Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private
foundations)
MediumBullet Do not enter social security numbers on this form as it may be made public.
MediumBullet Information about Form 990 and its instructions is at www.IRS.gov/form990.
OMB No. 1545-0047
2014
Open to Public Inspection
A For the 2014 calendar year, or tax year beginning 07-01-2014 , and ending 06-30-2015
BCheck if applicable:
CName of organization
DOUGLAS HOSPITAL INC
 
Doing business as
 
 
Number and street (or P.O. box if mail is not delivered to street address)
805 Sandy Plains Road
 
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
Marietta, GA300666340
D Employer identification number

58-2026750
E Telephone number

G Gross receipts $ 126,230,204
F Name and address of principal officer:
CANDICE L SAUNDERS
805 Sandy Plains Road
Marietta,GA300666340
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.wellstar.org
H(a)
Is this a group return for
subordinates?
H(b)
Are all subordinates
included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1992
M State of legal domicile: GA
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: TO PROVIDE WORLD-CLASS CHARITABLE HEALTHCARE TO THE COMMUNITY.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 18
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 9
5 Total number of individuals employed in calendar year 2014 (Part V, line 2a) ...... 5 948
6 Total number of volunteers (estimate if necessary) ............. 6 84
7a Total unrelated business revenue from Part VIII, column (C), line 12 ........ 7a 0
b Net unrelated business taxable income from Form 990-T, line 34 ......... 7b 0
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 0 0
9 Program service revenue (Part VIII, line 2g) ......... 113,708,367 125,072,565
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 2,572 -15,260
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 748,373 1,172,899
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 114,459,312 126,230,204
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 600 600
14 Benefits paid to or for members (Part IX, column (A), line 4)..... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 51,017,344 54,806,920
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 58,826,338 62,714,137
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 109,844,282 117,521,657
19 Revenue less expenses. Subtract line 18 from line 12....... 4,615,030 8,708,547
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 84,136,160 78,146,264
21 Total liabilities (Part X, line 26)............. 42,108,389 39,670,447
22 Net assets or fund balances. Subtract line 21 from line 20..... 42,027,771 38,475,817
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
Preparer's signature
Date
PTIN
Firm's name MediumBullet
Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ..........
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y Form 990 (2014)
Form 990 (2014)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response or note to any line in this Part III ..............
1
Briefly describe the organization’s mission: 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.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ......................
If "Yes," describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ............................
If "Yes," describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 95,822,644 including grants of $ 600 ) (Revenue $ 125,072,565 )
SEE SCHEDULE O
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet95,822,644
Form 990 (2014)
Form 990 (2014)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes," complete Schedule AClick to see attachment........................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? ...
2
 
No
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If "Yes," complete Schedule C, Part I..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If "Yes," complete Schedule C, Part II........
4
 
No
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If "Yes," complete Schedule C,
Part III............................
5
 
 
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If "Yes," complete Schedule D, Part IClick to see attachment........................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If "Yes," complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If "Yes," complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If "Yes," complete Schedule D, Part IVClick to see attachment..............
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If "Yes," complete Schedule D, Part VClick to see attachment......
10
 
No
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10?
If "Yes," complete Schedule D, Part VI.Click to see attachment...................
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VIIClick to see attachment.......
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VIIIClick to see attachment.......
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part IXClick to see attachment............
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If "Yes," complete Schedule D, Part XClick to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If "Yes," complete Schedule D, Part XClick to see attachment.........................
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If "Yes," complete Schedule D, Parts XI and XII Click to see attachment.................
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If "Yes," and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E....
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?.....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If "Yes," complete Schedule F, Parts I and IV.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or other assistance to or for any foreign organization? If “Yes,” complete Schedule F, Parts II and IV
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or other assistance to or for foreign individuals? If “Yes,” complete Schedule F, Parts III and IV...
16
 
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If "Yes," complete Schedule G, Part I (see instructions) ....
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If "Yes," complete Schedule G, Part II............
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If "Yes," complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospital facilities? If "Yes," complete Schedule H.... Click to see attachment
20a
Yes
 
b
If "Yes" to line 20a, did the organization attach a copy of its audited financial statements to this return? Click to see list of attachments
20b
Yes
 
Form 990 (2014)
Form 990 (2014)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants or other assistance to any domestic organization or domestic government on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II..
21
 
No
22
Did the organization report more than $5,000 of grants or other assistance to or for domestic individuals on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........
22
 
No
23
Did the organization answer "Yes" to Part VII, Section A, line 3, 4, or 5 about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If "Yes," complete Schedule J....................... Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25a................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an "on behalf of" issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If "Yes," complete Schedule L, Part I....
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If "Yes," complete Schedule L, Part I...................
25b
 
No
26
Did the organization report any amount on Part X, line 5, 6, or 22 for receivables from or payables to any current or former officers, directors, trustees, key employees, highest compensated employees, or disqualified persons? If "Yes," complete Schedule L, Part II................
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If "Yes," complete Schedule L, Part III.........
27
 
No
28
Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If "Yes," complete Schedule L, Part IV ..........................
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If "Yes,"
complete Schedule L, Part IV.....................
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner? If "Yes," complete Schedule L, Part IV...
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If "Yes," complete Schedule M..
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If "Yes," complete Schedule M.............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If "Yes," complete Schedule N, Part II......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If "Yes," complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If "Yes," complete Schedule R, Part II, III, or IV, and Part V, line 1........................ Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If "Yes," complete Schedule R, Part V, line 2... Click to see attachment
35b
 
No
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If "Yes," complete Schedule R, Part V, line 2............. Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If "Yes," complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2014)
Form 990 (2014)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response or note to any line in this Part V ..............
Yes
No
1a
Enter the number reported in Box 3 of Form 1096 Enter -0- if not applicable ..
1a
0
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable .
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
 
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................
2a
948
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?...
3a
 
No
b
If “Yes,” has it filed a Form 990-T for this year? If “No” to line 3b, provide an explanation in Schedule O...
3b
 
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)?..........................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR).
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If "Yes," to line 5a or 5b, did the organization file Form 8886-T? ............
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions?...
6a
 
No
b
If "Yes," did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If "Yes," did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If "Yes," indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?............................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?............................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?..........................
7h
 
 
8
Sponsoring organizations maintaining donor advised funds.
Did a donor advised fund maintained by the sponsoring organization have excess business holdings at any time during the year?.........................
8
 
 
9a
Did the sponsoring organization make any taxable distributions under section 4966?...
9a
 
 
b
Did the sponsoring organization make a distribution to a donor, donor advisor, or related person?...
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If "Yes," enter the amount of tax-exempt interest received or accrued during the year. ....................
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....
13b
 
c
Enter the amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If "No," provide an explanation in Schedule O..
14b
 
 
Form 990 (2014)
Form 990 (2014)
Page 6
Part VI
Governance, Management, and Disclosure For each "Yes" response to lines 2 through 7b below, and for a "No" response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response or note to any line in this Part VI ..............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year .....................
1a
18
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent ...................
1b
9
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? ...........................
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If "Yes," provide the names and addresses in Schedule O.......
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If "Yes," did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If "No," go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If "Yes," describe in Schedule O how this was done.......................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If "Yes," did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
GA
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how) the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, address, and telephone number of the person who possesses the organization's books and records:
MediumBulletJAMES M SWARTZ
805 SANDY PLAINS ROAD
Marietta,GA300666340 (770) 792-5023
Form 990 (2014)
Form 990 (2014)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response or note to any line in this Part VII ..............
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; OfficerInd; Key Employee; Highest compensated employee; FormerOfcrDirectorTrusteeInd;
(1) Avril P Beckford MD........................................................................
TRUSTEE
 2.0
.......................48.0 		X           0 484,008 29,400
(2) Jeffrey L Tharp MD........................................................................
TRUSTEE
 2.0
.......................48.0 		X           0 630,869 74,725
(3) RANDALL BENTLEY SR........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 19,268 0
(4) OTIS A BRUMBY III........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 14,475 0
(5) ROBERT N CROSS MD........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 14,446 0
(6) TE RUSTY DURHAM........................................................................
TRUSTEE emeritus
 1.0
.......................5.0 		X           0 661 0
(7) THOMAS E GEARHARD MD........................................................................
TRUSTEE
 2.0
.......................48.0 		X           0 347,375 73,211
(8) DAVID H HAFNER MD........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 26,233 0
(9) T FITZ JOHNSON........................................................................
TRUSTEE
 1.0
.......................7.0 		X           0 20,712 0
(10) CHARLES J JONES........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 4,075 0
(11) JANIE MADDOX........................................................................
TRUSTEE - CHAIR
 1.0
.......................5.0 		X           0 8,850 0
(12) GARY A MILLER........................................................................
TRUSTEE - VICE CHAIR
 1.0
.......................5.0 		X           0 4,387 0
(13) MITZI MOORE........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 1,730 0
(14) TOM PHILLIPS........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 2,903 0
(15) WALTER ROBINSON........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 4,672 0
(16) FRANK ROS........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 2,820 0
(17) ORIN SWAYZE MD........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 4,624 0
Form 990 (2014)
Form 990 (2014)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; OfficerInd; Key Employee; Highest compensated employee; FormerOfcrDirectorTrusteeInd;
(18) GREG MORGAN........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 1,624 0
(19) WILLIAM C BROCK........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 20,247 0
(20) STEVEN W OWEIDA MD........................................................................
TRUSTEE EMERITUS
 1.0
.......................5.0 		X           0 31,409 0
(21) W ALLEN SEPARK........................................................................
TRUSTEE EMERITUS
 1.0
.......................7.0 		X           0 8,177 0
(22) Valery A Akopov........................................................................
VP & Chief of Hospitalist Svcs
 2.0
.......................48.0 		    X       0 399,745 53,663
(23) David W Anderson........................................................................
EVP HR OL CCO
 2.0
.......................48.0 		    X       0 648,929 70,290
(24) Nicole V Ashe........................................................................
VP Finance & CFO WMG
 2.0
.......................48.0 		    X       0 262,185 45,885
(25) Barbara G Ballard........................................................................
VP Homecare & Hospice
 2.0
.......................48.0 		    X       0 282,836 64,915
(26) Melissa L Box........................................................................
VP CNO Patient Care Services
 50.0
.......................0.0 		    X       216,527 0 38,260
(27) Joseph L Brywczynski........................................................................
SVP Health Parks Development
 2.0
.......................48.0 		    X       0 570,096 70,144
(28) Anthony J Budzinski........................................................................
EVP & CFO
 2.0
.......................50.0 		    X       0 689,236 71,096
(29) Donald Campbell MD........................................................................
SVP Phys Educ & Student Aff
 2.0
.......................48.0 		    X       0 513,317 62,483
(30) Jill M Case-Wirth........................................................................
VP Pediatric SRVS.(BEGIN. 8/4)
 2.0
.......................46.0 		    X       0 72,410 4,759
(31) James E Clements........................................................................
VP Bus Dev & Strategic Prtnrsp
 2.0
.......................48.0 		    X       0 264,016 17,453
(32) Lee R Cook........................................................................
VP Med & Behavioral Health
 2.0
.......................48.0 		    X       0 592,708 45,052
(33) Barbara B Corey........................................................................
SVP Managed Care
 2.0
.......................48.0 		    X       0 379,163 48,129
(34) Bruce A Dean........................................................................
VP Real Estate Deputy Gen Cnsl
 2.0
.......................48.0 		    X       0 282,461 69,841
(35) Sarath Degala........................................................................
VP Revenue Cycle Management
 2.0
.......................48.0 		    X       0 19,850 2,923
(36) Marcia Delk-Payne MD........................................................................
SVP Med Affair & Chf Qlty Ofcr
 2.0
.......................48.0 		    X       0 925,812 49,890
(37) Nancy R Doelling........................................................................
VP Pediatric SRVS.(BEGIN. 8/4)
 2.0
.......................48.0 		    X       0 141,009 11,811
(38) Jimmy E Francis........................................................................
VP Info Technology Operations
 2.0
.......................48.0 		    X       0 257,027 36,192
(39) Steven L Grace........................................................................
VP Talent Acquisition
 2.0
.......................48.0 		    X       0 266,953 32,731
(40) Kristyn M Greifer MD........................................................................
VP Population Management
 2.0
.......................48.0 		    X       0 369,983 28,680
(41) Joel W Helmke........................................................................
VP Oncology (BEGIN. 7/21)
 2.0
.......................48.0 		    X       0 165,514 28,875
(42) Robert D Jansen md........................................................................
EVP & Pres Medical Group
 2.0
.......................48.0 		    X       0 782,540 75,243
(43) Reynold J Jennings........................................................................
president & ceo
 2.0
.......................50.0 		    X       0 1,701,981 2,056
(44) Peter R Jungblut MD........................................................................
SVP & Medical Dir WMG
 2.0
.......................48.0 		    X       0 398,803 69,399
(45) Christopher M Kane........................................................................
SVP Strategic Plan & Bus Dev
 2.0
.......................48.0 		    X       0 806,400 42,332
(46) Beth Kost........................................................................
VP Compliance Chf Privacy Ofcr
 2.0
.......................48.0 		    X       0 331,700 34,022
(47) Ellen Langford........................................................................
SVP & COO WellStar Med Group
 2.0
.......................48.0 		    X       0 279,307 58,966
(48) Elizabeth H Loudermilk........................................................................
VP Ent Intelligence & Intgrtn
 2.0
.......................48.0 		    X       0 308,160 25,651
(49) Sandra Lucius........................................................................
VP Info Technology Apps
 2.0
.......................48.0 		    X       0 224,424 46,993
(50) Robert Mandler........................................................................
VP Diagnostic Outreach
 2.0
.......................48.0 		    X       0 290,840 61,524
(51) Patricia A Mayne........................................................................
VP Emergency Services
 2.0
.......................48.0 		    X       0 311,329 50,119
(52) Kimberly W Menefee........................................................................
SVP Strategic Community Dev
 2.0
.......................48.0 		    X       0 362,955 46,026
(53) Christopher L Morgan........................................................................
VP & Admin. CLIO (BEGIN. 7/7)
 2.0
.......................48.0 		    X       0 168,139 21,747
(54) Jonathan B Morris MD........................................................................
SVP Chief Info Officer
 2.0
.......................48.0 		    X       0 462,389 50,258
(55) Bradford B Newton........................................................................
VP Information Technology Admi
 2.0
.......................48.0 		    X       0 232,340 47,711
(56) Craig Owens........................................................................
SVP & Hospital President
 48.0
.......................2.0 		    X       344,496 0 67,184
(57) Michael G Paul........................................................................
VP Facilities Eng Support Svcs
 2.0
.......................48.0 		    X       0 220,953 24,150
(58) Leo E Reichert........................................................................
EVP & General Counsel
 2.0
.......................48.0 		    X       0 752,077 29,200
(59) Bethany Robertson........................................................................
VP & Chief Learning Officer
 2.0
.......................48.0 		    X       0 218,673 41,608
(60) Michelle M Robinson........................................................................
VP Mktng/PR/Internal Comm
 2.0
.......................48.0 		    X       0 238,847 40,651
(61) Wanda Y Robinson........................................................................
VP Compliance PWHP(BEGIN.9/15)
 2.0
.......................48.0 		    X       0 82,927 2,538
(62) Deborah Roegge De Vita........................................................................
VP Women & Newborn Svc Line
 2.0
.......................48.0 		    X       0 231,925 31,900
(63) Candice L Saunders........................................................................
President & CEO
 2.0
.......................48.0 		    X       0 812,226 72,916
(64) Christopher B Scullen........................................................................
VP Pulmonology Operations
 2.0
.......................48.0 		    X       0 292,246 17,839
(65) Richard S Siegel........................................................................
VP Cardiology & CVM Admin
 2.0
.......................48.0 		    X       0 323,664 70,462
(66) Jeffery D Stanley........................................................................
VP Pharmacy & System Coor
 2.0
.......................48.0 		    X       0 216,271 30,238
(67) Daniel J Styf........................................................................
SVP PW Health Plan
 2.0
.......................48.0 		    X       0 337,033 27,733
(68) James M Swartz........................................................................
VP Accounting
 2.0
.......................48.0 		    X       0 272,353 42,262
(69) Mary L Tavernaro........................................................................
VP Human Resources Operations
 2.0
.......................48.0 		    X       0 259,157 49,126
(70) Adam C Thompson........................................................................
VP Surgery
 2.0
.......................48.0 		    X       0 228,073 21,830
(71) Anthony M Trupiano........................................................................
SVP Supply Chain
 2.0
.......................48.0 		    X       0 345,219 47,596
(72) Sean P Turner........................................................................
VP Rev.Cycle MGMT (BEGIN.9/28)
 2.0
.......................48.0 		    X       0 273,082 46,665
(73) Robin Wilson MD........................................................................
SVP Chief Hlth Innov Officer
 2.0
.......................48.0 		    X       0 637,993 22,144
(74) Chester A Zborowski........................................................................
VP Health Parks Operations
 2.0
.......................48.0 		    X       0 223,151 24,265
(75) MARGARET W CHASTAIN........................................................................
Dir Pharmacy
 50.0
.......................0.0 		        X   178,420 0 28,299
(76) CHRISTOPHER S GREENE........................................................................
Exec Dir Finance & Hosp Ops
 50.0
.......................0.0 		        X   168,972 0 21,764
(77) STEVEN W HARRIS........................................................................
Pharmacist Specialty
 50.0
.......................0.0 		        X   150,471 0 11,495
(78) BEVERLY M BATES........................................................................
RN Charge Nurse
 50.0
.......................0.0 		        X   149,018 0 40,806
(79) KAREN Y BEARD........................................................................
DIR SURGICAL SVS DH/WH
 50.0
.......................0.0 		        X   142,303 0 25,301
(80) Kenneth C Kunze MD........................................................................
FMR. SVP Chief Medical Officer
 0.0
.......................0.0 		          X 0 383,389 0
(81) MICHAEL L GRAUE........................................................................
FRMR. EBP & CHIEF OP. OFFICER
 0.0
.......................0.0 		          X 0 522,266 0
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 1,350,207 22,289,647 2,500,427
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet56
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If "Yes," complete Schedule J for such individual ..............
3
Yes
 
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If "Yes," complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If "Yes," complete Schedule J for such person ........
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
Inglett and Stubbs LLC,
PO Box 932506
ATLANTA,GA311932506 		CONSTRUCTION 476,980
QUEST DIAGNOSTICS,
PO BOX 740736
ATLANTA,GA303740736 		MEDICAL 403,233
ALLIANCE HEALTHCARE SERVICES,
PO BOX 6600
NEWPORT BEACH,CA92658 		MEDICAL 289,545
FRESENIUS MEDICAL CARE,
PO BOX 101518
ATLANTA,GA30392 		MEDICAL 265,000
BATSON-COOK COMPANY,
200 GALLERIA PARKWAY
ATLANTA,GA30399 		CONSTRUCTION 7,528,931
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet15
Form 990 (2014)
Form 990 (2014)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response or note to any line in this Part VIII .............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512-514
Contributions, Gifts, GrantAmt and OtherAmt Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d  
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		 
g Noncash contributions included in lines
1a-1f:$ 		 
h Total. Add lines 1a-1f.......MediumBullet 0
Program Service RevenueAmt Business Code
2a HOSPITAL PATIENT REVENUE 621990 125,053,336 125,053,336   0
b MEDICAL RECORDS REVENUE 621990 156 156    
c PATIENT EDUCATION 621990 19,073 19,073    
d
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 125,072,565
OtherAmt RevenueAmt 3 Investment income (including dividends, interest, and other similar amounts).......MediumBullet 0      
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties...........MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents 116,585  
b Less: rental expenses 0  
c Rental income or (loss) 116,585 0
d Net rental income or (loss).......MediumBullet 116,585   0 116,585
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory   -15,260
b Less: cost or other basis and sales expenses   0
c Gain or (loss)   -15,260
d Net gain or (loss)..........MediumBullet -15,260     -15,260
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ..
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet 0    
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet 0      
Miscellaneous Revenue Business Code
11a GROUND LEASE REVENUE 621990 428,105     428,105
b CAFETERIA SALES 621990 523,956     523,956
c LACTATION/IMMUNIZATIONS 621990 532     532
d All other revenue .... 103,721     103,721
e Total. Add lines 11a–11d ...... MediumBullet 1,056,314
12 Total revenue. See Instructions......MediumBullet 126,230,204 125,072,565 0 1,157,639
Form 990 (2014)
Form 990 (2014)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response or note to any line in this Part IX ...............
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 .... 0  
2 Grants and other assistance to domestic individuals. See Part IV, line 22 .... 600 600
3 Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16 ............ 0  
4 Benefits paid to or for members .... 0  
5 Compensation of current officers, directors, trustees, and key employees .... 681,560 592,957 88,603 0
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 0      
7 Other salaries and wages .... 43,043,336 37,240,309 5,803,027  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 2,161,840   2,161,840  
9 Other employee benefits ....... 5,767,146 4,990,063 777,083  
10 Payroll taxes ........... 3,153,038 2,728,188 424,850  
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 1,341   1,341  
c Accounting ........... 0      
d Lobbying ........... 0      
e Professional fundraising services. See Part IV, line 17 0  
f Investment management fees ...... 0      
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) .... 6,197,279 5,957,475 239,804  
12 Advertising and promotion .... 2,884 3,605 -721  
13 Office expenses ....... 4,196,186 3,317,685 878,501  
14 Information technology ...... 0      
15 Royalties .. 0      
16 Occupancy ........... 1,626,961 123,158 1,503,803  
17 Travel ............ 37,215 19,834 17,381  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 151,366 13,196 138,170  
20 Interest ........... 1,107,616   1,107,616  
21 Payments to affiliates ....... 25,904,584 22,414,119 3,490,465  
22 Depreciation, depletion, and amortization ..... 5,843,577 2,643,587 3,199,990  
23 Insurance .............. 1,215,665   1,215,665  
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a REPAIRS & MAINT 2,244,013 1,699,768 544,245  
b MEDICAL SUPPLIES 14,086,602 14,069,743 16,859  
c OTHER EXPENSES 98,848 8,357 90,491  
d
e All other expenses        
25 Total functional expenses. Add lines 1 through 24e 117,521,657 95,822,644 21,699,013 0
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2014)
Form 990 (2014)
Page 11
Part X Balance Sheet Check if Schedule O contains a response or note to any line in this Part X ..............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash–non-interest-bearing ............. 6,375 1 41,756
2 Savings and temporary cash investments ......... 18,779 2 0
3 Pledges and grants receivable, net ........... 0 3 0
4 Accounts receivable, net ............. 24,829,187 4 19,173,914
5 Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..................
0 5 0
6 Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
0 6 0
7 Notes and loans receivable, net ............. 0 7 0
8 Inventories for sale or use .............. 1,863,146 8 1,930,520
9 Prepaid expenses and deferred charges .......... 325,205 9 63,384
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 118,002,750
b Less: accumulated depreciation ..... 10b 62,394,564 55,761,421 10c 55,608,186
11 Investments—publicly traded securities .......... 0 11 0
12 Investments—other securities. See Part IV, line 11 ..... 0 12 0
13 Investments—program-related. See Part IV, line 11 ..... 0 13 0
14 Intangible assets ............... 0 14 0
15 Other assets. See Part IV, line 11 ........... 1,332,047 15 1,328,504
16 Total assets. Add lines 1 through 15 (must equal line 34)...... 84,136,160 16 78,146,264
Liabilities 17 Accounts payable and accrued expenses ......... 7,055,125 17 5,199,612
18 Grants payable ................. 0 18 0
19 Deferred revenue ................ 0 19 0
20 Tax-exempt bond liabilities ............. 0 20 0
21 Escrow or custodial account liability. Complete Part IV of Schedule D.. 0 21 0
22 Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L.......... 0 22 0
23 Secured mortgages and notes payable to unrelated third parties .. 0 23 0
24 Unsecured notes and loans payable to unrelated third parties .... 0 24 0
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.................... 35,053,264 25 34,470,835
26 Total liabilities. Add lines 17 through 25......... 42,108,389 26 39,670,447
Net Assets or Fund Balance Organizations that follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets .............. 42,027,771 27 38,475,817
28 Temporarily restricted net assets ........... 0 28 0
29 Permanently restricted net assets ........... 0 29 0
Organizations that do not follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds ........   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ........... 42,027,771 33 38,475,817
34 Total liabilities and net assets/fund balances ........ 84,136,160 34 78,146,264
Form 990 (2014)
Form 990 (2014)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response or note to any line in this Part XI ..............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
126,230,204
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
117,521,657
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
8,708,547
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
42,027,771
5
Net unrealized gains (losses) on investments ...............
5
 
6
Donated services and use of facilities .................
6
 
7
Investment expenses .....................
7
 
8
Prior period adjustments .....................
8
 
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
-12,260,501
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
38,475,817
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response or note to any line in this Part XII .............
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?
2a
 
No
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If "Yes," to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? .................
3a
 
No
b
If "Yes," did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits.
3b
 
 
Form 990 (2014)
Form 990 (2014)
Page 13
Form 990, Special Condition Description:
Special Condition Description
Form 990 (2014)
Form 990 (2014)
Page 14
Additional Data


Software ID:  
Software Version:  
SCHEDULE A
(Form 990 or 990EZ)

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.
right arrow Attach to Form 990 or Form 990-EZ.
right arrow Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2014
Open to Public
Inspection
Name of the organization
DOUGLAS HOSPITAL INC
 
Employer identification number

58-2026750
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
a
b
c
d
e
f
Enter the number of supported organizations .............................  
g
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 listed in your governing document? (v) Amount of monetary support (see instructions) (vi) Amount of other support (see instructions)
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) 2014
Schedule A (Form 990 or 990-EZ) 2014
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) right arrow (a) 2010 (b) 2011 (c) 2012 (d) 2013 (e) 2014 (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) right arrow (a) 2010 (b) 2011 (c) 2012 (d) 2013 (e) 2014 (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 VI.)..            
11 Total support Add lines 7 through 10.  
12
12
 
13
First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here........................................right arrow
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
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 ..................................................... right arrow
Schedule A (Form 990 or 990-EZ) 2014
Schedule A (Form 990 or 990-EZ) 2014
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) right arrow (a) 2010 (b) 2011 (c) 2012 (d) 2013 (e) 2014 (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) right arrow (a) 2010 (b) 2011 (c) 2012 (d) 2013 (e) 2014 (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 VI.) ..            
13 Total support. (Add lines 9, 10c, 11, and 12.)..            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2014
Schedule A (Form 990 or 990-EZ) 2014
Page 4
Part IV
Supporting Organizations
(Complete only if you checked a box on line 11 of Part I. If you checked 11a of Part I, complete Sections A and B. If you checked 11b of Part I, complete Sections A and C. If you checked 11c of Part I, complete Sections A, D, and E. If you checked 11d of Part I, complete Sections A and D, and complete Part V.)
Section A. All Supporting Organizations
Yes
No
1
Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.
1
 
 
2
Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).
2
 
 
3a
Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below.
3a
 
 
b
Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.
3b
 
 
c
Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.
3c
 
 
4a
Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked 11a or 11b in Part I, answer (b) and (c) below.
4a
 
 
b
Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations....
4b
 
 
c
Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.
4c
 
 
5a
Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer (b) and (c) below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed, (ii) the reasons for each such action, (iii) the authority under the organization's organizing document authorizing such action, and (iv) how the action was accomplished (such as by amendment to the organizing document).
5a
 
 
b
Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?
5b
 
 
c
Substitutions only. Was the substitution the result of an event beyond the organization's control?
5c
 
 
6
Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (a) its supported organizations; (b) individuals that are part of the charitable class benefited by one or more of its supported organizations; or (c) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.
6
 
 
7
Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in IRC 4958(c)(3)(C)), a family member of a substantial contributor, or a 35-percent controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990) .
7
 
 
8
Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If “Yes,” complete Part II of Schedule L (Form 990).
8
 
 
9a
Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.
9a
 
 
b
Did one or more disqualified persons (as defined in line 9(a)) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.
9b
 
 
c
Did a disqualified person (as defined in line 9(a)) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.
9c
 
 
10a
Was the organization subject to the excess business holdings rules of IRC 4943 because of IRC 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer b below.
10a
 
 
b
Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).
10b
 
 
11
Has the organization accepted a gift or contribution from any of the following persons?
a
A person who directly or indirectly controls, either alone or together with persons described in (b) and (c) below, the governing body of a supported organization?
11a
 
 
b
A family member of a person described in (a) above?
11b
 
 
c
A 35% controlled entity of a person described in (a) or (b) above? If “Yes” to a, b, or c, provide detail in Part VI.
11c
 
 
Schedule A (Form 990 or 990-EZ) 2014
Schedule A (Form 990 or 990-EZ) 2014
Page 5
Part IV
Supporting Organizations (continued)

Section B. Type I Supporting Organizations
Yes
No
1
Did the directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.
1
 
 
2
Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.
2
 
 
Section C. Type II Supporting Organizations
Yes
No
1
Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).
1
 
 
Section D. All Type III Supporting Organizations
Yes
No
1
Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (1) a written notice describing the type and amount of support provided during the prior tax year, (2) a copy of the Form 990 that was most recently filed as of the date of notification, and (3) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?
1
 
 
2
Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).
2
 
 
3
By reason of the relationship described in (2), did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.
3
 
 
Section E. Type III Functionally-Integrated Supporting Organizations
1
Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):
a
b
c
2
Activities Test. Answer (a) and (b) below.
Yes
No
a
Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.
2a
 
 
b
Did the activities described in (a) constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.
2b
 
 
3
Parent of Supported Organizations. Answer (a) and (b) below.
a
Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? Provide details in Part VI.
3a
 
 
b
Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI the role played by the organization in this regard.
3b
 
 
Schedule A (Form 990 or 990-EZ) 2014
Schedule A (Form 990 or 990-EZ) 2014
Page 6
Part V – Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations

1.   Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970. See instructions. All other Type III non-functionally integrated supporting organizations must complete Sections A through E.
Section A - Adjusted Net Income (A) Prior Year (B) Current Year
(optional)
1 Net short-term capital gain 1    
2 Recoveries of prior-year distributions 2    
3 Other gross income (see instructions) 3    
4 Add lines 1 through 3 4    
5 Depreciation and depletion 5    
6 Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) 6    
7 Other expenses (see instructions) 7    
8 Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) 8    

Section B - Minimum Asset Amount (A) Prior Year (B) Current Year
(optional)
1 Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): 1
a Average monthly value of securities 1a    
b Average monthly cash balances 1b    
c Fair market value of other non-exempt-use assets 1c    
d Total (add lines 1a, 1b, and 1c) 1d    
e Discount claimed for blockage or other factors (explain in detail in Part VI):  
2 Acquisition indebtedness applicable to non-exempt use assets 2    
3 Subtract line 2 from line 1d 3    
4 Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). 4    
5 Net value of non-exempt-use assets (subtract line 4 from line 3) 5    
6 Multiply line 5 by .035 6    
7 Recoveries of prior-year distributions 7    
8 Minimum Asset Amount (add line 7 to line 6) 8    

Section C - Distributable Amount Current Year
1 Adjusted net income for prior year (from Section A, line 8, Column A) 1  
2 Enter 85% of line 1 2  
3 Minimum asset amount for prior year (from Section B, line 8, Column A) 3  
4 Enter greater of line 2 or line 3 4  
5 Income tax imposed in prior year 5  
6 Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) 6  
7   Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions)
Schedule A (Form 990 or 990-EZ) 2014
Schedule A (Form 990 or 990-EZ) 2014
Page 7
Section D - Distributions Current Year
1 Amounts paid to supported organizations to accomplish exempt purposes  
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in
excess of income from activity		  
3 Administrative expenses paid to accomplish exempt purposes of supported organizations  
4 Amounts paid to acquire exempt-use assets  
5 Qualified set-aside amounts (prior IRS approval required)  
6 Other distributions (describe in Part VI). See instructions  
7Total annual distributions. Add lines 1 through 6.  
8 Distributions to attentive supported organizations to which the organization is responsive (provide
details in Part VI). See instructions		  
9 Distributable amount for 2014 from Section C, line 6  
10 Line 8 amount divided by Line 9 amount  

Section E - Distribution Allocations (see instructions) (i)
Excess Distributions 		(ii)
Underdistributions
Pre-2014 		(iii)
Distributable
Amount for 2014
1 Distributable amount for 2014 from Section C, line
6 		 
2 Underdistributions, if any, for years prior to 2014
(reasonable cause required--see instructions)		  
3 Excess distributions carryover, if any, to 2014:
a From 2009.......X
b From 2010.......X
c From 2011.......X
d From 2012.......X
e From 2013.......  
fTotal of lines 3a through e  
g Applied to underdistributions of prior years  
h Applied to 2014 distributable amount  
i Carryover from 2009 not applied (see
instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.  
4Distributions for 2014 from Section D, line 7:
$  
a Applied to underdistributions of prior years  
b Applied to 2014 distributable amount  
c Remainder. Subtract lines 4a and 4b from 4.  
5 Remaining underdistributions for years prior to
2014, if any. Subtract lines 3g and 4a from line 2
(if amount greater than zero, see instructions)		  
6 Remaining underdistributions for 2014. Subtract
lines 3h and 4b from line 1 (if amount greater than
zero, see instructions)		  
7 Excess distributions carryover to 2015. Add lines
3j and 4c.		  
8 Breakdown of line 7:
a From 2010.......X
b From 2011.......X
c From 2012.......X
d From 2013.......  
e From 2014.......  
Schedule A (Form 990 or 990-EZ) (2014)
Schedule A (Form 990 or 990-EZ) 2014
Page 8
Part VI
Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Return Reference Explanation
Schedule A (Form 990 or 990-EZ) 2014

Additional Data


Software ID:  
Software Version:  
SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b.
SchDMd Bullet Attach to Form 990.
Information about Schedule D (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2014
Open to Public Inspection
Name of the organization
DOUGLAS HOSPITAL INC
 
Employer identification number

58-2026750
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .........    
2 Aggregate value of contributions to (during year)    
3 Aggregate value of grants from (during year)    
4 Aggregate value at end of year ........    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................
9
In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:
(i)
Revenue included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:
a
Revenue included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 52283D
Schedule D (Form 990) 2014

Schedule D (Form 990) 2014
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIII and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability?
b
If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII .......
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current year (b)Prior year b (c)Two years back (d)Three years back (e)Four years back
1a Beginning of year balance ....          
b Contributions ........          
c Net investment earnings, gains, and losses          
d Grants or scholarships .....          
e Other expenditures for facilities
and programs ........ 		         
f Administrative expenses ....          
g End of year balance ......          
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet  
c
Temporarily restricted endowment SchDMd Bullet  
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
 
(ii) related organizations ........................
3a(ii)
 
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIII the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11a. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   59,570 59,570
b Buildings ................   56,425,656 23,547,556 32,878,100
c Leasehold improvements ............   1,121,454 722,701 398,753
d Equipment ................   58,540,763 37,800,056 20,740,707
e Other .................   1,855,307 324,251 1,531,056
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 55,608,186
Schedule D (Form 990) 2014

Schedule D (Form 990) 2014
Page 3
Part VII
Investments—Other Securities. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11b. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet  
Part VIII
Investments—Program Related. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11c. See Form 990, Part X, line 13.
(a) Description of investment (b) Book value (c) Method of valuation:
Cost or end-of-year market value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11d. See Form 990, Part X, line 15.
(a) Description (b) Book value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.
1.(a) Description of liability (b) Book value
Federal income taxes 0
OTHER LT LIABILITIES 14,646
ASSET RETIREMENT OBLIGATION LT 631,969
TAX EXEMPT BOND LIAB.DUE TO WHS 33,824,220






Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 34,470,835
2. Liability for uncertain tax positions. In Part XIII, 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 (ASC 740). Check here if the text of the footnote has been provided in Part XIII
Schedule D (Form 990) 2014

Schedule D (Form 990) 2014
Page 4
Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return Complete if the organization answered 'Yes' to Form 990, Part IV, line 12a.
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains (losses) on investments .... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIII.) ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIII.) ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5  
Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' to Form 990, Part IV, line 12a.
1 Total expenses and losses per audited financial statements ........... 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIII.) ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIII.) ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5  
Part XIII
Supplemental Information
Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.
Return Reference Explanation
SCHEDULE D, PART X, LINE 2 The following footnote is related to the organization's application of FIN 48 (ASC 740): Wellstar (including DOUGLAS Hospital) 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 501(C)(3) and, therefore, related income is generally not subject to Federal or state income taxes. Community Assurance Corporation 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.
Schedule D (Form 990) 2014

Additional Data


Software ID:  
Software Version:  




SCHEDULE H (Form 990)
Department of the TreasuryInternal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet Attach to Form 990.
MediumBullet Information about Schedule H (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2014
Open to Public Inspection
Name of the organization
DOUGLAS HOSPITAL INC
 
Employer identification number

58-2026750
Part I
Financial Assistance and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a ...
1a
Yes
 
b
If "Yes," was it a written policy? .......................
1b
Yes
 
2
If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.
3
Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.
a
Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate
which of the following was the family income limit for eligibility for discounted care: .........
3b
Yes
 
%
c
If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.
4
Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

4

Yes

 
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? ......
5b
Yes
 
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? ..............
5c
 
No
6a
Did the organization prepare a community benefit report during the tax year? ..........
6a
Yes
 
b
If "Yes," did the organization make it available to the public? ..............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance and
Means-Tested
Government Programs
 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) .. 		    11,958,733   11,958,733 10.890 %
b Medicaid (from Worksheet 3,
column a) .... 		    16,141,233 15,000,647 1,140,586 0.970 %
c Costs of other means-tested
government programs (from
Worksheet 3, column b) . 		           
d Total Financial Assistance
and Means-Tested
Government Programs . 		    28,099,966 15,000,647 13,099,319 11.860 %
Other Benefits
     242,966   242,966 0.220 %
e Community health
improvement services and
community benefit operations
(from Worksheet 4) ..
f Health professions education
(from Worksheet 5) .. 		           
g Subsidized health services
(from Worksheet 6) .. 		           
h Research (from Worksheet 7)            
i Cash and in-kind
contributions for community
benefit (from Worksheet 8) 		           
j Total. Other Benefits ..     242,966   242,966 0.220 %
k Total. Add lines 7d and 7j .     28,342,932 15,000,647 13,342,285 12.080 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2014
Schedule H (Form 990) 2014
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development            
3 Community support            
4 Environmental improvements            
5 Leadership development and training for community members            
6 Coalition building            
7 Community health improvement advocacy            
8 Workforce development            
9 Other            
10 Total            
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......
2
5,169,760
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......
3
630,171
4
Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
45,335,585
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
50,735,806
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-5,400,221
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

9b

Yes

 
Part IV
Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership % 		(e) Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2014
Schedule H (Form 990) 2014
Page
Part VFacility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest—see instructions)
How many hospital facilities did the organization operate during the tax year?1
Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility) 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital ResearchGrp Facility ER-24Hours ER-Other Other (describe) Facility reporting group
1 DOUGLAS HOSPITAL
8954 HOSPITAL DRIVE
DOUGLASVILLE,GA30134
www.wellstar.org
048-548 		X X         X      
Schedule H (Form 990) 2014
Schedule H (Form 990) 2014
Page
Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
DOUGLAS HOSPITAL
Name of hospital facility or letter of facility reporting group  
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A): 		1
Yes No
Community Health Needs Assessment
1 Was the hospital facility first licensed, registered, or similarly recognized by a State as a hospital facility in the current tax year or the immediately preceding tax year?....................... 1   No
2 Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C.......... 2   No
3 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12.................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 12
5 In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ................. 5 Yes  
6a Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C................................ 6a   No
b Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................ 6b   No
7 Did the hospital facility make its CHNA report widely available to the public? .............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. ............. 		8 Yes  
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 12
10 Is the hospital facility's most recently adopted implementation strategy posted on a website? ........ 10 Yes  
a If "Yes" (list url): SEE PART V, SECTION C
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b   No
11 Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)? ........................... 12a   No
b If "Yes" to line 12a, did the organization file Form 4720 to report the section 4959 excise tax? ...... 12b    
c If "Yes" to line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $  

Schedule H (Form 990) 2014
Schedule H (Form 990) 2014
Page
Part VFacility Information (continued)

DOUGLAS HOSPITAL
Name of hospital facility or letter of facility reporting group  
Yes No
Financial Assistance Policy (FAP)
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 Yes  
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
b
c
d
e
16 Included measures to publicize the policy within the community served by the hospital facility?....... 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
b
c
d
e
f
g
h
i
Billing and Collections
17 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon non-payment?.................................. 17 Yes  
18 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
b
c
d
e
Schedule H (Form 990) 2014
Schedule H (Form 990) 2014
Page
Part VFacility Information (continued)

DOUGLAS HOSPITAL
Name of hospital facility or letter of facility reporting group  
Yes No
19 Did the hospital facility or other authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?......... 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
20 Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 18. (check all that apply):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?................ 21 Yes  
If "No," indicate why:
a
b
c
d
Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
22 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
23 During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ................................ 23   No
If "Yes," explain in Section C.
24 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2014
Schedule H (Form 990) 2014
Page
Part V
Facility Information (continued)
Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16i, 18d, 19d, 20e, 21c, 21d, 22d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference Explanation
SCHEDULE H, PART V, SECTION B, LINE 3J OTHER DESCRIPTIONS FROM THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA): The Community Health Needs Assessment for DOUGLAS HOSPITAL provideS a list of WellStar Health System CHNA collaborators including individuals, organizations, and governmental agencies THAT WERE consulted AND contributed special knowledge of medically underserved and low income populations and/or expertise in public health. SCHEDULE H, PART V, SECTION B, LINE 5 INPUT FROM COMMUNITY REPRESENTATIVES & COMMUNITY SOURCES: DOUGLAS HOSPITAL integrated multiple sources of data from national and state web-based data platforms with multiple primary data gathering methods (see list below). As a partner in the strategic planning process utilized by Cobb & Douglas Public Health (CDPH) called Mobilizing for Action through Planning and Partners (MAPP) from the National Association of County & City Health Officials, the hospital leveraged the findings from THE community health needs assessments conducted in tax year 2012. Through a grant by the Centers for Disease Control and Prevention, DOUGLAS HOSPITAL partnered with CDPH and formed a coalition, Cobb 2020, to conduct its needs assessment via multiple modalities: MAPP workgroups, focus groups, surveys, Key Informant interviews, and implementation teams to act upon identified strategic issues in the community. To collect robust data for counties WellStar serves outside of Cobb, WellStar enlisted expertise of county and regional public health officials, independent consultants, and other Key Informants. A listing of collaborators can be found in the Appendix of the hospital facility's CHNA reports publicly available at wellstar.org. Quantitative Data Sources Including: 1. Georgia Department of Public Health, OASIS 2. Centers for Disease Control and Prevention (CDC) Vital Statistics 3. Agency for Healthcare Research and Quality (AHRQ) 4. U.S. Census Bureau 5. U.S. Department of Health and Human Services 6. Kaiser Permanente Web - Based CHNA Platform 7. Catholic Health Association CHNA resources 8. County Health Rankings & Roadmaps, University of Wisconsin 9. Healthy People 2020 10. Behavioral Risk Factor Surveillance System (BRFSS) 11. WellStar Health System - DOUGLAS Hospital's FY2012 utilization data to assess service area zip codes accounting for 90 percent of hospital admissions and visits and primary service areas. Qualitative Data Sources Including: 1. Cobb County Focus Group Report - 58 people participated in six focus group representing 14 zip codes. Demographics varied among the groups indicative of the zip codes represented. Two groups were conducted in Spanish and reflected low-income, low education attainment and medically underserved populations. 2. MAPP Assessment Workgroups with representatives from Douglas and Cobb counties conducted four community assessments which helped develop the Cobb 2020 Community Health Improvement Plan. This included the 2011 Field Test Local Public Health System Assessment by the National Public Health Performance Standards Program (NPHPSP). 3. Cobb Key Informant Interview Report - 20 participants identified by Cobb 2020's Community Strengths and Themes Workgroup to represent different sectors of the Cobb community who possessed above average knowledge of the healthcare issues, healthcare system or the community. 4. Cobb MAPP Community Survey Report - A 44 question telephone survey of 1,244 adults ages 18-94 performed by the A.L. Burruss Institute for Public Service and Research, Kennesaw State University. 5. Cobb County 2010 - How Healthy Are We? 6. Cobb County MAPP Forces of Change Assessment Summary Report 7. Bartow, Cherokee and Paulding County Key Informant interviews of community stakeholders led by Ron Chapman, Principal, Magnetic North, LLC, a third-party consultanT. SCHEDULE H, PART V, SECTION B, LINE 6A ORGANIZATIONS INCLUDED IN COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA): While DOUGLAS HOSPITAL conducted its own community health needs assessment there may be some overlap with the other hospitals in WellStar Health System simply because of the geographic constraints and structure of the organization. The community served therefore is defined by similar zip codes and areas of services. SCHEDULE H, PART V, SECTION B, LINES 7A & 7B THE DOUGLAS HOSPITAL CHNA CAN BE FOUND AT THE FOLLOWING: DOUGLAS HOSPITAL WEBSITE: Http://www.wellstar.org/about-us/documents/chna/douglas_chna_06172013.pdf AND WELLSTAR HEALTH SYSTEM WEBSITE: http://www.wellstar.org/pages/default.aspx SCHEDULE H, PART V, SECTION B, LINE 10A DOUGLAS HOSPITAL'S MOST RECENTLY ADOPTED IMPLEMENTATION STRATEGY CAN BE FOUND ON ITS WEBSITE at: http://www.wellstar.org/about-us/documents/implementation_strategy/douglas _implementation_strategy_11112013.pdf SCHEDULE H, PART V, SECTION B, LINE 11 PROGRAMS & STRATEGIES TO ADDRESS THE NEEDS OF THE COMMUNITY: DOUGLAS HOSPITAL Based on the prioritized health needs, WellStar will implement a five-year, two-phased Community Benefit program that is sustainable and strategically aligned with the WellStar Health System mission and vision to address the prioritized health needs of the uninsured and low-income populations. This is accomplished through expanding provider participation, education, outreach and prevention activities/programs to promote healthy lifestyles and access to care (Phase 1) and creating a collaborative safety net organization for shared accountability to leverage and maximize complementary skills and capacity building (Phase 2). Currently, Phase 2 has shifted from creating an organization to integrating this type of care delivery into the community benefit services WellStar delivers at a health system-level across all hospitals. Progress ongoing in Phase 2: Strategy: Improve access to care to vulnerable populations - Strengthen collaborative partnerships with community stakeholders to increase access to preventative and primary care, improve quality and reduce costs. - Reduce preventable hospital admissions, re-admissions and Emergency Department visits by redirecting care to community clinics and primary care via the hospital-based care management program. - Increase the number of hospital-affiliated/WellStar Physicians Group primary care providers and specialists providing free or low-cost healthcare programs/clinics via a Graduate Medical Education program. (Commences in 2017) - Develop a more collaborative delivery system for behavioral health services/resources through partnerships. (in process) - Improve medication access through centralized reduced cost Pharmaceutical Patient Access Programs and the Federal 340B Drug Pricing Program for the management of chronic disease and to reduce complications. (currently being assessed) - Evaluate hospital-based subsidized health services to more effectively and efficiently allocate assets addressing prioritized needs of the medically underserved and uninsured. STRATEGY: Promote healthy lifestyles via preventative care, programs and activities - Engage faith-based organizations in coordination and provision of care (MEMPHIS Model). (Pilot to be conducted at WellStar Paulding Hospital.) - Expand free health screenings to the underserved and uninsured through WellStar Corporate & Community Health. - Improve prevention-based educational resources and the referral process to free or low-cost healthcare clinics for continuity of care within the Emergency Department. - Provide community benefit leadership/consultation for the prevention and management of pulmonary diseases (asthma, lung cancer, chronic obstructive pulmonary disease) and cardiovascular disease. UNADDRESSED CHNA NEEDS - Selection criteria for DOUGLAS HOSPITAL'S prioritized health needs were primarily based upon the bandwidth to build a sustainable community benefit model focused on preventable health behaviors and access to care. Sexually transmitted infections and teen pregnancy are not addressed leaving awareness education with schools, family and churches since the health needs are more cultural and societal. Improvement to health needs stemming from socioeconomic and physical environmental FACTORS such as air quality and transportation, gain traction from public policy and education. A health system can complement efforts to impact policy, but has to rely on public health, state and local municipalities and federal governmental agencies to drive these types of health improvements. Key questions when addressing health needs are: 1.) Do we have existing facilities and resources dedicated to the health needs showing clear disparities and poor performance? And, 2.) Do we have effective and feasible interventions, a successful solution that has the potential to solve multiple problems, and the opportunity to intervene at the prevention level? Other needs not addressed are either beyond the scope or expertise of DOUGLAS Hospital, not being addressed at this time or are being addressed by WellStar on a system level or via other partners in public health. SCHEDULE H, PA
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Schedule H (Form 990) 2014
Schedule H (Form 990) 2014
Page
Part VFacility Information (continued)

Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, from largest to smallest)
How many non-hospital health care facilities did the organization operate during the tax year?  
Name and address Type of Facility (describe)
1
2
3
4
5
6
7
8
9
10
Schedule H (Form 990) 2014
Schedule H (Form 990) 2014
Page
Part VI
Supplemental Information
Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Form and Line Reference Explanation
SCHEDULE H, PART I, LINE 6A PUBLICATION OF COMMUNITY BENEFIT REPORT: DOUGLAS HOSPITAL is an affiliate of Wellstar Health System, Inc. which on an annual basis issues a community benefit report. This report is subsequently distributed in and around the five county service area of the health system. It is also annually filed with Cobb County and the state of Georgia Department of Community Health. Additionally the information on community benefit is included in aggregate for Wellstar Health System, Inc. and affiliated hospitals as part of the Georgia Hospital Association's annual report. On an annual basis the hospital reports its community health benefits report to the Georgia Hospital Association (GHA). GHA aggregates the hospital specific reports into a statewide community health benefit report. The State of Georgia also requires hospitals to file the Hospital Financial Survey and the Indigent Care Trust Fund Survey so that it can collect information on hospital financial class categories and also to determine the amount of uncompensated care by hospital. THE COMMUNITY BENEFIT REPORT CAN BE FOUND ON THE WELLSTAR WEBSITE AT: http://www.wellstar.org/about-us/documents/chna/douglas_chna_06172013.pdf Schedule H, Part I, Line 7 COST TO CHARGE RATIO: For purposes of the IRS Form 990 Schedule H, Wellstar Health System and Affiliates (including DOUGLAS HOSPITAL) have estimated the current year cost to charge ratio for each hospital as it is reported in the annual community benefit report and as it will be reported in the state's Annual Hospital Financial Survey. Schedule H, Part III, Section A, Line 2 METHODOLOGY USED TO ESTIMATE BAD DEBT: The reported bad debt charges is derived from the unpaid balances of patient accounts that are deemed uncollectible after 120 days of collection effort by the hospital's patient financial services staff. The unpaid patient accounts are then sent to collection agencies and any collected amount is deemed as bad debt recovery. The source of this data is the hospital's detailed financial trial balance. The net reported bad debt charges are then multiplied by the Hospital Financial Survey calculated cost to charge ratio to arrive at the estimated bad debt expense. Schedule H, Part III, Section A, Line 3 METHOLODOGY & RATIONALE USED TO DETERMINE BAD DEBT ATTRIBUTABLE TO PATIENT'S ELIGIBLE UNDER ORGANIZATION'S FAP: The bad debt attributable to patients eligible under the hospital's financial assistance program is determined using a weekly bad debt conversion report for a period of twelve months. The conversion rate for this period is used to determine this bad debt category. The total reported conversion charges is multiplied by a calculated cost to charge ratio to arrive at the cost of bad debt attributable to patient's eligible under the hospital's FAP. Schedule H, Part III, Section A, Line 4 FOOTNOTE ON BAD DEBT & RATIONALE FOR COMMUNITY BENEFIT: The following footnote is detailed in the Wellstar Health System, Inc. and Affiliates Combined Financial Statements related to bad debt or uncollectible accounts: "During 2011, Wellstar adopted the provisions of FASB Accounting Standards Update (2011-07), Healthcare Entities (Topic 954). ASU 2011-07 requires the reclassification of the provision for uncollectible accounts associated with patient service revenue from an operating expense to a deduction from patient service revenue (net of contractual allowances and discounts)." "Wellstar recognizes patient service revenue associated with services provided to patients with third-party payor coverage on the basis of contractual rates for the services rendered. For uninsured patients that do not qualify for community financial aid, Wellstar recognizes revenue on the basis of its discounted rates for services provided. On the basis of historical experience, a significant portion of Wellstar's uninsured patients are unable or unwilling to pay for the services provided. Thus, Wellstar records a significant provision for uncollectible accounts related to uninsured patients in the period the services are provided." Subsequent to the end of the reporting period a propensity to pay review of patient accounts often results in prior year bad debt accounts which are deemed eligible for the organization's financial assistance policy. Those bad debt accounts are reclassified as charity and thus our rationale for including in community benefit. Schedule H, Part III, Section B, Line 8 MEDICARE SHORTFALLS: DOUGLAS HOSPITAL IS A provider of inpatient and outpatient services to Medicare program beneficiaries at determined rates. Without the participation in the Medicare program these patients may not have had convenient access to those services. The Medicare shortfall on SCHEDULE H, Part III, Section B, line 7 represents the uncompensated difference between the expected reimbursement and the Medicare charges for those services stated at cost. We determine a cost to charge ratio for Medicare patients as part of the annual filing of the Medicare cost report. Schedule H, Part III, Section C, Line 9B COLLECTION PRACTICES: The policy written for collection practices that applies to all Wellstar Health System entities incorporates guidelines for personnel in the admissions and patient access areas to be trained in identifying patients that might qualify for financial assistance. It is also the policy of all Wellstar facilities to have at least one employee or contractor available at all times, especially in the hospitals with emergency rooms, who can provide assistance with the paperwork necessary to help patients who would qualify for governmental and other assistance programs. SCHEDULE H, PART VI, LINE 2 NEEDS ASSESSMENT: To assess the current health and well-being of the community served, WELLSTAR HEALTH SYSTEM, INC., AND DOUGLAS HOSPITAL conducted a Community Health Needs Assessment (CHNA), a collaborative effort involving hospital leadership, public health agencies, Cobb2020, and a diverse coalition of community stakeholders. Partners represented a broad knowledge base of the hospital's primary service area comprising Bartow, Douglas, Cherokee, Cobb, and Paulding counties and some outlying zip codes determined by utilization. To assess the current community health status and capture a broad base of input, collaborators engaged IN a strategic process called Mobilizing for Action Through Planning and Partnerships (MAPP) launched by Cobb & Douglas Public Health (CDPH). MAPP provides the framework for creating a community-driven health improvement plan through different assessments to evaluate: - Prevalent health issues - Health issues that are important to the community members - Availability of health services - Forces that impact community health Wellstar Health System (and affiliates) is a key stakeholder in MOBLIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIPS ("MAPP"). 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 collection 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 the 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. SCHEDULE H, PART VI, LINE 3 PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE: The hospital provides notice of the availability of community financial Assistance via: - Signage - Patient Brochure - Billing Statement - Collection Action Letter - Online at http://www.wellstar.org/pages/online-bill-pay.aspx DOUGLAS Hospital provide its patients with hospital personnel or contracted personnel who are trained in all aspects of governmental programs, payments plans, charity discounts, and other financial assistance offered to assist them in their hospital bills. If the patient is eligible for federal or state assistance programs, a staff member is knowledgeable in the steps necessary to qualify those individual
Schedule H (Form 990) 2014
Additional Data


Software ID:  
Software Version:  
Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, line 23.
SchJMediumBullet Attach to Form 990.
SchJMediumBullet Information about Schedule J (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2014
Open to Public Inspection
Name of the organization
DOUGLAS HOSPITAL INC
 
Employer identification number

58-2026750
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain....
1b
 
No
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked in line 1a? ..
2
Yes
 
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ................
4a
Yes
 
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? .........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.
5
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
Yes
 
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2014

Schedule J (Form 990) 2014
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(A) Name and Title (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation in column(B) reported as deferred in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
1Valery A AkopovVP & Chief of Hospitalist Svcs (i)
(ii)		 0
...............................
329,534 		0
...............................
59,170 		0
...............................
11,041 		0
...............................
28,200 		0
...............................
25,463 		0
...............................
453,408 		0
...............................
0
2David W AndersonEVP HR OL CCO (i)
(ii)		 0
...............................
414,523 		0
...............................
205,272 		0
...............................
29,134 		0
...............................
45,700 		0
...............................
24,590 		0
...............................
719,219 		0
...............................
0
3Nicole V AsheVP Finance & CFO WMG (i)
(ii)		 0
...............................
219,898 		0
...............................
32,783 		0
...............................
9,504 		0
...............................
22,403 		0
...............................
23,482 		0
...............................
308,070 		0
...............................
0
4Barbara G BallardVP Homecare & Hospice (i)
(ii)		 0
...............................
238,742 		0
...............................
33,691 		0
...............................
10,403 		0
...............................
43,913 		0
...............................
21,002 		0
...............................
347,751 		0
...............................
0
5Melissa L BoxVP CNO Patient Care Services (i)
(ii)		 175,219
...............................
0 		29,684
...............................
0 		11,624
...............................
0 		12,816
...............................
0 		25,444
...............................
0 		254,787
...............................
0 		0
...............................
0
6Joseph L BrywczynskiSVP Health Parks Development (i)
(ii)		 0
...............................
266,989 		0
...............................
285,443 		0
...............................
17,664 		0
...............................
45,700 		0
...............................
24,444 		0
...............................
640,240 		0
...............................
0
7Anthony J BudzinskiEVP & CFO (i)
(ii)		 0
...............................
539,386 		0
...............................
134,954 		0
...............................
14,896 		0
...............................
45,700 		0
...............................
25,396 		0
...............................
760,332 		0
...............................
0
8Donald Campbell MDSVP Phys Educ & Student Aff (i)
(ii)		 0
...............................
327,517 		0
...............................
167,537 		0
...............................
18,263 		0
...............................
45,700 		0
...............................
16,783 		0
...............................
575,800 		0
...............................
0
9James E ClementsVP Bus Dev & Strategic Prtnrsp (i)
(ii)		 0
...............................
207,563 		0
...............................
49,762 		0
...............................
6,691 		0
...............................
0 		0
...............................
17,453 		0
...............................
281,469 		0
...............................
0
10Lee R CookVP Med & Behavioral Health (i)
(ii)		 0
...............................
256,547 		0
...............................
327,425 		0
...............................
8,736 		0
...............................
27,624 		0
...............................
17,428 		0
...............................
637,760 		0
...............................
0
11Barbara B CoreySVP Managed Care (i)
(ii)		 0
...............................
301,454 		0
...............................
65,765 		0
...............................
11,944 		0
...............................
21,292 		0
...............................
26,837 		0
...............................
427,292 		0
...............................
0
12Bruce A DeanVP Real Estate Deputy Gen Cnsl (i)
(ii)		 0
...............................
227,781 		0
...............................
40,345 		0
...............................
14,335 		0
...............................
45,675 		0
...............................
24,166 		0
...............................
352,302 		0
...............................
0
13Marcia Delk-Payne MDSVP Med Affair & Chf Qlty Ofcr (i)
(ii)		 0
...............................
370,531 		0
...............................
544,886 		0
...............................
10,395 		0
...............................
45,700 		0
...............................
4,190 		0
...............................
975,702 		0
...............................
0
14Nancy R DoellingVP Pediatric SRVS.(BEGIN. 8/4) (i)
(ii)		 0
...............................
117,427 		0
...............................
16,910 		0
...............................
6,672 		0
...............................
11,120 		0
...............................
691 		0
...............................
152,820 		0
...............................
0
15Jimmy E FrancisVP Info Technology Operations (i)
(ii)		 0
...............................
205,005 		0
...............................
42,280 		0
...............................
9,742 		0
...............................
33,822 		0
...............................
2,370 		0
...............................
293,219 		0
...............................
0
16Steven L GraceVP Talent Acquisition (i)
(ii)		 0
...............................
200,013 		0
...............................
52,892 		0
...............................
14,048 		0
...............................
14,653 		0
...............................
18,078 		0
...............................
299,684 		0
...............................
0
17Kristyn M Greifer MDVP Population Management (i)
(ii)		 0
...............................
307,528 		0
...............................
52,230 		0
...............................
10,225 		0
...............................
18,722 		0
...............................
9,958 		0
...............................
398,663 		0
...............................
0
18Joel W HelmkeVP Oncology (BEGIN. 7/21) (i)
(ii)		 0
...............................
110,000 		0
...............................
51,610 		0
...............................
3,904 		0
...............................
20,081 		0
...............................
8,794 		0
...............................
194,389 		0
...............................
0
19Robert D Jansen mdEVP & Pres Medical Group (i)
(ii)		 0
...............................
591,219 		0
...............................
170,344 		0
...............................
20,977 		0
...............................
45,700 		0
...............................
29,543 		0
...............................
857,783 		0
...............................
0
20Reynold J Jenningspresident & ceo (i)
(ii)		 0
...............................
975,000 		0
...............................
708,390 		0
...............................
18,591 		0
...............................
0 		0
...............................
2,056 		0
...............................
1,704,037 		0
...............................
0
21Peter R Jungblut MDSVP & Medical Dir WMG (i)
(ii)		 0
...............................
307,528 		0
...............................
78,959 		0
...............................
12,316 		0
...............................
40,200 		0
...............................
29,199 		0
...............................
468,202 		0
...............................
0
22Christopher M KaneSVP Strategic Plan & Bus Dev (i)
(ii)		 0
...............................
341,744 		0
...............................
454,243 		0
...............................
10,413 		0
...............................
21,954 		0
...............................
20,378 		0
...............................
848,732 		0
...............................
0
23Beth KostVP Compliance Chf Privacy Ofcr (i)
(ii)		 0
...............................
244,733 		0
...............................
77,006 		0
...............................
9,961 		0
...............................
22,318 		0
...............................
11,704 		0
...............................
365,722 		0
...............................
0
24Kenneth C Kunze MDFMR. SVP Chief Medical Officer (i)
(ii)		 0
...............................
0 		0
...............................
0 		0
...............................
383,389 		0
...............................
0 		0
...............................
0 		0
...............................
383,389 		0
...............................
0
25Ellen LangfordSVP & COO WellStar Med Group (i)
(ii)		 0
...............................
220,376 		0
...............................
46,995 		0
...............................
11,936 		0
...............................
36,643 		0
...............................
22,323 		0
...............................
338,273 		0
...............................
0
26Elizabeth H LoudermilkVP Ent Intelligence & Intgrtn (i)
(ii)		 0
...............................
225,680 		0
...............................
73,283 		0
...............................
9,197 		0
...............................
6,309 		0
...............................
19,342 		0
...............................
333,811 		0
...............................
0
27Sandra LuciusVP Info Technology Apps (i)
(ii)		 0
...............................
185,834 		0
...............................
30,026 		0
...............................
8,564 		0
...............................
44,758 		0
...............................
2,235 		0
...............................
271,417 		0
...............................
0
28Robert MandlerVP Diagnostic Outreach (i)
(ii)		 0
...............................
214,261 		0
...............................
58,412 		0
...............................
18,167 		0
...............................
45,249 		0
...............................
16,275 		0
...............................
352,364 		0
...............................
0
29Patricia A MayneVP Emergency Services (i)
(ii)		 0
...............................
177,986 		0
...............................
122,895 		0
...............................
10,448 		0
...............................
26,305 		0
...............................
23,814 		0
...............................
361,448 		0
...............................
0
30Kimberly W MenefeeSVP Strategic Community Dev (i)
(ii)		 0
...............................
282,547 		0
...............................
66,726 		0
...............................
13,682 		0
...............................
28,200 		0
...............................
17,826 		0
...............................
408,981 		0
...............................
0
31Christopher L MorganVP & Admin. CLIO (BEGIN. 7/7) (i)
(ii)		 0
...............................
110,770 		0
...............................
52,731 		0
...............................
4,638 		0
...............................
20,102 		0
...............................
1,645 		0
...............................
189,886 		0
...............................
0
32Jonathan B Morris MDSVP Chief Info Officer (i)
(ii)		 0
...............................
369,512 		0
...............................
80,613 		0
...............................
12,264 		0
...............................
23,553 		0
...............................
26,705 		0
...............................
512,647 		0
...............................
0
33Bradford B NewtonVP Information Technology Admi (i)
(ii)		 0
...............................
192,691 		0
...............................
30,661 		0
...............................
8,988 		0
...............................
20,598 		0
...............................
27,113 		0
...............................
280,051 		0
...............................
0
34Craig OwensSVP & Hospital President (i)
(ii)		 270,317
...............................
0 		60,546
...............................
0 		13,633
...............................
0 		45,700
...............................
0 		21,484
...............................
0 		411,680
...............................
0 		0
...............................
0
35Michael G PaulVP Facilities Eng Support Svcs (i)
(ii)		 0
...............................
181,401 		0
...............................
27,532 		0
...............................
12,020 		0
...............................
0 		0
...............................
24,150 		0
...............................
245,103 		0
...............................
0
36Leo E ReichertEVP & General Counsel (i)
(ii)		 0
...............................
489,341 		0
...............................
247,184 		0
...............................
15,552 		0
...............................
0 		0
...............................
29,200 		0
...............................
781,277 		0
...............................
0
37Bethany RobertsonVP & Chief Learning Officer (i)
(ii)		 0
...............................
178,067 		0
...............................
31,215 		0
...............................
9,391 		0
...............................
13,097 		0
...............................
28,511 		0
...............................
260,281 		0
...............................
0
38Michelle M RobinsonVP Mktng/PR/Internal Comm (i)
(ii)		 0
...............................
196,373 		0
...............................
33,264 		0
...............................
9,210 		0
...............................
14,300 		0
...............................
26,351 		0
...............................
279,498 		0
...............................
0
39Deborah Roegge De VitaVP Women & Newborn Svc Line (i)
(ii)		 0
...............................
195,728 		0
...............................
27,621 		0
...............................
8,576 		0
...............................
25,759 		0
...............................
6,141 		0
...............................
263,825 		0
...............................
0
40Candice L SaundersPresident & CEO (i)
(ii)		 0
...............................
621,461 		0
...............................
174,240 		0
...............................
16,525 		0
...............................
45,334 		0
...............................
27,582 		0
...............................
885,142 		0
...............................
0
41Christopher B ScullenVP Pulmonology Operations (i)
(ii)		 0
...............................
172,411 		0
...............................
112,906 		0
...............................
6,929 		0
...............................
0 		0
...............................
17,839 		0
...............................
310,085 		0
...............................
0
42Richard S SiegelVP Cardiology & CVM Admin (i)
(ii)		 0
...............................
271,627 		0
...............................
40,496 		0
...............................
11,541 		0
...............................
45,700 		0
...............................
24,762 		0
...............................
394,126 		0
...............................
0
43Jeffery D StanleyVP Pharmacy & System Coor (i)
(ii)		 0
...............................
176,156 		0
...............................
30,945 		0
...............................
9,170 		0
...............................
21,580 		0
...............................
8,658 		0
...............................
246,509 		0
...............................
0
44Daniel J StyfSVP PW Health Plan (i)
(ii)		 0
...............................
281,902 		0
...............................
39,983 		0
...............................
15,148 		0
...............................
18,663 		0
...............................
9,070 		0
...............................
364,766 		0
...............................
0
45James M SwartzVP Accounting (i)
(ii)		 0
...............................
200,242 		0
...............................
63,140 		0
...............................
8,971 		0
...............................
16,856 		0
...............................
25,406 		0
...............................
314,615 		0
...............................
0
46Mary L TavernaroVP Human Resources Operations (i)
(ii)		 0
...............................
212,056 		0
...............................
37,659 		0
...............................
9,442 		0
...............................
27,690 		0
...............................
21,436 		0
...............................
308,283 		0
...............................
0
47Adam C ThompsonVP Surgery (i)
(ii)		 0
...............................
166,858 		0
...............................
51,698 		0
...............................
9,517 		0
...............................
0 		0
...............................
21,830 		0
...............................
249,903 		0
...............................
0
48Anthony M TrupianoSVP Supply Chain (i)
(ii)		 0
...............................
268,258 		0
...............................
61,742 		0
...............................
15,219 		0
...............................
45,700 		0
...............................
1,896 		0
...............................
392,815 		0
...............................
0
49Sean P TurnerVP Rev.Cycle MGMT (BEGIN.9/28) (i)
(ii)		 0
...............................
233,395 		0
...............................
36,468 		0
...............................
3,219 		0
...............................
20,091 		0
...............................
26,574 		0
...............................
319,747 		0
...............................
0
50Robin Wilson MDSVP Chief Hlth Innov Officer (i)
(ii)		 0
...............................
395,907 		0
...............................
232,368 		0
...............................
9,718 		0
...............................
0 		0
...............................
22,144 		0
...............................
660,137 		0
...............................
0
51Chester A ZborowskiVP Health Parks Operations (i)
(ii)		 0
...............................
165,755 		0
...............................
45,188 		0
...............................
12,208 		0
...............................
0 		0
...............................
24,265 		0
...............................
247,416 		0
...............................
0
52Avril P Beckford MDTRUSTEE (i)
(ii)		 0
...............................
395,084 		0
...............................
86,393 		0
...............................
2,531 		0
...............................
27,460 		0
...............................
1,940 		0
...............................
513,408 		0
...............................
0
53Jeffrey L Tharp MDTRUSTEE (i)
(ii)		 0
...............................
480,597 		0
...............................
147,676 		0
...............................
2,596 		0
...............................
45,700 		0
...............................
29,025 		0
...............................
705,594 		0
...............................
0
54THOMAS E GEARHARD MDTRUSTEE (i)
(ii)		 0
...............................
293,273 		0
...............................
48,916 		0
...............................
5,186 		0
...............................
42,668 		0
...............................
30,543 		0
...............................
420,586 		0
...............................
0
55MARGARET W CHASTAINDir Pharmacy (i)
(ii)		 165,194
...............................
0 		11,263
...............................
0 		1,963
...............................
0 		26,298
...............................
0 		2,001
...............................
0 		206,719
...............................
0 		0
...............................
0
56CHRISTOPHER S GREENEExec Dir Finance & Hosp Ops (i)
(ii)		 154,253
...............................
0 		14,273
...............................
0 		446
...............................
0 		11,521
...............................
0 		10,243
...............................
0 		190,736
...............................
0 		0
...............................
0
57STEVEN W HARRISPharmacist Specialty (i)
(ii)		 143,980
...............................
0 		1,250
...............................
0 		5,241
...............................
0 		 
...............................
0 		11,495
...............................
0 		161,966
...............................
0 		0
...............................
0
58BEVERLY M BATESRN Charge Nurse (i)
(ii)		 144,424
...............................
0 		3,750
...............................
0 		844
...............................
0 		13,363
...............................
0 		27,443
...............................
0 		189,824
...............................
0 		0
...............................
0
59KAREN Y BEARDDIR SURGICAL SVS DH/WH (i)
(ii)		 132,933
...............................
0 		8,817
...............................
0 		553
...............................
0 		14,175
...............................
0 		11,126
...............................
0 		167,604
...............................
0 		0
...............................
0
60MICHAEL L GRAUEFRMR. EBP & CHIEF OP. OFFICER (i)
(ii)		 0
...............................
0 		0
...............................
0 		0
...............................
522,266 		0
...............................
0 		0
...............................
0 		0
...............................
522,266 		0
...............................
0
Schedule J (Form 990) 2014

Schedule J (Form 990) 2014
Page 3
Part III
Supplemental Information
Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.
Return Reference Explanation
SCHEDULE J, PART I, LINE 1B REIMBURSEMENT POLICY While WellStar Health System and its affiliates do not have a written policy regarding payment or reimbursement of the items listed in Part I 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. These items are added as taxable wages on the individual's Form W-2 as appropriate. SCHEDULE J, PART I, LINE 4A SEVERANCE PAYMENTS Pursuant to their respective employment agreements, the following groups of officers are entitled to severance payments based on their compensation at that time in the event of certain identified circumstances. The severance payment periods are 24 months for Executive Vice Presidents, 18 months for Senior Vice Presidents, and 12 months for Vice Presidents. The following officerS/KEY EMPLOYEES received severance pay during the 2014 CALENDAR YEAR FROM EITHER THE ORGANIZATION OR A RELATED ORGANIZATION: KENNETH C. KUNZE, MD $ 383,389 MICHAEL L. GRAUE, MD 522,266 SCHEDULE J, PART I, LINE 4B The following officers/KEY EMPLOYEES PARTICIPATED IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN DURING THE YEAR. Valery Akopov Nicole Ashe Melissa Box Craig Owens JOSEPH L. BRYWCZYNSKI ANTHONY J. BUDZINSKI James Clements LEE R. COOK BARBARA B. COREY BRUCE ALAN DEAN Sarath Degala Marcia Delk-Payne JIMMY E. FRANCIS KRISTYN M. GREIFER ROBERT D. JANSEN PETER R. JUNGBLUT CHRISTOPHER MICHAEL KANE Beth Kost Ellen Langford Elizabeth Loudermilk PATRICIA A. MAYNE KIMBERLY W. MENEFEE JONATHAN B. MORRIS Bradford Newton Leo Reichert Bethany Robertson Michelle Robinson CANDICE LYNN SAUNDERS Richard Siegel CHRISTOPHER B. SCULLEN Jeffery Stanley Daniel Styf JAMES M. SWARTZ MARY LOUISE TAVERNARO Adam Thompson ANTHONY MICHAEL TRUPIANO Robin Wilson DONALD CAMPBELL ROBERT MANDLER DEBORAH ROEGGE DE VITA DAVID W. ANDERSON CHESTER ZBOROWSKI BARBARA BALLARD SCHEDULE J, PART I, LINE 7B NON-FIXED PAYMENTS TO OFFICERS As part of the WellStar Executive Compensation Philosophy a performance pay plan was instituted several years ago whereby the WellStar Board of Trustees approves an annual incentive plan which consists of several performance goals or factors that upon attainment will result in payouts to eligible plan participants. Those factors are: People & Customer Service goal for employee "Trust Index", Quality & Safety goal for clinical excellence and patient satisfaction, Financial goal for attaining a positive operating margin. Confirmation of achieving these goals is typically received through the annual external audit process and approved by the Board of Trustees at that time.
Schedule J (Form 990) 2014

Additional Data


Software ID:  
Software Version:  
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 990-EZ or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
MediumBullet Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2014
Open to Public
Inspection
Name of the organization
DOUGLAS HOSPITAL INC
 
Employer identification number

58-2026750
Return Reference Explanation
FORM 990, PART III, LINE 4A PROGRAM SERVICE ACCOMPLISHMENTS As discussed herein, Douglas Hospital, Inc. (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 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 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. Douglas Hospital committed approximately $15.3 million in capital expenditures for the year to meet the technology and program needs of the community we serve. Douglas Hospital, Inc. was organized in 1992. The hospital affiliated with the Northwest Georgia Health System in 1993. 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 and is now totally independent of PROMINA. Douglas Hospital is subordinate to, and subject to the authority of Wellstar Health System and its governing boards including the Hospital Authority of Douglas County. Wellstar Douglas provides a full range of inpatient and outpatient services characteristic of a community hospital. The hospital is licensed to operate 108 beds and is presently staffed to operate 102 beds. The original hospital was constructed in 1974 and has had three major structural additions since 1985. The following stats constitute the overall program services provided during the reporting period ended June 30, 2015: Adult Discharges - 6,914 Newborn Discharges - 464 Med & Surgical Short Stay Cases - 6 Emergency Room Visits - 66,753 Total Surgical Cases - 3,996 Outpatient Procedures Non-ED OP Radiology - 39,023 GI Laboratory - 1,072 Cath Lab Procedures - 972 Total FTEs Paid - 732 Community Benefit Reporting Community Outreach - $ 242,966 Unreimbursed Charity Care (at cost) - $ 11,958,733 Medicaid Shortfalls (at cost) - $ 1,140,586 Total Community Benefit - $ 13,342,285 As an affiliate of Wellstar Health System, Douglas Hospital participates in many community and educational programs for the overall health and benefit of the area that we serve. Some examples of those programs are: Community Health/Education Screenings and educational opportunities such as defensive driving for teens (offered at a minimal cost), smoking cessation, heart smart school, CPR and others. Community Activities--sponsors blood drives, provides funding to school health programs for medical and dental care for the underserved population. Community Events Latino Day for the community Hispanics to have a variety of screenings for health related issues. In all a total of over 200,000 area residents participated in some type of education or screening in health issues. Over 2,000 couples participated in prenatal educational offerings sponsored by WellStar. Sponorships-- Wellstar's Laundry services Department partnered with a local homeless shelter, MUST Ministries, to donate retired and faded scrubs to new arrivals at the shelter. MUST have integrated housing programs in Cobb, Cherokee, and Douglas counties (the heart of Wellstar"s service area). Recognition and Accomplishments Douglas Hospital continues to be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). All of the Wellstar system hospitals (including Douglas) have been 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. The Wellstar Cancer Program is accredited by the American College of Surgeons. The expansion of the cancer program has resulted in an increase in the services provided for cancer patients at both Douglas and Paulding Hospitals. The Wellstar Respiratory Care is accredited by the American Association for Respiratory Care with its "Recognition for Quality". Wellstar Health System is number five in the Top 100 Integrated Healthcare Networks as published by SDI. It is also the highest ranked integrated network in the state. Wellstar is named in the 100 Best Companies List by "Working Mothers" magazine and as a National Employer Team Member by AARP for its work on behalf of more mature workers within the organization. Wellstar was also named for a sixth year in a row to the Companies that Care Honor Roll. This distinction represents employers who create positive work environments for its employees and who are also active community partners. WellStar Douglas Hospital was awarded the Business Beautification Award for the month of July 2012 by Keep Douglasville Beautiful. The Keep Douglasville Beautiful Board of Directors presents the award to a local business each quarter throughtout the year for their efforts in community growth. In October WellStar completed the system-wide implementation of a new cleaning process called Xenex. The process uses ultraviolet light technology/machines to decontaminate rooms in five to 12 minutes. This includes patient rooms, emergency departments, public restrooms, supply rooms and nursing stations. Independent studies and lab samples have shown that the system is 20 times more effective than regular cleaning protocols for eliminating harmful bacteria and many other organisms. All hospitals have a least one machine in operation. WellStar Douglas Hospital's Neurodiagnostic/Electroencephalography (EEG) Laboratory was granted a five-year accreditation by the Laboratory Accreditation Board of the American Board of Registration of Electroencephalographic and Evoked Potential Technologists. The accreditation was based on an evaluation of the quality of the EEGs performed in the lab and on a review of the labs policy and procedures manual. To better serve behavioral health patients who visit WellStar Douglas Hospital's Emergency Department, the system began using an innovative technology to offer telemedicine. The technology is provided in a partnership with TeleHealth and allows psychiatrists at WellStar Cobb Hospital to securely and conveniently evaluate Douglas patients and expedite their discharge. With the success of the pilot program the system plans to expand to Paulding Hospital, which, like Douglas does not have an on-site psychiatrist. WellStar Kennestone Hospital launched an initiative called Best In Georgia (BIG) with a goal to improve patient safety and well-being across the system. A multidisciplinary team of physicians and other team members meet on a monthly basis to evaluate performance measures at the hospital. As many consumers research healthcare performance measures in sources such as Health Grades and US News and World Report as well as other online sites it is important to focus on improving the hospitals position in the public. Cobb, Douglas, Paulding and Windy Hill hospitals have also joined in this initiative at their respective hospitals. Douglas Hospital began construction during the reporting period on its Intensive Care Unit expansion and the Emergency Department renovation. The $18 million project is projected to be completed in late 2014 and will double the number of ICU beds. Plans also include relocating the cafeteria and new triage/treatment rooms in the Emergency Department. The project will add an additional 43,270 square feet to the campus and 10,702 square feet will be renovated.
FORM 990, PART I, LINES 7A & 7B UNRELATED BUSINESS INCOME DOUGLAS HOSPITAL, INC. GENERATED NO UNRELATED BUSINESS INCOME FOR THE REPORTING YEAR. AS A RESULT THE ATTACHED 990-T SHOWS NO ACTIVITY. IF SUBSEQUENT REVIEW OF THE BOOKS REVEALS ANY UNREPORTED UBI WE WILL FILE AN AMENDED RETURN FOR THE TAX PERIOD ENDED JUNE 30, 2015. FORM 990, PART IV, LINE 12B AUDITED FINANCIAL STATEMENTS DOUGLAS HOSPITAL, Inc. is audited on an annual basis by an outside auditing firm, KPMG, and as part of that audit a consolidated financial statement is issued for all of WellStar Health System, Inc. and its Affiliates. "The independent auditors report includes the accounts of WellStar and its controlled affiliates, Kennestone Hospital, Inc., Cobb Hospital, Inc., Douglas Hospital, Inc., Paulding Medical Center, Inc., WellStar Foundation, Inc. CHS Foundation, Inc., Community Assurance Company, Ltd., various WellStar owned physician practices, a hospice facility, a nursing facility, home health business, and entities for infusion therapy and durable medical equipment. All significant intercompany accounts and transactions have been eliminated in combination. The Board of Trustees of WellStar has the authority to approve appointments of the members of the board of trustees of all affiliate corporations." FORM 990, PART IV, LINE 24A TAX EXEMPT BOND REPORTING 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). Douglas Hospital, 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. FORM 990, PART VI, SECTION A, LINE 7B POWERS OF THE BOARD AS PER THE ARTICLES OF INCORPORATION, THE SOLE MEMBER OF THE ORGANIZATION IS WELLSTAR HEALTH SYSTEM, INC., A GEORGIA NONPROFIT CORPORATION. AS SOLE MEMBER, WELLSTAR HEALTH SYSTEM, INC. HOLDS CERTAIN POWERS OF ELECTION AND 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, PART B, SECTION B, LINE 11B BOARD REVIEW OF FORM 990 Internal staff prepareS the organization's Form 990. Before filing the return with the Internal Revenue Service an external accounting firm, PricewaterhouseCoopers LLP, reviews and sign-offs on the completed return of each organization. The current year Form 990 is then reviewed by the Finance Committee along with a question and answer session. A motion is then made by the Finance committee to approve the returns and present to the full board copies of the forms in an electronic (pdf. format) version as well as a hard copy. The organization's CFO or designee subsequently signs the return for either manual or electronic filing by the appropriate due date. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST POLICY Our conflict of interest policy requires all covered persons to annually review the policy and then 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 and Attestation 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. FORM 990, PART VII, SECTION B, LINES 15A & 15B COMPENSATION OF OFFICERS 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 compensation committee consists of five trustees as well as the CEO in an advisory role and not a voting member. Further in committee discussions about the compensation for the Chief Executive Officer, The CEO will recuse him/herself from that process and 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 by the full Board of Trustees at its next scheduled meeting. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS MADE AVAILABLE TO THE PUBLIC 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. FORM 990, PART VII OFFICERS HOURS WORKED The officers devote their time to all of the organizations within Wellstar Health System that are listed in Schedule R, Part II. As such, the total hours worked by the officers across all organizations exceeds 40 hours a week. FORM 990, PART VII & FORM 990, SCHEDULE J COMPENSATION 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). FORM 990, PART XI, LINE 9 OTHER CHANGES IN NET ASSETS Form 990 Part XI Line 9 For the reporting period DOUGLAS HOSPITAL, Inc. had a change in net assets of ($12,260,501) related to transfers to affiliates as part of the allocation of income statement and balance sheet transactions over the year.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2014

Additional Data


Software ID:  
Software Version:  
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBulletAttach to Form 990.
MediumBullet Information about Schedule R (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047
2014
Open to Public Inspection
Name of the organization
DOUGLAS HOSPITAL INC
 
Employer identification number

58-2026750
Part I
Identification of Disregarded Entities Complete if the organization answered "Yes" on Form 990, Part IV, line 33.
(a)
Name, address, and EIN (if applicable) of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income


 		(e)
End-of-year assets


 		(f)
Direct controlling
entity










Part II
Identification of Related Tax-Exempt Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.
(a)
Name, address, and EIN of related organization


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section


 		(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled entity?
Yes No
(1) CHS Foundation Inc
805 Sandy Plains Road

Marietta,GA30066
58-1649540 		Foundation GA 501(C)(3) 11 Type 2 WHS
 
Yes
 
(2) Cobb Hospital Inc
805 Sandy Plains Road

Marietta,GA30066
58-0968382 		Healthcare GA 501(C)(3) 3 WHS
 
Yes
 
(3) Kennestone Hospital Inc
805 Sandy Plains Road

Marietta,GA30066
58-2032904 		Healthcare GA 501(C)(3) 3 WHS
 
Yes
 
(4) Paulding Medical Center Inc
805 Sandy Plains Road

Marietta,GA30066
58-2095884 		Healthcare GA 501(C)(3) 3 WHS
 
Yes
 
(5) Wellstar Foundation Inc
805 Sandy Plains Road

Marietta,GA30066
58-1627413 		Foundation GA 501(C)(3) 11 Type 2 WHS
 
Yes
 
(6) Wellstar Health System Inc
805 Sandy Plains Road

Marietta,GA30066
58-1649541 		Healthcare GA 501(C)(3) 11 Type 2 NA
 
 
No


For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2014
Schedule R (Form 990) 2014
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V-UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No
(1) Cobb Hospital Parking Company LLC

805 Sandy Plains Road
Marietta,GA300666340
75-2999669 		PARKING GA WHS
  		N/A 0 0     0      
(2) KENNESTONE EAST PARKING DECK LLC

793 SAWYER ROAD
MARIETTA,GA30060
20-0537100 		PARKING GA WHS
  		N/A 0 0     0      










Part IV
Identification of Related Organizations Taxable as a Corporation or Trust Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.
(a)
Name, address, and EIN of
related organization
 		(b)
Primary activity
 		(c)
Legal
domicile
(state or foreign
country)
 		(d)
Direct controlling
entity
 		(e)
Type of entity
(C corp, S corp,
or trust) 		(f)
Share of total income
 		(g)
Share of end-of-year
assets
 		(h)
Percentage
ownership
 		(i)
Section 512(b)(13) controlled entity?
Yes No
(1) Community Assurance Co

805 Sandy Plains Road
Marietta,GA300666340
58-1649541 		Insurance CJ WHS Inc
  		C-CORP          












Schedule R (Form 990) 2014
Schedule R (Form 990) 2014
Page 3
Part V
Transactions With Related Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest, (ii) annuities, (iii) royalties, or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
 
No
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
 
No
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1m
 
No
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1n
 
No
o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
 
No
p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1s
 
No
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of related organization 		(b)
Transaction
type (a-s) 		(c)
Amount involved 		(d)
Method of determining amount involved





Schedule R (Form 990) 2014
Schedule R (Form 990) 2014
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 37.
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income (related, unrelated, excluded from tax under sections 512-514)

(e)
Are all partners
section
501(c)(3)
organizations? 		(f)
Share of total income




 		(g)
Share of
end-of-year
assets 		(h)
Disproprtionate allocations? 		(i)
Code V-UBI
amount in box 20
of Schedule K-1
(Form 1065) 		(j)
General or
managing
partner? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2014
Schedule R (Form 990) 2014
Page 5
Part VII
Supplemental Information
Provide additional information for responses to questions on Schedule R (see instructions).
Return Reference Explanation
Schedule R (Form 990) 2014
Additional Data


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