2013-07-15T01:12:25-05:00 2012-08-31 861065772 DELOITTE TAX LLP 1750 TYSONS BLVD MCLEAN VA 221024219 990 2011-09-01 611356023 Our Lady of Bellefonte Hospital Inc OURL 6068333333 St Christopher Drive Ashland KY 41101 Joe Buchheit 6068333600 2013-07-15 1 David A Craig P00542227 7032511000 2011 2016-02-24 21:20:13Z Kevin Halter St Christopher Drive Ashland KY 41101 157292756 0 0928 X www.olbh.com X 1999 KY Acute Care Hospital 19 14 1545 125 2050400 0 941431 2728884 150022362 149745567 426499 352056 4064403 4457326 155454695 157283833 372800 375315 0 0 59461273 58130093 0 0 0 87228960 90399736 147063033 148905144 8391662 8378689 98205634 114048363 50715835 77870120 47489799 36178243 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 135355908 375315 148858673 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. 135355908 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 1 0 0 0 0 0 1 0 0 0 0 1 105 0 1 1545 1 1 1 0 0 0 0 0 0 0 0 0 X 19 14 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X Aaron Akers 6068333333 OLBH St Christopher Drive Ashland KY 41101 X Gregory Bausch Pharm D 4.00 X 0 0 0 Mary Carolyn Carter 4.00 X 0 0 0 William Dickens 4.00 X 0 0 0 Larry Fields MD 4.00 X 0 0 0 Mary Catherine Flath PhD 4.00 X 0 0 0 John Gross III 4.00 X 0 0 0 Lawrence Hubbard CHCIO 50.00 X 0 588946 92858 Connie Johnson 4.00 X 0 0 0 Larry Jones 4.00 X 0 0 0 Elizabeth Keith 50.00 X 0 184254 36729 Phillip Bruce Leslie Esq 4.00 X 0 0 0 James Martin MD 4.00 X 0 0 0 EW Unnikrishnan MD 4.00 X 0 0 0 William Willan 4.00 X 0 0 0 Carol Allen 4.00 X X 0 0 0 Kevin Halter FACHE 50.00 X X 0 362079 58560 Daniel Huffman 6.00 X X 0 0 0 John Wallenhorst PhD 50.00 X X 0 250446 33699 Frank Warnock Esq 6.00 X X 0 0 0 Joe Buchheit 50.00 X 0 268350 40227 Jennifer Moore 50.00 X 0 230682 22073 Michele Friday MD 50.00 X 750159 0 47497 Daniel T Goulson MD 50.00 X 376508 0 27854 Kurt F Jaenicke MD 50.00 X 619074 0 31845 Phillip L Lackey MD 50.00 X 384541 0 40650 Yogendra Prasad MD 50.00 X 568194 0 50483 Mark Gordon 50.00 X 0 360340 72092 2698476 2245097 554567 41 1 1 0 Morrison Management Specialists Inc PO Box 102289 Atlanta GA 303682289 Cafeteria/Food Services 3577426 Ashland Anesthesia PSC PO Box 1377 Ashland KY 411051377 Medical Services 2717108 Aramark CTS Inc 12483 Collections Center Dr Chicago IL 60693 Equipment Maintenance 1788542 Aramark Healthcare 24863 Network PL Chicago IL 60693 Lift Team 1342123 Allied Barton PO Box 828854 Philadelphia PA 191828854 Security Services 1027202 31 226162 2482722 20000 19694 2728884 Patient Service Rev. 622110 149745567 148858673 886894 149745567 252292 252292 405092 0 405092 405092 405092 107187 1500 0 8923 107187 -7423 99764 99764 Retail Pharmacy Rev. 446110 2587419 1163506 1423913 Cafeteria/Vending 531120 846038 846038 Comm. Health & Fitness 621610 316126 316126 302651 302651 4052234 157283833 148858673 2050400 3645876 375315 375315 558706 502835 55871 43011862 38710676 4301186 3870869 3483782 387087 7610158 6849142 761016 3078498 2770648 307850 640092 576083 64009 179160 161244 17916 15667 14100 1567 4225101 3802591 422510 1490557 1341501 149056 286793 258114 28679 4123412 3711071 412341 5957300 5361570 595730 419796 377816 41980 2893069 2893069 10525714 9473143 1052571 1546785 1392107 154678 Medical Supplies 21674449 19507004 2167445 Purchased Services 15556951 14001256 1555695 Bad Debt 10144394 10144394 BSHSI Corporate Dues 5031548 4528393 503155 5688948 5120054 568894 148905144 135355908 13549236 0 9071874 18210455 17698609 18635012 1290667 876804 3669259 3495278 453826 1008536 125034786 70826555 55370063 54208231 7030076 7607838 388320 449980 3232940 9556229 98205634 114048363 14344504 12938926 3999967 3865059 32371364 61066135 50715835 77870120 X 47489799 36177683 0 560 47489799 36178243 98205634 114048363 X 8378689 -19690245 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 15667 15667 0 Explanation of Lobbying Activities: Part II-B, Line 1: Our Lady of Bellefonte Hospital paid dues to the Kentucky Hospital Association (KHA), Catholic Health Association (CHA), and American Hospital Association (AHA) a portion of which is used for lobbying activities. The portion of dues allocated to lobbying activities for each of these organizations is as follows: 18% ($8,858) to the KHA, 5.2% ($1,360) CHA, and 25.1% ($5,449) AHA for a total of $15,667. 4533456 4533456 57145204 23476256 33668948 2532517 1560480 972037 56851180 42601168 14250012 3972429 3188651 783778 54208231 HPL/GL 7884204 Other Pat and 3rd Party Payors 635916 Goodwill 265985 Miscellaneous Receivables 707762 Accrued Interest Receivables 14124 Due from Affiliate 48238 9556229 Mcare Settlements 4053068 LT Liability Pension 48774204 HPL/GL 7884204 Other LT Liability 354445 Unclaimed Property Accrual 214 61066135 Description of Uncertain Tax Positions Under FIN 48: Part X: 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 derecognition 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 (formerly FIN48). 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 $95,733 and $89,500 of net operating loss carryforwards as of August 31, 2012 and 2011, 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, 2012 and 2011. Any changes to the valuation allowance on the deferred tax asset are reflected in the year of the change. 1 1 X 1 X 1 X 1 1 0 1 1 2004386 492033 1512353 0.01090 19708539 14916157 4792382 0.03450 21712925 15408190 6304735 0.04540 998706 33985 964721 0.00700 1577618 162470 1415148 0.01020 770710 770710 0.00560 174660 174660 0.00130 3521694 196455 3325239 0.02410 25234619 15604645 9629974 0.06950 3 2028 10650 10650 0.00010 2 145 5990 5990 0.00000 2 1874 8293 8293 0.00010 18 6245 41222 41222 0.00030 3 6166 47817 47817 0.00030 1 898 4011 4011 0.00000 29 17356 117983 117983 0.00080 1 2566330 39789296 51022483 -11233187 X 1 1 1 1 Our Lady of Bellefonte Hospital Inc

St Christopher Drive Ashland KY 41101

X X X Our Lady of Bellefonte Hospital Inc 1 1 1 200.000000000000 1 200.000000000000 1 X X 1 1 X X 0 0 1 0 0 10 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

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

St Christopher Drive Ashland KY 41101

Behavioral Health Bellefonte Center

1000 Ashland Drive Ashland KY 41101

Womens Health, Pre-testing, Various physician offices 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: Primary Care Clinic subsidy: Bellefonte Physician Services, Inc., ("BPS") in conjunction with OLBH employs 70 providers in order to offer quality health care to the residents of Eastern Kentucky and Southeastern Ohio, more specifically Boyd, Greenup, Carter Counties in Kentucky and Lawrence County 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. Part I, L7 Col(f): The bad debt expense included in Part IX; line 25 and excluded from the "percent of total expense" calculation is: $10,144,349. Part II: Healthy Community Initiative: BSKHS' commitment to social and economic justice is integrated into the fabric of the organization through its Strategic Quality Plan and its common vision of a healthy community. Our vision of a healthy community is embodied in the following statements. "A healthy community is a good place to live for all residents. The rich diversity of cultures and capacities of the community are celebrated and mobilized, with a particular concern for the poor, marginalized and dying, to create physical and social environments that promote families, nurture youth and support senior citizens. Individuals have the opportunity to fully participate in defining holistic well-being and assuming responsibility for the development of their innate potential."BSKHS is working to engage and empower the members of the Argillite community located in Greenup County to support them in improving their quality of life and holistic health. The Director of Healthy Community Initiatives is coordinating efforts to unite the communities and aid in health and social issues. The Director is assessing the needs and assets of the communities through resident interviews, community forums, surveys and focus groups. With this data, the community members will choose the priority improvement initiatives that residents and supporting organizations want to address. Argillite is a rural community with approximately 1,000 residents. Single-family homes and trailers prevail. 47% of the households make less than $25,000 per year with 17% of that number making less than $15,000 annually. 43% of residents have no high school diploma; 16% of that number have less than a 9th grade education. Argillite Elementary has 68% of students receiving free and reduced lunch. Community projects include distribution of free books to students and a back pack program to assist low income students with school supplies and clothes and funding for a weekend snack sack program that provides students most at risk of going hungry with food during the weekend. A walking track was built in the community to provide a safe area for residents to exercise in close proximity to where they live, along with school and community gardens for students and residents.The Ironton, Ohio community is a small urban area of approximately 25,000 residents. The once thriving city with abundant jobs in the steel and industrial areas is now in a situation of high unemployment, low job opportunities and a strapped city budget with an aging infrastructure. The 9th street community is home to subsidize housing for seniors and families; high crime rates and drug abuse are taking a toll on the residents. One of the first initiatives was the purchase of computers for senior housing recreation rooms and a community center used by students and families. Financial support for a cash strapped after school program allowed services to be provided three days a week to low income students needing assistance with homework and providing a safe environment for students. Students participating in summer youth activities at the community center provides the opportunity to go on fieldtrips, safe summer day camp activities and mentors to work with on the various topics. Community garden is in the final stages of completion and will be available in the spring of 2013. The garden will provide community residents with space to grow fresh vegetables, support through master gardeners will assist residents in learning how to grow vegetables to use in family meals. Work on a local farmers market will provide fresh fruit and vegetables in an area that is labeled a food dessert. In FY12, Healthy Community Services conducted 100 health fairs providing a total of approximately 6,000 health screening tests. All participants in our health fairs received personal health counseling and those with abnormal results received appropriate educational materials and the offer of assistance in finding a health care provider if they had none. Information about the Northeast Kentucky Care Center, our local "free" clinic was also given to participants who were uninsured or couldn't afford a health care provider. We currently partner with 51 local churches with 21 additional congregations on our mailing list. We offered our area's first basic faith ministery education program during the summer of 2012. Six nurses completed the course. Our Healthy Community Services Van Ministry provides free non-emergency medical transportation to patients who are receiving outpatient services or appointments with affiliated physicians. We have two vans one is equipped with a wheelchair lift. In FY12, the number of "round trips" we provided increased from 2,013 in FY11 to 2,131 and we traveled slightly over 4,000 more miles in FY12 than in FY11.Healthy Community Services provides our community CPR classes. In FY12 we provided 20 classes and certified 133 individuals in CPR. We provided one Safe Sitter class in FY12 resulting in 8 certified Safe Sitters. BSKHS provides a Women's Services mobile clinic that offers mammography screening, monthly bone density screening In FY2012, we served 7,718 in the pre-osteoporosis or osteoporosis range. Two primary care physicians volunteered four times a month at Northeast Kentucky Care Center, our local free clinic, throughout FY2012, our medical students are also involved in the clinic. 14th Annual Bicycle Safety Camp in FY 2012 served 55 children. We also provided educational programs at both end-of-school activities 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 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 publicly 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. Part VI, Line 2: 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. OLBH conducted a community needs assessment in 2012. The survey was distributed to local community organizations, and residents. OLBH is also working with local health departments on a community assessment (MAPP) and has participated in meetings and community forums with local organizations and residents to assess the needs of the community. Community needs are also determined and updated with information from 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-Reuters market expert, is used to retrieve demographic information and trends for the primary and secondary service areas pertaining to OLBH. We have also developed regional alignment plans using this data to target our underserved areas to plan for future growth in the communities we serve by providing more access points for patients in our service areas. Our Primary service area consists of Boyd, Greenup and Carter Counties in Kentucky and Lawrence County in Ohio. Our Secondary service area consists of Lewis County Kentucky and Scioto County Ohio. We continually update our information for our market share and physician planning to offer services in underserved areas of our region utilizing hospital data including emergency department visits. 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.Major trends in the service area include a stable population that is aging. The 55 and older population is expected to increase by 14% over the next five years. The younger population tends to leave the area to find jobs. 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. Part VI, Line 5: BSKHS' Our Lady of Bellefonte Hospital, 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 four goal areas for the current three year period (2010-2012). One of those goals was to partner with communities to co-create a more humane world, improve health and model social justice. To accomplish this, two key strategies are to: - Engage communities to identify needs and assets and building partnerships to improve health and quality of life of a specific population.- Demonstrate sustainable stewardship for healing the earth as a way to improve health and life quality.As a member of the Catholic health ministry and a member of Bon Secours Health System, Inc. (BSHSI), this organization and its 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 OLBH Foundation St Christopher Drive Ashland KY 41101 521301088 501(c)(3) 375315 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: These funds are for General and Administrative Support and are tracked through a specific accounting unit (cost center) in the General ledger. 0 1 0 0 0 0 0 0 0 Lawrence Hubbard CHCIO 0 384617 0 0 0 204329 0 68458 0 24400 0 681804 0 159679 Elizabeth Keith 0 164126 0 18679 0 1449 0 17763 0 18966 0 220983 0 0 Kevin Halter FACHE 0 309929 0 29358 0 22792 0 26205 0 32355 0 420639 0 0 John Wallenhorst PhD 0 227839 0 0 0 22607 0 21913 0 11786 0 284145 0 0 Joe Buchheit 0 232474 0 13123 0 22753 0 18475 0 21752 0 308577 0 0 Jennifer Moore 0 193239 0 14204 0 23239 0 11294 0 10779 0 252755 0 0 Michele Friday MD 494362 0 254710 0 1087 0 19344 0 28153 0 797656 0 0 0 Daniel T Goulson MD 269465 0 106410 0 633 0 2730 0 25124 0 404362 0 0 0 Kurt F Jaenicke MD 344364 0 273157 0 1553 0 3972 0 27873 0 650919 0 0 0 Phillip L Lackey MD 364341 0 1650 0 18550 0 12653 0 27997 0 425191 0 0 0 Yogendra Prasad MD 406250 0 161017 0 927 0 20280 0 30203 0 618677 0 0 0 Mark Gordon 0 338075 0 0 0 22265 0 38340 0 33752 0 432432 0 0 Supplemental Information Part III Part I, Line 3: Bon Secours Health System, Inc., a related organization of Our Lady of Bellefonte Hospital, Inc., uses the following to establish the compensation of the organization's CEO/Executive Director: Compensation Committee Independent compensation consultant Written employment contracts Compensation survey or study Approval by the board/compensation committee Supplemental Information Part III 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: Lawrence "Skip" Hubbard, $162,275 LawFirm McBrayer McGinnis Leslie Phillip B. Leslie, Esq. (Board Member) is a partner at this firm 231219 Consulting Services 0 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'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: Hours worked are not tracked on an entity by entity basis. All officer's and director's hours reported on Form 990, Part VII, Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors represent aggregate hours worked per week. Volunteer Board Members are not compensated for their time. Kevin Halter's compensation is paid by Bon Secours Health System, Inc., a related organization. The compensation he receives is for his role as the CEO of Bon Secours Kentucky Health System, which includes direct management, monitoring and oversight of Bon Secours Kentucky Health System and its related organizations. John Wallenhorst's compensation is paid by Bon Secours Health Systems, Inc., a related organization. The compensation he receives is for his role as the VP of Mission & Ethics at Bon Secours Health Systems, Inc. Elizabeth Keith's compensation is paid by SFH, Inc., a related organization of Bon Secours Health System, Inc. The compensation she receives is for her role as the SVP, Mission Services at SFH, Inc. Lawrence "Skip" Hubbard's compensation is paid by Bon Secours Health System, Inc., a related organization. The compensation he receives is for his role as the Chief Information Officer of Bon Secours Health System, Inc. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized gains on investments: 339,102. Minimum Pension Liability -17,914,416. Transfers to affiliates -2,114,931. Total to Form 990, Part XI, Line 5: -19,690,245. 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 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 1 0 0 1 0 0 1 0 1 0