2012-08-14T15:34:42-05:00 2011-09-30 POSTLETHWAITE & NETTERVILLE 8550 UNITED PLAZA BLVD SUITE 1001 BATON ROUGE LA 70809 990 2010-10-01 720535375 LAFAYETTE GENERAL MEDICAL CENTER INC LAFA 3372898125 1214 COOLIDGE BLVD LAFAYETTE LA 705032621 ROGER MATTKE 3372898125 2012-08-14 1 RALPH STEPHENS 2259224600 2010 2016-02-24 21:20:13Z DAVID CALLECOD 1214 COOLIDGE BLVD LAFAYETTE LA 70503 214735013 0 X WWW.LAFAYETTEGENERAL.COM X 1911 LA THE ORGANIZATION PROVIDES MEDICAL CARE TO IMPROVE, MAINTAIN, AND RESTORE THE HEALTH OF THE PEOPLE IN THE COMMUNITIES WE SERVE, REGARDLESS OF THE PATIENTS' ABILITY TO PAY. 17 11 1854 112 2502731 -140101 38700 55685 191746083 208935210 3194256 4263716 3683321 -2497091 198662360 210757520 191479 164723 0 0 79967336 82736870 0 0 0 111203046 121466800 191361861 204368393 7300499 6389127 332063015 336016610 158906541 158533156 173156474 177483454 X LAFAYETTE GENERAL MEDICAL CENTER'S MISSION IS TO IMPROVE, MAINTAIN AND RESTORE THE HEALTH OF THE PEOPLE IN THE COMMUNITIES WE SERVE. 0 0 155340619 164723 210423586 PROGRAM SERVICES STATISTICS RELATED TO PROVIDING COMMUNITY MEDICAL CARE FOR THE HOSPITAL: TOTAL ACUTE PATIENT DAYS WERE 67,327, TOTAL NURSERY DAYS WERE 4,123, AND TOTAL REHAB DAYS WERE 3,209. OTHER SIGNIFICANT HEALTHCARE SERVICES PROVIDED INCLUDED 54,621 EMERGENCY ROOM VISITS, 8,918 SURGERIES (INPATIENT AND OUTPATIENT), AND 1,914 DELIVERIES.THE ORGANIZATION PROVIDES NEEDED MEDICAL CARE TO THE COMMUNITY, REGARDLESS OF THE PATIENT'S ABILITY TO PAY. SERVICES INCLUDED INPATIENT AND OUTPATIENT CARE IN FURTHERANCE OF THE ORGANIZATION'S HEALTHCARE MISSION. THE REVENUES FORM THESE SERVICES ARE $430,504,234 AND $276,862,283, RESPECTIVELY. THERE WERE ACUTE AND SKILLED CARE SERVICES NOT FULLY COMPENSATED. THESE INCLUDED MEDICARE / MEDICAID CONTRACTUALS WITH $329,193,140 OF UNCOMPENSATED SERVICES, OTHER CONTRACTUALS WITH $146,913,940 OF UNCOMPENSATED SERVICES, AND BAD DEBTS OF $22,324,227. THE NET REVENUES OF THE SERVICES PROVIDED WERE $208,935,210.LAFAYETTE GENERAL MEDICAL CENTER (LGMC) SERVES THE NINE PARISHES IN LOUISIANA DESIGNATED ACADIANA WITH 353 STAFFED BEDS AND 1800 EMPLOYEES. LGMC REMAINS THE AREAS LARGEST, FULL SERVICE, ACUTE-CARE MEDICAL CENTER.OUR HOSPITAL MISSION IS TO RESTORE, MAINTAIN, AND IMPROVE HEALTH OF PEOPLE IN THE COMMUNITIES WE SERVE. WE ARE A COMMUNITY-OWNED AND LOCALLY MANAGED HOSPITAL THAT STAYS TRUE TO OUR MISSION BY DEDICATING SIGNIFICANT RESOURCES TO COMPENSATE A COMPASSIONATE, HIGHLY SKILLED STAFF; ACQUIRE ADVANCED TECHNOLOGY; AND DEVELOP SERVICE IMPROVEMENTS EACH YEAR.IN LINE WITH OUR GOAL OF BUILDING A REGIONAL HEALTH CARE SYSTEM, LAFAYETTE GENERAL HAS ESTABLISHED CLINICAL AFFILIATIONS WITH OUTLYING HOSPITALS, EXTENDING OUR BEST PRACTICES IN CANCER TREATMENTS, CARDIOLOGY, AND NEUROSCIENCE SUPPORT TO OUTLYING PARISHES.LAFAYETTE GENERAL CONTINUES TO EXPAND ITS SERVICES AND FACILITIES IN ORDER TO MEET THE GROWING NEEDS OF OUR COMMUNITY. ORIGINALLY BUILT IN 1963, THE 10-STORY LAFAYETTE GENERAL MEDICAL CENTER MAIN BUILDING COMPLETED AN EXTERIOR AND INTERIOR DESIGN RENOVATION TO FOCUS ON PATIENT HEALTH CARE BY CREATING A HEALING-FOCUSED AND COMFORTABLE ENVIRONMENT. THE $70 MILLION RENOVATION PROJECT ADDED MORE THAN 65 SQUARE FEET OF SPACE TO PATIENT ROOMS AND MORE THAN 12,500 SQUARE FEET OF OVERALL SPACE WITH LARGER PATIENT BATHROOMS, SHOWERS AND A MODERNIZED PATIENT CARE INFRASTRUCTURE.OUR ACCOLADES AND ACCREDITATIONS GROW EACH YEAR. IN OUR FISCAL YEAR 2011 WE RECEIVED THE FOLLOWING: CONTINUED QUALITY IMPROVEMENT BY LAFAYETTE GENERAL WAS NOTED BY STUDER GROUP AND PRESS GANEY AS A RECIPIENT OF EXCELLENCE IN PATIENT CARE FOR PHYSICIANS AND TOP IMPROVER AWARD FOR EMERGENCY DEPARTMENTS, RESPECTIVELY. OTHER ACCOMPLISHMENTS INCLUDE THE STUDER AWARD AS THE MOST IMPROVED HOSPITAL IN PATIENT SATISFACTION AND CONSUMER CHOICE AWARD FROM NATIONAL RESEARCH CORPORATION THREE YEARS IN A ROW (2009-10, 2010-11, 2011-12). HEALTHGRADES RANKS LAFAYETTE GENERAL IN THE TOP 5% IN THE NATION AND NUMBER 1 IN LOUISIANA FOR OVERALL ORTHOPEDIC SERVICES. WE ARE RECOGNIZED BY HEALTHGRADES AS BEING IN THE TOP 5% IN THE NATION FOR OVERALL PROSTATECTOMY, NUMBER 1 IN LOUISIANA FOR GI SURGERY AND FIVE-STAR RATED FOR SPINE SURGERY 5 YEARS IN A ROW. PRIMARY STROKE CERTIFICATION FROM THE JOINT COMMISSION.LAFAYETTE GENERAL MEDICAL CENTER ASSUMES THE ROLE OF A COMMUNITY PARTNER IN A VARIETY OF WAYS. THROUGH FINANCIAL CONTRIBUTIONS WE WORK TO PRESERVE THE PROSPERITY OF OUR COMMUNITY, FURTHER MEDICAL EDUCATION AND RESEARCH AND HELP OUR CONSTITUENTS ACCESS THE MEDICAL CARE THEY NEED. WE COORDINATE EVENTS AND SCREENINGS FREE OF CHARGE TO MAINTAIN THE HEALTH OF THE LOCAL PUBLIC. WE ALSO EXTEND OUR WORKFORCE BEYOND THEIR DAILY RESPONSIBILITIES TO PARTICIPATE IN ACTIVITIES THAT PROVIDE FOR THE SAFETY AND BETTERMENT OF OUR COMMUNITY. FINANCIAL CONTRIBUTIONS:IN 2011 WE DONATED OVER $152,000 SUPPORTING ORGANIZATIONS THAT PARALLEL OUR MISSION IN THE COMMUNITY, EMPLOYEES THROUGH CONTINUING EDUCATION AND HELPING TO IMPROVE THE HEALTH OF THOSE WE SERVE. FROM OFFERING CLINICAL SUPPORT TO CAMP BON CEUR ATTENDEES TO SPONSORING EVENTS THAT RAISE RESEARCH MONEY AND AWARENESS FOR ILLNESSES LIKE BREAST CANCER, DIABETES AND HEART DISEASE. IN 2011 THESE MONIES WERE DONATED TO OVER 35 DIFFERENT ORGANIZATIONS IN OUR COMMUNITY.COMMUNITY OUTREACH & HEALTH CARE ACCESS CONTRIBUTIONS:LAFAYETTE GENERAL MEDIAL CENTER MAINTAINS A PROACTIVE APPROACH TO EDUCATION AND WELLNESS IN OUR COMMUNITY. ANNUALLY LGMC PROVIDES A MULTITUDE OF EDUCATIONAL SEMINARS AIMED AT EDUCATING THE PUBLIC ON PREVENTATIVE CARE AND MAINTAINING A HEALTHY LIFESTYLE. SOME OF THESE ACTIVITIES AND PROGRAMS INCLUDE:DONATED $9,392 IN DIAGNOSTIC SERVICES AS PART OF A PARTNERSHIP WITH THE LAFAYETTE COMMUNITY HEALTH CARE CLINIC.WOMEN'S AND CHILDREN'S SERVICES CURRENTLY OFFERS CLASSES WHICH INCLUDE NEWBORN CARE, LABOR AND DELIVERY PROCESS, BREASTFEEDING YOUR INFANT AND INFANT CPR. PARTICIPANT IN THE SHOTS FOR TOTS PROGRAM, BY PROVIDING CHILDREN'S IMMUNIZATIONS AT THE HOSPITAL FOUR TIMES DURING THE YEAR.FREE SUPPORT GROUPS ARE OPEN TO RESIDENTS DEALING WITH STROKE SURVIVAL, WEIGHT LOSS SURGERY, INFANT BEREAVEMENT, AND MULTIPLE BIRTHS. STAFFED FREE HEALTH BOOTHS INCLUDING AHA GO RED FOR WOMEN, SUSAN G KOEMAN'S RACE FOR THE CURE AND THE WALK FROM OBESITY. CONDUCTED SIX COMMUNITY EDUCATION LUNCHEONS, HEALTH IN GENERAL, AT WHICH DIFFERENT PHYSICIANS SPOKE TO VARIOUS TOPICS.LGMC ALSO PROVIDES FREE TRANSPORTATION FOR PATIENTS WITH SPECIAL NEEDS, IN ORDER TO ALLOW THEM ACCESS TO MEDICAL CARE AT THE HOSPITAL.TO IMPROVE HEALTH CARE ACCESS FOR THOSE UNINSURED WORKERS LIVING AT OR BELOW POVERTY LEVEL, LGMC MAINTAINS A REFERRAL AGREEMENT WITH THE LOCAL LAFAYETTE COMMUNITY HEALTHCARE CLINIC TO PROVIDE DIAGNOSTIC TESTING TO THEIR PATIENT POPULATION. LAFAYETTE GENERAL MEDICAL CENTER IS TRULY A COMMUNITY OWNED HOSPITAL CARING FOR THE NEEDS OF THE COMMUNITY AND INVESTING IN THE FUTURE WELLNESS OF OUR NEIGHBORS. 155340619 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 1 280 0 1 1854 1 1 1 0 0 0 0 0 0 0 0 0 X 17 11 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 0 X LAFAYETTE GENERAL MEDICAL CENTER 3372898125 1214 COOLIDGE BLVD LAFAYETTE LA 705032621 X CLAY ALLEN 1.00 X 0 0 0 DAVID CALHOUN 1.00 X 0 0 0 BRADLEY J CHASTANT MD 1.00 X 2000 0 0 BRADEN DESPOT 1.00 X 0 0 0 JULIE FALGOUT 1.00 X 0 0 0 WILLIAM H FENSTERMAKER 1.00 X 0 0 0 PHILIP GACHASSIN MD 1.00 X 89500 0 0 ROBERT GILES 1.00 X 0 0 0 G GARY GUIDRY MD 1.00 X 43200 0 0 JOBY JOHN PHD 1.00 X 0 0 0 ROSE KENNEDY MD 1.00 X 5600 0 0 EDWARD KRAMPE 1.00 X 0 0 0 FLO MEADOWS 1.00 X 0 0 0 RAE ROBINSON BRODNAX 1.00 X 0 0 0 GARY SALMON 1.00 X 0 0 0 E GREG VOORHIES 1.00 X 0 0 0 DANIEL BOURQUE MD 1.00 X 15800 0 0 DONALD J REED MD 1.00 X 0 0 0 BENJAMIN DOGA MD 1.00 X 20700 0 0 DAVID CALLECOD 40.00 X 728443 0 98166 PATRICK W GANDY JR 40.00 X 353592 0 37046 ROGER MATTKE 40.00 X 324820 0 48460 DEBRA CLARK 40.00 X 242276 0 38575 GORDON E ROUNTREE JR 40.00 X 291816 0 38382 KATHERINE HEBERT 40.00 X 225106 0 16835 DEAN DUCOTE 40.00 X 157930 0 76 EDWINA MALLERY 40.00 X 145546 0 4614 CORINE B JOSEPH 55.00 X 134112 0 4508 CHARISSE J CONNER 40.00 X 132965 0 5580 2913406 0 292242 48 0 1 0 HOSPITAL HOUSEKEEPING SYSTEMS LTD PO BOX 826 SAN ANTONIO TX 782930826 HOUSEKEEPING SERVICES 2279868 WASHER HILL LIPSCOMB 1744 OAKDALE DR BATON ROUGE LA 70810 ARCHITECTURE 2258991 PARISH ANESTHESIA OF LAFAYETTE 3510 N CAUSEWAY BLVD STE 404 METAIRIE LA 70002 ANESTHESIA SERVICES 1222018 ASSOC REGIONAL & UNIVERSITY PATHOLOGIST PO BOX 27964 SALT LAKE CITY UT 84112 REFERENCE LAB 842231 TOTAL RENALCARE INC PO BOX 404691 ATLANTA GA 30384 DIALYSIS SERVICES 693503 26 45685 10000 55685 MEDICAL PATIENT SERVIC 621990 208935210 208935210 208935210 3225862 3225862 9560 9560 1533 1533 3377659 259037 3118622 3118622 394346 2724276 4696801 34535 3703042 993759 34535 1028294 1028294 0 15414 -15414 -15414 INTERCOMPANY REVENUE 561000 1551521 805526 745995 HOSPITAL CAFETERIA 722210 1277942 1277942 REFERENCE LAB 621500 490508 490508 -8921803 1488376 812351 -11222530 -5601832 210757520 210423586 2502731 -2224482 152773 152773 11950 11950 1834574 1834574 69454833 56000366 13454467 557026 419327 137699 5727090 5294263 432827 5163347 4030069 1133278 926835 926835 867150 3569 863581 286158 286158 365753 365753 19525530 12517132 7008398 1186127 83522 1102605 55994506 54207165 1787341 3802682 9920 3792762 3585403 530996 3054407 468063 189190 278873 4006719 4006304 415 397845 657603 -259758 14031749 6624788 7406961 2960448 2960448 EQUIPMENT RENTAL AND MA 10196006 7505489 2690517 COMMUNITY AND PHYSICIAN 1841516 1521092 320424 RECRUITING 591581 327 591254 BOND FUND EXPENSE 186174 186174 246555 96012 150543 204368393 155340619 49027774 0 9360 9960 33354380 28005070 12459 37246717 36474682 1388458 5319705 5837931 6600609 2227116 2742021 325045563 149529409 138629667 175516154 65148967 63724191 9778 9778 19089105 8755928 1403925 1333333 27717611 7512720 332063015 336016610 32237951 29912905 12922 84140736 84164015 34363100 41470563 8151832 2985673 158906541 158533156 X 173156474 177483454 173156474 177483454 332063015 336016610 X 6389127 -2062147 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 23572 23572 204344821 204368393 1000000 250000 0 0 1000000 1000000 1000000 1000000 4000000 6000000 22141 20618 22710 23572 89041 250000 250000 250000 250000 1000000 1500000 22141 20618 22710 23572 89041 PART IV, SUPPLEMENTAL INFORMATION: 990 SCHEDULE C PART II-A, LINE 1A: ALL LOBBYING ACTIVITIES OCCUR INDIRECTLY THROUGH THE AMERICAN HOSPITAL ASSOCIATION AND THE LOUISIANA HOSPITAL ASSOCIATION. THE HOSPITAL DOES NOT HAVE ANY CONTROL OR DIRECTION IN DETERMINING HOW SUCH DUES PAID TO THESE TWO ORGANIZATIONS ARE USED. 8897052 8897052 196000283 65436638 130563645 2655150 1248039 1407111 117493078 82844732 34648346 175516154 SELF INSURANCE RESERVES 2954423 SAINTS STREET LAFAYETTE GENERAL AMB ENDOCOPY CENTER 31250 2985673 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE ORGANIZATION ACCOUNTS FOR UNCERTAIN TAX POSITIONS IN ACCORDANCE WITH FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ACS 740. FASB ACS 740 PRESCRIBES A RECOGNITION THRESHOLD AND MEASUREMENT PROCESS FOR FINANCIAL STATEMENT RECOGNITION OF UNCERTAIN TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN IN A TAX RETURN. THE INTERPRETATION ALSO PROVIDES GUIDANCE ON RECOGNITION, DERECOGNITION, CLASSIFICATION, INTEREST AND PENALTIES, ACCOUNTING IN INTERIM PERIODS, DISCLOSURE AND TRANSITION. THE ORGANIZATION'S VARIOUS FEDERAL INCOME TAX AND EXEMPT ORGANIZATION INCOME TAX RETURNS (IRS FORMS 1065, 1120, AND 990), WHETHER FILED ON A CALENDAR OR FISCAL YEAR BASIS, ARE SUBJECT TO EXAMINATION BY THE IRS, GENERALLY FOR THREE YEARS AFTER THEY ARE FILED. GALA OCT. 6, 2011 4400 1500 9514 4400 1500 9514 15414 -15414 PART II, LINE 3 AND LINE 10 THE DIRECT EXPENSES REPORTED FOR COSTS INCURRED IN THIS REPORTING PERIOD PRIOR TO THE EVENT HELD ON OCTOBER 6, 2011. THE GROSS INCOME AND THE COST INCURRED AFTER THIS REPORTING PERIOD WILL BE REPORTED ON OUR NEXT YEAR RETURN. 1 1 X 1 X 1 X 1 1 0 1 1 1561870 1561870 0.00760 28159823 22812471 5347352 0.02620 29721693 22812471 6909222 0.03380 1959375 1959375 0.00960 438103 245288 192815 0.00090 152773 152773 0.00070 2550251 245288 2304963 0.01120 32271944 23057759 9214185 0.04500 1 6075762 1211328 66943772 70815430 -3871658 X 0 1 1 LAFAYETTE GENERAL MEDICAL CENTER INC

1214 COOLIDGE BLVD LAFAYETTE LA 70503

X X X NA 1 PART I, LINE 7: PART I, LINE 7, COLUMN (F). THE HOSPITAL USED TOTAL EXPENSES FROM FORM 990, PART IX, LINE 25 WHICH EXCLUDED BAD DEBT EXPENSE.A COST-TO-CHARGE RATIO WAS USED TO ESTIMATE COSTS INCLUDED IN LINE 7. THE COST-TO-CHARGE WAS DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGE AS PROVIDED IN THE INSTRUCTIONS TO SCHEDULE H. PART III, LINE 4: PART III, LINE 4. FOOTNOTE TO THE AUDITED FINANCIAL STATEMENTS:THE MEDICAL CENTER REPORTS ACCOUNTS RECEIVABLE NET OF ESTIMATED ALLOWANCES FOR UNCOLLECTIBLE ACCOUNTS AND ADJUSTMENTS. TO PROVIDE FOR ACCOUNTS RECEIVABLE THAT COULD BECOME UNCOLLECTIBLE IN THE FUTURE, THE MEDICAL CENTER ESTABLISHES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS TO REDUCE THE CARRYING AMOUNT OF SUCH RECEIVABLES TO THEIR ESTIMATED NET REALIZABLE VALUE. THE AMOUNT CHARGED TO THE PROVISION FOR DOUBTFUL ACCOUNTS IS BASED UPON THE MEDICAL CENTER'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS, BUSINESS AND ECONOMIC CONDITIONS, AND TRENDS IN GOVERNMENT REIMBURSEMENT. UNCOLLECTIBLE ACCOUNTS ARE WRITTEN OFF WHEN THE MEDICAL CENTER HAS DETERMINED THE ACCOUNT WILL NOT BE COLLECTED.COSTING METHODOLOGY:WORKSHEET A, ESTIMATE BAD DEBT EXPENSE (AT COST) WAS USED TO DETERMINE THE AMOUNT OF BAD DEBT EXPENSE REPORTED ON LINE 2. THE HOSPITAL ANALYZED THE POPULATION THAT WAS WRITTEN OFF TO BOTH CHARITY AND BAD DEBT DURING THE YEAR. IT WAS ESTIMATED THAT 44% OF THE UNINSURED OUTPATIENT EMERGENCY ROOM VISITS THAT WERE ADJUSTED TO BAD DEBT MAY HAVE BEEN PATIENTS THAT COULD HAVE QUALIFIED FOR THE HOSPITAL'S CHARITY CARE POLICY BUT DID NOT INITIATE OR COMPLETE THE NECESSARY DOCUMENTATION.THE HOSPITAL DID NOT INCLUDE ANY BAD DEBTS IN OUR COMMUNITY BENEFIT CALCULATIONS. PART III, LINE 8: PART III, LINE 8. THE COSTING METHODOLOGY USED FOR LINE 6 WAS THE STANDARD MEDICARE COST REPORT COST SYSTEM. THE AMOUNTS WERE RECAPPED FROM THE HOSPITALS FILED 2011 COST REPORT. THE CORRESPONDING REVENUE AMOUNTS WERE INCLUDED ON LINE 5. THE HOSPITAL DID NOT INCLUDE THE MEDICARE SHORTFALL IN OUR COMMUNITY BENEFIT CALCULATIONS REPORTED ON PART I, LINE 7. PART VI, LINE 2: PART VI, LINE 2 NEEDS ASSESSMENT. A FORMAL NEEDS ASSESSMENT HAS NOT BEEN UNDERTAKEN; HOWEVER, THE HOSPITAL DOES HAVE A BOARD OF TRUSTEES AND MEMBERS OF THE CORPORATION COMPRISED OF INDIVIDUALS FROM THE LOCAL COMMUNITY, WHICH ARE INDEPENDENTLY AWARE OF THE MEDICAL NEEDS OF THE COMMUNITY. SURPLUS RECEIPTS OVER DISBURSEMENTS ARE INVESTED TO IMPROVE THE QUALITY OF PATIENT CARE, EXPAND HOSPITAL FACILITIES AND EQUIPMENT, ADVANCE MEDICAL TRAINING AND EDUCATION. THE HOSPITAL ALSO MAINTAINS AN OPEN MEDICAL STAFF. PART VI, LINE 3: PART VI, LINE 3. PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE. THE HOSPITAL COMPLIES WITH FEDERAL AND JACHO REQUIREMENTS OF POSTING NOTICES TO PATIENTS AS REQUIRED BY FEDERAL PROGRAMS. HANDOUTS ARE INCLUDED WITH THE ADMISSION PACKAGE THAT INFORMS THE PATIENT OF CONTACT INFORMATION TO DISCUSS PAYMENT OPTIONS. THE HOSPITAL IS A MEDICAID ENROLLMENT FACILITY, AND AS SUCH, THE HOSPITAL OFFERS SCREENING SERVICES FOR ELIGIBILITY FOR MEDICAID AND POSSIBLE CHARITY CARE ASSISTANCE. HOSPITAL PERSONNEL ALSO SCREEN LARGER ACCOUNTS AFTER THE ORIGINAL BILL IS ISSUED, AND CONTACT THE PATIENT TO DETERMINE QUALIFICATIONS FOR CHARITY CARE POLICY. PART VI, LINE 4: PART VI, LINE 4 COMMUNITY INFORMATION. THE HOSPITAL SERVES THE NINE PARISHES IN LOUISIANA DESIGNATED AS ACADIANA AS THE LARGEST, FULL SERVICE, ACUTE CARE MEDICAL CENTER. APPROXIMATELY ONE THIRD OF THE HOSPITAL'S DISCHARGES COME FROM LAFAYETTE PARISH. THE HOSPITAL MAINTAINS AN EMERGENCY ROOM OPEN TO ALL PEOPLE REQUIRING EMERGENCY CARE WITHOUT REGARD TO THEIR ABILITY TO PAY. PART VI, LINE 6: PART VI, LINE 5 PROMOTION OF COMMUNITY HEALTH. THE HOSPITAL DOES MAINTAIN AN OPEN MEDICAL STAFF THUS ALLOWING IT TO OFFER A VARIETY OF SPECIALISTS, AND CONTINUES TO RECRUIT PHYSICIANS TO OUR AREA TO ENSURE THAT THE HOSPITAL WILL CONTINUE TO BE THE FULL SERVICE HEALTHCARE PROVIDER THAT THE COMMUNITY EXPECTS. THE HOSPITAL JOINS FORCES WITH OTHER LOCAL ORGANIZATIONS TO PROVIDE HEALTHCARE SCREENINGS AND TEST AT LOCAL EVENTS. PART VI, LINE 7: PART VI, LINE 6. THE HOSPITAL IS AFFILIATED WITH OTHER HEALTHCARE ORGANIZATIONS. SEE FORM 990 SCHEDULE R FOR A COMPLETE LISTING. ALL OF THE ORGANIZATIONS ARE LOCAL HEALTHCARE ORGANIZATIONS WITH THE SAME PURPOSE AS THE HOSPITAL. 1 LAFAYETTE BALLET THEATER 100 PILLETTE ROAD LAFAYETTE LA 70508 720937048 501(C)3 5000 CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFT AND GOVERNMENT ORGAINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. AMERICAN CANCER SOCIETY 1604 W PINHOOK ROAD SUITE 182 LAFAYETTE LA 70508 581925867 501(C)3 10040 CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFT AND GOVERNMENT ORGAINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. AMERICAN HEART ASSOCIATION 139B JAMES COMEAUX RAOD 596 LAFAYETTE LA 70508 360726140 501(C)3 27500 CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFT AND GOVERNMENT ORGAINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. CAMP BON COUER 405 W MAINT ST LAFAYETTE LA 70501 581710741 501(C)3 13000 CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFT AND GOVERNMENT ORGAINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. PENNINGTON BIOMEDICAL RESEARCH 6400 PERKINS ROAD BATON ROUGE LA 70808 581767810 501(C)3 10000 CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFT AND GOVERNMENT ORGAINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. LAFAYETTE COMMUNITY HEALTH 1317 JEFFERSON ST LAFAYETTE LA 70501 721227982 501(C)3 11500 9392 FEE SCHEDULE LAB SERVICES CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFT AND GOVERNMENT ORGAINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. UNITED WAY OF ACADIANA PO BOX 52033 LAFAYETTE LA 70501 720513639 501(C)3 17050 CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFT AND GOVERNMENT ORGAINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. MILES PERRETT CENTER 2130 KALISTE SALOOM RD LAFAYETTE LA 70501 753023211 501(C)3 12500 CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFT AND GOVERNMENT ORGAINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. OIL CENTER RENAISSANCE ASSOC 1005 E SAINT MARY BLVD LAFAYETTE LA 70501 721257087 501(C)6 7500 CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFT AND GOVERNMENT ORGAINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. 32 3 DISBURSEMENT TO QUALIFYING LPN SCHOOL STUDENTS - HENRY P. HEBERT SCHOLARSHIPS 23 11950 OTHER INFORMATION: PART IV: CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFIT ORGINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. DISBURSEMENTS FOR SCHOLARSHIPS, FELLOWSHIPS, AND STUDENT LOANS ARE MADE DIRECTLY IN FURTHERANCE OF THE ORGANIZATION'S EXEMPT PROGRAMS - THE PURPOSE OF WHICH THE HOSPITAL WAS ORGANIZED AND OPERATES. THE DISBURSEMENTS ARE BASED ON PERSONAL INTERVIEWS, ACADEMIC ACHIEVEMENTS, AND THE APPROVAL OF THE HOSPITAL'S ADMINISTRATION. CERTAIN STANDARDS AND CONDITIONS ARE ESTABLISHED TO ENSURE THAT RECIPIENTS ARE QUALIFIED AND THE DISBURSEMENTS ARE FOR HEALTH CARE OCCUPATIONS. THE CRITERIA FOR EDUCATIONAL LOANS ARE: 1. EMPLOYEES MUST HAVE COMPLETED ONE YEAR OF EMPLOYMENT 2. EMPLOYEE HAS ATTEMPTED TO GAIN OTHER FINANCIAL ASSISTANCE. 3. MUST HAVE A LETTER OF RECOMMENDATION FROM DEPARTMENT DIRECTOR. 4. MUST NOT HAVE AN UNSATISFACTORY EVALUATION. 5. THE EMPLOYEE MUST SIGN A CONTRACT. 6. ANY SINGLE LOAN MUST NOT EXCEED $10,000. X X X X 1 1 X X X X X 0 1 0 0 0 1 1 0 0 DAVID CALLECOD 465750 0 124800 0 137893 0 83361 0 14805 0 826609 0 546332 0 PATRICK W GANDY JR 278145 0 61624 0 13823 0 28881 0 8165 0 390638 0 265194 0 ROGER MATTKE 264470 0 58317 0 2033 0 34669 0 13791 0 373280 0 243615 0 DEBRA CLARK 192821 0 43056 0 6399 0 35100 0 3475 0 280851 0 181707 0 GORDON E ROUNTREE JR 235638 0 51764 0 4414 0 29810 0 8572 0 330198 0 218862 0 KATHERINE HEBERT 172838 0 42179 0 10089 0 13511 0 3324 0 241941 0 168830 0 DEAN DUCOTE 130000 0 14484 0 13446 0 0 0 76 0 158006 0 118448 0 EDWINA MALLERY 128004 0 17157 0 385 0 2959 0 1655 0 150160 0 109160 0 PART I, LINE 1A THE ORGANIZATION DOES ALLOW FOR SPOUSAL TRAVEL FOR THE TRUSTEES AND OFFICERS. SUCH EXPENSES ARE REPORTED ON THEIR W-2S OR 1099S. A HOUSING ALLOWANCE WAS PAID TO THE PRESIDENT/CEO, BUT WAS INCLUDED AS COMPENSATION ON HIS W-2. SOCIAL CLUB DUES WERE PAID FOR THE PRESIDENT/CEO AND THE COO AND WERE INCLUDED AS WELL AS COMPENSATION ON THEIR W-2S. TAXABLE FRINGE BENEFITS SUCH AS SPOUSAL TRAVEL AND SOCIAL CLUB DUES ARE ACCUMULATED AND GROSSED UP WHEN ADDED TO THE W-2 EARNINGS FOR THE YEAR. PART I, LINE 4B A SUPPLEMENTAL EMPLOYEE RETIREMENT PLAN (SERP) WAS ADOPTED EFFECTIVE JANUARY 01, 2008. THE SERP IS CLASSIFIED AS A SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN, THE PURPOSE OF WHICH IS TO PROVIDE PARTICIPANTS WITH SUPPLEMENTAL RETIREMENT BENEFITS. CONTRIBUTION FOR THE YEAR WAS $196,375.00. THE BOARD DETERMINES WHICH EMPLOYEES ARE ELIGIBLE FOR PLAN CONTRIBUTIONS. PARTICIPANTS WERE DAVID CALLECOD, CEO; PATRICK GANDY, COO; ROGER MATTKE, CFO; GORDON ROUNTREE, GENERAL COUNSEL; DEBRA CLARK, CNO; KATHERINE HEBERT, VICE-PRESIDENT; CAROLYN HUVAL, VICE-PRESIDENT; AND ZIAD ASHKAR, MD, CMO. DEBRA CLARK, CNO PRIOR CONTRIBUTIONS WERE FORFEITED IN 2011 UPON HER SEPARATION. PART I, LINE 6 THE ORGANIZATION DOES HAVE A PROFIT SHARING PLAN (SUCCESS SHARING) FOR ALL EMPLOYEES IN GOOD STANDING, DETERMINED IN PART ON NET EARNINGS. THE CRITERIA USED TO DETERMINE IF PROFIT SHARING WILL BE MADE IS BASED ONE THIRD ON NET EARNINGS OF THE ORGANIZATION, ONE THIRD ON QUALITY MEASURES, AND ONE THIRD ON PATIENT SATISFACTION SCORES. PART 1, LINE 6B: OFFICERS', AS LISTED ON PART VII OF FORM 990, CALCULATION OF PROFIT SHARING IS IN PART BASED ON THE CONSOLIDATED NET EARNINGS. LOUISIANA PUBLIC FACILITIES AUTHORITY 720895871 546395H80 2010-08-12 84137555 CAPITAL IMPROVEMENT RENOVATIONS PROJECT & REFUND OF 8/18/98 ISSUE 0 0 0 LOUISIANA PUBLIC FACILITIES AUTHORITY 720895871 PRIVATEPL 2011-02-25 3850000 REPLACE/UPGRADE CARDIAC CATH LAB 0 0 0 84137555 3733975 1550751 78852829 2011 1 0 1 1 3850000 59703 3790297 2011 0 0 1 1 0 0 0 0 1 1 0 0 0 0 1 1 0 0 0 0 0 1 0 0 0 0 0 1 SCHEDULE K SUPPLENTAL INFORMATION PART I, COLUMN (C) ADDITIONAL CUSIP# 546395H98, 546395J21, 546395J39, 546395J47,546395J54 LAFAYETTE INVESTMENT GROUP LLC SEE SCHEDULE O 535331 SEE SCHEDULE O 0 LAFAYETTE GENERAL SURGICAL HOSPITAL LLC SEE SCHEDULE O 2252798 SEE SCHEDULE O 0 LAFAYETTE HEALTH VENTURES INC SEE SCHEDULE O 8088667 SEE SCHEDULE O 0 GBR LLC SEE SCHEDULE O 500000 SEE SCHEDULE O 0 FORM 990, PART VI, SECTION A, LINE 2 TRUSTEES, CLAY ALLEN AND ROBERT GILES, ARE INVOLVED IN SEPARATE BUSINESS VENTURES TOGETHER THAT ARE WHOLLY UNRELATED TO THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION IS A NON-STOCK NOT-FOR-PROFIT CORPORATION WITH ONE CLASS OF MEMBERSHIP. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS RATIFY THE SELECTION OF THE INDIVIDUALS THAT SERVE ON THE BOARD OF TRUSTEES (GOVERNING BODY) AFTER THOSE INDIVIDUALS HAVE BEEN SELECTED AS A TRUSTEE BY THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 7B YES, THE INDIVIDUALS OF THE TRUSTEES (GOVERNING BODY) AND THE MEMBERS MUST BE APPROVED BY THE MEMBERSHIP BODY. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990S ARE PREPARED AND REVIEWED BY THE ORGANIZATIONS ACCOUNTING STAFF. THE COMPLETED FORMS ARE REVIEWED BY THE OFFICERS AND THEN PRESENTED TO THE BOARD FOR REVIEW, COMMENT AND CORRECTIONS IF NEEDED BEFORE FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C AN ANNUAL SURVEY IS SENT TO THE BOARD MEMBERS AND OFFICERS REQUIRING THEM TO DISCLOSE CONFLICTS OF INTEREST. AFTER RECEIPT OF THESE SURVEYS, THE GOVERNANCE COMMITTEE AND ITS CHAIRPERSON REVIEW ALL CONFLICTS AND REPORT ON SAME TO THE GOVERNANCE COMMITTEE. THEREAFTER THE CHAIRPERSON OF THE GOVERNANCE COMMITTEE AND THE ORGANIZATION'S GENERAL COUNCIL (WHO ATTENDS ALL BOARD MEETINGS) INSURES THAT ALL CONFLICTS ARE TIMELY DISCLOSED AND APPROPRIATE RECUSALS ARE MADE ON BUSINESS MATTERS THAT MAY BE RELATED TO THE CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 AN INDEPENDENT EXTERNAL CONSULTANT FIRM, SULLIVAN COTTER AND ASSOCIATES, IS ENGAGED BY THE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES, WHICH IS COMPRISED OF DISINTERESTED DIRECTORS, TO PREPARE COMPENSATION SURVEY AND FAIR MARKET VALUE REPORT. THE COMPENSATION COMMITTEE ANNUALLY REVIEWS THE MARKET COMPARABLES AND MAKES ADJUSTMENT THE PRESIDENT/CEO'S COMPENSATION THEREAFTER. THIS SAME PROCESS IS FOLLOWED FOR THE FOLLOWING SENIOR EXECUTIVES OF THE ORGANIZATION: CHIEF OPERATING OFFICER, CHIEF FINANCIAL OFFICER, CHIEF NURSING OFFICER AND GENERAL COUNSEL. FORM 990, PART VI, SECTION C, LINE 19 BASIC FINANCIAL INFORMATION IS MADE AVAILABLE AND SENT OUT TO THE COMMUNITY BY MEANS OF THE ORGANIZATION'S ANNUAL REPORT. OTHER DOCUMENTS AND MORE DETAILED FINANCIAL INFORMATION ARE AVAILABLE TO THE PUBLIC UPON REQUEST WITHIN THE PARAMETERS OF REGULATORY / LEGAL AUTHORITIES. FORM 990, PART VII, SECTION A, LINE 1A PAYMENTS TO THE PHYSICIANS THAT SERVICE AS TRUSTEES WERE REPORTED ON 1099 MISC BOX 6. ALL SUCH PAYMENTS WERE IN CONSIDERATION FOR PROVIDING CALL COVERAGE IN OUR EMERGENCY ROOM, OR SERVING AS MEDICAL DIRECTORS FOR VARIOUS HOSPITAL DEPARTMENTS. NO PAYMENTS WERE MADE IN THEIR CAPACITY AS TRUSTEE. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -2,062,147. FORM 990, PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PREVIOUS YEAR. SCH. L PART IV LAFAYETTE INVESTMENT GROUP LLC (LIG) IS A RELATED ORGANIZATION OF LAFAYETTE GENERAL MEDICAL CENTER INC. CURRENT TRUSTEES, BRADLEY J CHASTANT, MD AND DAVID CALLECOD, PRESIDENT/CEO SERVE ON BOTH BOARDS. THE GROUP OWNS AND OPERATES A SURGICAL HOSPITAL AND MEDICAL OFFICE BUILDING. LGMC PAID LIG BUILDING RENT OF $463,190 AND EXPENSE TO BE REIMBURSED OF $72,141 TO PAY FOR CONSTRUCTION RELATED EXPENSES. LAFAYETTE GENERAL SURGICAL HOSPITAL LLC (LGSH) IS A RELATED ORGANIZATION OF LGMC. CURRENT TRUSTEE BRADLEY J CHASTANT, MD AND PATRICK W GANDY JR. COO SERVE ON BOTH BOARDS. FORMER TRUSTEE WW RUCKS III SERVES ON THE LGSH BOARD. THE SURGICAL HOSPITAL OPERATES A 10-LICENSED-BED ACUTE CARE HOSPITAL SPECIALIZING IN SHORT STAY SURGICAL PROCEDURES LOCATED IN THE LIG BUILDING. LGMC REIMBURSED LGSH FOR EXPENSES OF $4,749. LGSH PAID LGMC $184,392 FOR AN EQUIPMENT LOAN, $800,000 IN DISTRIBUTIONS, AND $1,273,155 FOR EXPENSES AND SERVICES. LAFAYETTE HEALTH VENTURES INC (LHVI) IS A RELATED ORGANIZATION OWNED ENTIRELY BY LGMC. CURRENT TRUSTEES JOBY JOHN, PH.D., BRADEN DESPOT, RAE ROBINSON AND GARY SALMON AND CURRENT OFFICERS DAVID CALLECOD AND PATRICK GANDY JR. SERVE ON LHVI'S BOARD. ROGER MATTKE, CFO SERVES AS AN OFFICER FOR LHVI. FORMER TRUSTEE MIKE ALEXANDER, MD SERVES ON THE LHVI BOARD. LHVI OPERATES A COLLECTION AGENCY, RETAIL STORE FOR DURABLE MEDICAL EQUIPMENT, OPERATES MEDICAL CLINICS, AND EMPLOYS PHYSICIAN PRACTICES. EFFECTIVE NOVEMBER 11, 2010, LHVI HAS APPLIED TO BE CONVERTED FROM A FOR-PROFIT TO A NON-PROFIT STATUS. LHVI REMAINS TO HAVE A RELATIONSHIP WITH LGMC, IN THAT IT SUPPORTS LGMC'S MISSION BY PROVIDING MEDICAL SERVICES TO THOSE COMMUNITIES AND PERSONS THAT LGMC SERVES. LAFAYETTE GENERAL MEDICAL CENTER, INC HAS ENTERED INTO A CONTRACT WITH GBH, LLC TO PROVIDE CRITICAL CARE SERVICES, PULMONARY/VENTILATOR CARE MANAGEMENT SERVICES AND INTENSIVIST SERVICES FOR HOSPITAL'S ICU AND ASSUME THE ROLE OF MEDICAL DIRECTOR OF THE ICU. TRUSTEE G. GARY GUIDRY MD IS A MEMBER OF GBH, LLC. ST MARTIN HOSPITAL INC 210 CHAMPAGNE BLVD BREAUX BRIDGE LA 70517 264626264 HOSPITAL LA PENDING 501(C)(3) HOSPITAL LAFAYETTE GENERAL 1 LAFAYETTE HEALTH VENTURES INC PO BOX 53092 LAFAYETTE LA 53092 721006966 PHYSICIAN PRACTICES LA PENDING 501(C)(3) SUPPORTING LAFAYETTE GENERAL 1 LAFAYETTE INVESTMENT GROUP 1000 W PINHOOK SUITE 206 LAFAYETTE LA 70503 421594593 MANAGEMENT LA N/A RELATED 47697 2306764 0 0 0.29430 LAFAYETTE GENERAL SURGICAL HOSPITAL LLC 1000 W PINHOOK LAFAYETTE LA 70503 481300080 SURGICAL HOSPITAL LA N/A RELATED 1017433 1270089 0 0 0.50000 GREATER LAFAYETTE PHYSICIANS HOSPITAL ORG 117 AUDUBON BLVD LAFAYETTE LA 70503 721286969 SUPPORT SERVICES LA N/A C 1.00000 0 0 1 1 1 0 0 0 1 1 1 1 0 0 1 1 0 0 ST MARTIN HOSPITAL INC D 250000 COST ST MARTIN HOSPITAL INC O 466868 COST ST MARTIN HOSPITAL INC K 296832 COST LAFAYETTE INVESTMENT GROUP J 463190 CONTRACT LAFAYETTE INVESTMENT GROUP O 72141 COST E ST MARTIN HOSPITAL INC P 1449652 COST LAFAYETTE GENERAL SURGICAL HOSPITAL LLC O 4749 COST LAFAYETTE GENERAL SURGICAL HOSPITAL LLC E 184392 COST LAFAYETTE GENERAL SURGICAL HOSPITAL LLC P 1273155 COST LAFAYETTE GENERAL SURGICAL HOSPITAL LLC C 800000 COST LAFAYETTE HEALTH VENTURES INC O 20810262 COST LAFAYETTE HEALTH VENTURES INC L 699790 COST LAFAYETTE HEALTH VENTURES INC P 13807500 COST LAFAYETTE HEALTH VENTURES INC I 386115 COST