDATION 2100 CENTRAL AVENUE SUITE D-1 AUGUSTA GA 30904 581343550 PHILANTHROPY GA 501(C)(3) 7 UNIVERSITY HEALTH INC 0 UNIVERSITY HEALTH INC 1350 WALTON WAY AUGUSTA GA 30901 581581102 CONSOLIDATING PARENT GA 501(C)(3) 9 N/A 0 UNIVERSITY MCDUFFIE COUNTY REGIONAL 1350 WALTON WAY AUGUSTA GA 30901 454166209 HOSPITAL GA 501(C)(3) 3 UNIVERSITY HEALTH INC 0 UNIVERSITY HEALTH RESOURCES INC 1350 WALTON WAY AUGUSTA GA 30901 581601372 SVC TO PHYSICIANS GA UNIVERSITY HEALTH INC C 0 UNIVERSITY HOSPITAL AIKEN INC 1350 WALTON WAY AUGUSTA GA 30901 472713774 HOSPITAL SC UNIVERSITY HEALTH INC C 0 0 0 0 1 1 0 0 0 0 1 0 1 0 0 1 0 0 0 0