Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions. Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
SAINT ELIZABETH REGIONAL MEDICAL CENTER
Employer identification number
47-0379836
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the supported organization?
................
11g(i)
(ii)
A family member of a person described in (i) above?
......................
11g(ii)
(iii)
A 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of monetary support
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 2
Part II
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year
(or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (see instructions)
..................
12
13
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.................................................
Section C. Computation of Public Support Percentage
14
Public support percentage for 2013 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2013.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
.......................
b
33 1/3% support test—2012.
If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2013.
If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization
.....................................................
b
10%-facts-and-circumstances test—2012.
If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported organization
................................................
18
Private foundation.
If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions
.....................................................
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c
Add lines 7a and 7b..
8
Public support (Subtract line 7c from line 6.)
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
9
Amounts from line 6...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
..
13
Total support. (Add lines 9, 10c, 11, and 12.)..
14
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public support percentage for 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2013.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
........
b
33 1/3% support tests—2012.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
.....
20
Private foundation.
If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 4
Part IV
Supplemental Information.
Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2013
Additional Data
Software ID:
13000248
Software Version:
2013v3.1
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
SAINT ELIZABETH REGIONAL MEDICAL CENTER
Employer identification number
47-0379836
Return Reference
Explanation
FORM 990, PART III, LINE 1, MISSION STATEMENT
THE MISSION OF THE CORPORATION IS TO NURTURE THE HEALING MINISTRY OF THE CHURCH, SUPPORTED BY EDUCATION AND RESEARCH. FIDELITY TO THE GOSPEL URGES THE CORPORATION TO EMPHASIZE HUMAN DIGNITY AND SOCIAL JUSTICE AS IT CREATES HEALTHIER COMMUNITIES. THE CORPORATION, SPONSORED BY A LAY-RELIGIOUS PARTNERSHIP, CALLS OTHER CATHOLIC SPONSORS AND SYSTEMS TO UNITE TO ENSURE THE FUTURE OF CATHOLIC HEALTH CARE. TO FULFILL THIS MISSION, THE CORPORATION, AS A VALUES-BASED ORGANIZATION, WILL ASSURE THE INTEGRITY OF THE MINISTRY IN BOTH CURRENT AND DEVELOPING ORGANIZATIONS AND ACTIVITIES; RESEARCH AND DEVELOP NEW MINISTRIES THAT INTEGRATE HEALTH, EDUCATION, PASTORAL, AND SOCIAL SERVICES; PROMOTE LEADERSHIP DEVELOPMENT AND FORMATION FOR MINISTRY THROUGHOUT THE ENTIRE ORGANIZATION; ADVOCATE FOR SYSTEMIC CHANGES WITH SPECIFIC CONCERN FOR PERSONS WHO ARE POOR, ALIENATED, AND UNDERSERVED; AND STEWARD RESOURCES BY GENERAL OVERSIGHT OF THE ENTIRE ORGANIZATION.
Form 990, Part VI, Sec A, Line 1a, Delegate broad authority to a committee
PURSUANT TO SECTION 8.1 OF THE CORPORATION'S BYLAWS, COMMITTEES, SUCH AS THE EXECUTIVE COMMITTEE, THAT ARE GRANTED AUTHORITY TO ACT ON BEHALF OF THE BOARD OF DIRECTORS MAY INCLUDE ONLY DIRECTORS OF THE CORPORATION.
Form 990, Part VI, Sec A, Line 6, Classes of members or stockholders
ACCORDING TO THE ORGANIZATION'S BYLAWS OF SAINT ELIZABETH REGIONAL MEDICAL CENTER, THE ENTITY'S SOLE CORPORATE MEMBER IS CHI NEBRASKA, A NEBRASKA NON-PROFIT CORPORATION.
Form 990, Part VI, Sec A, Line 7a, Members or stockholders electing members of governing body
ACCORDING TO THE ORGANIZATION'S BYLAWS, DIRECTORS SHALL BE APPOINTED OR REFUSED BY THE CORPORATE MEMBER. THE CORPORATE MEMBER MAY APPOINT ONE OR MORE INDIVIDUALS TO THE BOARD OF DIRECTORS, AND MAY AT ANY TIME REMOVE, WITH OR WITHOUT CAUSE, ANY MEMBER OF THE BOARD OF DIRECTORS. ACCORDING TO THE ORGANIZATION'S BYLAWS, DIRECTORS OF THE CORPORATION SHALL BE APPOINTED BY THE CORPORATE MEMBER NO LATER THAN JUNE 30 OF EACH YEAR. THE NAMES AND QUALIFICATIONS OF EACH INDIVIDUAL ACCEPTED BY THE BOARD OF DIRECTORS SHALL BE SUBMITTED TO THE CORPORATE MEMBER, WHO SHALL APPOINT OR REFUSE EACH NOMINEE IN ACCORDANCE WITH THE CORPORATE MEMBER'S BYLAWS AND WITH ENDORSEMENT OF THE SENIOR VICE PRESIDENT OF OPERATIONS. THE CORPORATE MEMBER MAY UNILATERALLY APPOINT ONE OR MORE INDIVIDUALS TO THE BOARD OF DIRECTORS SHOULD THE BOARD FAIL TO FURNISH THE CORPORATE MEMBER WITH A LIST OF INDIVIDUALS QUALIFIED TO SERVE ON THE BOARD OF DIRECTORS OF THE CORPORATION.
Form 990, Part VI, Sec A, Line 7b, Decisions requiring approval by members or stockholders
THE ORGANIZATION'S CORPORATE MEMBER IS CHI NEBRASKA. PURSUANT TO SECTION 5.4.1 OF THE ORGANIZATION'S BYLAWS, BOTH CHI NEBRASKA AND CATHOLIC HEALTH INITIATIVES ("CHI") HAVE RESERVED POWERS AS OUTLINED IN THE CHI GOVERNANCE MATRIX. PURSUANT TO THE GOVERNANCE MATRIX THE FOLLOWING RIGHTS ARE HELD BY THE CHI NEBRASKA'S BOARD: * APPROVE MEMBERS OF THE SAINT ELIZABETH REGIONAL MEDICAL CENTER BOARD. * AMENDMENT OF THE CORPORATE DOCUMENTS OF THE SAINT ELIZABETH REGIONAL MEDICAL CENTER. *APPROVE REMOVAL OF A MEMBER OF THE GOVERNING BODY OF THE SAINT ELIZABETH REGIONAL MEDICAL CENTER. * ADOPTION OF LONG RANGE AND STRATEGIC PLANS FOR THE SAINT ELIZABETH REGIONAL MEDICAL CENTER. THE FOLLOWING RIGHTS ARE RESERVED TO THE CHI BOARD DIRECTLY OR THROUGH POWERS DELEGATED TO THE CHI CHIEF EXECUTIVE OFFICER: * SUBSTANTIAL CHANGE IN THE MISSION OR PHILOSOPHY OF THE SAINT ELIZABETH REGIONAL MEDICAL CENTER. * REMOVAL OF A MEMBER OF THE GOVERNING BODY OF THE SAINT ELIZABETH REGIONAL MEDICAL CENTER. * APPROVAL OF ISSUANCE OF DEBT BY SAINT ELIZABETH REGIONAL MEDICAL CENTER. * APPROVAL OF PARTICIPATION OF SAINT ELIZABETH REGIONAL MEDICAL CENTER IN A JOINT VENTURE. *APPROVAL OF FORMATION OF A NEW CORPORATION BY SAINT ELIZABETH REGIONAL MEDICAL CENTER. * APPROVAL OF A MERGER INVOLVING THE SAINT ELIZABETH REGIONAL MEDICAL CENTER. * APPROVAL OF THE SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE SAINT ELIZABETH REGIONAL MEDICAL CENTER. * TO REQUIRE THE TRANSFER OF ASSETS BY THE SAINT ELIZABETH REGIONAL MEDICAL CENTER TO CHI TO ACCOMPLISH CHI'S GOALS AND OBJECTIVES, AND TO SATISFY CHI DEBTS. PURSUANT TO SECTION 5.5.2 OF THE ORGANIZATION'S BYLAWS, CHI NEBRASKA OR CHI MAY, IN EXERCISE OF THEIR APPROVAL POWERS, GRANT OR WITHHOLD APPROVAL IN WHOLE OR IN PART, OR MAY, IN ITS COMPLETE DISCRETION, AFTER CONSULTATION WITH THE BOARD AND ITS PRESIDENT AND THE CHIEF EXECUTIVE OFFICER OF THE ORGANIZATION, RECOMMEND SUCH OTHER OR DIFFERENT ACTIONS AS IT DEEMS APPROPRIATE
Form 990, Part VI, Sec B, Line 11b, Review of form 990 by governing body
CHI NEBRASKA'S (THE ORGANIZATION'S CORPORATE MEMBER) CFO IS RESPONSIBLE FOR REVIEWING THE FINAL TAX RETURN PREPARED BY THE CHI TAX DEPARTMENT FOR ANY POTENTIAL ERRORS, OMISSIONS, OR CLARIFICATIONS NEEDED FOR PROPER PRESENTATION. AFTER THE FINAL CHANGES ARE MADE TO THE FORM 990, THE RETURNS ARE POSTED TO A SECURED BOARD COLLABORATION SITE FOR REVIEW BY THE BOARD MEMBERS. SUBSEQUENT TO DISTRIBUTION TO THE BOARD, THE TAX DEPARTMENT FILES THE RETURN WITH THE APPROPRIATE FEDERAL AND STATE AGENCIES, MAKING ANY NON-SUBSTANTIVE CHANGES NECESSARY TO EFFECT E-FILING. ANY SUCH CHANGES ARE NOT RE-SUBMITTED TO THE BOARD.
Form 990, Part VI, Sec B, Line 12c, Conflict of interest policy
THE ORGANIZATION HAS A CONFLICT OF INTEREST POLICY THAT IT FOLLOWS WITH RESPECT TO ITS INTERESTED PERSONS. THE FOLLOWING DESCRIBES THE ORGANIZATION'S CONFLICT OF INTEREST MONITORING PROCEDURES. DISCLOSURE, REVIEW AND INITIAL DETERMINATION: 1. GENERAL OBLIGATION: EACH SAINT ELIZABETH ASSOCIATE MUST PROMPTLY AND FULLY REPORT TO THE ASSOCIATE'S DIRECT MANAGER OR SUPERVISOR ANY SITUATION OR CIRCUMSTANCE THAT MAY CREATE A CONFLICT OF INTEREST. THE ASSOCIATE MUST REPORT THE ACTUAL OR POTENTIAL CONFLICT AS SOON AS THE ASSOCIATE BECOMES AWARE OF IT. IN ANY SITUATION WHEN THE ASSOCIATE MAY BE IN DOUBT, THE ASSOCIATE IS TO MAKE A FULL DISCLOSURE SO AS TO PERMIT AN IMPARTIAL AND OBJECTIVE DETERMINATION TO BE MADE. 2. DISCLOSURE UPON INITIAL HIRING: AT THE TIME OF INITIAL HIRING, A SAINT ELIZABETH HUMAN RESOURCES ("HR") REPRESENTATIVE SHALL REVIEW THIS POLICY WITH THE ASSOCIATE AND HAVE THE ASSOCIATE COMPLETE AND SIGN A CONFLICT OF INTEREST DISCLOSURE STATEMENT. THE COMPLETED AND SIGNED DISCLOSURE STATEMENT SHALL BE MAINTAINED IN THE ASSOCIATES' HR FILE. 3. ANNUAL DISCLOSURE STATEMENT: THE FOLLOWING PROVISION APPLIES TO AN ASSOCIATE WHO IS A DIRECTOR AND ABOVE OR A KEY ASSOCIATE. KEY ASSOCIATES INCLUDE ASSOCIATES OF THE FOLLOWING DEPARTMENTS: ADMINISTRATION, PATIENT ACCOUNTING, INFORMATION TECHNOLOGY, PROCUREMENT, CASE MANAGEMENT, CLINICAL NURSE SPECIALISTS, MARKETING, FINANCE, AND PERFORMANCE IMPROVEMENT. OTHER DEPARTMENTS INVOLVED IN FINANCIAL DECISION MAKING MAY ALSO BE INCLUDED AS KEY ASSOCIATES, AT THE DIRECTOR'S DISCRETION. AT THE TIME OF THE ASSOCIATE'S ANNUAL EVALUATION, THE ASSOCIATE'S DIRECT MANAGER OR SUPERVISOR SHALL REVIEW THIS POLICY WITH THE ASSOCIATE AND HAVE THE ASSOCIATE COMPLETE AND SIGN A CONFLICT OF INTEREST DISCLOSURE STATEMENT. THE COMPLETED AND SIGNED DISCLOSURE STATEMENT SHALL BE MAINTAINED IN THE ASSOCIATE'S HR FILE. ASSOCIATES WHO ARE NOT DIRECTORS AND ABOVE OR KEY ASSOCIATES ARE SUBJECT TO THE GENERAL OBLIGATION ABOVE. 4. REVIEW, EVALUATION AND INITIAL DETERMINATION: ANY QUESTION ABOUT AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST SHOULD FIRST BE PRESENTED BY THE ASSOCIATE TO THE ASSOCIATES' DIRECT MANAGER OR SUPERVISOR FOR REVIEW AND DETERMINATION. IF THE ASSOCIATE DOES NOT IDENTIFY OR RECOGNIZE THE CONFLICT OR THE NEED TO REQUEST A REVIEW, THE MANAGER, WHO BECOMES AWARE OF A SITUATION THAT INVOLVES THE ASSOCIATE AND PRESENTS AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST, SHOULD MAKE A DETERMINATION AND ADVISE THE ASSOCIATE OF SAME. IF THE ASSOCIATE AND THE MANAGER DO NOT AGREE ABOUT THE APPLICABILITY OF THIS POLICY, OR IF THE ASSOCIATE SEEKS AN EXCEPTION OR EXEMPTION FROM THIS POLICY, THE MANAGER SHALL CONSULT WITH THE MANAGER'S VICE PRESIDENT (OR HIGHER IF THE MANAGER IS A VICE PRESIDENT) TO REACH A DETERMINATION. IF THE MATTER REMAINS UNRESOLVED, IT SHALL BE REFERRED TO THE SAINT ELIZABETH VICE PRESIDENT OF HUMAN RESOURCES AND THE SAINT ELIZABETH CORPORATE RESPONSIBILITY OFFICER FOR DETERMINATION. IF THE SAINT ELIZABETH VICE PRESIDENT OF HUMAN RESOURCES AND THE SAINT ELIZABETH CORPORATE RESPONSIBILITY OFFICER ARE UNABLE TO REACH AGREEMENT, THE MATTER SHALL BE REFERRED TO THE SAINT ELIZABETH'S ASSIGNED CHI LEGAL COUNSEL, WHOSE DECISION SHALL BE FINAL. EACH DECISION MAKER MAY INVESTIGATE AND CONSIDER THE CIRCUMSTANCES SURROUNDING THE POTENTIAL OR ACTUAL CONFLICT OF INTEREST, INCLUDING INTERVIEWING THE ASSOCIATE, AS THE DECISION MAKER DEEMS NECESSARY OR APPROPRIATE TO MAKE AN INFORMED DECISION. 5. CONSIDERATIONS: AMONG THE FACTORS THAT SHOULD BE CONSIDERED IN DETERMINING WHETHER A CONFLICT EXISTS ARE THE NATURE AND MAGNITUDE OF THE OPPORTUNITY, TRANSACTION OR ARRANGEMENT, THE DEGREE TO WHICH IT IS RELATED TO SAINT ELIZABETH'S BUSINESS, WHETHER THE INDIVIDUAL WITH THE CONFLICT IS THE ULTIMATE DECISION MAKER OR HOLDS SIGNIFICANT INFLUENCE OVER THE ULTIMATE DECISION MAKER (I.E., INDEPENDENCE OF THE DECISION MAKING PROCESS), THE UNIQUE NATURE OF THE OPPORTUNITY, TRANSACTION OR ARRANGEMENT, THE EXISTENCE OF OTHER VIABLE ALTERNATIVES AND THE QUALITY OF THOSE ALTERNATIVES, AND WHAT IS CUSTOMARY AND REASONABLE IN THE HEALTHCARE INDUSTRY. 6. WRITING REQUIRED: ANY ASSOCIATE REQUEST FOR AN EXCEPTION OR EXEMPTION FROM THIS POLICY, AS WELL AS THE FINAL DECISION THEREON, SHALL BE IN WRITING. COPIES OF ALL SUCH DOCUMENTS SHALL BE MAINTAINED IN THE ASSOCIATE'S HR FILE. 7. POLICY VIOLATIONS: IF AN ASSOCIATE FAILS TO DISCLOSE AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST, OR ALL MATERIAL FACTS SURROUNDING AN ACTUAL OR POTENTIAL CONFLICT, OR FAILS TO ABIDE BY THE FINAL DECISION REGARDING THE CONFLICT AS REQUIRED BY THIS POLICY, THE ASSOCIATE MAY BE SUBJECT TO DISCIPLINARY ACTION, INCLUDING TERMINATION.
FORM 990, PART VI, LINE 15A, COMPENSATION OF ORGANIZATION'S CEO
THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL'S COMPENSATION IS PAID BY FRANCISCAN HEALTH SYSTEM (FHS), A RELATED ORGANIZATION. FHS USES AN EXTERNAL COMPENSATION FIRM WHO UTILIZES ACTUAL MARKET DATA COMPENSATION FROM SIMILAR INSTITUTIONS WITH COMPARABLE POSITIONS AND COMPENSATION LEVELS AND CONSIDERING THE ORGANIZATION'S GEOGRAPHIC LOCATION. THE EXECUTIVE COMMITTEE OF THE BOARD ANNUALLY EVALUATES AND APPROVES THE EXECUTIVE COMPENSATION ARRANGEMENT FOR EACH EXECUTIVE FOR FAIR MARKET VALUE ALONG WITH OTHER APPLICABLE FACTORS RELIED ON BY THE BOARD'S DETERMINATION. THE SUPPORTING DOCUMENTATION BECOMES PART OF THE MINUTES OF THE MEETING. THIS PROCESS IS COMPLETED YEARLY.
Form 990, Part VI, Sec B, Line 15b, Process to establish compensation of other employees
COMPENSATION FOR OTHER OFFICERS IS COMPARED TO A STUDY COMPLETED BY HR ADVANTAGE AND IS APPROVED BY THE PRESIDENT/CEO. COMPENSATION FOR KEY EMPLOYEES IS COMPARED TO A STUDY COMPLETED BY MSA AND IS APPROVED BY THE INDIVIDUAL'S SUPERVISING VICE PRESIDENT. THE BOARD OF DIRECTORS ALSO OVERSEES AND APPROVES THE COMPENSATION SETTING PROCESS TO ENSURE REASONABLENESS AND COMPLIANCE WITH THE ORGANIZATION'S COMPENSATION PHILOSOPHY.
FORM 990, PART VI, LINE 16B, JOINT VENTURE POLICY
SAINT ELIZABETH REGIONAL MEDICAL CENTER HAS NOT FORMALLY ADOPTED A WRITTEN POLICY OR WRITTEN PROCEDURE REGARDING JOINT VENTURES. HOWEVER CHI'S SYSTEM-WIDE JOINT VENTURE MODEL OPERATING AGREEMENT INCORPORATES CONTROLS OVER THE VENTURE SUFFICIENT TO ENSURE THAT (1) THE EXEMPT ORGANIZATION AT ALL TIMES RETAINS CONTROL OVER THE VENTURE SUFFICIENT TO ENSURE THAT THE PARTNERSHIP FURTHERS THE EXEMPT PURPOSE OF THE ORGANIZATION; (2) IN ANY PARTNERSHIP IN WHICH THE EXEMPT ORGANIZATION IS A PARTNER, ACHIEVEMENT OF EXEMPT PURPOSES IS PRIORITIZED OVER MAXIMIZATION OF PROFITS FOR THE PARTNERS; (3) THE PARTNERSHIP DOES NOT ENGAGE IN ANY ACTIVITIES THAT WOULD JEOPARDIZE THE EXEMPT ORGANIZATION'S EXEMPTION; (4) RETURNS OF CAPITAL, ALLOCATIONS, AND DISTRIBUTIONS MUST BE MADE IN PROPORTION TO THE PARTNERS' RESPECTIVE OWNERSHIP INTERESTS; AND (5) ALL CONTRACTS ENTERED INTO BY THE PARTNERSHIP WITH THE EXEMPT ORGANIZATION MUST BE AT ARM'S-LENGTH, WITH PRICES SET AT FAIR MARKET VALUE. ANY JOINT VENTURE AGREEMENTS THAT DO NOT CONFORM TO THE MODEL AGREEMENT ARE GENERALLY REVIEWED BY COUNSEL.
Form 990, Part VI, Sec C, Line 19, Required documents available to the public
THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST FROM THE ADMINISTRATION DEPARTMENT. IN ADDITION, THE ARTICLES OF INCORPORATION ARE AVAILABLE FROM THE NEBRASKA SECRETARY OF STATE WEBSITE (HTTP://WWW.SOS.NE.GOV/BUSINESS). THE ORGANIZATION'S FINANCIAL STATEMENTS ARE INCLUDED IN CATHOLIC HEALTH INITIATIVES' CONSOLIDATED AUDITED FINANCIAL STATEMENTS THAT ARE AVAILABLE AT WWW.CATHOLICHEALTHINIT.ORG OR AT WWW.DACBOND.ORG.
Form 990, Part IX, Line 11g, Other Expenses
OTHER FEES FOR SERVICES - TOTAL EXPENSE: 844972, PROGRAM SERVICE EXPENSE: 802724, MANAGEMENT AND GENERAL EXPENSES: 42248, FUNDRAISING EXPENSES: ; MEDICAL FEES - TOTAL EXPENSE: 17286294, PROGRAM SERVICE EXPENSE: 16421979, MANAGEMENT AND GENERAL EXPENSES: 864315, FUNDRAISING EXPENSES: ; CONTRACT SERVICES - TOTAL EXPENSE: 15183579, PROGRAM SERVICE EXPENSE: 14424400, MANAGEMENT AND GENERAL EXPENSES: 759179, FUNDRAISING EXPENSES: ;
Form 990 , Part XI, Line 9, Other changes in net assets or fund balances
LINCOLN LEASING - DIVIDEND DISTRIBUTION - -160858;
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.