2016-11-12T09:39:47-06:00 2015-12-31 ERNST & YOUNG US LLP 800 YARD STREET SUITE 200 GRANDVIEW HEIGHTS OH 43212 990 2015-01-01 237296923 Good Samaritan Hospital Foundation - Dayton % J MICHAEL SIMS GOOD 9374999942 110 N MAIN ST Suite 500 Dayton OH 45402 BARBARA ROGERS TREASURER 9374999942 2016-11-01 true DIANE L BEAN P00104972 6142245678 2015 2017-02-10 21:41:12Z Jan Hillman President 2222 Philadelphia Dr Dayton OH 45406 1503433 false 0928 X www.premierhealth.com X 1973 OH Inspire philanthropy to enhance the health and well-being of Good Samaritan Hospital's patients and those who care for them. 17 16 4 60 0 595313 723400 0 0 624004 361274 -2110 -101951 1217207 982723 271192 330252 0 0 294457 293770 0 0 194244 122769 145058 688418 769080 528789 213643 11493260 11299888 132521 202365 11360739 11097523 X INSPIRE PHILANTHROPY TO ENHANCE THE HEALTH AND WELL-BEING OF GOOD SAMARITAN HOSPITAL'S PATIENTS AND THOSE WHO CARE FOR THEM. false false 134681 134681 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. Further support is provided through a 24-month post-partum program that provides child development education, counseling and referrals. 76097 76097 0 The foundation supports many educational programs. These include brochures and seminars for the community, scholarships for employees, certification programs, seminars, conferences and lectures for employees, physicians and community members. 9501 9501 0 The patient assistance program of the Samaritan Breast Center helps those 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 focus 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 and decreasing stress. 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 strength to help make the journey easier. 205034 109973 0 425313 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 true false false false true true true false false true 21 0 true 4 true false false false false false false false false false false X 17 16 false false false false true true false true true false false true true true true true true true true false X J MICHAEL SIMS 9374999942 110 N MAIN ST SUITE 500 Dayton OH 45402 DOUGLAS A TALMAGE BOARD CHAIR 0.5 0.0 X X 0 0 0 JOHN J HALUSCHAK MD BOARD VICE-CHAIR 0.5 0.0 X X 0 0 0 LISA Y ORR BOARD SECRETARY 0.5 0.0 X X 0 0 0 JAN HILLMAN PRESIDENT 40.0 0.0 X X 89166 0 6156 DAVID CLAPPER TRUSTEE (TO MAR) 0.5 0.0 X 0 0 0 JOHN E CLOUGH TRUSTEE 0.5 0.0 X 0 0 0 SUZANNE DONOVAN SC TRUSTEE 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 0.5 0.0 X 0 0 0 WALTER S HOY TRUSTEE 0.5 0.0 X 0 0 0 GAVIN D JENNEY PHD PE TRUSTEE 0.5 0.0 X 0 0 0 JOHN E LELAND TRUSTEE 0.5 0.0 X 0 0 0 STEPHEN B LEVITT MD TRUSTEE 0.5 0.0 X 0 0 0 RICHARD A MEYER TRUSTEE 0.5 0.0 X 0 0 0 STUART SORKIN MD TRUSTEE (TO MAY) 0.5 0.0 X 0 0 0 FR BENJAMIN SPEARE-HARDY III TRUSTEE 0.5 0.0 X 0 0 0 JENNIFER TOBIANSKY TRUSTEE 0.5 0.0 X 0 0 0 KENNETH M WATSON SR TRUSTEE 0.5 0.0 X 0 0 0 BARBARA A ROGERS BOARD TREASURER 0.5 39.5 X 0 76997 14262 MARC S MARTENS FORMER OFFICER 0.0 0.0 X 118950 0 25660 208116 76997 46078 1 true true false none 0 4017 105237 7706 606440 6835 723400 0 219063 219063 0 0 0 0 0 492042 390000 102042 142211 142211 28759 105237 130710 -101951 -101951 0 0 0 982723 259323 283550 283550 46702 46702 0 0 95322 23831 23831 47660 0 158922 39731 39730 79461 0 21821 5454 5456 10911 17705 4426 4427 8852 0 0 0 0 0 40169 40169 13543 3386 3386 6771 7090 7090 22559 5640 5640 11279 6979 5234 1745 0 2623 1967 656 1722 1722 0 0 0 0 0 0 PURCHASED SERVICES 42046 10512 10512 21022 TAXES 2549 637 637 1275 TRAINING & EDUCATION 389 97 97 195 EQUIPMENT RENTAL 224 56 56 112 5165 1291 1291 2583 769080 425313 149523 194244 0 150 289907 154499 159031 159492 0 0 0 0 0 0 0 0 0 0 0 0 61767 61767 61767 9016147 8779076 1966408 2112730 0 0 0 0 0 32174 11493260 11299888 29655 35516 0 0 0 0 0 0 0 0 0 0 0 0 0 0 102866 166849 132521 202365 X 3036459 2681325 4823104 4901576 3501176 3514622 11360739 11097523 11493260 11299888 X 213643 -365445 -111414 X X false true X true false X 474945 591080 630598 589930 723400 3009953 0 0 474945 591080 630598 589930 723400 3009953 256670 2753283 151677 221556 280755 255074 219063 1128125 0 0 4138078 0.66535 0.54230 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 8324280 537177 -3256 442003 8416198 8122600 434289 114695 347304 8324280 7904705 495976 277167 555248 8122600 7490592 619003 283548 488438 7904705 6115921 1707009 -16123 316215 7490592 0.41800 0.58200 false false 61767 61767 61767 ALTERNATIVE INVESTMENTS 2112730 F 2112730 0 DUE TO AFFILIATES 118696 DEFERRED ANNUITIES 48153 166849 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. The "categories" of permanently restricted endowments are as follows: to fund the Foundation operations (39%); To support Good Samaritan Hospital's Homeless Clinic operations (27%); To benefit specific programs for a Samaritan Health Partner's affiliate (13%); To provide educational programs for cancer patients(6%); and miscellaneous (15%). 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. 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 parent organization of Good Samaritan Hospital Foundation-Dayton (GSHF): Premier Health (Premier), MedAmerica Health Systems (MAHS), 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. Samaritan Health Partners (SHP) is tax-exempt under Section 501(c)(3) and is a public charity by reason of being included in the group ruling issued to the U.S. Catholic Church. As tax-exempt organizations, their income is exempt from federal income tax except to the extent of any unrelated business activities. PREMIER, MAHS, SHP, AHS, AND UVMC ALSO OWN OR CONTROL CERTAIN SUBSIDIARIES, WHICH ARE FOR PROFIT CORPORATIONS SUBJECT TO FEDERAL INCOME TAXES. Taxes payable at December 31, 2015 and 2014 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 142012 East Asia and the Pacific Investments 633591 Europe (Including Iceland and Greenland) Investments 1518433 Middle East and North Africa Investments 32772 North America Investments 152936 Russia and the Newly Independent States Investments 32772 South America Investments 109240 South Asia Investments 54620 Sub-Saharan Africa Investments 21848 2698224 2698224 false false false false false false RAY OF HOPE 22146 21051 1095 1705 365 1367 CARING GALA 111850 84186 27664 34849 2750 89674 0 0 0 133996 105237 28759 1705 34849 3115 91041 130710 -101951 true Good Samaritan Hospital 110 N Main St Suite 500 Dayton OH 45402 310536981 501(c)(3) 157525 N/A N/A Operations The Heart Institute of Dayton 110 N Main St Suite 500 Dayton OH 45402 300502367 501(c)(3) 32582 N/A N/A Operations FIVE RIVERS HEALTH CENTERS 3535 SALEM AVENUE NO 100 DAYTON OH 45406 450914398 501(C)(3) 10650 N/A N/A OPERATIONS CATHOLIC SOCIAL SERVICES 922 W RIVERVIEW AVENUE DAYTON OH 45402 310536645 501(C)(3) 82793 N/A N/A OPERATIONS 4 0 Educational Scholarships 60 46702 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 MARC S MARTENS FORMER OFFICER 0 0 0 0 118950 0 2238 0 23422 0 144610 0 91542 0 PART I, QUESTION 4A: Marc Martens received $123,850 of severance payments. X 2 4485 FMV X Travel certificates 2 2350 FMV 0 false true false Form 990, Part I, Question 10: The Good Samaritan Hospital Foundation-Dayton has designated its investments as trading. In accordance with the AICPA Guide for Healthcare, all unrealized gains and losses are recognized through the Profit and Loss statement. For 990 reporting, this activity is excluded per the instructions by the Internal Revenue Service. 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 6: Good Samaritan Hospital Foundation-Dayton has one corporate member. This member is Samaritan Health Partners, the parent of the Foundation. Form 990, Part VI, Section A, Question 7a: Samaritan Health Partners (SHP) has the sole authority to elect the Board of Trustees for Good Samaritan Hospital Foundation-Dayton. 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 with. 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 TO 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, 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 $(111,414) 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) 11C-III FI NA false Beneficiary Trust (1) Community Donor OH NA TRUST false false true true false false false false false false true false false false false true true false false Good Samaritan Hospital B 268941 FMV Good Samaritan Hospital P 702766 CASH Good Samaritan Hospital Q 52004 CASH The Heart Institute of Dayton C 32582 CASH