2011-07-15T11:23:38-05:00 2010-08-31 DELOITTE TAX LLP 1750 TYSONS BLVD MCLEAN VA 221024219 990 2009-09-01 141972807 Bon Secours Warwick Health Foundation BONS 8453685121 255 Lafayette Avenue Suffern NY 109015620 Stacey Kirschenbaum 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 36975 0 X www.stanthonycommunityhosp.org X 2002 NY Fundraising events to support the Hospital 13 8 0 8 0 0 2812 0 -36472 34163 80470 0 43998 36975 142167 0 0 0 2998 82725 17648 82725 159815 -38727 -122840 2562525 2353078 148 0 2562377 2353078 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 155404 142167 Bon Secours Warwick Health Foundation is the fundraising arm of St. Anthony's Community Hospital, Mount Alverno Center and Schervier Pavilion. Funds may be raised annually via the annual campaign, major gifts / planned giving and special events. Special events general include a Spring Ball, a fall golf classic and other fundraising activities. 155404 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 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 13 8 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 Duane Albro 4.00 X 0 0 0 Stratos Colman 4.00 X 0 0 0 Leo Robert Kaytes 4.00 X 0 0 0 Deborah Kennedy 4.00 X 0 0 0 Frank Petrucci 4.00 X 0 0 0 Philip A Patterson 50.00 X 0 331611 26844 Terence O'Brien 50.00 X 0 758300 20135 Lisa Randazzo 0.00 X 0 71302 14180 Jeffrey Reilly 50.00 X 0 161452 12681 Leah Cerkvenik 50.00 X 0 386135 79838 Helen Laskow 6.00 X X 0 0 0 Clare Brady 50.00 X X 0 100531 9823 Steven Kent 6.00 X X 0 0 0 Terry Quint 6.00 X X 0 0 0 Stacey Kirschenbaum 50.00 X 0 129836 17773 Stephen D Majetich 50.00 X 0 351880 50300 John Shea 0.00 X 0 792042 131791 Dominick Stanzione 0.00 X 0 567664 27073 0 3579451 376258 0 1 1 0 0 2812 2812 34163 34163 36975 0 0 34163 142167 142167 847 635 68 144 786 590 63 133 Printing 12482 9362 999 2121 Purchased services 3533 2650 283 600 0 0 0 0 0 0 0 0 0 0 0 0 159815 155404 1413 2998 2088288 1998743 84711 3426 372447 291771 17079 59138 2562525 2353078 148 148 0 X 2105219 2057881 457158 295197 2562377 2353078 2562525 2353078 X 0 1 1 X 1 1 X 2501340 354003 207510 2812 3065665 2501340 354003 207510 2812 3065665 77787 2987878 -36472 34163 -2309 217650 280686 160469 138510 797315 3860671 3065665 0.77390 0.77890 X 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. Spring Ball 0 St Francis Center at the Knolls dba Mount Alverno Center 20 Grand Street Warwick NY 109901028 061370576 501(c)(3) 39531 Equipment Purchase - Air Conditioning St Anthony Community Hospital 15-19 Maple Ave Warwick NY 109901028 141972807 501(c)(3) 38753 General Support St Anthony Community Hospital 15-19 Maple Ave Warwick NY 109901028 141972807 501(c)(3) 8718 Equipment Purchase - Cardiac Monitor St Anthony Community Hospital 15-19 Maple Ave Wwarwick NY 109901028 141972807 501(c)(3) 6500 Equipment Purchase - Portable Ultrasound St Anthony Community Hospital 15-19 Maple Ave Warwick NY 109901028 141972807 501(c)(3) 8810 Equipment Purchase - Fire Doors St Anthony Community Hospital 15-19 Maple Ave Warwick NY 109901028 141972807 501(c)(3) 39855 Equipment Purchase - Maquet OR Lights 6 0 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 Jeffrey Reilly 0 145526 0 14771 0 1155 0 4849 0 7832 0 174133 0 0 Leah Cerkvenik 0 256646 0 112277 0 17212 0 59241 0 20597 0 465973 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 Warwick Health Foundation, uses the following to establish the compensation of the organization's CEO/Executive Director: Compensation Committee Independent Compensation Committee 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 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 St. Anthony Community Hospital, which in turn is the sole member of Bon Secours Warwick Health Foundation. Form 990, Part VI, Section A, line 7a The governing body of Bon Secours Warwick Health Foundation is appointed by its Member, St. Anthony Community Hospital and subject to approval by Bon Secours Health System, Inc., one of two corporate members of Bon Secours Charity Health System along with the Sisters of Charity of Saint Elizabeth of Convent Station. Form 990, Part VI, Section A, line 7b Certain authorities of Bon Secours Warwick Health Foundation are reserved to its member, St. Anthony Community Hospital 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 Bon Secours Charity Health System, Inc.'s audit and compliance board committee and providing the form to the Bon Secours Warwick Health Foundations 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 Warwick Health Foundations 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 Warwick Health 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 Warwick Health 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 Warwick Health 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 Warwick Health 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 Warwick Health 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. 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. 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. 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 Good Samaritan Foundation for Better Health 255 Lafayette Avenue Suffern NY 109015620 133400353 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 NA