2012-05-15T13:44:45-04:00 2011-06-30 PricewaterhouseCoopers LLP 2001 MARKET ST SUITE 1700 PHILADELPHIA PA 19103 990 2010-07-01 582095884 PAULDING MEDICAL CENTER INC PAUL 7707925023 805 Sandy Plains Road Marietta GA 300666340 JIMMY SWARTZ 2012-05-15 true 2673303000 2010 2016-02-24 21:20:13Z A JAMES BUDZINSKI 805 Sandy Plains Road Marietta GA 300666340 55636770 false X www.wellstar.org X 1993 GA To deliver world-class charitable healthcare 18 14 570 85 0 0 889511 862003 64682449 54476459 1182350 -6737 389982 298308 67144292 55630033 0 0 0 0 25156709 27888675 0 0 0 39837899 25991213 64994608 53879888 2149684 1750145 29188765 33291391 11816978 11439314 17371787 21852077 TO CREATE AND DELIVER HIGH QUALITY HOSPITAL, PHYSICIAN AND OTHER HEALTHCARE RELATED SERVICES THAT IMPROVE THE HEALTH AND WELL-BEING OF THE INDIVIDUALS AND COMMUNITIES WE SERVE false false 45461103 54476459 Paulding Medical Center, Inc. (an affiliate of Wellstar Health System, Inc.) operates as a charitable organization consistent with the requirements of IRS Section 501 ( c ) (3) and the "community benefit standard: of IRS Revenue Ruling 69-545. In this regard, the governing body of the organization and/or its parent is composed of prominent citizens in the community, medical staff privileges in the hospital are available to all qualified physicians in the area, consistent with the size and nature of the facility; the hospital operates a full-time emergency room open to all regardless of ability to pay; the hospital provides care to needy members of its community consistent with its charity care policy regardless of their ability to pay for these services; and the hospitals excess funds are generally applied to expansion and replacement of existing facilities and equipment, amortization of indebtedness, improvement in patient care, community benefit activities, and charity care. Paulding had $4.8 million in capital expenditures disbursed during the tax period reviewed. Wellstar Paulding Hospital is a general acute care hospital providing a full range of services to the community. The hospital is licensed to operate 83 beds and is presently staffed to operate 34 beds. Paulding Medical Center, Inc. was organized in 1994. In 1994 Northwest Georgia Health System helped form the PROMINA Health System and changed its name to Promina Northwest Health System. In 1998 Promina Northwest changed its name to Wellstar Health System. Paulding Medical Center is subject to the authority and governing board of Wellstar Health System and the Paulding County Hospital Authority. Paulding Hospital provides a full range of inpatient and outpatient services characteristic of a community hospital. Paulding Nursing Home is located on the campus of the hospital and functions as part of the full range of health services provided to the community. The nursing home provides skilled long-term nursing care to persons requiring those services by reason of age or physical impairment. The nursing home is the only such facility in the Wellstar system. The following stats consitute the overall program services provided for the period ended June 30, 2011: Adult Discharges 2,174 Nursing Facility Days 63,874 Medical & Surgical Short Stay Cases 284 Emergency Room Visits- 37,948 Outpatient Surgical Cases - 1,408 Inpatient Surgical Cases - 729 Outpatient Procedures Non ED OP Radiology 29,171 (15% increase from prior year) GI Laboratory - 380 Total FTEs Paid - 440 Community Benefit Reporting Community Outreach (incl system generated allocation) $473,426 Unreimbursed Charity Care (at cost) $4,450,428 Medicaid Shortfalls (at cost) $2,226,674 As an affiliate of Wellstar Health System, Paulding Hospital participates in many community and educational programs for the overall health and benefit of the area that they serve. Accomplishments and Awards The Paulding Nursing Home provides both subacute and long term care services to patients in the community. Since the nursing home is one of very few in the area and located on the medical complex campus it is very crucial to an ever expanding service area. Paulding Hospital is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The parent company, Wellstar Health System, was again honored as one of the top 100 health systems in the country by Verispan. The system was ranked at #9 as listed in the magazine, "Modern Healthcare", and is the highest ranked system in the state. All of Wellstar hospital laboratories including Paulding were awarded "Accreditation with Distinction" by the Commission on Laboratory Accreditation of the College of American Pathologists (CAP). CAP awards are considered one of the most stringent in laboratory quality assurance in the industry. Wellstar Health System ranks in the Top 10 of the Working Mother 100 Best Companies List. Wellstar ranked number 13 in Atlanta's Top 25 Employers by the publication "Atlanta Business Chronicle". Wellstar was recognized as a "Company that Cares" for 2010-2011 which was the fourth year in a row the system was honored. The system began participating in Terrific Tales, a Company that Cares sponsored literacy project. Several Wellstar hospitals took on the challenge of purchasing quality books for local elementary school libraries in underserved areas. Paulding Hospital adopted a local school(Poole Elementary) and helped the system raise funds to purchase books for that and other local schools. Paulding Hospital and Nursing Home embraced the senior community it serves by celebrating National Older People's Month. The hospital has activities that help honor the seniors with events and educational sessions. Wellstar Health System was named to the AARP National Employer Team for its commitment to recruiting older employees. Wellstar also has several partnerships with local colleges to provide clinical training for nursing and therapy students to compliment their classroom curriculum in those areas. One of Wellstar's own, Cecilia Byers, was honored by the Governor of Georgia as the Biomedical Engineer of the Year. The award recognized her commitment to education, professional integrity and community involvement. Ms Byers serves the biomedical needs at Paulding, Douglas, Cobb and Windy Hill hospitals and other Wellstar entities. She helps mentor Chattahoochee Technical School students in an internship at Wellstar as well as a local high school Magnet program in Cobb County and Paulding County schools. Paulding Hospital was recognized by VHA, Inc. for sustaining impressive clinical results. VHA "blueprinted" the hospital's practices in reducing ventilator-associated penumonia and central line catheter-related blood stream infections to zero. These practices were then made available to other VHA member hospitals. Wellstar plans to build a new state-of-the-art 100 bed general acute care hospital in Paulding County by 2014 to replace the current facility. Paulding County is one of the fastest growing counties in not only the state by across the country which makes this endeavor even more crucial for the community. Wellstar's Congregational Health Ministry presented at the 24th Annual Westber Parish Nurse Symposium. The presentation was entitled "Diabetes Prevention for Hispanics/Latinos Using Community Health in Faith-based Setting: A Collaborative Approach." Hispanics/Latinos are at a high rish for Type 2 Diabetes. Through a collaboration with KSU's Ideal Project (Initiative for Diabetes Education Advancement for Latinos), two local parishes and Wellstar, a community health program was developed for Latinos to improve the acceptance of health messages and subsequently prevent or delay the onset of diabetes. The program is gaining acceptance even though the numbers and outcomes are small at this point. Wellstar Health System (including Paulding Hospital) has improved employee safety over the last several years through reporting, education and return to work programs. The results are: employee injury and illness rate decreased from 12.2 to 1.9 over three years; workers compnesation claims decreased 89% over the same period; and lost time /indemnity claims decreased 105 to 7 over three years. These safety initiatives translate into improved patient safety. Wellstar opened its Paulding Sleep Medicine location in November of 2010. Wellstar Sleep Medicine is one of the largest programs in the country accredited by the American Academy of Sleep Medicine. This location can accommodate four patients and provide convenient access for patients in the Paulding service area. Paulding Hospital received a Quality and Patient Safety Award from the GHA Partnership for Health and Accountability (PHA) for its project that reduced re-admissions. The project "Redesigning the Discharge Process to Reduce Re-admissions and Improve Patient Safety" won second place in the less than 100 bed category. 45461103 true true false false false false false false false true false false false true false false true false false false false false false false false true true false false true false false false false false false true false false false false false false true true false false false true 0 0 570 true false false false false false false false false false false X 18 14 true false true false true true true true true false false true true true true true true true true false GA X JAMES M SWARTZ 7707925023 805 SANDY PLAINS ROAD Marietta GA 300666340 X Randall Bentley 1.0 X 0 17242 0 Robert N Cross MD 1.0 X 0 4678 0 TE Durham 1.0 X 0 31751 1255 Thomas E Gearhard MD 1.0 X 0 389972 28532 David Hafner MD 1.0 X 0 16011 0 Charles J Jones 1.0 X 0 13123 0 Connie Kirk 1.0 X 0 5044 0 Janie Maddox 1.0 X 0 14609 0 Gary A Miller 1.0 X 0 2721 0 Steven W Oweida MD 1.0 X 0 17242 0 Tom Phillips 1.0 X 0 2754 0 Walter G Robinson 1.0 X 0 7065 0 Otis Brumby III 1.0 X 0 1727 0 W Allen Separk 1.0 X 0 7984 0 T Fitz Johnson 1.0 X 0 1742 0 Jeffery Tharp MD 1.0 X 0 446816 28567 Robert G Warner MD 1.0 X 0 3142 0 Charles Pete Wood 1.0 X 0 12872 0 A James Budzinski 2.0 X 0 585666 33803 Gregory L Simone MD 2.0 X 0 3972245 172966 Bonnie Wilson 2.0 X 0 1480015 71627 David Anderson 2.0 X 0 512652 29200 Donald Campbell MD 2.0 X 0 392680 24541 Barbara B Corey 2.0 X 0 353270 21091 Bruce Dean 2.0 X 0 246466 19958 Marcia Delk MD 2.0 X 0 424456 33113 K Darold Etheridge 2.0 X 0 231132 14571 Lee Evins 2.0 X 0 248506 18089 T Mark Haney 50.0 X 0 331882 23979 Christopher Kane 2.0 X 0 400365 26918 Kenneth Kunze MD 2.0 X 0 687208 37043 Lou Little 2.0 X 0 283210 24158 Kimberly Menefee 2.0 X 0 330316 22272 Ronald Strachan 2.0 X 0 417826 27923 ROBERT MANDLER 2.0 X 0 262785 18444 MICHAEL GRAUE 2.0 X 0 691292 44574 JONATHAN MORRIS 2.0 X 0 334194 23933 ELLEN LANGFORD 2.0 X 0 228643 16661 Anthony M Trupiano 2.0 X 0 285303 16534 Robin Wilson MD 2.0 X 0 340020 24726 Joseph L Brywcznski 2.0 X 0 216142 14427 Elizabeth A Hoffmann 2.0 X 0 230428 10860 Richard T Lopes MD 2.0 X 0 513606 28822 James M Swartz 2.0 X 0 169532 9148 Mary L Wesley 2.0 X 0 294140 14070 Barbara G Ballard 2.0 X 0 120827 7602 Carol S Edwards 2.0 X 0 117869 6022 Robert D Jansen MD 2.0 X 0 368959 20365 Beth Kost 2.0 X 0 244689 16135 Brett Scullen 2.0 X 0 80312 3785 Adam C Thompson 2.0 X 0 176957 9710 Leo E Reichert 2.0 X 0 0 0 Deborah DeVita Roegge 2.0 X 0 0 0 John Law 50.0 X 165321 0 12433 Andrea M Parson 50.0 X 143531 0 14687 Michael Ott 50.0 X 133794 0 13322 Vicky Lynn Hogue 50.0 X 182762 0 17100 Bolan Dreher 50.0 X 136253 0 11997 Marsha Burke 1.0 X 0 190475 12395 Linda A Clark 1.0 X 0 255306 10595 Bruce Harrison 2.0 X 0 455869 22304 761661 17471738 1060257 23 true true false Brasfield Gorrie 1990 Vaughn Rd NW Suite 100 MARIETTA GA 30144 General Contractor 189350 HKS Inc PO BOX 731121 DALLAS TX 753731121 General Contractor 107991 Progressive Transcription Service I PO Box 1357 BLUE RIDGE GA 30513 Transcription Serv 143366 Surgical Operational Service 505 Commerce Park Drive Suite G MARIETTA GA 30060 SUPPLY CONSULTING 161228 AIKEN GRADING COMPANY PO BOX 106 DALLAS GA 30132 General Contractor 119382 6 862003 862003 HOSPITAL PATIENT REVENUE 621990 54476414 54476414 MEDICAL RECORDS 621990 45 45 54476459 0 0 0 26031 26031 26031 26031 6737 -6737 -6737 -6737 0 0 0 GROUND LEASE REVENUE 532000 16000 16000 CAFETERIA 722210 207391 207391 IMMUNIZATIONS 621990 8645 8645 40241 40241 272277 55630033 54476459 0 291571 0 0 0 0 331881 279311 52570 0 22288852 18758714 3530138 1582712 1334226 248486 2050381 1728471 321910 1634849 1378178 256671 0 73894 44336 29558 0 0 0 0 1199648 1137753 61895 1716 513 1203 7239178 7036786 202392 0 0 1022772 657888 364884 51050 29520 21530 0 41590 10977 30613 55410 55410 11090644 9377140 1713504 3147615 2102620 1044995 30507 30507 REPAIRS & MAINTENANCE 1244564 792663 451901 OTHER OPERATING EXPENSE 2625 2007 618 NURSING HOME PROVIDER FEES 790000 790000 53879888 45461103 8418785 0 1550 1400 36495 64220 4752999 6795542 988957 1095030 616913 358555 51711362 27435831 22044961 24275531 746890 701113 29188765 33291391 4994847 5087405 298696 0 6523435 6351909 11816978 11439314 X 17371787 21852077 17371787 21852077 29188765 33291391 X 1750145 2730145 X false true true X false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 3170972 3170972 16758839 10472370 6286469 355612 271387 84225 24020605 16692074 7328531 7405334 7405334 24275531 0 ASSET RETIREMENT OTHER LT 573440 TAX EXEMPT BOND LIAB-DUE TO WHS 5778469 6351909 SCH D PART X, LINE 2-LIABILITIES The following footnote is taken from the audited financial statements for Wellstar Health System and Affiliates (including Paulding Medical Center): "WellStar and all but one of its affiliates have been recognized as exempt from Federal income tax under Internal Revenue Code Section 501(a) as organizations described in Section Sec 501(c)(3) and, therefore, related income is generally not subject to Federal or state income taxes. CAC is a controlled foreign corporation not subject to Federal tax. WellStar applies FASB ASC 740, Income Taxes, which addresses accounting for uncertainties in income tax positions. It also provides guidance on when tax positions are recognized in an entity's financial statements and how the values of these positions are determined. There is no impact on WellStar's combined financial statements as a result of the application of ASC 740." true true X true X 125. true X true true true false true true 4450428 4450428 0.08230 6656798 4430124 2226674 0.04120 11107226 4430124 6677102 0.12350 53563 53563 0.00100 53563 53563 0.00100 11160789 4430124 6730665 0.12450 true 5285894 1311742 10719079 16881952 -6162873 X true true 1 1 Wellstar Paulding Hospital

600 West Memorial Drive Dallas GA 300666340

X X X Skilled Nursing Home Wellstar Paulding Hospital 1 X Publication of Annual Community Benefit Report Sch H Part I Line 6a Paulding Medical Center, Inc. is an affiliate of Wellstar Health System, Inc. which on an annual basis issues a community benefit report. This report is subsequently distributed in and around the five county service area of the health system. Cost to Charge Ratio Sch H Part I Line 7 For purposes of the IRS Form 990 Schedule H, Wellstar Health System and Affiliates (including Paulding Hospital) have estimated the current year cost to charge ratio for each hospital as it is reported in the annual community benefit report and as it will be reported in the state's Annual Hospital Financial Survey. Footnote on Bad Debt and Rationale for Community Benefit Schedule H Part III Line 4 The following footnote is detailed in the Wellstar Health System, Inc. and Affiliates Combined Financial Statements related to bad debt or uncollectible accounts: "During 2011, Wellstar adopted the provisions of FASB Accounting Standards Update (2011-07), Healthcare Entities (Topic 954). ASU 2011-07 requires the reclassification of the provision for uncollectible accounts associated with patient service revenue from an operating expense to a deduction from patient service revenue (net of contractual allowances and discounts)." " Wellstar recognizes patient service revenue associated with services provided to patients with third-party payor coverage on the basis of contractual rates for the services rendered. For uninsured patients that do not qualify for community financial aid, Wellstar recognizes revenue on the basis of its discounted rates for services provided. On the basis of historical experience, a significant portion of Wellstar's uninsured patients are unable or unwilling to pay for the services provided. Thus, Wellstar records a significant provision for uncollectible accounts related to uninsured patients in the period the services are provided." Subsequent to the end of the reporting period a propensity to pay review of patient accounts often results in prior year bad debt accounts which are deemed eligible for the organization's financial assistance policy. Those bad debt accounts are reclassified as charity and thus our rationale for including as community benefit. Medicare Shortfalls Sch H Part III Line 8 Paulding Hospital is a provider of inpatient and outpatient services to Medicare program beneficiaries at determined rates. Without the participation in the Medicare program these patients may not have had convenient access to those services. The Medicare shortfall on line 7 represents the uncompensated difference between the expected reimbursement and the Medicare charges for those services stated at cost. We determine a cost to charge ratio for Medicare patients as part of the annual filing of the Medicare cost report. Collection Practices Sch H Part III Sec C Line 9b The policy written for collection practices that applies to all Wellstar Health System entities incorporates guidelines for personnel in the admissions and patient access areas to be trained in identifying patients that might qualify for financial assistance. It is also the policy of all Wellstar facilities to have at least one employee or contractor available at all times, especially in the hospitals with emergency rooms, who can provide assistance with the paperwork necessary to help patients who would qualify for governmental and other assistance programs. Hospital Description Schedule H Part V Wellstar Paulding Hospital is a general acute care hospital providing a full range of services. It is licensed to operate 83 beds by the State of Georgia but is staffed to operate 34 beds. The hospital is located on 50-acre campus in Dallas, Georgia in a complex of commercial buildings containing approximately 230,000 square feet. The original hospital was built in 1958 and since that time has seen at least five major structural additons and renovations. A new state of the art replacement hospital is planned to open in 2014. Needs Assessment Schedule H Part VI Line 2 Wellstar Health System (and affiliates) is a key stakeholder in MAPP, Mobilizing for Action through Planning and Partnerships. MAPP, developed by the National Association of County and City Health Officials (NACCHO) in collaboration with the CDC, provides a structured guidance on creating and implementing a community-wide strategic planning process focused on improving the health and safety of our population. Through MAPP, a broad collection of community partners and residents come together to identify and prioritize health and safety issues and to identify resources for addressing them. The process results in an actionable community health improvement plan (CHIP) for measurable improvements in the community's health and quality of life as well as a scorecard for implementation and evaluation. The resulting community plan does not focus on one agency or community health challenge; rather, MAPP provides a long-term strategy that addresses the multiple factors that affect health in the community. Community involvement throughout the creation and the implementation of a health improvement plan results in creative solutions to community health problems with an improved focus on priorities, reduced duplication of services, increased collaboration on projects and activities, and increased capacity to garner additional resources. Moreover, continous community involvement leads to community ownershiop of the process. Community ownership, in turn, increases the credibility and sustainability of the health improvement efforts. Patient Education of Eligibility for Assistance Schedule H Part VI Line 3 Paulding Hospital provides its patients with hospital personnel or contracted personnel who are trained in all aspects of governmental programs, payments plans, charity discounts, and other financial assistance offered to assist them in their hospital bills. If the patient is eligible for federal or state assistance programs, a staff member is knowledgeable in the steps necessary to qualify those individuals. If a patient is indigent or charity eligible they will be offered assistance through the hospital's charity and indigent care policy including the state's indigent care trust fund. If the patient has no other insurance and fails to qualify for indigent care assistance, the financial counselor can then offer the patient an opportunity to accept a payment plan with discounted payment options based on their ability to pay immediately or over time. All patient are afforded these opportunities. Community Information Schedule H Part VI Line 4 Paulding Hospital is one of five hospitals that are affiliated with the parent corporation, Wellstar Health System. The primary service area of the system is located in the Northwest Georgia area and receives the majority of its patients from one of five counties (Cherokee, Cobb, Douglas, Bartow and Paulding). Generally about 85% to 90% of the patient volume comes from this service area although other health systems have a presence in the area as well. Demographically the region is one of the fastest growing in the state as well as the country and the expansion of the services for the patient population reflects a desire to offer healthcare "closer to home" since Wellstar is considered a part of a larger metropolitan Atlanta market. Economically the region is strong in per capita income but given recent trends a rise in the uninsured and indigent population has occured. Affiliated Health Care System Roles Schedule H Part VI Line 7 As stated in the Wellstar Health System, Inc and Affiliates audited financial statments for the period ended June 30, 2011, Paulding Hospital (an affiliate of Wellstar Health System, Inc.) operates as a charitable organization consistent with the requirements of Internal Revenue Code Sect 501 (c) (3) and the "community benefit standard" of IRS Ruling 69-545. In this regard the governing body of the organization and/or ist parent is composed of prominent citizens in the community, medical staff privileges in the hospital are available to all qualifed physicians in the area consistent with the size and nature of the facility; the hospital operates a full-time emergency room open to all regardless of ability to pay; and the hospital provides care to the needy members of the community consistent with its charity care policy. The hospital's excess funds are genrally applied to expansion and replacement of existing facilities and equipment, amortization of indebtedness, improvement fo patient care, community benefit activities, and charity care. Paulding Hospital committed approximately $4.8 million in capital expenditures for the year to meet those needs. X X X X X X false true X X X X X true true false false false false true false Thomas E Gearhard MD 0 242155 0 139755 0 8062 0 21262 0 7270 0 418504 0 0 Jeffery Tharp MD 0 275580 0 119178 0 52058 0 23584 0 4983 0 475383 0 0 A James Budzinski 0 434410 0 138539 0 12717 0 29307 0 4496 0 619469 0 0 Marsha Burke 0 190475 0 0 0 0 0 10655 0 1740 0 202870 0 0 Linda A Clark 0 255306 0 0 0 0 0 10595 0 0 0 265901 0 0 Gregory L Simone MD 0 814552 0 372600 0 2785093 0 169533 0 3433 0 4145211 0 0 Bonnie Wilson 0 414885 0 126556 0 938574 0 66357 0 5270 0 1551642 0 0 David Anderson 0 379036 0 118871 0 14745 0 25947 0 3253 0 541852 0 0 Donald Campbell MD 0 304092 0 77660 0 10928 0 21047 0 3494 0 417221 0 0 Barbara B Corey 0 271931 0 70439 0 10900 0 19591 0 1500 0 374361 0 0 Bruce Dean 0 197308 0 39928 0 9230 0 14509 0 5449 0 266424 0 0 Marcia Delk MD 0 326735 0 86581 0 11140 0 22854 0 10259 0 457569 0 0 K Darold Etheridge 0 191995 0 30437 0 8700 0 13630 0 941 0 245703 0 0 Lee Evins 0 183954 0 36757 0 27795 0 14120 0 3969 0 266595 0 0 T Mark Haney 0 250475 0 67625 0 13782 0 18815 0 5164 0 355861 0 0 Bruce Harrison 0 283156 0 4564 0 168149 0 20737 0 1567 0 478173 0 0 Christopher Kane 0 308673 0 80630 0 11062 0 21648 0 5270 0 427283 0 0 Kenneth Kunze MD 0 532359 0 142962 0 11887 0 33411 0 3632 0 724251 0 0 Lou Little 0 219648 0 52762 0 10800 0 16822 0 7336 0 307368 0 0 Kimberly Menefee 0 252707 0 66022 0 11587 0 18694 0 3578 0 352588 0 0 Ronald Strachan 0 278129 0 73374 0 66323 0 21239 0 6684 0 445749 0 0 John Law 135650 0 21244 0 8427 0 9516 0 2917 0 177754 0 0 0 Andrea M Parson 130805 0 12626 0 100 0 8573 0 6114 0 158218 0 0 0 Vicky Lynn Hogue 150245 0 23467 0 9050 0 10764 0 6336 0 199862 0 0 0 ROBERT MANDLER 0 195977 0 37704 0 29104 0 14866 0 3578 0 281229 0 0 MICHAEL GRAUE 0 513657 0 164927 0 12708 0 33859 0 10715 0 735866 0 0 JONATHAN MORRIS 0 256833 0 50211 0 27150 0 18905 0 5028 0 358127 0 0 ELLEN LANGFORD 0 182066 0 37877 0 8700 0 14188 0 2473 0 245304 0 0 Anthony M Trupiano 0 230311 0 45692 0 9300 0 16534 0 0 0 301837 0 0 Robin Wilson MD 0 277804 0 53016 0 9200 0 14456 0 10270 0 364746 0 0 Joseph L Brywcznski 0 167838 0 0 48304 0 12397 0 2030 0 230569 0 0 Elizabeth A Hoffmann 0 171895 0 15669 0 42864 0 9605 0 1255 0 241288 0 0 Richard T Lopes MD 0 405473 0 0 108133 0 26209 0 2613 0 542428 0 0 James M Swartz 0 147399 0 14973 0 7160 0 7113 0 2035 0 178680 0 0 Mary L Wesley 0 214845 0 19059 0 60236 0 12190 0 1880 0 308210 0 0 Robert D Jansen MD 0 311389 0 48653 0 8917 0 15337 0 5028 0 389324 0 223267 Beth Kost 0 209311 0 30428 0 4950 0 14503 0 1632 0 260824 0 0 Adam C Thompson 0 148759 0 16996 0 11202 0 7351 0 2359 0 186667 0 0 SEVERANCE BENEFITS SCHEDULE J Pursuant to their respective employment agreements, the following groups of officers are entitled to severance payments based on their base salary and wages at that time in the event of certain identified circumstances. The officers with a severance payment period of 24 months as per their contractual agreement are: David Anderson, Marsha Burke, Linda Clark, Gregory Simone MD, and Bonnie Wilson. The officers with a severance payment period of 18 months as per their respective agreements are: Joseph Brywczynski, A James Budzinski, Donald Campbell MD, Barbara Corey, Marcia Delk MD, Michael Graue, T Mark Haney, Bruce Harrison, Robert Jansen MD, Christopher Kane, Kenneth Kunze MD, Lou Little, Richard Lopes MD, Kimberly Menefee, Craig Owens, Tarey Ray, Leo E Reichert, Ron Strachan, Mary L Wesley The officers with a severance payment period of 12 months as per their agreement: Barbara Ballard, Bruce Dean, Carol Edwards, Darold Etheridge, Lee Evins, Robert Hamilton, Elizabeth Hoffmann, Beth Kost, Ellen Langford, Robert Mandler, Jonathan Morris MD, Deborah Roegge DeVita, C Brett Scullen, James Swartz, Mary L Tavernaro, Adam Thompson, Anthony Trupiano, Robin Wilson MD During the calendar year, the following individuals received a payout in the amounts listed in accordance with their severance agreements as set forth above: Marsha Burke $ 190,475 Linda Clark $ 255,306 Teresa Ray $ 99,120 Bruce Harrison $ 455,868 Gregory L Simone $3,518,524 Bonnie Wilson $1,124,436 Non-Fixed Payments to Officers Form 990 Schedule J Line 7 Wellstar has instituted an annual incentive plan for key leaders in the company. On an annual basis performance measures are proposed by management and recommended and approved by the Compensation Committee of the Board. The plan is designed to retain and reward leaders with incentives that keep them competitive with the market and comparable health systems. The criteria used to measure the performance consists of weighted factors in the areas of financial performance, customer service, employee engagement and quality indicators. Upon successful acheivement in various targeted levels for each factor an overall performance measurement is developed for each individual. Based on that measurement a performance payout is recommended and approved by the Board of Trustees after the annual financial audit is completed. Other Compensation Form 990, Schedule J, Part 1B & 2 While Wellstar Health System and its affiliates do not have a written policy regarding payment or reimbursement of the items listed in Part 1 Line 1a, the organization follows IRS guidelines in the payment of any of these items to individuals listed in Form 990 Part VII Section A. These items are added as taxable wages on the individual's Form W-2 as appropriate. Compensation Exceptions On Schedule J of IRS Form 990 the following individuals were employed by Wellstar Health System, Inc. as officers during the fiscal year reporting period but had no salary and benefits reported during the calendar year for which this schedule applies: LEO E REICHERT DEBORAH ROEGGE DE VITA PAMELA ETHERIDGE WIFE OF OFFICER 53737 WELLSTAR EMPLOYEE false GREG FORTGANG SON-IN-LAW OF BD MEMBER 102382 WELLSTAR EMPLOYEE false GEORGE FLEMING BROTHER OF OFFICER 59478 WELLSTAR EMPLOYEE false AMY SIMONE DAUGHTER OF OFFICER 72052 WELLSTAR EMPLOYEE false MATTHEW MADDOX SON OF BOARD MEMBER 38489 WELLSTAR EMPLOYEE false BONNIE MILLER WIFE OF BOARD MEMBER 28417 WELLSTAR EMPLOYEE false GREG SEPARK SON OF BOARD MEMBER 25847 WELLSTAR EMPLOYEE false Business Transactions with Interested Parties Form 990 Schedule L Part IV All transactions listed in Schedule L Part IV are for interested parties or in this case family members of either trustees or officers of Kennestone Hospital, Inc. or its related organizations. The transactions all represent payment of services as employees of Wellstar Health System. Tax Compliance 990T Explanation Part V Line 3a & b UBIT Paulding Medical Center, Inc. had no unrelated business income for the reporting period but is filing a 990-T to supplement discovery of that income in future periods. Conflict of Interest Policy Part VI Policies Line 12a, b & c Our Conflict of Interest Policy requires all covered persons to annually review the policy and complete, sign and return the conflicts of interest survey and attestation to the Compliance Office. The policy requires an on-going disclosure obligation in the event a conflict arises during the year. The following is our process to regularly and consistently monitor and enforce the policy: Compliance identifies all covered persons who must complete the Survey and Attestation. Compliance verifies that the survey and attestation is distributed to these persons. Compliance verifies that these persons return a fully completed and signed survey and attestation. Compliance reviews each completed and signed survey to identify all conflicts listed in the document. All conflicts, potential conflicts and incidences of non-compliance are referred to the Chief Compliance Officer. The CCO takes appropriate action to completely resolve all identified conflicts and incidences of non-compliance. Process for Determining Executive Compensation Part VI Section B Policies Line 15A & B Wellstar engages the Hay Group to work with the governing board to review and recommend executive compensation. The executive compensation process at Wellstar is overseen by a committee of independent trustees, which follows a board-approved executive compensation philosophy. The current members of the Wellstar committee are: Pete Wood Janie Maddox Al Separk Board Chairman Ex Officio CEO Ex Officio In committtee discussions about the compensation for the Chief Executive Officer, the CEO will recuse himself from that process but is a non-voting committee member for discussions on all other officers. The executive compensation philosophy empowers the committee to oversee the executive compensation process and administer the executive compensation program on behalf of the full board of trustee of Wellstar; provided, however, the full Board of Trustees evaluates and approves the compensation of the Chief Executive Officer. The philosophy requires annual disclosure of the committee's actions and decisions to the full board, which it has done. The committee is guided by the board-approved philosophy. Overall, the philosophy is intended to reward for organizational and individual performance. When performance is at a predetermined targeted level, the compensation is intended to be at or around the median of compensation paid to similar positions at similar organizations (the "market"). Wellstar's executive compensation philosophy defines the market as being comprised of comparable not-for-profit health care delivery systems, i.e., not-for-profit organizations similar in complexity and scale to Wellstar. To assist the committee in fulfilling its duties, the committee engaged the Hay Group to provide market compensation data to compare to the Wellstar positions whose compensation the committee oversees. The committee uses this data to provide context when making decisions in administering the compensation program. Accurate minutes of the committee's discussion and decisions are recorded during each committee meeting, and reviewed and approved at the following committee meeting. Consolidated Financial Statements Form 990 Part IV Line 12 & Part XI Line 2b Paulding Medical Center, Inc. is audited on an annual basis by an outside auditing firm, KPMG, and as part of that audit a consolidated financial statement is issued for all of WellStar Health System, Inc and its Affiliates. "The independent auditors report includes the accounts of Wellstar and its controlled affiliates, Kennestone Hospital, Inc., Cobb Hospital, Inc., Douglas Hospital, Inc., Paulding Medical Center, Inc., Wellstar Foundation, Inc. CHS Foundation, Inc., Community Assurance Company, Ltd., various Wellstar owned physician practices, a hospice facility, a nursing facility, home health business, and entities for infusion therapy and durable medical equipment. All significant intercompany accounts and transactions have been eliminated in combination. The Board of Trustees of Wellstar has the authority to approve appointments of the members of the board of trustees of all affiliate corporations." Tax-Exempt Bonds Allocation Form 990 Part IV Line 24a & Part X For purposes of the Form 990 reporting, Wellstar Health System, Inc EIN 58-1649541 will list all tax-exempt bonds issued since January 1, 2003 on Schedule K as it typically allocates the proceeds of the bonds to members of the Obligated Group (including the hospitals and physician group). Paulding Medical Center, Inc. will report this tax exempt bond liability on Part X, Line 25 Other Liabilities. Paulding Medical Center, Inc. has also restated its beginning balance sheet with respect to tax exempt bond liabilities as the amounts allocated to tax exempt bond liabilities are now included on Line 25. Compensation Reported on Form 990 Form 990 Part X Lines 5-10 & Schedule J, J-1 & J-2 All compensation amounts reported on Form 990 Part IX Lines 5-10 and Schedules J, J-l & J-2 represent compensation provided to individuals that provide services to Paulding Medical Center, Inc. Likewise the number of employees reported on Part V Line 2a represent the number of individuals providing services to the organization. All Federal Employment Tax responsibilities for those individuals are handled by Wellstar Health System, Inc. (EIN 58-1649541). Organizational Structure Form 990 Part VI Section A Lines 6, 7a & 7b As per the articles of incorporation, the sole member of the organization is Wellstar Health System, Inc., a GA nonprofit corporation. As sole member, Wellstar Health System holds certain powers of election an approval in connection with the governing body of the organization. These powers are presented in detail in the governing documents which the company makes available to the public upon request. Form 990 Copy to Board of Directors Form 990 Part VI Line 11A Internal staff prepare the organization's Form 990. Before filing the return with the Internal Revenue Service an external accounting firm, PricewaterhouseCoopers, reviews and sign-offs on the completed return of each organization. The current year Form 990 is then reviewed by the Finance Committee along with a question and answer session. A motion is then made by the Finance committee to approve the returns and present to the full board copies of the forms in an electronic (pdf. format) version as well as a hard copy . The organization's CFO or designee subsequently signs the return for either manual or electronic filing by the appropriate due date. Officers Hours Worked Form 990 General Statement & Schedule J The officers devote their time to all of the organizations with Wellstar Health System that are listed in Schedule R, Part II. As such, the total hours worked by the officers across all of the organizations exceeds 40 hours per week. Current Officers/Directors Relationships FORM 990 PART VI, SECTION A LINE 2 For a portion of the tax year two officers and directors for WellStar Health System, Inc. --EIN 58-1649541 are related to each other through family. Lou Little, Sr VP Post Acute Services and Administrator of Windy Hill Hospital is the brother-in-law of Gregory Simone, former President and CEO for the system. Disclosure of Financial Documents FORM 990 PART VI SECTION C Line 19 The organization and its subsidiaries are subject to the Open Records Law in the State of Georgia. Therefore, by law, citizens are permitted to inspect and copy its governing documents, policies and financial statements as may be requested from time to time. Additionally, the organization's Form 990 is made readily available on the Guidestar website. Periodically, the organization publishes its financial performance in the local newspaper for citizens to review, and it also publishes a community benefit report once a year for distribution to the public. Bylaws Changes Form 990, Line VI, Line 4 In November 2010 the bylaws of Wellstar Health System were amended to reflect that any retired trustees be provided benefits upon their retirement from service on the Board. SCHEDULE L PART IV TRANSACTIONS WITH INTERESTED PARTIES Several transactions with interested parties of Paulding Medical Center Inc. all fall below the $100,000 threshold in business transactions. Changes In Net Assets Form 990 Part XI Line 5 For the reporting period Paulding Medical Center, Inc. had a change in net assets of $2,730,145 related to transfers to affiliates as part of the allocation of income statement and balance sheet transactions over the year. HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Thomas E Gearhard, MD TITLE:Board Member HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Jeffery Tharp MD TITLE:Board Member HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:A James Budzinski TITLE:Exec VP and CFO HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Gregory L Simone, MD TITLE:President and CEO HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Bonnie Wilson TITLE:Exec VP and General Counsel HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:David Anderson TITLE:Exec VP HR/OL/CCO HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Donald Campbell, MD TITLE:SrVP & Medical Director HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Barbara B Corey TITLE:Sr VP Managed Care HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Bruce Dean TITLE:VP & Asst Gen Counsel HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Marcia Delk, MD TITLE:Sr VP Medical Affairs & CQO HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:K. Darold Etheridge TITLE:VP Finance HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Lee Evins TITLE:VP Revenue Cycle Mgmt HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Christopher Kane TITLE:Sr VP Strategic Planning HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Kenneth Kunze, MD TITLE:Sr VP and Chief Med Officer HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Lou Little TITLE:Sr VP Post Acute & Hosp Admin HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Kimberly Menefee TITLE:Sr VP Public Affairs & Gov Rel HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Ronald Strachan TITLE:Sr VP & CIO HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:ROBERT MANDLER TITLE:VP Diagnostic Outreach HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:MICHAEL GRAUE TITLE:EXEC VP COO HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:JONATHAN MORRIS TITLE:VP & Chief Med Info Officer HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:ELLEN LANGFORD TITLE:VP & COO PHY GRP HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Anthony M Trupiano TITLE:VP Supply Chain HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Robin Wilson, MD TITLE:VP Medical Management HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Joseph L Brywcznski TITLE:Sr VP Health Parks Admin HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Elizabeth A Hoffmann TITLE:VP Budget & Analysis HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Richard T Lopes, MD TITLE:Sr VP & Pres Wellstar Phy Grp HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:James M Swartz TITLE:VP Accounting HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Mary L Wesley TITLE:Sr VP Nursing Services & CNE HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Barbara G Ballard TITLE:VP Homecare and Hospice HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Carol S Edwards TITLE:VP Cardiac Services HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Robert D Jansen, MD TITLE:VP Medical Affairs HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Beth Kost TITLE:VP Compliance/Ch Privacy Offr HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Brett Scullen TITLE:VP Pulmonology Operations HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Adam C Thompson TITLE:VP Surgery HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Leo E Reichert TITLE:Exec VP and General Counsel HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Deborah DeVita Roegge TITLE:VP Women's and Newborn Srvcs HOURS:50 CHS Foundation 805 Sandy Plains Road Marietta GA 30066 581649540 Foundation GA 501 (C) (3) 11 NA true Cobb Hospital Inc 805 Sandy Plains Road Marietta GA 30066 580968382 Healthcare GA 501 (C) (3) 3 NA true Douglas Hospital Inc 805 Sandy Plains Road Marietta GA 30066 582026750 Healthcare GA 501 (c) (3) 3 NA true Kennestone Hospital Inc 805 Sandy Plains Road Marietta GA 30066 582032904 Healthcare GA 501 (c) (3) 3 NA true Wellstar Foundation 805 Sandy Plains Road Marietta GA 30066 581627413 Foundation GA 501 (c) (3) 11 NA true Wellstar Health System 805 Sandy Plains Road Marietta GA 30066 581649541 Healthcare GA 501 (c) (3) 11 NA false Cobb Hospital Parking Company LLC 805 Sandy Plains Road Marietta GA 300666340 752999669 Parking GA NA INVESTMENT 26313 808030 false false Kennestone East Parking Deck LLC 805 Sandy Plains Road Marietta GA 300666340 200537100 Parking GA NA INVESTMENT -64045 2719346 false false Community Assurance Co 3rd Fl Barclays House Shedden Rd George Town Grand Cayman, BWI CJ 581649541 Insurance CJ WHS Inc C 58594428 1.00000 false false false false false false false false false false false false false false false false false false