2016-07-12T14:15:38-05:00 2015-08-31 861065772 Deloitte Tax LLP 191 Peachtree St Suite 2000 Atlanta GA 303031749 990 2014-09-01 540793767 St Mary's Hospital of Richmond Inc STMA 8042818413 8580 Magellan Parkway Building IV Richmond VA 23227 Stephan F Quiriconi Treasurer BSR-VP Finance 8042818316 2016-07-12 1 John W Sadoff Jr P00540589 4042201500 2014 2016-09-27 15:27:22Z St Mary's Hospital Toni R Ardabell 5801 Bremo Road Richmond VA 23226 695000534 0 X www.bonsecours.com X 1961 VA Acute Care Hospital 21 17 4971 770 1705919 0 3237171 5031944 665247391 676068247 14195720 8991403 3168783 4172721 685849065 694264315 5491932 24563738 0 0 296365567 303839926 0 0 0 338867317 346988951 640724816 675392615 45124249 18871700 905515684 920062513 309937386 333473607 595578298 586588906 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 623707562 24563738 556286996 St. Mary's Hospital provides medical care to patients without regard to their ability to pay. As the major community not for profit hospital in Richmond, St. Mary's is the access for under-insured and financially disadvantaged who will not be treated at the for profit hospitals. In addition, St. Mary's provides support for community services. Please refer to the Community Benefit information on Schedule H. 0 0 120609979 St. Mary's Hospital provides shared services to related organizations to assist with furthering its mission of providing help to those in need. 842781 0 150350 The Bon Secours St. Mary's Hospital School of Medical Imaging offers an accredited 18-month radiography program designed to prepare individuals to enter the workforce as Diagnostic Radiologic Technologists. This new and innovative curriculum will allow students to enter the workforce more quickly while maintaining high standards of education. The Radiography program quality and depth has remained the same and continues to meet requirements established by the American Society of Radiologic Technologists. 624550343 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 1 0 0 0 0 1 0 0 0 1 262 0 1 4971 1 1 1 0 0 0 0 0 0 0 0 0 X 21 17 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 1 1 0 VA X Laura Ellison 4433673835 8990 Old Annapolis Road Columbia MD 21045 X Toni Ardabell CEO-SMH / CEO-Richmond (Sep-Dec / Jan-Aug) 19.20 9.70 X X 0 734625 46332 Jean Bolling Board Member 2.00 0.00 X 0 0 0 John Bowman MD Board Member 2.00 0.00 X 0 0 0 Barry Case Board Member (Sep-Jun) 2.00 1.00 X 0 0 0 Chandrashekar Challa Board Member 2.00 0.00 X 0 0 0 John Daniel III MD Board Member 2.00 0.00 X 0 0 0 Anup Gokli MD Board Member 2.00 0.00 X 0 0 0 Mark Gordon Board Member 2.00 48.00 X 0 546935 53356 Pamela Hacker Board Member 2.00 0.00 X 0 0 0 James Holmes Board Member (Jan-Aug) 2.00 48.00 X 0 233879 29009 BH Hubbard Board Member (Jan-Aug) 2.00 0.00 X 0 0 0 Sr Anne Mack CBS President 3.00 47.00 X X 0 0 0 Joanne Nattrass Board Member 2.00 0.00 X 0 0 0 Fr Jack Podsiadlo Board Member (Jan-Aug) 2.00 0.00 X 0 0 0 Michael Robinson Board Member 2.00 48.00 X 0 730851 25808 Sr Victoria Segura CBS Board Member 10.00 40.00 X X 0 0 0 William Shewmake Board Member 2.00 0.00 X 0 0 0 Shannon Sinclair Board Member 2.00 0.00 X 0 0 0 William Stallings MD Board Member 2.00 0.00 X 0 0 0 Nancy Thomas Chairman 3.00 0.00 X X 0 0 0 Michael Williams Board Member 2.00 0.00 X 0 0 0 Thomas Winfree Board Member 2.00 0.00 X 0 0 0 Peter Bernard CEO - Virginia 6.90 43.10 X 0 1489553 205165 Allen Goolsby III Secretary 2.00 2.00 X 0 0 0 Stephan Quiriconi Treasurer 9.00 41.00 X 307530 0 14228 Jim Godwin VP HR 20.50 29.50 X 254827 0 31651 John Turner VP Orthopedics 16.00 34.00 X 273216 0 30873 Francine Barr VP COO 50.00 0.00 X 390343 0 3906 Eleanor League VP CNE 50.00 0.00 X 166775 0 24594 Marc Katz MD Cardiologist 50.00 0.00 X 923877 0 34979 Alexander Stojadinovic Surgeon (Sep-Oct) 50.00 0.00 X 687318 0 14644 Julia Padgett MD Dermatologist 50.00 0.00 X 751795 0 13000 Christine Browning MD Cardiologist 50.00 0.00 X 719624 0 46747 Mark Bladergroen MD CMIO 50.00 0.00 X 692991 0 21000 Kathleen Santini Former Key Employee 0.00 0.00 X 151246 0 15658 5319542 3735843 610950 329 1 1 0 Aramark CTS Inc 12483 Collections Ctr Dr Chicago IL 60693 Medical Equipment Maintenance/Rental 9048103 Free Agents Marketing 4800 Cox Road Suite 100 Glen Allen VA 23060 Marketing/Advertising 7693147 Morrison Mgt Specialists PO Box 102289 Atlanta GA 303682289 Dietary Management 6235302 Central VA Health Network 2201 W Broad St Ste 202 Richmond VA 232202022 Care Management 5940060 Inhealth 2201 W Broad St Ste 202 Richmond VA 232202022 Care Management 4160000 138 4028362 1003582 2544862 5031944 Patient Service Rev. 621300 553603318 553603318 Shared Services 561000 122314579 120609979 1704600 Sch. of Imag. Tuition 611310 150350 150350 676068247 3436018 3436018 737251 736219 1032 1032 1319 -287 5536385 19000 0 0 5536385 19000 5555385 5555385 Clinical Drug Trials 900099 2021501 2021501 Care Coordination 900099 662177 662177 Joint Venture 900099 530440 530440 957571 957571 4171689 694264315 677047325 1705919 10479127 24563738 24563738 1534359 1380923 153436 234401596 210961436 23440160 14778934 13301041 1477893 35679234 32111311 3567923 17445803 15701223 1744580 1494309 1344878 149431 36750 33075 3675 13410194 13410194 10724049 9651644 1072405 7676546 6908891 767655 34665537 31198983 3466554 19958466 17962619 1995847 1781296 1603166 178130 2058020 1852218 205802 6448192 6448192 31613804 28452424 3161380 2206151 1985536 220615 Medical Supplies 99079000 99079000 Purchased Services 76997537 69297783 7699754 Bad Debt Expense 23468783 23468783 Prof Org & Assoc Dues 1298489 1168640 129849 14071828 12664645 1407183 675392615 624550343 50842272 0 2081 1530 299135203 302115638 63367492 69113258 20518 1411562 8048879 10011895 4030187 4177362 417818777 280484908 135580250 137333869 371892583 373125817 50000 50000 23388491 22721582 905515684 920062513 80418371 84675556 14157062 13213197 43637927 39901221 171724026 195683633 309937386 333473607 X 595547413 586585249 30885 3657 595578298 586588906 905515684 920062513 X 18871700 -6423685 -21437407 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 36750 36750 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. 4926706 4926706 170125640 82202015 87923625 19706090 9239048 10467042 212603994 186269370 26334624 10456347 2774475 7681872 137333869 LT Pension Liability 116612028 Due to BSHSI 37688901 Other Liabilities (MOB Reynolds lease from 2008) 23079962 HPL/GL Liability 14552392 Due to Affiliates 2519550 Medicare/Medicaid Settlement 832850 Other LTL & Deferred Credits 397617 Unclaimed Property 333 195683633 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 10882436 32046 10850390 0.01660 56944005 40073484 16870521 0.02590 67826441 40105530 27720911 0.04250 13 19200 6601584 104192 6497392 0.01000 1 33 1821004 838530 982474 0.00150 1 0 1955 0 1955 0.00000 0 0 0 0 1 0 1138666 0 1138666 0.00170 16 19233 9563209 942722 8620487 0.01320 16 19233 77389650 41048252 36341398 0.05570 0 0 0 0 0 0 0 0 1 0 10000 0 10000 0.00000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 10000 10000 1 23468783 0 105485627 119399615 -13913988 X 1 1 1 1 St Mary's Hospital of Richmond Inc 5801 Bremo Road Richmond VA 23226 http://richmond.bonsecours.com H1833 X X X X X St Mary's Hospital of Richmond Inc 1 0 0 1 X X X X X X X X X 12 1 0 0 1 X http://richmond.bonsecours.com X 1 12 1 http://richmond.bonsecours.com 1 0 1 X 200.000000000000 X 1 1 X X X 1 X http://richmond.bonsecours.com X http://richmond.bonsecours.com X X X X X 1 X 1 X X X X X 1 X 0 0 St. Mary's Hospital of Richmond, Inc. Part V, Section B, Line 5: Community SurveyAn electronic survey using Survey Monkey was developed and administered to 488 community members and partners by CHS. Individuals were invited to participate based on their ability to represent: underserved, low-income and minority population needs; needs of chronically ill patients; and awareness of healthcare needs in their respective communities. A total of 152 (31%) responded, though not all participants completed each question. Participants represented over 60 agencies from across the primary service area, including concerned citizens, faith community leaders, free clinics, physicians, elected officials and governmental servants. Participants were asked to share their viewpoints on:- Important health concerns in the community;- Significant service gaps in the community; - Ideas for addressing concerns and service gaps.To gauge the importance of various health concerns, respondents were asked to identify issues of community concern from a list modified from topics in Healthy People 2020. Respondents were able to enter additional concerns in an open-ended response item. Participants were also asked to review a list of services typically important to addressing health concerns. Respondents were then asked to indicate services that needed to be strengthened in terms of availability, access, or quality. Open-ended response items were provided for participants to indicate additional service gaps in the community and ideas for addressing concerns and service gaps. Priority Needs The Bon Secours Richmond CHNA Community Review session covered all four hospitals, and was facilitated by Becky Clay Christensen. This review included: Medical Directors and Associate Medical Directors covering Health Departments for four jurisdictions; Health Department Registered Nurses from two jurisdictions; Chief Operating Officer of a Free Clinic; Executive Director of a Federally Qualified Health Center; Executive Director for Community Health Services; Director of Richmond Promise Neighborhoods. In addition to these community health leaders, the following internal leaders also participated: Senior Vice President of Sponsorship for Bon Secours Richmond; Administrative Director for Community Health Services; Administrative Director for Advocacy; Manager for Evaluation and Sustainability; Manager for Community Nutrition; Two Healthy Community Liaisons. After hearing a presentation on initial findings, which included secondary and survey data, this group discussed and made "dot choices" to help prioritize issues by distributing dots on issues from the report and raised by the group. St. Mary's Hospital of Richmond, Inc. Part V, Section B, Line 11: The Implementation Plan focuses on three broad areas including Health Prevention and Promotion, Access to Health Care and Support Services. A focus in the area of Health Prevention and Promotion is access to and preparation of healthy food. Multiple community partnerships advance this work including provision of fresh produce in identified food deserts, creation of community gardens in underserved neighborhoods and nutrition instruction in school and community settings. Over 11,500 community members were engaged in nutrition activities.Access to Health Care addresses the needs of the uninsured in the greater metropolitan Richmond area. The mobile health program, Care-A-Van, provides culturally competent primary care services to the uninsured in collaboration with 21 church partners. Over 19,000 patient visits were rendered in FY 2015. Bon Secours also supports the free clinic safety net by providing financial support, lab services and in-kind inpatient and outpatient services.Healthy Beginnings is an example of a Support Service focused on prenatal, postpartum and newborn care. Assistance is provided to women helping them identify and access resources to support their pregnancy. Services include Medicaid enrollment, parenting classes and nutritional support (WIC) among others.Dental Care/Oral HealthDental Care was identified in the CHNA community survey as a gap. Oral health is important because it can impact general health. Multiple community organizations are engaged in providing dental care services to the uninsured. They include Virginia Commonwealth University's School of Dentistry, Daily Planet, FQHC, Vernon J. Harris FQHC Dental Clinic, CrossOver Ministry and Goochland Free Clinic and Family Services. As such Bon Secours will not be addressing dental needs at this time.Transportation Other community organizations are better positioned to provide transportation. The Greater Richmond Transit Authority (GRTC) serves the City of Richmond and Henrico County. They have 186 buses and 40 routes. Each bus is equipped with a wheel chair lift. GRTC serves the Richmond Community Hospital campus.GRTC CARE service provides curb-to-curb public transportation to disabled individuals who may not be reasonably able to use the GRTC fixed route bus. It is also available for persons aged 80 or older. Richmond Community Hospital provides limited patient transportation. Patients who reside within a 10-mile radius of the hospital may utilize the patient transport van to reach the hospital campus. This service includes behavioral health patients.Lack of adequate transportation can be a barrier to accessing health care services. The Bon Secours Care-A-Van is a mobile health outreach program providing primary care services in local neighborhoods in the Richmond Community Hospital service area. The Care-A-Van contributes to the elimination of transportation as a barrier to care for uninsured patients. St. Mary's Hospital of Richmond, 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. St. Mary's Hospital of Richmond, 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. St. Mary's Hospital of Richmond, 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 out 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 St. Mary's Hospital of Richmond, Inc. Part V, Section B, line 16a website: http://richmond.bonsecours.com St. Mary's Hospital of Richmond, Inc. Part V, Section B, line 16b website: http://richmond.bonsecours.com 46 Cardiovascular Associates of VA 7001 Forest Avenue Suite 200 Richmond VA 232301727 Physician Practice Women's Imaging Center 5875 Bremo Road MOB South Suite 105 Richmond VA 23226 Imaging PTOTSPLymphedema 5875 Bremo Road MOB South Suite 611 Richmond VA 23226 Physicial Therapy, Outpatient Care, Etc. Patterson Avenue Family Practice 9600 Patterson Avenue Richmond VA 23229 Physician Practice Sleep Lab (located at St Mary's) 5875 Bremo Rd Suite 709 Richmond VA 23226 Sleep Lab Cardiac Surgery Specialists 5875 Bremo Road MOB South Suite G-5 Richmond VA 231226234 Physician Practice West End Internal Medicine 7001 Forest Avenue Suite 2500 Richmond VA 23230 Physician Practice Surgical Dermatology Center 5207 Hickory Park Drive Suite A Glen Allen VA 230592624 Physician Practice Perinatal Center 5855 Bremo Road MOB North Suite 306 Richmond VA 232261926 Physician Practice Associated Internists 5855 Bremo Road MOB North Suite 207 Richmond VA 232261930 Physician Practice Sports Medicine 9600 Patterson Avenue Richmond VA 232296053 Sports Medicine Rehab Sleep Center - Chesterfield 13520 Hull St Midlothian VA 23112 Sleep Lab Commonwealth Gynecologic Oncology (GYN O 5875 Bremo Road MOB South Suite G-7 Richmond VA 232261934 Physician Practice Monument Internal Medicine 5855 Bremo Road MOB North Suite 102 Richmond VA 23226 Physician Practice Commonwealth Internal Medicine 9220 Forest Avenue Suite 1-A Richmond VA 23235 Physician Practice OP Wound Care 6900 Forest Avenue Suite 115 Richmond VA 23230 OP Wound Care Senior Care Services 7001 Forest Avenue Suite 100 Richmond VA 23230 Physician Practice Pediatric Gastreonterology 5875 Bremo Road MOB South Suite 303 Richmond VA 23175 Physician Practice Neurology Clinic at St Mary's 5801 Bremo Road Richmond VA 23226 Physician Practice Arthritis & Osteroporosis Center 9600 Patterson Avenue Richmond VA 232296053 Physician Practice Oncology Associates 5875 Bremo Road Richmond VA 23226 Physician Practice Redskins Sports Performance 2401 W Leigh Street Richmond VA 23226 Sports Medicine Rehab Glen Allen Internal Medicine 5207 Hickory Park Drive Suite A Glen Allen VA 23059 Physician Practice Pediatric Endo & Diabetes Assoc 5875 Bremo Road MOB South Suite 207 Richmond VA 232261926 Physician Practice Liver Institute of Virginia 5855 Bremo Road MOB North Suite 509 Richmond VA 232261926 Physician Practice Liver Institute of Virginia-MIH 5855 Bremo Road MOB North Suite 509 Richmond VA 232261926 Physician Practice Cure and Care 5875 Bremo Road MOB South Suite 110 Richmond VA 232261926 Physician Practice Palliative Care Clinic 2366 Colony Crossing Midlothian VA 231124280 Physician Practice Advan Heart Fail Cntr-LVAD program 7001 Forest Avenue Suite 103 Richmond VA 23230 Cardiac Rehabilitation Cardiac Rehab 7001 Forest Avenue Suite 101 Richmond VA 23230 Cardiac Rehabilitation Pediatric Lung Care 5875 Bremo Road MOB South Suite 104 Richmond VA 232261930 Physician Practice Bon Sec Sports Med and Fam Pra 2401 W Leigh Street Richmond VA 23226 Physician Practice Pediatric Dental 6900 Forest Avenue Suite 110 Richmond VA 23141 Physician Practice Diabetes Treatment Center 5875 Bremo Road MOB South Suite 712 Richmond VA 23226 Diabetes Treatment BS Infectious Disease Specialists 5855 Bremo Road MOB North Suite 102 Richmond VA 23225 Physician Practice BS Developme & Special Needs Peds 5875 Bremo Road MOB South Suite 104 Richmond VA 232261934 Physician Practice Parham Road Internal Medicine 2600 E Parham Road Richmond VA 23228 Physician Practice Good Health Clinic 5875 Bremo Road MOB South Suite 204 Richmond VA 232261926 Physician Practice BS Canal Crossing Internal Med 5801 Bremo Road Richmond VA 23226 Physician Practice Pediatric Neurology Clinic 5875 Bremo Road MOB South Suite 207 Richmond VA 232261926 Physician Practice Neurointerventional Surg Serv 5875 Bremo Road MOB South Suite 208 Richmond VA 232261926 Physician Practice Surgical Oncology 5855 Bremo Rd MOB N Ste 406 506 Richmond VA 23226 Physician Practice BS Pediatric Hematology-Oncology 5875 Bremo Road MOB South Suite 303 Richmond VA 23226 Physician Practice Lactation Center (A Woman's Place) 4121 Cox Road Suite 110 Glen Allen VA 23059 Physician Practice BS Behavioral Hth Group at SMH 5855 Bremo Road MOB North Suite 104 Richmond VA 23226 Physician Practice Pediatric Infectious Disease 5875 Bremo Road MOB South Suite 303 Richmond VA 232261934 Physician Practice 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 Richmond Health System (BSRHS) publishes a report for the community on the 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 online at www.bonsecours.com/about-us-about-bon-secours.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: $23,468,783. Part II, Community Building Activities: A healthy community liaison (HCL) was employed by St. Mary's Hospital during FY 2013. The purpose of the HCL is to improve community health in targeted neighborhoods by engaging stakeholders and residents to identify and prioritize community needs. 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: $301,076. 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: BSR contracted with Community Health Solutions (CHS), a local Healthcare Consultant who was recommended by the Virginia Hospital and Healthcare Association (VHHA) to assist with data collection and analysis. Becky Clay Christenson, of The Clay Christensen Group, facilitated conversation to prioritize and vet findings from the initial data collection. Jason W. Smith, PhD, consulted on the CHNA and implementation strategy process, documenting method, analyzing data, and synthesizing components into a public document. The CHNA was conducted during Fiscal Year 2013 (September 1, 2012 to August 31, 2013.) in order to prepare documents by the end of the fiscal year. It was determined that existing secondary data, augmented by a key informant survey, would be used to identify and prioritize health indicators. An executive summary and report was then presented to system leadership from Mission and Business Development. Findings were then presented to the St. Mary's Hospital Senior Operations Team for further review and comment. Finally, a presentation was made to the Bon Secours Richmond Health System Board for final approval prior to being made available to the public.Secondary DataThe core of the secondary data analysis was conducted by CHS in order to develop a Community Health Indicator Profile. The analysis intentionally did not include every possible indicator, but instead focused on key metrics that provide a broad insight into community health. Availability of data sources was also considered in selection of content. In many cases, results can be considered in comparison to Virginia averages. Foundational source of data include: Alteryx, Inc.; Virginia Department of Health; hospital discharge data from Virginia Health Information, Inc.; Health Resources and Administration data. In other cases, data was only readily available at the state or national levels and synthetic estimates were created by CHS in order to further develop the community profile. CHS developed statistical models to produce estimates where local data was not available. This analysis was based on the CDC's Behavioral Risk Factor Surveillance Survey; the Virginia Foundation for Youth's Market Decisions' 2010 Obesity Survey; a report produced for Virginia Healthcare Foundation by Urban Institute; and local demographic characteristics obtained by Alteryx, Inc. Because the data is extrapolated, meaningful comparisons to state and national averages cannot be made. Community Input Input from community members was included in assessing health care needs as described in Part V, Line 5 below. 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: The St. Mary's Hospital service area consists of sixty-one zip codes that fall primarily within the counties of Chesterfield, Goochland, Hanover, Henrico and Louisa; and the cities of Petersburg and Richmond. The community of the St. Mary's Hospital primary service area contained 1,230,852 people as of 2010, of which 52% are female and 48% male--a population that is expected to grow to 1,293,100 by 2015. Compared to the Commonwealth of Virginia as a whole, this region is more densely populated (329.6 people per sq. mile) and is proportionately more Black/African American (29%). The median income of the community is $58,538, just under the median household income in Virginia of $60,034. The study region also has higher rates of low-income households (28% are Low Income Households with income less than $35,000) and slightly more adults age 25+ with a high school education. Part VI, Line 5: St. Mary's Hospital has an open medical staff with privileges available to all qualified physicians in the area. St. Mary's Hospital through the Bon Secours Richmond Health System is governed by a board of directors whose composition is representative of the community.St. Mary's Hospital engages in medical research. Inpatient and outpatient research-related activities are conducted by St. Mary's with oversight from the Bon Secours Richmond Health System Institutional Review Board. St. Mary's Hospital provides training and education of health care professionals. The Bon Secours St. Mary's School of Imaging, sponsored by St. Mary's Hospital had 33 enrolled students in fiscal year 2015. Noah's Children, located at St. Mary's Hospital, is Central Virginia's only pediatric hospice and palliative care program. It is a specialized program of comprehensive care serving infants, children and adolescents who have been diagnosed with a life-threatening illness, and their families. This holistic program ensures compassionate care at the most difficult time for a family by addressing their physical, emotional, social, spiritual and practical needs, so that they can focus on making sure their child's remaining time is as rich and meaningful as possible. In FY 15, 44 families were served.The Care-A-Vans are mobile health care clinics, which travel throughout the Richmond Metro area to provide free primary, urgent and preventive care to patients. Patients on these vans speak many different languages. Approximately one-third of the Care-A-Van's staff are bilingual in English and Spanish. Each van is a self-contained mobile clinic with examining rooms, storage, bathroom, and waiting area. Services include health screenings, childhood immunizations, flu shots for adults, school physicals for uninsured children and examination and treatment of sick patients who are uninsured. Patients who need health care from specialists are referred to volunteer physicians within the community including Bon Secours Medical Group physicians. The vans make regular stops six days a week at churches providing 12,137 patient visits in FY 15. Bon Secours Richmond Health System partnered with the Daily Planet, a federally qualified health center and St. Joseph's Villa for Children, a not-for-profit organization serving children with special needs, at risk youth, and adults with disabilities to create St. Joseph's Outreach Clinic. The clinic provides primary care services to both the insured and the uninsured and serves a large Hispanic population. In FY 15, 6,996 patient visits were provided. Controlling Asthma in the Richmond Metropolitan Area (CARMA) works to improve the management of pediatric asthma through collaborative partnerships with multiple health care systems, schools, American Lung Association, community physicians and schools, case management organizations, and universities. In FY 15 over 2,794 children, parents, teachers and physicians were directly served through CARMA's services. Every Women's Life (EWL), Virginia Breast and Cervical Cancer Early Detection Program is a partnership with the Virginia Department of Health, with funding through the Centers for Disease Control and Prevention. This program provides breast and cervical cancer screenings and diagnostic testing if needed for low income, uninsured women who are 40 to 64 years old. If cancer is found, women are enrolled in Medicaid for treatment. BSRHS holds clinics in six facilities in the Richmond Metro area. Additionally, BSRHS provides case management, follow-up and patient education for these women. In FY 15, 799 screenings were provided. BSRHS assists low to moderate-income families whose children may qualify for state-sponsored insurance programs (Medicaid and FAMIS). Partnerships have developed with other agencies that have enrollers to identify and refer uninsured children, avoid duplication of effort, and to share responsibilities for case managing to complete the enrollment process. Two BSRHS outreach specialists enrolled or re-enrolled over 140 children in FAMIS or Medicaid in FY 15.The nationally recognized Reach Out and Read (ROR) program provides books for young children when they visit the Care-A-Van. Volunteers transform the sites into literary rich areas for children and parents while helping families learn the joys and techniques of reading aloud. Volunteers distributed 482 books in FY 2015 to children at Care-A-Van sites. 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 VA 1 Bon Secours Richmond Healthcare Foundation 7229 Forest Avenue Suite 200 Richmond VA 23226 541201346 501(C)(3) 3518295 General Support Bon Secours Richmond Health System 8580 Magellan Parkway Richmond VA 23227 521988421 501(C)(3) 17846352 General Support for Rappahannock Access Now Inc 2821 Emerywood Parkway Richmond VA 23294 261695468 501(C)(3) 75000 Coordination of Specialist Care for un/underinsured All Saints Catholic School 3418 Noble Ave Richmond VA 23222 541199580 501(C)(3) 5000 Afterschool Programming ART 180 114 W Marshall St Richmond VA 23220 541935207 501(C)(3) 5000 Youth Program Beacon Tree Foundation 9201 Arboretum Parkway Midlothian VA 23236 262471438 501(C)(3) 10000 Mental Health for Youth Benedictine Catholic High School 12829 River Rd Richmond VA 23238 453960058 501(C)(3) 50000 Mentoring program for students Benedictine Society of Virginia 12829 River Rd Richmond VA 23238 453960058 501(C)(3) 47500 Programming for students Better Housing Coalition 23 West Broad St Richmond VA 23219 541479059 501(C)(3) 95000 Senior Health & Wellness Program Blessed Sacrament Huguenot Catholic School 2501 Academy Rd Powhaten VA 23139 541901367 501(C)(3) 5000 Programming for students Challenge Discovery Projects 1503 Santa Rosa Rd Richmond VA 23229 510250681 501(C)(3) 10000 Counseling for youth for substance abuse The Children's Museum of Richmond 2626 W Broad St Richmond VA 23220 510220694 501(C)(3) 50000 Parenting Classes Church Hill Activities 601 N 31st St Richmond VA 23223 200220263 501(C)(3) 27639 Programming for East End teens Circle Center Adult Day Care Services 4900 W Marshall St Richmond VA 23230 540991287 501(C)(3) 25000 Day Care for Senior Citizens-Dementia Care Code For America Labs Inc 115 9th St San Francisco CA 94103 271067272 501(C)(3) 75000 Electronic Medical Records for Free Clinics Commonwealth Catholic Charities 1601 Rolling Hill Dr Richmond VA 23229 540505877 501(C)(3) 75000 Programming Support - Mental Health counseling Crossover Healthcare Ministries 8600 Quiccasin Rd Richmond VA 23229 541371067 501(C)(3) 161000 Health Clinic for un/underinsured - programming / support The Daily Planet 517 W Grace St Richmond VA 23220 540900368 501(C)(3) 165833 Health Clinic for un/underinsured - programming / support East District Resource Center 2405 Jefferson Ave Richmond VA 23223 311769142 501(C)(3) 122392 Programs / Support for East End Resource Center Faison School for Autism 1701 Byrd Ave Richmond VA 23230 030387451 501(C)(3) 20000 Support for specialized autistic school programming Fan Free Clinic 1010 N Thompson St Richmond VA 23230 540927792 501(C)(3) 75000 Health Clinic for un/underinsured - programming / support First Things First of Greater Richmond 2121 Maywill St Richmond VA 23230 593766981 501(C)(3) 5000 Programs for Fathers/ families Free Clinic of Powhatan 3908 Old Buckingham Rd Powhatan VA 23139 261275136 501(C)(3) 43280 Health Clinic for un/underinsured - programming / support Full Circle Grief Center 10611 Patterson Ave Richmond VA 23238 263324192 501(C)(3) 66000 Program for children who have experienced a loss Goochland Free Clinic PO Box 116 Goochland VA 23063 541967650 501(C)(3) 50000 Health Clinic for un/underinsured - programming / support Great Aspirations 4551 Cox Road Ste 115 Glen Allen VA 23060 521277427 501(C)(3) 5500 Education planning and assistance Greater Richmond Fit4Kids 2500 W Broad St Richmond VA 23220 272817718 501(C)(3) 25000 Childhood obesity prevention program Groundwork RVA PO Box 14568 Richmond VA 23221 462191744 501(C)(3) 22417 East End Park project with Armstrong HS students Hanover Safe Place 629-A N Washington Hwy Ashland VA 23005 311415701 501(C)(3) 15000 Offering aid to domestic & sexual assault victims Hanover Tavern Foundation PO box 487 Hanover VA 23069 541559861 501(C)(3) 8190 Program support -Youth education HARPS Foundation 4200 Dover Rd Richmond VA 23221 311657824 501(C)(3) 31600 Hospital music program Henrico CASA 3001 Hungary Spring Rd Ste A Henrico VA 23228 541710746 501(C)(3) 5000 Court Appointed Special Advocates Program support Henrico Police Athletic League PO Box 15892 Richmond VA 23227 753243082 501(C)(3) 5000 Add swimming to at-risk youth summer camp Higher Achievement 4009 Fitzhugh Ave Ste 200 Richmond VA 23230 541383374 501(C)(3) 20000 Academic assistance for underserved middle school students Housing Families First 3900 Nine Mile Road Richmond VA 23223 541995917 501(C)(3) 25000 Rapid re-housing program Jack & Abby Neonatal Foundation PO Box 2628 Glen Allen VA 23058 270960848 501(C)(3) 5000 5K - Proceeds come back to Bon Secours Legal Info for Cancer PO Box 73281 Richmond VA 23235 541817025 501(C)(3) 10000 Financial & legal education for those with cancer Little Sisters of the Poor 1503 Michaels Road Henrico VA 23229 540608201 501(C)(3) 50000 Living assistance for the elderly Mechanicsville Churches Emergency Functions PO Box 604 Mechanicsville VA 23111 331168177 501(C)(3) 15000 Financial & transportation assistance to seniors Medical Society of Virginia 2924 Emerywood Pkwy Ste 300 Richmond VA 23294 521394768 501(C)(3) 25000 DOC Rx Program NAMI Virginia PO Box 8260 Richmond VA 23226 541267632 501(C)(3) 5000 Mental Illness Awareness program support Neighborhood Resource Center 1519 Williamsburg Rd Richmond VA 23231 331024355 501(C)(3) 30000 Office manager position support Partnership for the Future 4521 Highwoods Parkway Glen Allen VA 23060 311482889 501(C)(3) 15000 East End tutoring and mentoring program Peter Paul Development Center 1708 N 22nd Street Richmond VA 23223 541137164 501(C)(3) 25000 After school learning Positive Vibe Caf 2825 Hathaway Rd Richmond VA 23225 800016181 501(C)(3) 7500 Food service training for the disabled Prevent Blindness Mid Atlantic 11618 Busy St Richmond VA 23236 311662841 Other 25000 Vision Screening in Catholic Schools Project Homes 88 Carnation St Richmond VA 23225 541595851 501(C)(3) 262534 Acquisition, construction and assistance with homes. Rebuilding Together Richmond 406 W Franklin St Ste B Richmond VA 23220 541652359 501(C)(3) 5000 Safe home renovations for low income seniors Richmond Academy of Medicine 2821 Emerywood Pkwy Ste 200 Richmond VA 23294 510160045 501(C)(3) 40000 Advanced Care Planning Initiative Richmond Area High Blood Pressure Center 1200 W Cary Street Richmond VA 23220 521303481 501(C)(3) 18000 Program Support Richmond City Health District 1519 Williamsburg Rd Richmond VA 23231 331024355 501(C)(3) 80000 Resource Center support Richmond Cycling Corps 1717 Summit Ave Richmond VA 23230 582508155 501(C)(3) 62500 Expansion of program in East End of Richmond Richmond Hill 2209 E Grace St Richmond VA 23223 541360535 501(C)(3) 20000 Education assistance low income high school students Richmond Metro Habitat for Humanity 2281 Dabney Rd Ste A Richmond VA 23230 541385198 501(C)(3) 55000 Housing Richmond Public Schools 301 N 9th Street 17th Floor Richmond VA 23219 542025186 501(C)(3) 39500 Armstrong Priorities - Armstrong High School Robinson Theater 2903 Q Street Richmond VA 23223 264176813 501(C)(3) 15000 Hoop it Up for the Arts Fundraiser Rx Drug Access Partnership 2924 Emerywood Parkway 300 Richmond VA 23294 571186937 501(C)(3) 20000 Prescription Drug assistance program Safe Harbor PO Box 17996 Richmond VA 23226 541950038 501(C)(3) 50000 Counseling for domestic and sexual violence Saint Benedict School 3100 Grove Ave Richmond VA 23221 541752652 501(C)(3) 6500 Minds in Motion Program Salvation Army Central VA Chapter 2 West Grace St Richmond VA 23226 580660607 501(C)(3) 50000 Program and Aquatic Center support Greater Richmond SCAN 103 East Greace St Richmond VA 23219 541584969 501(C)(3) 20000 Program Support to fight child abuse Senior Connections 24 East Cary St Richmond VA 23219 540950714 501(C)(3) 40000 Triple Care Program Senior Navigator 7501 Boulders View Dr 201 North Chesterfield VA 23225 541977334 501(C)(3) 45000 Advanced Care Planning Initiative Shepherds Center of Chesterfield 6800 Lucy Corr Blvd Chesterfield VA 23832 542056732 501(C)(3) 10044 Transportation for elderly Southside Center for Violence PO Box 487 Blackstone VA 23824 541920837 501(C)(3) 13010 Support for Domestic Violence program Sportable Richmond Adaptable 1365 Overbrook Rd Room 2 Richmond VA 23220 208924701 501(C)(3) 15000 Playground equipment for children with disabilities St Francis Home 65 W Clopton Street Richmond VA 23225 541819325 501(C)(3) 30000 Nutrition Center St Gertrudes Catholic School 3215 Stuart Ave Richmond VA 23212 540551903 501(C)(3) 50000 Health programs St Joseph's Villa 8000 Brook Rd Richmond VA 23227 540505950 501(C)(3) 17500 Flagler House and after school program Steward School 11600 Gayton Rd Richmond VA 23238 510251819 501(C)(3) 5000 LEAP Program Transformation Retreats 1805 Monument Ave Ste 400 Richmond VA 23220 541914651 501(C)(3) 10000 Program support for the HIV/Aids population Tricycle Gardens 2314 Jefferson Ave Richmond VA 23223 753253795 501(C)(3) 125000 Urban Garden United Methodist Urban Shalom Farms 1010 W Laburnum Ave Richmond VA 23227 237136747 501(C)(3) 15000 Food prescription program United Way 2001 Maywill St Ste201 Richmond VA 23230 237375346 501(C)(3) 5000 Kindergarten registration program VA Hemophilia Society 410 N Ridge Ste 215 Richmond VA 23229 541183181 501(C)(3) 5000 Camp Youngblood VA State University Foundation PO Box 9027 Petersburg VA 23806 546074532 501(C)(3) 7150 Healthcare alliance program Valentine Richmond History Center 1015 East Clay St Richmond VA 23219 540505967 501(C)(3) 20000 Richmond history programs VA Homes for Boys and Girls 8716 West Broad St Richmond VA 23294 540506330 501(C)(3) 7000 Program support Virginia LISC 413 Stuart Circle Ste 300 Richmond VA 23220 133030229 501(C)(3) 215000 SEED Program and business education VA Center for Inclusive Communities 5511 Staples Mill Rd Ste 202 Richmond VA 23228 203188273 501(C)(3) 10000 VCIC Humanities Award Dinner Virginia Early Childhood Foundation 1703 N Parham Rd Suite 110 Richmond VA 23229 203970624 501(C)(3) 25000 Obesity program support VA Repertory Theater 114 W Broad St Richmond VA 23220 510159357 501(C)(3) 5000 Hugs & Kisses - Child abuse prevention Weinstein Jewish Community Center 5403 Monument Ave Richmond VA 23226 540535104 501(C)(3) 7000 Program funding support World Pediatric Project 7201 Glen Forest Drive Richmond VA 23226 541953305 501(C)(3) 25000 Staff in eastern Caribbean YMCA of Greater Richmond 2 West Franklin Street Richmond VA 23220 540505986 501(C)(3) 79863 Program support 84 1 Part I, Line 2: St. Mary's Hospital of Richmond, Inc. complies with Bon 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. X 1 1 0 1 0 0 0 0 0 0 0 Toni Ardabell CEO-SMH / CEO-Richmond (Sep-Dec / Ja 0 493876 0 159372 0 81377 0 43832 0 2500 0 780957 0 25794 Mark Gordon Board Member 0 336416 0 144733 0 65786 0 25236 0 28120 0 600291 0 17280 James Holmes Board Member (Jan-Aug) 0 233879 0 0 0 0 0 7939 0 21070 0 262888 0 0 Michael Robinson Board Member 0 464732 0 154883 0 111236 0 15600 0 10208 0 756659 0 0 Peter Bernard CEO - Virginia 0 789743 0 326469 0 373341 0 174403 0 30762 0 1694718 0 186126 Stephan Quiriconi Treasurer 248452 0 57920 0 1158 0 3945 0 10283 0 321758 0 0 0 Jim Godwin VP HR 206334 0 47086 0 1407 0 9594 0 22057 0 286478 0 0 0 John Turner VP Orthopedics 218380 0 53296 0 1540 0 3395 0 27478 0 304089 0 0 0 Francine Barr VP COO 284941 0 91003 0 14399 0 3906 0 0 0 394249 0 0 0 Eleanor League VP CNE 164110 0 1400 0 1265 0 3214 0 21380 0 191369 0 0 0 Marc Katz MD Cardiologist 919377 0 0 0 4500 0 3529 0 31450 0 958856 0 0 0 Alexander Stojadinovic Surgeon (Sep-Oct) 636916 0 692 0 49710 0 14644 0 0 0 701962 0 0 0 Julia Padgett MD Dermatologist 546649 0 204897 0 249 0 13000 0 0 0 764795 0 0 0 Christine Browning MD Cardiologist 426732 0 292165 0 727 0 13000 0 33747 0 766371 0 0 0 Mark Bladergroen MD CMIO 687115 0 300 0 5576 0 0 0 21000 0 713991 0 0 0 Kathleen Santini Former Key Employee 132654 0 75 0 18517 0 3296 0 12362 0 166904 0 0 0 Part I, Line 1a Select executives receive country club memberships primarily for business use and certain business related expenses are reimbursed. Receipts are required to substantiate the amounts eligible for reimbursement. 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: Peter Bernard, $241,741; Toni Ardabell, $37,602; Mark Gordon, $25,011. Martha E Merchent Married to Officer Stephan Quiriconi 177928 Employment 0 X 1 2544862 Cost or selling price Other: 0 0 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 Richmond LLC which was formerly Bon Secours Richmond Health Corp, a nonprofit tax exempt organization prior to conversion. Bon Secours Richmond LLC holds the majority interest in Bon Secours - Richmond Health System, which in turn is the sole member of St. Mary's Hospital of Richmond, Inc. Form 990, Part VI, Section A, line 7a The governing body of St. Mary's Hospital of Richmond, Inc. is appointed by it's member Bon Secours - Richmond Health System and subject to approval by Bon Secours Health System, Inc. Form 990, Part VI, Section A, line 7b Certain authorities of St. Mary's Hospital of Richmond, 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 an independent external compensation consultant to ensure they receive appropriate analysis of market and follow the practices necessary to obtain full compliance with the IRS' 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 The filing organization makes all documents available to the general public 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. The governing bodies of the hospitals of Bon Secours Richmond Health System, including Bon Secours St. Mary's Hospital, Bon Secours St. Francis Medical Center, Bon Secours Memorial Regional Medical Center and Richmond Community Hospital, are comprised of the same board members and board officers (Chairman, President, Secretary and Treasurer). These governing bodies are referred to as the Richmond Joint Board. Hours reported for these voluntary board positions represent total hours worked per week, which include responsibilities for all four hospitals). Sr. Anne Marie Mack and Sr Victoria Segura do not receive payroll distributions as they have taken vows of poverty. Form 990, Part XI, line 9: Transfers to and from Affiliates for Lease Buy Outs and Pension -1,159,677. Transfers to BSHSI for Debt, Swaps & Other -3,982,615. Minimun Pension Liability -16,295,115. 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 Bon Secours Richmond Healthcare Foundation 8580 Magellan Parkway Richmond VA 23227 541201346 Grant Making Foundation VA 501(c)(3) Line 7 Bon Secours Richmond LLC 0 Bon Secours Richmond Health System 8580 Magellan Parkway Richmond VA 23227 521988421 Local System Parent Org. VA 501(c)(3) Line 9 Bon Secours Richmond LLC 0 Bon Secours Memorial Regional Medical Center 8580 Magellan Parkway Richmond VA 23227 541744931 Health Care VA 501(c)(3) Line 3 Bon Secours Richmond Health System 0 Bon Secours Richmond Community Hospital 8580 Magellan Parkway Richmond VA 23227 540647482 Health Care VA 501(c)(3) Line 3 Bon Secours Richmond Health System 0 Bon Secours St Francis Medical Center 8580 Magellan Parkway Richmond VA 23227 311716973 Health Care VA 501(c)(3) Line 3 Bon Secours Richmond Health System 0 Laburnum Properties 8580 Magellan Parkway Richmond VA 23227 521260700 Title Holding Company VA 501(c)(2) Bon Secours Richmond Health System 0 Rappahanock General Hospital Foundation 101 Harris Road Kilmarnock VA 22482 541210450 Supporting Organization VA 501(c)(3) Line 7 Bon Secours Richmond Health System 0 Chesapeake Medical Group 101 Harris Road Kilmarnock VA 22482 541857174 Healthcare Services VA 501(c)(3) Line 9 Bon Secours Richmond Health System 0 Chesapeake Hospital Corporation PO Box 1449 Kilmarnock VA 22482 237424835 Health Care VA 501(c)(3) Line 3 Bon Secours Richmond Health System 0 St Mary's MRI LP 8580 Magellan Parkway Richmond VA 23227 541568022 Imaging Services VA N/A RI LP 8580 Magellan Parkway Richmond VA 23227 541708835 Imaging Services VA N/A Broad64 Imaging LLC 8580 Magellan Parkway Richmond VA 23227 205886018 Imaging Services VA N/A Richmond Radiation Oncology Center I LLC 8580 Magellan Parkway Richmond VA 23227 208444551 Radiation Oncology Services VA N/A Chesterfield Community Healthcare Center MOB I LLC 435 Southlake Blvd Richmond VA 23236 541745670 Rental - Medical Office Building VA N/A CCHC Inc 8580 Magellan Parkway Richmond VA 23227 541812738 Ambulatory Healthcare Services VA N/A C 0 RHS Management Corporation 8580 Magellan Parkway Richmond VA 23227 541313425 Independent Living Facility VA N/A C 0 Bon Secours - Virginia HealthSource Inc 8580 Magellan Parkway Richmond VA 23227 541417686 Ambulatory Healthcare Services VA N/A C 0 Richmond MRI Inc 8580 Magellan Parkway Richmond VA 23227 541568452 Imaging Services VA N/A C 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 1 1 1 1 0