2011-07-14T17:59:18-05:00 2010-08-31 DELOITTE TAX LLP 1750 TYSONS BLVD MCLEAN VA 221024219 990 2009-09-01 611356023 Our Lady of Bellefonte Hospital Inc OURL 6068333333 St Christopher Drive Ashland KY 41101 Joe Buchheit 6068333600 2011-07-14 1 Emily Hayes Smith 7032511000 2009 2016-02-24 21:20:13Z Kevin Halter St Christopher Drive Ashland KY 41101 153782023 0 0928 X www.olbh.com X 1999 KY Acute Care Hospital 27 18 1332 150 1768578 0 0 156175731 148921164 -467017 325050 4360653 4297822 160069367 153544036 0 0 59491023 56546781 0 0 97351220 89177766 156842243 145724547 3227124 7819489 91747643 91664809 58976908 55485081 32770735 36179728 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 133838757 148921164 To bring compassion to healthcare and to be good helpto those in need by providing healthcare services. Please see community benefit disclosures in Sch H. 133838757 1 0 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 144 0 1 1332 1 1 1 0 0 0 0 0 0 0 0 27 18 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 0 1 1 0 X Pam Hall 6068333601 OLBH St Christopher Drive Ashland KY 41101 Gregory Bausch 4.00 X 0 0 0 Danny Bentley 4.00 X 0 0 0 Mary Carolyn Carter 4.00 X 0 0 0 William Dickens 4.00 X 0 0 0 Larry Fields 4.00 X 0 0 0 Mary Catherine Flath 4.00 X 0 0 0 John Gross III 4.00 X 0 0 0 Sr Karen Hartman 4.00 X 0 0 0 Skip Hubbard 50.00 X 0 694737 99499 Daniel Huffman 4.00 X 0 0 0 Sr Rose Marie Jasinski 4.00 X 0 0 0 Connie Johnson 4.00 X 0 0 0 David Jones 50.00 X 0 898058 91577 Larry Jones 4.00 X 0 0 0 Elizabeth Keith 50.00 X 0 0 32292 Phillip Leslie 4.00 X 0 0 0 Angela Lewis 4.00 X 15449 0 0 George Moore 4.00 X 0 0 0 Sam Ross 50.00 X 0 623476 85946 Valinda Rutledge 50.00 X 0 798608 92051 Ramona Salyer 4.00 X 0 0 0 EW Unnikrishnan MD 4.00 X 0 0 0 William Willan 4.00 X 0 0 0 Kevin Halter 50.00 X X 0 385942 62878 Joe Buccheit 50.00 X X 354134 0 47427 John Wallenhorst 50.00 X X 0 269069 42368 Frank Warnock 6.00 X X 0 0 0 Jennifer Moore 50.00 X 212496 0 19590 Emilio A Punzal MD 50.00 X 421826 0 27736 Jose Marie Makalinao MD 50.00 X 274623 0 9333 Peter O Lyn MD 50.00 X 229283 0 26306 Myra L Carroll 50.00 X 156175 0 13501 Thomas G Lyons 50.00 X 147382 0 3513 Mark Gordon 0.00 X 0 681718 59405 Charles Rhodes MD 0.00 X 0 0 0 Mark Neff 0.00 X 0 0 0 Thomas Wolf 0.00 X 0 0 0 Angela Foltz 0.00 X 0 0 0 1811368 4351608 713422 7 1 1 0 Morrison Management Specialists Inc PO Box 102289 Atlanta GA 303682289 Cafeteria/Food Services 3335763 Ashland Anesthesia PSC PO Box 1377 Ashland KY 411051377 Anesthesia 2695660 Aramark Healthcare Facility Services In 24863 Network Place Chicago IL 606731248 Healthcare Cleaning 1820011 Aramark CTS Inc 12483 Collections Center Dr Chicago IL 60693 Equipment maintenance 1385429 Ashland GI Svcs LLC 6339 E Speedway Suite 201 Tucson AZ 85710 Gastrointestinal Services 961920 91 Patient Service Rev. 622110 148921164 148921164 148921164 517732 517732 1125 1125 1125 1125 45305 237987 -192682 -192682 -192682 Retail Pharmacy Rev. 446110 2430186 607547 1822639 Non-patient Lab Svcs. 531120 1159906 1159906 JV - Infusion Sols. 621610 -14177 -14177 720782 720782 4296697 153544036 148921164 1768578 2854294 1305666 949207 356459 40276946 36265654 4011292 4140360 3726324 414036 7856762 7071086 785676 2967047 2670342 296705 419151 419151 86758 86758 14411 14411 5603377 5603377 1172288 1055059 117229 14485515 13121575 1363940 383459 260502 122957 4870131 3652598 1217533 8653966 7788569 865397 Medical Supplies 19107614 19107614 0 0 Purchased Services 12871366 11595969 1275397 0 Bad Debt 12694325 12694325 0 0 Corporate Dues 3426912 3426912 0 0 0 0 0 0 5388493 4849644 538849 145724547 133838757 11885790 0 1008131 4894049 14444063 14879379 822688 802885 3537039 3535658 159245 966986 115255138 57506652 62652544 57748486 463418 5796335 6686874 2864180 2150492 91747643 91664809 46862143 12878637 4114833 12114765 38491611 58976908 55485081 X 32770735 36179728 0 0 32770735 36179728 91747643 91664809 X 0 1 1 X 1 1 X 0 0 0 0 0 0 0 0 1 14411 14411 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: Our Lady of Bellefonte Hospital paid dues to the Kentucky Hospital Association, Catholic Health Association, and American Hospital Association a portion of which is used for lobbying activities. The portion of dues allocated to lobbying activities for each of these organizations is as follows: 15.6% ($8,069) to the KHA, 4.68% (1,367) CHA, 23.76% (4,975) AHA. 4583456 4583456 57030296 20423501 36606795 2528936 1046046 1482890 48073825 34352333 13721492 3038625 1684772 1353853 57748486 Mellon Investments 6686874 F 6686874 Pension Liability 35441002 Mcare/Mcaid Liability 2248855 Other Miscellaneous 650843 Payroll and State Liabilities 150911 38491611 Part X: 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. 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: FIN 48 addresses the accounting for uncertainty in income taxes recognized in an entity's financial statements and prescribes a threshold of more-likely-than-not for recognition and derecognition of tax positions taken or expected to be taken in a tax return. The adoption of FIN 48 by BSHSI on September 1, 2007 did not have a material impact on BSHSI's consolidated financial statements. 1 1 1 X 1 X 1 1 1 0 1 1 2903 3809518 953115 2856403 0.02150 25754 20739543 15198912 5540631 0.04160 28657 24549061 16152027 8397034 0.06310 30 56195 542164 60346 481818 0.00360 3 215 1162828 163801 999027 0.00750 2 924162 924162 0.00690 10 2137 43529 43529 0.00030 45 58547 2672683 224147 2448536 0.01830 45 87204 27221744 16376174 10845570 0.08140 2 1102 6388 6388 0.00000 2 271 172707 172707 0.00130 2 775 4917 4917 0.00000 9 1602 160350 160350 0.00120 3 21878 41002 41002 0.00030 1 140 799 799 0.00000 1 890 890 0.00000 20 25768 387053 387053 0.00280 1 3535840 41496975 41825111 -328136 X 1 1 Our Lady of Bellefonte Hospital Inc

St Christopher Dr Ashland KY 41101

X X X Bellefonte Home Health Care Agency

1819 Ashland Road Greenup KY 41144

X OLBH Pediatric Rehabilitation Clinic

1629 Ashland Road Unit 2 Greenup KY 41144

X Sleep Lab

118 St Christopher Dr Ashland KY 41101

X Bellefonte Behavioral Health

St Christopher Dr Ashland KY 41101

X Bellefonte Center

1000 Ashland Drive Ashland KY 41101

X Women's and Administrative Services Renaissance Sleep Lab

2920 Winchester Avenue Ashland KY 41101

Sleep Lab Ironton MRI

1015 East Ring Road Ironton OH 45638

Diagnostic MRIs Part I, Line 6a: Bon Secours Kentucky Health System annually develops a report to the community, explaining the various community benefit services and programs that exist. This report also includes the annual financial commitment of the local system to the community, detailing monetary contributions for government sponsored healthcare shortfall, community benefit programs and charity care at cost. This report is published each year and posted on the web at http://www.olbhfoundation.com. Part I, Line 7: Part I, line 7a: Charity Care at cost is computed by applying a cost-to-charge ratio to the aggregate charity adjustments recorded in the general ledger. Part I, line 7b: Unreimbursed Medicaid is computed by determining the cost of Medicaid services supplied less payments received for these services. To determine the cost of Medicaid services provided, a cost-to-charge ratio is applied to traditional and managed Medicaid gross charges recorded in the general ledger. Payments include payments for individual claims, payments from the Medicaid program paid outside the claim process (such as medical education payments) and expected or actual cost report settlements.Part I, line 7c: Unreimbursed costs from other means-tested government programs are computed by applying a cost-to-charge ratio to the total charges to patients covered under these programs. The charges are identified by the financial class assigned to the patient. For Part I, Line 7 a-c computations: The cost-to-charge ratio is derived using the suggested computation in Worksheet 2, Ratio of Patient Care Cost-to-Charges. Operating expenses and gross patient charges are taken from the general ledger. Expenses for non patient care activities recorded in operating expenses are approximated as directly equaling other operating revenue, assuming these activities do not provide profit. Part I, line 7e: Community health improvement services and community benefit operations are accumulated throughout the year and reported at actual cost in a software program that specifically addresses this purpose.Part I, line 7f: Health professions education cost is determined as the direct and indirect cost of qualifying education activities as traditionally reported in columns 21-24 on Worksheet B of the Medicare cost report as a Medical Education program, nursing school or other allied health program. Part I, Line 7f: Current year bad debt expense not included in the calculation for line 7, Column (f) is $12,694,325. Part III, Line 4: Part III, line 2: Bad Debt Expense at cost is computed by applying the cost-to-charge ratio computed on Worksheet 2 to the aggregate bad debt expense for patient accounts recorded in the general ledger. Bad debt expense on the general ledger includes: 1) actual write offs of discounted gross charges where it is determined an uninsured patient can pay and does not pay; and 2) the estimated write offs for uninsured patient accounts with outstanding balances after discount. Estimates are based on historical collection rates.When an uninsured patient is billed for patient care services, the charges are automatically discounted and the patient is requested to only pay the amount after discount. The discount is recorded as an adjustment to gross revenue and is not recorded in bad debt expense. If the balance after discount is not paid or not paid in full, the unpaid amount will be written off to bad debt expense. When a patient remits a payment on an account that has already been written off to bad debt expense, the payment is recorded as a recovery of bad debt, which reduces bad debt expense.Part III, line 3: The organization does not report an estimate for the portion of bad debt expense that may have been likely to qualify for financial assistance under the hospital's charity care policy. The organization takes the position that ample opportunity and assistance is provided to the patient to qualify under the financial assistance policy. If sufficient information is not provided, the organization must assume the patient does not qualify. Part III, Line 8: Part III, Line 6: Medicare allowable costs reflected in Part III come directly from the facility's Medicare cost report. The cost report segregates the total facility actual expenses into costs for support departments, clinical departments (routine and ancillary) and non reimburseable departments. The cost report uses appropriate statistical bases to "step down" support costs to allowable clinical and non reimburseable departments. The charges for clinical departments are matched to the total cost for these departments for a cost-to-charge ratio. Medicare-specific allowable costs for in and outpatient ancillary departments are computed by applying the department-specific cost-to-charge ratio to the Medicare program charges by department. For routine departments, a per diem total cost is computed and applied to Medicare program days for the Medicare routine program cost.Part III, Line 8: The total shortfall of Medicare reimbursement compared to computed Medicare allowable costs should be treated as community benefit. The hospital improves access to patient care by providing services regardless of a patient's ability to pay or the hospital's ability to receive full cost reimbursement for services. The hospital also relieves the government of a financial burden when it provides care to publically insured patients where reimbursement is less than cost of providing the service. Part III, Line 9b: The hospital has a written policy that describes collection practices applying to patients that qualify for charity care or financial assistance. If full assistance is approved, no collection efforts are pursued on that patient's account(s). If partial assistance is provided, the patient is responsible for the adjusted account balance and collection efforts will follow the established practices for all patients where a self-pay balance exists. Collection efforts are not pursued on any pending FAP account.Specific criteria exist for how much assistance, partial or total, will be provided to the patient based on the assessed need. Criteria is based on Federal Poverty Guidelines and is reviewed and updated annually. Once a patient has been deemed eligible for the Patient Financial Assistance Program (FAP), the patient is notified by letter within 60 days after receipt of the application and supporting documentation. The patient retains eligibility for a period of twelve months from the date of the approval. This eligibility is signaled to hospital admissions, billing and collection staff by the assignment of a specific financial class with accompanying eligibility dates. At the end of those twelve months, the patient is responsible for reapplying for FAP eligibility. Part VI, Line 2: Bon Secours Kentucky, Our Lady of Bellefonte Hospital (OLBH) uses multiple approaches to assess the health needs of the communities it serves. We have a community based Board of Directors that provides the hospital with guidance and input on services needed in the local community through contacts with local business and government leaders. Community health screening data is gathered through the year and analyzed for use in planning. OLBH currently partners with the Greenup County Health Department in its MAPP (Mobilize for Action through Planning & Partnerships) project which is a state mandated program that will result in a comprehensive community health plan for each county in Kentucky. OLBH also supports the Northeast Kentucky Care Center (NEKCC), a free health care clinic serving uninsured adult residents of Boyd and Greenup Counties. The clinic provides an option other than the emergency department for our uninsured adult population that needs primary care services. OLBH has provided financial support, volunteer personnel, and supplies for the clinic.The most recent comprehensive community needs assessment for our tri-state area was a collaborative effort by the Lewis College of Business at Marshall University in Huntington, WV, and the River Cities Community Health Coalition. Conducted in 2002, a survey questionnaire of 88 questions was jointly developed and then administered by telephone to a random sample of households in the 12-county, tri-state area that comprises the River Cities (Ashland, KY; Huntington, WV; and Portsmouth, OH). Significant findings include:- Nearly 30% of respondents did not participate in any kind of physical activity.- Nearly 50% of respondents were trying to lose weight.- It had been more than one year since 20% of respondents had had their blood pressure checked.- Slightly over 25% of the survey respondents smoked cigarettes and over 80% of these respondents said they would like to quit smoking if they could.- 33% of male respondents had not had prostate or testicular cancer screening.- 36% of female respondents over the age of 40 had never had a mammogram.- 52% of respondents had not had a tetanus shot in the past 10 years.- Nearly 24% of respondents said they had never had their cholesterol checked by a health professional.- Almost 43% of the overall survey respondents said they had needed medical care but did not seek it because of a lack of money, lack of insurance or lack of transportation.OLBH has been instrumental in developing programs to meet these needs that include a van ministry that provides free non-emergency medical transportation for outpatient services at our campus and primary care centers; developing the Greenup County Interagency Council; a county drug task force, Greenup Residents Ending Addiction Together (GREAT); church partnerships with 52 churches to develop health ministry and/or faith community nursing programs; and our support of the previously mentioned Northeast Kentucky Care Center and Greenup County Health Department MAPP project.Community need assessments are updated using a variety of informational sources including Kentucky Health Information for state-based performance data, Kentucky Hospital Association info site for market and geographic data. Thomson-Reuters Market Expert is used to retrieve demographic information and trends for the primary and secondary service areas pertaining to Our Lady of Bellefonte Hospital.Our primary service area consists of Boyd, Greenup, and Carter Counties in Kentucky and Lawrence County in Ohio. Our secondary service area consists of Lewis County, Kentucky and Scioto County, Ohio. We continually update our information for our market share and physician planning to offer services in underserved areas of our region utilizing hospital databases, 3rd party databases, and US Census Bureau data. We have also developed regional alignment plans using this data and tying it to our underserved areas to plan for future growth in the communities we serve by providing more access points to our patients in our service areas. Part VI, Line 3: Patient financial assistance policy is communicated to patients verbally upon registration and there are visible postings of the policy in common areas throughout the hospital OLBH is committed to ensuring access to health care services for all. As a health care provider, OLBH treats all patients, whether insured, underinsured or uninsured, with dignity, respect and compassion throughout admission, delivery of services, discharge and billing and collection processes. OLBH addresses the needs of the uninsured by providing free or reduced fees on hospital services. OLBH proactively screens to identify individuals and their families who may qualify for federal, state or local health insurance programs or the Bon Secours Patient Financial Assistance Program ("FAP") and assist the potential eligible patients through the qualification process. Potentially eligible patients that do not qualify for a federal or state health insurance program are referred to the Financial Assistance Coordinator located in Patient Financial Services for assistance in completing the documentation required to establish FAP eligibility. Patients are responsible for providing the information necessary to complete the documentation. The FAP aids uninsured and underinsured patients who do not qualify for government-sponsored health insurance and who communicate their inability to pay for their medical care. The FAP provides 100% financial assistance to uninsured patients with annual family incomes at or below 200% of the Federal Poverty Guidelines ("FPG"), as adjusted by the Medicare geographic wage index for each community served to reflect that communitys relative cost of living ("Adjusted FPG"). A sliding scale assistance policy is afforded patients that exceed the income guidelines for 100% assistance. Sliding scale assistance is provided to patients over 200% of the Adjusted FPG and progressively declines in proportion to the patients higher income level. Additionally, all uninsured (i.e. self pay) patients are given a reduction to the amount of the full charges for medically necessary services through a community service adjustment ("CSA"). Part VI, Line 4: BSKHS serves a region of approximately to 400,000 people in northeastern Kentucky, southern Ohio, and western West Virginia. The service areas includes six counties in northeastern Kentucky (Greenup, Boyd, Lawrence, Carter and Elliott which comprise the FIVCO Area Development District as well as Lewis County); two counties in southern Ohio (Lawrence and Scioto counties); and Wayne and Cabell counties in western West Virginia. Due to our growing aging population, services for our community residents aged 55 and older are needed, particularly women's health, orthopedics, diabetes, cardiopulmonary services and wound care. Major trends in the service area indicate a stable population that is aging. The 55 and older population is expected to increase by 14% over the next five years. The younger population tends to leave the area to find jobs. The high poverty and high unemployment rate in the area result in a low socioeconomic status. It is a very industrialized region which creates carcinogens and unhealthy life styles especially in eastern Kentucky which has some of the highest incidences in the country of smoking, diabetes, obesity and carcinogens. These demographic characteristics create a high demand for chronic disease health care including diabetes, cancer and heart disease among others. Part VI, Line 5: BSKHS commitment to social and economic justice is integrated into the fabric of the organization through its Strategic Quality Plan and its common vision of a healthy community. Our vision of a healthy community is embodied in the following statements. A healthy community is a good place to live for all residents. The rich diversity of cultures and capacities of the community are celebrated and mobilized, with a particular concern for the poor, marginalized and dying, to create physical and social environments that promote families, nurture youth and support senior citizens. Individuals have the opportunity to fully participate in defining holistic well being and assuming responsibility for the development of their innate potential. Healthy Community Services provided education and support to nurse volunteers in 61 area churches through its health ministry/faith community nursing ministry. BSKHS assists these faith communities in developing health and wellness programs that blend with existing ministries to meet the unique needs of each congregation. In all programs, the relationship between physical and spiritual health is emphasized. Through the programs and screenings, health problems such as glaucoma, diabetes, peripheral vascular disease, heart disease and hypertension, result in participants seeking early intervention and treatment. In August 2010, we became an educational partner with the International Parish Nurse Resource Center and we now have trained faculty and the rights to their basic parish nurse preparation curriculum. We are now well-positioned to transition from a lay health-ministry approach to a true parish nurse model in FY2011. HCS Van Ministry provided free non-emergency transportation to outpatient services to 203 individuals which represents 1,704 round trips and nearly 40,000 miles traveled to outpatient destinations such as rehabilitative therapies (i.e., PT, OT, ST, cardiac and pulmonary rehab); chemotherapy and radiation treatment at the Ashland-Bellefonte Cancer Center; and visits to physician offices on the OLBH campus and OLBH Primary Care Centers. With little or no public transportation available in the areas we serve, this been a tremendous help in providing access to these services that are so desperately needed by the people we serve.Senior Services: Our Senior Services program had to discontinue the newest Meals on Wheels program that served an outlying area of Boyd County due to a lack of volunteers. We have, however, successfully maintained eight programs that serve ten communities in our service area. Each month 212 volunteers deliver over 4,500 meals to 212 elderly and/or disabled individuals who reside in these communities. Additionally, 27 volunteers provide support services such as friendly visits and assistance with laundry to 12 care receivers. This represents approximately 2,000 volunteer hours of service each month which has a dollar value of $48,600 annually. As our senior services coordinator has transitioned into the role of grant writer, we have found community partners such as the FIVCO Area Council on Aging to assume responsibility for the Alzheimers education and support groups we were providing. BSKHS provides Women's Services mobile clinic that offers osteoporosis and mammography screening. Additionally, Healthy Community Services provides bone density screening monthly at the Greenup County Health Department. In FY 2010, we served 73 women at the health department identifying 24 in the pre-osteoporosis or osteoporosis range.Children and Youth Services: Healthy Community Services participated in our 12th Annual Bicycle Safety Camp in FY 2010 and assisted a local congregation in providing a camp for children in Ironton, OH. These two camps served a total of 112 children. We also provided educational programs at both end-of- school activities and back-to-school events such as Ready fest in both Greenup and Boyd Counties.Primary Care Clinic Subsidy: Bellefonte Physician Services, Inc. (BPS), in conjunction with Our Lady of Bellefonte Hospital, employs 49 providers in order to offer quality healthcare to the residents of Eastern Kentucky, more specifically Boyd, Greenup, and Carter Counties. BPS providers offer healthcare services to patients who are either uninsured or are covered by Medicaid, which equals approximately 12% and 23% of our overall patient population, respectively. Part VI, Line 6: BSKHS is working to engage and empower the members of the Argillite community located in Greenup County to support them in improving their quality of life and holistic health. Argillite is a rural community with approximately 1,000 residents. Single-family homes and trailers prevail. 47% of the households make less than $25,000 per year with 17% of that number making less than $15,000 annually. 43% of residents have no high school diploma; 16% of that number have less than a 9th grade education. Argillite Elementary has 71% of students receiving free and reduced lunch. The Director of Healthy Community Initiatives is coordinating efforts to unite the community and aid in health and social issues. The Director is assessing the needs and assets of the community through resident interviews, community forums, community survey and focus groups. With this data, the community members will choose the priority improvement initiatives that residents and supporting organizations want to begin to address. One of the first initiatives was a summer feeding and reading program for children in collaboration with the Greenup County School's Family Resource and Youth Service Center. Other community projects include distribution of free dictionaries and books to students and Thanksgiving food baskets to needy families; a Back pack program to assist low income students with school supplies and clothes and funding for a weekend snack sack program that provides students most at risk of going hungry with food during the weekend. Part VI, Line 7: Bon Secours Health System, Inc., a Maryland nonprofit, non stock membership corporation (BSHSI), and all of the other entities that are controlled directly or indirectly by Bon Secours, Inc., a Maryland nonprofit, non stock membership corporation (BSI) are described collectively as the System. BSI, which is the sole corporate member of BSHSI, has no healthcare operations. The System was organized in June 1983 to fulfill the healthcare mission of the United States Province of the Congregation of the Sisters of Bon Secours of Paris, a congregation of religious women of the Roman Catholic Church founded in France in 1824. The System's activities are in the states of New York, Pennsylvania, Maryland, Virginia, Kentucky, South Carolina, and Florida, each referred to as a local system. The Ministry of BSHSI aids those in need, particularly those who are sick and dying, by offering services that include but are not limited to acute inpatient, outpatient, pastoral, palliative, home health, nursing home, rehabilitative, primary and secondary care and assisted living without regard to race, religion, color, gender, age, marital status, national origin, sexual orientation, or disability. Activities directly associated with this purpose are considered operating activities. Operating activities also include other incidental services that are closely related to healthcare. BSKHS hospital, Our Lady of Bellefonte Hospital, operates an emergency room that is open 24 hours 7 days a week to all persons regardless of ability to pay. Three years ago, the hospital implemented the 30-minute guarantee that patients will be evaluated within 30 minutes of their arrival. This access to care guarantee continues to be the benchmark of performance. Our Lady of Bellefonte Hospital has an open medical staff with privileges available to all qualified physicians in the area. BSKHS has a governing body in which independent persons representative of the community comprise a majority. The governing body of BSKHS consists of 18 members - 16 of which represent the local community. Their expertise includes health care and health care administration, pharmacy, education, business, finance, insurance/real estate and the law. Educational preparation ranges from high school with some college to doctoral degrees in medicine, pharmacy, and law. BSKHS engages in medical and scientific research programs such as a lung cancer study with such prestigious institutions as the University of Kentucky and the Cleveland Clinic. BSKHS engages in the training and education of health care professionals. As a teaching hospital, BSKHS is affiliated with several medical schools (Marshall University and the West Virginia and Pikeville Schools of Osteopathic Medicine) as well as local schools of nursing. BSKHS also offers a Family Practice Residency program. OLBH is the only teaching hospital in the southern Ohio and far northeastern Kentucky area. BSKHS participates in Medicaid, Medicare, CHAMPUS, Tricare, and other government-sponsored health care programs. KY X X X X X 0 1 0 0 0 0 0 0 0 Skip Hubbard 0 359458 0 283459 0 51820 0 79795 0 19704 0 794236 0 0 David Jones 0 393968 0 305114 0 198976 0 68174 0 23403 0 989635 0 0 Sam Ross 0 392569 0 226397 0 4510 0 63612 0 22334 0 709422 0 0 Valinda Rutledge 0 428528 0 356742 0 13338 0 72325 0 19726 0 890659 0 0 Kevin Halter 0 288386 0 83943 0 13613 0 40233 0 22645 0 448820 0 0 Joe Buccheit 224034 0 47590 0 82510 0 31452 0 15975 0 401561 0 0 0 John Wallenhorst 0 196349 0 59243 0 13477 0 33533 0 8835 0 311437 0 0 Jennifer Moore 175112 0 35886 0 1498 0 11473 0 8117 0 232086 0 0 0 Emilio A Punzal MD 158811 0 262498 0 517 0 3984 0 23752 0 449562 0 0 0 Jose Marie Makalinao MD 160392 0 114097 0 134 0 0 0 9333 0 283956 0 0 0 Peter O Lyn MD 124543 0 104336 0 404 0 0 0 26306 0 255589 0 0 0 Myra L Carroll 153849 0 2259 0 67 0 4176 0 9325 0 169676 0 0 0 Thomas G Lyons 134427 0 11240 0 1715 0 2268 0 1245 0 150895 0 0 0 Mark Gordon 0 335043 0 235710 0 110965 0 33893 0 25512 0 741123 0 0 Part I, Line 4b: Our Lady of Bellefonte Hospital, Inc., participates in a BSHSI sponsored executive retirement program that allows for deposits into additional retirement plans and is 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 Our Lady of Bellefonte Hospital, Inc., 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 Board members Philip B. Leslie and Frank Warnock have a business relationship. Form 990, Part VI, Section A, line 6 Bon Secours Health System, Inc. is the sole member of Bon Secours Kentucky Health System, which in turn is the sole member of Our Lady of Bellefonte Hospital, Inc. Form 990, Part VI, Section A, line 7a The governing body of Our Lady of Bellefonte Hospital, Inc. is appointed by its Member, Bon Secours Kentucky Health System, Inc. and subject to approval by Bon Secours Health System, Inc. Form 990, Part VI, Section A, line 7b Certain authorities of Our Lady of Bellefonte Hospital, Inc. 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 Kentucky Health System's audit and compliance board committee and providing the form to the Our Lady of Bellefonte Hospital, Inc.'s board of directors to allow for a thorough review by both before the filing date of July 15, 2011. Bon Secours Kentucky Health System's audit and compliance board committee and Our Lady of Bellefonte Hospital, Inc.'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 Our Lady of Bellefonte Hospital, Inc. 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 Our Lady of Bellefonte Hospital, Inc. 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). 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 Our Lady of Bellefonte Hospital, Inc., 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 BS-KY 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 Our Lady of Bellefonte Hospital, Inc. provides any documents open to public inspection upon request. Form 990, Part VI, Section B, Line 14: 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 HIPPA requirements. An organization-wide policy is currently in place for fiscal year ending August 31, 2011. Form 990, Part VII Hours worked are not tracked on an entity by entity basis. All officers' and directors' 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. Kevin Halter's compensation is paid by Bon Secours Health System, Inc., a related organization. The compensation he receives is for his role as the CEO of Our Lady of Bellefonte Hospital, Inc. John Wallenhorst's compensation is paid by Bon Secours Health System, Inc., a related organization. The compensation he receives is for his role as the VP of Mission & Ethics at Bon Secours Health System, Inc. Samuel L. Ross, M.D.'s compensation is paid by Bon Secours Health System, Inc., a related organization. The compensation he receives is for his role as the Chief Executive Officer of Bon Secours Baltimore Health System, Inc. David Jones' compensation is paid by Bon Secours Health System, Inc., a related organization. The compensation he receives is for his role as the SVP of Human Resources for Bon Secours Health System, Inc. Skip Hubbard's compensation is paid by Bon Secours Health System, Inc., a related organization. The compensation he receives is for his role as the Chief Information Officer of Bon Secours Health System, Inc. Valinda Rutledge's compensation is paid by Bon Secours Health System, Inc., a related organization. The compensation she receives is for her role as the CEO of Bon Secours St. Francis Health System, Inc. Bon Secours Health System Inc 1505 Marriottsville Rd Marriottsville MD 21104 521301088 Parent Org. Management Services MD 501(c)(3) Line 11, Type II: 50 N/A Bellefonte Physician Services Inc St Christopher Dr Ashland KY 41101 352320780 Physician Practices KY 501(c)(3) Line 3: 170(b)(1)(A) N/A Our Lady of Bellefonte Hospital Foundation St Christopher Dr Ashland KY 41101 611381952 Grant Making Foundation KY 501(c)(3) Line 9: 509(a)(2) N/A Bon Secours Kentucky Health System St Christopher Dr Ashland KY 41101 611356024 Local System Parent Org. KY 501(c)(3) Line 11, Type II: 50 N/A Tri State Quality Health Network 1000 St Christopher Dr Ashland KY 41101 611263174 Physician Hospital Organization KY N/A C 0.50000 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 None