2011-07-11T07:47:35-05:00 2010-08-31 DELOITTE TAX LLP 1750 TYSONS BLVD MCLEAN VA 221024219 990 2009-09-01 810667395 Bon Secours Community Hospital Foundation BONS 9143685121 255 Lafayette Avenue Suffern NY 109015620 Stacey Kirschenbaum 8453685303 2011-07-08 1 John W Sadoff Jr 7032511000 2009 2016-02-24 21:20:13Z Philip A Patterson 255 Lafayette Avenue Suffern NY 109015620 173539 0 0928 X www.bonsecourscommunityhosp.org X 2002 NY Fundraising to support patient related activities at Bon Secours Community Hospital. 24 19 0 19 0 0 131237 0 -33344 26295 80420 -12503 47076 145029 96420 0 82204 0 14877 36272 16975 36272 195599 10804 -50570 1485489 1448923 0 1485489 1448923 The mission is to bring compassion to health care and to be good help to those in need, especially those who are poor and dying. As a system of caregivers, we commit ourselves to help bring people and communities to health and wholeness. 0 0 173780 96420 Bon Secours Communitry Hospital Foundation is the fundraising arm of Bon Secours Community Hospital. Funds may be raised via the annual campaign, major gifts / planned giving, and special events. Special events included a Spring Ball, a fall golf classic, and other fundraising events. 173780 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 24 19 0 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 0 1 1 0 NY X Julie Owen 8458567215 20 Grand Street Warwick NY 10990 X Philip A Patterson 50.00 X 0 331611 26844 Kathleen Hylas 4.00 X 0 0 0 Sally Beecher 4.00 X 0 0 0 James Biondi 4.00 X 0 0 0 John Bell 4.00 X 0 0 0 Barbara Buchanan 4.00 X 0 0 0 Ronald Demczak 4.00 X 0 0 0 Howard Kuperman 4.00 X 0 0 0 Thomas McCarron 4.00 X 0 0 0 Darryl R McKeeby 4.00 X 0 0 0 John Meder 4.00 X 0 0 0 Shaun Parker 4.00 X 0 0 0 Steve Albanese 4.00 X 0 0 0 Barry Short 4.00 X 0 0 0 Lisa Toaldo DMD 4.00 X 0 0 0 R Michael Worden 4.00 X 0 0 0 Gerald Hansen 4.00 X 0 0 0 Terence O'Brien 50.00 X 0 758300 20135 Leah Cerkvenik 50.00 X 0 386135 79838 Jeffrey Reilly 50.00 X 0 161452 12681 Paul Brislin 6.00 X X 0 0 0 Clare Brady 50.00 X X 0 100531 9823 John Donahue 6.00 X X 0 0 0 Linda Hannigan 6.00 X X 0 0 0 Stacey Kirschenbaum 50.00 X 0 129836 17773 Lisa Randazzo 0.00 X 0 71302 14180 Stephen D Majetich 50.00 X 0 351880 50300 John Shea 0.00 X 0 792042 131791 Thomas Brunelle 0.00 X 0 0 0 Dominick Stanzione 0.00 X 0 567664 27073 0 3579451 376258 0 1 1 0 0 86653 10000 34584 131237 26295 26295 16007 86653 28510 -12503 -12503 145029 0 0 13792 96420 96420 76391 59585 5347 11459 601 469 42 90 5212 4065 365 782 Purchased Services 16203 12639 1134 2430 Bank Fees 512 399 36 77 Taxes - Business Licens 260 203 18 39 195599 173780 6942 14877 1035012 693210 258051 11311 190708 725234 1718 19168 1485489 1448923 0 0 X 1036730 712378 -163639 119179 612398 617366 1485489 1448923 1485489 1448923 X 0 1 1 X 1 1 X 1087704 139686 131237 1358627 1087704 139686 131237 1358627 908546 450081 24218 26295 50513 168333 165934 271547 104813 16007 726634 2135774 1358627 0.21070 0.64440 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 Part X: Description of Uncertain Tax Positions Under FIN 48: Schedule D, Part X, Line 2 requires that the organization provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48. As the organization does not conduct a separate audit of its financial statement, below is the related statement from the Bon Secours Health System, Inc. consolidated audited financial statements: The System and most of its subsidiaries (including certain joint venture entities) are exempt from federal income taxes under Section 501(c)(3) of the Internal Revenue Code of 1986, as amended. The system accounts for uncertain tax positions in accordance with ASC Topic 740. Income taxes of the System's for-profit subsidiaries are not material to the accompanying consolidated financial statements. The System's taxable subsidiaries have approximately $98,300 and $117,200 of net operating loss carryforwards as of August 31, 2010 and 2009, respectively, which expire in varying periods through 2030 and are available to offset future taxable income. The System's deferred tax assets are fully reserved at August 31, 2010 and 2009. Any changes to the valuation allowance on the deferred tax asset are reflected in the year of the change. Golf Classic 107660 5000 102660 8229 20281 107660 5000 102660 8229 20281 28510 74150 1 Bon Secours Community Hospital 160 East Main Street Port Jervis NY 127712245 141347717 501(C)(3) 40600 Replacement of Zeiss Microscope for ENT surgery. Bon Secours Community Hospital 160 East Main Street Port Jervis NY 127712245 141347717 501(C)(3) 9125 Video Laryngoscope for Emergency Incubations Bon Secours Community Hospital 160 East Main Street Port Jervis NY 127712245 141347717 501(C)(3) 19941 Replacement of Vascular testing system Bon Secours Community Hospital 160 East Main Street Port Jervis NY 127712245 141347717 501(C)(3) 26754 Construction and face lift of Sun porch at St. Josephs Place at BSCH. 4 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: The Bon Secours Community Hospital Foundation asks for grant requests at the beginning of each fiscal year. The organizations and individuals requesting grants are required to fill out an application. The grant committee reviews each grant application and may request additional information, interviews, etc. The grants committee approves applications based on merit and need. X X X X X 1 1 0 0 0 0 0 0 0 Philip A Patterson 0 236729 0 0 0 94882 0 13896 0 12948 0 358455 0 0 Terence O'Brien 0 505610 0 135745 0 116945 0 6716 0 13419 0 778435 0 0 Leah Cerkvenik 0 256646 0 112277 0 17212 0 59241 0 20597 0 465973 0 0 Jeffrey Reilly 0 145526 0 14771 0 1155 0 4849 0 7832 0 174133 0 0 Stephen D Majetich 0 291497 0 41127 0 19256 0 35041 0 15259 0 402180 0 0 John Shea 0 446997 0 341161 0 3884 0 116092 0 15699 0 923833 0 0 Dominick Stanzione 0 60543 0 0 0 507121 0 0 0 27073 0 594737 0 0 Part I, Lines 4a-b: Dominick Stanzione and Terence O'Brien received a severance payment of $503,654 and $60,096, respectively. Part I, Line 4b: The Charity Health System participates in a BSHSI sponsored executive retirement program that allows for deposits into additional retirements plans and available only to officers and key employees. The 457F plan is a non-qualified plan and is subject to a minimum three-year service requirement before vesting on deposits are made into this plan. Supplemental Information Part III Part I, Line 3: Bon Secours Health System, Inc., a related organization of Bon Secours Community Hospital Foundation, uses the following to establish the compensation of the organization's CEO/Executive Director: Compensation Committee Independent Compensation Consultant Written Employment Contract Compensation Survey or Study Approval by the Board or Compensation Committee Form 990, Part VI, Section A, line 4 Effective April 26, 2010, the orgnization amended its governing documents to remove term limitations for members of the Foundation's board of directors. Form 990, Part VI, Section A, line 6 Bon Secours Health System, Inc. is the sole member of Bon Secours Charity Health System, Inc., which in turn is the sole member of Bon Secours Community Hospital Foundation. Form 990, Part VI, Section A, line 7a The governing body of Bon Secours Community Hospital Foundation is appointed by its Member, Bon Secours Charity Health System, Inc. and subject to approval by Bon secours Health system, Inc. Form 990, Part VI, Section A, line 7b Certain authorities of Bon Secours Community Hospital Foundation are reserved to its member or to Bon Secours Health System, Inc. Form 990, Part VI, Section B, line 11 The process the organization uses to review the Form 990 consists of a review by Bon Secours Charity Health System, Inc.'s audit and compliance board committee and providing the form to the Bon Secours Community Hospital Foundation's board of directors to allow for a thorough review by both before the filing date of July 15, 2011. Bon Secours Charity Health System, Inc.'s audit and compliance board committee and Bon Secours Community Hospital Foundation's board of directors will review the Form 990 and ask any additional questions regarding the Form 990 before the return is filed July 15, 2011. Form 990, Part VI, Section B, line 12c Bon Secours Community Hospital Foundation regularly and consistently monitors compliance with the conflict of interest policy. On an annual basis all persons subject to the policy, including all officers, directors and key employees are required to make certain disclosures. These include disclosures related to certain personal, financial and organizational relationships that may present a conflict, or the appearance of a conflict of interest, with Bon Secours Community Hospital Foundation. All disclosures go through a three-part review process: (1) disclosures are reviewed first by the corporate responsibility officer (CRO); (2) a governance team comprised of the CEO, board president, board chair, CRO, and the BSHSI CRO participates in a second review of all disclosures during which recommendations are made as to the resolution of any conflicts or potential conflicts. Depending on the facts and circumstances, resolutions may include ongoing disclosure, recusal or removal of the conflict; and (3) all disclosures and recommendations are reviewed by a board committee (audit and compliance committee reviews the disclosures of management and the governance committee reviews the disclosures of the board and board committee members). Part VI, Section B, Line 14: Document Retention and Destruction Policy While Bon Secours Health System, Inc. does not have a written organization-wide document retention and destruction policy, individual department policies and practices are in place to ensure that each department of the organization maintains their documentation in compliance with state and federal requirements. In addition, any areas responsible for medical records have department policies in compliance with Medicare and HIPAA requirements. An organization-wide policy is currently in place for fiscal year ending August 31, 2011. Form 990, Part VI, Section B, line 15 The compensation committee of the board of Bon Secours Health System, Inc. engages in a comprehensive process for the oversight and management of remuneration for executive employees and disqualified parties of Bon Secours Community Hospital Foundation as well as other officers, key employees and highest paid employees. The compensation committee consists of a group of independent board members and engages an independent external compensation consultant to ensure the reasonableness of compensation paid to executives and disqualified parties. The committee maintains a Board-approved compensation philosophy, reviews pay practices against local, regional and national healthcare organizations and approves all remunerative decisions for this group of individuals. The committee reviews and receives assurances that all levels of pay within the organization are reasonable based on performance and validates incentives are met. These decisions are reported to the BSHSI Board of Directors and documented in the BSHSI compensation committee minutes. Form 990, Part VI, Section b , Line 15b - Compensation Process Other Officers/ Key Employees: For those key employees and highest paid employees that are not reviewed by the BSHSI compensation committee, the process included a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision. In the review, the other officers or key employees of Bon Secours Community Hospital Foundation were compared to other hospitals' employees in the area that hold the same title. During the review and approval of the compensation, documentation of the decision was recorded in human resources. Form 990, Part VI, Section C, line 19 Bon Secours Community Hospital Foundation provides any documents open to public inspection upon request. Form 990, Part VII: Hours worked are not tracked on an entity by entity basis. All officer's and director's hours reported on Form 990, Part VII, Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors represent aggregate hours worked per week. Terence O'Brien's compensation is paid by Bon Secours Health System, Inc., a related organization. The compensation he receives is for his role as CEO of Bon Secours Charity Health System, Inc. Philip Patterson's compensation is paid by Bon Secours Health System, Inc., a related organization. The compensation he receives is for his role as CEO of Bon Secours Charity Health System, Inc. Jeffrey Reilly's compensation is paid by St. Anthony Community Hospital, a related organization. The compensation he receives is for his role as the VP of Operations of Bon Secours Charity Health System, Inc. Leah Cerkvenik's compensation is paid by St. Anthony Community Hospital, a related organization. The compensation she receives is for her role as the VP of Operations of Bon Secours Charity Health System, Inc. Clare Brady's compensation is paid by Bon Secours Community Hospital, a related organization. The compensation she receives is for her role as the VP of Mission of Bon Secours Charity Health System, Inc. Stephen Majetich's compensation is paid by Good Samaritan Hospital, a related organization. The compensation he receives is for his role as CFO of Bon Secours Charity Health System, Inc. Stacey Kirschenbaum's compensation is paid by Good Samaritan Hospital, a related organization. The compensation she receives is for her role as the Executive Director of Bon Secours Community Hospital Foundation, Bon Secours Warwick Health Foundation and the Good Samaritan Foundation for Better Health. Bon Secours Health System Inc 1505 Marriottville Road Marriottsville MD 21104 521301088 Management MD 501(c)(3) Line 11, Type II: 50 N/A Bon Secours Charity Health System Inc 255 Lafayette Avenue Suffern NY 10901 912135195 Management NY 501(c)(3) Line 11, Type II: 50 N/A Good Samaritan Hospital 255 Lafayette Avenue Suffern NY 10901 131740104 Hospital NY 501(c)(3) Line 3: 170(b)(1)(a) N/A Bon Secours Community Hospital 160 E Main Street Port Jervis NY 127712245 141347717 Hospital NY 501(c)(3) Line 3: 170(b)(1)(a) N/A St Francis Center at the Knolls (dba Mount Alverno Center) 20 Grand Street Warwick NY 109901020 061370576 Long-term Care NY 501(c)(3) Line 3: 170(b)(1)(a) N/A St Anthony Community Hospital 15-19 Maple Avenue Warwick NY 109901028 141340100 Hospital NY 501(c)(3) Line 3: 170(b)(1)(a) N/A Good Samaritan Foundation for Better Health 255 Lafayette Avenue Suffern NY 10901 133400353 Foundation NY 501(c)(3) Line 7: 170(b)(1)(a) N/A Bon Secours Warwick Health Foundation 20 Grand Street Warwick NY 109901020 141972807 Foundation NY 501(c)(3) Line 7: 170(b)(1)(a) N/A Villa Francis at the Knolls (dba Schervier Pavilion) 22 Van Duzer Place Warwick NY 109901020 061381994 Skilled Nursing Facility NY 501(c)(3) Line 3: 170(b)(1)(a) N/A GSH Medical Care OC 255 Lafayette Avenue Suffern NY 109015620 223636986 Primary Care NY C 0 1 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0