2012-03-01T19:14:08-07:00 2011-06-30 990 2010-07-01 920077523 CENTRAL PENINSULA GENERAL HOSPITAL INC CENT 9077144404 250 Hospital Place Soldotna AK 99669 Loren Weimer 9077144404 2012-03-01 2010 2016-02-24 21:20:13Z Central Peninsula Hospital Richard Davis 250 Hospital Place Soldotna AK 99669 163036521 0 X www.cpgh.org X 1994 AK We are a community initiated and community nurtured organization dedicated to promoting wellness and providing high quality health care that ensures the confidence and loyalty of our patients. We strive to improve individual and community health and achieve national standards of excellence. 11 9 826 234 34703 40110 1086302 1164424 139479810 160821053 349551 280501 2458737 671090 143374400 162937068 122672 139192 0 0 52650261 59648477 0 0 109110 87918395 97675498 140691328 157463167 2683072 5473901 121468958 121920884 51977585 46955610 69491373 74965274 We are a community initiated and community nurtured organization dedicated to promoting wellness and providing high quality health care that ensures the confidence and loyalty of our patients. We strive to improve individual and community health and achieve national standards of excellence. 0 0 138842498 140718083 Our 49 bed hospital provided patient and ancillary services for 2,253 inpatients and 76,474 outpatients during the 2010 tax year. The hospital provides emergency medical services regardless of ability to pay. Emergency medical services were provided to 16134 individuals, while 1,471 were admitted to the hospital. The surgery department performed over 3,400 surgical cases. The imaging department performed 35,981 procedures. Over 41,000 physical therapy procedures were performed. Over $6 million in gross charges were written off for patients that received charity care. 9763261 10067520 Skilled nursing and longterm care services were provided by our 60 bed skilled nursing facility, Heritage Place. Heritage Place provides healing and compassionate residential care in a home like setting. Total admissions for the 2010 tax year were 62 while total resident days of care were 19,536. An average of 54 residents per day were provided longterm care and nursing. Ancillary services for residents included 7,813 physical therapy treatments. 6170179 8802233 Family and specialty physician clinics were added to the array of healthcare services provided by the Hospital during tax year 2009. A community healthcare need existed for general and specialty physicians that provide medical services to patients who are financially indigent. During the tax year 2010, the hospital added one family practice physician and one surgeon. A total of 24,378 patients were provided care at the various medical clinics during the year. 0 0 0 154775938 1 1 0 1 0 0 1 0 0 0 1 0 0 1 0 0 1 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 1 0 0 0 0 1 128 0 1 826 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 0 0 1 1 1 1 0 1 1 1 1 1 1 1 1 0 X X Central Peninsula Hospital Finance Department 9077144525 250 Hospital Place Soldotna AK 99669 John Bramante 4 X 4050 0 0 Thomas Boedeker 17 X 15100 0 0 Henry Krull 4 X 0 0 0 Michael Navarre 6.00 X 0 0 0 John Hoyt 9.00 X 5500 0 0 Silverio Mattero 4 X 3350 0 0 Russell Peterson 7.00 X 0 0 0 Richard Ross 8.00 X 4900 0 0 Judith Salo 7.00 X 6200 0 0 Alyson Stogsdill 7.00 X 6100 0 0 Trena Richardson 8.5 X 5350 0 0 John Torgerson 1.85 X 4700 0 0 Loren Wiemer 15.0 X 6700 0 0 Ryan K Smith 40 X 466558 0 38781 Jason D Paret 40 X 199041 0 36564 Andrea D Posey 40 X 176140 0 36191 Johnny L Dodd 40 X 106694 0 11707 Matthew Dammeyer 40 X 185646 0 36275 Peter Brennan 40 X 93829 0 31195 Gregg Motonaga 40.00 X 594435 0 37247 Charles C Mickelson 33 X 489552 0 32619 David S Innes 40 X 789489 0 14130 Angus Warren 35 X 448479 0 14252 Cynthia Kahn 40 X 463025 0 4636 4074838 0 293597 63 0 1 0 McDermott Will & Emery LLP PO Box 6043 Chicago IL 606806043 Attorney Services 276087 Molloy Schmidt LLC 110 South Willow St Suite 101 Kenai AK 99611 Attorney Services 428330 Sound Physicians 1123 Pacific Avenue Tacoma WA 98402 Physician Services 380761 Staff Care Inc PO Box 281923 Atlanta GA 303841923 Medical Services 151296 Juniper Advisory LLC 2727 Allen Parkway Suite 1350 Houston TX 77019 Managment Consulting Services 173544 8 0 0 0 211947 932477 20000 792 1164424 Hospital Service Revenue 622000 140718083 140718083 0 0 Nursing Home Revenue 623000 10067520 10067520 0 0 Physician Clinic Revenue 621110 8802233 8802233 0 0 1233217 1233217 0 0 160821053 277766 0 0 277766 51 0 0 51 0 0 0 0 76733 0 42030 0 34703 0 34703 0 34703 0 0 2684 0 0 0 2684 2684 2684 0 0 0 209370 57423 151947 151947 0 0 Property tax revenue 900099 127125 127125 0 0 USAC telephone service revenue 900099 357315 357315 0 0 0 0 0 0 484440 162937068 161460124 34703 277817 139192 139192 5401937 3563022 1729805 109110 38081788 38081788 1285966 1285966 11996737 11996737 2882049 2882049 783347 783347 54128 54128 10839 10839 2456470 2456470 212806 212806 12618240 12618240 2466060 2466060 2076827 2076827 369895 369895 340703 340703 1696960 1696960 8036307 8036307 879612 879612 Medicare Patient Deductions 25560536 25560536 0 0 Medicaid Patient Deductions 13916915 13916915 0 0 Charity Care Patient Deductions 6114450 6114450 0 0 Commercial, Government, other Patient Deductions 9147431 9147431 0 0 Bad Debt Expense 6331500 6331500 0 0 4602472 4602472 157463167 154775938 2578119 109110 0 0 23245962 21281704 114102 200722 14831114 15114899 0 0 0 0 0 0 2699469 3133692 486090 715429 112805991 44970418 68357506 67835573 0 0 501471 500000 0 0 0 0 11233244 13138865 121468958 121920884 11982197 8708436 0 0 12642 12136 39982746 38235038 0 51977585 46955610 X 68991373 74465274 500000 500000 0 0 69491373 74965274 121468958 121920884 5473901 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 963 0 1 9876 10839 0 SchC_P2B_S00_L01 Schedule C, Part II-B, Line 1 The Hospital engages in very little lobbying on an ongoing basis. However, educational discussions with lawmakers and general support of healthcare legistlation do occur on occasion. Lobbying expenses for tax year 2010 consisted of one trip to the state capital to meet with legislators ($963) and the % of dues paid to the American Hospital Association and the Alaska State Hospital and Nursing Home Association which were reportedly used for lobbying expenses ($9,876). X X 1 40 0 0 0 1 0 0 0 0 1786117 0 1786117 70413745 0 29783738 40630007 657495 0 177378 480117 38008556 0 14510109 23498447 1940078 0 499193 1440885 67835573 Plant Replacement Funds 10097241 Long Term Investments 3034960 Proceeds from 2004 Bond 6664 13138865 162937068 157463167 5473901 0 0 0 0 85480 85480 5559381 102084334 0 0 0 218097 218097 101866237 0 61070831 61070831 162937068 96524953 0 0 0 132617 132617 96392336 0 61070831 61070831 157463167 SchD_P02_S00_L09 Schedule D, Part II, Line 9 In 2008 the Hospital purchased a building which resides on 40 acres of land subject to a 'perpetual covenant' for the benefit of all Alaska residents, restricting the use of the land to agricultural purposes as defined in Alaska Statute 38.05.321. The building is used by the Hospital's chemical dependency department. There is no value placed on the easement itself and therefore it does not appear on the hospital financial statements or footnotes to those statements. However, the cost of the land and the building is recorded on the Hospital's balance sheet at their net book value. SchD_P11_S00_L08 Schedule D, Part XI, Line 8 The Hospital's audited financial statements are consolidated with Central Peninsula Health Foundation, a related organization. This adjustment is the net income for the tax year 2010 of the Foundation. It must be added to the Change in Net Assets in order to balance to the attached audited financials. The Foundation is a separate legal entity however and files its own 990. SchD_P12_S00_L02d Schedule D, Part XII, Line 2d Revenues included on line 1, and on the audited financial statements but not on line 12 of 990 Part VIII are $118,644 in revenue of Central Peninsula Health Foundation (a related organization which files its own 990), $42,030 in rental expenses, and $57,423 in Cost of inventory sold. SchD_P12_S00_L04b Schedule D, Part XII, Line 4b Amounts reported on the line 1, and the Audited Financial Statements are reported 'net' of certain allowances and deductions from revenue. 990 Part VIII, line 12 revenue is reported 'gross' of allowances and deductions of $61,070,831. Deductions include writeoffs for third party payors such as Medicare and Medicaid, Bad debt expenses, and Charity care writeoffs. SchD_P13_S00_L02d Schedule D, Part XIII, Line 2d Amounts reported on line 1 which are not included in Part IX, line 25 include $33,164 in expenses of Central Peninsula Health Foundation (a related organization which files its own 990), $42,030 in rent expenses reported in Part VIII, and $57,423 in Cost of Inventory reported in Part VIII. SchD_P13_S00_L04b Schedule D, Part XIII, Line 4b Amounts not reported on line 1, which are reported in Part IX line 25 include certain allowances and deductions from revenue for third party payors, charity care write-offs, and bad debt write-offs. 1 1 X 1 X 1 X 1 1 1 0 0 1 7705 3473979 0 3473979 0.0361 1 20392 18463737 17113562 1350175 0.014 1 263 44913 22698 22215 0.0002 3 28360 21982629 17136260 4846369 0.0503 403 19019 518559 100496 418063 0.0043 117 643 60222 25810 34412 0.0004 9 13998 2461874 770693 1691180 0.0176 0 0 0 0 0 0 549 2539 159192 0 159192 0.0017 1078 36199 3199847 896999 2302847 0.0240 1081 64559 25182476 18033259 7149216 0.0743 20 0 5124 0 5124 0.0001 20 0 5124 0 5124 0.0001 0 3645785 2661423 23304868 24184106 -879238 X 1 1 1 1 Central Peninsula Hospital

250 Hospital Place Soldotna AK 99669

X X X Central Peninsula Hospital 1 1 X X X X X X X X X 09 1 0 1 X X X X X X X 0 1 1 200 1 400 1 X X X X X X 1 1 X X X 1 X 1 X X X X 1 X 0 0 15 Heritage Place

232 Rockwell Ave Soldotna AK 99669

Skilled nursing facility, long term care Serenity House

47480 Kristina Way Soldotna AK 99669

Chemical dependency treatment center Central Peninsula Pain Management

289 N Fireweed Unit B Soldotna AK 99669

Pain Management clinic. Central Peninsula Neurology

198 West Corral Soldotna AK 99669

Neurology clinic Central Peninsula Family Practice Kenai

506 Lake Street Kenai AK 99611

Family practice clinic Kenai Physical Medicine

130 Willow Street Unit 1 Kenai AK 99611

Physical therapy clinic Soldotna Physical Medicine

35551 Kenai Spur Hwy Soldotna AK 99669

Physical Therapy clinic Kenai Health Center

630 Barnacle Way Kenai AK 99611

Diagnostic Imaging, lab, and DV services Central Peninsula Family Practice Kobuk

431 S Kobuk Suite B Soldotna AK 99669

Family practice clinic Central Peninsula Surgical Services

245 N Binkley Street Suite 101 Soldotna AK 99669

Surgical clinic Central Peninsula Pediatrics

289 N Fireweed Unit C Soldotna AK 99669

Pediatric clinic Central Peninsula Family Practice Fireweed

289 N Fireweed Unit D Soldotna AK 99669

Family practice clinic Serenity House Intake Office

245 N Binkley St Suite 203 Soldotna AK 99669

Chemical dependency intake, behavioral health Peninsula Medical Center

265 N Binkley St Soldotna AK 99669

Owned medical office building Central Peninsula Medical Center

245 N Binkley St Soldotna AK 99669

Owned Medical office building Central Peninsula Hospital Residential building

158 W Corral Soldotna AK 99669

Vacant building for remodel Central Peninsula Hospital Residential Building

166 W Corral Soldotna AK 99669

Vacant building for remodel SchH_P01_S00_L07 Schedule H, Part I, Line 7 In activities where costs were reasonably able to be compiled, we used actual costs. For activities such as charity, and cost to provide patient care, we used the Cost to Charge ratio as calculated by actual Medicare cost report figures. SchH_P01_S00_L072f Schedule H, Part I, Line 7, Column f Total bad debt (at gross charges) reported was $6,331,500. However using a cost to charge ratio of 57.58% we reduced bad debt to $3,645,785 to report the amount of 'cost' to the organization for unpaid accounts. Of this balance, approximately 72% is estimated to be attributable to patients who may be eligible to receive free or discounted care under the organizations charity care policy. SchH_P02_S00_L00 Schedule H, Part II Community building activities consisted of staff involvement in Local Emergency Planning Committee meetings, communications with the Borough medical reserve corps, Mass casualty blood availability meetings, and Emergency disaster planning. Each of these events help to build the medical infrastructure of our community and properly prepare for an emergency. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 Footnote Text: Bad debt provisions are made for the amount of revenue that will not be collected from patients to whom services were billed but not paid. The Hospital has determined these patients are neither medically nor financially indigent and do not qualify for the Hospital's charity care program. Bad debt provisions are determined by management's assessment with consideration of business and economic conditions, changes and trends in healthcare coverage, and other collection indicators. The adequacy of this provision is periodically reviewed and further modified based upon the accounts receivable payor composition and aging, and historical write-off experience by payor category. The amount reported on Line 1 is based on total gross charges written off to bad debt $6,331,500 x cost to charge ratio of 57.5% to arrive at Cost of services written off to bad debt. The amount reported on Line 2 is based on an estimated 72% of bad debts which may be attributable to patients that qualify for a discount or free care under our financial assistance policy. Because Bad Debts are primarily related to uninsured and underinsured patients to which services are provided despite the ability to pay, we believe that bad debts are also considered a community benefit. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 The cost to charge ratio has been calculated based on current charges and costs reported on our 2011 Draft Medicare Cost Report. The ratio is slightly lower than that reported due to the removal of community benefit expenses from the total 'costs' (for the purposes of the 990 Schedule H). It is the position of management that virtually all of the shortfall of medicare costs vs reimbursement are considered community benefit. The reason for this stance is that the Hospital is required to write off contractual allowances for medicare patients regardless of the shortfall created to provide services. The hospital may only collect the portion which is patient co-pay or deductible and may not engage in collection efforts for the remainder. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b The hospital's collection policy PFS-546 addresses the various classes of private pay patients and defines the individuals which may request financial assistance based on either financial or medical indigence. The collection policy refers the collector first to the Charity care policy for instruction on determining eligiblity. As noted in Part I, the charity care policy is based on FPG which is the basis for a sliding scale between 200% and 400% of those guidelines. Applicants on the upper end of the scale (400%) are eligible for partial write-off, while those on the lower end (200%) are eligible for free care. SchH_P05_S0B_L05 Schedule H, Part V, Section B, Line 5 In addition to the above methods of disbursement, the Health Needs Assessment was also provided via email to Administrators, Hospital board members, and supervisory staff of Central Peninsula Hospital. SchH_P05_S0B_L06 Schedule H, Part V, Section B, Line 6 Hospital Adminitrators and key personnel have not only prioritized the key findings of the health needs assessment, but are already working on meeting those needs. These management decisions have not been formally adopted by the board, however, programs are already in place which meet more than half of the findings. The remainder have long term solutions which must be developed. SchH_P05_S0B_L07 Schedule H, Part V, Section B, Line 7 The health findings which require long term planning are as follows: 1. Smoking rates among Central Kenai Peninsula residents remains elevated. 2. Cancer risks on the Central Kenai Peninsula are elevated. 3. Barriers to oral health care exist due to cost for a large number of residents. These items require additional efforts to devise a strategy and implement solutions. Management is beginning to address item 2 by recruiting an Oncologist or Oncology group to provide services on the Kenai Peninsula from a Cancer Center which would be built on the hospital campus. SchH_P05_S0B_L13 Schedule H, Part V, Section B, Line 13 The Hospital employs 2 full time Financial Counselors that meet personally with patients to review bills, set payment arrangements, explain the financial assistance policy, and assist patients with the application process for receiving free or discounted care. SchH_P05_S0B_L17 Schedule H, Part V, Section B, Line 17 Our Financial Counselors attempt to contact all patients with suspected financial need to communicate the various options for payment arrangements or charity assistance prior to sending an account to collections. SchH_P05_S0B_L19 Schedule H, Part V, Section B, Line 19 The Hospital offers all self pay patients a prompt pay discount of 25% on hospital charges. This discount is greater than commercial payer discounts. Additionally, those patients which are uninsured, underinsured, or medically indigent may qualify for either free or discounted care. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 In addition to the Health Needs Assessment report, the Hospital also determines health needs of the community through a variety of ways. A Patient Advisory committee comprised of area residents and hospital representavies assists in determining the adequacy of facilities and services to meet the health needs of the community. The Hospital periodically employs consultants to determine the physician and specialty physician needs of the community to direct physician recruiting and strategic planning. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 The Hospital attempts to provide a Financial Assistance Program Brochure to every patient during discharge. The brochure is also available on our website under Patient Financial Services. Additionally, the hospital has two full time Financial counselors who personally contact patients and explain the financial assistance policy, assist with the completion of the application, and set up payment plans if necessary. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 The area served by Central Peninsula Hospital is comprised of 13 Census Designated Places or towns, and has a total population of nearly 35,000 residents according to the 2008 census estimates. The Geographic region is in the Central Kenai Peninsula of the State of Alaska. Based on the 2000 Census , approximately 7 percent of the population is age 65 or older, 25 percent are between 45 and 64, while 37 percent are between age 18 and 44. Basic social and economic characteristics of the region indicate high unemployement and uninsured rates, nearly 3 percent higher than the US average and 2 percent higher than the State average. SchH_P06_S00_L05 Schedule H, Part VI, Line 5 The Hospital engages in numerous community efforts to improve the health of the region served. Monetary and personnel support of local non-profits, public service announcements, healthy choice advertising campaigns, child safety programs, low cost health fairs, physician speakers bureau, community health newsletters, and many other programs. 1 Kenai Watershed Forum PO BOX 2937 Soldotna AK 99669 911829284 501 c 3 7500 $5,000 Capital campaign donation $2,500 Run for the River sponsorship donation. Cash contributions support the mission of the Forum, to provide for healthy watersheds on the Kenai Peninsula. Kenai Peninsula United Way 11355 Frontage Road Benco Building Suite 101 Kenai AK 99611 920111698 501 c 3 10500 $10,000 2010/2011 Match for Employee giving campaign $500 program donation. The United Way on the Kenai peninsula provides support to financial indigent area residents as well as support to other local non-profits. Kenai Peninsula Youth Foundation Kenai River Brown Bears PO Box 2605 Soldotna AK 99669 262580744 501 c 3 7500 2010/11 Season Sponsorship -- Peninsula Youth Foundation The Kenai Peninsula Youth Foundation is an organization dedicated to providing developmental programs for aspiring student athletes. This cash contribution was made to the foundation owned Kenai River Brown Bears to support a Breast Cancer Awareness sporting event. All proceeds from the event were donated to the Breast Cancer fund of Central Peninsula Health Foundation, a related organization. Boys and Girls club of the Kenai Peninsula 705 Frontage Road Suite B Kenai AK 99611 943067142 501 c 3 13800 $2,500 Annual 2010 auction sponsorship $500 Adult basketball season sponsorship $300 Are you Smarter than our kids sponsorship $500 Kids soccer sponsorship $10,000 Golf classic sponsorship 2011. Cash contributions are used to support the provision of safe after-school programs and healthy activities and events for Peninsula children. Kenai River Sportfishing Association 224 Kenai Ave Suite 102 Soldotna AK 99669 920142688 501 c 3 11500 $10,000 Kenai River Women's Classic 2010 sponsorship $1,500 Annual Fundraiser sponsorship. Cash contributions to KRSA fundraisers help to ensure the sustainability of the Kenai River through programs focused on habitat, fishing management, research and education. Kenai River Professional Guide Association PO box 3674 Soldotna AK 99669 920162358 501 c 3 10000 Wounded warrior program sponsor 2010 Kenai Peninsula Food Bank Inc 33955 Community College Drive Soldotna AK 99669 943112445 501 c 3 26000 $25,000 Building fund donation $1,000 Soup Supper sponsorship Southcentral Foundation 4501 Diplomacy Drive Anchorage AK 99508 920086076 501 c 3 5500 All Alaska Pediatric Partnership sponsor Soldotna Chamber of Commerce 44790 Sterling Highway Soldotna AK 99669 920061612 501 c 6 5400 $400 Alaska chamber awards banquet $5,000 Community partner sponsorship. Cash contributions to the Chamber of commerce help support scholarships for local teens, foster community partnerships, and support the Toys for tots program. Friends of Kenai Community Library PO Box 656 Kenai AK 99611 920133770 501 c 3 10000 Support for construction of new Kenai Community library. 9 1 SchI_P01_S00_L02 Schedule I, Part I, Line 2 The hospital does not provide 'grants' but cash contributions to local organizations which support community initiatives and healthy living on the Kenai Peninsula. The Hospital provides funding to organizations of good community standing. Hospital officers are responsible for approving all assistance payments to organizations, and do so with discretion. X X 0 1 X X X X X 0 1 0 1 0 1 0 0 0 Gregg Motonaga 543177 0 52310 0 1004 0 21983 0 20556 0 639030 0 0 Charles C Mickelson 491615 0 30 0 944 0 5283 0 30374 0 528246 0 0 David S Innes 547815 0 210267 0 32977 0 0 0 15700 0 806759 0 0 0 Angus Warren 448927 0 30 0 519 0 5283 0 9966 0 464725 0 0 0 Ryan K Smith 257764 0 161319 0 50512 0 14575 0 30374 0 514544 0 0 0 Jason D Paret 153497 0 28634 0 19948 0 9228 0 30374 0 241681 0 0 0 Andrea D Posey 134778 0 26313 0 18086 0 8855 0 30374 0 218406 0 0 0 Johnny L Dodd 84081 0 20223 0 3453 0 2144 0 10625 0 120526 0 0 0 Cynthia Kahn 429335 0 30 0 34175 0 0 0 5151 0 468691 0 0 0 Matthew Dammeyer 139774 0 26931 0 21978 0 8939 0 30374 0 227996 0 0 0 SchJ_P01_S00_L01a Schedule J, Part I, Line 1a Gross up payments are made for certain fringe benefits and for the value of life insurance over $50,000. A year end wage adjustment is made for all affected employees to include the gross up for fringe benefits and excess life insurance benefits. The Hospital has historically paid all social security and medicare taxes on such benefits. The employee is responsible for federal income taxes. Among the fringe benefits offered to the employees are health club discounts. The hospital pays for one-half of gym membership fees. SchJ_P01_S00_L01b Schedule J, Part I, Line 1b The year end gross up adjustment for fringe benefits and life insurance over $50,000 is based on historical practice of the hospital and is not governed by a hospital policy. The hospital maintains that at some future date, employees may be required to pay their own FICA taxes on fringe benefits. Similarly, payment of one-half of health club memberships is also not a written policy. Although the hospital currently extends this benefit to its employees, it may not always choose to do so. SchJ_P01_S00_L03 Schedule J, Part I, Line 3 The hospital contracts with an independent consultant to perform a review of CEO wages and benefits using comparable data. The resulting report is provided to the Board of Directors for review. The Board then sets the compensation for the CEO. The CEO has a written employment contract with the organization. SchJ_P01_S00_L04 Schedule J, Part I, Line 4 The hospital provides a 457 Top Hat plan to certain key employees and management. The following individuals on Schedule J participated in the 457 plan and either deferred their own compensation or received hospital contribution into the plan during the tax year: Gregg Motonaga $15,865, Ryan Smith $8,970, Jason Paret $3,993, Andrea Posey $3,500, Johnny Dodd $2,606, Matthew Dammeyer $3,582, and Peter Brennan $1,680. SchJ_P01_S00_L05 Schedule J, Part I, Line 5 In accordance with their employment contract, Emergency Room Physicians receive a percentage of their physician fees billed. However, physician compensation is not based on the entity's overall performance of revenues. SchJ_P01_S00_L06 Schedule J, Part I, Line 6 The Hospital pays an annual incentive plan bonus to all employees, supervisors, and officers based on a series of 4 operational quality measures. One of these 4 measures is based on the hospital meeting its net earnings budget. This element comprises only one-fourth of the potential incentive plan bonus payment. The remaining measures are 1) patient satisfaction 2) quality measures, and 3) utilization. Kenai Peninsula Borough 920030894 488530NF9 2003-12-18 47985000 Hospital expansion project 0 0 0 0 0 53952406 518266 0 0 544896 0 53587225 0 6664 2008 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 John Bramante Dr. Bramante is employed by Peninsula Internal Medicine and on the active medical staff of Hospital 85976 Payments from Hospital to Peninsula Internal Medicine 0 Charles Weimer Mr. Weimer is the husband of CPGH Board President Loren Weimer 10000 Fair market value for rental of residential real estate to house LifeMed crew 0 F990_P06_S0A_L07b Form 990, Part VI, Section A, Line 7b Central Peninsula General Hospital Inc manages the hospital through a Lease and Operating Agreement with the Kenai Peninsula Borough. CPGH Inc Board's decisions regarding the purchase of significant capital assets and plant expansion are subject to approval by the Borough Assembly. Bonds, loans, and capital expenditures not funded through the Hospital's plant replacement funds must be approved by a vote of Borough constituents if greater than $1.0 million. F990_P06_S0A_L09 Form 990, Part VI, Section A, Line 9 Jason Paret: 651229A Opelo Rd Kamuela, HI 96743 F990_P06_S0B_L11a Form 990, Part VI, Section B, Line 11a The 990 is prepared by the Finance Department and submitted to management for review. Management submits edits to the Finance Dept. The 2nd Draft and all schedules and statements are then submitted to each Board Member for review and comment. Final edits are made to the 990 prior to electronic submission by the CFO or Board President. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c After completion of the conflict of interest questionnaire, the board reviews and discusses any conflicts which may arise and appropriate action which should be taken. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 An independent professional Executive remuneration study was performed for 2011 by the HayGroup, project manager Ronald Keimach. Remuneration reports are submitted to the Board for review and used to set wage scales for the CEO, CFO, CNO, and COO. Contemporaneous documentation exists for this study. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 The Hospital publishes its 3 most recent 990s on its website at www.cpgh.org. The 990 is also available at Guidestar.com. The Hospital provides its governing documents, conflict of interest policy, and audited financial statements, in electronic format upon request. Central Peninsula Health Foundation 250 Hospital Place Soldotna AK 99669 202778670 To support quality healthcare activities AK 501(c)3 Public Charity N/A 0 Kenai Peninsula Borough 144 N Binkley Street Soldotna AK 99669 920030894 Local Government which owns the hospital assets. AK 115 N/A 0 0 0 1 0 0 0 0 0 0 1 0 1 1 1 1 1 1 0 Central Peninsula Health Foundation c 211947 Actual cash value of contributions or payments received from Central Peninsula Health Foundation. Kenai Peninsula Borough j 1 Central Peninsula General Hospital Inc operates the Hospital through a lease and operating agreement with the Kenai Peninsula Borough. Ultimately, the Borough owns the hospital facility and all related assets under the agreement and leases them to CPGH Inc to operate on its behalf. The amount stated in that lease and operating agreement is $1 per annum. Central Peninsula Health Foundation m 15331 Central Peninsula Hospital provides office space to Central Peninsula Health Foundation. The value of that space is determined based on our most recently filed Medicare Cost Report (2010) facility, administrative, and support service values allocated per square foot. Central Peninsula Health Foundation n 93206 Actual cost of wages, payroll taxes, pension contribution, and health insurance for shared employees. Central Peninsula Health Foundation p 61498 Actual dollar value of services and operating expenses purchased by the Hospital and reimbursed by the Foundation. Kenai Peninsula Borough q 5723773 Per the Lease and Operating agreement all cash on hand >90 days must be transferred to an account held by the Kenai Peninsula Borough. This is the total amount of cash transferred to that account during FY11. N/A - Form 8868 Request for Extension was timely filed and accepted by the IRS.