2015-11-12T11:18:42-06:00 2014-12-31 381357951 PLANTE & MORAN PLLC 65 EAST STATE STREET COLUMBUS OH 43215 990 2014-01-01 340714535 SAMARITAN REGIONAL HEALTH SYSTEM SAMA 4192890491 1025 CENTER STREET ASHLAND OH 44805 DANNY L BOGGS PRESIDENT & CEO 4192890491 2015-11-11 1 BERNIE OSTROWSKI P00366367 6148493000 2014 2016-02-25 16:41:14Z SEE SCHEDULE O DANNY L BOGGS 1025 CENTER STREET ASHLAND OH 44805 82938137 0 X WWW.SAMARITANHOSPITAL.ORG X 1910 OH SAMARITAN REGIONAL HEALTH SYSTEM PROVIDES QUALITY MEDICAL HEALTHCARE SERVICES AND EDUCATION REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR ABILITY TO PAY. THE HOSPITAL PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS. SERVICES PROVIDED TO MEDICARE AND MEDICAID PATIENTS ARE SOMETIMES PROVIDED BELOW COST. TO THE EXTENT REIMBURSEMENT IS BELOW COST, THE HOSPITAL RECOGNIZES THESE AMOUNTS AS CHARITY CARE. CHARITY CARE IS ALSO PROVIDED THROUGHOUT THE YEAR BASED UPON ACTIVITIES AND SERVICES WHICH THE HOSPITAL BELIEVES WILL SERVE A BONA FIDE COMMUNITY HEALTH NEED. CHARITY CARE FOR 2014 WAS VALUED AT $2,083,763. DURING 2014, THE HOSPITAL ALSO PROVIDED NUMEROUS OUTREACH PROGRAMS WHICH SERVE AND EDUCATE THE COMMUNITY. 15 12 652 175 2855092 -512891 831596 813301 73670305 76725961 -327702 135883 5252637 4866146 79426836 82541291 39650 99739 0 0 33447735 32600104 0 0 0 42738788 41719996 76226173 74419839 3200663 8121452 73083240 76259954 27976873 26047142 45106367 50212812 X THE MISSION OF SAMARITAN REGIONAL HEALTH SYSTEM IS TO TAKE THE LEAD IN PROMOTING THE HEALTH AND WELLNESS OF PEOPLE IN THE COMMUNITIES WE SERVE. 0 0 49153133 99739 77505677 SAMARITAN REGIONAL HEALTH SYSTEM PROVIDES QUALITY MEDICAL HEALTHCARE SERVICES AND EDUCATION REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE OR ABILITY TO PAY. THE HOSPITAL PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS. SERVICES PROVIDED TO MEDICARE AND MEDICAID PATIENTS ARE SOMETIMES PROVIDED BELOW COST. TO THE EXTENT REIMBURSEMENT IS BELOW COST, THE HOSPITAL RECOGNIZES THESE AMOUNTS AS CHARITY CARE. CHARITY CARE IS ALSO PROVIDED THROUGHOUT THE YEAR BASED UPON ACTIVITIES AND SERVICES WHICH THE HOSPITAL BELIEVES WILL SERVE A BONA FIDE COMMUNITY HEALTH NEED.DURING 2014, THE HOSPITAL PROVIDED NUMEROUS OUTREACH PROGRAMS WHICH SERVE AND EDUCATE THE COMMUNITY. THESE INCLUDED:COMMUNITY HEALTH IMPROVEMENT SERVICES: $50,827 SERVING 2,159 PEOPLEHEALTH PROFESSIONS EDUCATION: $98SUBSIDIZED HEALTH SERVICES: $5,674,019 SERVING THE COMMUNITYFINANCIAL AND IN-KIND CONTRIBUTIONS: $22,684 SERVING 1,048 PEOPLECOMMUNITY BUILDING ACTIVITIES: $18,643 SERVING 18 PEOPLECOMMUNITY BENEFIT OPERATIONS: $12,547 SERVING THE COMMUNITY 49153133 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 0 0 1 53 0 1 652 1 1 1 0 0 0 0 0 0 0 0 0 X 15 12 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X MARY GRIEST CFO 4192077837 663 EAST MAIN STREET ASHLAND OH 44805 DANNY BOGGS PRESIDENT/CEO 35.00 11.00 X X 283744 0 37232 STEPHEN STUART PHD CHAIR (END 4/22/14) 2.00 1.00 X X 0 0 0 HAROLD KEENER PHD CHAIR 2.00 1.00 X X 0 0 0 ANNE BEER SECRETARY 2.00 0.00 X X 0 0 0 TIM COWEN VICE CHIAR 2.00 1.00 X 0 0 0 MATTHEW BERNHARD MEDICAL STAFF VP (1/1/14-8/26/14) 2.00 0.00 X 68106 0 0 MICHAEL MARTIN MD MEDICAL STAFF PRESIDENT 2.00 0.00 X 11000 0 0 PAUL MYERS BOARD MEMBER 2.00 1.00 X 0 0 0 MICHAEL STENCEL MD BOARD MEMBER 2.00 0.00 X 8250 63625 3700 ROGER KRAMER CPA BOARD MEMBER (END 4/22/14) 2.00 1.00 X 0 0 0 POLLY CHANDLER BOARD MEMBER 2.00 0.00 X 0 0 0 RALPH KELSEY BOARD MEMBER 2.00 0.00 X 0 0 0 TOM MCGEE BOARD MEMBER 2.00 1.00 X 0 0 0 ANNETTE SHAW BOARD MEMBER 2.00 0.00 X 0 0 0 MICHAEL J KELLY SR BOARD MEMBER (START 5/1/14) 2.00 1.00 X 0 0 0 THOMAS GILMAN BOARD MEMBER (START 5/1/14) 2.00 0.00 X 0 0 0 PARTICIA DAWSON BOARD MEMBER (START 6/24/14) 2.00 1.00 X 0 0 0 JOYCE HUNT BOARD MEMBER (START 6/24/14) 2.00 0.00 X 0 0 0 MARY GRIEST VP FINANCE/CFO 40.00 5.00 X 156735 0 23538 CHRISTOPHER HUNT VP CLINICAL SERVICES 40.00 0.00 X 127724 0 14048 ALYCE LEGG VP RESOURCE DEVELOPMENT 40.00 0.00 X 131039 0 18214 PHILIP MYERS MD VP MEDICAL AFFAIRS 30.00 1.00 X 121936 0 21038 RONALD MANCHESTER VP SUPPORT SERVICES 40.00 0.00 X 127122 0 17793 KARIN SCHWAN CNO/VP PATIENT CARE 40.00 0.00 X 124763 0 17480 1160419 63625 153043 13 0 1 0 ASHLAND ANESTHESIA 1 RIVERFRONT PLACE6TH FLOOR NEWPORT KY 41071 MEDICAL SERVICES AND NON EMPL COMP 917260 SAMARITAN EMERGENCY PHYSICIANS LLP PO BOX 674579 DETROIT MI 48267 NONEMPL COMP 869750 AMERICAN KIDNEY STONE MANAGEMENT 100 WEST THIRD ST STE 350 COLUMBUS OH 43201 RENT, MEDICAL SVCS 667808 LABORATORY COPORATION OF AMERICA PO BOX 12140 BURLINGTON NC 27216 MEDICAL SVCS 514491 SLEEP MED INC 200 CORPORATE PL STE 5-B PEABODY MA 01960 MEDICAL SVCS 350844 13 728546 84755 178430 813301 PATIENT SERVICES 621110 76555423 76555423 RENTS FROM AFFILIATE 900099 170538 170538 76725961 174731 174731 329389 357998 -28609 -28609 -28609 38848 -38848 -38848 -38848 PHARMACY RETAIL 446110 2370801 2370801 AARA INCENTIVE PAYMENTS 621110 805969 805969 AIMS REVENUE 621110 467752 467752 1250233 16539 1233694 4894755 82541291 77503321 2855092 1369577 X 77851 77851 21888 21888 588605 148127 440478 24314888 16073830 8241058 1828423 1014769 813654 4071373 2300454 1770919 1796815 1017694 779121 403466 346666 56800 255222 255222 269221 269221 11457371 5636614 5820757 77587 77587 2398126 1193299 1204827 147647 147647 1633025 892507 740518 150962 92419 58543 399860 225454 174406 5575982 2434166 3141816 808801 350870 457931 MEDICAL SUPPLIES 12738485 12738485 PROVISION FOR BAD DEBTS 4011181 4011181 FACILITIES ENGINEERING 142134 142134 SAMARITAN ON MAIN 99496 99496 1151430 576859 574571 74419839 49153133 25266706 0 18996271 16571895 6734252 6592106 1649655 4341652 1600291 1524227 1910621 1934262 108523008 70545175 39781255 37977833 33488 0 2377407 7317979 73083240 76259954 8106103 7988774 0 475535 15223367 13783224 566101 444290 4081302 3355319 27976873 26047142 X 45022476 50142683 83891 70129 45106367 50212812 73083240 76259954 X 8121452 196376 -3211383 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5752 5752 0 PART II-B, LINE 1: MEMBERSHIP DUES IN THE AMOUNT OF $20,940 AND $28,779 WERE PAID TO THE AMERICAN HOSPITAL ASSOCIATION AND THE OHIO HOSPITAL ASSOCIATION, RESPECTIVELY. $4,774 AND $978 OF THE DUES PAYMENTS WERE FOR LOBBYING EXPENSES. 401415 20071 20071 401415 476415 -75000 401415 476415 476415 476415 476415 476415 476415 1.00000 0 1 1 2346208 2346208 17169160 8849116 8320044 2321822 1751151 570671 39777064 32441889 7335175 46908754 27503019 19405735 37977833 BOND ISSUE COSTS 24048 ACCRUED INTEREST INCOME 2249943 INVESTMENT IN PAIN MANAGEMENT 143988 INTEREST IN MIFFLIN MEDICAL OFFICE BUILDING 4900000 7317979 COST REPORT SETTLEMENT PAYABLE 3172746 INTEREST RATE SWAP 182573 3355319 X PART V, LINE 4: THE INTENDED USE OF ENDOWMENT ASSETS INCLUDES FUTURE CAPITAL IMPROVEMENTS, SCHOLARSHIPS, AND OTHER SUCH PURPOSES AT THE DISCRETION OF THE BOARD OF DIRECTORS. PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE SYSTEM AND RECOGNIZE A TAX LIABILITY IF THE SYSTEM HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS OR OTHER APPLICABLE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE SYSTEM AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2014, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILTIY OR DISCLOSURE IN THE CONSOLIDATED FINANCIAL STATEMENTS. THE SYSTEM FILES FEDERAL AND STATE TAX RETURNS AND IS NO LONGER SUBJECT TO FEDERAL, STATE, OR LOCAL INCOME TAX EXAMINATIONS BY TAX AUTHORITIES FOR THE YEARS BEFORE FISCAL YEAR 2011. 1 1 X 1 X 0 1 1 0 1 1 2083763 1640250 443513 0.00630 8576169 4597878 3978291 0.05650 10659932 6238128 4421804 0.06280 2159 63374 6381 56993 0.00080 98 98 0.00000 1048 22684 22684 0.00030 3207 86156 6381 79775 0.00110 3207 10746088 6244509 4501579 0.06390 1640 1640 0.00000 2115 2115 0.00000 1420 1420 0.00000 13468 13468 0.00020 18643 18643 0.00020 1 4011181 10265 10805938 12627287 -1821349 X 1 1 1 1 SAMARITAN HOSPITAL 1025 CENTER STREET ASHLAND OH 44805 X X X SAMARITAN REGIONAL HEALTH SYSTEM 1 0 0 1 X X X X X X X X 13 1 0 0 1 X HTTP://WWW.SAMARITANHOSPITAL.ORG 1 13 1 HTTP://WWW.SAMARITANHOSPITAL.ORG 0 0 1 X 200.000000000000 X X X X X X 1 1 X X X 1 X X X X X 1 0 X X X X 1 X 0 0 SAMARITAN REGIONAL HEALTH SYSTEM PART V, SECTION B, LINE 5: THE FIRST SECTION OF THE CHNA IS A COMMUNITY HEALTH SURVEY OF ASHLAND COUNTY RESIDENTS. THE SURVEY CONSISTED OF FILL-IN-THE-BLANK QUESTIONS DESIGNED TO ELICIT RESPONSES FROM ASHLAND COUNTY RESIDENTS' OPINION OF HEALTHCARE NEEDS IN THE COUNTY. THE SECOND SECTION OF THE CHNA PRESENTS A FOCUS GROUP ASSESSMENT OF STAKEHOLDERS' OPINIONS OF HEALTHCARE NEEDS IN THE COUNTY. THE THREE FOCUS GROUPS INCLUDE MEMBERS OF REPRESENTING BUSINESS AND COMMUNITY LEADERS, MEDICAL PROFESSIONALS AND END USERS- PATIENTS. THE SURVEY AND FOCUS GROUP ASSESSMENTS WERE PERFORMED UNDER THE GUIDANCE AND COLLABORATION OF OSCAR MCKNIGHT, PH.D., A PROFESSOR AT ASHLAND UNIVERSITY AND STATISTICAL CONTRACTOR FOR BUSINESS IN OHIO AND SURROUNDING STATES. DR. MCKNIGHT WAS ALSO THE MODERATOR FOR THE FOCUS GROUPS. SAMARITAN REGIONAL HEALTH SYSTEM PART V, SECTION B, LINE 11: BOTH THE FOCUS GROUPS AND THE COMMUNITY SURVEYS RESULTS WERE THAT MORE HEALTHCARE SERVICES ARE NOT NECESSARY FOR ASHLAND COUNTY. HOWEVER, BOTH RESEARCH GROUPS DID OFFER SERVICES TO CONSIDER: WELLNESS, ELDERCARE, AND MENTAL HEALTH. COMMUNITY WELLNESS: EXTENDED THE QCARE PROGRAM FROM MON-THURS 11AM-6:30PM TO MON-FRI 11AM-6:30PM. A WIDE VARIETY OF EDUCATION CLASSES ARE OFFERED ON A MONTHLY BASIS. THESE INCLUDE : CHILDBIRTH, BREAST-FEEDING, FREEDOM FROM SMOKING, PRE-OP EDUCATION CLASSES FROM KNEE AND HIP REPLACEMENT PATIENTS, COMMUNITY EDUCATION SERIES (PHYSICIANS AND OTHER HEALTHCARE PROFESSIONALS PRESENT ONE-HOUR TALKS ON THE HOT TOPICS CURRENTLY IN HEALTHCARE AS WELL AS TOPICS SUGGESTED BY THE PUBLIC). SRHS IS WORKING CLOSELY WITH LOCAL MENTAL HEALTH PROFESSIONALS TO STRENGTHEN THE SERVICES AND CREATE NEW OPPORTUNITIES TO EDUCATE EMPLOYEES AND THE COMMUNITY ABOUT MENTAL HEALTH ISSUES. THE VP OF CLINICAL SERVICES NOW SITS ON THE APPLESEED COMMUNITY MENTAL HEALTH BOARD AND IS COORDINATING MEETINGS BETWEEN PHYSICIAN OFFICES AND MENTAL HEALTH PROVIDERS.TWO NEEDS IDENTIFIED BY BOTH THE COMMUNITY SURVEY AND THE FOCUS GROUPS THAT ARE NOT BEING ADDRESSED IN THE FORM OF PRIMARY CARE BY SRHS IS ELDERCARE AND MENTAL HEALTH SERVICES. WHILE THESE ARE NOT PRIMARY SERVICE AREAS OFFERED BY THE HOSPITAL FOR STRATEGIC PLANNING AND OPERATIONS PURPOSES, AS WELL AS BECAUSE OF LIMITED RESOURCES, THEY ARE BOTH SUPPORTED BY THIS ORGANIZATION IN MANY WAYS. THE HOSPITAL PARTICIPATES IN SEVERAL COMMITTEES INVOLVING THE ELDER AND MENTAL HEALTH COMMUNITIES. MANY MENTAL HEALTH AND ELDERCARE EDUCATIONAL AND WELLNESS OPPORTUNITIES ARE OFFERED BY THE HOSPITAL THROUGHOUT THE YEAR. THE VP OF CLINICAL SERVICES SERVES ON THE APPLESEED COMMUNITY MENTAL HEALTH AND RECOVERY BOARD AND THE SOCIAL SERVICES DEPARTMENT IS INSTRUMENTAL IN ADDRESSING ELDERCARE NEEDS AS PATIENT ADVOCATES. SRHS IS ALSO EXPLORING THE POSSIBILITY OF ADDING A PSYCHIATRIST TO STAFF. SAMARITAN REGIONAL HEALTH SYSTEM PART V, SECTION B, LINE 13H: FOR DISCOUNTED CARE THE FOLLOWING CRITERIA IS USED: MONTHLY EXPENSES, AND BANK STATEMENTS. DISCOUNT IS DETERMINED BY THE % OVER THE 200% FPL AND IS DECREASING THE GREATER THE VARIANCE IS. FOR 100% DISCOUNT, THE CRITERIA IS LESS THAN 100% OF THE FEDERAL POVERTY LEVEL. SAMARITAN REGIONAL HEALTH SYSTEM PART V, SECTION B, LINE 15E: A COMPLETED APPLICATION IS SUBMITTED TO PATIENT ACCOUNTING. THE DOCUMENTATION REQUIRED IS PROOF OF INCOME, WHICH MAY INCLUDE W2S AND/OR TAX RETURNS. SAMARITAN REGIONAL HEALTH SYSTEM PART V, SECTION B, LINE 16I: THE HOSPITAL USES BROCHURES, THIER WEBSITE, STATEMENTS, AND PHONE CALLS AS OTHER MEANS TO PUBLICIZE ITS FINANCIAL ASSISTANCE POLICY. SAMARITAN REGIONAL HEALTH SYSTEM PART V, SECTION B, LINE 22D: IF QUALIFIED BASED ON POLICY, 100% IS DISCOUNTED. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY SAMARITAN REGIONAL HEALTH SYSTEM PART V, SECTION B, LINE 16B WEBSITE: HTTP://WWW.SAMARITANHOSPITAL.ORG 7 SAMARITAN HEALTH & REHAB CENTER 2163 CLAREMONT AVENUE ASHLAND OH 44805 OUTPATIENT PHYS, OCC, SPEECH REHAB KETTERING SAMARITAN HEALTH CENTER 546 NORTH UNION STREET ASHLAND OH 44842 OUTPATIENT ANCILLARY SVC SAMARITAN PROFESSIONAL PARK 2212 MIFFLIN AVENUE ASHLAND OH 44805 OUTPATIENT ENDOSCOPY SAMARITAN PROFESSIONAL PARK 2212 MIFFLIN AVENUE ASHLAND OH 44805 WOMEN'S HEALTH, OCC MEDICINE SAMARITAN PROFESSIONAL PARK 2212 MIFFLIN AVENUE ASHLAND OH 44805 SLEEP LAB, PHYSICIAN OFFICES SAMARITAN BANEY RD OUTPATIENT FACILITY 1941 BANEY ROAD ASHLAND OH 44805 OUTPATIENT ANCILLARY SVCS SAMARITAN ADMINISTRATIVE BUILDING 663 EAST MAIN STREET ASHLAND OH 44805 ADMINISTRATIVE OFFICES PART I, LINE 3C: SAMARITAN'S POLICY INCLUDES FEDERAL POVERTY GUIDELINES ALONG WITH EVALUATION OF MONTHLY EXPENSES AND BANK STATEMENTS TO DETERMINE ELIGIBILITY FOR CHARITY CARE. IN SOME CIRCUMSTANCES WHEN A PATIENT DOES NOT MEET THE CRITERIA, FURTHER DOCUMENTATION MAY BE REQUESTED (RELATED TO INCOME AND EXPENSES), AND THE CFO MAY GRANT A DISCOUNT AS A SPECIAL CIRCUMSTANCE. PART I, LINE 7: CHARITY CARE AND MEDICAID COSTS WERE CALCULATED USING A COST TO CHARGE RATIO USING THE WORKSHEET 2 METHOD TO CALCULATE THE COST TO CHARGE RATIO. PART I, LINE 7G: NOT APPLICABLE PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25(A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN, IS $4,011,181. PART II, COMMUNITY BUILDING ACTIVITIES: SAMARITAN REGIONAL HEALTH SYSTEM'S MISSION IS TO "TAKE THE LEAD IN PROMOTING THE HEALTH AND WELLNESS OF PEOPLE IN THE COMMUNITIES WE SERVE." AT THE FOREFRONT OF THESE EFFORTS IS SRHS'S FREE COMMUNITY EDUCATION CLASSES THAT ARE OFFERED SEVERAL TIMES A MONTH, SEPTEMBER-MAY. PHYSICIANS, PROVIDERS, NURSES AND CLINICAL EXPERTS SHARE THEIR KNOWLEDGE ON A VARIETY OF TOPICS. IN ADDITION, SEVERAL SAMARITAN NURSES SERVE AS COORDINATORS OF SUPPORT GROUPS, HOSTING REGULAR MEETINGS FOR PATIENTS AND FAMILIES DEALING WITH CARDIAC DISEASE OR DIABETES. SRHS IS ACTIVELY INVOLVED IN SERVICE CLUB ORGANIZATIONS AND SOCIAL SERVICE BOARDS, AND ROUTINELY PARTICIPATES IN HEALTH FAIRS. SRHS IS A STRONG SUPPORTER OF THE UNITED WAY OF ASHLAND COUNTY. PART III, LINE 3: MATCHED BAD DEBT REVERSALS ACCOUNTS DATE OF SERVICE 2013 TO CHARITY WRITE OFFS DATE OF SERVICE 2013 BOTH LIST POSTED DATE 2014. THIS AMOUNT AS A PERCENTAGE OF TOTAL BAD DEBT DATE OF SERVICE 2013. THIS PERCENTAGE IS USED AGAINST TOTAL BAD DEBT DATE OF SERVICE 2014 POSTED IN 2014. PART III, LINE 4: FINANCIAL STATEMENT FOOTNOTE: AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS ESTABLISHED ON AN AGGREGATE BASIS BY USING HISTORICAL WRITE-OFF RATE FACTORS APPLIED TO UNPAID ACCOUNTS BASED ON AGING. LOSS RATE FACTORS ARE BASED ON HISTORICAL LOSS EXPERIENCE AND ADJUSTED FOR ECONOMIC CONDITIONS AND OTHER TRENDS AFFECTING THE SYSTEM'S ABILITY TO COLLECT OUTSTANDING AMOUNTS. UNCOLLECTIBLE AMOUNTS ARE WRITTEN OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE.THE BAD DEBT ESTIMATE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE FINANCIAL ASSISTANCE POLICY WAS DETERMINED BY USING THE PERCENTAGE OF ACCOUNTS WRITTEN OFF TO BAD DEBT AND LATER REVERSED FROM BAD DEBT TO WRITE OFF AS A CHARITY ACCOUNT. THIS PERCENTAGE WAS APPLIED TO ALL BAD DEBT WRITE OFFS, THEN THE COST TO CHARGE RATIO APPLIED. PART III, LINE 8: MEDICARE REVENUE WAS 46.4% OF TOTAL REVENUE FOR SAMARITAN FOR 2014. BASED ON A COST TO CHARGE RATIO, THE COST OF PROVIDING CARE TO THE MEDICARE POPULATION IN 2014 WAS $12,627,287. THE PAYMENTS RELATED TO THESE SERVICES TOTALED $10,925,014. THIS LEAVES A MEDICARE SHORTFALL OF $1,702,273 FOR THE YEAR. THIS IS CONSIDERED A COMMUNITY BENEFIT BASED ON THE ELDERLY POPULATION. PART III, LINE 9B: PATIENTS RECEIVE 3 STATEMENTS FOR SELF PAY BALANCES. FOR BALANCES GREATER THAN $200, ONE ATTEMPT IS MADE TO CALL THE PATIENT TO MAKE PAYMENT ARRANGEMENTS. PART VI, LINE 2: FOCUS GROUPS FROM A CROSS SECTION OF COMMUNITY MEMBERS AND KEY STAKEHOLDERS WERE SURVEYED FOR THEIR INPUT. WE ALSO COLLABORATED WITH OTHER NON-PROFIT AGENCIES WHO CONDUCTED SIMILAR STUDIES AND VIEWED THEIR FINDINGS USEFUL AND PRACTICAL. OUR OCCUPATIONAL MEDICINE PROGRAM SERVES INDUSTRY AND FUNCTIONS AS A "LISTENING POST" TO GATHER INPUT FROM OUR BUSINESS COMMUNITY. PART VI, LINE 3: INFORMATION RELATED TO THE CHARITY PROGRAM AT SAMARITAN IS PROVIDED IN A NUMBER OF WAYS. BROCHURES ARE PROVIDED AT EACH POINT OF ADMISSION ALONG WITH THE PUBLICLY POSTED INFORMATION NOTICES. EACH STATEMENT SENT LISTS THE FEDERAL POVERTY GUIDELINES AND WHAT INFORMATION IS NEEDED TO QUALIFY. AN APPLICATION FOR FREE CARE IS ON THE BACK OF EACH STATEMENT SENT TO PATIENTS. PART VI, LINE 4: SAMARITAN REGIONAL HEALTH SYSTEM DEFINES ASHLAND COUNTY AND THE 10 ZIP CODES THAT COMPRISE IT AS OUR PRIMARY SERVICE AREA (PSA). FURTHER, WE INCLUDE AT LEAST ONE ZIP CODE FROM EACH OF THE 5 CONTIGUOUS COUNTIES WITHIN OUR PSA. OUR PSA IS PRIMARILY RURAL WITH GREATER THAN 50% OF THE POPULATION LIVING IN THE 44805 ZIP CODE AREA. AS A COMMUNITY HOSPITAL WE MEET A BROAD RANGE OF NEEDS FOR A COMMUNITY THAT IS DIVERSE IN AGE AND SOCIO ECONOMIC MAKE-UP. OUR COMMUNITY INCLUDES A LARGE AMISH POPULATION AND A DEMOGRAPHIC THAT HAS BEEN SEVERLY IMPACTED BY THE ECONOMIC DOWNTURN DUE TO THE DECLINE IN MANUFACTURING BASE OVER THE PAST SEVERAL YEARS. PART VI, LINE 5: SAMARITAN REGIONAL HEALTH SYSTEM IS VIEWED AS THE LEADER IN THE COMMUNITY FOR PROVIDING INFORMATION THAT LEADS TO EARLY TREATMENT AND BETTER OUTCOMES WITH LOWER ASSOCIATED COSTS. SAMARITAN HAS AN EFFECTIVE EDUCATIONAL PROGRAM (FREE OF CHARGE) THAT GATHERS DIRECT INPUT AS TO THE NEEDS AND CONCERNS OF THE COMMUNITY. PART VI, LINE 6: SAMARITAN REGIONAL HEALTH SYSTEM IS A GENERAL ACUTE-CARE FACILITY LOCATED IN ASHLAND, OHIO WHERE IT OPERATES FOUR MEDICAL OFFICE BUILDINGS, AN OUTPATIENT CLINIC, AN OFFSITE REHAB FACILITY, AND AN ADMINISTRATIVE OFFICE BUILDING. SRHS IS THE PARENT ORGANIZATION OF SAMARITAN PROFESSIONAL CORPORATION AND THE SOLE BENEFICIARY OF SAMARITAN HOSPITAL FOUNDATION.SAMARITAN PROFESSIONAL CORPORATION CONTINUED ITS MISSION TO RETAIN QUALITY PHYSICIANS AND EXPAND SERVICES IN THE COMMUNITY. THE STRUCTURE OF THE ORGANIZATION ENABLED THE PHYSICIANS TO CONTINUE THEIR OPERATIONS AND TO ENHANCE SERVICES PROVIDED BY THE LOCAL HEALTHCARE NETWORK.SAMARITAN HOSPITAL FOUNDATION PROVIDES A PROVISION OF FUNDRAISING AND ASSET MANAGEMENT IN SUPPORT OF SAMARITAN REGIONAL HEALTH SYSTEM. 1 UNITED WAY 132 W MAIN ST LOWER LEVEL ASHLAND OH 44805 346004364 501(C)(3) 26673 TO MATCH THE EMPLOYEE CONTRIBUTIONS TO THE UNITED WAY OF ASHLAND COUNTY OHIO INC. 1 0 MEDICAL FINANCIAL ASSISTANCE 8 21888 PART I, LINE 2: SAMARITAN REGIONAL HEALTH SYSTEM MAKES CONTRIBUTIONS IN SUPPORT OF ITS RELATED PARTIES AS WELL AS ORGANIZATIONS WITHIN THE COMMUNITY. WHEN A PATIENT APPLIES FOR FINANCIAL ASSISTANCE, THE FINANCIAL COUNSELOR FOLLOWS THE FINANCIAL ASSISTANCE POLICY. IF THE PATIENT IS OVER INCOME GUIDELINES AND MAY NOT BE ABLE TO RETURN TO WORK DUE TO THE ILLNESS, THE FINANCIAL COUNSELOR WRITES AN EXCEPTION LETTER EXPLAINING THE PATIENT'S CIRCUMSTANCES. THIS LETTER IS ATTACHED TO THE SUPPORTING PAPERWORK AND FORWARDED TO THE CFO FOR APPROVAL. AN E-MAIL IS SENT TO THE FOUNDATION OFFICE EXPLAINING THE PATIENT'S CIRCUMSTANCES WITHOUT GIVING PERSONAL INFORMATION. THE OFFICE MAINTAINS A LOG OF ACCOUNTS WRITTEN OFF USING FOUNDATION FUNDS. X 1 1 X X X X X 0 0 0 0 0 0 0 0 0 DANNY BOGGS PRESIDENT/CEO 281764 0 0 0 1980 0 30000 0 7232 0 320976 0 0 0 MARY GRIEST VP FINANCE/CFO 154755 0 0 0 1980 0 18034 0 5504 0 180273 0 0 0 PART I, LINE 1A THE PRESIDENT/CEO RECEIVES HEALTH/SOCIAL CLUB DUES WHICH ARE NON TAXABLE. THE HOSPITAL IS REIMBURSED FOR ANY PERSONAL USE. A COUNTY OF ASHLAND OHIO 346000122 2008-12-19 9500000 ED & OB BUILDING & STRUCTURE RENOVATION & IMPROVEMENTS; EQUIPMENT 1 0 0 B COUNTY OF ASHLAND OHIO 346000122 2009-01-09 4495023 REFUND PRIOR ISSUE 1 0 0 C COUNTY OF ASHLAND OHIO 346000122 2009-01-27 6004977 BUILDING & STRUCTURE RENOVATION; EQUIPMENT 1 0 0 A 2083155 9665616 119942 1744 9543930 2010 0 0 1 1 B 1371923 4495023 4495023 4495023 2006 1 0 1 1 C 1321555 6208273 41424 57 6166792 2011 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 C 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 1 1 FIFTH THIRD BANK 6.900000000000 0 0 0 0 0 B 0 0 1 1 1 1 FIFTH THIRD BANK 6.900000000000 0 0 0 0 0 C 0 0 0 1 1 1 FIFTH THIRD BANK 6.900000000000 0 0 0 0 0 A 0 B 0 C 0 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: COUNTY OF ASHLAND, OHIO DATE THE REBATE COMPUTATION WAS PERFORMED: 04/14/2014 ISSUER NAME: COUNTY OF ASHLAND, OHIO DATE THE REBATE COMPUTATION WAS PERFORMED: 04/14/2014 ISSUER NAME: COUNTY OF ASHLAND, OHIO DATE THE REBATE COMPUTATION WAS PERFORMED: 04/14/2014 X EQUIPMENT 17 178430 COST OF THE EQUIPMEN 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 THE CFO REVIEWS THE 990 PRIOR TO FILING. THE 990 IS REVIEWED AT THE BOARD OF DIRECTORS MEETING WITH SUFFICIENT TIME TO MAKE ANY AND ALL INQUIRIES REGARDING THE INFORMATION CONTAINED THEREIN. A COPY OF THE FORM 990 IS AVAILABLE TO EACH BOARD MEMBER BEFORE IT IS FILED. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS AND KEY EMPLOYEES ARE REQUIRED TO SIGN A DISCLOSURE OF POTENTIAL CONFLICT OF INTEREST AND CONFIDENTIALITY OF INFORMATION AGREEMENT ANNUALLY OR WHEN THEY FIRST JOIN. THE FORMS ARE SENT FROM THE CEO'S OFFICE AND ARE MAINTAINED THERE UPON COMPLETION. SHOULD A CONFLICT OF INTEREST ARISE, A BOARD MEMBER MAY RESIGN FROM THE BOARD DEPENDING ON THE LEVEL OF CONFLICT. IN ADDITION, THE BOARD MEMBER WILL ABSTAIN FROM VOTING AND IF APPROPRIATE WILL BE EXCUSED FROM THE BOARD MEETING DURING THE DISCUSSION REGARDING A POTENTIAL CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 EVERY TWO YEARS, SINCE 2004, AN INDEPENDENT CONSULTANT PERFORMS A MARKET ANALYSIS OF THE SENIOR LEADERSHIP POSITIONS USING THE RESULTS OF AT LEAST THREE INDEPENDENT WAGE SURVEYS. THEIR REPORT IS USED TO DEVELOP/REVISE WAGE RANGES FOR ALL LEADERSHIP POSITIONS. THE INFORMATION IS THEN PRESENTED TO THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS FOR THEIR APPROVAL. DECISIONS REGARDING THE CEO'S COMPENSATION ARE DOCUMENTED IN THE BOARD OF DIRECTOR MINUTES WHEN IT IS APPROVED AS WELL AS A NOTIFICATION THAT IS KEPT IN THE CEO'S FILE. THE INDEPENDENT REVIEW PROCESS FOR DETERMINING COMPENSATION OF THE ORGANIZATION'S CEO AND OFFICERS WAS LAST UNDERTAKEN DURING 2014. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G CONTRACT SERVICES- MEDICAL: PROGRAM SERVICE EXPENSES 2,745,937. MANAGEMENT AND GENERAL EXPENSES 1,036,225. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,782,162. CONTRACT SERVICES- NON PATIENT: PROGRAM SERVICE EXPENSES 1,614,704. MANAGEMENT AND GENERAL EXPENSES 3,656,599. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,271,303. MAINTENANCE: PROGRAM SERVICE EXPENSES 1,275,973. MANAGEMENT AND GENERAL EXPENSES 720,948. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,996,921. COLLECTION FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 358,468. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 358,468. COMMUNITY RELATIONS: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 34,648. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 34,648. OTHER FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 13,869. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 13,869. FORM 990, PART XI, LINE 9: TRANSFER TO SAMARITAN PROFESSIONAL CORPORATION -3,211,383. FORM 990, PAGE 12, PART XII, LINE 2C THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT AND SELECTION OF THE INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. FORM 990, PAGE 1, PART I, LINE C DOING BUSINESS AS: SAMARITAN HOSPITAL PEOPLES HOSPITAL FORM 990, PAGE 6, PART VI, LINE 16 THERE IS A PROCEDURE IN PLACE THAT INVOLVED ATTORNEYS IN REVIEWING THE JOINT VENTURE ARRANGEMENT TO ENSURE TAX EXEMPT PROTECTION. SAMARITAN PROFESSIONAL CORPORATION 1025 CENTER STREET ASHLAND OH 44805 341856531 PHYSICIAN BASED HEALTH SERVICES OH 501(C)(3) 3 SAMARITAN REGIONAL HEALTH SYSTEM 1 SAMARITAN HOSPITAL FOUNDATION 663 EAST MAIN STREET ASHLAND OH 44805 341783215 FUNDRAISING AND ASSET MANAGEMENT OH 501(C)(3) 11A SAMARITAN REGIONAL HEALTH SYSTEM 1 SAMARITAN REGIONAL PAIN MANAGEMENT LLC 1025 CENTER STREET ASHLAND OH 44805 462286785 HOSPITAL SUPPORT-MEDICAL SERVICES OH SAMARITAN REGIONAL HEALTH SYSTEM RELATED 187427 219232 0 1 0.51000 1 0 1 0 0 0 0 0 0 0 1 1 0 1 1 0 0 1 1 SAMARITAN PROFESSIONAL CORP A 369758 ACTUAL RENT RECORDED SAMARITAN PROFESSIONAL CORP R 3211383 CASH VALUE SAMARITAN HOSPITAL FOUNDATION C 704414 ACTUAL CONTRIBUTIONS RECEIVED SAMARITAN HOSPITAL FOUNDATION K 228500 ACTUAL LEASE PAYMENT SAMARITAN PROFESSIONAL CORP L 384230 ACTUAL PAYROLL EXPENSE SAMARITAN PROFESSIONAL CORP O 121108 PAYROLL