2013-12-17T12:51:34-07:00 2013-06-30 990 2012-07-01 920077523 CENTRAL PENINSULA GENERAL HOSPITAL INC CENT 9077144404 250 Hospital Place Soldotna AK 99669 Shaun Keef 9077144722 2013-12-17 2012 2016-03-07 17:11:31Z Central Peninsula Hospital Richard Davis CEO 250 Hospital Place Soldotna AK 99669 221259277 0 X www.cpgh.org X 1994 AK We are a community initiated and community nurtured organization dedicated to promoting wellness and providing high quality health care that ensures the confidence and loyalty of our patients. We strive to improve individual and community health and achieve national standards of excellence. We are dedicated to offering the highest quality patient and resident centered care in a healing environment. 11 9 893 239 27713 56069 1122562 2802938 196563665 215314333 267126 45397 1305676 2849386 199259029 221012054 179256 182869 0 0 67350906 67730487 0 0 0 122895004 138890586 190425166 206803942 8833863 14208112 132450612 146313507 48651475 48306258 83799137 98007249 We are a community initiated and community nurtured organization dedicated to promoting wellness and providing high quality health care that ensures the confidence and loyalty of our patients. We strive to improve individual and community health and achieve national standards of excellence. We are dedicated to providing the highest quality patient and resident centered care in a healing environment. 0 0 181753977 188648203 Our 49 bed hospital provided patient and ancillary services to 2,403 inpatients and 84,606 outpatients during the 2012 tax year. The hospital provides emergency medical services regardless of ability to pay. Emergency medical services were provided to 17,260 individuals, and 1,396 of those individuals were admitted to the hospital. 4,071 surgical procedures were performed in the hospital during the tax year. The imaging department performed 38,951 procedures. Over 62,180 physical therapy procedures were provided to area residents. During the 2012 tax year, free medical services in the amount of $9,031,980 (gross charges) were provided to patients eligible for charity care. 10152548 11529884 Skilled nursing and long term care services were provided by our 60 bed skilled nursing facility. Heritage Place provides healing and compassionate residential care in a home like setting. Total admissions for the 2012 tax year were 74 and total resident days of care were 19,799. An average of 54 residents per day were provided long term care and nursing. Ancillary services for residents included 12,778 physical therapy treatments, while outpatients received 3,100 therapy treatments. 12916809 15136246 The hospital operates 6 family and specialty physician services clinics providing care in the following areas: Family medicine, Pediatrics, Neurology, Pain Management, Surgery, and Orthopedics. Other outpatient clinics include Wound care, Sleep studies, Forensic services, and the provision of Durable medical equipment. During the 2012 tax year physician and specialty services were provided for 23,926 patients. Over 3,306 wound care procedures, 165 forensic exams, and 208 sleep studies were also performed. 0 0 0 204823334 1 1 0 1 0 0 1 0 0 0 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 1 0 1 0 1 108 0 1 893 1 1 1 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 0 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X X X Central Peninsula Hospital Finance Department 9077144525 250 Hospital Place Soldotna AK 99669 John Hoyt 4 X 3050 0 0 Silverio Mattero 4 X 4325 0 0 Richard Ross 4 X 3425 0 0 Judith Salo 4 X 5150 0 0 Alyson Stogsdill 6 X 4750 0 0 Trena Richardson 6 X 5250 0 0 Loren Wiemer 4 X 14173 0 0 Irving Carlisle 6 X 2975 0 0 Henry Peter Sprague 4 X 3525 0 0 Gregg Motonaga 44 X X 582238 0 39485 Mark Dixon 4 X 0 0 0 Mark Premo 4 X 0 0 0 Joseph Bujak 4 X 0 0 0 Andrea D Posey 40 X 181476 0 38636 Johnny L Dodd 40 X 159591 0 28580 Matthew Dammeyer 40 X 195150 0 38709 Richard Davis 40 X 381841 0 27432 Shaun Keef 40 X 117772 0 20142 David S Innes 40 X 1188083 0 35082 Cynthia Kahn 40 X 550791 0 15240 Justin Evans 40 X 484983 0 52082 Jason Lattin 40 X 533133 0 35082 4421681 0 330470 69 0 1 0 Sound Physicians 1123 Pacific Avenue Tacoma WA 98402 Physician Services 897498 Molloy Schmidt LLC 110 South Willow St Suite 101 Kenai AK 99611 Attorney Services 503991 C&A Industries Aureus PO Box 3037 Omaha NE 68103 Contract Labor Provider 319085 KL Gates 210 Sixth Ave Pittsburgh PA 15222 Attorney Services 254269 Alaska Surgical Services LLC 6339 E Speedway Blvd Suite 201 Tucson AZ 85710 Surgical medical professional services 157067 10 0 0 0 249999 2527177 25762 5762 2802938 Hospital Service Revenue 622000 188648203 188648203 0 0 Long-term Care Revenue 623000 11529884 11529884 0 0 Physician Clinic Revenue 621110 15136246 15136246 0 0 0 0 0 0 215314333 44523 0 0 44523 0 0 0 0 0 0 0 0 167562 0 139849 0 27713 0 27713 0 27713 0 0 874 0 0 0 874 874 874 0 0 0 457650 107374 350276 350276 0 0 Property tax 900099 94695 94695 0 0 USAC Telephone service revenue 900099 474984 474984 0 0 1901718 1901718 0 0 2471397 221012054 218136880 27713 44523 182869 182869 0 0 0 0 0 0 5052979 3684748 1368231 0 0 0 0 0 43346833 43346833 0 0 1459592 1459592 0 0 14642503 14642503 0 0 3228580 3228580 0 0 0 0 0 0 518714 518714 0 76330 0 76330 0 17333 0 17333 0 0 0 0 0 0 0 3127034 3127034 0 0 292711 292711 0 0 19926254 19926254 0 0 3461763 3461763 0 0 0 0 0 0 2338895 2338895 0 0 296383 296383 0 0 0 0 0 0 245138 245138 0 0 1218937 1218937 0 0 0 0 0 0 7897232 7897232 0 0 954971 954971 0 0 Medicare patient deductions from revenue 42557717 42557717 0 0 Medicaid patient deductions from revenue 16522878 16522878 0 0 Charity care 9031980 9031980 0 0 Commercial, Gov't, Other deductions from revenue 17110066 17110066 0 0 13296250 13296250 0 0 206803942 204823334 1980608 0 0 0 27803487 35197813 128492 31686 19371223 22175972 322465 0 0 0 0 0 3539385 4247583 1341753 1219529 121913366 52483407 64853893 69429959 0 0 500000 500000 0 0 0 0 14589914 13510965 132450612 146313507 12807111 13438967 0 0 14194 14006 35830170 34853285 48651475 48306258 X 83299137 97507249 500000 500000 0 0 83799137 98007249 132450612 146313507 14208112 0 0 0 0 0 X 0 1 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 1 6313 0 1 11020 17333 0 SchC_P2B_S00_L01 Schedule C, Part II-B, Line 1 The Hospital engages in very little lobbying. Educational discussions with lawmakers and general support of healthcare legislation does occur on occasion. Total labor and travel expense for the tax year amounted to $6,313. Certain organizations to which Central Peninsula Hospital pays membership dues, engage in lobbying activities. The amount reported on this line represents the % of those membership dues which are spent on lobbying type activities. Total Hospital dues spent on lobbying activities by other organizations was $11,020. X 1 40 0 0 0 1 0 0 0 0 1942517 0 1942517 76321508 0 34493798 41827710 551163 0 201831 349332 39257315 0 17029992 22227323 3840863 0 757786 3083077 69429959 Plant Replacement and Expansion Fund 11322729 Deferred loss on bond refunding 1499047 Excess consideration paid for business acquisition 689189 13510965 136036636 0 0 0 247223 247223 135789413 0 85222641 85222641 221012054 121828524 0 0 0 247223 247223 121581301 0 85222641 85222641 206803942 SchD_P02_S00_L09 Schedule D, Part II, Line 9 In 2008 the hospital purchased a building which resides on 40 acres of land subject to a perpetual covenant for the benefit of all Alaska residents, restricting use of the land for agricultural purposes pursuant to AK statute 38.05.321. The building is used by the Hospital's chemical dependency unit. There is no value placed on the easement itself and therefore it does not appear in the hospital financials statements or footnotes. The cost of the real property is recorded on the Hospital's balance sheet at its net book value. SchD_P11_S00_L02d Schedule D, Part XI, Line 2d Part VIII revenues are reported net of certain items which appear as expenses in the audited financial statements. These items are Cost of Good Sold on durable medical equipment ($107,374) and expenses pertaining to unrelated business income ($139,849). SchD_P11_S00_L04b Schedule D, Part XI, Line 4b These expenses represent the total deductions from revenue for third party payors (Medicare, Medicaid, etc) and the amount of Charity care discounts. The audited financials report revenue net of contractual allowances, rather than gross. SchD_P12_S00_L02d Schedule D, Part XII, Line 2d These expenses reported on the audited financial statements have been reclassified to Part VIII in accordance with 990 instructions for cost of goods sold on inventory ($107,374) and expenses pertaining to unrelated business income ($139,849). SchD_P12_S00_L04b Schedule D, Part XII, Line 4b These are contractual allowances which are not reported as 'expenses' on the audited financial statements as patient revenue is instead reported net of contractual write-offs from Medicare, Medicaid, and other payor classes. 1 1 X 1 X 1 X 1 1 1 0 0 1 6224 4242806 0 4242806 0.0384 1 12958 19483235 17397271 2085964 0.0189 1 194 61442 37685 23757 0.0002 3 19376 23787483 17434956 6352527 0.0575 472 28653 685759 130244 555515 0.005 123 1390 81067 8525 72542 0.0007 11 24761 3471950 1549458 1922492 0.0174 0 0 0 0 0 0 288 1712 192399 0 192399 0.0017 894 56516 4431175 1688227 2742948 0.0248 897 75892 28218658 19123183 9095475 0.0823 0 0 0 0 0 0 1 25 648 0 648 0 3 0 2602 0 2602 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 168 46205 0 46205 0.0004 0 0 0 0 0 0 12 193 49455 0 49455 0.0004 0 4716532 3631730 23890270 26164858 -2274588 X 1 1 1 1 Central Peninsula Hospital

250 Hospital Place Soldotna AK 99669

X X X Central Peninsula Hospital 1 1 X X X X X X X X X 09 1 0 1 X X X X X X X X 0 0 1 1 200 1 400 1 X X X X X 1 1 X X X X 1 X 1 X X X 1 X 0 0 16 Heritage Place

232 Rockwell Ave Soldotna AK 99669

Skilled nursing facility, longterm care Serenity House

47480 Kristina Way Soldotna AK 99669

Chemical dependency treatment center Central Peninsula Pain Management

289 N Fireweed Unit C/D Soldotna AK 99669

Pain management clinic Central Peninsula Neurology

198 West Corral Soldotna AK 99669

Neurology clinic Central Peninsula Family Practice Kenai

506 Lake Street Kenai AK 99611

Family practice clinic Kenai Physical Medicine

130 Willow Street Unit 1 Kenai AK 99611

Physical therapy clinic Soldotna Physical Medicine

35551 Kenai Spur Hwy Soldotna AK 99669

Physical Therapy clinic Kenai Health Center

630 Barnacle Way Kenai AK 99611

Diagnostic imaging, lab, and domestic violence services Central Peninsula Family Practice Kobuk

245 N Binkley St Suite 101 Soldotna AK 99669

Family practice clinic Central Peninsula Surgical Services

289 N Fireweed St Unit B Soldotna AK 99669

Surgical clinic Central Peninsula Family Practice Fireweed

245 N Binkley Street Suite 101 Soldotna AK 99669

Family practice clinic Serenity House intake office

245 N Binkley Street Suite 203 Soldotna AK 99669

Chemical dependency intake, behavioral health clinic Peninsula Medical Center

265 N Binkley Street Soldotna AK 99669

Owned medical office building Central Peninsula Medical Center

245 N Binkley Street Soldotna AK 99669

Owned medical office building Vacant building

158 Corral Street Soldotna AK 99669

Vacant building for remodel Vacant building

166 W Corral Street Soldotna AK 99669

Vacant building for remodel Medical Office Space

108 E Corral St Soldotna AK 99669

Medical office building purchased - leased to Kenai Spine Radiation Oncology Building

240 Hospital Place Soldotna AK 99669

Radiation Oncology Building - leased to RBS Evolution Vacant Building - Kenai Physical Medicine

260 Caviar Street Kenai AK 99611

Building purchased during the tax year but still under renovation at June 30, 2013. SchH_P01_S00_L07 Schedule H, Part I, Line 7 In areas where costs were reasonably able to be compiled we used actual costs. For activities such as charity care and the cost to provide such care, we used the cost to charge ratios as calculated by figures reported on our most recently filed Medicare cost report. SchH_P01_S00_L072f Schedule H, Part I, Line 7, Column f Bad debt was reported at gross charges in 990 Part IX, line 25 or $9,941,178. However for the purposes of this schedule H we have used the cost to charge ratio calculated herein (47.44%) to reduce these bad debts to the estimated cost to provide this care $4,716,532. Of this balance, approximately 73% is estimated to be attributable to patients who may have been eligible to receive free or discounted care under the Hospital's financial assistance policy but failed to apply for free care. SchH_P02_S00_L00 Schedule H, Part II The Hospital supported local community job fairs for high school students and jobless community members. Additionally, the Hospital served as a sponsoring organization and host to the SEARCH program in cooperation with the Kenai Peninsula Borough School District to train, provide mentoring, shadowing, and internships for at risk teens with learning or behavioral disabilities. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 Bad Debt Footnote per audited financial statements: Bad debt provisions are made for the amount of revenue that will not be collected from patients to whom services were billed but not paid. The Hospital has determined these patients are neither medically nor financially indigent and do not qualify for the Hospital's charity care program. Bad debt provisions are determined by management's assessment with consideration of business and economic conditions, changes and trends in healthcare coverage, and other collection indicators. The adequacy of this provision is periodically reviewed and further modified based upon the accounts receivable payor composition and aging, and historical write-off experience by payor category. The amount reported in Schedule H, Part III is based on the estimated cost to provide care for individual patient accounts which were classified as bad debt during the year. The amount which may be attributable to patients who qualify for charitable assistance of free care is estimated at approximately 73% of that total. These are accounts which our financial counselors made every effort to contact and assist patients to apply for financial assistance, but they refused to do so. It is our belief that all of these bad debts should be considered community benefits as they provide a necessary and vital health benefit to members of our service area free of charge. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 It is our belief that all of the shortfall in actual receipts from Medicare compared to the cost to provide care to Medicare patients should be considered a community benefit. The reason for this stance is that the Hospital is required to write off all contractual allowances for Medicare patients regardless of the amount of the shortfall. The Hospital may only collect the portion which is the patients co-pay or deductible and may not engage in collection efforts for the remainder. The Medicare costs reported herein are based on actual costs as reported on the fiscal year 2013 Medicare cost report. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b The Hospital's collection policy PFS-546 addresses the various classes of private pay patients and defines the individuals which are eligible to receive financial assistance based on either financial or medical indigence. The collection policy refers the collectors first to the charity care policy for instructions on determining eligibility. As noted in Part I, the charity care policy is based on FPG which are the bases for a sliding scale between 200% and 400% of those guidelines. Applicants on the upper end of the scale (400%) are eligible for partial write-off, while those on the lower end (200%) are eligible for free care. SchH_P05_S0B_L05 Schedule H, Part V, Section B, Line 5 In addition to the above methods of disbursement, the Health Needs Assessment was also provided via email to Administrators, Hospital Board members, and supervisory staff of Central Peninsula Hospital. SchH_P05_S0B_L06 Schedule H, Part V, Section B, Line 6 Hospital management and the board of directors address the needs assessment findings through frequent strategic planning and the implementation of new services whenever financially viable. Additionally, the hospital supports the provision of health services by community health partners when it cannot supply those needs itself. SchH_P05_S0B_L07 Schedule H, Part V, Section B, Line 7 Two of the 2013 CHNA health findings require long-term planning or community collaboration to meet the health need: 1. Respiratory Health and COPD affect over 10% of the population surveyed. Although the service area reports lower rates of smoking than peer communities, COPD rates remain the same. Additional attention on smoking cessation is needed. The Hospital does treat patients admitted for services with smoking cessation patches free of charge. However, an external campaign to reduce smoking rates has not yet been developed and it is unclear at this time what community collaboration effort would best serve this need. 2. Diabetes - nearly 10% of the population surveyed reported a diagnosis of diabetes. Age and obesity are major risk factors in developing diabetes, and nearly 68% of the population is either overweight or obese. The Hospital has therefore focused much of it's attention not on diabetes itself but on prevention through one of its major risk factors, obesity. The Healthy Lifestyles department specifically targets healthy eating and healthy living habits which can help lower the occurrence of diabetes. SchH_P05_S0B_L13 Schedule H, Part V, Section B, Line 13 The hospital employs 2 full time financial counselors that meet personally with patients to review their bills, set up payment arrangements, explain the financial assistance policy, and assist with the financial assistance application process. In addition, the Hospital has purchased advertising space in the local newspaper to notify the public at large or its financial assistance program and how patients can reach our financial counselors to apply. SchH_P05_S0B_L14 Schedule H, Part V, Section B, Line 14 The Hospital has published its financial assistance policy and forms on it's public website and has also purchased advertising space in the local newspaper to widely publicize it's financial assistance program to the community at large. SchH_P05_S0B_L20 Schedule H, Part V, Section B, Line 20 The Hospital offers all self pay patients a prompt pay discount of 25% on hospital gross charges, which is more advantageous that substantially all of our commercial rates. For those patients who are unable to pay because they are financially or medically indigent they are given the opportunity to enroll in our financial assistance policy for a further discount, or free care. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 In addition to having a CHNA performed and creating a strategic plan to address those needs, the Hospital also determines health needs of the community through a variety of other ways. Hospital officials meet regularly with an advisory committee comprised of areas residents and former patients to determine the adequacy of facilities and services which meet the health needs of the community. The Hospital periodically employs consultants to determine the physician and specialty physician needs of the community in order to direct strategic planning and physician recruiting. Finally, open dialogue between Hospital management and patients, staff, and area medical staff is another source of determining what additional community health needs exist. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 The Hospital attempts to provide a financial assistance program brochure to every patient during discharge. The brochures is also available upon request, and on the Hospital's website under Patient Financial Services. Financial counselors personally contact patients and explain the financial assistance policy, assist with completion of the application, and set up payment plans if necessary. Finally, the Hospital has begun advertising the existence of our financial assistance program in the local newspaper. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 The area served by the Hospital is comprised of 13 Census designated places or towns and has a total population of approximately 36,000 residents according to the 2010 census. The geographic region is in the Central Kenai peninsula in the state of Alaska. Based on the 2010 Census, approximately 11% of the population is age 65 or older, 32% are between 45 and 64, and 32% are between age 19 and 44. Basic social and economic characteristics of the region indicate an 8.6% unemployment rate with a median household income of $60,378, while 8.9% of residents live below the federal poverty line. More than 22% of adults age 18 to 64 years are uninsured, just 1% higher than the US average and equal to the state average. SchH_P06_S00_L05 Schedule H, Part VI, Line 5 The Hospital engages in numerous community efforts year-round to improve health awareness and education in our service areas. Monetary donations to local non-profits that support health initiatives and healthy living, personnel support of local non-profits, public service announcements, conference room space for community organizations and support groups, health speakers bureaus, child safety program, health fairs, immunization clinics, community health newsletters and numerous other programs, initiatives, and collaborations. 1 Southcentral Foundation 4501 Diplomacy Drive Anchorage AK 99508 920086076 501c3 6250 Monetary support for the All Alaska Pediatric Partnership. Kenai River Professional Guide Association PO Box 3674 Soldotna AK 99669 920162358 501c3 10000 Monetary donation to support the Wounded Warrior Program. Kenai Peninsula Food Bank 33955 Community College Drive Soldotna AK 99669 943112445 501c3 5001 Monetary support for the Food bank which provides low-cost or free nutritious food to families with financial need. Hospice of the Central Peninsula PO Box 2584 Soldotna AK 99669 920118694 501c3 29200 Monetary donation to support the Hospice Bereavement Program as well as general contributions to support the entity. Boys & Girls Club 705 Frontage Road Suite B Kenai AK 99611 943067142 501c3 40000 Monetary donations for annual support of the Boys & Girls club for two program years. The club provides safe after-school programs, breakfast programs, and healthy activities for local children. Kenai Peninsula Youth Foundation Kenai River Brown Bears PO Box 2605 Soldotna AK 99669 262580744 501c3 7500 Monetary support for 2012-2013 season sponsorship. The Kenai Peninsula Youth Foundation is an organization dedicated to providing developmental programs for aspiring student athletes. Bridges Community Resource Network PO Box 1612 Soldotna AK 99669 920151271 501c3 9100 Monetary support for the Imagination Library program, and the Pink Ribbon Rally for breast cancer awareness. Kenai Peninsula United Way 11355 Frontage Road Benco Building Suite 101 Kenai AK 99611 920111698 501c3 10000 Monetary support of United Way of the Kenai Peninsula which promotes healthy living, financial stability, and education improvement through its many community program. 8 0 SchI_P01_S00_L02 Schedule I, Part I, Line 2 The Hospital does not provide 'grants' but cash contributions to local organizations which support community initiatives and healthy living on the Kenai Peninsula. Contributions are only made to organization in good community standing. Hospital officers are responsible for approving all assistance payments to outside organizations and do so with discretion. X X 0 1 X X X X X 0 1 0 1 0 1 0 0 0 David S Innes 760496 0 353992 0 78126 0 5550 0 32814 0 1230978 0 0 Gregg Motonaga 555760 0 27460 0 1239 0 22550 0 22207 0 629216 0 0 Justin Evans 455947 0 32743 0 824 0 22550 0 32814 0 544878 0 0 Jason Lattin 391427 0 37689 0 107299 0 5550 0 32814 0 574779 0 0 Cynthia Kahn 416654 0 77625 0 57589 0 5550 0 10766 0 568184 0 0 Richard Davis 295854 0 69236 0 20222 0 7446 0 22207 0 414965 0 0 Shaun Keef 113172 0 0 0 6573 0 2385 0 19730 0 141860 0 0 Andrea D Posey 133870 0 22084 0 28803 0 9104 0 32814 0 226675 0 0 Johnny L Dodd 131506 0 7877 0 22928 0 8594 0 22207 0 193112 0 0 Matthew Dammeyer 165659 0 9437 0 22076 0 9176 0 32814 0 239162 0 0 SchJ_P01_S00_L01a Schedule J, Part I, Line 1a Gross up payments are made for certain taxable fringe benefits and for the value of life insurance over $50,000. A year-end wage adjustment is made for all affected employees to include the gross up for fringe benefits and excess life insurance benefits. The Hospital has historically paid all social security and medicare taxes on such benefits while the employee is responsible for federal income taxes. Also among the fringe benefits offered to employees are health club discounts. The hospital pays for one-half of gym membership dues to promote the health and welfare of its employees and their family members. The health club benefit has been discontinued in fiscal year 2014. SchJ_P01_S00_L01b Schedule J, Part I, Line 1b The year end gross up adjustment for fringe benefits and life insurance over $50,000 is based on historical practice of the hospital and is not governed by a written policy. The hospital maintains that at some future date, employees may be required to pay their own FICA taxes on fringe benefits. Similarly, payment of one-half of gym fees is also not a written policy. Due to the rising costs of gym membership fees, the Hospital decided not to continue to extend this benefit for fiscal year 2014. SchJ_P01_S00_L03 Schedule J, Part I, Line 3 The hospital contracts with an independent consultant every 3 years to perform a review of all executive salaries and benefits using comparable data. The resulting report is provided to the Board of Directors and Management for review. The Board then sets compensation levels for the CEO through a written employment contract with the organization. The CEO is responsible for hiring the remainder of the Hospital's executive staff and for using comparable data studies for setting their salaries. SchJ_P01_S00_L04 Schedule J, Part I, Line 4 The Hospital provides a 457 Top Hat plan to certain key employees and executives. The following individuals on Schedule J participated in the 457 plan and either deferred their own compensation or received hospital contributions into the plan during the tax year; Gregg Motonaga ($17,402), Justin Evans ($17,406), Richard Davis ($7,518), Shaun Keef ($3,863), Andrea Posey ($3,600), Johnny Dodd ($3,128), and Matthew Dammeyer ($4,165). SchJ_P01_S00_L05 Schedule J, Part I, Line 5 In accordance with their employment contract, Emergency Room Physicians receive a percentage of their professional physician fees billed. This compensation is not based on the entity's overall revenue. SchJ_P01_S00_L06 Schedule J, Part I, Line 6 The hospital pays an annual incentive plan bonus to all employees, supervisors, and executives based on a series of 4 operational and quality measures. One of these 4 measures is meeting the hospital's net earnings budget. This element comprises only one-fourth of the potential plan bonus payment. The remaining measures are 1)patient satisfaction, 2)quality, and 3)utilization. A Kenai Peninsula Borough 920030894 488530NF9 2003-12-18 47985000 Hospital expansion project 2003 GO bonds 0 0 0 B Kenai Peninsula Borough 920030894 01179PX51 2011-09-15 27905000 Refunding bonds - 2011 GO 0 0 1 A 43635000 0 53963243 0 3376615 32616814 544896 0 0 53418347 0 0 2008 0 0 1 1 B 0 0 32616814 0 0 0 201610 0 0 0 0 0 2008 0 1 1 1 A 0 0 0 0 0 0 0 0 0 1 B 0 0 0 0 0 0 0 0 0 1 A 1 1 0 0 1 0 B 0 0 0 0 1 0 0 0 0 Charles Weimer Spouse of Board Member 12000 Leases rease estate at FMV to Hospital 0 F990_P06_S0A_L07b Form 990, Part VI, Section A, Line 7b Central Peninsula Hospital Inc. operates the Hospital through a lease and operating agreement (LOA) with the Kenai Peninsula Borough. The CPGH Board's decisions regarding the acquisition of significant capital assets and plant expansion are subject to the approval of the Kenai Peninsula Borough assembly. Bonds, loans, and capital expenditures not funded through the Hospital's plant replacement fund must be approved by a vote of Borough constituents if greater than $1.0 million. F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b The 990 is prepared by the Hospital's Finance Department and submitted to Hospital management for review. Management then returns any edits to the Finance Committee for preparation of a 2nd draft. The 2nd Draft and all schedules and statements are then submitted to each member of the Board for review and comment. Final edits are provided to the Finance Department and made prior electronic submission by the CFO or Board President. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c Both senior leadership and members of the Board of Directors complete an annual conflict of interest statement which is reviewed by management and the Finance team. The board also reviews and discusses any conflicts of interest which arise throughout the year and take appropriate action if needed. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 An independent professional executive remuneration study is performed every 2-3 years. The most recently performed study by the Haygroup was performed in 2012. Remuneration reports are submitted to the Board for review and used to set the wage scales for the CEO, CFO, CNO, COO, and VP of Human Resources. Contemporaneous documentation exists for this study. F990_P06_S0C_L18 Form 990, Part VI, Section C, Line 18 The Hospital publishes its 3 most recent 990s on it's own website at www.cpgh.org. The Hospital's 990 is also published on Guidestar.com and is available upon request via email. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 The Hospital makes its governing documents, conflict of interest policy, and audited financial statements available to the public upon request. It's audited financials are also published on it's public website. Central Peninsula Health Foundation 250 Hospital Place Soldotna AK 99669 202778670 To support quality healthcare activities AK 501(c)3 Public Charity N/A 0 Kenai Peninsula Borough 144 N Binkley Street Soldotna AK 99669 920030894 Local Government which owns the hospital assets. AK 115 N/A 0 0 0 0 0 0 0 0 0 0 0 1 0 1 1 1 1 1 1 0 Central Peninsula Health Foundation n 14545 The Hospital provides office space to Central Peninsula Health Foundation. The value of the space is determined based on our most recently filed Medicare Cost Report (2012) expenses for facility, administration, and support services allocated per square foot. Central Peninsula Health Foundation o 63983 The Hospital shares certain paid employees for directorship, and accounting functions necessary to operate Central Peninsula Health Foundation. Central Peninsula Health Foundation q 53712 Actual expenses incurred by the Hospital are stated at the dollar value paid which is reimbursed at cost by Central Peninsula Health Foundation. Kenai Peninsula Borough k 1 The Hospital is operated by Central Peninsula General Hospital Inc. through a lease and operating agreement with the Kenai Peninsula Borough. The amount of the lease stated in the agreement is $1 per annum. Kenai Peninsula Borough p 3951514 The Hospital reimburses the Kenai Peninsula Borough for expenses related to it's debt service on bonds, property insurance premiums, refuse, and sales tax. This amount represents actual cash transfers to the borough for these expenses. Kenai Peninsula Borough r 8630696 Per the lease and operating agreement with the Kenai Peninsula Borough, all cash >90 days operating must be transferred to an account held by the Borough for Plant replacement and Expansion of facilities at the hospital. This is the total amount of cash transferred to the borough during FY13. N/A - An extension was filed and accepted by the IRS