2016-06-27T14:11:07-05:00 2015-08-31 861065772 Deloitte Tax LLP 191 Peachtree St Suite 2000 Atlanta GA 303031749 990 2014-09-01 611356023 Our Lady of Bellefonte Hospital Inc OURL 6068333333 St Christopher Drive Ashland KY 41101 Joe Buchheit CFO - BSKHS 6068333600 2016-06-27 1 John W Sadoff Jr P00540589 4042201500 2014 2016-12-15 16:53:06Z Kevin Halter St Christopher Drive Ashland KY 41101 169553957 0 0928 X www.olbh.com X 1999 KY Acute Care Hospital 19 15 1201 125 2431011 114861 819164 2386354 158821195 163534004 536553 563011 1109367 3070588 161286279 169553957 505633 582583 0 0 57560684 61271825 0 0 0 90484793 92115449 148551110 153969857 12735169 15584100 130194416 147223745 62831488 72376697 67362928 74847048 The mission is to bring compassion to health care and to be good help to those in need, especially those who are poor and dying. As a system of caregivers, we commit ourselves to help bring people and communities to health and wholeness. 0 0 142861242 582583 162938115 To bring compassion to healthcare and to be good help to those in need by providing healthcare services. Please see community benefit disclosures in Sch H. 142861242 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 100 0 1 1201 1 1 1 0 0 0 0 0 0 0 0 0 X 19 15 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 1 0 KY X Aaron Akers 6068334136 St Christopher Drive Ashland KY 41101 X Carol Allen Board Member 2.00 0.00 X 0 0 0 Lori Arthur Board Member (Jan-Aug) 2.00 0.00 X 0 0 0 Gregory Bausch PhD Board Member 2.00 0.00 X 0 0 0 Mary Carter Jasper Board Member 2.00 0.00 X 0 0 0 Mary Flath PhD Board Member 2.00 0.00 X 0 0 0 Kevin Halter FACHE CEO - BSKY 20.00 30.00 X X 0 477490 54826 Lawrence Hubbard CHCIO Board Member 2.00 48.00 X 0 647371 36753 Daniel Huffman Chairman 3.00 0.00 X X 0 0 0 Gregory Jackson Board Member 2.00 0.00 X 0 0 0 Connie Johnson Board Member 2.00 0.00 X 0 0 0 Larry Jones Board Member 2.00 0.00 X 0 0 0 Elizabeth Keith Board Member 2.00 48.00 X 0 234515 27691 Phillip Leslie Esq Board Member 2.00 0.00 X 0 0 0 James Martin Jr MD Board Member 2.00 0.00 X 0 0 0 Jason McCloud OD Board Member 2.00 0.00 X 0 0 0 Thomas Morris PhD President 3.00 47.00 X X 0 436432 59475 Laura Timberlake Board Member 2.00 0.00 X 0 0 0 EW Unnikrishnan MD Board Member 2.00 0.00 X 0 0 0 William Willan PhD Board Member 2.00 0.00 X 0 0 0 Joe Buchheit Treasurer/CFO-BSKY 37.00 13.00 X 331669 0 28215 Rodney Hieneman Secretary 2.00 48.00 X 169699 0 31387 Daniel Goulson CMO 50.00 0.00 X 381226 0 37459 Michele Friday MD Cardiologist 49.50 0.50 X 651496 0 31848 Yogendra Prasad MD Cardiologist 50.00 0.00 X 646626 0 32677 Kurt Jaenicke MD Obstetrician 50.00 0.00 X 621960 0 32371 Phillip Lackey MD Plastic Surgeon 50.00 0.00 X 396432 0 30353 Jason Ford MD Pediatrician 50.00 0.00 X 312378 0 30111 3511486 1795808 433166 42 0 1 0 Ashland Anesthesia PSC PO Box 1377 Ashland KY 411051377 Anesthesia Services 2797051 Morrison Mgt Specialists PO Box 102289 Atlanta GA 303682248 Food Services 2758405 Aramark CTS INC 12483 Collections Center Dr Chicago IL 60693 Equipment Maintenance 2319525 Aramark Healthcare 24863 Network Place Chicago IL 606731248 Housekeeping/Laundry and Linen/Lift Team 2304094 Apogee Medical Management 15059 North Scottsdale Rd Suite 600 Scottsdale AZ 85254 Medical Services 1255325 40 1657113 729241 1158614 2386354 Patient Service Rev. 622110 163534004 162633096 900908 163534004 418204 418204 600279 0 600279 600279 600279 141059 3748 0 0 141059 3748 144807 144807 Retail Pharmacy Rev. 446110 1952709 1530103 422606 Comm. Health & Fitness 713940 305019 305019 Cafeteria/Vending 900099 74618 74618 137963 137963 2470309 169553957 162938115 2431011 1798477 582583 582583 983850 885465 98385 45014749 40513274 4501475 4366113 3929502 436611 7338072 6604265 733807 3569041 3212137 356904 267201 240481 26720 30160 27144 3016 16649 14984 1665 7265074 7265074 696953 627258 69695 1896069 1706462 189607 4447959 4003163 444796 5769259 5192333 576926 508219 457397 50822 54623 49161 5462 2195983 2195983 8365138 7528624 836514 1200754 1080679 120075 Medical Supplies 25746562 25746562 0 Purchased Services 16036776 14433098 1603678 Bad Debt 7162594 7162594 0 UBI Tax 7677 0 7677 10447799 9403019 1044780 153969857 142861242 11108615 0 873 927 38782744 57063295 17273772 17850837 636277 642685 3335481 3796375 1532048 502212 131863027 85582704 47682061 46280323 9396308 9453513 308715 358940 265985 252734 10980152 11021904 130194416 147223745 12774454 12985219 4960737 4719377 45096297 54672101 62831488 72376697 X 67362368 74846488 560 560 67362928 74847048 130194416 147223745 X 15584100 -163587 -7936393 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 16649 16649 0 Part II-B, Line 1: The filing organization maintains memberships to various professional healthcare associations. Portions of their membership dues are used for lobbying activities. The lobbying portion of such dues is included on line 1i. 4557950 4557950 57759005 29272526 28486479 2563271 2327925 235346 63702138 51057648 12644490 3280663 2924605 356058 46280323 HPL/GL 8227160 Other Pat and 3rd Party Payers 983939 Due From Affiliates 921636 Other Accrued Revenue 368440 Due From BSHSI 134986 KHCP 134096 Medicare/Medicaid Settlements 120968 Pharm AR 96210 Other Misc Assets 34469 11021904 LT Liab - Pension Liability 44430743 HPL/GL Liability 8227160 Reserves for Medicare and Medicaid 1064351 Due to BSHSI 921736 Unclaimed Prop Accrual 28111 54672101 X Part X, Line 2: Schedule D, Part X, Line 2 requires that the organization provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under ASC 740. ASC 740 addresses the accounting for uncertainty in income taxes recognized in an entity's financial statements and prescribes a threshold of more-likely-than-not for recognition and derecognition of tax positions taken or expected to be taken in a tax return. The adoption of ASC 740 by BSHSI on September 1, 2007 did not have a material impact on BSHSI's consolidated financial statements. As the organization does not conduct a separate audit of its financial statements, below is the related statement from the Bon Secours Health System, Inc. consolidated audited financial statements: The System and most of its subsidiaries (including certain joint venture entities) are exempt from federal income taxes under Section 501(c)(3) of the Internal Revenue Code of 1986, as amended. The system accounts for uncertain tax positions in accordance with ASC Topic 740. The System's taxable subsidiaries have approximately $84,748 and $61,513 of net operating loss carryforwards as of August 31, 2015 and 2014, respectively, which expire in varying periods through 2035 and are available to offset future taxable income. The System's deferred tax assets are fully reserved at August 31, 2015 and 2014 as the System considers it more likely than not that these amounts will not be recognized. Any changes to the valuation allowance on the deferred tax asset are reflected in the year of the change. 1 1 X 1 X 0 1 1 0 1 1 663029 512701 150328 0.00100 35861493 22851857 13009636 0.08860 36524522 23364558 13159964 0.08960 26 16693 450594 0 450594 0.00310 3 313 1076384 253342 823042 0.00560 0 0 0 0 0 0 0 0 12 2482 116751 0 116751 0.00080 41 19488 1643729 253342 1390387 0.00950 41 19488 38168251 23617900 14550351 0.09910 0 0 0 0 4 3157 8501 0 8501 0.00010 1 188 780 0 780 0.00000 1 110 0 0 2 1094 3992 0 3992 0.00000 14 6430 43785 0 43785 0.00030 8 11855 43913 0 43913 0.00030 1 100 73 0 73 0.00000 0 0 0 0 31 22934 101044 101044 0.00070 1 7162594 0 42870129 46269497 -3399368 X 1 1 1 1 Our Lady of Bellefonte Hospital Inc St Christopher Drive Ashland KY 41101 www.olbh.com 100154 X X X X Our Lady of Bellefonte Hospital Inc 1 0 0 1 X X X X X X X X X 12 1 0 0 1 X http://www.olbh.com/assets/pdfs/KY_CHNA_Final.pdf X X 1 12 0 1 0 1 X 200.000000000000 X 0 1 X X X 1 X http://www.olbh.com X X X X X 1 X 1 X X X X X 1 X 0 0 Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 5: In preparing the OLBH CHNA the hospital collaborated with community service organizations to provide feedback on the questions to be included in the survey. Local Health Dept., local police officers, fire dept., school districts, community based service org, local businesses and representatives from local faith communities, local residents and organizations. Interviews were conducted with several individuals with special knowledge and expertise in public health, representatives of medically underserved and those with chronic disease - Chris Crum, Director of Greenup Co. Health Dept., Maria Hardy, Director Boyd Co. Health Dept., Laura Brown, Director Ironton OH Health Dept. , Debbie Fisher Director Lawrence Co. Ohio Health Dept., Kelli Prater, Director Boyd Co. Head Start, Mary Crowley, NEKCC Free clinic, Debbie Sivis, Director at Shelter of Hope, Alfreda Moore, Director Ashland Community Kitchen, Debbie Blevins, Director of Helping Hands of Greenup KY, Ann Perkins, Director of Safe Harbor, Trish Hall Director of CARES, Eve Greene Nurse at Greenup co. health dept. Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 7d: The CHNA is available through the OLBH Foundation and is also made available by the Foundation upon request. Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 11: Through collaboration with Healthy Choices KY; Obesity has been addressed through several community events including festival of fitness, A.P.P.L.E (Appalachian partnership for positive living and eating) focus on school age children and families. Supported PE in the schools through a grant with the Ashland city school system. Funded walking tracks and trails in several communities. Financial support for school and community gardens, funded two community bicycle safety programs, Safe routes to schools, Policy work through schools to support active recess and healthy eating in child care centers. Complete streets work in several communities. Cancer support groups, free skin and colon cancer screenings and colonoscopies for uninsured and underinsured individuals through a grant with the State of KY. Mobile mammograms van provided screenings in rural communities free to uninsured and underinsured individuals in the community. Sponsored community events to bring awareness to colon cancer through an event at the mall in collaboration with the American cancer society. Heart disease has been addressed through the collaborative work to create a free mobile app to track progress of life style changes. Free screenings in the community for Blood Pressure, Blood sugar, A1C, Hemoglobin and Cholesterol. Provide a van ministry program to transport patients to doctor appointments including rehab for surgery, cardiac and pulmonary patients, cancer treatments, and screenings . Work with Asthma patients and provided families an opportunity to be involved in a pilot program for healthy homes; trained community members to be healthy home specialist. Worked with Greenup Co. Interagency on several projects including 2 good for drugs program in collaboration with Pathways, 24-7 smoke free policy in schools, truth or consequences in collaboration with UK extension office and law enforcement. Other significant needs are continuing to be addressed by BSKY and other local health care facilities and agencies. Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 13h: The facility approved free care for patients at or below 200% of the FPL. For patients above 200% of the FPL we utilize a sliding scale with no cap. Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 16i: Information regarding the FAP is available on our websites and brochures are available at the time of registration. We have on site Counselors who can assist the patients. We have eligibility vendors who work with the patients and our statements indicate we have an FAP. Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 22d: Bon Secours offers 75% discounts to all self pay patients in the following markets: Virginia, South Carolina and Kentucky. We also offer an 80% discount to our patients in our New York Market. Form 990, Schedule H, Part V, Section B, Line 14: The Community Service Adjustment was based on the average amounts paid by our insurance companies. Part V, Section B, Line 16 Financial Assistance Policy Website Availability Our Lady of Bellefonte Hospital, Inc. Part V, Section B, line 16b website: http://www.olbh.com 14 Med Plaza Pharmacy 700 St Christopher Drive Ashland KY 41101 Pharmacy Bellefonte Sleep Lab 118 St Christopher Drive Ashland KY 41101 Sleep Lab Ironton MRI 1015 East Ring Road Ironton OH 45638 Imaging Center Vitality Center 1100 St Christopher Drive Ashland KY 41101 Cardio/Vascular Rehab Same Day Surgery Center 1101 St Christopher Drive Ashland KY 41101 Surgery Center Bellefonte Home Health Care Agency 700 St Christopher Drive MOB 3 Ashland KY 41101 Home Health OLBH Pediatric Rehabilitation Clinic 1100 St Christopher Drive Ashland KY 41101 Pediatric Rehab Bellefonte Behavioral Health 1000 St Christoopher Drive Ashland KY 41101 Behavioral Health Bellefonte Center 1000 Ashland Drive Ashland KY 41101 Womens Health, Pre-testing, Various physician Offices Ashland Infusion Center 2930 Carter Ave Ashland KY 41101 Infusion Therapy Ashland Lab 1816 Carter Ave Ashland KY 41101 Lab Services Ashland Imaging 1816 Carter Ave Ashland KY 41101 Imaging Center Wheelersburg PT 8985 Ohio River Road Wheelersburg OH 45694 Physical Therapy Bellefonte Home Health Care Agency 109 N 3rd St Ironton OH 45638 Home Health Part I, Line 3c: For patients with income above 200% of the FPG, the organization utilizes a sliding scale with no cap. Part I, Line 6a: Annually, Bon Secours KY/Our Lady of Bellefonte Hospital through its Foundation publishes a report for the community, explaining the various community benefit services and programs that exist. This report also includes the annual financial commitment of the local system to the community, detailing monetary contributions for government sponsored healthcare shortfall, community benefit programs and charity care at cost. This report is available to the public each year on or around March 15. This report is available online at http://kentucky.bonsecours.com/about-us-foundation.html Part I, Line 7: Part I, line 7a: Charity Care at cost is computed by applying a cost-to-charge ratio to the aggregate charity adjustments recorded in the general ledger. Part I, line 7b: Unreimbursed Medicaid is computed by determining the cost of Medicaid services supplied less payments received for these services. To determine the cost of Medicaid services provided, a cost-to-charge ratio is applied to traditional and managed Medicaid gross charges captured in the patient accounting system and general ledger. Payments include payments for individual claims, payments from the Medicaid program paid outside the claim process (such as medical education payments) and expected or actual cost report settlements.Part I, line 7c: Unreimbursed costs from other means-tested government programs are computed by applying a cost-to-charge ratio to the total charges to patients covered under these programs. The charges are identified by the financial class assigned to the patient. For Part I, Line 7 a-c computations: The cost-to-charge ratio is derived using the suggested computation in Worksheet 2, Ratio of Patient Care Cost-to-Charges. Operating expenses and Gross patient charges are taken from the general ledger. Expenses for nonpatient care activities recorded in operating expenses are approximated as directly equaling other operating revenue, assuming these activities do not provide profit. Part I, line 7e: Community health improvement services and community benefit operations are accumulated throughout the year and reported at actual cost in a software program that specifically addresses this purpose.Part I, line 7f: Health professions education cost is determined as the direct and indirect cost of qualifying education activities as traditionally reported in columns 21-24 on Worksheet B of the Medicare cost report as a Medical Education program, nursing school or other allied health program. Part I, Ln 7 Col(f): Bad debt expense included in Part IX; line 25 and excluded from the "percent of total expense" calculation is: $7,162,594. Part II, Community Building Activities: BSKHS is working to engage and empower the members of the Ironton Ohio community. The Director of Healthy community initiatives is coordinating efforts to aid in health and social issues to support them in improving their quality of life and health. The Ironton, Ohio community is a small urban area of approximately 25,000 residents. The 9th street community is home to subsidized housing for low income seniors and families. Initiatives include computers used by residents and families, funding after-school and summer programs for low income students needing assistance with homework and providing a safe environment for students. Summer youth activities at the community center provide the opportunity to go on field trips. The safe summer day camp activities provides the students mentors along with activities to keep the kids active and incorporates a variety of topics to enrich the lives of the kids. Raised garden beds were added to the community center the Ohio University extension and 4H club leaders work with the students on a weekly basis to learn to grow and prepare fresh vegetables. A 35 plot Community garden opened in the spring of 2013, the garden provides community residents with space to grow fresh vegetables to use in family meals. BSKY continues to support a local farmers market; the organization of the market has resulted in availability of fresh fruit and vegetables in an area that is labeled a food desert. BSKY continues to support the Argillite KY Community located in Greenup County, which is a rural community with approximately 1,000 residents; 66% of students receive free and reduced lunches. School gardens and walking trails continue to be utilized and provide opportunities for education on how to grow fresh vegetables. The trails also provide a venue for the community and the school students and personnel to walk in a safe atmosphere. Further, this project is aimed to help fight obesity. BSKY continues to use First Book market place to purchase books to distribute free to students in the low income communities of Argillite and Ironton. Support of backpack program and weekend snack sack program supplying food to students most at risk of going hungry during the weekend continues to assist the high risk students in our service area. Healthy Community Services conducted 115 health fairs, providing approximately 7,321 health screenings for chronic conditions such as heart disease, diabetes, osteoporosis, anemia, glaucoma, and peripheral vascular disease. All participants in our health fairs received personal health counseling and those with abnormal results received educational materials and the offer of assistance in finding a health medical home or care provider if they had none. Information about the Northeast KY care center (NEKCC), the local "Free Clinic" was also given to participants who were uninsured or could not afford a health care provider. Three of our BPS physician staff volunteer at least once a month at the NEKCC. Additionally Healthy Community services conducted 17 community CPR classes in 2014 resulting in 57 individuals being certified in adult, infant and child CPR. We offered 2 safe sitter classes and certified 21 young people as safe sitters. We offered bicycle safety camp with 102 children and their families in attendance. We currently have faith ministry or faith community nurse partnerships with 56 local churches with 25 additional congregations on our mailing list. Our Healthy Community Services Van Ministry provided free non-emergency medical transportation for outpatient services on the OLBH campus and to patients who had appointments with campus or BPS-affiliated physicians. We operate three vans - one of which is equipped with a wheelchair lift. In an area which has very limited public transportation, our van ministry provides an option for our patients who need treatment but have no means of affordable non-emergency medical transportation. Our van ministry provided over 2,883 round trips and traveled over 75, 717 miles. We served over 360 individuals in transporting most of these individuals multiple times. Our Meals on Wheels programs serve 200 home-bound seniors in 10 communities for an average of 3,600 meals delivered each month. We provide approximately $2,000 in free or reduced price meals each month. BSKHS provided mammography screening through grant funding to 48 uninsured or underinsured individuals. Part III, Line 2: Bad debt expense on the general ledger includes: 1) actual write offs of discounted gross charges where it is determined an uninsured patient can pay and does not pay; and 2) the estimated write offs for uninsured patient accounts with outstanding balances after discount. Estimates are based on historical collection rates.When an uninsured patient is billed for patient care services, the charges are automatically discounted and the patient is requested to only pay the amount after discount. The discount is recorded as an adjustment to gross revenue and is not recorded in bad debt expense. If the balance after discount is not paid or not paid in full, the unpaid amount will be written off to bad debt expense. When a patient remits a payment on an account that has already been written off to bad debt expense, the payment is recorded as a recovery of bad debt, which reduces bad debt expense. Part III, Line 3: The organization does not report an estimate for the portion of bad debt expense that may have been likely to qualify for financial assistance under the hospital's charity care policy. The organization takes the position that ample opportunity and assistance is provided to the patient to qualify under the financial assistance policy. If sufficient information is not provided, the organization must assume the patient does not qualify. Part III, Line 4: Please see Footnote "(2d) Accounts Receivable, net" discussing "accounts receivable" on pages 11-12 in the attached BSHSI consolidated audited financial statements ("AFS"). "Allowance for uncollectible accounts" is discussed in the second paragraph in Footnote "(10) Net Patient Service Revenue" on page 45 of the attached AFS. There is not a separate "bad debt expense" footnote in the AFS. Part III, Line 8: Medicare allowable costs reflected in Part III come directly from the facility's Medicare cost report. The cost report segregates the total facility actual expenses into costs for support departments, clinical departments (routine and ancillary) and nonreimburseable departments. The cost report uses appropriate statistical bases to "step down" support costs to allowable clinical and nonreimburseable departments. The charges for clinical departments are matched to the total cost for these departments for a cost-to-charge ratio. Medicare-specific allowable costs for in- and outpatient ancillary departments are computed by applying the department-specific cost-to-charge ratio to the Medicare program charges by department. For routine departments, a per diem total cost is computed and applied to Medicare program days for the Medicare routine program cost.The organization feels the total shortfall of Medicare reimbursement compared to computed Medicare allowable costs should be treated as community benefit. The hospital improves access to patient care by providing services regardless of a patient's ability to pay or the hospital's ability to receive full cost reimbursement for services. The hospital also relieves the government of a financial burden when it provides care to publically insured patients where reimbursement is less than cost of providing the service.In addition to the costs reported above, the organization incurred additional costs relating to medicare support that are not includable in the Medicare Cost Report in the amount of: $1,749,750. Part III, Line 9b: The hospital has a written policy that describes collection practices applying to patients that qualify for charity care or financial assistance. If full assistance is approved, no collection efforts are pursued on that patient's account(s). If partial assistance is provided, the patient is responsible for the adjusted account balance and collection efforts will follow the established practices for all patients where a self-pay balance exists. Collection efforts are not pursued on any pending FAP account.Specific criteria exist for how much financial assistance, partial or total, will be provided to the patient based on the assessed need. Criteria is based on Federal Poverty Guidelines and is reviewed and updated annually. Once a patient has been deemed eligible for the Patient Financial Assistance Program (FAP), the patient is notified by letter within 60 days after receipt of the application and supporting documentation. The patient retains eligibility for a period of twelve months from the date of the application. This eligibility is signaled to hospital admissions, billing and collection staff by the assignment of a specific financial class with accompanying eligibility dates. At the end of those twelve months, the patient is responsible for reapplying for FAP eligibility. Part VI, Line 2: Bon Secours Kentucky, Our Lady of Bellefonte Hospital (OLBH) uses multiple approaches to assess the health needs of the communities it serves. We have a community based Board of Directors that provides the hospital with guidance and input on services needed in the local community through contacts with local business and government leaders. Community health screening data is gathered through the year and analyzed for use in planning. Community need assessments are updated using a variety of informational sources including Kentucky Health Information for state-based performance data, Kentucky Hospital Association info site for market and geographic data bases, third party data bases, US Census Bureau data and Thomson-Reuter's Market Expert is used to retrieve demographic information and trends for the primary and secondary service areas pertaining to Our Lady of Bellefonte Hospital. We have also developed regional alignment plans using this data and tying it to our underserved areas to plan for future growth in the communities we serve by providing more access points for patients in our service areas.The community health care needs assessment was open to the public through a web based survey and available as a print copy. Working with local health departments we participated in health needs assessments through these organizations, conversations with local residents and health professionals, public forums and community meetings and coalitions. Part VI, Line 3: Patient financial assistance policy is communicated to patients verbally upon scheduling, registration, visible postings of the policy in common areas throughout the hospital, brochures and on Bon Secours website. In addition, patient statements request that patients apply for financial assistance, if needed, once any patient financial obligation is determined.Bon Secours is committed to ensuring access to health care services for all. As a health care provider, Bon Secours treats all patients, whether insured, underinsured or uninsured, with dignity, respect and compassion throughout admission, delivery of services, discharge and billing and collection processes. Bon Secours addresses the needs of the uninsured by providing free or reduced fees on hospital services, community outreach efforts to assist with enrollment in Medicaid and other medical coverage programs, including free community-based preventive and primary care services. Bon Secours proactively screens to identify individuals and their families who may qualify for federal, state or local health insurance programs or the Bon Secours Patient Financial Assistance Program ("FAP") and assist the potential eligible patients through the qualification process. Potentially eligible patients that do not qualify for a federal or state health insurance program are referred to the Financial Assistance Coordinator located in Patient Financial Services for assistance in completing the documentation required to establish FAP eligibility. Patients are responsible for providing the information necessary to complete the documentation. The FAP aids uninsured and underinsured patients who do not qualify for government-sponsored health insurance and who communicate their inability to pay for their medical care. The FAP provides 100% financial assistance to uninsured patients with annual family incomes at or below 200% of the Federal Poverty Guidelines ("FPG"), A sliding scale assistance policy is afforded patients that exceed the income guidelines for 100% assistance. Sliding scale assistance is provided to patients and progressively declines in proportion to the patient's higher income level. Additionally, all uninsured (i.e. self pay) patients are given a reduction to the amount of the full charges for medically necessary services through a community service adjustment ("CSA"). The CSA is market adjusted and based on the payment discount received by other health care payers doing business in the community. For these patients, the FAP also sets a maximum annual family payment liability to ensure that no family suffers a catastrophic financial burden to receive necessary health care services. Based on research conducted by the Tax Foundation, a non partisan tax research group based in Washington DC, the maximum annual family liability is based on a sliding scale determined by the family income and size. In addition, a variety of other potential payment options are available. Bon Secours is dedicated to meeting the needs of non-English speaking patients by having on-site Spanish translators, and other language translation services. In addition, Bon Secours employs a telephone language service which assists in meeting any language needs that arise. The translation services are offered to non-English speaking patients from admission to discharge, including the financial process. Part VI, Line 4: Bon Secours Kentucky Health System (BSKHS), Our Lady of Bellefonte Hospital (OLBH) serves a region of approximately 400,000 people in northeastern Kentucky, southern Ohio, and western West Virginia, The service areas includes six counties in northern Kentucky (Greenup, Boyd, Lawrence, Carter, and Elliott) which comprises the FIVCO Area Development District as well as Lewis County, two counties in southern Ohio (Lawrence, Scioto) and Wayne and Cabell counties in western West Virginia. Due to our growing aging population services for our community residents aged 55 and older are needed, particularly women's health, orthopedics, diabetes, cardiopulmonary services, cancer, drug rehab and wound care. The 55 and older population is expected to increase by 14% over the next five years. The high poverty and high unemployment rate in the area result in a low social economic status. It is a very industrialized region which creates carcinogens and unhealthy life styles especially in eastern Kentucky, which has some of the highest incidence in the country of smoking, diabetes, obesity and carcinogens. These demographic characteristics create a high demand for chronic disease health care, including diabetes, cancer and heart disease among others.OLBH conducted a demographic analysis of the hospitals service. OLBH is located in Greenup County, Ky., with approximately 14,000 households about 14 percent are living in poverty and 15 percent are age 65 and older. In adjacent counties, the poverty rate is 15 percent in Boyd County; 22 percent in Carter County; 29 percent in Lewis County; and approximately 19 percent in Lawrence County, Ohio. Lack of well-paying jobs has contributed to the rate of poverty in this area. According the U.S. Census gathered in 2010, Hispanics make up less than one percent of the hospital's service area. However, there are marked increases of the Hispanic population at OLBH's primary care centers in Carter County KY, in particular, where many residents still make a living through tobacco and other farm crops. According to the County Health rankings data 2011, the counties in OLBH primary service area rank among the highest in the state at risk for poor health outcomes and poor Health factors. Consistent with the state and national trends five chronic diseases account for most of the spending on health care: diabetes, heart disease, hypertension, asthma and depression. Prescription drug abuse and addiction is a growing problem in the area as is illegal drug use including methamphetamine, cocaine and marijuana. Access to quality preventative care and disease management education is critical in minimizing future hospitalizations as well as the seriousness of these diseases. Health insurance coverage is also a factor in determining whether patients will seek preventative care or wait for symptoms to become more severe, thus requiring more extensive treatments, including hospitalization.The area's growing drug addiction problems puts these individuals more at risk for depression, suicides and kidney failure. The area's population of drug abuse by all ages is growing at a relatively fast pace and will necessitate planning of and access to health care services unique to this population. There are few exceptions to our local community versus state averages with regard to health impacts. Our service area has higher overall cancer rates in Lung Cancer than the state average. Other cancers that are prevalent in our primary and secondary service areas are breast, colon, bladder, prostate and lymphoma. Part VI, Line 5: OLBH has been instrumental in developing and collaborating with other local agencies on programs to meet the needs of uninsured and low income families. A free health care clinic Northeast Kentucky Care Center (NEKCC), serves uninsured adult residents of Boyd and Greenup Counties. OLBH has provided the clinic with financial support, volunteer personnel, and supplies. A van ministry that provides free non-emergency medical transportation for outpatient services at our campus and primary care centers; developing the Greenup County Interagency Council; a county drug task force, Greenup Residents Ending Addiction Together (GREAT); church partnerships with 54 churches to develop health ministry and/or faith community nursing programs; and our support of the previously mentioned Northeast Kentucky Care Center and Greenup County Health Department MAPP project. Healthy Choices Kentucky: This coalition is tackling the obesity problem in our communities. HCK has focused on providing more opportunities for increasing physical activity and on improving nutrition. Some of the successes of the Coalition in 2014 include the development of some new walking trails in the city of Ashland, implementing a geocaching program in both Boyd and Greenup counties, and partnering with local restaurants and grocers to improve community access to healthy foods.OLBH Homeless Care Initiative: This coalition of nurses and other OLBH personnel has provided health screening and flu shots to the homeless population of our community. Many of them volunteer at Church Without Walls, a worship service in Central Park on Saturday mornings that also provides breakfast. This initiative has collected coats, toiletries and food throughout the year to meet the needs of the homeless population.OLBH Green Team: The OLBH Green Team has implemented recycling programs (plastic, aluminum, electronics, printer cartridges and toners, cardboard, batteries, etc.) that offer the opportunity for our community residents to be better stewards of our earth and live in a healthier environment. In 2014, the team took on the project of renovating a walking trail on our campus that provides an opportunity for employees and community residents to walk, garden (adopt-a-flower-bed program) or just enjoy nature. The team also operates a clothing closet, has regular clean-up days for our campus and participates in Cell Phones for Soldiers by donating old cell phones to provide talk time for American military personnel around the world.Greenup County Interagency Council: OLBH provides leadership for this council that provides an opportunity for service agencies in Greenup County to meet monthly for networking and collaboration. These meetings have resulted in multiple partnerships and projects that benefit the community including a volunteer mentoring program that matches trained mentors from local congregations with students and/or families dealing with substance abuse issues; a nutrition education program that included cooking and canning classes by the cooperative extension agency, provision of fresh produce by the county farmers' markets and a celebratory health fair at the conclusion of the program that provided health screenings and information; and a Greenup County diabetes coalition. We work with companies to assist them in identifying needs for care for their employees by providing a health screening and analysis tool and help develop programming to address those needs. We also provide a free program to local business community to provide employee health assessments and DOT physicals as well as drug screenings for their employees. Diabetes Today Coalition partnered with Greenup County Extension and the local Farmers' Markets to provide cooking classes in July 2014 and food preservation classes in August 2014. These classes had capacity attendance.The 2 Good 4 Drugs curriculum is now in all schools in the Greenup County system. Plans are to implement it in the Russell and Raceland Independent systems during the current school yearRetired Judge Lew Nichols has developed a curriculum for families dealing with drug addiction and this is being piloted at McKell Middle SchoolTruth and Consequences was successfully piloted at Raceland High School in April, 2015. This was coordinated by Greenup County Extension but participating organizations included law enforcement, OLBH, the Greenup County Coroner, Social Services, local funeral directors, clergy and inmates from Summit FCI. The real-life scenarios depicting what actually happens when young people make decisions was extremely eye-opening for the freshmen at RHS--particularly, their encounters with inmates that are currently serving sentences for drug-related offenses. We plan to expand the program to the other two school systems in Greenup County during this school year.The Greenup County Health Department provided a free, drive-through flu immunization clinic in November, 2015. They gave approximately 500 immunizations. Part VI, Line 6: Bon Secours Health System, Inc., a Maryland nonprofit, nonstock membership corporation (BSHSI), and all of the other entities that are controlled directly or indirectly by Bon Secours, Inc, a Maryland nonprofit, nonstock membership corporation (BSI) are described collectively as the System. BSI, which is the sole corporate member of BSHSI, has no healthcare operations. The System was organized in June 1983 to fulfill the healthcare mission of the United States Province of the Congregation of the Sisters of Bon Secours of Paris, a congregation of religious women of the Roman Catholic Church founded in France in 1824. The System's activities are in the states of New York, Pennsylvania, Maryland, Virginia, Kentucky, South Carolina, and Florida, each referred to as a local system. The Ministry of BSHSI aids those in need, particularly those who are sick and dying, by offering services that include but are not limited to acute inpatient, outpatient, pastoral, palliative, home health, nursing home, rehabilitative, primary and secondary care and assisted living without regard to race, religion, color, gender, age, marital status, national origin, sexual orientation, or disability. BSHSI's vision to bring about the holistic health of the communities it serves is implemented through its Strategic Quality Plan which provides focus in five goal areas for the current three year period (2013-2015). One of those goals was to bring our communities to wholeness. To accomplish this, two key strategies are to: - Improve Health Locally and Globally- Build Partnerships for Population Health As a member of the Catholic health ministry and a member of Bon Secours Health System, Inc. (BSHSI), this organization and it's related entities are called to continue the healing ministry of Jesus. We exist to benefit the people living in the communities it serves. Through all of the services offered to the community, the mission is "to bring compassion to health care and to be good help to those in need, especially those who are poor and dying. As a System of caregivers, we commit ourselves to help bring people and communities to health and wholeness as part of the healing ministry of Jesus Christ and the Catholic Church." This organization and related organizations share the BSHSI Vision. "Inspired by the healing ministry of Jesus Christ and the charism of Bon Secours, Bon Secours Health System will be recognized for its leadership in justice, transforming the communities in which we serve and work into places of health and hope, and being a prophetic voice for systemic US health reform and a more humane world." Please see Schedule R for listings of the related organizations. Part VI, Line 7, Reports Filed With States KY 1 Bon Secours Kentucky Health System Foundation Inc St Christopher Drive Ashland KY 41101 611381952 501(c)(3) 582583 General and Administrative Support 1 0 Part I, Line 2: The organization complies with Bons Secours Health System, Inc's system-wide financial and accounting policies. Contributions are generally made as reimbursements for funds spent. In such cases, the donee/grantee organization must provide documentation to the filing organization before funds are approved for disbursement. Grant administration is maintained within the Foundation arm and recieved by the hospital as reimbursement for spend. 0 1 0 0 0 0 0 0 0 Kevin Halter FACHE CEO - BSKY 0 321216 0 110244 0 46030 0 24861 0 29965 0 532316 0 3452 Lawrence Hubbard CHCIO Board Member 0 387377 0 123245 0 136749 0 15600 0 21153 0 684124 0 0 Elizabeth Keith Board Member 0 151907 0 22815 0 59793 0 10438 0 17253 0 262206 0 13778 Thomas Morris PhD President 0 297010 0 95892 0 43530 0 39792 0 19683 0 495907 0 16418 Joe Buchheit Treasurer/CFO-BSKY 225440 0 65389 0 40840 0 9647 0 18568 0 359884 0 0 0 Rodney Hieneman Secretary 140045 0 29062 0 592 0 4908 0 26479 0 201086 0 0 0 Daniel Goulson CMO 316247 0 63612 0 1367 0 11700 0 25759 0 418685 0 0 0 Michele Friday MD Cardiologist 490718 0 159328 0 1450 0 4312 0 27536 0 683344 0 0 0 Yogendra Prasad MD Cardiologist 439878 0 205403 0 1345 0 4224 0 28453 0 679303 0 0 0 Kurt Jaenicke MD Obstetrician 340641 0 279766 0 1553 0 4406 0 27965 0 654331 0 0 0 Phillip Lackey MD Plastic Surgeon 394881 0 500 0 1051 0 4217 0 26136 0 426785 0 0 0 Jason Ford MD Pediatrician 131829 0 180041 0 508 0 4206 0 25905 0 342489 0 0 0 Part I, Line 3 Bon Secours Health System, Inc., a related organization of the filing organization, uses the following to establish the compensation of the organization's CEO/Executive Director: Compensation Committee Independent Compensation Consultant Written Employment Contract Compensation Survey or Study Approval by the Board or Compensation Committee Part I, Line 4b The filing organization participates in a BSHSI sponsored executive retirement program that allows for deposits into additional retirement plans and available only to key employees. The 457F plan is a non-qualified plan and is subject to a minimum three-year service requirement before vesting on deposits made into this plan. Individuals that received a distribution include: Kevin Halter, FACHE, $4,608; Thomas Morris, PhD, $20,852; Elizabeth Keith, $19,747. X 1 1158614 Cost or selling price 0 0 1 0 Part I, Column (b): The amount reported in Column (b) refers to the number of contributions. Form 990, Part VI, Section A, line 6 Bon Secours Health System, Inc. is the sole member of Bon Secours Kentucky Health System, Inc. which in turn is the sole member of Our Lady of Bellefonte Hospital, Inc. Form 990, Part VI, Section A, line 7a The governing body of Our Lady of Bellefonte Hospital, Inc. is appointed by its Member, Bon Secours Kentucky Health System, Inc. and subject to approval by Bon Secours Health System, Inc. Form 990, Part VI, Section A, line 7b Certain authorities of Our Lady of Bellefonte Hospital, Inc. are reserved to its member or to Bon Secours Health System, Inc. Form 990, Part VI, Section B, line 11 The process the organization uses to review the Form 990 consists of a review by the local system's audit and compliance board-committee and providing the form to the local system board of directors to allow for a thorough review by both before the filing date. The local system's audit and compliance committee and board of directors have reviewed the Form 990, scheduled time on meeting agendas, and asked questions regarding the Form 990 before the return is filed. Form 990, Part VI, Section B, line 12c The organization regularly and consistently monitors compliance with the conflict of interest policy. On an annual basis, all persons subject to the policy, including all officers, directors and key employees are required to make certain disclosures. These include disclosures related to certain personal, financial and organizational relationships that may present a conflict, or the appearance of a conflict of interest with the organization. All disclosures go through a three-part review process: (1) disclosures are reviewed first by the corporate responsibility officer (CRO); (2) a governance team comprised of the CEO, board president, board chair, CRO, and the BSHSI CRO participate in a second review of all disclosures during which recommendations are made as to the resolution of any conflicts or potential conflicts. Depending on the facts and circumstances, resolutions may include ongoing disclosure, recusal or removal of the conflict; and (3) all disclosures and recommendations are reviewed by a board committee (audit and compliance committee reviews the disclosures of management and the governance committee reviews the disclosures of the board and board committee members). Form 990, Part VI, Section B, line 15b The compensation committee of the board of Bon Secours Health System, Inc. (BSHSI) engages in a comprehensive process for the oversight and management of remuneration for executive employees and disqualified parties of the BSHSI. The compensation committee consists of a group of independent board members and engages independent external compensation consultant to ensure they receive appropriate analysis of market and follow the practices necessary to obtain full compliance with the IRS's rebuttable presumption of reasonableness. The committee establishes and maintains a compensation philosophy; reviews pay practices against local, regional and national healthcare organizations and approves all remunerative decisions for this group of individuals. The committee reviews and receives assurances that all levels of pay within the organization are reasonable based on performance and validates incentives are met. These decisions are documented in the BSHSI board of directors and compensation committee minutes. Compensation Process Other Officers/Key Employees: For those key employees and highest paid employees that are not reviewed by the BSHSI compensation committee, the process included a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision. In the review, the other officers or key employees of the organization were compared to other hospitals' employees in the area that hold the same title. During the review and approval of the compensation, documentation of the decision was recorded in human resources. Form 990, Part VI, Section C, line 19 Our Lady of Bellefonte Hospital, Inc. provides any documents open to public inspection upon request. Form 990, Part VII - Additional Disclosure: Board Member positions are generally voluntary in nature. Compensated employees of the filing organization and other related organizations who also hold board positions are compensated only in relation to their employment and do not receive additional compensation for their board responsibilities. Form 990, Part XI, line 9: Minimum Pension Liability -6,544,308. Transfer to BSHSI for Swaps & Debt -1,392,085. Bon Secours Health System Inc 1505 Marriottsville Road Marriottsville MD 21104 521301088 Parent Org. Management Services MD 501(c)(3) Line 11c, III-FI Bon Secours Inc 0 Bellefonte Physician Services Inc 1000 St Christopher Drive Ashland KY 41101 352320780 Physician Practices KY 501(c)(3) Line 9 Bon Secours Kentucky Health System Inc 0 Bon Secours Kentucky Health System Foundation Inc 1000 St Christopher Drive Ashland KY 41101 611381952 Grant Making Foundation KY 501(c)(3) Line 7 Bon Secours Kentucky Health System Inc 0 Bon Secours Kentucky Health System Inc 1000 St Christopher Drive Ashland KY 41101 611356024 Local System Parent Org. KY 501(c)(3) Line 11c, III-FI Bon Secours Health System Inc 0 Our Lady of Bellefonte Hospital Auxiliary 1000 St Christopher Drive Ashland KY 41101 610488859 Fundraising for Our Lady of Bellefonte Hospital KY 501(c)(3) N/A 0 0 1 1 0 0 0 0 0 0 1 0 0 1 0 0 1 1 1 0