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← GOOD SAMARITAN HOSPITAL SELF INSURANCE AGAINST MALPRACTICE TRUS

Form 990 for tax year 2022

Filed by GOOD SAMARITAN HOSPITAL SELF INSURANCE AGAINST MALPRACTICE TRUS.

Totals

Total revenue
$25,001
Total expenses
$0
Contributions and grants received
$0
Grants paid
$0
Program service revenue
$0
Investment income
$25,001
Other revenue
$0
Total assets, end of year
$4,847,065
Total liabilities, end of year
$0
Net assets or fund balances, end of year
$4,847,065
Program services expenses (Part IX)
$0
Management and general expenses
$0
Fundraising expenses
$0
Program service expenses (Part III)
$0

Line items

Every line the filer filed in Parts VIII, IX and X, as filed and in filed order. Blank columns are left out, and the lines are not forced to add up to the totals above.

Revenue

Part VIII, the statement of revenue.

  • 3 · Investment income

    total $30,524 · excluded $30,524

  • 4 · Income from investment of tax-exempt bond proceeds

    total $0

  • 5 · Royalties

    total $0

  • 6c · Rental income or loss

    real property $0 · personal property $0

  • 6d · Net rental income or loss

    total $0

  • 7a · Gross sales of assets other than inventory

    securities $4,661,190

  • 7b · Less cost or other basis and sales expenses

    securities $4,666,713

  • 7c · Gain or loss

    securities -$5,523

  • 7d · Net gain or loss

    total -$5,523 · excluded -$5,523

  • 8a · Fundraising events: gross income

    $0

  • 8b · Fundraising events: direct expenses

    $0

  • 8c · Net income from fundraising events

    total $0

  • 9a · Gaming: gross income

    $0

  • 9b · Gaming: direct expenses

    $0

  • 9c · Net income from gaming

    total $0

  • 10a · Gross sales of inventory

    $0

  • 10b · Cost of goods sold

    $0

  • 10c · Net income from sales of inventory

    total $0

  • 11e · Other revenue, total

    $0

Functional expenses

Part IX, the statement of functional expenses.

  • 1 · Grants to domestic organizations and governments

    total $0

  • 2 · Grants to domestic individuals

    total $0

  • 3 · Grants to foreign organizations and individuals

    total $0

  • 4 · Benefits paid to or for members

    total $0

  • 5 · Compensation of officers, directors and key employees

    total $0

  • 6 · Compensation of disqualified persons

    total $0

  • 7 · Other salaries and wages

    total $0

  • 8 · Pension plan contributions

    total $0

  • 9 · Other employee benefits

    total $0

  • 10 · Payroll taxes

    total $0

  • 11a · Fees: management

    total $0

  • 11b · Fees: legal

    total $0

  • 11c · Fees: accounting

    total $0

  • 11d · Fees: lobbying

    total $0

  • 11e · Fees: professional fundraising services

    total $0

  • 11f · Fees: investment management

    total $0

  • 11g · Fees: other

    total $0

  • 12 · Advertising and promotion

    total $0

  • 13 · Office expenses

    total $0 · program services $0 · management and general $0 · fundraising $0

  • 14 · Information technology

    total $0

  • 15 · Royalties

    total $0

  • 16 · Occupancy

    total $0

  • 17 · Travel

    total $0

  • 18 · Travel or entertainment for public officials

    total $0

  • 19 · Conferences, conventions and meetings

    total $0

  • 20 · Interest

    total $0

  • 21 · Payments to affiliates

    total $0

  • 22 · Depreciation, depletion and amortization

    total $0

  • 23 · Insurance

    total $0

Balance sheet

Part X, book values.

  • 1 · Cash, non-interest-bearing

    beginning of year $0 · end of year $0

  • 2 · Savings and temporary cash investments

    beginning of year $0 · end of year $0

  • 3 · Pledges and grants receivable

    beginning of year $0 · end of year $0

  • 4 · Accounts receivable

    beginning of year $0 · end of year $0

  • 5 · Loans and receivables from officers and key people

    beginning of year $0 · end of year $0

  • 6 · Loans and receivables from disqualified persons

    beginning of year $0 · end of year $0

  • 7 · Other notes and loans receivable

    beginning of year $0 · end of year $0

  • 8 · Inventories for sale or use

    beginning of year $0 · end of year $0

  • 9 · Prepaid expenses and deferred charges

    beginning of year $0 · end of year $0

  • 10c · Land, buildings and equipment, net

    beginning of year $0 · end of year $0

  • 11 · Investments: publicly traded securities

    beginning of year $4,822,064 · end of year $4,847,065

  • 12 · Investments: other securities

    beginning of year $0 · end of year $0

  • 13 · Investments: program-related

    beginning of year $0 · end of year $0

  • 14 · Intangible assets

    beginning of year $0 · end of year $0

  • 15 · Other assets

    beginning of year $0 · end of year $0

  • 17 · Accounts payable and accrued expenses

    beginning of year $0 · end of year $0

  • 18 · Grants payable

    beginning of year $0 · end of year $0

  • 19 · Deferred revenue

    beginning of year $0 · end of year $0

  • 20 · Tax-exempt bond liabilities

    beginning of year $0 · end of year $0

  • 21 · Escrow or custodial account liability

    beginning of year $0 · end of year $0

  • 22 · Loans and payables to officers and key people

    beginning of year $0 · end of year $0

  • 23 · Secured mortgages and notes payable

    beginning of year $0 · end of year $0

  • 24 · Unsecured notes and loans payable

    beginning of year $0 · end of year $0

  • 25 · Other liabilities

    beginning of year $0 · end of year $0

  • 27 · Net assets without donor restrictions

    beginning of year $4,822,064 · end of year $4,847,065

  • 28 · Net assets with donor restrictions

    beginning of year $0 · end of year $0

Mission and programs · 2022

Mission

SEE SCHEDULE O

Activities or mission (Part I)

WE, AT CH, HUMBLY JOIN TOGETHER TO BRING CHRISTS HEALING MISSION AND THE MISSION OF MERCY OF THE CATHOLIC CHURCH EXPRESSED IN CATHOLIC HEALTH CARE TO OUR COMMUNITIES.

  • GOOD SAMARITAN SELF INSURANCE AGAINST MALPRACTICE IS REQUIRED TO ACCOMPLISH GOOD SAMARITAN UNIVERSITY HOSPITAL'S AND NURSING HOME'S EXEMPT PURPOSE. THE AMOUNT FUNDED IS DEPENDENT UPON THE NEEDS OF THE HOSPITAL TO COVER MALPRACTICE CLAIMS. GOOD SAMARITAN UNIVERSITY HOSPITAL IS A 437 BED MEDICAL CENTER LOCATED ON THE SOUTH SHORE OF LONG ISLAND IN WEST ISLIP, NEW YORK. A PREMIER HEALTHCARE FACILITY, PROVIDING QUALITY AND COST EFFECTIVE HEALTH CARE SERVICES EXTENDING ACROSS THE CONTINUUM OF CARE TO ALL DISCIPLINES, BOTH FOR INPATIENTS AND OUTPATIENTS.

As filed on the 2022 return. The filer continues this part on Schedule O, which is not shown here.

Listed in Part VII

  • Patrick O'Shaughnessy

    PRESIDENT & CEO

    Total calculated
    $3,276,291
    From this org
    $0
    From related orgs
    $2,439,713
    Other
    $836,578
    Hours/week
    50

    Schedule J breakdown matched by us

    Base
    $0 + $1,656,290 related
    Bonus
    $0 + $753,000 related
    Other
    $0 + $30,423 related
    Deferred
    $0 + $785,411 related
    Nontaxable benefits
    $0 + $51,167 related
    Filer's total
    $0 + $3,276,291 related

  • Daniel Debarba

    EVP & CFO THRU 8/5/22

    Total calculated
    $1,411,216
    From this org
    $0
    From related orgs
    $1,103,144
    Other
    $308,072
    Hours/week
    50

    Schedule J breakdown matched by us

    Base
    $0 + $626,446 related
    Bonus
    $0 + $350,000 related
    Other
    $0 + $126,698 related
    Deferred
    $0 + $274,411 related
    Nontaxable benefits
    $0 + $33,661 related
    Filer's total
    $0 + $1,411,216 related

  • Ruth Hennessey

    PRESIDENT

    Total calculated
    $1,221,305
    From this org
    $0
    From related orgs
    $1,037,879
    Other
    $183,426
    Hours/week
    50

    Schedule J breakdown matched by us

    Base
    $0 + $666,635 related
    Bonus
    $0 + $170,000 related
    Other
    $0 + $201,244 related
    Deferred
    $0 + $164,167 related
    Nontaxable benefits
    $0 + $19,259 related
    Filer's total
    $0 + $1,221,305 related

  • Patrick Minicus

    EVP & CFO AS OF 12/12/22

    Total calculated
    $875,086
    From this org
    $0
    From related orgs
    $805,216
    Other
    $69,870
    Hours/week
    50

    Schedule J breakdown matched by us

    Base
    $0 + $607,424 related
    Bonus
    $0 + $180,000 related
    Other
    $0 + $17,792 related
    Deferred
    $0 + $21,411 related
    Nontaxable benefits
    $0 + $48,459 related
    Filer's total
    $0 + $875,086 related

  • John Francfort MD

    TRUSTEE RESIGNED 5/22

    Total calculated
    $302,277
    From this org
    $0
    From related orgs
    $281,765
    Other
    $20,512
    Hours/week
    2 + 37.5 related

    Schedule J breakdown matched by us

    Base
    $0 + $281,765 related
    Bonus
    $0
    Other
    $0
    Deferred
    $0 + $19,554 related
    Nontaxable benefits
    $0 + $958 related
    Filer's total
    $0 + $302,277 related

  • Salvatore Sodano

    CHAIRMAN

    Total calculated
    $0
    Hours/week
    2

  • Brian McGuire

    VICE CHAIR

    Total calculated
    $0
    Hours/week
    2

  • Jerome Poller

    SECRETARY

    Total calculated
    $0
    Hours/week
    2

  • Robert Zuccaro

    TREASURER

    Total calculated
    $0
    Hours/week
    2

  • Chris Pascucci

    TRUSTEE

    Total calculated
    $0
    Hours/week
    2

  • Virginia Ewen

    TRUSTEE

    Total calculated
    $0
    Hours/week
    2

  • Frank L Kurre

    TRUSTEE

    Total calculated
    $0
    Hours/week
    2

  • Rev Msgr Robert Morrisey

    TRUSTEE

    Total calculated
    $0
    Hours/week
    2

  • Daniel T Rowe

    TRUSTEE RESIGNED 12/22

    Total calculated
    $0
    Hours/week
    2

  • Rev John McCartney

    TRUSTEE

    Total calculated
    $0
    Hours/week
    2

  • Kevin J Conway

    TRUSTEE

    Total calculated
    $0
    Hours/week
    2

  • Peter D'Angelo

    TRUSTEE

    Total calculated
    $0
    Hours/week
    2

  • Rev Peter Dugandzic

    TRUSTEE

    Total calculated
    $0
    Hours/week
    2

  • Hon Anthony Marano

    TRUSTEE

    Total calculated
    $0
    Hours/week
    2

  • Stephen F McLoughlin

    TRUSTEE

    Total calculated
    $0
    Hours/week
    2

  • William Ward

    TRUSTEE

    Total calculated
    $0
    Hours/week
    2

  • Peter Quick

    TRUSTEE

    Total calculated
    $0
    Hours/week
    2

  • Thomas Christman

    TRUSTEE

    Total calculated
    $0
    Hours/week
    2

  • Debra Del Vecchio

    TRUSTEE AS OF

    Total calculated
    $0
    Hours/week
    2

  • Regina Piscazzi

    TRUSTEE AS OF

    Total calculated
    $0
    Hours/week
    2

  • John Romaneli MD

    TRUSTEE AS OF

    Total calculated
    $0
    Hours/week
    2

  • Andrew Zucaro

    TRUSTEE AS OF

    Total calculated
    $0
    Hours/week
    2

Compensation is as filed in Part VII: reportable pay from this organization and from related organizations, other compensation, and hours per week. The total, marked calculated, is our sum of the three dollar columns, with a blank column counted as $0; the form itself has no total. On a Form 990-EZ the columns are Part IV's instead, and on a Form 990-PF Part VIII's — compensation, contributions to benefit plans, and expense account — and the total sums those. A Schedule J breakdown is as filed: base pay, bonus, other, deferred compensation and nontaxable benefits from this organization, with any from related organizations beside each, and the filer's own total. It is shown with the Part VII listing of the same name on the same return. The form gives no key between the two, so that pairing is ours, and is marked matched by us.

Schedule J

Answered yes

  • 4b · Supplemental nonqualified retirement plan

Answered no

  • 4a · Severance or change-of-control payment
  • 4c · Equity-based compensation arrangement
  • 5a · Pay contingent on this organization's revenues
  • 5b · Pay contingent on a related organization's revenues
  • 6a · Pay contingent on this organization's net earnings
  • 6b · Pay contingent on a related organization's net earnings
  • 7 · Other non-fixed payments
  • 8 · Paid under the initial-contract exception

The filer's explanations (Part III)

PART I, LINE 3 - METHODS TO ESTABLISH COMPENSATION BY RELATED ORGANIZATION
THE FOLLOWING METHODS ARE USED BY A RELATED ORGANIZATION TO ESTABLISH COMPENSATION OF THE CEO/EXECUTIVE DIRECTOR: A COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY OR STUDY, FORM 990 OF OTHER ORGANIZATIONS, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE.
PART I, LINE 4B - SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN
THE FOLLOWING INDIVIDUALS PARTICIPATED IN THE SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN. THE AMOUNTS BELOW ARE INCLUDED ON SCHEDULE J, PART II, COLUMN C. DANIEL DEBARBA $253,000 PARTICIPATION IN THE PLAN RUTH HENNESSY $143,000 PARTICIPATION IN THE PLAN. PATRICK O'SHAUGHNESSY $764,000 PARTICIPATION IN THE PLAN THE DEFERRED COMPENSATION IN COLUMN C FOR THESE INDIVIDUALS INCLUDES BOTH QUALIFIED AND NON-QUALIFIED RETIREMENT PLANS. THE FOLLOWING INDIVIDUALS VESTED IN THE SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN. THE AMOUNTS BELOW ARE INCLUDED ON SCHEDULE J, PART II, COLUMN B (III). THESE AMOUNTS INCLUDE A TAX GROSS UP. RUTH HENNESSY $176,818 VESTED IN PLAN. THE AMOUNTS OUTLINED HEREIN WERE INCLUDED IN EACH INDIVIDUAL'S 2022 FORM W-2, BOX 5 AS TAXABLE WAGES BECAUSE THEY ARE VESTED, BUT ARE NOT DISTRIBUTED UNTIL RETIREMENT.
PART II - FORMER OFFICERS & DIRECTORS
EFFECTIVE 12/19/18, RUTH HENNESSEY WAS TRANSFERRED TO GOOD SAMARITAN HOSPITAL MEDICAL CENTER, A RELATED ENTITY, TO SERVE AS THE PRESIDENT/CAO.

Part I's answers as filed. A line not listed was left unanswered; on lines 1a and 3 that means the box was not checked.

Grants on this return

No itemized grants to organizations on this return.

Related organizations on this return

Schedule R Part II: tax-exempt organizations related to the filer by control. It does not record shared board members or money.

Taxable family on this return

Schedule R Parts I, III and IV, as filed. These record ownership and control, not shared board members or money moved.

Related partnerships

Part III: related organizations taxable as a partnership, with the filer's share.

  • BIPO HOLDINGS LLC

    N/A · PHYSICIAN ASSN · NY

    Directly controlled by NA

  • IDHC LLC

    N/A · HEALTH SERVICES · PA

    Directly controlled by NA

  • BEACON HEALTH PTNRS

    N/A · HEALTHCARE · NY

    Directly controlled by NA

  • WISDOM GARDENS LP

    N/A · SR HOUSING · NY

    Directly controlled by NA

  • CHS PHYSICIAN PARTNERS ACO LLC

    N/A · HEALTHCARE · NY

    Directly controlled by NA

  • LONG ISLAND HEALTHCARE NETWORK

    N/A · CONTRACTING · NY

    Directly controlled by NA

Related corporations and trusts

Part IV: related organizations taxable as a corporation or trust.

  • RADIOLOGY CONSULTING OF LONG ISLANDPLLC

    C-CORP · HEALTHCARE SVC · NY

    Directly controlled by GOOD SAMARITAN

  • SAMARITAN PEDIATRIC SERVICES PC

    C-CORP · HEALTHCARE SVC · NY

    Directly controlled by GOOD SAMARITAN

  • SAMARITAN MEDICAL SERVICES PC

    C-CORP · HEALTHCARE SVC · NY

    Directly controlled by GOOD SAMARITAN

  • SOUTHWEST SUFFOLK MEDICAL PC

    C-CORP · HEALTHCARE SVC · NY

    Directly controlled by GOOD SAMARITAN

  • CARDIAC EKG INTERPRETATION PC

    C-CORP · HEALTHCARE SVC · NY

    Directly controlled by GOOD SAMARITAN

  • LI REGIONAL ARTHRITIS & OSTEOPOROSIS CAR

    C-CORP · HEALTHCARE SVC · NY

    Directly controlled by GOOD SAMARITAN

  • SAMARITAN MANAGEMENT SERVICES

    C-CORP · HEALTHCARE SVC · NY

    Directly controlled by CHSLI

  • ADVANCED REHABILIATION MEDICINE PLLC

    C-CORP · HEALTHCARE SVC · NY

    Directly controlled by STCHARLES HOSP

  • ST FRANCIS CARDIAC PREVENTION SERVICES

    C-CORP · HEALTHCARE SVC · NY

    Directly controlled by STFRANCIS HOSP

  • SOUTH SHORE PRACTICE MANAGEMENT

    C-CORP · HEALTHCARE SVC · NY

    Directly controlled by SAMARITAN MGMT

  • SAMARITAN HOME CARE AMERICA

    C-CORP · HEALTHCARE SVC · NY

    Directly controlled by SAMARITAN MGMT

  • MERCY INTERNAL MEDICINE PC

    C-CORP · HEALTHCARE SVC · NY

    Directly controlled by MERCY MED CTR

  • LONG ISLAND EMERGENCY CARE PC

    S-CORP · PHYSICIAN SVC · NY

    Directly controlled by MERCY MED CTR

  • MY CHS RX INC

    C-CORP · PHARMACY · NY

    Directly controlled by CHSLI

Provenance

Return type
form_990
Tax year
2022
Filed
9 November 2023
IRS schema version
2022v5.0
Source object
202343179349309734

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