2013-11-12T15:06:43-06:00 2012-12-31 ERNST & YOUNG US LLP 111 MONUMENT CIRCLE ST 2600 INDIANAPOLIS IN 46204 990 2012-01-01 310536981 GOOD SAMARITAN HOSPITAL % J MICHAEL SIMS GOOD 9374999942 110 N MAIN ST Suite 500 Dayton OH 45402 TIMOTHY D SNIDER 9374999942 2013-11-12 true 3176817000 2012 2016-02-24 21:20:13Z Eloise Broner PresidentCEO 2222 PHILADELPHIA DR DAYTON OH 45406 404069437 false 0928 X www.premierhealth.com X 1932 OH GOOD SAMARITAN HOSPITAL IS COMMITTED TO BUILDING A HEALTHIER DAYTON, OHIO COMMUNITY THROUGH HIGH QUALITY, COST COMPETITVE HEALTH CARE. 11 8 3304 342 1596918 -181300 1806863 1420927 371970759 361936801 5480315 10831758 3662966 4184823 382920903 378374309 2570355 2406279 0 0 175360527 177459287 0 0 0 185079996 179144548 363010878 359010114 19910025 19364195 491563235 495186632 199684274 174297552 291878961 320889080 GOOD SAMARITAN HOSPITAL IS COMMITTED TO BUILDING A HEALTHIER DAYTON, OHIO COMMUNITY THROUGH HIGH QUALITY, COST COMPETITVE HEALTH CARE. false false 321020958 2406279 361943158 SEE SCHEDULE H 321020958 true true false true false false false false false false true true false false true true false true false false true false false false false false true true true false true true false false false false false false false false false false false false false false false true true true false false true 233 0 true 3304 true true true false false false false false false false false false X 11 8 false false false false true true true true true false false true true true true true true true true true true OH X J MICHAEL SIMS 9374999942 110 N MAIN ST SUITE 500 DAYTON OH 45402 GEORGE BRODERICK 0.5 0.0 X 0 0 0 ELOISE P BRONER 40.0 0.0 X X 430542 0 20403 MARTIN FUJIMURA MD 0.5 0.0 X 0 0 0 LYNN HEPER SC 0.5 0.0 X 0 0 0 MICHAEL KERSH 0.5 0.0 X 0 0 0 MONICA ANN LUCAS SC 0.5 0.0 X 0 0 0 JAMES R PANCOAST 0.5 0.0 X 0 0 0 LARRY TAYLOR 0.5 0.0 X 0 0 0 REV VANESSA OLIVER WARD 0.5 0.0 X 0 0 0 Jeffrey S Levine 0.5 0.0 X X 0 0 0 Atindra Chatterji MD 0.5 0.0 X 12285 0 0 William Kurby 0.5 0.0 X 0 0 0 John Ayers 0.5 0.0 X 0 0 0 DALE E CREECH 7.75 22.25 X 0 598155 56953 THOMAS R CURTIN 40.0 0.0 X 217309 0 41468 ANITA ADAMS 40.0 0.0 X 232680 0 20064 MARY M CLANCY 8.0 32.0 X 0 482163 39747 MARY E GARMAN 40.0 0.0 X 242574 0 24486 RENEE P GEORGE 8.0 32.0 X 0 276674 34514 WILLIAM E LINESCH 8.0 32.0 X 0 445854 38785 DANIEL L SCHOULTIES MD 40.0 0.0 X 0 410725 46872 MARK S SHAKER 8.0 32.0 X 0 746571 33540 MARK W SHAW 8.0 32.0 X 0 403205 57358 Michael Maiberger 8.0 32.0 X 0 569067 75958 CHARLES HENDRICKS 40.0 0.0 X 221857 0 40394 JEROME SCHULTE JR 40.0 0.0 X 278409 0 55901 CRAIG SELF 40.0 0.0 X 243178 0 31330 SHARON K THORNTON 40.0 0.0 X 196752 0 16943 Stacey M Lawson 40.0 0.0 X 189920 0 29148 2265506 3932414 663864 106 false true false DAWSON RESOURCES 3650 OLENTANGY RIVER RD COLUMBUS OH 43214 EMPLOYMENT SERVICES 1759864 ANESTHESIA ASSOC OF NW DAYTON 3180 KETTERING BVD DAYTON OH 45439 MEDICAL SERVICES 3114000 MEDICAL RADIOLOGISTS 1563 EAST DOROTHY SUITE 101 KETTERING OH 45429 MEDICAL SERVICES 798149 Laboratory Corporation of America PO Box 2140 BURLINGTON NC 272162140 Medical Services 573426 TGC LLC Po Box 130 HIGHLAND MD 20777 Consulting 999785 46 327643 968788 124496 1420927 NET PATIENT REVENUE 621110 183538449 181947888 1590561 MEDICARE/MEDICAID 621110 166058597 166058597 CLINICAL RESEARCH 541712 65863 65863 JOINT OPERATING AGREEMENT 900099 1905000 1905000 FRANCHISE TAX RECOVERIES 900099 10224677 10224677 144215 144215 361936801 5115964 6357 5109607 0 0 4374197 4289806 84391 0 84391 84391 23914432 26750 18225388 5689044 26750 5715794 5715794 0 0 4185964 3179934 1006030 1006030 CAFETERIA 721110 2212033 2212033 PARKING GARAGE 812930 306977 306977 LAUNDRY 812390 52995 52995 522397 522397 3094402 378374309 360346240 1596918 15010224 2406279 2406279 0 0 0 1229526 1047679 181847 0 0 138764071 118240865 20523206 6923051 5899132 1023919 21635276 18435419 3199857 8907363 7589964 1317399 3924312 3343906 580406 482783 411379 71404 425171 425171 36652 36652 0 649319 649319 17452997 17452997 2124164 2124164 2137081 1821007 316074 7223566 6155201 1068365 0 7124327 6070639 1053688 318554 271440 47114 0 4943 4212 731 5708010 5708010 0 28594707 24365554 4229153 1056896 900581 156315 OPERATING SUPPLIES 75328619 75328619 PURCHASED SERVICES 14765390 12581588 2183802 REPAIRS & MAINTENANCE 2080890 1773126 307764 HOSPITAL FRANCHISE TAX 5286818 5286818 4419349 3765727 653622 359010114 321020958 37989156 0 9990 18590 13144737 9828478 175871 171622 44397297 50237537 0 0 0 0 430842 82274 6502407 5817766 2887443 4279878 531311157 326748523 213100298 204562634 157901114 165462064 35455171 33140110 0 0 5555580 3938913 12002485 17646766 491563235 495186632 28000633 29017159 5161469 4207270 1164185 1210978 7578750 5052500 0 0 0 0 120664104 114725651 0 0 37115133 20083994 199684274 174297552 X 291878961 320889080 0 0 0 0 291878961 320889080 491563235 495186632 X 19364195 12367024 1027799 -3748899 X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false true 29632 false false true 7020 36652 false PART II-B, LINE F: PORTION OF DUES PAID TO GREATER DAYTON AREA HOSPITAL ASSOCIATION AND OHIO HOSPITAL ASSOCIATION. PART II-B, LINE I: WE CONTRACT WITH A LOBBYIST FOR HEALTHCARE RELATED ISSUES. 9685728 9685728 264888214 155945024 108943190 5755902 3568760 2187142 240535591 167234739 73300852 10445722 10445722 204562634 0 0 MALPRACTICE INSURANCE 12228748 FICA RESIDENTS PAYABLE 4104242 FRANCHISE TAX LIABILITY 1407414 OTHER LIABILITIES 777034 INTERCOMPANY PAYABLES 782376 WORKERS COMPENSATION 626991 PHYSICIAN-RELATED 122429 INTEREST SWAP LIABILITY 34760 20083994 X Form 990, Schedule D, Part X, Line 2: Good Samaritan Hospital (GSH) is a member, under a joint operating agreement, of Premier Health (Premier) which is tax-Exempt under 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 are no material uncertain tax positions that require recognition in the combined financial statements. GSH and its respective subsidiaries are a group of corporations that are tax-exempt corporations under section 501(c)(3) of the internal revenue code except for the following subsidiaries: Samaritan Family Care (subsidiary of Samaritan Health Partners (SHP) and Samaritan North Surgery Center Limited (a joint-venture partnership of which SHP is an 80% owner.) Central America and the Caribbean Investments 1800024 East Asia and the Pacific Investments 11520154 Europe (Including Iceland and Greenland) Investments 21420287 Middle East and North Africa Investments 360005 North America Investments 360005 Russia and the Newly Independent States Investments 540007 South America Investments 2160029 South Asia Investments 540007 Sub-Saharan Africa Investments 899837 Central America and the Caribbean Program Services Insurance 23712 39624067 39624067 true false false false false false true true X true X true X true true false true true 18603000 6340000 12263000 0.03380 55108000 47209000 7899000 0.02180 1420000 1099000 321000 0.00090 75131000 54648000 20483000 0.05650 1822000 1822000 0.00500 257000 257000 0.00070 12262000 12262000 0.03380 70000 70000 0.00020 14411000 14411000 0.03970 89542000 54648000 34894000 0.09620 551000 551000 0.00150 138000 138000 0.00040 689000 689000 0.00190 true 10279000 86764000 99967000 -13203000 X true true SAM NORTH SURG CTR SURGICAL SERVICES 0.80000 0.20000 1 1 Good Samaritan Hospital

2222 Philadelphia Dr Dayton Ohio OH 45406

www.premierhealth.com X X X X Good Samaritan Hospital true true 200. true 400. true X X X X true true X X X X X X true false X X X X true X false false 4 GOOD SAMARITAN NORTH HEALTH CENTER

9000 N MAIN ST DAYTON OH 45415

GENERAL MEDICAL AND SURGICAL GOOD SAMARITAN NORTH SURGERY CENTER

9000 N MAIN ST DAYTON OH 45415

GENERAL MEDICAL AND SURGICAL GOOD SAMARITAN HEALTH CTR-HUBER HEIGHTS

6521 GOOD SAMARITAN WAY BRANDT PIKE HUBER HEIGHTS OH 45424

GENERAL MEDICAL AND SURGICAL SAMARITAN HOMELESS CLINIC

921 S Edwin C Moses Blvd DAYTON OH 45417

HOMELESS CLINIC Part I, Line 6a: The community benefit report for Good Samaritan Hospital is part of the Premier Health report. Part I, Line 7: A cost to charge ratio was used to calculate this financial assistance at cost. This calculation takes total operating expenses less other operating revenues divided by total gross revenues. Unreimbursed Medicaid and other means-tested governmental programs were calculated using a cost accounting system. This system addresses all patient segments and includes fully loaded costs. For the remaining items the organization used specific numbers for expense paid directly for these services. Part I, Line 7g: Good Samaritan Hospital provides the following subsidized services: 1. Good Samaritan Homeless Clinic: This Clinic is the only health clinic in the surrounding area specifically for the homeless. The clinic takes an integrated approach toward primary and preventative services. With the mission of serving the total well-being of the homeless, the Clinic aims to deliver quality, compassionate care and to get our patients back on their feet. The Clinic is staffed with a full-time physician and a dedicated nursing team. The Clinic provides a number of services to the homeless, including (but not limited to) respite care, dental services, mental health and substance abuse treatment and counseling, pharmacy services, vision screenings, podiatry, case management, health education, outreach services, transportation, life skills training, cancer prevention services, diabetes services and blood pressure monitoring. 2. Lifestages, LLC: This limited liability company provides healthcare to women of all ages that includes Obstetric services, gynecology services and heart, bone and breast health. Lifestages is built around the core beliefs that each woman is unique and that all women deserve the best care available. This company serves a large population of Medicaid and uninsured patients. Good Samaritan Hospital provides support through funding for Lifestages' indigent patients and medical education. The funding for 2012 was $2,087,000. 3. Emergency Services: Good Samaritan Hospital operates a 24-hour emergency room 365 days per year. This emergency room is open to all individuals regardless of their ability to pay. The hospital incurs expenses related to call time and physician subsidies due to the large number of indigent patients coming through the emergency room. For 2012, the amounts paid for call time and subsidies were $10,175,000. Part III, Line 2 & 3: Bad debt expense is incurred when an account is taken out of Accounts Receivable and turned over to a collection agency. This action may occur if a patient refuses payment arrangements, refuses to apply for financial assistance, and there is not an insurance balance being contended. An account is written off to bad debt after 120 days if an attempt to collect from the patient is made within our collection policy and the patient has not returned phone calls, set up a payment plan, applied for financial assistance, and there is not an insurance balance being contended. The collection agency attempts to collect the account in accordance with established guidelines. Collection attempts are ceased and the account returned back to the organization if the patient applies for financial assistance. Any amounts collected from these accounts are credited back against bad debt expense. The organization recognizes that there are accounts written off to bad debt that may have qualified for charity care if the patient had provided the necessary financial information. In order to resolve this, the organization has engaged a third party vendor to analyze data based on credit scores to reallocate some of this expense to charity care. These accounts are then sent to our third party vendor who gathers external credit data that presents the account as less than 100% Federal Poverty Level or not enough information (typically indicative of indigent). These accounts are reclassed from bad debt expense to charity expense on our income statement. Any credit score that presents the accounts as greater than 100% Federal Poverty Level remains in bad debt expense. Due to this process, the organization has used best efforts to not report bad debt expense for patients eligible under the organization's charity care policy. Part III, Line 4: The organization does not have a footnote in the audited financial statements which discusses this calculation. Part III, Section B, Lines 5, 6, and 7 The amounts reported on Lines 5, 6, and 7 do not include certain Medicare program revenues and costs, and thus do not reflect all of the organization's revenues and costs associated with its participation in Medicare programs. In addition to the amounts reported on Line 5, 6, and 7, the organization received revenue of $69,653,000 and incurred cost of $88,038,000, for an additional net shortfall of $18,385,000 associated with these programs. Below is a reconciliation of the amounts associated with Medicare programs. Allowable Medicare revenue per Medicare Cost Report (Part III, Section B) 86,764,000 Medicare revenue not reported in Part III, Section B 69,653,000 Total Medicare associated revenue 156,417,000 Allowable Medicare cost per Medicare Cost Report (Part III, Section B) 99,967,000 Medicare cost not reported in Part III, Section B 88,038,000 Total Medicare associated cost 188,005,000 Medicare shortfall per Part III, Section B 13,203,000 Additional shortfall not included in Part III, Section B 18,385,000 Total Medicare shortfall 31,588,000 Part III, Line 8: The organization's shortfall should be considered charity care because it is providing high-quality care in excess of the cost to our community residents that need care. The Medicare population at the organization is in excess of 44% of net patient revenue. The organization used a cost accounting system to calculate the Medicare allowable costs. Part III, Line 9b: The organization makes reasonable efforts to determine whether or not an individual is eligible for assistance under the state or hospital financial assistance policy before engaging in extraordinary collective actions against that individual. Patients who are known to qualify for financial assistance are offered reasonable payment plan arrangements for any remaining balances. Any third party collecting self-pay receivables on our behalf is required to make reasonable efforts to determine if the individual meets the qualifications of the state or of our hospital financial assistance programs. Reasonable efforts include: A. Validating that the patient owes the unpaid bills and that all sources of third party payment have been identified and billed by the hospital. B. Documenting that the organization has or has attempted to offer the patient the opportunity to apply for charity care under its financial assistance policy. C. Documented that the patient does not qualify for financial assistance D. Document that the patient has been offered a payment plan, but has not honored the terms of that plan. The financial counselors meet with inpatient, outpatient self-pay, and other patients upon request who may need financial assistance. In addition to assisting patients who want to apply for assistance through the Medicaid program, the Financial Counselor will provide the patient with a financial assistance application. Part V, Section B, Line 12H: If the patient's family's income falls within 400% of the federal poverty guidelines, the patient qualifies for assistance under the hospital financial assistance policy. All or part of the account will be written off to charity care, based upon a Sliding Fee Schedule. The amounts charged to patients who are eligible for financial assistance are not more than the amounts generally billed to individuals who have insurance covering such care. Patients who qualify for financial assistance are not billed gross charges for emergency or medically necessary care. We offer reasonable payment plans to those who have qualified for charity care. Patients may also qualify for charity care discounts due to a medically-based catastrophic event which has occurred in their life. If a patient qualifies for this discount, he/she would only be held responsible for payment of his/her family's medical expenses up to 15% of their annual income. Part V, Section B, Line 14G: The hospital widely distributes information about its financial assistance policy within the area that it serves. This information includes the method of applying for and accessing financial assistance. Notices are publicized in patients' bills and are posted in the emergency room, admitting and registration areas, as well as other public areas. A summary of the financial assistance policy is published on the hospital's website. Financial counselors, patient advocates, and customer service representatives discuss the financial assistance policy with all uninsured patients, and any patient who expresses financial hardship with p true THE HEART INSTITUTE OF DAYTON 2200 PHILADELPHIA DR DAYTON OH 45406 300502367 501(c)(3) 432764 N/A N/A HEART EDUCATION PREMIER COMMUNITY HEALTH 23 Jasper St 45409 DAYTON OH 45409 311122883 501(c)(3) 252000 N/A N/A HEALTH EDUCATION PHOENIX NEIGHBORHOOD DEV PROJ 8 N MAIN ST 45402 DAYTON OH 45402 310821189 GOVERNMENT 550580 N/A N/A COMMUNITY DEVELOP UNITED WAY 33 W First St 45406 DAYTON OH 45402 310536658 501(c)(3) 35000 N/A N/A COMMUNITY SUPPORT Dayton Philharmonic 109 N Main St Suite 200 Dayton OH 45402 316000101 501(c)(3) 15025 N/A N/A Performing Arts Catholic Education Collaborative 266 Bainbridge St Dayton OH 45402 310536710 501(c)(3) 25000 N/A N/A Education Dayton Foundation 500 Kettering Tower Dayton OH 45423 316027287 501(c)(3) 1223531 N/A N/A Community Support American Heart Association 5455 N High St Columbus OH 43214 135613797 501(c)(3) 36920 N/A N/A Education Good Samaritan Hospital Foundation - Dayton 110 N Main St Suite 500 Dayton OH 454021857 237296923 501(c)(3) 23120 N/A N/A Community Develop Downtown Dayton Partnership 10 W 2nd St Suite 611 Dayton OH 45402 341722175 501(c)(3) 18000 N/A N/A Community Support Lifestages Samaritan Centers for Women 9000 N Main St Suite 234 Dayton OH 45415 311582936 501(C)(3) 13047 N/A N/A Women's Health Salvation Army 615 Slaters Ln Alexandria VI 223141112 135562351 501(c)(3) 19500 N/A N/A Community Support Dayton-Montgomery County 500 Kettering Tower Dayton OH 45423 311358532 501(c)(3) 13000 N/A N/A Scholarship Dayton Area Chamber of Commerce 22 E 5th Dayton OH 45402 311113395 501(c)(3) 7200 N/A N/A Community Support Dayton Opera Association 138 N Main St Dayton OH 45402 310643964 501(c)(3) 5200 N/A N/A Community Support 14 1 SCHEDULE I, SUPPLEMENTAL INFORMATION: 1) COMMUNITY BENEFITS BUDGETED ALLOCATIONS ARE APPROVED BY GOOD SAMARITAN BOARD ANNUALLY. 2) INVOICES ARE RECEIVED IN ACCOUNTS PAYABLE UPON APPROVAL BY THE VICE PRESIDENT OF MISSIONS. 3) DISBURSEMENTS OCCUR ACCORDING TO STANDARD ACCOUNTS PAYABLE GUIDELINES. X X X X false true false false false true true false false ANITA ADAMS 179733 0 50994 0 1953 0 9896 0 10168 0 252744 0 0 0 ELOISE P BRONER 313385 0 106843 0 10314 0 16982 0 3421 0 450945 0 8108 0 MARY M CLANCY 0 326023 0 115798 0 40342 0 25126 0 14621 0 521910 0 37243 DALE E CREECH 0 359156 0 110992 0 128007 0 32434 0 24519 0 655108 0 123092 THOMAS R CURTIN 179832 0 34870 0 2607 0 16399 0 25069 0 258777 0 0 0 MARY E GARMAN 200774 0 40441 0 1359 0 9175 0 15311 0 267060 0 112 0 RENEE P GEORGE 0 215265 0 60657 0 752 0 8225 0 26289 0 311188 0 0 CHARLES HENDRICKS 220594 0 0 0 1263 0 17104 0 23290 0 262251 0 0 0 WILLIAM E LINESCH 0 313022 0 92384 0 40448 0 31351 0 7434 0 484639 0 31031 DANIEL L SCHOULTIES MD 0 335222 0 69562 0 5941 0 21509 0 25363 0 457597 0 0 JEROME SCHULTE JR 236855 0 34686 0 6868 0 27795 0 28106 0 334310 0 199 0 CRAIG SELF 194205 0 47649 0 1324 0 8292 0 23038 0 274508 0 0 0 MARK S SHAKER 0 424644 0 163966 0 157961 0 28111 0 5429 0 780111 0 153170 MARK W SHAW 0 255582 0 87080 0 60543 0 33040 0 24318 0 460563 0 52525 SHARON K THORNTON 157426 0 38713 0 613 0 8014 0 8929 0 213695 0 0 0 Michael Maiberger 0 266440 0 146051 0 156576 0 45625 0 30333 0 645025 0 0 Stacey M Lawson 162732 0 26066 0 1122 0 14333 0 14815 0 219068 0 0 0 Part I, Line 4b: Due to restrictions imposed by the Internal Revenue Code, certain persons are limited in the amount of benefit that can be earned under a qualified retirement plan. Like many employers, Good Samaritan Hospital (GSH) compensates for this limitation and supplements the affected executives' qualified pension through certain nonqualified plans. GSH supplements through a Pension Restoration Plan and a Supplemental Executive Retirement Plan (SERP). The benefits under these supplemental nonqualified plans are subject to multi-year vesting and a participant can forfeit benefits earned if vesting requirements are not satisfied. Under the terms of the supplemental plans, and because of tax rules pertaining to taxation of the earned benefits upon vesting, certain individuals received a payout of the cumulative vested benefits under their supplemental plan during 2012. The individuals listed below have met the multi-year vesting requirement under the Pension Restoration Plan and received the associated payment in 2012: Mark Shaker $153,170; William Linesch $31,031; Mary Clancy $37,243; Eloise Broner $8,108; Dale Creech $123,092; Mary Garman $112; Mark Shaw $52,525 and Jerome Schulte $199. The individual listed below has met the multi-year vesting requirement under the SERP and received the associated payment in 2012: Michael Maibeberger $29,210. BASED ON THE GUIDANCE PROVIDED IN THE INSTRUCTIONS TO THE FORM 990, ANY PAYMENTS TO THE PARTICIPANTS RELATED TO THESE PLANS THAT WERE MADE WITHIN 2-1/2 MONTHS AFTER THE END OF THE ORGANIZATION'S TAX YEAR ARE NOT TREATED AS DEFERRED COMPENSATION FOR PURPOSES OF SCHEDULE J. SUCH AMOUNTS ARE PROPERLY REPORTED AS COMPENSATION FOR FORM 990 PURPOSES WHEN INCLUDED IN THE PARTICIPANTS' FORM W-2 WAGES. ANY PAYMENTS MADE AFTER THE 2-1/2 MONTHS WERE PROPERLY REPORTED ON PRIOR YEARS' FILED IRS FORM 990 RETURNS, DISCLOSING COMPENSATION EARNED BY THESE INDIVIDUALS UNDER THE PLANS FOR EACH SUCH YEAR. Part I, Line 6a and 6b: Premier Health (Premier), which Good Samaritan Hospital is an affiliate, 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%), Customer Satisfaction (25%), Physician Partnership (15%) Financial (25%). The financial category of the scorecard is based on net earnings of the individual hospital and the net earnings of the system of a whole. This financial target is set based on the margin required to maintain the system Aa credit ratings. Incentive objectives for Directors and above are weighted 45% on organizational criteria, 45% on individual criteria, and 10% on operational 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. A COUNTY OF MONTGOMERY OHIO 316000172 2010-12-09 10105000 REFINANCE TAXABLE LOANS & LEASES false false false A 5052500 0 10105000 0 0 0 143150 0 0 0 0 0 2010 false false true true A false false false false 0.01000 0.00000 0.01000 false false false true A false false true true FIFTH THIRD BANK 2.1 false false false 0 false true A true FORM 990 - PART I - QUESTION 10: GOOD SAMARITAN HOSPITAL 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 VI, Section A Question 6: Good Samaritan Hospital has two corporate members. One member is Samaritan Health Partners, the parent company of the hospital. The second member is Premier Health (Premier), an Ohio non-profit corporation formed pursuant to the joint operating agreement. Samaritan Health Partners has the sole authority to elect the Board of Trustees of the corporation. Premier has the general authority to operate and manage the operational activities of the corporation. Form 990, Part VI, Section A, Question 7a: Samaritan Health Partners (SHP) has the sole authority to elect the Board of Trustees of Good Samaritan Hospital (GSH). SHP has the authority to remove trustees at any regular or special meeting or by written consent. Premier Health (Premier) has the right to request that SHP remove a trustee of SHP or GSH if Premier has determined that such trustee is frustrating the goals and purposes of Premier's network. Such removal shall not be unreasonably refused by SHP. Form 990, Part VI, Section A, Question 7b: Premier Health (Premier), as the operator of Good Samaritan Hospital (GSH), develops and oversees the implementation of the strategic plan for GSH, which includes (but is not limited to) such matters as location of clinical and administrative expenses. GSH shall comply with and implement this plan and shall not take any action that materially departs from this plan without Premier's approval. GSH develops and submits an annual capital and operating budget to Premier for approval. GSH shall adopt and implement the capital and operating budget so approved and/or revised for it by Premier. GSH may periodically develop and submit a business plan to Premier for approval. GSH shall implement any business plan approved by Premier. Premier is the sole agent to negotiate all relationships with payors on behalf of GSH with all third party payors and alternative delivery systems including, but not limited to insurers. GSH must have approval from Premier to borrow in any fiscal year, guarantee in any year, or incur any lien or other encumbrance on any property in an amount equal to or greater than $1,000,000. GSH must seek Premier's approval for any acquisitions, sale or transfer of any material asset used in Premier's activities. 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 is an affiliate. 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 Chief Financial Officer 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 is an affiliate, 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 Conflict 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. 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 conflict 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 is an affiliate, 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, CFO, COO, 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 VII, Column B: Atindra Chatterji M.D. serves as a Trustee on the Good Samaritan Hospital (GSH) Board where he averages 0.5 hours per week in this capacity. The compensation listed was a Stipend provided for GSH's Chief of Staff. Form 990, Part XI, Question 9: Equity transfers $(18,262,740) Pension Adjustment 10,627,392 Dividends received from SNSC 6,920,000 CHI non-Liquidative Distribution (2,110,000) Investment in SNSC (953,840) Capital Donations from GSHF 358,022 GSHF contribution (327,643) Other (90) Total $(3,748,899) SAMARITAN HEALTH PARTNERS (SHP) 110 N Main St Suite 500 DAYTON OH 45402 311107411 PARENT OH 501(c)(3) 11-I NA false PREMIER HEALTH 110 N Main St Suite 500 DAYTON OH 45402 311446699 SUPPRTG. ORG. OH 501(c)(3) 11-I NA false Good SAMARITAN HOSPITAL FOUNDATION-Dayto 110 N Main St Suite 500 DAYTON OH 45402 237296923 FOUNDATION OH 501(c)(3) 7 SHP true CATHOLIC HEALTH INITIATIVES 198 INVERNESS DR W SUITE 500 ENGLEWOOD CO 80112 470617373 PARENT CO 501(c)(3) 9 NA false THE HEART INSTITUTE OF DAYTON 2200 PHILADELPHIA DR DAYTON OH 45406 300502367 EDUCATION OH 501(c)(3) 9 SHP true Samaritan Behavorial Health 601 Edwin C Moses Blvd Dayton OH 45417 020633634 Behavorial He OH 501(c)(3) 7 SHP true SAMARITAN NORTH SURGERY CENTER 9000 N MAIN ST DAYTON OH 45415 311618587 O/P SURGERY OH GSH Related 6252321 4213462 false 0 true 0.80000 SAMARITAN FAMILY CARE 110 N Main St DAYTON OH 45402 311299450 PHYSICIANS OH SHP C CORP true false true true false false true false false false false false false false false false true true true false Good Samaritan Hospital Foundation - Dayton C 685665 Cash Good Samaritan Hospital Foundation - Dayton Q 430946 FMV Samaritan Family Care P 443056 Cash Samaritan Family Care Q 213752 FMV Samaritan Family Care R 6201262 Cash Samaritan North Surgery Center Q 1603115 FMV Samaritan North Surgery Center Q 483293 FMV Samaritan North Surgery Center F 6920000 Cash Samaritan North Surgery Center B 953840 Cash The Heart Institute of Dayton Q 432764 FMV Samaritan Health Partners B 175129 FMV Catholic Health Initiatives R 5862000 Cash