Pih Health Good Samaritan Hospital

“The Organization is a member of an integrated healthcare system controlled by PIH Health, Inc. The following individuals have a business relationship by virtue of their positions as officers or directors of related entities within the system: J. Richard Atwood, Jeffrey Hamar, Paula Cowan, Alex Alvarez, Blayne Cutler, Jane Dicus, Patrick Monroe, Charlotte Weaver, Kenton Woods, Peter Greaney, Paul Treinen, James West, Peggy Chulack, Anita Chou, and Rosalio Lopez. Mrs. Maribeth Borthwick, a Board Member of Good Samaritan Hospital, has a family relationship with Mr. Charles Munger, Chairman of the Board. Mr. Clark W. Porter has a family relationship with Mr. Glen H. Mitchel, Jr., who are both board members.”

“Good Samaritan Hospital amended its Bylaws to show PIH Health, Inc. as the sole member.”

“PIH Health, Inc. is the sole member of Good Samaritan Hospital.”

“PIH Health, Inc. has authority to elect all the members of the board of directors of Good Samaritan Hospital.”

“PIH Health, Inc. has all voting rights and the power to elect the board of directors of Good Samaritan Hospital.”

“The Organization works with an independent accountant, RSM US LLP, to prepare the Form 990. Once the return is prepared, the return is reviewed by the Chief Financial Officer and the Controller, who will provide any final comments to RSM US LLP. RSM US LLP makes all changes necessary and a final Form 990 is made available to all Board Members prior to filing.”

“Each year, all management and board of directors members are required to complete a conflict of interest disclosure form. All positive responses are reviewed by the General Counsel and Chief Administrative Officer of PIH Health, Inc. Each positive response is considered in light of magnitude of ownership interest, financial transaction(s), etc. If deemed necessary, conflicts of interest could be resolved by insisting that the incumbent either divest their ownership interest, that the organization terminate the business relationship, or even that the director resign. Directors with potential conflicts of interest may recuse themselves from voting on certain matters and/or may excuse themselves from meetings during the discussion, deliberation, and voting on of matters.”

“A subcommittee of the Governing Board's Executive Committee is responsible for determining the Chief Executive Officer's compensation. This Subcommittee is given comparison data on CEO salaries and benefits from comparable hospitals in the local area, prepared by human resources from 990s; and salary surveys completed by the local association. The decision of the Subcommittee on the CEO's salary is documented by the Subcommittee in writing. The compensation of the Organization's Vice Presidents are reviewed and approved by the Organization's CEO. Their salaries and benefits are determined using comparable hospitals in the local area, prepared by human resources from 990s; and salary surveys completed by the local hospital association.”

“Good Samaritan Hospital's organizing documents and the Conflict of Interest Policy are not made available to the public. The financial information from the financial statements is included in the Organization's Form 990, which is available for public inspection upon request.”

“Good Samaritan Hospital holds a 12.5% interest a joint venture arrangement that exists to further the charitable and community-based health care purposes, mission, vision, and values of its controlling tax exempt members. Good Samaritan Hospital annually evaluates its participation in joint venture arrangements.”

“Physician Fees: Program service expenses 11,649,488. Management and general expenses 0. Fundraising expenses 0. Total expenses 11,649,488. Consulting and Management Fees: Program service expenses 421,876. Management and general expenses 1,227,616. Fundraising expenses 0. Total expenses 1,649,492. Medical Purchased Services: Program service expenses 2,544,953. Management and general expenses 0. Fundraising expenses 0. Total expenses 2,544,953. Repairs and Maintenance: Program service expenses 9,195,425. Management and general expenses 538,287. Fundraising expenses 2,413. Total expenses 9,736,125. Software Maintenance: Program service expenses 3,490,330. Management and general expenses 0. Fundraising expenses 0. Total expenses 3,490,330. Other Purchased Services: Program service expenses 21,116,376. Management and general expenses 6,333,053. Fundraising expenses 2,831. Total expenses 27,452,260. Outside Provider Cost: Program service expenses 16,785,873. Management and general expenses 0. Fundraising expenses 0. Total expenses 16,785,873. Purchased Labor: Program service expenses 20,178,088. Management and general expenses 280,384. Fundraising expenses 0. Total expenses 20,458,472.”

“Pension related changes 1,353,192. Change in value of split-interest agreements -7,000. TRF Transfer 57,044. Net assets released from restrictions -94,514. Intercompany Transfer 171,836.”

“This line reflects a prior period adjustment for the organization's fair market valuation of assets, primarily fixed assets. This adjustment was identified during the opening balance sheet audit conducted during the tax year in connection with the acquisition of Good Samaritan Hospital and its affiliates by PIH Health, Inc. Schedule D Part VI similarly reflects changes resulting from this revaluation.”