2012-05-15T13:41:03-04:00 2011-06-30 PricewaterhouseCoopers LLP 2001 MARKET ST SUITE 1700 PHILADELPHIA PA 19103 990 2010-07-01 582026750 DOUGLAS HOSPITAL INC DOUG 7707925023 805 Sandy Plains Road Marietta GA 300666340 JIMMY SWARTZ 2012-05-15 true 2673303000 2010 2016-02-24 21:20:13Z A JAMES BUDZINSKI 805 Sandy Plains Road Marietta GA 300666340 95592032 false X www.wellstar.org X 1992 GA To provide world class charitable healthcare to the community 18 14 776 100 0 0 0 0 117086651 94854673 3090172 0 1037909 737359 121214732 95592032 0 0 0 0 40571998 43038270 0 0 0 71803866 43492307 112375864 86530577 8838868 9061455 56518043 58798093 40741478 45809603 15776565 12988490 TO CREATE AND DELIVER HIGH QUALITY HOSPITAL, PHYSICIAN AND OTHER HEALTHCARE RELATED SERVICES THAT IMPROVE THE HEALTH AND WELL-BEING OF THE INDIVIDUALS AND COMMUNITIES WE SERVE false false 73853046 94854673 As discussed herein, Douglas Hospital, Inc (an affiliate of Wellstar Health System, Inc.) operates as a charitable organization consistent with the requirements of Internal Revenue Code section 501 (c) (3) and the "community benefit standard" of IRS Revenue Ruling 69-545. In this regard, the governing body of the organization and/or its parent is composed of prominent citizens in the community, medical staff privileges in the hospital are available to all qualified physicians in the area consistent with the size and nature of the facility; the hospital operates a full-time emergency room open to all regardless of ability to pay; the hospital provides care to the needy members of the community consistent with its charity care policy regardless of their ability to pay for these services. The hospital's excess funds are generally applied to expansion and replacement of existing facilities and equipment, amortization of indebtedness, improvement of patient care, community benefit activities, and charity care. Douglas Hospital committed approximately $4 million in capital expenditures for the year to meet the technology and program needs of the community we serve. Douglas Hospital, Inc. was organized in 1992. The hospital affiliated with the Northwest Georgia Health System in 1993. In 1994 Northwest Georgia Health System helped form the PROMINA Health System and changed its name to Promina Northwest Health System. In 1998 Promina Northwest changed its name to Wellstar Health System and is now totally independent of PROMINA. Douglas Hospital is subordinate to, and subject to the authority of Wellstar Health System and its governing boards including the Hospital Authority of Douglas County. Wellstar Douglas provides a full range of inpatient and outpatient services characteristic of a community hospital. The hospital is licensed to operate 108 beds and is presently staffed to operate 102 beds. The original hospital was constructed in 1974 and had one major structural addition in 1985. The following stats constitute the overall program services provided during the reporting period ended June 30, 2011: Adult Discharges 6,696 Med & Surgical Short Stay Cases 106 Emergency Room Visits 54,596 Outpatient Surgical Cases 4,384 Inpatient Surgical Cases 1,284 Outpatient Procedures Non-ED OP Radiology 43,629 GI Laboratory 1,314 Total FTEs Paid 602 Community Benefit Reporting Community Outreach $ 401,114 incl system generated allocated benefits Unreimbursed Charity Care (at cost)$7,723,889 Medicaid Shortfalls (at cost) $141,999 Total $8,267,002 As an affiliate of Wellstar Health System, Douglas Hospital participates in many community and educational programs for the overall health and benefit of the area that we serve. Some examples of those programs are: Community Health/Education--screenings and educational opportunities such as defensive driving for teens (offered at a minimal cost), smoking cessation, heart smart school, CPR and others. Community Activities--sponsors blood drives, provides funding to school health programs for medical and dental care for the underserved population. Community Events--Latino Day for the community Hispanics to have a variety of screenings for health related issues. In all a total of over 200,000 area residents participated in some type of education or screening in health issues. Sponorships--A group of employees participated in the annual "Relay for Life event to locally raise funds and awareness for cancer research and prevention (held in conjunction with the American Cancer Society). System-wide a total of $10,000 was raised for this important cancer prevention and treatment program. Wellstar's Laundry services Department partnered with a local homeless shelter, MUST Ministries, to donate retired and faded scrubs to new arrivals at the shelter. MUST has integrated housing programs in Cobb, Cherokee, and Douglas counties (the heart of Wellstar"s service area) Recognition and Accomplishments Douglas Hospital continues to be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). All of the Wellstar system hospitals (including Douglas) have been awarded "Accreditation with Distinction" by the Commission on Laboratory Accreditation of the College of American Pathologists (CAP). CAP awards are considered one of the most stringent in laboratory quality assurance in the industry. The Wellstar Cancer Program is accredited by the American College of Surgeons. The expansion of the cancer program has resulted in an increase in the services provided for cancer patients at both Douglas and Paulding Hospitals. The Wellstar Respiratory Care is accredited by the American Association for Respiratory Care with its "Recognition for Quality". Wellstar Health System is number nine in the Top 100 Integrated Healthcare Networks as published by SDI. It is also the highest ranked integrated network in the state. Wellstar is named in the 100 Best Companies List by "Working Mothers" magazine and as a National Employer Team Member by AARP for its work on behalf of more mature workers within the organization. Wellstar was also named for a fourth year in a row to the Companies that Care Honor Roll. This distinction represents employers who create positive work environments for its employees and who are also active community partners. Douglas Hospital's Ambulatory Surgery Department was selected by a national customer service company, the Studer Group, for its Fire Starter Award. The department is in the 90th percentile in patient satisfaction and customer service and has been above the 90th percentile for the past three or four years. Douglas Hospital received a Partnership for Health and Accountability Quality and Patient Safety Award from Georgia Hospital Association related to the reduction of healthcare associated infections. For the last several years Wellstar Douglas Hospital has sponsored a joint class for patients who are scheduled to have some type of joint replacement surgery. These twice a month classes prepar the patients for not only surgery and the risk involved but post-operative realities and their new "pain free" activities and rehabilitation that is involved. This program has educated approximately 250 patients over a four year period. Wellstar continues to expand its participation in the annual American Heart Association-Heart Walk as a major sponsor (the Wellstar Cardiac Network). For the past several years Wellstar has participated with walkers and donations now totalling more than $100,000 per year. Wellstar was named one of America's Best Adoption-Friendly Workplaces on a list released by the Dave Thomas Foundation for Adoption. Wellstar ranked fifth in the hospital and health industry. The rankings are based on a survey of companies to analyze their adoption benefits. Wellstar's policy includes a $5,000 per finalized adoption (and a $10,000 lifetime maximum) for employees with at least six months of continuous employment to assist in the adoption process. Douglas Hospital initiated a new patient experience called "Zero Sleepless Nights" in its Diagnostic services department for mammography patients. The service is intended to provide screening results to patients within 24 hours of their procedure to reduce and hopefully eliminate the stress associated with unknown diagnoses. As a system Wellstar performs more than 73,000 mammograms each year and this new service has proven to be very well received by those patients. Cobb, Douglas, Kennestone, and Paulding hospitals continue to meet the Appropriate Care Measures (ACM) of 93 percent thresholds in quality for the Presidental Level of Quality Honor Roll as reported by the Georgia Hospital Association. Wellstar has progressed in this area from an 81.4 percent threshold to 94.6 percent. Wellstar (including Cobb, Douglas, and Kennestone hospitals) received a "3 STAR" rating from the Society of Thoracic Surgeons (STS) for the quality of its cardiac surgery (only 12-15 percent of hospitals across the country receive this rating). This rating helps validate that quality cardiovascular care will remain a priority of the system's program. 73853046 true false false false false false false false false true false false false true false true false false false false false false false false false true true false false true false false false false false false true false false false false false false true true false false false true 0 0 776 true false false false false false false false false false false X 18 14 true false true false true true true true true false false true true true true true true true true false GA X JAMES M SWARTZ 7707925023 805 SANDY PLAINS ROAD Marietta GA 300666340 X Randall Bentley 1.0 X 0 17242 0 Robert N Cross MD 1.0 X 0 4678 0 T E Durham 1.0 X 0 31751 1255 Thomas E Gearhard 1.0 X 0 389972 28532 David Hafner MD 1.0 X 0 16011 0 Charles J Jones 1.0 X 0 13123 0 Connie Kirk 1.0 X 0 5044 0 Janie Maddox 1.0 X 0 14609 0 Gary A Miller 1.0 X 0 2721 0 Steven W Oweida MD 1.0 X 0 17242 0 Tom Phillips 1.0 X 0 2754 0 Walter G Robinson 1.0 X 0 7065 0 Otis Brumby III 1.0 X 0 1727 0 W Allen Separk 1.0 X 0 7984 0 T Fitz Johnson 1.0 X 0 1742 0 Jeffrey Tharp MD 1.0 X 0 446816 28567 Robert G Warner MD 1.0 X 0 3142 0 Charles Pete Wood 1.0 X 0 12872 0 A James Budzinski 2.0 X 0 585666 33803 Gregory L Simone MD 2.0 X 0 3972245 172966 Bonnie Wilson 2.0 X 0 1480015 71627 David Anderson 2.0 X 0 512652 29200 Donald Campbell MD 2.0 X 0 392680 24541 Barbara B Corey 2.0 X 0 353270 21091 Bruce Dean 2.0 X 0 246466 19958 Marcia Delk MD 2.0 X 0 424456 33113 K Darold Etheridge 2.0 X 0 231132 14571 Lee Evins 2.0 X 0 248506 18089 Mark Haney 2.0 X 0 331882 23979 Christopher M Kane 2.0 X 0 400365 26918 Kenneth C Kunze MD 2.0 X 0 687208 37043 Louis W Little 2.0 X 0 283210 24158 Kimberly W Menefee 2.0 X 0 330316 22272 Ronald J Strachan 2.0 X 0 417826 27923 Robert Mandler 2.0 X 0 262785 18444 Jonathan B Morris 2.0 X 0 334194 23933 MICHAEL GRAUE 2.0 X 0 691292 44574 Robin Wilson MD 2.0 X 0 340020 24726 ELLEN LANGFORD 2.0 X 0 228643 16661 CRAIG OWENS 50.0 X 311694 0 21752 Anthony M Trupiano 2.0 X 0 285303 16534 Joseph L Brywczynski 2.0 X 0 216142 14427 Elizabeth A Hoffmann 2.0 X 0 230428 10860 Richard T Lopes MD 2.0 X 0 513606 28822 James M Swartz 2.0 X 0 169532 9148 Mary L Wesley 2.0 X 0 294140 14070 Barbara Ballard 2.0 X 0 120827 7602 Robert Jansen MD 2.0 X 0 368959 20365 Beth Kost 2.0 X 0 244509 16135 Carol S Edwards 2.0 X 0 117869 6022 C Brett Scullen 2.0 X 0 80312 3785 Adam C Thompson 2.0 X 0 176957 9710 Leo E Reichert 2.0 X 0 0 0 Deborah DeVita Roegge 2.0 X 0 0 0 Betty Ann Brakovich 50.0 X 0 0 0 Laura Caramanica 50.0 X 0 0 0 Martha Seahorn 50.0 X 179779 0 14189 Margaret W Chastain 50.0 X 148957 0 9542 Beverly Bates 50.0 X 130411 0 13953 Steven W Harris 50.0 X 126342 0 12423 Peggy Tyndall 50.0 X 133422 13587 Linda A Clark 1.0 X 0 255306 10595 Bruce Harrison 1.0 X 0 455869 22304 Marsha L Burke 1.0 X 0 190475 12395 1030605 17471558 1076164 27 true true false Batchelor Kimball PO Box 70 LITHONIA GA 30058 Maintenance 771036 Martin General Contracting Inc 3633 Ivy Gulledge Road DALLAS GA 30132 General Contractor 337202 RCC Marietta PO Box 101518 ATLANTA GA 303921518 Medical 915495 Quest Diagnostics PO Box 740736 ATLANTA GA 303740736 Medical Lab 220095 Urology Associates Lithrotripsy LLC 9825 Spectrum Drive Bldg 3 AUSTIN TX 78717 Medical 312400 8 0 HOSPITAL PATIENT REVENUE 621990 94854613 94854613 MEDICAL RECORDS REVENUE 621990 60 60 94854673 0 0 0 111296 111296 111296 111296 0 0 0 0 GROUND LEASE REVENUE 84328 84328 CAFETERIA SALES 425009 425009 LACTATION/IMMUNIZATIONS 21970 21970 94756 94756 626063 95592032 94854673 0 737359 0 0 0 0 311693 276254 35439 0 34939044 30967173 3971871 2560257 2269156 291101 2691983 2385905 306078 2535293 2247030 288263 0 1502 1502 0 0 0 0 1330857 1106825 224032 0 13168122 12558024 610098 0 0 2275676 1048079 1227597 35848 21352 14496 0 36223 31966 4257 26749 26749 19686790 17448409 2238381 4514733 2117855 2396878 703840 703840 REPAIRS & MAINT 1699382 1370296 329086 OTHER OPERATING EXPENSE 12585 4722 7863 86530577 73853046 12677531 0 2150 2150 16919 6294 12584352 16052926 1494690 1609493 600343 371288 90028560 51243996 38935519 38784564 2884070 1971378 56518043 58798093 6143371 6303534 34598107 39506069 40741478 45809603 X 15776565 12988490 15776565 12988490 56518043 58798093 X 9061455 -11849530 X false true true X false X 59570 59570 41546798 18415375 23131423 1127482 489472 638010 46366881 32339149 14027732 927829 927829 38784564 0 DUE FROM AFFILIATIES 4774742 ASSET RETIREMENT OBLIGATION LT 576803 TAX EXEMPT BOND LIAB-DUE TO WHS 34154524 39506069 95592032 86530577 9061455 9061455 SCHEDULE D PART X, LINE 2 FIN 48 FOOTNOTE The following footnote is related to the organization's application of FIN 48 (ASC 740). "Wellstar (including Douglas Hospital) and all but one of its affiliates have been recognized as exempt from Federal income tax under Internal Revenue Code Section 501 (a) as organizations described in Section 501 (c)(3) and, therefore, related income is generally not subject to Federal or state income taxes. CAC is a controlled foreign corporation not subject to Federal tax. Wellstar applies FASB ASC 740, Income Taxes, which addresses accounting for uncertainties in income tax positions. It also provides guidance on when tax positions are recognized in an entity's financial statements and how the values of these positions are determined. There is no impact on Wellstar's combined financial statements as a result of the application of ASC 740." true true true X 125. true X true true true false true true 7723889 7723889 0.08890 12384648 12242649 141999 0.00160 20108537 12242649 7865888 0.09050 318140 318140 0.00370 318140 318140 0.00370 20426677 12242649 8184028 0.09420 true 5078038 940920 31314387 33692688 -2378301 X 1 1 Douglas Hospital Inc

8954 Hospital Drive Douglasville GA 30134

X X X Douglas Hospital Inc 1 Publication of Annual Community Benefit Report Part I Line 6a Douglas Hospital, Inc. is an affiliate of Wellstar Health System, Inc. which on an annual basis issues a community benefit report. This report is subsequently distributed in and around the five county service area of the health system. Cost to Charge Ratio Schedule H Part 1 Line 7 For purposes of the IRS Form 990 Schedule H, Wellstar Health System and Affiliates (including Douglas Hospital) have estimated the current year cost to charge ratio for each hospital as it is reported in the annual community benefit report and as it will be reported in the state's Annual Hospital Financial Survey. Footnote on Bad Debts and Rationale for Community Benefit Schedule H Part III Line 4 The following footnote is detailed in the Wellstar Health System, Inc. and Affiliates Financial Statementsrelated to bad debt or uncollectible accounts: "During 2011, Wellstar adopted the provisions of FASB Accounting Standards Update (2011-07), Healthcare Entities (Topic 954). ASU 2011-07 requires the reclassification of the provision for uncollectible accounts associated with patient service revenue from an operating expense to a deduction from patient service revenue (net of contractual allowances and discounts)." " Wellstar recognizes patient service revenue associated with services provided to patients with third-party payor coverage on the basis of contractual rates for the services rendered. For uninsured patients that do not qualify for community financial aid, Wellstar recognizes revenue on the basis of its discounted rates for services provided. On the basis of historical experience, a significant portion of Wellstar's uninsured patients are unable or unwilling to pay for the services provided. Thus, Wellstar records a significant provision for uncollectible accounts related to uninsured patients in the period the services are provided." Subsequent to the end of the reporting period a propensity to pay review of patient accounts often results in prior year bad debt accounts which are deemed eligible for the organization's financial assistance policy. Those bad debt accounts are reclassified as charity and thus our rationale for including as community benefit. Medicare Shortfalls Part III Line 8 Douglas Hospital is a provider of inpatient and outpatient services to Medicare program beneficiaries at determined rates. Without the participation in the Medicare program these patients may not have had convenient access to those services. The Medicare shortfall on line 7 represents the uncompensated difference between the expected reimbursement and the Medicare charges for those services stated at cost. We determine a cost to charge ratio for Medicare patients as part of the annual filing of the Medicare cost report. Collection Practices Part III Sec C Line 9b The policy written for collection practices that applies to all Wellstar Health System entities incorporates guidelines for personnel in the admissions and patient access areas to be trained in identifying patients that might qualify for financial assistance. It is also the policy of all Wellstar facilities to have at least one employee or contractor available at all times, especially in the hospitals with emergency rooms, who can provide assistance with the paperwork necessary to help patients who would qualify for governmental and other assistance programs. Hospital Description Schedule H Part V Douglas Hospital is a general acute care hospital providing a full range of services, is licensed to operate 108 beds, and is presently staffed to operate 102 beds. It is located on an approximately 50-acre campus in Douglasville, Georgia and is housed within a complex of connected buildings which contain a total square footage of over 98,000 square feet. The original hospital was constructed in 1974 and has had several additions and improvements which represent the current structure. Needs Assessment Schedule H Part VI Line 2 Wellstar Health System (and affiliates) is a key stakeholder in MAPP, Mobilizing for Action through Planning and Partnerships. MAPP, developed by the National Association of County and City Health Officials (NACCHO) in collaboration with the CDC, provides a structured guidance on creating and implementing a community-wide strategic planning process focused on improving the health and safety of our population. Through MAPP, a broad collection of community partners and residents come together to identify and prioritize health and safety issues and to identify resources for addressing them. The process results in an actionable community health improvement plan (CHIP) for measurable improvements in the community's health and quality of life as well as a scorecard for implementation and evaluation. The resulting community plan does not focus on one agency or community health challenge; rather, MAPP provides a long-term strategy that addresses the multiple factors that affect health in the community. Community involvement throughout the creation and the implementation of a health improvement plan results in creative solutions to community health problems with an improved focus on priorities, reduced duplication of services, increased collaboration on projects and activities, and increased capacity to garner additional resources. Moreover, continous community involvement leads to community ownership of the process. Community ownership, in turn, increases the credibility and sustainability of the health improvement efforts. Patient Education of Eligibility for Assistance Part VI Line 3 Douglas Hospital provides its patients with hospital personnel or contracted personnel who are trained in all aspects of governmental programs, payments plans, charity discounts, and other financial assistance offered to assist them in their hospital bills. If the patient is eligible for federal or state assistance programs, a staff member is knowledgeable in the steps necessary to qualify those individuals. If a patient is indigent or charity eligible they will be offered assistance through the hospital's charity and indigent care policy including the state's indigent care trust fund. If the patient has no other insurance and fails to qualify for indigent care assistance, the financial counselor can then offer the patient an opportunity to accept a payment plan with discounted payment options based on their ability to pay immediately or over time. All patient are afforded these opportunities. Community Information Part VI Line 4 Douglas Hospital is one of five hospitals that are affiliated with the parent corporation, Wellstar Health System. The primary service area of the system is located in the Northwest Georgia area and receives the majority of its patients from one of five counties (Cherokee, Cobb, Douglas, Bartow and Paulding). Generally about 85% to 90% of the patient volume comes from this service area although other health systems have a presence in the area as well. Demographically the region is one of the fastest growing in the state as well as the country and the expansion of the services for the patient population reflects a desire to offer healthcare "closer to home" since Wellstar is considered a part of a larger metropolitan Atlanta market. Economically the region is strong in per capita income but given recent trends a rise in the uninsured and indigent population has occured. Affiliated Health Care System Roles Part VI Line 7 As stated in the Wellstar Health System, Inc and Affiliates audited financial statments for the period ended June 30, 2011, Douglas Hospital (an affiliate of Wellstar Health System, Inc.) operates as a charitable organization consistent with the requirements of Internal Revenue Code Sect 501 (c) (3) and the "community benefit standard" of IRS Ruling 69-545. In this regard the governing body of the organization and/or its parent is composed of prominent citizens in the community, medical staff privileges in the hospital are available to all qualifed physicians in the area consistent with the size and nature of the facility; the hospital operates a full-time emergency room open to all regardless of ability to pay; and the hospital provides care to the needy members of the community consistent with its charity care policy. The hospital's excess funds are genrally applied to expansion and replacement of existing facilities and equipment, amortization of indebtedness, improvement fo patient care, community benefit activities, and charity care. Douglas Hospital committed approximately $4.1 million in capital expenditures for the year to meet those needs. X X X X X X false true X X X X X true true false false false false false true false Thomas E Gearhard 0 242155 0 139755 0 8062 0 21262 0 7270 0 418504 0 0 Jeffrey Tharp MD 0 275580 0 119178 0 52058 0 23584 0 4983 0 475383 0 0 A James Budzinski 0 434410 0 138539 0 12717 0 29307 0 4496 0 619469 0 0 Linda A Clark 0 255306 0 0 0 0 0 10595 0 0 0 265901 0 0 Gregory L Simone MD 0 814552 0 372600 0 2785093 0 169533 0 3433 0 4145211 0 0 Bonnie Wilson 0 414885 0 126556 0 938574 0 66357 0 5270 0 1551642 0 0 David Anderson 0 379036 0 118871 0 14745 0 25947 0 3253 0 541852 0 0 Donald Campbell MD 0 304092 0 77660 0 10928 0 21047 0 3494 0 417221 0 0 Barbara B Corey 0 271931 0 70439 0 10900 0 19591 0 1500 0 374361 0 0 Bruce Dean 0 197308 0 39928 0 9230 0 14509 0 5449 0 266424 0 0 Marcia Delk MD 0 326735 0 86581 0 11140 0 22854 0 10259 0 457569 0 0 K Darold Etheridge 0 191995 0 30437 0 8700 0 13630 0 941 0 245703 0 0 Lee Evins 0 183954 0 36757 0 27795 0 14120 0 3969 0 266595 0 0 Mark Haney 0 250475 0 67625 0 13782 0 18815 0 5164 0 355861 0 0 Bruce Harrison 0 283156 0 4564 0 168149 0 20737 0 1567 0 478173 0 0 Christopher M Kane 0 308673 0 80630 0 11062 0 21648 0 5270 0 427283 0 0 Kenneth C Kunze MD 0 532359 0 142962 0 11887 0 33411 0 3632 0 724251 0 0 Louis W Little 0 219648 0 52762 0 10800 0 16822 0 7336 0 307368 0 0 Kimberly W Menefee 0 252707 0 66022 0 11587 0 18694 0 3578 0 352588 0 0 Ronald J Strachan 0 278129 0 73374 0 66323 0 21239 0 6684 0 445749 0 0 Marsha L Burke 0 190475 0 0 0 0 0 10655 0 1740 0 202870 0 0 Martha Seahorn 157114 0 21440 0 1225 0 8111 0 6078 0 193968 0 0 0 Margaret W Chastain 137564 0 11243 0 150 0 8933 0 609 0 158499 0 0 0 Robert Mandler 0 195977 0 37704 0 29104 0 14866 0 3578 0 281229 0 0 Jonathan B Morris 0 256833 0 50211 0 27150 0 18905 0 5028 0 358127 0 0 MICHAEL GRAUE 0 513657 0 164927 0 12708 0 33859 0 10715 0 735866 0 0 Robin Wilson MD 0 277804 0 53016 0 9200 0 14456 0 10270 0 364746 0 0 ELLEN LANGFORD 0 182066 0 37877 0 8700 0 14188 0 2473 0 245304 0 0 CRAIG OWENS 241388 0 58911 0 11395 0 17960 0 3792 0 333446 0 0 0 Anthony M Trupiano 0 230311 0 45692 0 9300 0 16534 0 0 0 301837 0 0 Joseph L Brywczynski 0 167838 0 0 0 48304 0 12397 0 2030 0 230569 0 0 Elizabeth A Hoffmann 0 171895 0 15669 0 42864 0 9605 0 1255 0 241288 0 0 Richard T Lopes MD 0 405473 0 0 0 108133 0 26209 0 2613 0 542428 0 0 James M Swartz 0 147399 0 14973 0 7160 0 7113 0 2035 0 178680 0 0 Mary L Wesley 0 214845 0 19059 0 60236 0 12190 0 1880 0 308210 0 0 Robert Jansen MD 0 311389 0 48653 0 8917 0 15337 0 5028 0 389324 0 0 Beth Kost 0 209311 0 30248 0 4950 0 14503 0 1632 0 260644 0 0 Adam C Thompson 0 148759 0 16996 0 11202 0 7351 0 2359 0 186667 0 Severance Benefits Schedule J Pursuant to their respective employment agreements, the following groups of officers are entitled to severance payments based on their base salary and wages at that time in the event of certain identified circumstances. The officers with a severance payment period of 24 months as per their contractual agreement are: David Anderson, Marsha Burke, Linda Clark, Gregory Simone MD, and Bonnie Wilson. The officers with a severance payment period of 18 months as per their respective agreements are: Joseph Brywczynski, A James Budzinski, Donald Campbell MD, Barbara Corey, Marcia Delk MD, Michael Graue, T Mark Haney, Bruce Harrison, Robert Jansen MD, Christopher Kane, Kenneth Kunze MD, Lou Little, Richard Lopes MD, Kimberly Menefee, Craig Owens, Tarey Ray, Leo E Reichert, Ron Strachan, Mary L Wesley The officers with a severance payment period of 12 months as per their agreement: Barbara Ballard, Bruce Dean, Carol Edwards, Darold Etheridge, Lee Evins, Robert Hamilton, Elizabeth Hoffmann, Beth Kost, Ellen Langford, Robert Mandler, Jonathan Morris MD, Deborah Roegge DeVita, C Brett Scullen, James Swartz, Mary L Tavernaro, Adam Thompson, Anthony Trupiano, Robin Wilson MD During the calendar year, the following individuals received a payout in the amounts listed in accordance with their severance agreements as set forth above: Marsha Burke $ 190,475 Linda Clark $ 255,306 Teresa Ray $ 99,120 Bruce Harrison $ 455,868 Gregory L Simone $3,518,524 Bonnie Wilson $1,124,436 Non-Fixed Payments to Officers Form 990 Schedule J Part 1 Line 7 Wellstar has instituted an annual incentive plan for key leaders in the company. On an annual basis performance measures are proposed by management and subsequently approved by the Compensation Committee of the Board. The plan is designed to retain and reward leaders with incentives that keep them competitive with the market and comparably sized health systems. The criteria used to measure the performance consists of weighted factors in the areas of financial performance, customer service, employee engagement and quality and growth indicators. Upon successful achievement up to various targeted levels for each factor the performance payout is recommended and approved by the board after the annual financial audit is finalized and approved. Other Compensation Form 990 Schedule J Part 1 Line 1b and 2 While Wellstar Health System does not have a written policy regarding payment or reimbursement of the items listed in Part 1 Line 1a, the organization follows IRS guidelines in the payment of any items to individuals listed in Form 990 Part VII Section A. All of these items are added as taxable wages on the individual's W-2. Compensation Exceptions On Schedule J of Form 990 the following individuals were employed as officers with Wellstar Health System Inc. during the reporting period but did not have compensation during the calendar year for which salary and benefits totals apply: LEO E REICHERT DEBORAH ROEGGE DE VITA BETTY ANN BRAKOVICH LAURA CARAMANICA Pamela Etheridge Wife of Officer 53737 Employee of Wellstar Greg Fortgang Son-in-Law of Trustee 102382 Employee of Wellstar Amy Simone Daughter of Officer 72052 Employee of Wellstar false George Fleming Brother of Officer 59478 Employee of Wellstar false Greystone Power Board Member - Pres of Co 739493 Electric Services false Bonnie Miller Wife of Board Member 28417 Employee of Wellstar false Matthew Maddox Son of Board Member 38489 Employee of Wellstar false Greg Separk Son of Board Member 25847 Employee of Wellstar false Business Transactions with Interested Parties Form 990 Sch L Part The business transactions listed on Schedule L Part IV are for interested parties (family members) of either a trustee or officer of Douglas Hospital or a related organization. All transaction with the exception of Greystone Power are for employment services with Wellstar Health System and its Affiliates. The transaction with Greystone Power is for utility services provided to Douglas Hospital by a company whose CEO is also a trustee of Wellstar Health System Filing of 990 T Part V Line 3 a & b Douglas Hospital, Inc. has elected to file a blank 990-T for the reporting period as there is no known unrelated business income. However in the event a subsequent disclosure of any unrelated business income is made we will amend the currently filed return. Conflict of Interest Policy Form 990 Part VI Section B Line 12 Our Conflict of Interest Policy requires all covered persons to annually review the policy and then complete, sign and return the Conflicts of Interest Survey and Attestation to the Compliance Office. The following is our process to regularly and consistently monitor and enforce the policy: Compliance identifies all covered persons who must complete the Survey and Attestation annually. Compliance verifies that the Survey and Attestation is distributed to these persons. Compliance verifies that these persons return a fully completed and signed Survey and Attestation. Compliance reviews each completed and signed Survey and Attestation to identify all conflicts listed in the document. All conflicts, potential conflicts and incidences of non-compliance are referred to the Chief Compliance Officer. The CCO takes appropriate action to completely resolve all identified conflicts and incidences of non-compliance. Process for Determining Compensation for Top Execs Form 990 Part VI Section B Line 15 Wellstar engages the Hay Group to work with the governing board to review and recommend executive compensation. The executive compensation process at Wellstar is overseen by a committee of independent trustees, which follows a board-approved executive compensation philosophy. The current members of the Wellstar committee are: Pete Wood Janie Maddox Al Separk Randall Bentley Ex Officio CEO Ex Officio In committtee discussions about the compensation for the Chief Executive Officer, the CEO will recuse himself from that process but is a non-voting committee member for discussions on all other officers. The executive compensation philosophy empowers the committee to oversee the executive compensation process and administer the executive compensation program on behalf of the full board of trustee of Wellstar; provided, however, the full Board of Trustees evaluates and approves the compensation of the Chief Executive Officer. The philosophy requires annual disclosure of the committee's actions and decisions to the full board, which it has done. The committee is guided by the board-approved philosophy. Overall, the philosophy is intended to reward for organizational and individual performance. When performance is at a predetermined targeted level, the compensation is intended to be at or around the median of compensation paid to similar positions at similar organizations (the "market"). Wellstar's executive compensation philosophy defines the market as being comprised of comparable not-for-profit health care delivery systems, i.e., not-for-profit organizations similar in complexity and scale to Wellstar. To assist the committee in fulfilling its duties, the committee engaged the Hay Group to provide market compensation data to compare to the Wellstar positions whose compensation the committee oversees. The committee uses this data to provide context when making decisions in administering the compensation program. Accurate minutes of the committee's discussion and decisions are recorded during each committee meeting, and reviewed and approved at the following committee meeting. Process for Public Disclosure of Important Documents Form 990 Part VI Section C Line 19 The organization and its subsidiaries are subject to the Open Records Law in the State of Georgia. Therefore, by law, citizens are permitted to inspect and copy its governing documents, policies and financial statements as may be requested from time to time. Additionally, the organization's Form 990 is made readily available on the Guidestar website for charitable organizations. Periodically, the organization publishes its financial performance in the local newspaper for citizens to review, and it also publishes a community benefit report once a year for distribution to the public. Audited Financial Statements Form 990 Part IV Line 12 Douglas Hospital, Inc. is audited on an annual basis by an outside auditing firm, KPMG, and as part of that audit a consolidated financial statement is issued for all of WellStar Health System, Inc and its Affiliates. "The independent auditors report includes the accounts of Wellstar and its controlled affiliates, Kennestone Hospital, Inc., Cobb Hospital, Inc., Douglas Hospital, Inc., Paulding Medical Center, Inc., Wellstar Foundation, Inc. CHS Foundation, Inc., Community Assurance Company, Ltd., various Wellstar owned physician practices, a hospice facility, a nursing facility, home health business, and entities for infusion therapy and durable medical equipment. All significant intercompany accounts and transactions have been eliminated in combination. The Board of Trustees of Wellstar has the authority to approve appointments of the members of the board of trustees of all affiliate corporations." Tax Exempt Bond Reporting Form 990 Part IV Line 24a For purposes of the Form 990 reporting, Wellstar Health System, Inc EIN 58-1649541 will list all tax-exempt bonds issued since January 1, 2003 on Schedule K as it typically allocates the proceeds of the bonds to members of the Obligated Group (including the hospitals and physician group). Douglas Hospital, Inc. will report this tax exempt bond liability on Part X, Line 25 Other Liabilities. Current Officers/Directors Relationships Form 990 Part VI Section A Line 2 Two of the current officers and trustees for Wellstar Health System, Inc. --EIN 58-1649541 are related to each other through family. Gregory Simone, President and CEO is the brother-in-law of Lou Little, Sr VP Post Acute Services and Administrator of Windy Hill Hospital. Organizational Structure Form 990 Part VI Section A Lines 6, 7a & 7b As per the articles of incorporation, the sole member of the organization is Wellstar Health System, Inc., a GA nonprofit corporation. As sole member, Wellstar Health System holds certain powers of elections and approval in connection with the governing body of the organization. These powers are presented in detail in the governing documents which the company makes available to the public upon request. Officers Hours Worked Form 990 General Statement and Schedule J The officers devote their time to all of the organizations within Wellstar Health System that are listed in Schedule R, Part II. As such, the total hours worked by the officers across all organizations exceeds 40 hours a week. Compensation Schedule J, Part II All compensation amounts reported on Form 990 Part V, Part VII, and Part IX as well as Schedule J represent compensation provided to individuals that provide services to the organization. Likewise, the number of employees reported on Form 990 represent the number of individuals providing services to the organization. All Federal employment tax responsibilities for these individuals (including Federal Employment Tax reporting responsibilities) are handled by Wellstar Health System, Inc (EIN 58-1649541). 990 Board Review Form 990 Part VI Line 11A Internal staff prepare the organization's Form 990. Before filing the return with the Internal Revenue Service an external accounting firm, PricewaterhouseCoopers, reviews and sign-offs on the completed return of each organization. The current year Form 990 is then reviewed by the Finance Committee along with a question and answer session. A motion is then made by the Finance committee to approve the returns and present to the full board copies of the forms in an electronic (pdf. format) version as well as a hard copy . The organization's CFO or designee subsequently signs the return for either manual or electronic filing by the appropriate due date. Bylaws Changes Form 990, Part VI, Line 4 In November 2010 the bylaws of Wellstar Health System, Inc. were amended to state that benefits would be provided for trustees upon their retirement from the Board. Changes in Net Assets Form 990 Part XI Line 5 For the reporting period Douglas Hospital, Inc. had a change in net assets of ($11,849,530) related to transfers to affiliates as part of the allocation of income statement and balance sheet transactions over the year. HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Thomas E Gearhard TITLE:Board Member HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Jeffrey Tharp, MD TITLE:Board Member HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:A James Budzinski TITLE:Exec VP and CFO & Acting CEO HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Gregory L Simone, MD TITLE:President & CEO HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Bonnie Wilson TITLE:Exec VP & Gen Counsel HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:David Anderson TITLE:Exec VP HR/OL/CCO HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Donald Campbell, MD TITLE:Sr VP & Medical Director HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Barbara B Corey TITLE:Sr VP Managed Care HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Bruce Dean TITLE:VP & Asst Gen Counsel HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Marcia Delk, MD. TITLE:Sr VP Med Affairs & CQO HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:K. Darold Etheridge TITLE:VP Finance HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Lee Evins TITLE:VP Revenue Cycle Mgmt HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Mark Haney TITLE:Sr VP Business Development HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Christopher M. Kane TITLE:Sr VP Strategic Planning HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Kenneth C Kunze, MD TITLE:Sr VP Chief Med Officer HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Louis W. Little TITLE:Sr VP Post Acute Srv & Admin HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Kimberly W. Menefee TITLE:Sr VP Public & Govt Affairs HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Ronald J Strachan TITLE:Sr VP Chief Info Officer HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Robert Mandler TITLE:VP Diagnostic Outreach HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Jonathan B Morris TITLE:VP & Chief Med Info Officer HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:MICHAEL GRAUE TITLE:EXEC VP COO HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Robin Wilson MD TITLE:VP Medical Management HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:ELLEN LANGFORD TITLE:VP & COO MED GROUP HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Anthony M Trupiano TITLE:VP Supply Chain HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Joseph L Brywczynski TITLE:Sr VP Health Parks Admin HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Elizabeth A Hoffmann TITLE:VP Budget & Anaysis HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Richard T Lopes, MD TITLE:Sr VP & Pres Wellstar Phy Grp HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:James M Swartz TITLE:VP Accounting HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Mary L Wesley TITLE:Sr VP Nursing Srvcs & CNE HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Barbara Ballard TITLE:VP Homecare and Hospice HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Robert Jansen, MD TITLE:VP Medical Affairs HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Beth Kost TITLE:VP Compliance/Chief Privacy Of HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Carol S Edwards TITLE:VP Cardiac Services HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:C Brett Scullen TITLE:VP Pulmonology Operations HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Adam C Thompson TITLE:VP Surgery HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Leo E Reichert TITLE:Exec VP General Counsel HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Deborah DeVita Roegge TITLE:VP Women's and Newborn Srvs HOURS:50 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Linda A Clark TITLE:Exec VP and COO HOURS:1 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Bruce Harrison TITLE:Sr VP and CAO Phys Group HOURS:1 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Marsha L. Burke TITLE:Former Exec VP & CFO HOURS:1 CHS Foundation 805 Sandy Plains Road Marietta GA 30066 581649540 Foundation GA 501 (c) (3) 11 WHS true Cobb Hospital Inc 805 Sandy Plains Road Marietta GA 30066 580968382 Healthcare GA 501 (c) (3) 3 WHS true Kennestone Hospital Inc 805 Sandy Plains Road Marietta GA 30066 582032904 Healthcare GA 501 (c) (3) 3 WHS true Paulding Medical Center Inc 805 Sandy Plains Road Marietta GA 30066 582095884 Healthcare GA 501 (c) (3) 3 WHS true Wellstar Foundation 805 Sandy Plains Road Marietta GA 30066 581627413 Foundation GA 501 (c) (3) 11 WHS true Wellstar Health System 805 Sandy Plains Road Marietta GA 30066 581649541 Healthcare GA 501 (c) (3) 11 NA false Cobb Hospital Parking Company LLC 805 Sandy Plains Road Marietta GA 300666340 752999669 PARKING GA NA INVESTMENT 26313 808030 false false Kennestone East Parking Deck LLC 805 Sandy Plains Road Marietta GA 300666340 200537100 PARKING GA NA INVESTMENT -64045 2719346 false false Community Assurance Co 805 Sandy Plains Road Marietta GA 300666340 581649541 Insurance CJ WHS Inc C 58594426 1.00000 false false false false false false false false false false false false false false false false false false