2011-07-15T11:23:38-05:00 2010-08-31 DELOITTE TAX LLP 1750 TYSONS BLVD MCLEAN VA 221024219 990 2009-09-01 133400353 Good Samaritan Foundation For Better Health GOOD 9143685121 255 Lafayette Avenue Suffern NY 109015620 Stacey Kirshenbaum 8453685303 2011-07-15 1 John W Sadoff Jr 7032511000 2009 2016-02-24 21:20:13Z Stacey Kirschenbaum 255 Lafayette Avenue Suffern NY 109015620 1106914 0 0928 X www.goodsamhosp.org/html/foundation.html X 1986 NY Fundraising events to support the Hospital 30 28 0 28 0 0 158467 886320 0 333788 41008 465473 -42900 957728 884428 2305399 0 328837 0 75674 304528 175667 304528 2809903 653200 -1925475 6362019 4294978 125208 149060 6236811 4145918 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 2698914 2305399 407449 Good Samaritan Foundation for Better Health is the fundraising arm of Good Samaritan Hospital. Funds may be raised via the annual campaign, major gifts, planned giving and special events. Special events for this past year included a Spring Ball and a fall Golf Classic. 2698914 1 1 0 0 0 0 0 0 0 1 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 1 0 0 0 0 0 0 1 1 0 0 0 30 28 1 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 Dr Beatrice Bloom 4.00 X 0 0 0 Joseph Allen 4.00 X 0 0 0 Dr Carmine Caponigro 4.00 X 0 0 0 Dr Richard Clarkin 4.00 X 0 0 0 John DeCicco 4.00 X 0 0 0 David Evangelista 4.00 X 0 0 0 Roberta Goldstein 4.00 X 0 0 0 Sister Fran Gorsuch CBS 50.00 X 0 0 0 Gilbert Heim 4.00 X 0 0 0 Gayle Hirsch 4.00 X 0 0 0 Andrew Kritzer 4.00 X 0 0 0 Dr Michael Lippe 4.00 X 0 0 0 Pierson Mapes 4.00 X 0 0 0 Jeff Marangi 4.00 X 0 0 0 Michael Mastrangelo 4.00 X 0 0 0 Dr Glenn Mendoza 4.00 X 0 0 0 Harold Peterson 4.00 X 0 0 0 Janetlee Pillitteri 4.00 X 0 0 0 Louis Siracusano 4.00 X 0 0 0 Margaret Telscher 4.00 X 0 0 0 Dr John Urcioli 4.00 X 0 0 0 Dr Thomas Snopek 4.00 X 0 0 0 Terence O'Brien 50.00 X 0 758300 20135 Philip A Patterson 50.00 X 0 331611 26844 Frank Stillo 6.00 X X 0 0 0 Mark Rothenberg 6.00 X X 0 0 0 Sr Joan Granville SC 6.00 X X 0 0 0 Sr Mary Louise Moran SC 50.00 X X 0 0 0 Daniel Rifkin 6.00 X X 0 0 0 Patricia Lefkowitz 6.00 X X 0 0 0 Stacey Kirshenbaum 50.00 X 0 129836 17773 Stephen D Majetich 50.00 X 0 351880 50300 John Shea 0.00 X 0 792042 131791 Michael Schneiders 0.00 X 0 341887 22480 Dominick Stanzione 0.00 X 0 567664 27073 0 3273220 296396 0 1 1 0 0 666787 33500 186033 886320 41008 41008 179586 450349 222486 -42900 -42900 884428 0 0 -1892 2305399 2305399 305575 238350 21390 45835 2402 1874 168 360 20860 16271 1460 3129 7500 5850 525 1125 639 498 45 96 31815 24816 2227 4772 1106 863 77 166 5447 4249 381 817 Purchased Services 103900 81042 7273 15585 Misc Expenses 21145 16492 1481 3172 Bank Fees 3855 3007 270 578 Taxes/Business Licenses 260 203 18 39 2809903 2698914 35315 75674 2518821 673947 1170585 558925 1162 2671451 3062106 6362019 4294978 36243 1680 88965 147380 125208 149060 X 2394774 524888 3842037 3608981 12049 6236811 4145918 6362019 4294978 X 0 1 1 X 1 1 X 1888299 1138903 374957 158467 886320 4446946 1888299 1138903 374957 158467 886320 4446946 69846 4377100 333788 41008 374796 662737 641217 757737 699277 2760968 7582710 0.57720 0.51550 X Schedule A, Part IV, Supplemental Information: Schedule A, Part II, Line 10, Explanation for Other Income: Special Events Other Income RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 Due to Affiliates 147380 147380 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. Spring Ball 354461 285357 69104 38000 73604 Golf Classic 275474 164992 110482 10000 76477 24405 629935 450349 179586 10000 114477 98009 222486 -42900 0 Good Samartian Hospital 255 Lafayette Suffern NY 109015620 131740104 501(c)(3) 2234806 Purchase of Equipment Good Samartian Hospital 255 Lafayette Avenue Suffern NY 109015620 131740104 501(c)(3) 70593 General Support 2 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: The Good Samaritan Foundation for Better Health 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 Terence O'Brien 0 505610 0 135745 0 116945 0 6716 0 13419 0 778435 0 0 Philip A Patterson 0 236729 0 0 0 94882 0 13896 0 12948 0 358455 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 Michael Schneiders 0 106633 0 0 0 235254 0 10446 0 12034 0 364367 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, Terence O'Brien, and Michael Schneiders received severence payments of $503,654, $60,096, and $228,274, 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 Good Samaritan Foundation for Better Health, uses the following to establish the compensation of the organization's CEO/Executive Director: Compensation Committee Independent compensation consultant Written employment contracts Compensation survey or study Approval by the board/compensation committee. Form 990, Part VI, Section A, line 2 Margaret Telscher and Dr. Thomas Snopek have a family relationship. 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 Foundations board of directors. Form 990, Part VI, Section A, line 6 Bon Secours Health System, Inc. is one of two corporate members of Bon Secours Charity Health System along with the Sisters of Charity of Saint Elizabeth of Convent Station. Bon Secours Charity Health System, Inc. is the sole member of Good Samaritan Foundation for Better Health. Form 990, Part VI, Section A, line 7a The governing body of Good Samaritan Foundation for Better Health is appointed by its Member, Bon Secours Charity Health System, Inc. and subject to approval by Bon Secours Health System, Inc., one of two corporate members of Bon Secours Charity Health System, Inc. along with the Sisters of Charity of Saint Elizabeth of Convent Station. Form 990, Part VI, Section A, line 7b Certain authorities of Good Samaritan Foundation for Better Health are reserved to its member, Bon Secours Charity Health System, Inc. or is jointly reserved to Bon Secours Health System, Inc. and the Sisters of Charity of Saint Elizabeth of Convent Station, the two corporate members of Bon Secours Charity 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 the Bon Secours Charity Health System's audit and compliance board committee and providing the form to the Good Samaritan Foundation for Better Health'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's audit and compliance board committee and the Good Samaritan Foundation for Better Health'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 The Good Samaritan Foundation for Better Health 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 the Good Samaritan Foundation for Better Health. 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 the Good Samaritan Foundation for Better Health 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 the Good Samaritan Foundation for Better Health 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 The Good Samaritan Foundation for Better Health 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. 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. Sr. Mary Louise Moran and Sr. Fran Gorsuch did not receive payroll distributions as they have taken vows of poverty. Bon Secours Health System Inc 1505 Marriottsville Road Marriottsville MD 21104 521301088 Parent Org - Management Services MD 501(c)(3) Line 11b, Type 2: 50 N/A Bon Secours Charity Health System Inc 255 Lafayette Avenue Suffern NY 109015620 912135195 Local System Parent Org. NY 501(c)(3) Line 11b, Type 2: 50 N/A Good Samaritan Hospital 255 Lafayette Avenue Suffern NY 109015620 131740104 Healthcare NY 501(c)(3) Line 3: 170(b)(1)(a) N/A Bon Secours Community Hospital 160 E Main Street Port Jervis NY 127712253 141347717 Healthcare 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 109901028 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 Healthcare NY 501(c)(3) Line 3: 170(b)(1)(a) N/A Bon Secours Warwick Health Foundation 20 Grand Street Warwick NY 109901028 141972807 Grant Making Foundation NY 501(c)(3) Line 7:170(b)(1)(a)( N/A Bon Secours Community Hospital Foundation 255 Lafayette Avenue Suffern NY 109015620 810667395 Grant Making Foundation NY 501(c)(3) Line 7:170(b)(1)(a)( N/A Villa Francis at the Knolls (dba Schervier Pavilion) 20 Grand Street Warwick NY 109901028 061381994 Skilled Nursing Facility NY 501(c)(3) Line 3: 170(b)(1)(a) N/A GSH Medical Care PC 255 Lafayette Avenue Suffern NY 109015620 223636986 Primary Care NY N/A C 0 1 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0