TY 2014 Form 990 Schedule O

efile Public Visual Render ObjectId: 201632239349301598 - Submission: 2016-08-10 TIN: 04-2103586

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.
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Attach to Form 990 or 990-EZ.
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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

LAWRENCE GENERAL HOSPITAL

Employer identification number

04-2103586

Return Reference	Explanation
FORM 990, PART VI, SECTION B, LINE 11	FORM 990 IS PREPARED BY THE CONTROLLER OF THE HOSPITAL AND REVIEWED BY THE VICE PRESIDENT OF FINANCE AND CFO. THE HOSPITAL'S EXTERNAL ACCOUNTANT ALSO REVIEWS THE FORM 990. ONCE FORM 990 IS COMPLETED, THE FORM AND ALL ITS ACCOMPANYING SCHEDULES ARE MADE AVAILABLE TO THE HOSPITAL'S BOARD OF TRUSTEES VIA A SECURE INTERNET PORTAL FOR REVIEW. THE VICE PRESIDENT OF FINANCE AND CFO ARE MADE AVAILABLE TO FACILITATE THE REVIEW AND ANSWER ANY QUESTIONS REGARDING THE FORM THE TRUSTEES MAY HAVE.
FORM 990, PART VI, SECTION B, LINE 12C	ON AN ANNUAL BASIS, THE HOSPITAL DISTRIBUTES A CONFLICT OF INTEREST POLICY TO THE BOARD OF TRUSTEES. THE TRUSTEES ARE REQUIRED TO DISCLOSE IN WRITING, ANY POTENTIAL CONFLICT THAT THEY ARE AWARE OF. ALL KNOWN INTEREST HAVE BEEN DISCLOSED IN SCHEDULE L.
FORM 990, PART VI, SECTION B, LINE 15	THE CEO'S ANNUAL COMPENSATION IS REVIEWED & APPROVED BY AN EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES. THE COMPENSATION FOR THE CFO, COO, AND SENIOR MANAGEMENT IS DETERMINED BY THE CEO AND REVIEWED BY AN EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES. INDEPENDENT SURVEYS ARE ALSO PERFORMED TO DETERMINE SALARY REASONABLENESS.
FORM 990, PART VI, SECTION C, LINE 18	THE HOSPITAL MAKES ALL DOCUMENTS INCLUDING FORM 990 AVAILABLE TO THE GENERAL PUBLIC UPON REQUEST.
FORM 990, PART VI, SECTION C, LINE 19	THE HOSPITAL MAKES ALL DOCUMENTS INCLUDING COPIES OF ITS BY-LAWS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE GENERAL PUBLIC UPON REQUEST.
FORM 990, PART VIII, LINE 11A:	ON OCTOBER 30, 2014, CMS APPROVED A FIVE-YEAR MASSACHUSETTS MEDICAID WAIVER EXTENSION FOR THE PERIOD OF OCTOBER 30, 2014 THROUGH JUNE 30, 2019 THAT INCLUDED DELIVERY SYSTEM TRANSFORMATION INITIATIVE (DSTI) POTENTIAL FUNDING OF $15,876,000 ANNUALLY FOR LGH, FOR EACH YEAR OF THE WAIVER. THE DSTI FUNDING IS DESIGNED AS INCENTIVE PAYMENTS TO SUPPORT INITIATIVES THAT FURTHER INVESTS IN HEALTHCARE DELIVERY SYSTEMS. THE AMOUNT IS REFLECTED AS OTHER OPERATING REVENUE IN OUR FINANCIAL STATEMENTS AND FORM 990.
FORM 990, PART XI, LINE 9:	CHANGE IN VALUE OF NET ASSETS HELD BY LGH CHARITABLE TRUST, INC. 130,000. NET ASSET TRANSFER TO LGH ADMINISTRATIVE SERVICES, INC. -2,451,180. NET ASSET TRANSFER FROM LGH ADMINISTRATIVE SERVICES, INC. 154,837. NET ASSET TRANSFER FROM LGH CHARITABLE TRUST, INC. 417,343. OTHER 76,221.

Return Reference

Explanation

FORM 990, PART VI, SECTION B, LINE 11

FORM 990 IS PREPARED BY THE CONTROLLER OF THE HOSPITAL AND REVIEWED BY THE VICE PRESIDENT OF FINANCE AND CFO. THE HOSPITAL'S EXTERNAL ACCOUNTANT ALSO REVIEWS THE FORM 990. ONCE FORM 990 IS COMPLETED, THE FORM AND ALL ITS ACCOMPANYING SCHEDULES ARE MADE AVAILABLE TO THE HOSPITAL'S BOARD OF TRUSTEES VIA A SECURE INTERNET PORTAL FOR REVIEW. THE VICE PRESIDENT OF FINANCE AND CFO ARE MADE AVAILABLE TO FACILITATE THE REVIEW AND ANSWER ANY QUESTIONS REGARDING THE FORM THE TRUSTEES MAY HAVE.

FORM 990, PART VI, SECTION B, LINE 12C

ON AN ANNUAL BASIS, THE HOSPITAL DISTRIBUTES A CONFLICT OF INTEREST POLICY TO THE BOARD OF TRUSTEES. THE TRUSTEES ARE REQUIRED TO DISCLOSE IN WRITING, ANY POTENTIAL CONFLICT THAT THEY ARE AWARE OF. ALL KNOWN INTEREST HAVE BEEN DISCLOSED IN SCHEDULE L.

FORM 990, PART VI, SECTION B, LINE 15

THE CEO'S ANNUAL COMPENSATION IS REVIEWED & APPROVED BY AN EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES. THE COMPENSATION FOR THE CFO, COO, AND SENIOR MANAGEMENT IS DETERMINED BY THE CEO AND REVIEWED BY AN EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES. INDEPENDENT SURVEYS ARE ALSO PERFORMED TO DETERMINE SALARY REASONABLENESS.

FORM 990, PART VI, SECTION C, LINE 18

THE HOSPITAL MAKES ALL DOCUMENTS INCLUDING FORM 990 AVAILABLE TO THE GENERAL PUBLIC UPON REQUEST.

FORM 990, PART VI, SECTION C, LINE 19

THE HOSPITAL MAKES ALL DOCUMENTS INCLUDING COPIES OF ITS BY-LAWS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE GENERAL PUBLIC UPON REQUEST.

FORM 990, PART VIII, LINE 11A:

ON OCTOBER 30, 2014, CMS APPROVED A FIVE-YEAR MASSACHUSETTS MEDICAID WAIVER EXTENSION FOR THE PERIOD OF OCTOBER 30, 2014 THROUGH JUNE 30, 2019 THAT INCLUDED DELIVERY SYSTEM TRANSFORMATION INITIATIVE (DSTI) POTENTIAL FUNDING OF $15,876,000 ANNUALLY FOR LGH, FOR EACH YEAR OF THE WAIVER. THE DSTI FUNDING IS DESIGNED AS INCENTIVE PAYMENTS TO SUPPORT INITIATIVES THAT FURTHER INVESTS IN HEALTHCARE DELIVERY SYSTEMS. THE AMOUNT IS REFLECTED AS OTHER OPERATING REVENUE IN OUR FINANCIAL STATEMENTS AND FORM 990.

FORM 990, PART XI, LINE 9:

CHANGE IN VALUE OF NET ASSETS HELD BY LGH CHARITABLE TRUST, INC. 130,000. NET ASSET TRANSFER TO LGH ADMINISTRATIVE SERVICES, INC. -2,451,180. NET ASSET TRANSFER FROM LGH ADMINISTRATIVE SERVICES, INC. 154,837. NET ASSET TRANSFER FROM LGH CHARITABLE TRUST, INC. 417,343. OTHER 76,221.

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

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