2017-11-14T16:31:50-06:00 2016-12-31 ERNST & YOUNG US LLP 800 YARD ST SUITE 200 GRANDVIEW HTS OH 43212 990 2016-01-01 237296923 Good Samaritan Hospital Foundation - Dayton % J MICHAEL SIMS GOOD 9374999942 110 N MAIN ST Suite 500 Dayton OH 45402 KATIE MCKEE TREASURER 9374999942 2017-11-07 true DIANE L BEAN P00104972 6142245678 208.102.97.33 31499120173185000018 2017-11-14 P 582F47EFACDD6166E52205D1FBFEA2601660FA18 8EFF0C77748B9BD402565CEF41270569F54FE33A 2016 2021-01-29 14:40:06Z Jan Hillman President 2222 Philadelphia Dr Dayton OH 45406 2179429 false 0928 X www.premierhealth.com X 1973 OH Inspire philanthropy that enhances the health and well-being of Good Samaritan Hospital's patients and those who care for them. 14 13 4 59 0 723400 716921 0 0 361274 912508 -101951 -20119 982723 1609310 330252 500198 0 0 293770 393139 0 0 272357 145058 191150 769080 1084487 213643 524823 11299888 11475037 202365 195410 11097523 11279627 X INSPIRE PHILANTHROPY THAT ENHANCES THE HEALTH AND WELL-BEING OF GOOD SAMARITAN HOSPITAL'S PATIENTS AND THOSE WHO CARE FOR THEM. false false 123440 123440 0 Mothers Empowered (ME) provides free medical care and prenatal and parenting education to pregnant women in need, ages 11-23. ME is a partnership of Good Samaritan Hospital Foundation and two area service organizations: Lifestages-Samaritan Centers for Women and Catholic Social Services of the Miami Valley. Through group prenatal care, the mothers meet in small groups of women with similar due dates to learn to care for themselves and their baby, complete regular pregnancy check-ups, and form a support network with other young mothers. Approximately 76 women were served in 2016. 111658 111658 0 The foundation supports many educational programs. These include brochures and seminars for the community, 40 scholarships for employees and their children, certification programs, seminars, conferences and lectures for employees and physicians. 10413 10413 0 The patient assistance program of the Samaritan Breast Center helped 20 patients struggling to pay for the basic necessities during their breast cancer treatment. Often, these patients find themselves worrying about how to pay a bill, rather than focusing on following their treatment plan. Assistance with paying bills such as rent, utilities, food, transportation, prescriptions and medical fees, allows them to focus on their health. The Sharing Our Strength (SOS) Support Group allows patients to share their stories, concerns and questions about their journey. They learn from each other and share their strengths to help make the journey easier. 388259 254687 0 633770 true true false false false false false false false true true true false false true true false true false false true false false false true false false true true true false false false false false false false false false false false false false true true true false false true 19 0 true 4 true false false false false false false false false false false X 14 13 false false true false true true true true true false false true true true true true true true true false OH X J MICHAEL SIMS 9374999942 110 N MAIN ST SUITE 500 Dayton OH 45402 JOHN J HALUSCHAK MD BOARD CHAIR 0.5 0.0 X X 0 0 0 RICHARD A MEYER BOARD VICE-CHAIR 0.5 0.0 X X 0 0 0 SUZANNE DONOVAN SC BOARD SECRETARY 0.5 0.0 X X 0 0 0 JAN HILLMAN PRESIDENT 40.0 0.0 X X 176829 0 10296 ZACHARY ALLEN TRUSTEE 0.5 0.0 X 0 0 0 DIANE ANDERSON DO TRUSTEE 0.5 0.0 X 0 0 0 JOHN E CLOUGH TRUSTEE (TO JUL) 0.5 0.0 X 0 0 0 HON PATRICK J FOLEY TRUSTEE 0.5 0.0 X 0 0 0 JAMES E GHORY JR TRUSTEE 0.5 0.0 X 0 0 0 REV JOSEPH W GOETZ TRUSTEE (TO JAN) 0.5 0.0 X 0 0 0 WALTER S HOY TRUSTEE 0.5 0.0 X 0 0 0 JOHN E LELAND TRUSTEE (TO JAN) 0.5 0.0 X 0 0 0 JO ANNE REILING TRUSTEE 0.5 0.0 X 0 0 0 ANN SCHUERMAN TRUSTEE 0.5 0.0 X 0 0 0 FR BENJAMIN SPEARE-HARDY III TRUSTEE 0.5 0.0 X 0 0 0 DOUGLAS A TALMAGE TRUSTEE 0.5 0.0 X 0 0 0 JENNIFER TOBIANSKY TRUSTEE (TO FEB) 0.5 0.0 X 0 0 0 KENNETH M WATSON SR TRUSTEE 0.5 0.0 X 0 0 0 BARBARA A ROGERS TREASURER (TO DEC) 0.5 39.5 X 0 82835 47388 176829 82835 57684 1 false true false none 0 3810 102592 54130 556389 1750 716921 0 222066 222066 0 0 0 0 0 1240442 550000 690442 690442 690442 0 102592 20119 -20119 -20119 0 0 0 0 0 0 0 1609310 892389 378127 378127 122071 122071 0 0 187125 46781 46781 93563 0 157181 39295 39294 78592 0 28618 7154 7156 14308 20215 5054 5054 10107 0 0 0 0 0 34909 34909 22783 5696 5696 11391 3346 3346 20611 5153 5153 10305 6086 4565 1521 0 2623 1967 656 3042 3042 0 0 0 0 0 0 PURCHASED SERVICES 89534 22384 22384 44766 REAL ESTATE TAXES 1042 261 261 520 TRAINING & EDUCATION 2823 706 706 1411 EQUIPMENT RENTAL 951 238 238 475 3400 850 850 1700 1084487 633770 178360 272357 150 150 154499 120815 159492 153027 0 0 0 0 0 0 0 0 0 0 0 0 61767 61767 61767 8779076 9074726 2112730 1942103 0 0 0 0 32174 122449 11299888 11475037 35516 62087 0 0 0 0 0 0 0 0 0 0 0 0 0 0 166849 133323 202365 195410 X 2681325 2574159 4901576 5168334 3514622 3537134 11097523 11279627 11299888 11475037 X 524823 -198624 -144095 X false true X true false X 591080 630598 589930 723400 716921 3251929 0 0 591080 630598 589930 723400 716921 3251929 417073 2834856 221556 280755 255074 219063 222066 1198514 0 0 4450443 0.63698 0.66535 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 8416198 524734 155578 391043 8705467 8324280 537177 -3256 442003 8416198 8122600 434289 114695 347304 8324280 7904705 495976 277167 555248 8122600 7490592 619003 283548 488438 7904705 0.40600 0.59400 false false 61767 61767 61767 ALTERNATIVE INVESTMENTS 1942103 F 1942103 0 DEFERRED ANNUITIES 133323 133323 X Part V, Line 4: The Good Samaritan Hospital Foundation-Dayton (GSHF) makes every effort to follow the intent and wishes of all its donors. The intended uses of the organization's endowment funds and/or earnings from endowment funds are driven by the wishes/restrictions placed on the funds by the donor. Permanent endowments result when a donation is received with a restriction that the principal or gift amount is to be retained in perpetuity and cannot be spent. The earnings from the permanent endowments are then used for the purpose specified by the donor. Temporary endowments are funds in which all or part of the principal may be expended only after the expiration of a stated period of time or occurrence of a specified event, depending on the donor's wishes. Earnings from temporarily restricted endowments can be either unrestricted or restricted. The GSHF uses the temporarily restricted endowments for the intended purpose set up by the donor, only after the period of time or specified event set by the donor has been met. The "categories" of restricted endowments are as follows: to fund the Foundation operations (16%); To support the local community Homeless Clinic operations (14%); To fund educational programs / scholarships (12%); To Support ELDERCARE ( 12%); To benefit specific programs for a Samaritan Health Partner's affiliate (8%); and miscellaneous (38%). Part X, Line 2: The following footnote is from the audited combined financial statements for Premier Health and affiliates. Samaritan Health Partners (SHP) is the sole member of Good Samaritan Hospital Foundation-Dayton (GSHF). Premier Health (Premier), MedAmerica Health Systems (MAHS), Samaritan Health Partners (SHP), Atrium Health System (AHS), 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, 2016 and 2015 for such unrelated business activities are not significant. Management annually reviews its tax positions and has determined that there are no material uncertain tax positions. Central America and the Caribbean Investments 187000 Sub-Saharan Africa Investments 22000 East Asia and the Pacific Investments 22000 Europe (Including Iceland and Greenland) Investments 1047000 Russia and the Newly Independent States Investments 55000 South America Investments 121000 South Asia Investments 672000 Middle East and North Africa Investments 44000 2170000 2170000 true false true false true false RAY OF HOPE 102592 102592 5323 14796 0 102592 102592 5323 14796 20119 -20119 true Good Samaritan Hospital 110 N Main St Suite 500 Dayton OH 45402 310536981 501(c)(3) 235570 N/A N/A Operations FIVE RIVERS HEALTH CENTERS 3535 SALEM AVENUE NO 100 DAYTON OH 45406 450914398 501(C)(3) 66505 N/A N/A OPERATIONS CATHOLIC SOCIAL SERVICES 922 W RIVERVIEW AVENUE DAYTON OH 45402 310536645 501(C)(3) 76052 N/A N/A OPERATIONS 3 Educational Scholarships 58 111658 CATASTROPHIC FINANCIAL ASSISTANCE 20 10413 Part 1, Question 2: All distributions (grants paid) follow the entities disbursement policy, including: (A) Assuming funds availability, hospital departmental personnel completes a foundation request form. For amounts in excess of $1,000, Director's & Vice-President's signatures are required to request foundation funding. (B) For request greater than $5,000, the Foundation's Distribution Committee reviews and approves the request. The check also requires a 2nd signature. (C) Reporting for grants is the responsibility of the operational unit. (D) Before disbursing funds, each request is verified/matched for its intended purpose. For example, scholarship requirements include: a) GPA requirements; b) length of service; c) specific fields of study. X X X X true false false false false false false false false JAN HILLMAN PRESIDENT 138289 0 36722 0 1818 0 1118 0 9178 0 187125 0 0 0 PART I, ITEM 4A THE FOLLOWING INDIVIDUAL ELECTED TO PARTICIPATE IN A VOLUNTARY RETIREMENT PROGRAM, AND RECEIVED THE FOLLOWING PAYMENTS: BARBARA ROGERS $3,009 in 2016 and will receive $33,097 in 2017. Form 990, Part III, Question 4D: This number represents the balance of total expenditures of temporarily restricted funds for Good Samaritan Hospital net of programs described in service accomplishments. Form 990, Part VI, Section A, Question 4: Good Samaritan Hospital Foundation-Dayton made the following significant changes to its Code Of Regulations in 2016: * minimum number of trustees changed from 15 (fifteen) to 12 (twelve). * Trustees are limited to 3 (three) consecutive terms and may not hold more than 1 (one) office at any given time. * Voting Trustees of the Board are required to attend 75% of the Board meetings otherwise the Trustee is subject to being removed from the Board. Form 990, Part VI, Section A, Question 6: Good Samaritan Hospital Foundation-Dayton has one corporate member. This member is Samaritan Health Partners. Form 990, Part VI, Section A, Question 7a & 7b: Samaritan Health Partners (SHP) has the sole authority to elect the Board of Trustees for Good Samaritan Hospital Foundation-Dayton. SHP approves all amendments to the Articles of Incorporation and Code of Regulations. Form 990, Part VI, Section B, Question 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 Foundation-Dayton is affiliated. 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 Treasurer and President 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 a 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, Question 12C: PREMIER HEALTH (PREMIER), OF WHICH Good Samaritan Hospital Foundation-Dayton IS AN AFFILIATE, REQUIRES ALL BOARD MEMBERS, OFFICERS, EXECUTIVE DIRECTORS, VICE PRESIDENTS, DIRECTORS, PURCHASING DEPARTMENT STAFF, AUTHORIZED PURCHASERS, MEDICAL DIRECTORS, DEPARTMENT AND SECTIONS CHAIRS, 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 OFFICER. 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 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, Question 15A and 15B: COMPENSATION FOR GOOD SAMARITAN HOSPITAL FOUNDATION-DAYTON's (GSHF) CEO IS REVIEWED AND APPROVED BY PREMIER HEALTH (PREMIER), OF WHICH GSHF 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 which are independent. This committee reviews in detail the compensation for the Premier CEO, COO, CFO, Chief Strategy Officer, Chief Integration 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, Question 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, Question 9: TRANSFER TO AFFILIATE $(130,757) PLEDGE RESERVES $( 13,338) TOTAL $(144,095) Good Samaritan Hospital 110 N Main St Suite 500 Dayton OH 45402 310536981 Hospital OH 501(c)(3) 3 SHP true Samaritan Health Partners (SHP) 110 N Main St Suite 500 Dayton OH 45402 311107411 Parent OH 501(c)(3) 12C-III FI NA false Beneficiary Trust (1) Community Don OH NA TRUST false false true true false false false false false false false true false false false false true false false false Good Samaritan Hospital B 366328 FMV Good Samaritan Hospital C 54130 CASH Good Samaritan Hospital P 613176 CASH