2015-07-13T14:29:46-05:00 2014-08-31 861065772 Deloitte Tax LLP 191 Peachtree St Suite 2000 Atlanta GA 303031749 990 2013-09-01 611356023 Our Lady of Bellefonte Hospital Inc OURL 6068333333 St Christopher Drive Ashland KY 41101 Joe Buchheit Chief Financial Officer-BSKHS 6068333600 2015-07-13 1 David A Craig P00542227 4042201500 2013 2016-02-25 16:41:14Z Kevin Halter St Christopher Drive Ashland KY 41101 161324654 0 0928 X www.olbh.com X 1999 KY Acute Care Hospital 18 14 1166 175 2352120 0 2226497 819164 154224825 158821195 1039437 536553 3594480 1109367 161085239 161286279 398990 505633 0 0 62560342 57560684 0 0 0 93531062 90484793 156490394 148551110 4594845 12735169 117497443 130194416 56898322 62831488 60599121 67362928 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 138009935 505633 156651840 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. 138009935 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 0 0 0 0 0 1 0 0 0 1 110 0 1 1166 1 1 1 0 0 0 0 0 0 0 0 0 X 18 14 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 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 Gregory Bausch PharmD Board Member 2.00 0.00 X 0 0 0 Mary Carter Board Member 2.00 0.00 X 0 0 0 William Dickens Board Member (Sep-Dec) 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 397047 50246 Lawrence Hubbard CHCIO Board Member 2.00 48.00 X 0 567216 35405 Daniel Huffman Chairman 3.00 0.00 X X 0 0 0 Gregory Jackson Board Member (Jan-Aug) 2.00 0.50 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 251584 21389 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 (Jan-Aug) 3.00 47.00 X X 0 404206 56063 Laura Timberlake Board Member (Jan-Aug) 2.00 0.00 X 0 0 0 EW Unnikrishnan MD Board Member 2.00 0.00 X 0 0 0 John Wallenhorst PhD President (Sep-Dec) 3.00 47.00 X X 0 337082 24753 Frank Warnock Esq Board Member (Sep-Dec) 2.00 0.50 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 294689 0 22721 Rodney Hieneman Secretary (Feb-Aug) 2.00 48.00 X 151235 0 29810 Jennifer Moore Secretary (Sep-Dec) 2.00 48.00 X 245758 0 16013 Daniel Goulson Chief Medical Officer 50.00 0.00 X 309103 0 36044 Kurt Jaenicke MD Obstetrician 50.00 0.00 X 702880 0 29991 Yogendra Prasad MD Cardiologist 50.00 0.00 X 615211 0 31565 Michele Friday MD Cardiologist 49.50 0.50 X 574651 0 29273 Phillip Lackey MD Plastic Surgeon 50.00 0.00 X 395368 0 29170 Jason Ford MD Pediatrician 50.00 0.00 X 320901 0 28844 3609796 1957135 441287 44 0 1 0 Ashland Anesthesia PSC PO Box 1377 Ashland KY 411051377 Anesthesia 2873513 Morrison Management Specialists Inc PO Box 102289 Atlanta GA 303682289 Cafeteria/Food Services 2713904 Aramark Healthcare 24863 Network Place Chicago IL 606731248 Housekeeping/Laundry and Linen/Lift Team 2047255 Biomet 75 Remittance Dr Ste 3283 Chicago IL 606753273 Equipment Maintenance 1668946 Aramark Cts 12483 Collections Center Dr Chicago IL 60693 Equipment Maintenance 1589069 27 194161 625003 10000 819164 Patient Service Rev. 622110 158821195 156469075 2352120 158821195 254732 254732 479052 0 479052 479052 479052 261826 58370 38375 0 223451 58370 281821 281821 Comm. Health & Fitness 621610 291435 291435 Retail Pharmacy Rev. 446110 182765 182765 Cafeteria/Vending 531120 78861 78861 77254 77254 630315 161286279 156651840 2352120 1463155 505633 505633 1125174 1012656 112518 42293454 38064109 4229345 4205574 3785016 420558 6697569 6027812 669757 3238913 2915022 323891 459517 413565 45952 103957 93561 10396 14969 13472 1497 5882907 5882907 656149 590534 65615 2179411 1961470 217941 4221773 3799596 422177 5343661 4809295 534366 475052 427547 47505 46831 42148 4683 2202100 2202100 8110899 7299809 811090 913009 821708 91301 Medical Supplies 24706822 24706822 Purchased Services 15424287 13881858 1542429 Bad Debt 9854494 9854494 UBI Tax 1398 1398 9887557 8898801 988756 148551110 138009935 10541175 0 2514 873 24007552 38782744 25000 15063673 17273772 547507 636277 3412570 3335481 1308471 1532048 127974561 80292500 52241137 47682061 8419434 9396308 386930 308715 265985 265985 11816670 10980152 117497443 130194416 10347979 12774454 5060840 4960737 41489503 45096297 56898322 62831488 X 60598561 67362368 560 560 60599121 67362928 117497443 130194416 X 12735169 625620 -6596982 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 14969 14969 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 57560245 27408921 30151324 2563271 2069307 493964 59723377 47861905 11861472 3569718 2952367 617351 47682061 HPL/GL 8197328 Other Patient and 3rd Party Payers 1628576 Due From Affiliates 461810 Medicare and Medicaid Settlement 359154 Pharm A/R 241236 Kentucky Hospital Care Program A/R 80403 Lifeline A/R/Accrued Int/Misc Clearing 11645 10980152 LT Liab - Pension Liability 35924813 HPL/GL Liability 8197328 Reserves for Medicare and Medicaid 660743 Medicare and Medicaid Settlements 226667 Other Misc LT Liability 58635 Unclaimed Prop Accrual 28111 45096297 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. Income taxes of the System's for-profit subsidiaries are not material to the accompanying consolidated financial statements. The System's taxable subsidiaries have approximately $61,513 and $66,681 of net operating loss carryforwards as of August 31, 2014 and 2013, respectively, which expire in varying periods through 2034 and are available to offset future taxable income. The System's deferred tax assets are fully reserved at August 31, 2014 and 2013. Any changes to the valuation allowance on the deferred tax asset are reflected in the year of the change. 1 1 1 X 1 X 1 1 0 1 1 1365573 460462 905111 0.00650 27545220 15913453 11631767 0.08390 28910793 16373915 12536878 0.09040 26 16271 195284 640 194644 0.00140 3 800 1047081 247819 799262 0.00580 12 8897 130170 130170 0.00090 41 25968 1372535 248459 1124076 0.00810 41 25968 30283328 16622374 13660954 0.09850 0 0 0 0 4 3232 7440 0 7440 0.00010 1 254 1801 0 1801 0.00000 1 118 0 0 2 1263 2368 0 2368 0.00000 15 5110 22280 0 22280 0.00020 5 14427 33398 0 33398 0.00020 1 74 628 0 628 0.00000 0 0 0 0 29 24478 67915 67915 0.00050 1 9854494 0 42543938 44438576 -1894638 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 1 X X X X X X X X X 12 1 0 1 X http://www.olbh.com X X X X X X X X X 0 0 1 1 200.000000000000 1 200.000000000000 1 X X 1 1 X X X X 0 0 1 X 0 0 Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 3: 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 7: There were 9 health needs identified within the community health needs assessment. Although our efforts focus on obesity the other needs identified are not ignored. Diabetes, (certain) cancer, heart disease, stroke, respiratory problems, and some mental illnesses are all addressed through the obesity focus. This is being done in conjunction with area wide partners. The remaining health issues, some of which are likely to improve with reduction in obesity, have health resources available across the community. Many are being addressed by the larger health system in our community, Kings Daughters Medical Center. There are several other local services addressing these three issues. Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 12i: Please see the narrative for Part VI, Line 3 regarding the Financial Assistance Policy. Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 14g: Please see the narrative for Part VI, Line 3 regarding the Financial Assistance Policy. Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 20d: Please see the narrative for Part VI, Line 3 regarding the Financial Assistance Policy. 13 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 1819 Ashland Road Greenup KY 41144 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 Ashland Sleep Lab 2920 Winchester Ave Ashland KY 41101 Sleep Lab Part I, Line 6a: Annually, Bon Secours Kentucky Health System/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 avaliable 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): The bad debt expense included in Part IX; line 25 and excluded from the "percent of total expense" calculation is: $9,854,494. Part II, Community Building Activities: BSKHS is working to engage and empower the members of the Argillite Community located in Greenup County. The Director of Healthy community initiatives is coordinating efforts to unite the communities and aid in health and social issues to support them in improving their quality of life and health. Argillite is a rural community with approximately 1,000 residents; 47% make less than $25,000 per year, 69% of students receive free and reduced lunches. School gardens and walking trails have been built to address nutrition and opportunities for fresh vegetables to help fight obesity. Distribution of free books, backpack program and weekend snack sack program supplying food to students most a risk of going hungry during the weekend. The Ironton, Ohio community is a small urban area of approximately 25,000 residents. The 9th street community is home to subsidize housing for low income seniors and families. Initiatives include computers for community center and senior housing rec rooms used by residents and families, funding after-school programs for low income students needing assistance with homework and providing a safe environment for students. Students participate in summer youth activities at the community center provides the opportunity to go on field trips, safe summer day camp activities and mentors to work with on the various topics. Community garden opened in the spring of 2013, the garden provides community residents with space to grow fresh vegetables to use in family meals. Work with a local farmers market resulted in availability of fresh fruit and vegetables in an area that is labeled a food dessert. Healthy Community Services conducted 127 health fairs, providing approximately 8,696 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 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 87 individuals being certified in adult, infant and child CPR. We offered 3 safe sitter classes and certified 20 young people as safe sitters. With grant funding from the Paula Nye foundations, we were able to offer an expanded bicycle safety camp in 2014 with 91 children and their families in attendance. We currently have faith ministry or faith community nurse partnerships with 54 local churches with 27 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. In FY14 our van ministry provided over 2,479 round trips and traveled over 64,000 miles. We served over 403 individuals in FY14 transporting most of these individuals multiple times. This represents 103 more individuals served than in 2013. Our Meals on Wheels programs serve 212 home-bound seniors in 10 communities for an average of 4,664 meals delivered each month. We provide approximately $1,150 in free or reduced price meals each month. BSKHS provides a women's services mobile health clinic that offers mammography screening monthly. In FY14 we provided 912 mobile mammography screenings and 210 in house screenings through grant funding to individuals that are uninsured or underinsured. 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 page 10 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 40 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.Part III, Line 7: 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. 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 Health System / Our Lady of Bellefonte Hospital 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 all contribute to the assessment of the community health care needs. 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, Our Lady of Bellefonte Hospital 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 adduction 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 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. 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, 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) 505633 General and Administrative Support 1 0 Part I, Line 2: The organization 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 0 0 0 1 0 0 0 0 0 0 0 Kevin Halter FACHE CEO - BSKY 0 302354 0 49988 0 44705 0 23626 0 26620 0 447293 0 1525 Lawrence Hubbard CHCIO Board Member 0 374924 0 99856 0 92436 0 15300 0 20105 0 602621 0 0 Elizabeth Keith Board Member 0 148792 0 42396 0 60396 0 10185 0 11204 0 272973 0 11022 Thomas Morris PhD President (Jan-Aug) 0 286607 0 77693 0 39906 0 36404 0 19659 0 460269 0 11391 John Wallenhorst PhD President (Sep-Dec) 0 225989 0 63875 0 47218 0 14568 0 10185 0 361835 0 801 Joe Buchheit Treasurer/CFO-BSKY 220097 0 29649 0 44943 0 4536 0 18185 0 317410 0 3075 0 Rodney Hieneman Secretary (Feb-Aug) 137150 0 13178 0 907 0 6036 0 23774 0 181045 0 0 0 Jennifer Moore Secretary (Sep-Dec) 179795 0 24067 0 41896 0 6672 0 9341 0 261771 0 0 0 Daniel Goulson Chief Medical Officer 281069 0 26395 0 1639 0 11475 0 24569 0 345147 0 0 0 Kurt Jaenicke MD Obstetrician 342349 0 358828 0 1703 0 4512 0 25479 0 732871 0 0 0 Yogendra Prasad MD Cardiologist 440358 0 173150 0 1703 0 4188 0 27377 0 646776 0 0 0 Michele Friday MD Cardiologist 492942 0 80241 0 1468 0 4404 0 24869 0 603924 0 0 0 Phillip Lackey MD Plastic Surgeon 393853 0 0 0 1515 0 4200 0 24970 0 424538 0 0 0 Jason Ford MD Pediatrician 128899 0 191022 0 980 0 5076 0 23768 0 349745 0 0 0 Part I, Line 1a Tax indemnification and gross-up: Certain full time individuals (7) listed on Form 990, Part VII received gift cards valued at $100. The value of the gift cards were reported as taxable compensation. In an effort to reduce the tax impact of these gifts, each recipient received additional taxable compensation of $50 which was added to their paycheck. 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: Elizabeth Keith, $20,272; Kevin Halter, FACHE, $3,706; John Wallenhorst, PhD, $903; Joe Buchheit, $3,956; Thomas Morris, PhD, $17,448. Form 990, Part VI, Section A, line 2 Board members Philip B. Leslie and Frank Warnock have a business relationship. 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 15 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. Form 990, Part VI, Section b, Line 15b - 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 -4,570,231. Transfer to BSHSI for Swaps & Debt -2,026,751. 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 Our Lady of Bellefonte Hospital Foundation 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 0 1 0