2013-11-12T15:51:40-06:00 2012-12-31 ERNST & YOUNG US LLP 111 MONUMENT CIRCLE SUITE 2600 INDIANAPOLIS IN 46204 990 2012-01-01 237296923 Good Samaritan Hospital Foundation - Dayton % J MICHAEL SIMS GOOD 9374999942 110 N MAIN ST Suite 500 Dayton OH 45402 TIMOTHY D SNIDER 9374999942 2013-11-12 true 3176817000 2012 2016-03-07 17:11:31Z Marc S Martens President 2222 Philadelphia Dr Dayton OH 45406 1229617 false 0928 X www.premierhealth.com X 1973 OH TO SUPPORT THE PATIENTS, STAFF AND EMPLOYEES OF GOOD SAMARITAN HOSPITAL AND ITS AFFILIATES BY FOSTERING CHARITABLE GIFTS FROM THOSE SHARING OUR COMMITMENT TO HEALTHCARE WITH EXCELLENCE AND COMPASSION. 20 18 0 36 0 3010153 787608 0 0 263012 440483 -3033 -2454 3270132 1225637 460683 342643 0 0 299578 430946 0 0 247773 123085 104293 883346 877882 2386786 347755 9579944 10360810 182404 415709 9397540 9945101 X TO SUPPORT THE PATIENTS, STAFF AND EMPLOYEES OF GOOD SAMARITAN HOSPITAL AND ITS AFFILIATES BY FOSTERING CHARITABLE GIFTS FROM THOSE SHARING OUR COMMITMENT TO HEALTHCARE WITH EXCELLENCE AND COMPASSION. false false 152097 152097 The Samaritan Homeless Clinic sees 2,500 patients annually with strong support from the Good Samaritan Hospital Foundation-Dayton. The Foundation provides funds for operating expenses, equipment updates and the expanded dental program. 121146 121146 The equipment purchased through grants from the Duarte Foundation over the last three years has benefited Good Samaritan Hospital's patients in phenomenal ways. The microscope has provided more accuracy and increased safety to the patients. The new micro saws make huge differences to our patients and surgeons. The staff and surgeons truly appreciate this new state-of-the-art equipment that offers ease of handling and results in better outcomes for patients. 111815 111815 A new fitness center for physicians and employees was opened in 2012 with state-of-the-art equipment funded by the Good Samaritan Hospital Foundation-Dayton. The center helps promote healthy lifestyles, thereby reducing health care costs for everyone. Over 1,000 physicians and employees are signed up to use the center. 78508 69400 463566 true true false false false false false false false true true true false false true true false true false false true false false false true false false true true true false false false false false false false false false false false false false true true true false false true 12 0 true 0 false false false false false false false false false false X 20 18 false false false false true true false true true false false true true true true true true true true false OH X J MICHAEL SIMS 9374999942 110 N MAIN ST SUITE 500 Dayton OH 45402 Clark E Beck Sr 0.5 0.0 X 0 0 0 Atindra N Chatterji MD 0.5 0.0 X 0 12285 0 John E Clough 0.5 0.0 X 0 0 0 Robert S Copeland 0.5 0.0 X 0 0 0 Karen O Crim 0.5 0.0 X 0 0 0 The Rev Joseph W Goetz 0.5 0.0 X 0 0 0 John J Haluschak MD 0.5 0.0 X 0 0 0 Laura G Harrelson ESQ 0.5 0.0 X 0 0 0 Hon Cynthia M Heck 0.5 0.0 X 0 0 0 Walter S Hoy 0.5 0.0 X 0 0 0 Gavin D Jenney PhD 0.5 0.0 X 0 0 0 E Michael Kersh 0.5 0.0 X 0 0 0 Lisa Orr 0.5 0.0 X X 0 0 0 Walter A Reiling MD 0.5 0.0 X X 0 0 0 Douglas A Talmage 0.5 0.0 X X 0 0 0 Marc Martens 40.0 0.0 X X 179039 0 16626 Hon Patrick J Foley 0.5 0.0 X 0 0 0 Stephen B Levitt MD 0.5 0.0 X 0 0 0 Jennifer Tobiansky 0.5 0.0 X 0 0 0 Richard A Meyer 0.5 0.0 X 0 0 0 Janet Rogers 0.5 39.5 X 0 155348 41583 179039 167633 58209 1 false true false none 0 5990 58502 723116 15900 787608 0 221556 221556 0 0 0 0 0 218927 218927 218927 218927 1526 58502 3980 -2454 -2454 0 0 0 1225637 438029 327643 327643 15000 15000 0 0 179397 44849 44849 89699 0 214923 53640 53640 107643 0 15788 3947 3947 7894 20838 5209 5209 10420 0 0 0 0 0 31575 31575 0 3090 3090 22156 5539 5539 11078 8748 6561 2187 0 4503 1126 3377 2882 2882 0 0 0 0 386 386 0 OUTSIDE SERVICES 24550 6138 6138 12274 OTHER 6403 1601 1601 3201 877882 463566 166543 247773 0 0 2355478 349982 338840 245791 0 0 0 0 0 0 0 0 0 0 0 0 61767 61767 61767 5540823 8076098 1283036 1627172 0 0 0 0 0 0 9579944 10360810 38670 80685 0 0 106579 114214 0 0 0 0 0 0 0 0 0 0 37155 220810 182404 415709 X 1906948 2040396 4190935 4497410 3299657 3407295 9397540 9945101 9579944 10360810 X 347755 564134 -364328 X false true X true false X 1071796 493995 778384 474945 591080 3410200 0 0 1071796 493995 778384 474945 591080 3410200 413195 2997005 141224 177632 182292 151677 221556 874381 0 0 4284581 0.69949 0.69724 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 7490592 619003 283548 488438 7904705 6115921 1707009 -16123 316215 7490592 5840402 648712 283214 656407 6115921 5612636 254000 351106 377340 5840402 6295198 501402 -834842 349122 5612636 0.43000 0.57000 false true true 61767 61767 61767 ALTERNATIVE INVESTMENTS 1627172 F 1627172 0 INTER-COMPANY PAYABLES 220810 220810 X Part V, Line 4: The Good Samaritan Hospital Foundation-Dayton (GSHF) makes every effort to always follow the intent and wishes of all its donors. The intended uses of the organization's endowment funds and/or earnings from endowment funds are driven by the wishes/restrictions placed on the funds by the donor. Permanent endowments result when a donation is received with a restriction that the principal or gift amount is to be retained in perpetuity and cannot be spent. The earnings from the permanent endowments are then used for the purpose specified by the donor. The "categories" of permanently restricted endowments are as follows: to fund the Foundation operations(40%); To support Good Samaritan Hospital's Homeless Clinic operations (26%); To benefit specific programs for a Samaritan Health Partners affiliate (9%); To provide educational programs for cancer patients(5%); and miscellaneous (20%). Temporary endowments are funds in which all or part of the principal may be expended only after the expiration of a stated period of time or occurrence of a specified event, depending on the donor's wishes. Earnings from temporarily restricted endowments can be either unrestricted or restricted. The GSHF uses the temporarily restricted endowments for the intended purpose set up by the donor, only after the period of time or specified event set by the donor has been met. Part X, Line 2: Good Samaritan Hospital Foundation-Dayton (GSHF) is affiliated with Premier Health (Premier), which is tax-exempt under section 501(c)(3) of the Internal Revenue Code. As such, there is no income tax liability recorded at December 31, 2012 and 2011. In addition, management annually reviews its tax positions and has determined that there no material uncertain tax positions that require recognition in the combined financial statements. Central America and the Caribbean Investments 97033 North America Investments 19407 Sub-Saharan Africa Investments 48509 East Asia and the Pacific Investments 621009 Europe (Including Iceland and Greenland) Investments 1154689 Middle East and North Africa Investments 19407 Russia and the Newly Independent States Investments 29110 South America Investments 116439 South Asia Investments 29110 2134713 2134713 false false false false false false Ray of Hope 60028 58502 1526 3980 0 60028 58502 1526 3980 3980 -2454 true Good Samaritan Hospital 110 N Main St Suite 500 Dayton OH 45402 310536981 501(c)(3) 327643 N/A N/A Operations 1 Educational Scholarships 15 15000 Part 1, Question 2: All distributions (grants paid) follow the entities disbursement policy, including: (A) Assuming funds availability, hospital departmental personnel completes a foundation request form. For amounts in excess of $1,000, Director's & Vice-President's signatures are required to request foundation funding. (B) For request greater than $5,000, the Foundation's Distribution Committee reviews and approves the request. The check also requires a 2nd signature. (C) Reporting for grants is the responsibility of the operational unit. (D) Before disbursing funds, each request is verified/matched for its intended purpose. For example, scholarship requirements include a) GPA requirements; b) length of service; c) specific fields of study. X X X X false false false false false true true false false Janet Rogers 0 125828 0 27297 0 2223 0 20840 0 20743 0 196931 0 0 Marc Martens 120569 0 57046 0 1424 0 6400 0 10226 0 195665 0 0 0 Part I, Question 6A and 6B: Premier Health (Premier), which Good Samaritan Hospital Foundation-Dayton is affiliated with, has an incentive component for all executive and director level employees that ties a portion of their total compensation to organizational and individual objectives and outcomes. The organizational criterion is weighted according to balanced scorecard categories: Positive Work Environment (15%), Quality (30%), Patient Satisfaction (15%), Physician Partnership (15%), and Financial (25%). The financial category of the scorecard is based upon net earnings of the individual hospital and net earnings of the system as a whole. This financial target is set based upon the margin required to maintain the system AA credit rating. Incentive objectives for Directors and above are weighted 45% on organizational criteria, 45% on individual criteria, and 10% Organizational Effectiveness. The 2012 incentive plan amounts were paid to the participants in 2013. These are not reported as deferred compensation on the 2012 Form 990 based on the definition of deferred compensation contained in the Form 990 instructions. Per the instructions, "deferred compensation is generally treated as earned or accrued in the year that services are rendered, except when entitlement to payment is contingent on satisfaction of organizational goals or specified performance criteria (other than mere longevity of service) under the deferred compensation plan." Based on the incentive program's criteria outlined above, we believe the incentive payments meet the exception noted in the instructions. Such amounts are properly reported as compensation for Form 990 purposes when included in the participants' Form W-2 wages. Form 990, Part I, Question 10: The Good Samaritan Hospital-Dayton has designated its investments as trading. In accordance with the AICPA Guide for Healthcare, all unrealized gains and losses are recognized through the Profit and Loss statement. For 990 reporting, this activity is excluded per the instructions by the Internal Revenue Service. Form 990, Part III, Question 4d: This number represents the total expenditures of temporarily restricted funds for Good Samaritan Hospital net of programs described in service accomplishments. Form 990, Part VI, Section A, Question 6: Good Samaritan Hospital Foundation-Dayton has one corporate member. This member is Samaritan Health Partners, the parent of the Foundation. Form 990, Part VI, Section A, Question 7a: Samaritan Health Partners (SHP) has the sole authority to elect the Board of Trustees for Good Samaritan Hospital Foundation-Dayton. Form 990, Part VI, Section B, Question 11B: This 990 tax return and attached schedules (the return) are prepared by a staff member in the Tax Department of Premier Health (Premier), which Good Samaritan Hospital Foundation-Dayton is affiliated with. The return is reviewed by the Tax Manager and the Director of Tax Compliance of Premier. The return is concurrently sent to Ernst & Young U.S. LLP for their review. After all changes from the above groups are made, the return is reviewed by the Vice President/Controller of Premier and the Treasurer and President of this entity. A final version of the return is sent to Ernst & Young U.S. LLP for a final review and then provided to the Board of Trustees for review. At the meeting, the Vice President/Controller of Premier (or designee) shares detailed information on compensation and other key areas, as well as address any other questions from the Board of Trustees, pending their review. The 990 tax return is also shared with the Audit Committee of Premier. At the meeting, the Vice President/Controller of Premier (or designee) shares detailed information on compensation and other key areas, as well as addresses any other questions from the committee. Form 990, Part VI, Section B, Question 12C: Premier Health (Premier), which Good Samaritan Hospital Foundation-Dayton is affiliated with, requires all board members, officers, executives, and management personnel to annually review the Premier Comprehensive Conflict of Interest Statement, an explanatory memorandum, the Antitrust Compliance Policy, and complete an individual questionnaire disclosing any potential conflicts as defined in the Conflicts of Interest Policy. This is accomplished with a memo sent out annually from the Chairman of the Board and Chief Executive Officer of Premier to all board members, executive directors, vice presidents, directors, purchasing department staff, authorized purchasers, medical directors, department and section chairs, and all employed physicians. It includes an explanatory memorandum of specific activities that might give cause to a conflict and an individual questionnaire to disclose all such activities. This questionnaire must be completed and signed by the individual. Last, this memo includes a copy of the Antitrust Compliance Policy that must be signed by the individual. All of these documents are sent to the Corporate Compliance Officer. The Corporate Compliance Department ensures all forms are returned and retains the documents for five years. In addition, at each meeting of the Board or any Board Committee, following approval of the previous meeting's minutes, the Board or Committee Chair shall request any board member who perceives a potential conflict of interest on any of the meeting's agenda items to disclose the potential conflict. Additionally, at any Board or Board Committee meeting where the subject of conflicts of interest is discussed, the minutes shall contain the name of the party discussing a potential conflict of interest, the nature of the potential conflict of interest and whether a conflict of interest was found to exist. If a conflict of interest is determined by the board to exist, the member will be excused from participating in any discussion or voting on the particular agenda item. The Corporate Compliance Officer reports the results of the Premier Conflict of Interest questionnaires no less than annually to the Board of Trustees by way of the Compliance and Audit Committee. This review is documented in the minutes of the meeting. Periodically, the Internal Audit department will review a sample of completed Conflict of Interest questionnaires and report the results to the Compliance and Audit Committee. The annual conflict of interest questionnaires are individually summarized in a Word document and sent electronically to the Finance department for any necessary disclosures required on the 990 tax return. Form 990, Part VI, Section B, Question 15A and 15B: Premier Health (Premier), which Good Samaritan Hospital Foundation-Dayton is affiliated with, follows a market based compensation philosophy designed to attract and retain the executive talent required to meet the high performance standards of our board and our community. Premier annually reviews executive compensation survey data for a regional peer group of systems and hospitals that are similar in size and complexity to Premier and its affiliates. The data for the survey is provided by a third party consultant group that is independent of Premier. This report includes comparability for key executives, vice presidents, and director level positions. The independent comparability data is reviewed by the executive compensation committee on an annual basis. This committee is comprised of three members, all of which are independent. This committee reviews in detail the compensation for the Premier CEO, COO, CFO, Chief Strategy Officer, and the hospital CEOs. Other positions are reviewed at a high level for reasonableness. All the meeting minutes are documented and kept on file along with any comparability data and the consultant report. After the compensation committee reviews and approves the compensation actions, the process is audited by the internal audit department. The executive compensation committee presents the compensation actions to the Premier board annually. Form 990, Part VI, Section C, Question 19: The governing documents and financial statements are made available to the public when required by law or for accreditation purposes. The conflict of interest policy is available on the company website. Form 990, Part XI, Question 9: Pledge write-offs $(6,306) Capital Distributions (358,022) Total $(364,328) Good Samaritan Hospital 110 N Main St Suite 500 Dayton OH 45402 310536981 Hospital OH 501(c)(3) 3 SHP true Samaritan Health Partners (SHP) 110 N Main St Suite 500 Dayton OH 45402 311107411 Parent OH 501(c)(3) 11-I NA false Beneficiary Trust (1) Community Donor OH NA TRUST false false true false false false false false false false false false false false false true false false false Good Samaritan Hospital B 685665 Cash Good Samaritan Hospital P 430946 Fair Value