2012-11-14T12:34:15-06:00 2011-12-31 911194016 Clark Nuber PS 10900 NE 4th Suite 1700 Bellevue WA 98004 990 2011-01-01 510216589 PROVIDENCE HEALTH SYSTEM -SO CALIFORNIA PROV 4255253985 1801 Lind Avenue SW No 9016 Renton WA 980579016 Todd Hofheins 4255253985 2012-11-14 1 Sara Elizabeth J Hyre CPA P00235495 4254544919 2011 2016-02-24 21:20:13Z John F Koster MD 1801 Lind Avenue SW No 9016 Renton WA 980579016 1746339243 0 X www2.providence.org/california/Pages/default.aspx X 1903 CA Healthcare with special concern for the poor & vulnerable in So. California. 13 13 11693 2735 700000 699000 13976543 32258250 1363669257 1542061864 6034226 8047853 88936155 25673650 1472616181 1608041617 5381160 3698520 0 0 837019951 896995752 0 0 383723 562921450 754617997 1405322561 1655312269 67293620 -47270652 3279160875 3422595451 2618522196 2740654563 660638679 681940888 X As People of Providence, we reveal God's love for all, especially the poor and vulnerable, through our compassionate service.Healthcare with special concern for the poor & vulnerable in Southern California. 0 0 916956830 0 1078768074 Acute Care - Inpatient Patient Days - 326,235Admissions - 73,064OUR MISSION - As people of Providence, we reveal God's love for all, especially the poor and vulnerable, through our compassionate service.OUR CORE VALUES - Respect, Compassion, Justice, Excellence, and StewardshipPROVIDENCE CARESWhether tenderly holding a special-needs child who requires round-the-clock care, or easing the way for a stroke patient who faces both physical and financial struggles, the people of Providence are called to a mission of service. Our lifework is to provide excellent care for everyone, at all stages of life, regardless of ability to pay. This has been the Providence mission since the Sisters of Providence arrived on the shores of the Columbia River 150 years ago, committed to the care and healing of poor and vulnerable frontier neighbors. Providence Health System-Southern California is a not-for-profit network of hospitals, care centers, physicians, clinics, home health services and affiliated services. We continue a tradition of caring that the Sisters of Providence began in the West 150 years ago.There is nothing more valuable than good health, but in 2011, when the unemployment rate in Los Angeles County surpassed 10 percent, many people were in need of help with not only basic healthcare needs, but critical needs.Providence Health & Services Southern California answered needs across the region, contributing nearly $138 million in charity care and in services to the under-served in 2011 through its community benefits program. Providence Cares.We care about school children who've never seen a dentist, about indigent emergency patients who desperately need follow-up care and for the elderly who need a ride to the doctor or just a friendly phone call to say hello.In the South Bay, employees collected boxes and boxes of Christmas gifts for families in need, many from working families who had lost their homes. In the San Fernando Valley, an outbreak of whooping cough prompted our School Nurse Program to provide free vaccinations to children. Providence Cares about the communities we serve.We understand the importance of preventive care and provide several programs aimed at keeping people out of the hospital by meeting their basic healthcare needs, diagnosing chronic illnesses and providing care before a treatable conditions become critical.We are driven by a commitment to the Providence Mission of compassionate care for all, especially the poor and vulnerable, and to our core values of Respect, Compassion, Justice, Stewardship and Excellence. Providence honored that tradition in 2011 by providing a total of $250,000 to 14 nonprofit groups in the San Fernando and Santa Clarita valleys that served the homeless, the uninsured in need of medical care, school children in low-income areas and others in need. The money came from the Mother Joseph Fund, which held a portion of proceeds from the Valley Service Area ministries.As part of the South Bay Service Area's community benefits programs, employees of Providence Little Company of Mary Medical Center San Pedro donated children's outfits to Barton School. Nearly 60 percent of the school's 800 children are from lower-income households. The ministry also collected more than 200 pairs of shoes to donate to a project that helped the homeless. Finally, a Christmas appeal drew gifts for 23 families in need. We help our neighbors across Southern California - and the West - because Providence Cares. OUR FACILITIES:Providence Saint Joseph Medical Center in BurbankProvidence Holy Cross Medical Center in Mission HillsProvidence Tarzana Medical Center in TarzanaProvidence Little Company of Mary Medical Center in TorranceProvidence Little Company of Mary Medical Center in San PedroProvidence Health System - Southern California has entered into a joint agreement with the Bioethics Institute at Loyola Marymount University in Westchester, California. Loyola Marymount faculty will now be available to Providence hospitals to assist with bioethics education and Little Company 333128492 0 391864206 Acute Care - Outpatient - including emergency/trauma services. Patient Visits - 707,733 San Pedro Peninsula Hospital dba Little Company of Mary-San Pedro Hospital (LCM-SPH) provides care to the sick and dying and their families through the Catholic Health Ministry. In October 1992, LCM-SPH affiliated with Little Company of Mary Health Services (LCMHS) and became part of its integrated system. Due to the changing economic conditions of health care, LCMHS sought a strategic partner to be able to continue its commitment to meet the health needs of the community and remain financially strong. On September 1, 1999 LCMHS affiliated with Providence Health & Services, an exempt 501(c)(3) corporation headquartered in Renton, Washington. Providence Health & Services is a not - for - profit Catholic organization with the same mission and values as LCMHS and its affiliated organizations.LCM-SPH accomplishes its Mission of providing health care services to the community in a variety of hospital and ambulatory settings. LCM-SPH operates an acute general hospital that provides comprehensive inpatient, outpatient and emergency services. Major service areas within the acute hospital include medical/surgical, obstetrics, geropsychiatry, rehabilitation and chemical dependency. The hospital also has an outpatient diagnostic imaging center. In addition to its acute hospital, LCM-SPH provides sub-acute care services to the community .The Mission of Little Company of Mary Sisters and the Sisters of Providence is reflected in the historical significance of their names to continue the healing ministry of Jesus. They are committed to care for the sick, dying and needy.Providence Health & Services Southern California - LCM Services Area is committed to the fulfillment of the Mission of the Sisters through the delivery of expanded charitable services. In keeping with this mission it has established a Social Accountability budget to return the value of the system's tax exemption to the community.Providence Little Company of Mary San Pedro was among the first recipients of Press Ganey's new Best Place to Practice Award which was given to only six hospitals nationwide. This award recognizes hospitals who have reached and sustained the 95th percentile on their physician surveys for two consecutive reporting periods that are not more than twenty-four months apart.HealthGrades recognized Providence Tarzana Medical Center with 5-Star ratings for the treatment of heart attack and heart failure for the sixth consecutive year and Providence Saint Joseph Medical Center with a Maternity Care Excellence Award, ranking Providence Saint Joseph among the top five percent of rated hospitals in the nation for five years. 58180196 0 68426651 Long-Term Care, Subacute Skilled Nursing & Home Health Programs. Long-Term Care Days - 95,631; Home Health Visits - 57,918. 3931178 233410 4776134 Providence High School for children of the Northern San Fernando Valley and surrounding area. School Days - 185 Students - 375.Providence High School is a Catholic, accredited, college-preparatory school for young men and women. The School is located in the San Fernando Valley and serves the Greater Los Angeles area. The School offers a challenging college-preparatory academic program, carefully designed to give students opportunities for growth and experience in preparation for university course work. The School has received full accreditation from the Western Association of Schools and Colleges, and the Western Catholic Educational Association. 3465110 3465110 0 Grant & Allocations - See Schedule I. 7396288 3698520 4776134 1315661806 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 1 1890 0 1 11693 1 1 1 0 0 0 0 1 1 0 0 0 0 X 13 13 0 0 0 0 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 CA X Karl E Fritschel CPA 4255253339 1801 Lind Ave SW 9016 Renton WA 980579016 X Lucille Dean SP 16.70 X X 0 0 0 M Adrian Davis LCM 5.10 X 0 0 0 Mary Corita Heid RSM 4.70 X 0 0 0 Michael A Stein 6.40 X 0 19271 0 Michael Holcomb 6.50 X 0 16045 0 Dana A Rasmussen 5.50 X 0 16420 0 James S Roberts MD 6.00 X 0 21564 0 Peter J Snow 5.40 X 0 21643 0 Jeffrey B Clode MD 7.40 X 0 21545 0 Sallye Liner 2.60 X 0 19893 0 Owen B Robinson 5.50 X 0 16065 0 Cheryl M Scott 4.70 X 0 16143 0 Ellen L Wolf 9.00 X 0 16065 0 John F Koster MD 54.00 X 0 4776573 1602882 Jeffrey W Rogers 50.00 X 0 1614579 524852 Todd Hofheins 56.00 X 0 330772 44868 Michael L Butler 65.00 X 0 1162565 582548 Karl J Carrier 55.00 X 0 2021039 306721 Michael Hunn 60.00 X 0 1319956 257022 Gregory Van Pelt 55.00 X 0 3311411 947178 Arnold R Schaffer 60.00 X 0 2709303 779042 Kerry L Carmody 40.00 X 0 2115765 378041 John V Fletcher 55.00 X 0 1825505 613859 Janice J Jones 55.00 X 0 2720021 566298 Larry S Bowe 40.00 X 0 1529106 479559 Eugene Al Parrish 50.00 X 0 1051632 489361 John O Mudd 55.00 X 0 860943 408169 Myron Berdischewsky MD 65.00 X 0 674529 464404 Claudia Haglund 50.00 X 0 1909927 456179 Cindra R Syverson 60.00 X 0 494955 174335 Nancy Carlson 50.00 X 0 981946 196743 Barry Wolfman 40.00 X 0 517387 182012 Dale Surowitz 40.00 X 0 482520 147130 Terry L Smith 60.00 X 0 3216132 671539 Craig L Wright MD 60.00 X 0 638787 284670 Bruce Lamoureux 60.00 X 0 599685 217743 Andy Agwunobi MD Thru 1130 50.00 X 0 693875 198720 David T Brooks 60.00 X 0 565551 207530 Medrice Coluccio 55.00 X 0 583584 380601 Bernard MD J Klein 40.00 X 420353 0 47322 Glen Komatsu 40.00 X 414375 0 44141 Dan C Cusator 40.00 X 393955 0 17234 William C Scott 40.00 X 388746 0 40680 David Mast 40.00 X 362380 0 34328 Keith Marton 0.00 X 0 1234802 157078 Russell Danielson 0.00 X 0 233389 0 1979809 40360893 11902789 1508 1 1 0 Swinerton Builders 17731 Mitchell N Ste 200 Irvine CA 926146028 Construction 13188044 Healthcare Partner Inc MED 19191 S Vermont Avenue 21F Torrance CA 90502 Medical Services 9291356 Crothall Services Group 955 Chesterbrook Blvd Ste 300 Wayne PA 19087 Laundry/Housekeeping 6303314 Therapeutic Associates Inc 7100 Fort Dent Way Ste 220 Seattle WA 98188 Physical/Occup. Therapy Svc 4961933 Perot Systems Healthcare PO Box 31498 Hartford CT 061501498 IT Consulting 4726722 480 8554 4105 24854230 6479724 911637 32258250 Acute - Inpatient 900099 1077475964 1077475964 Acute - Outpatient 621400 391444756 391444756 LTC/HomeCare/Hospice 623000 68365010 68365010 Tuition & Fees 611600 4776134 4776134 1542061864 7173188 7173188 4456894 3298430 1158464 1158464 1158464 135329688 309741 134511841 252923 817847 56818 874665 874665 96776 4105 47987 48789 48789 38152 2822 35330 35330 348298 183623 164675 164675 Cafeteria 722210 4139968 4139968 Pharmacy Services 446110 1422306 1422306 Management Services 900099 700000 700000 18004118 1773201 16230917 24266392 1608041617 1543835065 700000 31248302 3415110 3415110 283410 283410 10767941 10767941 589606898 485083713 104268695 254490 39817077 31829838 7977801 9438 212919266 178029243 34870832 19191 43884570 35527488 8338840 18242 10025890 2194971 7830919 7133 7133 44286 44286 143979106 109112686 34866420 1838841 845530 949143 44168 42337658 34388909 7915100 33649 9353037 1249602 8103435 35586287 18970487 16615800 1808478 713391 1095087 1155481 397146 757393 942 27131210 27071242 59968 32267521 2706525 29560996 70203055 42992522 27210533 9719732 9128442 591290 Medical Supplies 177156075 175693829 1462246 Provider Tax 77316674 57192752 20123922 Bad Debts 57696351 57696351 UBI Taxes 428676 0 428676 56562506 41138619 15420284 3603 1655312269 1315661806 339266740 383723 3721548 5690631 83427057 51912765 1100568 667599 189554906 196218679 3442627 52856704 23059946 22661294 26040713 10183581 1669231049 812372476 844668295 856858573 79849974 84211177 69548922 59432694 1954746319 2081901754 3279160875 3422595451 496158886 158168423 4554084 18250477 6113023 435840001 433935002 117469 1663601279 2142438115 2618522196 2740654563 X 601933824 639990616 37926383 22041981 20778472 19908291 660638679 681940888 3279160875 3422595451 X -47270652 68572861 X X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 1 0 0 1 0 0 0 0 Explanation of Lobbying Activities: Part II-B, Line 1: Lobbying activities, with the exception of advocacy, are limited to direct contact with government officials and mailings to the general public and legislators for the purpose of expressing opinions on legislative matters. Expenses include employee salaries, postage and incidental traveling expenditures. Providence Health System - Southern California does not allocate expenses to lobbying activities. 357604 10000 1737 369341 104970 238850 13784 357604 103609 1361 104970 103609 103609 0.00000 1.00000 0.00000 0 1 1 102843876 102843876 790594731 296947949 493646782 26415326 18477264 7938062 677175630 496947263 180228367 72201486 72201486 856858573 Unamortized Bond Financing Costs 6326903 Due from Affiliates 2022034164 Miscellaneous Receivables 19244649 Library Inventory 13000 Third Party Settlements 23157735 Bond Premium Discount 8572768 Trustee Held Funds 2552535 2081901754 39975 Due to Affiliates 2043039105 Liability for Risk Sharing 5275502 Miscellaneous Other Liabilities 227007 Capitalized Lease Obligation 5817334 LT Asset Retirement Obligation - FIN 47 13774031 IBNR Payable 2246672 Taxable Bond Issue 55954178 Third Party Settlements 14802329 Liability for Unpaid Claims 1261982 2142438115 Description of Intended Use of Endowment Funds: Part V, Line 4: The School has one endowment fund established for scholarship purposes that is donor-restricted. Description of Uncertain Tax Positions Under FIN 48: Part X: The Health System recognizes the effect of income tax positions only if those positions are more likely than not of being sustained. Recognized income tax positions are measured at the largest amount that is greater than 50% likely of being realized. Changes in recognition or measurement are reflected in the period in which the change in judgment occurs. GALA 77286 4105 73181 20395 2000 10470 Magazine Drive 22463 22463 9717 1 1132 1132 5405 100881 4105 96776 20395 2000 25592 47987 48789 38152 2822 1 1.00000 38152 2822 2822 35330 CA 1 0 0 0 1.00000 Paula Green 511 S Buena Vista Street Burbank CA 91505 0 Vickie Bagwell 0 All activities related to the raffle are coordinated through the Development Department. X 0 1 1 X 1 X 250.000000000000 1 X 350.000000000000 1 1 1 0 1 1 37669500 8747564 28921936 0.01810 363140136 301515059 61625077 0.03860 400809636 310262623 90547013 0.05670 9785443 171152 9614291 0.00600 5519347 4795 5514552 0.00350 5336083 222014 5114069 0.00320 1574583 1574583 0.00100 22215456 397961 21817495 0.01370 423025092 310660584 112364508 0.07040 0 57696351 0 396631076 362012938 34618138 X 1 1 5 1 Providence St Joseph Medical Center

501 S Buena Vista St Burbank CA 91505

X X X 2 Providence LCM Med Ctr - Torrance

4101 Torrance Boulevard Torrance CA 90505

X X X 3 Providence Holy Cross Medical Center

15031 Rinaldi St Mission Hills CA 91345

X X X X X 4 Providence Tarzana Medical Center

18321 Clark Street Tarzana CA 91356

X X X 5 Providence LCM Med Ctr - San Pedro

1300 West Seventh Street San Pedro CA 90732

X X X Providence St Joseph Medical Center 1 1 1 250.000000000000 1 350.000000000000 1 X X X X X X 1 1 X X 1 X X X X 0 1 X 0 1 Providence LCM Med Ctr - Torrance 2 1 1 250.000000000000 1 350.000000000000 1 X X X X X X X 1 1 X X 1 X X X X 0 1 X 0 1 Providence Holy Cross Medical Center 3 1 1 250.000000000000 1 350.000000000000 1 X X X X X X X 1 1 X X 1 X X X X 0 1 X 0 1 Providence Tarzana Medical Center 4 1 1 250.000000000000 1 350.000000000000 1 X X X X X X X 1 1 X X 1 X X X X 0 1 X 0 1 Providence LCM Med Ctr - San Pedro 5 1 1 250.000000000000 1 350.000000000000 1 X X X X X X X 1 1 X X 1 X X X X 0 1 X 0 1 3 Providence St Elizabeth Care Center

10425 Magnolia Boulevard North Hollywood CA 91601

Skilled Nursing Providence LCM Sub-Acute Care Center

1322 West Sixth Street San Pedro CA 90732

Skilled Nursing Providence LCM Transitional Care Ctr

4320 Maricopa Street Torrance CA 90503

Transitional Care Part I, Line 6a: In addition to having Community Benefit information included in the consolidated Providence Health & Services Community Benefit Report, this information is also included in the Providence Health System - Southern California Regional Community Benefit Report. Part I, Line 7, Column (f): The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 57696351. Part II: COMMUNITY BUILDING ACTIVITIES:Providence Health & Services, California Region did not track or report the financial impact of their community building activities. Part III, Line 8: It is Providence's policy to exclude any Medicare shortfall from Community Benefit information.The amount reported on Part III, Section B, Line 6, was determined by applying the Cost-to-Charge Ratio to the Medicare revenue. Part III, Line 9b: BILLING & COLLECTION PRACTICESProvidence has written policies about when and under whose authority patient debt is advanced for collection, and uses its best efforts to ensure that patient accounts are processed fairly and consistently.Providence ensures that practices to be used by their outside (non-hospital) collection agencies conform to the standards set forth in this policy, and obtains written commitments from such agencies that they will adhere to those standards. Providence also conducts an assessment of each collection agency's adherence to the policy. Such assessments are conducted at least annually.At time of billing, we provide to all low-income uninsured patients the same information concerning services and charges provided to all other patients who receive care at the hospital.When sending a bill to a patient, Providence includes a) a statement that indicates that if the patient meets certain income requirements the patient may be eligible for a government-sponsored program or for financial assistance from the hospital; and b) a statement that provides the patient with the name and telephone number of a hospital employee or office from whom or which the patient may obtain information about Providence's financial assistance policies for patients and how to apply for such assistance.Any patient (or the patient's legal representative) seeking financial assistance from Providence provides the individual facility with information concerning health benefits coverage, financial status (i.e. income, assets) and any other information that is necessary for the hospital to make a determination regarding the patient's status relative to Providence's financial assistance policy, discounted payment policy, or eligibility for government-sponsored programs.For patients who have an application pending determination for either government-sponsored coverage or for the hospitals' own financial assistance program, Providence will not knowingly send that patient's bill to a collection agency.Eligibility for financial assistance will be determined as closely as possible to the date of service. PART III, SECTION A, LINE 1The reporting entity reports bad debt expense in accordance with HFMA Statement #15 with the exception of the following sections: 8.1(b) and 9.1. PART III - LINE 4It is Providence's policy to exclude all bad debts from Community benefit information.The Consolidated Audited Financial Statements do not contain a footnote specific to Bad Debt Expense.Bad debt expense is reported in the audited financials as a separate line item within expenses from operations. Bad debt expense represents the amount of gross charges for patients who do not have insurance and which Providence was unable to qualify for assistance under either government programs or our internal charity care policy. Providence St. Joseph Medical Center Part V, Section B, Line 13g: Charity and Discount policies are posted on the Office of Statewide Health Planning and Development's website as required by California law. Notices of the availability of financial assistance are provided on the hospital's website, in admitting departments, on billing notices and given to the patient at time of admission/registration. Providence LCM Med. Ctr. - Torrance Part V, Section B, Line 13g: Charity and Discount policies are posted on the Office of Statewide Health Planning and Development's website as required by California law. Notices of the availability of financial assistance are provided on the hospital's website, in admitting departments, on billing notices and given to the patient at time of admission/registration. Providence Holy Cross Medical Center Part V, Section B, Line 13g: Charity and Discount policies are posted on the Office of Statewide Health Planning and Development's website as required by California law. Notices of the availability of financial assistance are provided on the hospital's website, in admitting departments, on billing notices and given to the patient at time of admission/registration. Providence Tarzana Medical Center Part V, Section B, Line 13g: Charity and Discount policies are posted on the Office of Statewide Health Planning and Development's website as required by California law. Notices of the availability of financial assistance are provided on the hospital's website, in admitting departments, on billing notices and given to the patient at time of admission/registration. Providence LCM Med. Ctr. - San Pedro Part V, Section B, Line 13g: Charity and Discount policies are posted on the Office of Statewide Health Planning and Development's website as required by California law. Notices of the availability of financial assistance are provided on the hospital's website, in admitting departments, on billing notices and given to the patient at time of admission/registration. Providence St. Joseph Medical Center Part V, Section B, Line 21: For non medically necessary services a patient may be charged full billed charges. Providence LCM Med. Ctr. - Torrance Part V, Section B, Line 21: For non medically necessary services a patient may be charged full billed charges. Providence Holy Cross Medical Center Part V, Section B, Line 21: For non medically necessary services a patient may be charged full billed charges. Providence Tarzana Medical Center Part V, Section B, Line 21: For non medically necessary services a patient may be charged full billed charges. Providence LCM Med. Ctr. - San Pedro Part V, Section B, Line 21: For non medically necessary services a patient may be charged full billed charges. Part VI, Line 2: NEEDS ASSESSMENT:We recognize that caring for the poor and vulnerable is not a task we can do on our own. On a routine basis we conduct a formal community assessment to determine who in our communities is experiencing the greatest need. This outreach connects us to many not-for-profits and social service agencies as well as care providers and their clients in the communities. To ensure that we conduct a comprehensive assessment, our process includes research, meetings, interviews, focus groups and surveys.Additionally, Providence ministries have community and foundation boards. The civic leaders that serve on Providence Boards connect our Mission with a local perspective on community needs.Our assessment findings are assembled to make certain we understand and respond to local and regional needs, which often vary from one city or county to another. Identified areas of need not only guide our community benefit giving, but also guide our strategic planning. We believe meaningful community needs assessment provides insight into the complete community benefit that is required, beyond just free and discounted care. Part VI, Line 3: COMMUNICATION TO THE PUBLIC:Providence hospitals post notices regarding the availability of financial assistance to low-income uninsured patients. These notices are posted in visible locations throughout the hospital such as admitting/registration, billing office, emergency department and other outpatient settings.Every posted notice regarding financial assistance policies contains brief instructions on how to apply for financial assistance or a discounted payment. The notices also include a contact telephone number that a patient or family member can call to obtain more information.Providence ensures that appropriate staff members are knowledgeable about the existence of the hospital's financial assistance policies. Training is provided to staff members (i.e., billing office, financial department, etc.) who directly interact with patients regarding their hospital bills.When communicating to patients regarding their financial assistance policies, Providence attempts to do so in the primary language of the patient, or his/her family, if reasonably possible, and in a manner consistent with all applicable federal and state laws and regulations.Providence shares their financial assistance policies with appropriate community health and human services agencies and other organizations that assist such patients. Part VI, Line 4: COMMUNITY INFORMATION:Providence Health & Services, Southern California Region, operates five medical centers and outpatient centers, clinics, hospice and community outreach programs serving a wide area stretching from the northern reaches of Los Angeles County to the South Bay Area. The region is marked by great wealth, but also by large pockets of poverty. The region is composed of the coastal South Bay Service Area and the inland Valley Service Area. The service areas are separated by some 30 miles, but work as one sharing quality practices and commitment to the Providence Mission to serve those who are poor and vulnerable. The Providence Mission drives numerous programs aimed at easing those challenged by the continuing economic slump, providing free and low-cost health care, partnering with agencies with similar missions and focusing on preventive care with the hopes of improving the health of the communities served by Providence. In the California Region's Valley Service Area, home to more than 2.1 million, 39.4% of the population is Hispanic; 42.7%, white; 10%, Asian; and 3.6%, African-American. Nearly 20% of the population is uninsured, 17.9% receive Medi-Cal; 10.3%, Medicare; and 51.8%, private or other insurance. Approximately 11.2% of the population is age 65 and above. Children, newborn to age 13, represent 19% of the total population. The 65- to 84-year-old age group is projected to increase the most over the next five years while the 25- to 44-year-old age group is projected to decrease during that period. While Providence provides outreach to those who are poor and vulnerable across the service area, pockets of lower income households tend to be clustered in the northeastern San Fernando Valley. Our community benefit services are especially concentrated there and focused on preventive medicine and health education.The South Bay Service Area covers 14 separate municipalities with a total population of 824,038, of which 35.7% are Hispanic; 34%, white;16.8%, Asian; 9.7%, African-American; and 3.8%, other. The coastal area includes upper income and affluent communities, while the crescent of communities forming the eastern Service Area boundaries are among the most impoverished in Los Angeles County. Data show 18.9% of residents are uninsured; 14.1% receive Medi-Cal; 11.8%, Medicare; and 55.3% have private insurance. Twelve percent of the population is 65 and older; children, newborn to 13 years, represent 18.7% of the total population. South Bay Service Area ZIP code demographics vividly document significant disparities related to age, educational attainment, household income and home ownership. With the Providence Mission as our guide, community outreach resources are directed to six underserved communities in the South Bay Service Area: Gardena, Hawthorne and Lawndale on the northern boundaries and Harbor City, Wilmington and the 90731 ZIP code area of San Pedro along the southern boundaries. Part VI, Line 5: PROMOTION OF COMMUNITY HEALTH:As a not-for-profit Catholic health care ministry, Providence Health & Services live out its Mission and embraces its responsibility to provide for the needs of the communities it serves - especially the poor and vulnerable. Providence's not-for-profit, tax-exempt status enables Providence to serve its communities, to solicit donations through its foundations and to access capital to respond to community needs that otherwise would go unmet. The charitable purpose of Providence Health & Services and each of its ministries is guided by one Mission and set of core values based on Catholic health care and guided by the legacy of the Sisters of Providence. As one system committed to caring for those who are poor and vulnerable, Providence Health & Services has developed a single framework for consistently reporting charity care and community benefit. Locally, Providence ministries are empowered to apply these policies to meet the needs of their community. Additionally, Providence ministries conduct local assessments to make sure the needs of the community are met. The Greater Los Angeles Area has a growing population of poor, uninsured and under-insured in need of basic health care, and the safety net has been further stretched by the current economic slowdown. In each service area, access to low cost or free primary care is the top health care need identified by the separate needs assessments conducted in the San Fernando Valley and South Bay regions. As the home to a large number of immigrants, all of whom have immediate health care and health education needs, finding a medical home and connecting children and adults to health care remains our greatest challenge. Untreated diabetes is epidemic, and among the growing Latino population the ability to provide services in Spanish is critical to successful clinical outcomes. Providence plays a leadership role in providing program infrastructure to the most economically disadvantaged communities in the service area and seeks to improve management of these chronic conditions. Each hospital's emergency department is open 24 hours and no patient is ever denied emergency care regardless of ability to pay. Because more and more patients utilize emergency rooms as primary care, Providence medical centers provide fast-track service for routine health issues and bilingual lay people to guide and direct children and adults to appropriate community based follow up services. Providence Southern California coordinates programs for vulnerable populations and sponsors and recruits volunteers for efforts by other groups and government agencies that share the Providence Mission of outreach to the poor and vulnerable. A mobile health clinic travels the San Fernando Valley five days a week providing very low-cost medical care for those in need, focusing on those with chronic illnesses to help them manage their conditions. In the South Bay, a mobile clinic visits 10 schools each week and provides free primary care to uninsured children. Across both service areas, medical teams work also with patients to find low-cost medical care and resources, and Providence provides free and low-cost laboratory and imaging work to area community clinics. Providence also provides several outreach programs for vulnerable populations including the elderly, immigrants and children from low-income families. Those community benefit programs, funded by medical center operations and external grants, include: a school nurse program at 14 Catholic schools in lower-income areas; senior peer counseling; Latino Health Promoters who provide health screenings and education; free removal of anti-social tattoos for former gang members and others; a faith community nurse outreach program that brings health care services to our communities through partnerships with area faith congregations; and a team of promotoras who reach out to help parents enroll their children in Medi-Cal or Healthy Families. A portion of proceeds from each hospital ministry is held in the Mother Joseph Fund and distributed to support community benefit projects that support the Providence Mission of outreach to the poor and vulnerable. For example, Providence partnered over the summer with the Los Angeles County Department of Public Health to provide free T-DAP vaccinations (tetanus, diphtheria and pertussis) at a dozen schools in the San Fernando Valley and South Bay. The goal was not only preventive medicine but to help families meet the demands of a new state law requiring vaccinations for the 2011-12 school year and exclusion of students who could not provide evidence of TDAP vaccination. Based on the findings of the needs assessments conducted in each of the service areas, programs have been developed to address the needs of those who are poor and vulnerable and that run the spectrum from birth to the elderly. Providence funds programs for young parents; provides a developmental therapy program for infants with special needs; free flu shot campaigns for all ages; counseling for adolescents, teens and young adults who have strayed off their paths; and health screenings and health education programs for all ages. Providence has developed palliative care programs at all its medical centers and operates the largest hospice program in Southern California, one that includes the area's only children's hospice. In the San Fernando Valley, a new program, Providence Access to Care, was initiated in 2011. This program involves community care coordinators and other professionals who identify indigent and uninsured emergency department patients to ensure they have access to free or low-cost prescriptions, specialists and ongoing medical care. Access to Care staff members contact these patients after discharge from the emergency department to arrange for free or low-cost follow-up medical care and track their progress, reminding them of appointments and keeping records of the referrals made.In 2011, the Providence Access to Care Program had 2,998 patients referred to the program for assistance. Of this total, 2,502 were new client referrals to the program. In the first year that the program was operating, 50% of the patients referred to the Access to Care Program did not return to the emergency departments after being linked with a medical provider in the community. For those patients who did have a return visit to the emergency department during this time period, in the majority of cases their visit to the emergency department was justified as a serious or emergent condition. After factoring in the costs to operate the program compared to the financial benefits to the medical centers, there was a net benefit of more than $47,700 during this first year.In the South Bay Service Area, a program called Creating Opportunity for Physical Activity (COPA) is offered in partnership with 13 urban public schools across three public school districts and offers a "peer coach" training model to almost 200 classroom teachers who have little or no training in physical education. Over a two year period, these teacher peer coaches become independent in physical education instruction using a curriculum developed by Providence that is directly linked to California grade level physical education standards. At six Lawndale elementary schools, a new pilot program known as "Instant Recess," in partnership with the UCLA School of Public Health, uses the same peer coach training model to help teachers integrate 10 minute bursts of physical activity into the classroom schedule. COPA trains teachers to provide P.E. instruction, using fun, skill and compassion to create a culture of daily physical activity. Preliminary evaluation by an independent evaluator has documented statistically significant increases in the number of students achieving the Healthy Fitness Zone, as measured by Fitnessgram.The other major program improvement, directly linked to the needs assessment, was the implementation of a pilot project, Get Out and Live (GOAL), designed to help adults improve their ability to manage their diabetes. This program is offered at the Vasek Polak Health Clinic, a primary care clinic for uninsured adults, sponsored by Providence Southern California. The clinic uses a low cost, fixed price service delivery model staffed by nurse practitioners and in 2011, was a medical home for 4,869 adults. The GOAL project, for adults with diabetes, involves the modification of a standardized self care curriculum to incorporate three additional classes that include group visits. During the group visit, one of the clinicians that the patient normally sees in the clinic provides both medical education and a one on one visit with the patient to go over lab results and answer any questions. Part VI, Line 6: AFFILIATED HEALTH CARE SYSTEM:Providence Health & Services owns and operates 27 general acute care hospitals, six long-term care facilities, seven homecare and hospice entities, five assisted living facilities, a children's nursing center and Montessori school, a high school, a university, 12 low-income housing projects, the Health Plan, a health services contractor, two programs of all inclusive care for the elderly, and 20 controlled fundraising foundations.The Health System provides inpatient, outpatient, primary care, and home care services in Alaska, Washington, Montana, Oregon and Southern California. The Health System operates these businesses primarily in the greater metropolitan areas of Anchorage, Alaska; Everett, Seattle, Spokane and Olympia, Washington; Missoula, Montana; Portland and Medford, Oregon; and Los Angeles, California.Providence Southern California continuously looks toward more efficient processes to ensure funding is available for community outreach programs to help those most in need. The poor and vulnerable run the spectrum from birth to the elderly, all with specific needs that are addressed by the Providence's outreach efforts. Providence funds programs for young parents; provides a developmental therapy program for infants with special needs; free flu shot campaigns for all ages; counseling for adolescents, teens and young adults who have strayed off their paths; and health screenings and health education programs for all ages. Providence has developed palliative care programs at all its medical centers and operates the largest hospice program in Southern California, one that includes the area's only children's hospice.In terms of community outreach, each of the five medical centers serves vastly different populations and tailors programs appropriately. In many cases, Providence Southern California partners with local charities such as Meet Each Need with Dignity (MEND) in the northern San Fernando Valley, the Burbank Temporary Aid Center (BTAC) in Burbank and Harbor Interfaith in San Pedro, which supports the working poor with shelter, food, job training, life skills education and other services. Reports Filed With States Part VI, Line 7 CA,WA,OR,MT,AK 1 Providence Little Company of Mary Foundation 4101 Torrance Blvd Torrance CA 91505 510224944 501 ( c)(3) 1699086 Operating Support/Emilie Gamelin Fund Providence Health & Services Foundation 501 S Buena Vista St Burbank CA 91505 953544877 501 ( c)(3) 1574631 Operational Support/Contribution Westfield America PO Box 57187 Los Angeles CA 90074 361127608 Other 19088 Mall Walker Sponsorship Valley Economic Alliance 5121 Van Nuys Blvd 200 Sherman Oaks CA 91403 954524503 501 ( c)(3) 25000 Community Support Children'S Hospital Los Angeles Foundation 4650 Sunset Blvd Mail Stop 29 Los Angeles CA 90027 951690977 501 ( C)(3) 10000 Operational Support City of Burbank Parks & Recreation 275 East Olive Ave Burbank CA 91502 956000683 Government 10000 Centennial Sponsorship Cystic Fibrosis Foundation 6931 Arlington Rd 200 Bethesda MD 20814 131930701 501( c)(3) 10000 Memorial Donation National Health Foundation 515 S Figueroa St 1300 Los Angeles CA 90071 237314808 501 ( c)(3) 5250 Recuperative Care American Heart Association PO Box 4002030 Des Moines IA 50340 135613797 501 ( C)(3) 5000 LA Heart Walk Arthritis Foundation 800 West 6Th St Suite 1250 Los Angeles CA 90017 951885447 501 ( C)(3) 5000 Arthritis Walk Sponsorship Valley Cultural Center 21550 Oxnard St 470 Woodland Hills CA 91367 510172702 501 ( c)(3) 5000 Sponsorship July 4th & First Aid Booth Valley Industry & Commerce Assn 5121 Van Nuys Blvd 203 Sherman Oaks CA 91403 237182039 Other 5000 Community Support 10 2 Family Allowance - 2nd Student 30 37250 FMV Tuition Reduction Scholarship - Department $100 33 3300 FMV Tuition Reduction Employee Discount 16 47400 FMV Tuition Reduction Academic Scholarships 20 5200 FMV Scholarships Financial Aid 48 75200 FMV Tuition Reduction Scholarships 50 1000 FMV Scholarships Charity 8 18260 FMV Tuition Reduction Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: In the application for support, we request a detailed explanation of the kind of services provided to the community along with specific financial data. If the application for support is approved, we send a letter indicating the amount of the support along with a request for documentation of how the funds were used, along with a report of the number of children/families served over the year. X X X X X 1 1 0 0 0 0 0 0 0 John F Koster MD 0 1128700 0 3611373 0 36500 0 1585488 0 17394 0 6379455 0 0 Jeffrey W Rogers 0 428372 0 1171207 0 15000 0 505409 0 19443 0 2139431 0 0 Todd Hofheins 0 260430 0 57803 0 12539 0 24688 0 20180 0 375640 0 0 Michael L Butler 0 775091 0 367474 0 20000 0 556768 0 25780 0 1745113 0 0 Karl J Carrier 0 403837 0 1585702 0 31500 0 284164 0 22557 0 2327760 0 0 Michael Hunn 0 470781 0 829175 0 20000 0 239155 0 17867 0 1576978 0 0 Gregory Van Pelt 0 690516 0 2584395 0 36500 0 925680 0 21498 0 4258589 0 0 Arnold R Schaffer 0 667785 0 1931749 0 109769 0 756443 0 22599 0 3488345 0 0 Kerry L Carmody 0 448846 0 1635419 0 31500 0 355132 0 22909 0 2493806 0 0 John V Fletcher 0 534720 0 1150130 0 140655 0 593141 0 20718 0 2439364 0 0 Janice J Jones 0 572386 0 2081316 0 66319 0 542507 0 23791 0 3286319 0 0 Larry S Bowe 0 340957 0 1173149 0 15000 0 455630 0 23929 0 2008665 0 0 Eugene Al Parrish 0 507395 0 524212 0 20025 0 466528 0 22833 0 1540993 0 0 John O Mudd 0 336906 0 487537 0 36500 0 389793 0 18376 0 1269112 0 0 Myron Berdischewsky MD 0 477310 0 138533 0 58686 0 442395 0 22009 0 1138933 0 0 Claudia Haglund 0 323326 0 1485333 0 101268 0 438152 0 18027 0 2366106 0 0 Cindra R Syverson 0 377057 0 102898 0 15000 0 153119 0 21216 0 669290 0 0 Nancy Carlson 0 307577 0 654858 0 19511 0 177975 0 18768 0 1178689 0 0 Barry Wolfman 0 368202 0 117685 0 31500 0 161216 0 20796 0 699399 0 0 Dale Surowitz 0 357378 0 110142 0 15000 0 126950 0 20180 0 629650 0 0 Terry L Smith 0 597366 0 2544661 0 74105 0 649540 0 21999 0 3887671 0 0 Craig L Wright MD 0 460242 0 163545 0 15000 0 263284 0 21386 0 923457 0 0 Bruce Lamoureux 0 442134 0 123718 0 33833 0 196191 0 21552 0 817428 0 0 Andy Agwunobi MD Thru 1130 0 473492 0 128430 0 91953 0 178836 0 19884 0 892595 0 0 David T Brooks 0 407789 0 142762 0 15000 0 186874 0 20656 0 773081 0 0 Medrice Coluccio 0 402506 0 149578 0 31500 0 367079 0 13522 0 964185 0 0 Bernard MD J Klein 348303 0 72050 0 0 0 32460 0 14862 0 467675 0 0 0 Glen Komatsu 329910 0 67965 0 16500 0 29225 0 14916 0 458516 0 0 0 Dan C Cusator 165183 0 50000 0 178772 0 3620 0 13614 0 411189 0 0 0 William C Scott 318088 0 70658 0 0 0 25594 0 15086 0 429426 0 0 0 David Mast 308383 0 53997 0 0 0 27436 0 6892 0 396708 0 0 0 Keith Marton 0 0 0 786086 0 448716 0 146314 0 10764 0 1391880 0 0 Russell Danielson 0 0 0 108402 0 124987 0 0 0 0 0 233389 0 0 Part I, Line 1a The reporting organization did not provide any of the benefits listed in Part I, Line 1a. However, as part of Providence's philosophy of transparency, the narrative that follows relates to the compensation and benefits provided by the related organization. Providence Health & Services Expense Reimbursement Procedures include the following policies: First Class Travel or Charter Travel or Travel of Companions Air travel is reimbursable for tourist or economy class and should be at the least expensive airfare; which permits departures and arrivals at reasonable times and reasonable distance traveled. Employees are encouraged to plan in advance to get available discounts. Airline frequent flyer upgrades will never be reimbursed. First class air travel will only be reimbursed when tourist or economy class air travel is not available and business travel is mandated by a supervisor. In the rare circumstance that an executive must fly on a first class full fare ticket, their senior level supervisor must approve this expense. Companion travel will only be reimbursed by the organization for travel related to relocation, and should not exceed two relocation-related visits, unless approval by the VP/Chief Human Resources Officer. During 2011, a total of three first-class tickets were purchased for disclosed personnel. Tax Indemnifications or Gross-Up Payments Providence Health & Services follows the federal and state taxation laws related to relocation expenses paid to the employee or to a third party on the employee's behalf. They are considered income and are therefore subject to payroll taxes. Based on the way Providence has chosen to pay the relocation expenses, Providence reports reimbursements and payments to vendors as income and these expense payments are reflected on the executive's Form W-2. Providence will gross-up the relocation benefits to offset the personal tax burden to the employee for IRS allowable expenses. During 2011, the following Key Employees received gross-up payments: Arnold R. Schaffer Myron Berdischewsky Terry L. Smith Orest Holubec The amounts reported for these gross-up payments are included on Schedule J, Part II, Column B (iii) - Other Reportable Compensation. Discretionary Spending Account Providence Health & Services provides an executive flex spending allowance per year (paid bi-weekly). This benefit is provided as discretionary spending because the organization does not reimburse for or provide additional executive benefits, such as a car allowance, additional executive life or disability insurance, or other market-based executive benefits practices. Housing Allowance or Residence for Personal Use Providence Health & Services provides housing allowances for purposes of relocation assistance only. Providence may pay temporary living expenses for the employee up to a maximum of 90 calendar days. Covered expenses are rent (excluding "rent" which may be paid in order to occupy a new permanent residence until the title clears) and utilities, including heat, electricity, gas, water, local internet and local telephone and garbage services. The VP/Chief Human Resources Officer may approve temporary housing assistance for up to six months when family relocation is delayed to accommodate the school year or equivalent circumstances. Only in extenuating circumstances is housing extended beyond this six month period. During 2011, the following Key Employees received relocation payments: Arnold R. Schaffer Myron Berdischewsky Terry L. Smith Orest Holubec The amounts reported for these relocation payments are included on Schedule J, Part II, Column B (iii) - Other Reportable Compensation. Part I, Lines 4a-b NONQUALIFIED RETIREMENT PLANS A) DBSERP = Defined Benefit Supplemental Executive Retirement Plan B) DCSERP = Defined Contribution Supplemental Executive Retirement Plan C) DBCBRP = Defined Benefit Cash Balance Restoration Plan D) DCRP = Defined Contribution Restoration Plan E) ESP = Elective Survivor Plan F) SOP = Share Option Plan 1) John F. Koster, MD a) Taxable DBSERP Earned but not Paid- $3,063,813 b) Non-Taxable DBSERP Earned but not Paid - $781,587 c) Non-Taxable DCSERP Earned - $339,126 d) DBSERP Interest Credit - $439,580 2) Jeffrey W. Rogers a) Taxable DBSERP Earned but not Paid - $1,005,741 b) Non-Taxable DBSERP Earned but not Paid - $135,144 c) Taxable DCSERP Earned but not Paid - $8,561 d) Non-Taxable DCSERP Earned - $48,099 e) ESP Interest Credit - $79,952 f) DBSERP Interest Credit - $202,199 3) Todd Hofheins a) Non-Taxable DCRP Earned - $9,603 4) Gregory Van Pelt a) Taxable DBSERP Earned but not Paid - $ 2,008,828 b) Non-Taxable DBSERP Earned but not Paid - $185,993 c) Taxable DCSERP Earned but not Paid - $276,749 d) Non-Taxable DCSERP Earned - $292,233 e) ESP Interest Credit - $88,256 f) DBSERP Interest Credit - $319,032 5) Terry L. Smith a) Taxable DBSERP Earned but not Paid - $2,293,039 b) Non-Taxable DBSERP Earned but not Paid - $236,604 c) Taxable DCSERP Earned but not Paid - $21,722 d) Taxable DBCBRP Earned - $400 e) Non-Taxable DCSERP Earned - $69,165 f) ESP Interest Credit - $61,528 g) DBSERP Interest Credit - $231,388 6) Janice J. Jones a) Taxable DBSERP Earned but not Paid - $ 1,844,829 b) Non-Taxable DBSERP Earned but not Paid - $189,772 c) Taxable DBCBRP Earned but not Paid - $ 142 d) Non-Taxable DCSERP Earned - $154,703 e) SOP Paid - $29,819 f) DBSERP Interest Credit - $184,939 7) Arnold R. Schaffer a) Taxable DBSERP Earned but not Paid - $750,268 b) Non-Taxable DBSERP Earned but not Paid - $33,694 c) Taxable DCSERP Earned but not Paid - $832,896 d) Non-Taxable DCSERP Earned - $630,732 e) DBSERP Interest Credit - $82,122 8) Claudia Haglund a) Taxable DBSERP Earned but not Paid - $1,339,590 b) Non-Taxable DBSERP Earned but not Paid - $195,498 c) Taxable DCSERP Earned but not Paid - $29,245 d) Non-Taxable DCSERP Earned - $37,706 e) ESP Interest Credit - $22,834 f) SOP Paid - $ 69,768 g) DBSERP Interest Credit - $141,491 9) John V. Fletcher a) Taxable DBSERP Earned but not Paid - $648,808 b) Non-Taxable DBSERP Earned but not Paid - $52,905 c) Taxable DCSERP Earned but not Paid - $290,961 d) Non-Taxable DCSERP Earned - $388,497 e) ESP Interest Credit - $46,196 f) SOP Paid - $104,155 g) DBSERP Interest Credit - $86,372 10) Michael Hunn a) Taxable DBSERP Earned but not Paid - $327,914 b) Taxable DCSERP Earned but not Paid - $370,385 c) Non-Taxable DCSERP Earned - $216,958 d) DBSERP Interest Credit - $20,014 11) Michael L. Butler a) Non-Taxable DCSERP Earned - $435,962 b) DBSERP Interest Credit - $95,665 12) Eugene "Al" Parrish a) Taxable DBSERP Earned but not Paid - $346,852 b) Non-Taxable DBSERP Earned but not Paid - $268,971 c) Non-Taxable DCSERP Earned - $56,382 d) DBSERP Interest Credit - $128,312 13) John O. Mudd a) Taxable DBSERP Earned but not Paid - $226,235 b) Non-Taxable DBSERP Earned but not Paid - $71,542 c) Taxable DCSERP Earned but not Paid - $125,304 d) Non-Taxable DCSERP Earned - $254,702 e) DBSERP Interest Credit - $53,501 14) Andrew Agwunobi, MD a) Non-Taxable DCSERP Earned - $158,816 b) DBSERP Interest Credit - $8,147 15) Myron Berdischewsky, MD a) Non-Taxable DCSERP Earned - $404,844 b) DBSERP Interest Credit - $12,137 16) Craig L. Wright, MD a) Non-Taxable DCSERP Earned - $199,302 b) DBSERP Interest Credit - $38,604 17) Bruce Lamoureux a) Taxable DBCBRP Earned - $518 b) Non-Taxable DCSERP Earned - $166,650 c) DBSERP Interest Credit - $22,275 18) Medrice Coluccio a) Non-Taxable DCSERP Earned - $344,898 b) DBSERP Interest Credit - $4,529 19) David T. Brooks a) Non-Taxable DCSERP Earned - $149,660 b) DBSERP Interest Credit - $21,641 20) Cindra R. Syverson a) Non-Taxable DCSERP Earned - $130,173 b) DBSERP Interest Credit - $14,305 21) Keith Marton, MD a) Taxable DBSERP Earned but not Paid - $501,372 b) Taxable DCSERP Earned but not Paid - $284,714 c) Non-Taxable DCSERP Earned - $114,423 d) DBSERP Interest Credit - $30,600 22) Russell Danielson a) Taxable DBSERP Paid - $ 108,402 b) ESP Paid - $57,407 23) Karl J. Carrier a) Taxable DBSERP Earned but not Paid - $1,439,533 b) Non-Taxable DBSERP Earned but not Paid - $37,214 c) DBSERP Interest Credit - $127,985 d) Taxable DCSERP Earned but not Paid - $8,200 e) Non-Taxable DCSERP Earned - $106,408 24) Kerry L. Carmody a) Taxable DBSERP Earned but not Paid - $1,488,241 b) Non-Taxable DBSERP Earned but not Paid - $48,658 c) DBSERP Interest Credit - $143,906 d) Non-Taxable DCSERP Earned - $112,149 25) Larry S. Bowe a) Taxable DBSERP Earned but not Paid - $927,429 b) Non-Taxable DBSERP Earned but not Paid - $119,792 c) DBSERP Interest Credit - $98,507 d) Taxable DCSERP Earned but not Paid - $128,857 e) Non-Taxable DCSERP Earned - $226,393 26) Nancy Carlson a) Taxable DBSERP Earned but not Paid - $533,995 b) Non-Taxable DBSERP Earned but not Paid - $25,682 c) DBSERP Interest Credit - $57,312 d) Taxable DBCBRP Earned but not Paid - $300 e) Non-Taxable DCSERP Earned - $85,111 27) Barry Wolfman a) DBSERP Interest Credit - $11,200 b) Non-Taxable DCSERP Earned - $138,142 28) Dale Surowitz a) DBSERP Interest Credit - $4,636 b) Non-Taxable DCSERP Earned - $118,217 Part I, Lines 4a-b SEVERANCE 1) Keith Marton, MD - $428,716 Supplemental Information Part III FORM 990, SCHEDULE J, PART II - EXECUTIVE PERFORMANCE AWARDS PROGRAM The Providence Executive Performance Awards Program provides a lump sum award annually as a percent of the executive's base pay. Percent opportunities are aligned with our total compensation philosophy as outlined in Part VI, Section B, Line 15 (Process for determining compensation of top management, officers & key employees). The performance award is based on the level of accomplishment of annual system objectives and personal objectives. In 2011, 50 percent of the participant awards were based on pre-determined organizational goals consistent with Providence's five strategic priorities of: mission driven, financially responsible, people centered, service oriented and quality focused. In 2011 the percent allocation for each of these strategic priorities was: Mission driven 10% Financially responsible 10% People centered 10% Service oriented 10% Quality focused 10%. To ensure affordability of the program, the organization (system, region or entity) must meet a threshold of 50 percent of budgeted net operating income CA Health Facilities Financing Authority 521643828 13033LLC9 2008-11-06 284698621 Refinance bank loan used for Acquisition of Providence Tarzana Medical Ctr. 1 0 0 CA Health Facilities Financing Authority 521643828 13033LBZ9 2009-07-29 145060500 Construction of Patient Tower @ Holy Cross Med. Ctr. 0 0 0 7900000 2070000 284698621 59 1644982 4582212 68711930 3011850 2008 1 0 1 1 145060500 30 2072500 127000577 13434940 2552423 2011 0 0 1 1 0 1 0 0 0.00010 0.00000 0.00010 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 0 0 0 0 0 0 X SCHEDULE K, PART III, LINE 2 PRIVATE BUSINESS USE Lease of Pediatric Services to Children's Hospital of Los Angeles. John F Koster MD Officer 169050781 Purchase of Supplies through cooperative of which Dr. Koster is a Director 0 Form 990, Part VI, Section A, line 6 The sole Member of the Corporation is Providence Health & Services. Form 990, Part VI, Section A, line 7a The powers of the Corporate Member include the provision to appoint the number of Directors, appoint the Board of Directors and to remove such Directors at any time with or without cause. Form 990, Part VI, Section A, line 7b The following powers are reserved exclusively to the Corporate Member: A) To adopt and amend the Articles of Incorporation and the Bylaws of the Foundation after consultation with the Foundation's Board of Directors. B) To approve the merger, consolidation, or affiliation of the Foundation with another corporation, organization or program, or the dissolution of the Foundation. C) To approve any strategic plan of the Foundation. D) To approve the annual fundraising plan including special events, annual, capital and planned giving activities. E) To approve the acceptance of any gift that carries conditions or limitations or any gift restricted to services, programs or facilities not currently offered or approved to be offered by the Corporate Member's Board of Directors. Form 990, Part VI, Section B, line 11 The Form 990 is prepared internally by experienced staff and reviewed by the internal Director of Taxes and external tax advisors. The Board of Directors reviewed the Form 990 prior to filing with the IRS. Form 990, Part VI, Section B, line 12c Providence Health & Services maintains a conflict of interest policy that applies to board members and management of all Providence-related organizations. The purpose of the policy is to guide and direct those serving the Providence Health & Services' corporations and other legal entities so they can (1) fulfill their fiduciary responsibilities and exercise stewardship in ways that promote and protect the best interests of Providence and, (2) avoid situations that create a conflict, or the appearance of a conflict, between the interests of an individual associated with Providence and Providence. On an annual basis, each board member and management level employee must complete and submit an updated conflict of interest statement. Conflict of interest disclosures are reviewed by the System Integrity Department working in conjunction with the Department of Legal Affairs. If it is determined that an actual conflict exists, appropriate follow-up action is taken with the individual to rectify the conflict. Form 990, Part VI, Section B, line 15 It is Providence's intention to make financial information accessible and transparent. Although the filing of Form 990 provides insight into how Providence achieves its Mission, delivers its programs and stewards its finances, deciphering the information directly from Form 990 can be challenging. The following paragraphs provide further information about the process we use to determine compensation for top management, officers and key employees. Providence has a single fiduciary Board, with responsibility for financial oversight associated with fulfillment of the Providence Mission, developing system policies, protecting the assets entrusted to the organization and overseeing the strategic and operational affairs of Providence's legal entities. Providence also maintains a network of community ministry boards with responsibility for quality of care oversight, community relations, advocacy and community needs assessments. Providence has a consistent compensation philosophy for all of its employees, including our senior executives. Salaries for senior executives are determined by the Providence Board's Human Resources Committee and approved by the full Board of Directors, none of whom is a Providence employee. The Board retains an independent consultant each year to review salaries of those in the most significant leadership roles in the organization. Part of the consultant's role is to review an extensive array of compensation surveys of large, not-for-profit health care systems in the United States. Providence is one of the larger health systems in the country, and as such, the Board benchmarks executive compensation against other large, not-for-profit health systems whose revenue is similar to that of Providence. Base salaries for Providence executives are set at the median level of the market, as identified by the independent consultant and reviewed with the Human Resources Committee. Each year, the Board Chair conducts a formal performance evaluation of the President/CEO that considers input from the other directors and senior leaders reporting to the President. The evaluation is discussed with the Human Resources Committee and then a recommendation is made by the committee to the full Board. The Board Chair and the Chair of the Human Resources Committee also meet with an independent consultant to develop a salary recommendation; which is reviewed and approved first by the committee and then by the Board of Directors. Additionally, the President/CEO utilizes the market information provided by the consultant along with formal performance evaluations, to determine salary recommendations for other senior executives. This process includes a rigorous analysis of those recommendations with the Human Resources Committee as a part of the review and approval process. Performance incentives allow executives to earn additional compensation if they achieve specific organizational and individual goals for furthering Providence operating principles - advancing the Providence Mission and core values, meeting benchmarks for charity care, achieving quality targets, delivering top-rated customer satisfaction, meeting employee satisfaction goals and reaching financial performance objectives. The Board of Directors conducts a thorough process to ensure performance incentives are aligned with appropriate practices for not-for-profit health care systems. The Board's process for executive compensation fully complies with IRS standards and mirrors the best practices recommended in the "Report to Congress and the Nonprofit Sector on Governance, Transparency, and Accountability" submitted to the Senate Finance Committee by the Panel on the Nonprofit Sector. Form 990, Part VI, Section C, line 19 Public disclosure of governing documents, conflict of interest policy and 990 filings are made available to the public upon written request. The consolidated Health System financial statements are available on our public Internet site www2.providence.org. All governing policies including the conflict of interest policy, as well as 990 filings are available to employees on the Intranet site. Contact Addresses for Officers, Directors, Etc Form 990, Part VII Karl J. Carrier - 501 S. Buena Vista St., Burbank, CA 91505. Kerry L. Carmody - 501 S. Buena Vista St., Burbank, CA 91505. Larry S. Bowe - 15031 Rinaldi St., Mission Hills, CA 91346. Michael Hunn - 501 S. Buena Vista St., Burbank, CA 91505. Nancy Carlson - 1300 West 7th Street, San Pedro, CA 90732. Barry Wolfman - 501 S. Buena Vista St., Burbank, CA 91505. Dale Surowitz - 18321 Clark Street, Tarzana, CA 91356. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized gains on investments: 1,002,920. FAS 136 -2,458,909. IAF Consolidated Equity Transfers 70,180,910. Effects of Auxiliary Income -165,432. Rounding 1. Effects of Auxiliary Expenses 13,371. Total to Form 990, Part XI, Line 5: 68,572,861. VOLUNTEERS FORM 990, PART I, LINE 6 Our volunteers provide valuable assistance to all of our ministries through a variety of services. Some specific examples include the following: BEYOND FIFTY VOLUNTEER In conjunction with the Beyond Fifty Program, volunteers may sign up to work on Beyond Fifty projects with the Beyond Fifty Program manager. These projects usually involve mailings and/or filing. CLERICAL VOLUNTEERS Clerical volunteers perform general office work such as filing, mailing, data entry, word processing, answering phones, making charts and copying forms. They work in most of the business and clinical offices throughout the hospital. CLINICAL VOLUNTEERS Clinical volunteers work on the nursing floors in 4 hour shifts. They help with trays and feeding, check on patients to be sure they are comfortable. They also put away clean linens, make beds, run errands for the nurses, keep the nurse's kitchen in order, take patients for wheelchair walks and discharge patients. EMERGENCY ROOM VOLUNTEERS These volunteers work a four hours shift once a week. Duties include making phone calls to recently discharged patients checking on their condition and asking a few brief questions regarding the care they received while a patient, helping at the registration desk, checking on each patient to see if they need anything, running errands for the staff, answering phones, discharging patients by wheel chair, making beds, etc. INFORMATION DESK They must be able to multi-task answer phones, direct patients and be willing to walk patients to their destinations. They must have excellent customer relation skills. MESSENGER CENTER Volunteers work a four hours shift answering the messenger phone, carrying lab samples, charts, x-rays, etc. and transporting ambulatory patients by wheel chair within the hospital. The messengers also work on mailing projects for various departments. This is an opportunity for those who like to walk and enjoy a variety of experiences as well as enjoying the constant contact with others. MUSIC PROGRAM Volunteers who sing or play a musical instrument schedule four hours per week to visit patients and sing or play for them. Harpists and guitar players are needed as well as other movable instruments which can be played individually. PATIENT VISITOR These volunteers visit the newly admitted patients to welcome them and provide a friendly ear for requests, complaints or just a brief visit. The volunteer must be outgoing and friendly, able to make easy conversation. PETS WITH A PURPOSE This program is in conjunction with Recreation Therapy. Pet volunteers visit patients with their dogs. The dogs are chosen for their friendly personalities and must pass behavioral tests and training to qualify. Visiting is done on a rotating schedule. All applications must be approved by Recreation Therapy Manager. SPIRITUAL CARE VOLUNTEERS Eucharistic Ministers visit the sick and bring Holy Communion to patients requesting the service. This is done on a rotating basis as the volunteer is available. Other volunteers work on projects such as little gifts and handouts for patients. SURGERY WAITING ROOM DESK Another customer service job places the volunteer in the Surgery Waiting room. He/she must keep track of all patients' family members and other visitors and dispense information regarding the patient in surgery. Duties include keeping the room neat, monitoring the television, making and service coffee and tea and cleaning up at the end of the shift. The volunteer must also maintain a pleasant, helpful attitude at all times. Volunteers with Providence High School assist in the following capacities: Clerical work Chaperoning field trips Staffing athletic snack shop Aiding teachers in the classroom or on extracurricular activities RELIGIOUS COMMUNITY MEMBERS FORM 990, PART VII As members of the Religious Community, each Sister has taken a vow of poverty as a compulsory part of her religious life. Any compensation for services of a Sister inures only for the benefit of the Community, not the individual members. All payments for services are made directly to the Religious Community. HOURS WORKED FORM 990, PART VII, SECTION A Hours shown reflect the hours worked for the entire Health System and have not been allocated to the individual reporting entity. Providence Health & Services - Washington 1801 Lind Avenue SW 9016 Renton WA 980579016 510216586 Healthcare System WA 501( c)(3) Line 3 Providence Health & Services 0 Providence Health & Services - Oregon 1801 Lind Avenue SW 9016 Renton WA 980579016 510216587 Healthcare System OR 501( c)(3) Line 3 Providence Health & Services 0 Everett Transitional Care Services PO Box 1067 Everett WA 982061067 943264605 Transitional Care WA 501( c)(3) Line 9 N/A 0 Providence Oregon Management Corporation 1801 Lind Avenue SW 9016 Renton WA 980579016 930813977 Shell Corporation OR 501( c)(3) Line 1 PH & S - Oregon 0 Providence Plan Partners 3601 SW Murray Blvd 10 Beaverton OR 97005 911861964 Healthcare Services OR 501( c)(4) N/A PH & S - Oregon 0 Providence Health Plan 3601 SW Murray Blvd 10 Beaverton OR 97005 930863097 Health Service Contractor OR 501( c)(4) N/A Providence Plan Partners 0 Providence Health Assurance 3601 SW Murray Blvd 10 Beaverton OR 97005 550828701 Medicaid Healthcare Provider OR 501( c)(4) N/A Providence Health Plan 0 Providence Medical Institute 4101 Torrance Blvd Torrance CA 90503 330283773 Healthcare CA 501( c)(3) Line 11/Type I PHS - So California 0 Little Company of Mary Ancillary Services Corporation 4101 Torrance Blvd Torrance CA 90503 330844408 Imaging Services CA 501( c)(3) Line 9 PHS - So California 0 Providence TrinityCare Hospice 2601 Airport Drive 230 Torrance CA 90505 953264139 Hospice CA 501( c)(3) Line 9 PHS - So California 0 Providence Blanchet Association 1700 Providence Pl Centralia WA 98531 911789266 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 St Luke Association 350 Washington Ave SE Chehalis WA 98352 943176618 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Rossi Association 1700 Providence Pl Centralia WA 98531 311584166 Housing WA 501( c)(3) Line 9 PH & S - Washington 0 Lundberg Association 5921 E Burnside Portland OR 97215 911562797 Housing OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence St Francis Association 3415 12th Avenue NE Olympia WA 98506 943244854 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Peter Claver Association 7101 38th Avenue South Seattle WA 98118 311629656 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence St Elizabeth House Association 3201 SW Graham St Seattle WA 98126 912171539 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Gamelin House Association 4515 MLK Jr Way S Ste 200 Seattle WA 98108 311744654 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 The Gamelin Association 312 North Fourth St Yakima WA 98901 911180824 Housing WA 501( c)(3) Line 1 PH & S - Washington 0 The Gamelin Oregon Association 5520 NE Glisan Portland OR 97213 911214491 Housing OR 501( c)(3) Line 9 PH & S - Oregon 0 The Gamelin California Association 540 23rd St Oakland CA 94612 911293869 Housing CA 501( c)(3) Line 9 PHS - So California 0 Gamelin Washington Association 1423 First Avenue Seattle WA 98101 201910170 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Foundation 1801 Lind Avenue SW 9016 Renton WA 980579016 943078543 Support PH&S Institutions WA 501( c)(3) Line 11/Type I PH & S - Washington 0 Providence Alaska Foundation 3300 Providence Drive - B Tower2 Anchorage AK 99508 920093565 Support PHS-Alaska AK 501( c)(3) Line 11/Type I PH & S - Washington 0 Providence St Peter Foundation 413 Lilly Road NE Olympia WA 985065166 911097056 Support Affiliated Tax-Exempt Organization WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Health Care Foundation (Centralia) 914 S Scheuber Road Centralia WA 98531 911433382 Support Providence Centralia Hospital WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Mount St Vincent Foundation 4831 - 35th Avenue SW Seattle WA 981262799 911188119 Support Providence Mount St.Vincent WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Marianwood Foundation 3725 Providence Point Drive SE Issaquah WA 980297219 931554288 Support Providence Marianwood WA 501( c)(3) Line 11/Type I PH & S - Washington 0 Providence Newberg Health Foundation 1001 Providence Drive Newberg OR 97132 930889144 Support Providence Newberg Medical Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Seaside Hospital Foundation 725 S Wahanna Rd Seaside OR 97138 930927320 Support Providence Seaside Hospital OR 501( c)(3) Line 7 PH & S - 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Montana MT 501( c)(3) Line 7 PH & S - Washington 0 University of Great Falls 1301 20th Street South Great Falls MT 59405 810231777 Post Secondary Education MT 501( c)(3) Line 2 PH & S - Washington 0 E WA & MT Unemployment Compensation Insurance Trust 1801 Lind Avenue SW 9016 Renton WA 980579016 911082119 Unemployment Benefits WA 501( c)(3) Line 11/Type I PH & S - Washington 0 Providence Willamette Falls Medical Foundation 1500 Division Street Oregon City OR 97045 931003750 Support Willamette Falls Hospital OR 501( c)(3) Line 11/Type I PH & S - Oregon 0 Willamette Falls Hospital dba Providence Willamette Falls Medical Center 1500 Division Street Oregon City OR 97045 930426018 Healthcare OR 501(c )(3) Line 3 PH & S - Oregon 0 Providence Hood River Memorial Hospital Foundation Inc 811 13th St Hood River OR 97031 930921990 Support Providence Hood River Memorial Hospital OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Hospice and Home Care Foundation 2731 Wetmore Avenue Suite 500 Everett WA 98201 272552749 Support Program & Activities of PHHC WA 501(c )(3) Line 7 PH & S - 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