2014-07-23T15:09:22-05:00 2013-08-31 861065772 Deloitte Tax LLP 191 Peachtree Street Suite 2000 Atlanta GA 303031749 990 2012-09-01 611356023 Our Lady of Bellefonte Hospital Inc OURL 6068333333 St Christopher Drive Ashland KY 41101 Joe Buchheit 6068333600 2014-07-23 1 David A Craig P00542227 4042201500 2012 2015-11-30 17:44:51Z Our Lady of Bellefonte Hospital Ironton Imaging Center Kevin Halter St Christopher Drive Ashland KY 41101 161085239 0 0928 X www.olbh.com X 1999 KY Acute Care Hospital 19 15 1181 125 2088273 0 2728884 2226497 149745567 154224825 352056 1039437 4457326 3594480 157283833 161085239 375315 398990 0 0 58130093 62560342 0 0 0 90399736 93531062 148905144 156490394 8378689 4594845 114048363 117497443 77870120 56898322 36178243 60599121 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 142459344 398990 154824012 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. 142459344 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 95 0 1 1181 1 1 1 0 0 0 0 0 0 0 0 0 X 19 15 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 OLBH St Christopher Drive Ashland KY 41101 X Carol Allen 2.00 0.00 X 0 0 0 Gregory Bausch Pharm D 2.00 0.00 X 0 0 0 Mary Carolyn Carter 2.00 0.00 X 0 0 0 William Dickens 2.00 0.00 X 0 0 0 Mary Catherine Flath PhD 2.00 0.00 X 0 0 0 John Gross III 2.00 0.00 X 0 0 0 Lawrence Skip HubbardSVPCIO 2.00 48.00 X 0 767237 33748 Connie Johnson 2.00 0.00 X 0 0 0 Larry Jones 2.00 0.00 X 0 0 0 Elizabeth Keith 2.00 48.00 X 0 251266 19085 Phillip Bruce Leslie Esq 2.00 0.00 X 0 0 0 James Martin MD 2.00 0.00 X 0 0 0 Jason McCloud OD 2.00 0.00 X 0 0 0 EW Unnikrishnan MD 2.00 0.00 X 0 0 0 Frank Warnock Esq 2.00 0.50 X 0 0 0 William Willan PhD 2.00 0.00 X 0 0 0 Kevin Halter FACHE 20.00 30.00 X X 0 584283 42787 Daniel Huffman 3.00 0.00 X X 0 0 0 John Wallenhorst PhD 3.00 47.00 X X 0 304186 23434 Joe Buchheit 37.00 13.00 X 326400 0 25031 Jennifer Moore 50.00 0.00 X 262239 0 17103 Michele Friday MD 49.50 0.50 X 640734 0 27459 Daniel T Goulson MD 50.00 0.00 X 318749 0 34195 Kurt F Jaenicke MD 50.00 0.00 X 634233 0 27550 Phillip L Lackey MD 50.00 0.00 X 364863 0 27231 Yogendra Prasad MD 50.00 0.00 X 576023 0 32263 Mark Gordon 0.00 50.00 X 0 609630 56092 3123241 2516602 365978 46 1 1 0 Morrison Management Specialists Inc PO Box 102289 Atlanta GA 303682289 Cafeteria/Food Services 3285362 Ashland Anethesia PSC PO Box 1377 Ashland KY 411051377 Anesthesia 2453644 Aramark Healthcare 24863 Network Place Chicago IL 606731248 Housekeeping/Laundry and Linen/Lift Team 1790092 Aramark CTS Inc 12483 Collections Center Dr Chicago IL 60693 Equipment Maintenance 1742978 Biomet 75 Remittance Dr Ste 3283 Chicago IL 606753283 Equipment Maintenance 1534196 35 1021736 1204761 2226497 Patient Service Rev. 622110 154224825 153238543 986282 154224825 273080 273080 435629 0 435629 435629 435629 751539 14818 0 0 751539 14818 766357 766357 Retail Pharmacy Rev. 446110 2381258 1279267 1101991 Comm. Health & Fitness 621610 306202 306202 Income from JV 621498 295284 295284 176107 176107 3158851 161085239 154824012 2088273 1946457 398990 398990 617175 555457 61718 42258637 38032773 4225864 7565173 6808655 756518 8333694 7500325 833369 3785663 3407097 378566 240661 216595 24066 167742 150968 16774 15254 13729 1525 4492624 4043362 449262 662544 596290 66254 2016296 1814666 201630 4147151 3732436 414715 5132618 4619356 513262 340979 306881 34098 76739 69065 7674 2288952 2288952 9508873 8557986 950887 1370288 1233259 137029 Medical Supplies 25352950 22817655 2535295 Purchased Services 14861154 13375039 1486115 Bad Debt 13491947 13491947 BSHSI Corporate Dues 5002389 4502150 500239 4361901 3925711 436190 156490394 142459344 14031050 0 0 2514 18210455 24007552 25000 18635012 15063673 876804 547507 3495278 3412570 1008536 1308471 126917282 74676145 54208231 52241137 7607838 8419434 449980 386930 707762 265985 8848467 11816670 114048363 117497443 12938926 10347979 3865059 5060840 61066135 41489503 77870120 56898322 X 36177683 60598561 560 560 36178243 60599121 114048363 117497443 X 4594845 42208 19783825 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 15254 15254 0 Explanation of Lobbying Activities: 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. 4547950 4547950 57291550 25404184 31887366 2528249 1808466 719783 58677721 44262470 14415251 3871812 3201025 670787 52241137 HPL/GL 8709254 Other Pat and 3rd Party Payors 2808029 Medicare Receivables 211084 Pharmacy AR 37835 Lifeline AR/Accrued Int/Misc Clearing 36833 Due from Affiliates 13635 11816670 LT Liab - Pension Liability 30461440 HPL/GL Liability 8709254 Reserves for Mcare and Mcaid 1209840 Mcare and Mcaid Settlements 874317 Other Misc LT Liab 206541 Unclaimed Prop Accrual 28111 41489503 X Description of Uncertain Tax Positions Under FIN 48: 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 (Formerly FIN48). ASC 740 (Formerly FIN48) 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 de-recognition of tax positions taken or expected to be taken in a tax return. The adoption of ASC 740 (Formerly FIN48) 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 $66,681 and $95,733 of net operating loss carryforwards as of August 31, 2013 and 2012, respectively, which expire in varying periods through 2032 and are available to offset future taxable income. The System's deferred tax assets are fully reserved at August 31, 2013 and 2012. 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 1 0 1 1 2837285 501724 2335561 0.01630 23150936 15313300 7837636 0.05480 25988221 15815024 10173197 0.07110 26 18026 914753 880 913873 0.00640 2 167 1082910 216961 865949 0.00610 1 973837 973837 0.00680 10 7710 116195 0 116195 0.00080 39 25903 3087695 217841 2869854 0.02010 39 25903 29075916 16032865 13043051 0.09120 3 1528 7875 7875 0.00010 1 38 2685 2685 0.00000 2 888 6956 6956 0.00000 15 4871 43534 43534 0.00030 4 9692 84600 84600 0.00060 2 134 532 532 0.00000 27 17151 146182 146182 0.00100 1 13484685 3161645 40880859 45098541 -4217682 X 1 1 1 1 Our Lady of Bellefonte Hospital Inc

St Christopher Drive Ashland KY 41101

www.OLBH.com 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 X 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 13 Med Plaza Pharmacy

700 St Christopher Drive Ashland KY 41101

Pharmacy Ashland Sleep Lab

2920 Winchester Avenue Ashland KY 41101

Sleep Lab 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

1629 Ashland Road Unit 2 Greenup KY 41144

Pediatric Rehab Bellefonte Behavioral Health

1000 St Christopher 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 Avenue Ashland KY 41101

Infusion therapy Ashland Lab

1816 Carter Avenue Ashland KY 41101

Lab Services Ashland Imaging

1816 Carter Avenue Ashland KY 41101

Imaging Center 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 recorded in the 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, Line 7g: Bellefonte Physician Services, Inc., ("BPS") in conjunction with Our Lady of Bellefonte Hospital, employs 72 providers in order to offer quality healthcare to the residents of Eastern Kentucky, and Southeastern Ohio, more specifically Boyd, Greenup, and Carter Counties in KY and Lawrence County in Ohio. BPS providers offer healthcare services to patients who are either uninsured or are covered by Medicaid, which equals approximately 12% and 23% of our overall patient population, respectively. Part I, L7 Col(f): Bad debt expense included in Part IX; line 25 and excluded from the "percent of total expense" calculation is: $13,491,947. Part II: Bon Secours Kentucky Health System (BSKHS), is working to engage and empower the members of the Argillite Community located in Greenup County, Kentucky. 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 at 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 subsidized housing for 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 local farmers market resulted in availability of fresh fruit and vegetables in an area that is labeled a food dessert. Healthy Community Services conducted 114 health fairs, providing approximately 9,500 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, the local "Free Clinic" was also given to participants who were uninsured or could not afford a health care provider. We currently partner with 52 local churches with 21 additional congregations on our mailing list. We offered our second basic education course for faith community nurses in 2013 with seven nurses completing that course. 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 positions. 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 FY13 our van ministry provided over 2,300 round trips and traveled over 67,000 miles. 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. Healthy Community Services also provides our community CPR classes and certified Safe sitter classes. BSKHS provides a women's services mobile health clinic that offers mammography screening monthly bone density test. Two Primary care physicians and our medical students volunteered four times a month at Northeast KY Care Center. Sponsored 15 annual Bicycle safety camp served over 50 children. Part III, Line 4: Part III, line 2: Bad Debt Expense at cost is computed by applying the cost-to-charge ratio computed on Worksheet 2 to the aggregate bad debt expense for patient accounts recorded in the general ledger. 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 10-11 in the attached BSHSI consolidated audited financial statements ("AFS"). "Allowance for doubtful accounts" is discussed in the second paragraph in Footnote "(10) Net Patient Service Revenue" on page 41 of the attached AFS. There is not a separate "bad debt expense" footnote in the AFS. Part III, Line 8: Part III, Line 6: 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 8: 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 Financial Assistance Program (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 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. 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. , Maxine Lewis Director Lawrence Co. Ohio Health Dept., Ginger Clark, 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 5c: The CHNA is also available on the website of the OLBH Foundation and is also made available by the Foundation upon request. Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 7: While there were nine health needs identified within the community health needs assessment, the issue of obesity was so prevalent and significant that OLBH decided to dedicate substantial effort to impacting this condition across the entire community. 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. Our Lady of Bellefonte Hospital, Inc. Part V, Section B, Line 12h: 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. Part VI, Line 2: Bon Secours Kentucky, Our Lady of Bellefonte Hospital (OLBH) uses multiple approaches to assess the health needs of the communities it serves. We have a community based Board of Directors that provides the hospital with guidance and input on services needed in the local community through contacts with local business and government leaders. Community health screening data is gathered through the year and analyzed for use in planning. Community need assessments are updated using a variety of informational sources including Kentucky Health Information for state-based performance data, Kentucky Hospital Association info site for market and geographic data bases, third party data bases, US Census Bureau data and Thomson-Reuter's Market Expert is used to retrieve demographic information and trends for the primary and secondary service areas pertaining to Our Lady of Bellefonte Hospital. We have also developed regional alignment plans using this data and tying it to our underserved areas to plan for future growth in the communities we serve by providing more access points for patients in our service areas.The community health care needs assessment was open to the public through a web based survey and available as a print copy, working with local health departments we participated in health needs assessments through these organizations, conversations with local residents and health professionals, public forums and community meetings and coalitions 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"), as adjusted by the Medicare geographic wage index for each community served to reflect that community's relative cost of living ("Adjusted FPG"). Adjustments to these guidelines are made in certain States, where applicable. 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. The standard sliding scale is adjusted by the Medicare geographic wage index of each community served to reflect that community's relative cost of living. All patients are also eligible for a Prompt Pay Discount. In addition, a variety of other potential payment options are available. Bon Secours is dedicated to meeting the needs of non-English speaking patients by having on-site Spanish translators, and other language translation services. In addition, Bon Secours employs a telephone language service which assists in meeting any language needs that arise. The translation services are offered to non-English speaking patients from admission to discharge, including the financial process. Part VI, Line 4: Bon Secours Kentucky Health System (BSKHS), Our Lady of Bellefonte Hospital (OLBH) serves a region of approximately to 400,000 people in northeastern Kentucky, southern Ohio, and western West Virginia, The service areas includes six counties in northern Kentucky (Greenup, Boyd, Lawrence, Carter, and Elliott) which comprises the FIVCO Area Development District as well as Lewis County, two counties in southern Ohio (Lawrence, Scioto) and Wayne and Cabell counties in western West Virginia. Due to our growing aging population services for our community residents aged 55 and older are needed, particularly women's health, orthopedics, diabetes, cardiopulmonary services, cancer, drug rehab and wound care. The 55 and older population is expected to increase by 14% over the next five years. The high poverty and high unemployment rate in the area result in a low social economic status. It is a very industrialized region which creates carcinogens and unhealthy life styles especially in eastern Kentucky, which has some of the highest incidence in the country of smoking, diabetes, obesity and carcinogens. These demographic characteristics create a high demand for chronic disease health care, including diabetes, cancer and heart disease among others.OLBH conducted a demographic analysis of the hospitals service. OLBH is located in Greenup County, KY., with approximately 14,000 households about 14 percent are living in poverty and 15 percent are age 65 and older. In adjacent counties, the poverty rate is 15 percent in Boyd County; 22 percent in Carter County; 29 percent in Lewis County; and approximately 19 percent in Lawrence County, Ohio. Lack of well-paying jobs has contributed to the rate of poverty in this area. According the U.S. Census gathered in 2010, Hispanics make up less than one percent of the hospital's service area. However, there are marked increases of the Hispanic population at OLBH's primary care centers in Carter County KY, in particular, where many residents still make a living through tobacco and other farm crops. According to the County Health rankings data 2011, the counties in OLBH primary service area rank among the highest in the state at risk for poor health outcomes and poor Health factors. Consistent with the state and national trends five chronic diseases account for most of the spending on health care: diabetes, heart disease, hypertension, asthma and depression. Prescription drug abuse and addiction is a growing problem in the area as is illegal drug use including methamphetamine, cocaine and marijuana. Access to quality preventative care and disease management education is critical in minimizing future hospitalizations as well as the seriousness of these diseases. Health insurance coverage is also a factor in determining whether patients will seek preventative care or wait for symptoms to become more severe, thus requiring more extensive treatments, including hospitalization.The area's growing drug addiction problems puts these individuals more at risk for depression, suicides and kidney failure. The area's population of drug abuse by all ages is growing at a relatively fast pace and will necessitate planning of and access to health care services unique to this population. There are few exceptions to our local community versus state averages with regard to health impacts. Our service area has higher overall cancer rates in Lung Cancer than the state average. Other cancers that are prevalent in our primary and secondary service areas are breast, colon, bladder, prostate and lymphoma. Part VI, Line 5: OLBH has been instrumental in developing 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 52 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. OLBH operates an emergency room that is open 24 hours 7 days a week to all persons regardless of ability to pay. Our Lady of Bellefonte Hospital has an open medical staff with privileges available to all qualified physicians in the area. 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. Reports Filed With States Part VI, Line 7 KY 1 Bon Secours Kentucky Health System Foundation Inc St Christopher Drive Ashland KY 41101 611381952 501(c)(3) 398990 0 General and Administrative Support 1 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, 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. 0 1 0 0 0 0 0 0 0 Lawrence Skip HubbardSVPCIO 0 368632 0 277018 0 121587 0 15000 0 18748 0 800985 0 0 Elizabeth Keith 0 145825 0 34743 0 70698 0 9936 0 9149 0 270351 0 0 Kevin Halter FACHE 0 300812 0 235226 0 48245 0 18006 0 24781 0 627070 0 4937 John Wallenhorst PhD 0 210819 0 50734 0 42633 0 13866 0 9568 0 327620 0 2402 Joe Buchheit 215606 0 55955 0 54839 0 8035 0 16996 0 351431 0 9225 0 Jennifer Moore 175785 0 45421 0 41033 0 8268 0 8835 0 279342 0 0 0 Michele Friday MD 503902 0 135499 0 1333 0 4176 0 23283 0 668193 0 0 0 Daniel T Goulson MD 268693 0 48674 0 1382 0 11250 0 22945 0 352944 0 0 0 Kurt F Jaenicke MD 343693 0 288987 0 1553 0 4344 0 23206 0 661783 0 0 0 Phillip L Lackey MD 363366 0 150 0 1347 0 3948 0 23283 0 392094 0 0 0 Yogendra Prasad MD 438699 0 135833 0 1491 0 3960 0 28303 0 608286 0 0 0 Mark Gordon 0 322518 0 244532 0 42580 0 28121 0 27971 0 665722 0 2450 Part I, Line 3 Bon Secours Health System, Inc., a related organization of the filing organization, uses the following to establish the compensation of the organization's CEO/Executive Director: Compensation Committee Independent Compensation Consultant Written Employment Contract Compensation Survey or Study Approval by the Board or Compensation Committee Part I, Line 4b The filing organization participates in a BSHSI sponsored executive retirement program that allows for deposits into additional retirement plans and available only to key employees. The 457F plan is a non-qualified plan and is subject to a minimum three-year service requirement before vesting on deposits made into this plan. Individuals that received a distribution include: Kevin Halter, $7,749; Joe Buchheit, $14,445; John Wallenhorst, Ph.D, $2,843; Mark Gordon, $2,655. 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, 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' 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 The filing organization provides any documents open to public inspection upon request. Form 990, Part VII: 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. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Minimum Pension Liability 21,538,245. Released from Restrictions -1,754,310. Other misc changes -110. Bon Secours Health Systems Inc 1505 Marriottsville Road Marriottsville MD 21104 521301088 Parent Org. Management Services MD 501(c)(3) 11b Bon Secours Inc 0 Bellefonte Physician Services Inc 1000 St Christopher Drive Ashland KY 41101 352320780 Physician Practices KY 501(c)(3) 3 Bon Secours Kentucky Health System 0 Our Lady of Bellefonte Hospital Foundation 1000 St Christopher Drive Ashland KY 41101 611381952 Grant Making Foundation KY 501(c)(3) 9 Bon Secours Kentucky Health System 0 Bon Secours Kentucky Health System 1000 St Christopher Drive Ashland KY 41101 611356024 Local System Parent Org. KY 501(c)(3) 11b Bon Secours Health Systems 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