2011-05-16T16:33:23-05:00 2010-06-30 PricewaterhouseCoopers LLP 2001 MARKET ST SUITE 1700 PHILADELPHIA PA 19103 990 2009-07-01 582095884 PAULDING MEDICAL CENTER INC PAUL 7707925023 805 Sandy Plains Road Marietta GA 300666340 JAMES M SWARTZ 2011-05-16 true 2673303000 2009 2016-02-24 21:20:13Z A JAMES BUDZINSKI 805 Sandy Plains Road Marietta GA 300666340 75885244 false X www.wellstar.org X 1993 GA To deliver world-class charitable healthcare 18 14 535 85 0 0 671615 889511 54664190 64682449 -355158 1182350 380177 389982 55360824 67144292 0 0 0 0 20517980 25156709 0 0 0 35057477 39837899 55575457 64994608 -214633 2149684 37627994 41006415 20244938 21345031 17383056 19661384 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 56408776 64682449 Paulding Medical Center, Inc. (an affiliate of Wellstar Health System, Inc.) operates as a charitable organization consistent with the requirements of IRS 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 needy members of its community consistent with its charity care policy regardless of their ability to pay for these services; and the hospitals excess funds are generally applied to expansion and replacement of existing facilities and equipment, amortization of indebtedness, improvement in patient care, community benefit activities, and charity care. Paulding had $6.0 million in capital expenditures disbursed during the tax period reviewed. Wellstar Paulding Hospital is a general acute care hospital providing a full range of services to the community. The hospital is licensed to operate 83 beds and is presently staffed to operate 34 beds. Paulding Medical Center, Inc. was organized in 1994. 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. Paulding Medical Center is subject to the authority and governing board of Wellstar Health System and the Paulding County Hospital Authority. Paulding Hospital provides a full range of inpatient and outpatient services characteristic of a community hospital. Paulding Nursing Home is located on the campus of the hospital and functions as part of the full range of health services provided to the community. The nursing home provides skilled long-term nursing care to persons requiring those services by reason of age or physical impairment. The nursing home is the only such facility in the Wellstar system. The following stats consitute the overall program services provided for the period ended June 30, 2010: Adult Discharges 1,951 Nursing Facility Days 64,255 Medical & Surgical Short Stay Days 604 Emergency Room Visits- 36,755 Outpatient Surgical Cases - 1,290 Inpatient Surgical Cases - 235 Outpatient Procedures Non ED OP Radiology 25,975 (35% increase from prior year) GI Laboratory - 465 Total FTEs Paid - 416 Community Benefit Reporting Community Outreach (incl system generated allocation) $218,162 Unreimbursed Charity Care (at cost) $2,242,963 Medical Shortfalls (at cost) $1,442,942 As an affiliate of Wellstar Health System, Paulding Hospital participates in many community and educational programs for the overall health and benefit of the area that they serve. Accomplishments and Awards The Paulding Nursing Home provides both subacute and long term care services to patients in the community. Since the nursing home is one of very few in the area and located on the medical complex campus it is very crucial to an ever expanding service area. Paulding Hospital is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The parent company, Wellstar Health System, was again honored as one of the top 100 health systems in the country by Verispan. The system was ranked at #9 as listed in the magazine, "Modern Healthcare", and is the highest ranked system in the state. All of Wellstar hospital laboratories including Paulding were 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. Wellstar Health System ranks in the Top 20 of the Working Mother 100 Best Companies List. Wellstar Paulding Imaging Center opened in November 2008 with the first truly high-field open MRI in Georgia. This system allows clinical excellence and comfort for all patients especially the elderly. This center allows local residents a more convenient location for physician and imaging procedures. The new imaging center later won an award at the Annual American Society of Interior Designers. Wellstar ranked number 13 in Atlanta's Top 25 Employers by the publication "Atlanta Business Chronicle". Wellstar was recognized as a "Company that Cares" for 2009-2010 which was the third year in a row the system was honored. The system began participating in Terrific Tales, a Company that Cares sponsored literacy project. Several Wellstar hospitals took on the challenge of purchasing quality books for local elementary school libraries in underserved areas. Paulding Hospital adopted a local school(Poole Elementary) and helped the system raise funds to purchase books for that and other local schools. Paulding Hospital and Nursing Home embraced the senior community it serves by celebrating National Older People's Month. The hospital had activities that helped honor the seniors with events and educational sessions. More than 100 people attended Wellstar East Paulding Primary Care's Diabetes Community Health Fair during the year. This fair attempted to identify local residents at risk for this disease. Wellstar Health System was named to the AARP National Employer Team for its commitment to recruiting older employees. Wellstar also has several partnerships with local colleges to provide clinical training for nursing and therapy students to compliment their classroom curriculum in those areas. One of Wellstar's own, Cecilia Byers, was honored by the Governor of Georgia as the Biomedical Engineer of the Year. The award recognized her commitment to education, professional integrity and community involvement. Ms Byers serves the biomedical needs at Paulding, Douglas, Cobb and Windy Hill hospitals and other Wellstar entities. She helps mentor Chattahoochee Technical School students in an internship at Wellstar as well as a local high school Magnet program in Cobb County and Paulding County schools. Paulding Hospital instituted a recycling program which resulted in: 40,000 pounds (20 tons) of recycled material 7,600 gallons of oil saved 60 cubic yards of landfill space saved 80,000 kilowatts of energy saved 140,000 gallons of water saved and 8,000 pounds of plastic recycled Paulding Hospital was recognized by VHA, Inc. for sustaining impressive clinical results. VHA "blueprinted" the hospital's practices in reducing ventilator-associated penumonia and central line catheter-related blood stream infections to zero. These practices were then made available to other VHA member hospitals. Wellstar plans to build a new state-of-the-art 100 bed general acute care hospital in Paulding County to replace the current facility. Paulding County is one of the fastest growing counties in not only the state by across the country which makes this endeavor even more crucial for the community. 56408776 true true false false false false false false false true false true false false false false false false false false true false false true false false false false false false true false false false false false false true true false false true 0 0 535 true false false false false false false false false false 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 7707925393 805 SANDY PLAINS ROAD Marietta GA 300666340 Randall Bentley 1.0 X 0 16471 0 Robert N Cross MD 1.0 X 0 4767 0 TE Durham 1.0 X 0 34715 2135 Thomas E Gearhard MD 1.0 X 0 320689 31087 David Hafner MD 1.0 X 0 15651 0 Charles J Jones 1.0 X 0 12635 0 Connie Kirk 1.0 X 0 4195 0 Janie Maddox 1.0 X 0 4884 0 Gary A Miller 1.0 X 0 2609 0 Steven W Oweida MD 1.0 X 0 17488 0 Tom Phillips 1.0 X 0 2774 0 Walter G Robinson 1.0 X 0 3372 0 Ronald P Roper MD 1.0 X 0 9713 0 W Allen Separk 1.0 X 0 7230 0 Kessel D Stelling 1.0 X 0 1252 0 Jeffery Tharp MD 1.0 X 0 374975 32823 Ken Thigpen 1.0 X 0 10151 0 Robert G Warner MD 1.0 X 0 3581 0 Charles Pete Wood 1.0 X 0 12025 0 A James Budzinski 2.0 X 0 542322 42617 Gregory L Simone MD 2.0 X 0 1127407 76939 Bonnie Wilson 2.0 X 0 564617 45500 David Anderson 2.0 X 0 500879 38389 Donald Campbell MD 2.0 X 0 392181 31906 Barbara B Corey 2.0 X 0 354487 28277 Bruce Dean 2.0 X 0 231199 23450 Marcia Delk MD 2.0 X 0 420898 41645 K Darold Etheridge 2.0 X 0 257321 24944 Lee Evins 2.0 X 0 237160 22440 T Mark Haney 25.0 X 0 348007 32214 Patrick Jansen 2.0 X 0 233543 19687 Christopher Kane 2.0 X 0 361179 32046 Kenneth Kunze MD 2.0 X 0 497872 35952 Lou Little 2.0 X 0 290248 31176 Kimberly Menefee 2.0 X 0 322123 28095 Ronald Strachan 2.0 X 0 398320 34634 ROBERT MANDLER 2.0 X 0 235075 21295 MICHAEL GRAUE 2.0 X 0 658068 49874 JONATHAN MORRIS 2.0 X 0 148980 12644 ELLEN LANGFORD 2.0 X 0 188974 17817 Anthony M Trupiano 2.0 X 0 233753 17874 Robin Wilson MD 2.0 X 0 154726 13389 Joseph L Brywcznski 2.0 X 0 0 0 Elizabeth A Hoffmann 2.0 X 0 0 0 Richard T Lopes MD 2.0 X 0 0 0 James M Swartz 2.0 X 0 0 0 Mary L Wesley 2.0 X 0 0 0 John Law 50.0 X 168785 0 18361 Andrea M Parson 50.0 X 136778 0 17929 Carol S O'Connell 50.0 X 121887 0 12808 Vicky Lynn Hogue 50.0 X 176150 0 20156 Bolan Dreher 50.0 X 120065 0 14266 Marsha Burke 1.0 X 0 550796 43614 Linda A Clark 1.0 X 0 402300 24741 Bruce Harrison 2.0 X 0 378334 34449 Nancy Kemp 1.0 X 0 226912 13955 Teresa Ray 1.0 X 0 322133 19811 Andrew Tatnall 1.0 X 0 187893 11548 723665 11626884 1020487 17 true true false Brasfield Gorrie 1990 Vaughn Rd NW Suite 100 MARIETTA GA 30144 General Contractor 236251 HKS Inc PO BOX 731121 DALLAS TX 753731121 General Contractor 551254 Clark Ambulance Service Inc PO Box 1789 DALLAS GA 30132 Medical Service 175654 Surgical Operational Service 505 Commerce Park Drive Suite G MARIETTA GA 30060 SUPPLY CONSULTING 143185 CDH Partners 675 Tower Rd MARIETTA GA 30060 General Contractor 118018 8 889511 889511 HOSPITAL PATIENT REVENUE 621990 64682380 64682380 MEDICAL RECORDS 621990 69 69 64682449 514453 514453 0 0 25608 25608 25608 25608 9408849 8740952 667897 667897 667897 0 0 0 GROUND LEASE REVENUE 532000 16000 16000 CAFETERIA 722210 181557 181557 IMMUNIZATIONS 621990 15994 15994 150823 150823 364374 67144292 64682449 0 1572332 0 0 0 0 380221 320298 59923 0 0 19977246 16829764 3147482 0 1436977 1210509 226468 0 1875599 1580005 295594 0 1486666 1252368 234298 0 0 22 0 22 0 0 0 0 0 935243 866636 68607 0 337 31 306 0 6282750 6086125 196625 0 0 0 1226410 466731 759679 0 50018 26841 23177 0 0 50129 11565 38564 0 108882 108882 0 9143245 7702270 1440975 0 2617238 1655768 961470 0 691294 0 691294 0 REPAIRS & MAINTENANCE 913078 580612 332466 BAD DEBT 17040120 17040120 OTHER OPERATING EXPENSE 779133 779133 64994608 56408776 8585832 0 1500 1550 1353257 848845 5424458 4752999 768745 1073473 524185 783154 50082853 26753690 20401082 23329163 8334113 9242968 820654 974263 37627994 41006415 7152200 7468587 1340887 420321 11751851 13456123 20244938 21345031 X 17383056 19661384 17383056 19661384 37627994 41006415 X false true true X false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2986659 2986659 14902121 9660471 5241650 354662 263059 91603 23474725 16830160 6644565 8364686 8364686 23329163 0 ACCRUED PENSION LIABILITY 6519253 OTHER LT LIABILITIES (ARO) 586300 OTHER LT LIABILITIES (ALLOCATE 91206 UNCLAIMED PROPERTY (ALLOCATED) 40613 ASSET RETIREMENT OBLIGATION LT 169600 INSURANCE RESERVE 414067 TAX EXEMPT BOND LIAB-DUE TO WHS 5635084 13456123 SCH D PART X, LINE 2-LIABILITIES The following footnote is taken from the audited financial statements for Wellstar Health System and Affiliates (including Paulding Medical Center): "WellStar 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 Sec 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 X true X 125. true X true true true false true true 2242962 2242962 0.04710 4775942 3333000 1442942 0.03030 7018904 3333000 3685904 0.07740 86177 86177 0.00180 86177 86177 0.00180 7105081 3333000 3772081 0.07920 true 4733057 61296 9347405 12527615 -3180210 X true true Wellstar Paulding Hospital

600 West Memorial Drive Dallas GA 300666340

X X X Skilled Nursing Home Paulding Medical Center, Inc. is an affiliate of Wellstar Health System, Inc. and as such is included in the consolidated Community Benefit Report that is annually issued to members of the five county service areas located in the northwest area of the state of Georgia. This report addresses the services and accomplishments of the entire health system for the reporting period. This information is also made a part of the annual Georgia Hospital Association report of community benefit along with other hospitals and healthcare systems throughout the state. Wellstar Health System (including Paulding Medical Center, Inc.) has elected to use the cost to charge ratio from our FY2009 Hospital Financial Survey filed with the state of Georgia. This cost to charge ratio reconciles with the community benefit reporting done both internally in the system and with our annual published community benefit report which is distributed to the Wellstar service areas as well as reported to the Georgia Hospital Association. The $3.8 million in net community benefit represents 7.9% of total operating expenses (less bad debt). As part of the IRS ruling 69-545 for community benefit and a requirement of charitable organizations under IRS code Section 501 ( c ) this represents the commitment of the hospital and healthcare system to providing care to the needy members of the community consistent with its charity care policy regardless of their ability to pay for those services. The percentage of net community benefit to total expenses from Form 990, Part IX, Line 25, column (A) is documented on Schedule H, Part 1, line 7, column (f) for each charity, means tested government programs and other community benefits. However we have adjusted the amount of total expenses ($64,994,608) by subtracting the bad debt expense of $17,040,120 for the calculation and subsequent percentage. In the audited financial statements for WellStar Health System and Affiliates for the reporting period there is not a specific footnote related to bad debt expense but the following notes are mentioned: "The preparation of financial statements in conformity with US generally accepted accounting principles requires that management make estimates and assumptions affecting the reported amounts of assets, liabilities, revenue, and expenses, as well as disclosure of contingent assets and liabilities. Actual results could differ from those estimates. Significant items subject to such estimates and assumptions include the determination of the allowances for uncollectible accounts and contractual adjustments." Also regarding net patient service revenue the audited statements note the following: "Net patient service revenue is reported at the estimated net realizable amounts from patients, third-party payors, and others for services rendered, including estimated retroactive adjustments due to future audits, reviews and investigations." Certain accounts with unrealizable amounts are deemed uncollectible and written off as bad debt. And as patient accounts navigate throughout the collection process some of those accounts are classified as bad debt as it appears it is less likely that the bill will be paid. Some of those accounts will subsequently be determined to have qualified or currently qualify for charity or other financial assistance. Some patients will not provide the necessary paperwork to meet these qualifications. Other patients will be reluctant or unresponsive to the request for information because of their particular situation such as a victim of crime or an undocumented alien. While the percentage of these type of patients is not substantial we have determined that there is a portion (approximately 1.2%) that would have been counted in the community benefit totals if they had been more cooperative. Generally speaking however, Wellstar and its affiliaties do not treat the majority of bad debt accounts as uncompensated care. The Medicare shortfall reported on line 7 is similar in some ways to the Medicaid shortfall from Part I of Schedule H. Medicare shortfalls generally represent the uncompensated difference between the expected reimbursement and the Medicare charges stated at cost. The costing methodology to determine the amounts reported on line 6 of part III comes from the annual Medicare cost report filed for the hospital. The policy written for collection practices at all Wellstar Health System entities incorporates quidelines for personnel in the admissions and patient access areas to be trained in identifying those patients that might qualify for charity care or other financial assistance. Since it is the policy of Wellstar hospitals to treat any and all patients regardless of their ability to pay especially in the hospital emergency rooms, efforts are made to provide at least one employee or contractor at all times to assist patients in the necessary paperwork to qualify for charity care or governmental assistance programs. This assistance often extends even after the initial visit as the collection process continues. Wellstar Paulding Hospital is a general acute care hospital providing a full range of services. It is licensed to operate 83 beds by the State of Georgia but is staffed to operate 34 beds. The hospital is located on a 50-acre campus in Dallas, Georgia in a complex of commercial buildings containing approximately 230,000 square feet. The original hospital was built in 1958 and since that time has seen at least five major structural additions and renovations. A new state of the art hospital is planned to replace this facility in the next few years. Wellstar (and its affiliated hospitals) 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 coalition 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 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, continuous community involvement leads to community ownership of the process. Community ownership, in turn, increases the credibility and sustainability of the health improvement efforts. Paulding Hospital is a provider for both Medicare and Medicaid beneficiaries. As such, the hospital provides patients with financial counselors who are trained to assist them in all of the programs offered by the system including governmental programs, uncompensation programs, payment plans, charity discounts, and other programs. These financial counselors are well versed in the eligibility for the traditional Medicare and Medicaid program including SSI Disability through the Medicare. Special programs through the state Medicaid program for expectant mothers and children are presented as options to obtain payment for needed medical care. Indigent and charity eligible patients are offered assistance through the hospital's Charity and Indigent Care Policy which includes funds through the state's Indigent Care Trust Fund. If the patient has no other insurance and fails to qualify for indigent care 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 patients are afforded these options and opportunities. Paulding 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 and is expected to receive the majority of its patients from one of the following five counties--Bartow, Cherokee, Cobb, Douglas and Paulding-generally about 85% to 90%. While these counties are in the metropolitan Atlanta area (or border on the metro area) they are in some of the fastest growing areas in the entire country. The system has therefore expanded to bring many services to the geographic area that previously were not available except in the Atlanta community. Economically the region is strong in per capita income but as in may areas of the country the system has seen an increase in the unemployment numbers and thus an increase in the uninsured and indigent population for the patients it serves. The system remains positioned to meet the changing needs of the community. As stated in the Wellstar Health System and Affiliates Audited Financial Statements for the period ending June 30, 2010, Paulding Medical Center (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 Ruling 69-545. In this regard the governing body of the organization and/or it 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. Paulding Hospital committed approximately $6.0 million in capital expenditures for the year to meet the technology and program needs of the community it serves. X X X X X X false true X X X X X true true false false false false true false Thomas E Gearhard MD 0 277415 0 0 0 43274 0 0 0 0 0 320689 0 0 Jeffery Tharp MD 0 252457 0 0 0 122518 0 0 0 0 0 374975 0 0 A James Budzinski 0 420659 0 108651 0 13012 0 38425 0 4192 0 584939 0 0 Marsha Burke 0 550796 0 0 0 0 0 39033 0 4581 0 594410 0 0 Linda A Clark 0 402300 0 0 0 0 0 24741 0 0 0 427041 0 0 Gregory L Simone MD 0 809466 0 302279 0 15662 0 73802 0 3137 0 1204346 0 0 Bonnie Wilson 0 417321 0 134446 0 12850 0 39687 0 5813 0 610117 0 0 David Anderson 0 368147 0 120049 0 12683 0 35424 0 2965 0 539268 0 0 Donald Campbell MD 0 295414 0 85967 0 10800 0 28784 0 3122 0 424087 0 0 Barbara B Corey 0 263238 0 80299 0 10950 0 26777 0 1500 0 382764 0 0 Bruce Dean 0 191680 0 30424 0 9095 0 18417 0 5033 0 254649 0 0 Marcia Delk MD 0 316598 0 92972 0 11328 0 31275 0 10370 0 462543 0 0 K Darold Etheridge 0 186959 0 55161 0 15201 0 20084 0 4860 0 282265 0 0 Lee Evins 0 171405 0 39268 0 26487 0 18665 0 3775 0 259600 0 0 T Mark Haney 0 242031 0 91501 0 14475 0 26541 0 5673 0 380221 0 0 Bruce Harrison 0 278872 0 87392 0 12070 0 28459 0 5990 0 412783 0 0 Patrick Jansen 0 178558 0 27979 0 27006 0 18097 0 1590 0 253230 0 0 Christopher Kane 0 288428 0 60926 0 11825 0 27233 0 4813 0 393225 0 0 Nancy Kemp 0 166656 0 11166 0 49090 0 13955 0 0 0 240867 0 0 Kenneth Kunze MD 0 405444 0 80238 0 12190 0 35410 0 542 0 533824 0 0 Lou Little 0 210372 0 68687 0 11189 0 23133 0 8043 0 321424 0 0 Kimberly Menefee 0 235766 0 74822 0 11535 0 24820 0 3275 0 350218 0 0 Teresa Ray 0 218400 0 18610 0 85123 0 19811 0 0 0 341944 0 0 Ronald Strachan 0 270123 0 57603 0 70594 0 28407 0 6227 0 432954 0 0 Andrew Tatnall 0 147670 0 11584 0 28639 0 11548 0 0 0 199441 0 0 John Law 131170 0 28865 0 8750 0 13172 0 5189 0 187146 0 0 0 Andrea M Parson 125617 0 11011 0 150 0 10924 0 7005 0 154707 0 0 0 Vicky Lynn Hogue 143660 0 23765 0 8725 0 13881 0 6275 0 196306 0 0 0 ROBERT MANDLER 0 183917 0 27811 0 23347 0 18020 0 3275 0 256370 0 0 MICHAEL GRAUE 0 492184 0 88589 0 77295 0 45369 0 4505 0 707942 0 0 JONATHAN MORRIS 0 116750 0 25000 0 7230 0 11056 0 1588 0 161624 0 0 ELLEN LANGFORD 0 153885 0 26364 0 8725 0 15558 0 2259 0 206791 0 144223 Anthony M Trupiano 0 185075 0 11541 0 37137 0 17874 0 0 0 251627 0 0 Robin Wilson MD 0 120878 0 0 0 33848 0 9717 0 3672 0 168115 0 0 SEVERANCE BENEFITS SCHEDULE J PURSUANT TO THEIR RESPECTIVE EMPLOYMENT AGREEMENTS, THE FOLLOWING OFFICERS ARE ENTITLED TO SERVERANCE PAYMENTS BASED ON THEIR BASE SALARY AND WAGES AT THAT TIME IN THE EVENT OF CERTAIN IDENTIFIED CIRCUMSTANCES. OFFICER -----SEVERENCE BENEFIT PERIOD ----------------- DAVID W. ANDERSON 24 MONTHS DONALD H. CAMPBELL 18 MONTHS LINDA C. CLARK 24 MONTHS RANDY COOK 12 MONTHS BARBARA B. COREY 18 MONTHS MARCIA L. DELK, M.D. 18 MONTHS DAROLD ETHERIDGE 12 MONTHS LEE EVINS 12 MONTHS T. MARK HANEY 18 MONTHS BRUCE HARRISON 12 MONTHS NANCY KEMP 12 MONTHS JOHN LAW 12 MONTHS LOU LITTLE 18 MONTHS KIMBERLY W. MENEFEE 18 MONTHS TAREY RAY 18 MONTHS ANDY TATNALL 18 MONTHS LEIGH COX 12 MONTHS BONNIE L. WILSON 24 MONTHS MARSHA BURKE 24 MONTHS GREGORY L. SIMONE 24 MONTHS CHRISTOPHER KANE 18 MONTHS RON STRACHAN 12 MONTHS CANDICE SAUNDERS 18 MONTHS JIM BUDZINSKI 18 MONTHS MIKE GRAUE 18 MONTHS ROBERT HAMILTON 12 MONTHS ROBERT JANSEN 12 MONTHS ELLEN LANGFORD 12 MONTHS KENNETH KUNZE, MD 18 MONTHS ROBERT MANDLER 12 MONTHS JONATHAN MORRIS 12 MONTHS ANTHONY TRUPIANO 12 MONTHS ROBIN WILSON, MD 12 MONTHS JOSEPH BRYWCZYNSKI 18 MONTHS ELIZABETH HOFFMAN 12 MONTHS RICHARD LOPES, MD 18 MONTHS JAMES SWARTZ 12 MONTHS MARY WESLEY 18 MONTHS During the year, the following individuals received a payout in the amounts listed in accordance with their severance agreements as set forth above: MARSHA BURKE $362,882 LINDA CLARK $236,146 LEIGH COX $144,000 NANCY KEMP $ 55,878 TERESA RAY $ 65,111 Non-Fixed Payments to Officers Form 990 Schedule J 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 recommended and 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 comparable 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 indicators. Upon successful acheivement in various targeted levels for each factor an overall performance measurement is developed for each individual. Based on that measurement a performance payout is recommended and approved by the Board of Trustees after the annual financial audit is completed. Other Compensation Form 990, Schedule J, Part 1B & 2 While Wellstar Health System and its affiliates do not have a written policy regarding payment or reimbursement fo the items listed in Part 1 Line 1a, the organization follows IRS guidelines in the payment of any of these items to individuals listed in Form 990 Part VII Section A. Compensation Exceptions On Schedule J of IRS Form 990 the following individuals were employed by Wellstar Health System, Inc. as officers during the fiscal year reporting period but had no salary and benefits reported during the calendar year for which this schedule applies: Joseph L Brywczynski Elizabeth A Hoffmann Richard T Lopes MD James M Swartz Mary L Wesley PAMELA ETHERIDGE WIFE OF OFFICER 51723 WELLSTAR EMPLOYEE false GREG FORTGANG SON-IN-LAW OF BD MEMBER 88813 WELLSTAR EMPLOYEE false GEORGE FLEMING BROTHER OF OFFICER 56575 WELLSTAR EMPLOYEE false AMY SIMONE DAUGHTER OF OFFICER 88061 WELLSTAR EMPLOYEE false MATTHEW MADDOX SON OF BOARD MEMBER 36500 WELLSTAR EMPLOYEE false BONNIE MILLER WIFE OF BOARD MEMBER 26996 WELLSTAR EMPLOYEE false Tax Compliance 990T Explanation Part V Line 3a & b UBIT Paulding Medical Center, Inc. had no unrelated business income for the reporting period but is filing a 990-T to supplement discovery of that income in future periods. Conflict of Interest Policy Part VI Policies Line 12a, b & c Our Conflict of Interest Policy requires all covered persons to annually review the policy and complete, sign and return the conflicts of interest survey and attestation to the Compliance Office. The policy requires an on-going disclosure obligation in the event a conflict arises during the year. 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. 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 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 Executive Compensation Part VI Section B Policies Line 15A & B 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: Kessel Stelling Chair Pete Wood Janie Maddox Al Separk Board Chairman 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. Consolidated Financial Statements Form 990 Part IV Line 12 & Part XI Line 2b Paulding Medical Center, Inc. is audited on an annual basis as part of the consolidated financial statement audit of Wellstar Health System, Inc. and its Affiliates. Tax-Exempt Bonds Allocation Form 990 Part IV Line 24a & Part X 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). Paulding Medical Center, Inc. will report this tax exempt bond liability on Part X, Line 25 Other Liabilities. Paulding Medical Center, Inc. has also restated its beginning balance sheet with respect to tax exempt bond liabilities as the amounts allocated to tax exempt bond liabilities are now included on Line 25. Compensation Reported on Form 990 Form 990 Part X Lines 5-10 & Schedule J, J-1 & J-2 All compensation amounts reported on Form 990 Part IX Lines 5-10 and Schedules J, J-l & J-2 represent compensation provided to individuals that provide services to Paulding Medical Center, Inc. Likewise the number of employees reported on Part V Line 2a represent the number of individuals providing services to the organization. All Federal Employment Tax responsibilities for those individuals are handled by Wellstar Health System, Inc. (EIN 58-1649541). 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 election an 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. Form 990 Copy to Board of Directors 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. This reviewed form is then made available to both the organization's Finance committee of the Board of Trustees as well as the full board in the form of an electronic (pdf. format) version and hard copy of the return. The organization's CFO subsequently signs the return for either manual or electronic filing by the appropriate due date. Officers Hours Worked Form 990 General Statement & Schedule J The officers devote their time to all of the organizations with Wellstar Health System that are listed in Schedule R, Part II. As such, the total hours worked by the officers across all of the organizations exceeds 40 hours per week. Current Officers/Directors Relationships FORM 990 PART VI, SECTION A LINE 2 Two of the current officers and directors for Wellstar Health System, Inc. --EIN 58-1649541 are related to each other through family. Lou Little, Sr VP Post Acute Services and Administrator of Windy Hill Hospital is the brother-in-law of Gregory Simone, President and CEO for the system. Disclosure of Financial 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. 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. Bylaws Changes Form 990, Line VI, Line 4 On June 17, 2010, the Wellstar Health System and its affiliates amended its bylaws to address the manner of election and terms of office for members of the Board of Trustees. The Chair appoints a Governance Committee consisting of three (3) or more Trustees for purposes of recommending nominations. Nominations are voted upon by the full Board and each Trustee is appointed to serve terms of three years, although the Board can establish a shorter term at the time of election. Each Trustee may serve a "Term Limit" of not more than four (4) consecutive terms of three years. To provide continuity on the Board, there is established a methodology of rotation off the Board for the 18 existing Trustees effective June 30, 2010. One Trustee will rotate off the Board in year one; two Trustees will rotate off the Board in year two; one Trustee will rotate off the Board in year three; and continuing for all remaining positions until all Trustees have expired terms or elect to leave the Board. At the end of the "term limit" the Trustee may be re-elected after a one year absence from the Board. Compensation Form 990, Part V, Line 2 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). SCHEDULE L PART IV TRANSACTIONS WITH INTERESTED PARTIES Several transactions with interested parties of Paulding Medical Center Inc. all fall below the $100,000 threshold in business transactions. CHS Foundation 805 Sandy Plains Road Marietta GA 30066 581649540 Foundation GA 501(c)(3) 11 NA Cobb Hospital Inc 805 Sandy Plains Road Marietta GA 30066 580968382 Healthcare GA 501(c)(3) 3 NA Douglas Hospital Inc 805 Sandy Plains Road Marietta GA 30066 582026750 Healthcare GA 501(c)(3) 3 NA Kennestone Hospital Inc 805 Sandy Plains Road Marietta GA 30066 582032904 Healthcare GA 501(c)(3) 3 NA Wellstar Foundation 805 Sandy Plains Road Marietta GA 30066 581627413 Foundation GA 501(c)(3) 11 NA Wellstar Health System 805 Sandy Plains Road Marietta GA 30066 581649541 Healthcare GA 501(c)(3) 3 NA Cobb Hospital Parking Company LLC 805 Sandy Plains Road Marietta GA 300666340 752999669 Parking GA NA INVESTMENT 41418 840467 false false Kennestone East Parking Deck LLC 805 Sandy Plains Road Marietta GA 300666340 200537100 Parking GA NA INVESTMENT 193986 1887789 false false Community Assurance Co 3rd Fl Barclays House Shedden Rd George Town Grand Cayman, BWI CJ 581649541 Insurance CJ WHS Inc C 0 72634317 1.00000 false false false false false false false false false false false false false false false false false false