2022-11-11T11:09:50-06:00 2021-12-31 930418710 DELAP LLP 5885 MEADOWS ROAD NO 200 LAKE OSWEGO OR 97035 990 2021-01-01 930583856 COLUMBIA LUTHERAN CHARITIES COLU 5033254321 2111 EXCHANGE STREET ASTORIA OR 971033329 ZACHARY SCHMITT CFO 5033254321 2022-11-10 1 ZACHARY SCHMITT 999009999 ROBERT J WOLFER CPA P01299726 5036974118 2022-11-10 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z COLUMBIA MEMORIAL HOSPITAL ZACHARY SCHMITT 2111 EXCHANGE STREET ASTORIA OR 971033329 187562899 0 X WWW.COLUMBIAMEMORIAL.ORG X 1958 OR PROVIDE EXCELLENCE, LEADERSHIP & COMPASSION IN THE ENHANCEMENT OF HEALTH FOR THOSE WE SERVE. 14 13 833 25 1728392 0 7719091 3783458 151371571 167670216 5238893 6561457 2673253 2756130 167002808 180771261 127401 2880675 0 0 64950516 69210278 0 0 224365 73145244 83330258 138223161 155421211 28779647 25350050 214285423 246096987 79290208 78824102 134995215 167272885 THE MISSION OF COLUMBIA MEMORIAL HOSPITAL IS TO PROVIDE EXCELLENCE, LEADERSHIP, AND COMPASSION IN THE ENHANCEMENT OF HEALTH FOR THOSE WE SERVE. 0 0 103754184 2880675 168697954 SEE SCHEDULE O 103754184 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 1 71 0 1 833 1 0 0 0 0 0 0 0 0 0 0 0 0 X 14 13 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OR X ZACHARY SCHMITT 5033384613 2111 EXCHANGE STREET ASTORIA OR 97103 PAUL HAINES BOARD MEMBER 3.00 X 0 0 0 NANCY MCALLISTER BOARD MEMBER 3.00 X 0 0 0 HEATHER SEPPA BOARD MEMBER 3.00 X 0 0 0 SHERIFF MATT PHILLIPS BOARD MEMBER 3.00 X 0 0 0 MARK SMITH BOARD MEMBER 3.00 X 0 0 0 DOUG KAUP BOARD MEMBER 3.00 X 0 0 0 JEAN DANFORTH QUALITY CHAIR 3.00 X 0 0 0 DAVE NYGAARD SECRETARY 3.00 X X 0 0 0 BILL LANDWEHR TREASURER 3.00 X X 0 0 0 CONSTANCE WAISANEN BOARD MEMBER 3.00 X 0 0 0 JAMES HEILMAN MD BOARD MEMBER/PHYSICIAN 3.00 X 0 0 0 CAMILO ROSALES MD BOARD MEMBER/PHYSICIAN 3.00 X 0 0 0 ROBERT HOLLAND MD BOARD PRESIDENT/PHYSICIAN 3.00 X X 3245 0 0 MIKE AUTIO BOARD VICE-PRESIDENT 3.00 X X 0 0 0 ERIK THORSEN CEO 40.00 1.00 X 800089 0 115206 NICOLE WILLIAMS COO 40.00 X 384838 0 53913 ZACHARY SCHMITT CFO 40.00 1.00 X 349735 0 53666 JARROD KARNOFSKI VP - ANCILLARY SERVICES 40.00 X 268893 0 49442 JUDY GEIGER VP - PATIENT CARE 40.00 X 265186 0 29800 CHRISTOPHER LAMAN VP - STRATEGY 40.00 X 261543 0 59570 DOUGLAS ABBOTT MD PHYSICIAN 40.00 X 374328 0 39672 PETER BALES MD PHYSICIAN 40.00 X 361414 0 40830 DAVID LEIBEL DO PHYSICIAN 40.00 X 337607 0 36498 KERI BROWN MD PHYSICIAN 40.00 X 242093 0 16350 MICHAEL MURDOCK MD PHYSICIAN 40.00 4.00 X 226592 0 29039 3875563 0 523986 185 0 1 0 OHSU (CONSOLIDATED) 3181 SAM JACKSON PARK RD MAIL CODE PORTLAND OR 97239 PHYSICIAN FEES 16172151 ANESTHESIA ASSOCIATES NORTHWEST LLC 6400 SE LAKE RD STE 130 PORTLAND OR 97222 ANESTHESIOLOGY PHYSICIANS 2019757 HIMAGINE SOLUTIONS 600 EMERSON ROAD 225 ST LOUIS MO 63141 HEALTHCARE IP & OP CODING 1535149 CERNER CORPORATION 2800 ROCKCREEK PARKWAY NORTH KANSAS CITY MO 64117 ELECTRONIC MEDICAL RECORDS 1518856 MAXIM HEALTHCARE SERVICES 12558 COLLECTONS CENTER DRIVE CHICAGO IL 60693 HEALTHCARE STAFFING 1448085 50 15919 3205906 561633 3783458 OUTPATIENT REVENUE 621990 199063588 199063588 EMERGENCY ROOM REVENUE 621990 56010078 56010078 INPATIENT REVENUE 621990 46784709 46784709 CONTRACTUAL ALLOWANCE 621990 -139509584 -139509584 5321425 5321425 167670216 1938577 1938577 201467 189717 11750 11750 11750 11224801 6601921 4622880 4622880 4622880 PHARMACY SALES 446110 1728392 1728392 HOSPITALIST 621110 552131 552131 463857 463857 2744380 180771261 168697954 1728392 6561457 X 162709 162709 2717966 2717966 2508618 2508618 49826809 36180799 13492387 153623 3425551 2455635 965953 3963 9284663 6848089 2414085 22489 4164637 2932127 1219813 12697 410293 410293 205693 205693 21870579 20004713 1865866 254853 254828 25 14407194 735463 13645878 25853 3049730 677202 2369693 2835 4107617 1001494 3104923 1200 68710 58861 9849 320615 103360 216155 1100 6251425 2145798 4105627 1275853 481963 793890 UBIT TAX 24055 24055 MEDICAL SUPPLIES & PHAR 22524777 22370860 153917 OTHER PURCHASED SERVICE 5683784 3033184 2650020 580 REPAIRS & MAINTENANCE 2733260 1797270 935990 141820 46691 95129 155421211 103754184 51442662 224365 81395 97563 20868514 6930204 13524580 16173699 3852216 4049081 1757938 2597917 125976370 72769562 55606613 53206808 105532125 144650132 19112 18856 2475000 2475000 10567930 15897727 214285423 246096987 16566866 19433651 44017786 43014252 18705556 16376199 79290208 78824102 X 134995215 167272885 134995215 167272885 214285423 246096987 X 25350050 404251 6523369 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 7480255 3280803 10761058 8014667 36064269 25593957 18484979 3692237 1975014 1717223 64463214 45200591 19262623 2980925 2980925 53206808 OTHER RECEIVABLES 3473974 INSURANCE ANNUITIES - DEFERRED COMP PLAN 1357192 MEDICAL MALPRACTICE RECEIVABLE 405000 ASC 842 RIGHT OF USE ASSETS 10661561 15897727 ESTIMATED 3RD PARTY PAYOR 3488000 DEFERRED COMPENSATION 1357192 MEDICAL MALPRACTICE CLAIMS 1048768 ACCRUED RETIREMENT PLAN LIABILITY 557748 ASC 842 LEASE LIABILITIES 9924491 16376199 X PART X, LINE 2: INCOME TAX POSITIONS THAT MEET A "MORE-LIKELY-THAN-NOT" RECOGNITION THRESHOLD ARE MEASURED AT THE LARGEST AMOUNT OF INCOME TAX BENEFIT THAT IS MORE THAN 50% LIKELY OF BEING REALIZED UPON SETTLEMENT WITH THE APPLICABLE TAXING AUTHORITY. THE PORTION OF THE BENEFITS ASSOCIATED WITH INCOME TAX POSITIONS TAKEN THAT EXCEEDS THE AMOUNT MEASURED AS DESCRIBED ABOVE WOULD BE REFLECTED AS A LIABILITY FOR UNRECOGNIZED INCOME TAX BENEFITS IN CHARITIES' CONSOLIDATED BALANCE SHEETS ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. INTEREST AND PENALTIES ASSOCIATED WITH UNRECOGNIZED INCOME TAX BENEFITS WOULD BE CLASSIFIED AS INCOME TAXES IN CHARITIES' CONSOLIDATED STATEMENTS OF OPERATIONS. THERE WERE NO UNRECOGNIZED INCOME TAX BENEFITS, NOR ANY INTEREST AND PENALTIES ASSOCIATED WITH UNRECOGNIZED INCOME TAX BENEFITS, ACCRUED OR EXPENSED AS OF AND FOR THE YEARS ENDED DECEMBER 31, 2021 AND 2020. 1 1 X 1 X 300.000000000000 1 X 1 1 0 1 1 1341477 1341477 0.00860 26021309 21984093 4037216 0.02600 10207708 9275534 932174 0.00600 37570494 31259627 6310867 0.04060 132676 132676 0.00090 3060 3060 0.00000 158614 158614 0.00100 294350 294350 0.00190 37864844 31259627 6605217 0.04250 24570 24570 0.00020 24570 24570 0.00020 1 455000 0 71601519 64148299 7453220 X 1 1 1 COASTAL HEALTH ASSURANCE CE/PHYSICIAN ASSC. MEDICAL CONTRACTS 0.50000 0.50000 3 1 COLUMBIA MEMORIAL HOSPITAL 2111 EXCHANGE STREET ASTORIA OR 97103 WWW.COLUMBIAMEMORIAL.ORG 14-1146 X X X X 2 CMH PRIMARY CARE CLINICCMH URGENT CARE 1639 SE ENSIGN LANE STE B103 WARRENTON OR 97146 WWW.COLUMBIAMEMORIAL.ORG 14-1146-1 X X HOSPITAL SATELLITE A 3 SEASIDE PRIMARY CARE CLINICCMH IMAGING & LAB 1111 N ROOSEVELT DRIVE SUITE 210 SEASIDE OR 97138 WWW.COLUMBIAMEMORIAL.ORG 14-1146-2 X HOSPITAL SATELLITE A COLUMBIA MEMORIAL HOSPITAL 0 0 1 X X X X X X X X 19 1 1 0 1 X WWW.COLUMBIAMEMORIAL.ORG X 1 19 1 WWW.COLUMBIAMEMORIAL.ORG 0 1 X 300.000000000000 400.000000000000 X X X X X X 0 1 X X X X 1 X WWW.COLUMBIAMEMORIAL.ORG X WWW.COLUMBIAMEMORIAL.ORG X WWW.COLUMBIAMEMORIAL.ORG X X X 1 X X 0 X X X 1 0 0 PART V, SECTION B, LINE 5 COMMUNITY REPRESENTATION FOR PRIMARY DATA:DATA FROM A NUMBER OF FEDERAL AND STATE SOURCES WERE USED TO BETTER UNDERSTAND THE DEMOGRAPHICS, HEALTH BEHAVIORS, SOCIAL & ECONOMIC FACTORS, PHYSICAL ENVIRONMENT, AND CLINICAL CARE CHARACTERISTICS OF THE TWO-COUNTY SERVICE AREA. ADDITIONALLY THE HOSPITAL WAS A MEMBER AND ACTIVE PARTICIPANT IN THE 2018-2019 COLUMBIA PACIFIC COMMUNITY CARE ORGANIZATION'S (CCO) REGIONAL HEALTH ASSESSMENT (RHA) & REGIONAL HEALTH IMPROVEMENT PLAN (RHIP). THIS ASSESSMENT COMMENCED IN 2018 AND WAS COMPLETED IN JUNE OF 2019. THE ASSESSMENT ENGAGED THE COO'S THREE COUNTY SERVICE AREAS IN CONVERSATIONS ABOUT FACTORS THAT CREATE HEALTH AND WELLBEING FOR INDIVIDUALS. PART V, SECTION B, LINE 11 THE NEEDS IDENTIFIED BY THE REGIONAL HEALTH ASSESSMENT WERE COMBINED WITH INPUT SECURED BY LOCAL COMMUNITY LEADERS VIA A KEY INFORMANT SURVEY. SURVEY RESULTS DEMONSTRATE THAT KEY INFORMANTS PERCEIVE IMPROVEMENT IN ACCESS TO CARE SINCE THE 2016-2019 CHNA, BUT THAT ACCESS TO CARE, BEHAVORIAL HEALTH, CHRONIC CONDITIONS AND SOCIAL DETERMINANTS OF HEALTH AND WELL BEING CONTINUE TO BE HIGH PRIORITIES FOR INTERVENETION IN THE 2020-2022 IMPLEMENTATION PLAN. AFTER CONSIDERATION OF THE PREVIOUSLY MENTIONED DATA, THE RHA AND THE KEY INFORMANT SURVEY, THE FOLLOWING WERE IDENTIFIED AS TOP HEALTH NEEDS/PRIORITIES FOR 2020-2022: ACCESS TO CARE - PRIMARY CARE; ACCESS TO CARE - BEHAVIORAL HEALTH; SOCIAL DETERMINANTS OF HEALTH: ADVERSE CHILDHOOD EXPERIENCES/TRAUMA. PART V, SECTION B, LINE 13H A PATIENT'S ELIGIBILITY IS DETERMINED BY THE FINANCIAL COUNSELOR DURING THE SCREENING PROCESS BASED UPON THE FEDERAL POVERTY LEVEL GUIDELINES, HOUSEHOLD SIZE, LIVING EXPENSES, AND OTHER ASSETS WHICH ARE AVAILABLE FOR PAYMENT. A PATIENT/GUARANTOR'S PRIMARY RESIDENCE AND AUTOMOBILES WILL NOT BE CONSIDERED IN ASSET EVALUATION. THE PATIENT'S INCOME HISTORY AND FINANCIAL SITUATION WILL BE REVIEWED, AND IF THERE ARE INSUFFICIENT ASSETS AVAILABLE FOR PAYMENT, ASSISTANCE WILL BE PROVIDED BASED UPON THE SCHEDULE BELOW.INCOME % OF THE FEDERAL POVERTY LEVEL: 0% - 300%DISCOUNT %: 100%INCOME % OF THE FEDERAL POVERTY LEVEL: 301% - 400%DISCOUNT %: 65%*INCOME % OF THE FEDERAL POVERTY LEVEL: >400% UNINSUREDDISCOUNT %: 20% SELF-PAY DISCOUNT*MINIMUM CHARITY DISCOUNT IS BASED ON AGB AS DESCRIBED BELOW AND WILL BE REVIEWED ANNUALLY AND REVISED IF NECESSARY TO COMPLY WITH IRS 501(R). 19 1 - INFUSION CENTER 1905 EXCHANGE ST ASTORIA OR 97103 INFUSION SERVICES 2 - CARDIOLOGY CLINIC 2095 EXCHANGE ST SUITE 301 ASTORIA OR 97103 CARDIOLOGY SERVICES 3 - ORTHOPEDIC CLINIC 2265 EXCHANGE ST 3RD FLOOR ASTORIA OR 97103 ORTHOPEDIC SERVICES 4 - WOMEN'S CENTER CLINIC 2265 EXCHANGE ST 2ND FLOOR ASTORIA OR 97103 WOMEN'S SERVICES 5 - SEASIDE CLINIC 111 N ROSEVELT DRIVE 210 SEASIDE OR 97138 PRIMARY CARE SERVICES 6 - WARRENTON PRIMARY CARE (RHC) 1639 SE ENSIGN LANE SUITE B103 WARRENTON OR 97146 PRIMARY CARE SERVICES 7 - GENERAL SURGERY CLINIC 2055 EXCHANGE ST SUITE 270 ASTORIA OR 97103 GENERAL SURGERY SERVICES 8 - ASTORIA PRIMARY CARE CLINIC 2158 EXCHANGE ST SUITE 107 ASTORIA OR 97103 PRIMARY CARE SERVICES 9 - PEDIATRIC CLINIC 2265 EXCHANGE ST 3RD FLOOR ASTORIA OR 97103 PEDIATRIC SERVICES 10 - FOOT & ANKLE CLINIC 2265 EXCHANGE ST 3RD FLOOR ASTORIA OR 97103 PODIATRY SERVICES 11 - UROLOGY CLINIC 2265 EXCHANGE ST 3RD FLOOR ASTORIA OR 97103 UROLOGY SERVICES 12 - LOWER COLUMBIA HOSPICE 2158 EXCHANGE ST SUITE 206 ASTORIA OR 97103 HOSPICE SERVICES 13 - MEDICAL ONCOLOGY CLINIC 1905 EXCHANGE ST ASTORIA OR 97103 MEDICAL ONCOLOGY SERVICES 14 - URGENT CARE CLINIC 2265 EXCHANGE ST 1ST FLOOR ASTORIA OR 97103 URGENT CARE SERVICES 15 - PULMONOLOGY CLINIC 2055 EXCHANGE ST SUITE 210 ASTORIA OR 97103 PULMONOLOGY SERVICES 16 - ENDOCRINOLOGY CLINIC 2158 EXCHANGE ST SUITE 205 ASTORIA OR 97103 ENDOCRINOLOGY SERVICES 17 - RADIATION ONCOLOGY CLINIC 1905 EXCHANGE ST ASTORIA OR 97103 RADIATION THERAPY SERVICES 18 - WOUND CARE CLINIC 2265 EXCHANGE ST ASTORIA OR 97103 WOUND CARE SERVICES 19 - INTERV RADIOLOGY CLINIC 2111 EXCHANGE ST ASTORIA OR 97103 INTERVENTIONAL RADIOLOGY SERVICES PART I, LINE 3C: THE HOSPITAL'S CRITERIA FOR THE DETERMINATION OF CHARITY CARE INCLUDE PATIENT'S - OR THE OTHER RESPONSIBLE PARTY'S - ANNUAL HOUSEHOLD INCOME, HOUSEHOLD SIZE, ASSETS, CREDIT HISTORY, EXISTING DEBT OBLIGATIONS, AND OTHER INDICATORS OF THE PATIENT'S ABILITY TO PAY. PART I, LINE 7: A COST-TO-CHARGE RATIO IS USED, BASED ON WORKSHEET 2. PART III, LINE 2: THE METHODOLOGY USED TO ESTIMATE BAD DEBT EXPENSE IS THE TOTAL OF ACTUAL BAD DEBT WRITE-OFFS, OFFSET WITH BAD DEBT RECOVERIES PLUS A RESERVE FOR SELF PAY ACCOUNTS EXPECTED TO BE UNCOLLECTABLE BASED ON THE AGING OF THE ACCOUNT. PART III, LINE 3: THE HOSPITAL'S BAD DEBT EXPENSE INCLUDES IMPLICIT PRICE CONCESSIONS FOR PATIENTS WHO DO NOT QUALIFY FOR FINANCIAL ASSISTANCE. BAD DEBT EXPENSE DOES NOT INCLUDE CHARITY CARE. PART III, LINE 4: SEE PAGE 12 OF ATTACHED AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: AS A MISSION-DRIVEN HOSPITAL, HEALTHCARE SERVICES ARE OFFERED TO THE COMMUNITY EVEN WHEN THE COST OF THAT CARE IS KNOWN TO BE MORE THAN THE REVENUE THAT WILL BE RECEIVED. AS THE HOSPITAL ABSORBS THESE LOSSES FROM MEDICARE (DETERMINED BY THE RATIOS USED IN THE MEDICARE COST REPORT), THE ENTIRE COMMUNITY BENEFITS BECAUSE MANY OF THESE PROGRAMS/SERVICES WOULD NOT EXIST WITHOUT HOSPITAL SUPPORT. PART III, LINE 9B: PERSONAL PAY ACCOUNTS AND THE BALANCE AFTER INSURANCE ARE SUBJECT TO A MINIMUM PAYMENT SCHEDULE. IF THE PATIENT OR GUARANTOR IS UNABLE TO MEET THIS PAYMENT SCHEDULE, APPLICATION MAY BE MADE THROUGH PATIENT FINANCIAL SERVICES CREDIT AND COLLECTION CLERK'(S) AND OR THE PATIENT FINANCIAL SERVICES MANAGER FOR CHARITY, FINANCIAL ASSISTANCE, OR REDUCED PAYMENTS. PART VI, LINE 2: THE ORGANIZATION CONTRACTS WITH A THIRD PARTY VENDOR TO PERFORM THE COMMUNITY HEALTH NEEDS ASSESSMENT. THIS IS PERFORMED EVERY THREE YEARS. PART VI, LINE 3: THE ORGANIZATION EMPLOYS FINANCIAL COUNSELORS WHO ARE AVAILABLE TO ASSIST PATIENTS WITH ELIGIBILITY FOR ASSISTANCE WITH ALL FEDERAL, STATE, OR LOCAL GOVERNMENT PROGRAMS. PART VI, LINE 4: THE ORGANIZATION IS LOCATED IN ASTORIA,OREGON AT THE ESTUARY WHERE THE COLUMBIA RIVER AND THE PACIFIC OCEAN MEET ALONG THE NORTH COAST OF OREGON. OUR SERVICE AREA INCLUDES NORTHWEST OREGON AND SOUTHWEST WASHINGTON STATE. PART VI, LINE 5: THE ORGANIZATION IS A MEMBER AND ACTIVE PARTICIPANT IN THE COLUMBIA PACIFIC COMMUNITY CARE ORGANIZATION'S REGIONAL HEALTH ASSESSMENT AND REGIONAL HEALTH IMPROVEMENT PLAN PROGRAMS. PART VI, LINE 7, REPORTS FILED WITH STATES OR 0 CLATSOP COMMUNITY COLLEGE FOUNDATION 1651 LEXINGTON AVENUE ASTORIA OR 97103 237100856 501(C)(3) 80000 0 NURSING PROGRAM CLATSOP COUNTY JUNIOR MARKET AUCTION ASSN PO BOX 43 WARRENTON OR 97146 931321009 501(C)(3) 10935 0 PROVIDE 4-H AND FFA YOUTH EDUCATION NAMI OREGON 4701 SE 24TH AVENUE SUITE E PORTLAND OR 97202 930875209 501(C)(3) 15000 0 BEACON CLUBHOUSE ASTORIA-WARRENTON AREA CHAMBER OF COMMERCE PO BOX 176 ASTORIA OR 97103 930115760 501(C)(6) 12500 0 GREAT COLUMBIA CROSSING 10K RUN/WALK ASTORIA HIGH SCHOOL SCHOLARSHIPS INC PO BOX 598 ASTORIA OR 97103 930724422 501(C)(3) 9400 0 SCHOLARSHIP GRANTS 4 1 CHARITY CARE 4529 2717966 X X 1 1 X X X X 0 1 0 0 0 1 0 0 0 ERIK THORSEN CEO 677645 0 115294 0 7150 0 87492 0 27714 0 915295 0 0 0 NICOLE WILLIAMS COO 343021 0 40068 0 1749 0 21220 0 32693 0 438751 0 0 0 DOUGLAS ABBOTT MD PHYSICIAN 372248 0 2000 0 80 0 23200 0 16472 0 414000 0 0 0 ZACHARY SCHMITT CFO 312927 0 35680 0 1128 0 21253 0 32413 0 403401 0 0 0 PETER BALES MD PHYSICIAN 356414 0 5000 0 0 0 23200 0 17630 0 402244 0 0 0 DAVID LEIBEL DO PHYSICIAN 335957 0 1650 0 0 0 23200 0 13298 0 374105 0 0 0 CHRISTOPHER LAMAN VP - STRATEGY 237471 0 24072 0 0 0 19842 0 39728 0 321113 0 0 0 JARROD KARNOFSKI VP - ANCILLARY SERVICES 239013 0 28604 0 1276 0 20138 0 29304 0 318335 0 0 0 JUDY GEIGER VP - PATIENT CARE 232053 0 28549 0 4584 0 16563 0 13237 0 294986 0 0 0 KERI BROWN MD PHYSICIAN 226193 0 5500 0 10400 0 5254 0 11096 0 258443 0 0 0 MICHAEL MURDOCK MD PHYSICIAN 189395 0 27197 0 10000 0 15010 0 14029 0 255631 0 0 0 PART I, LINE 4B ERIK THORSEN, CEO IS PARTICIPATING IN A 457(F) PLAN WHICH STARTED IN 2015. COLUMBIA MEMORIAL HOSPITAL CONTRIBUTED $64,292 TO THIS PLAN IN 2021. PART I, LINE 6 MANAGEMENT BONUSES ARE CONTINGENT ON THE NET EARNINGS OF THE ORGANIZATION. PART I LINE 1A DISCRETIONARY SPENDING ACCOUNT: BASED ON SIGNED EMPLOYMENT CONTRACTS, COLUMBIA MEMORIAL HOSPITAL PAID ONE LUMP SUM PAYMENT ON THE FIRST PAY-PERIOD OF EACH YEAR TO COVER DISCRETIONARY EXPENSE OF ERIK THORSEN, CEO, ($2,500), IN ADDITION, COLUMBIA MEMORIAL HOSPITAL PAID $609.78 PER MONTH TO COVER THE CEO CAR, ($609.78/MONTH - $7,317.36 ANNUALLY) HEALTH OR SOCIAL CLUB DUES OR INITIATION FEES: BASED ON SIGNED EMPLOYMENT CONTRACTS, COLUMBIA MEMORIAL HOSPITAL REIMBURSED MONTHLY COUNTRY CLUB MEMBERSHIP DUES FOR ERIK THORSEN, CEO ($365/MONTH FROM JANURARY TO JUNE AND $375/MONTH FROM JULY TO DECEMBER - $4,440 ANNUALLY) AND ROTARY CLUB DUES FOR ERIK THORSEN, CEO, OF $200 QUARTERLY ($800 ANNUALLY). THESE EXPENSES WERE SUBMITTED ON MONTHLY EXPENSE REPORTS OR DIRECT INVOICES FROM THE CLUB AND WERE REVIEWED AND APPROVED IN ACCORDANCE WITH THE ORGANIZATION'S FINANCIAL AUTHORITY POLICY AND BUSINESS EXPENSE POLICY. PART I, LINE 3 COMPENSATION SURVEY OR STUDY AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE: COMPENSATION OF ALL OFFICERS IS REVIEWED WITH COMPARABILITY DATA BY A THIRD PARTY CONSULTANT. THE RESULTS OF THE STUDY ARE REVIEWED AND DISCUSSED AT THE BOARD OF TRUSTEES MEETING. A THE HOSPITAL FACILITIES AUTHORITY OF THE CITY OF ASTORIA 270034718 046279BS3 2012-09-27 31993533 FINANCE EHR SYSTEM, ASSET ACQUISTION, REFUNDING OF 2002 & 2007 BOND ISSUES 1 0 0 B THE HOSPITAL FACILITIES AUTHORITY OF THE CITY OF ASTORIA 270034718 046279CAI 2016-07-07 20451436 BUILDING OF THE CMH-OHSU KNIGHT CANCER COLLABORATIVE AND ER REMODEL 0 0 0 A 33350211 2128275 639870 12501380 18080686 2015 1 0 1 1 B 20447424 1667755 870640 409029 17500000 2017 0 0 1 1 A 0 0 0 0 0 0 1 B 0 0 0 0 0 0 1 A 0 0 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 0 0 A 0 B 0 PART 1 SECTION (C) CUSIP # 2016 BOND 046279CAI 046279B27 046279C89 FORM 990, PART III, LINE 4A: STATMENT OF PROGRAM SERVICE ACCOMPLISHMENTS SCHEDULE K PART I LINE A COLUMN E AND PART II LINE 3 COLUMN A RECONCILIATION OF ISSUE PRICE AND TOTAL PROCEEDS OF ISSUE: ISSUE PRICE: 31,993,553 DEBT SERVICE RESERVE FUND RELEASE: 829,500 BOND FUND RELEASE: 527,179 ROUNDING: -21 TOTAL PROCEEDS OF ISSUE: 33,350,211 X 1 45000 APPRAISAL 0 0 0 PART I, LINE 33: NO RECEIPT OR 8283 WAS FILED FOR THIS TRANSACTION. A BUILDING WAS SOLD AT BELOW-MARKET-VALUE, AND THE $45,000 DIFFERENCE BETWEEN APPRAISAL AND SELLING PRICE WAS RECOGNIZED AS A BARGAIN PURCHASE AND RECORDED AS AN ADJUSTMENT TO NET ASSETS. FORM 990, PART VI, SECTION B, LINE 11B A DRAFT OF THE 990 IS MADE AVAILABLE, ELECTRONICALLY, TO THE BOARD OF TRUSTEES, PRIOR TO THE BOARD MEETING. THE 990 IS REVIEWED AND DISCUSSED AT THE BOARD FINANCE COMMITTEE MEETING PRIOR TO FINALIZING AND FILING THE RETURN. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY IS REVIEWED BY THE BOARD OF TRUSTEES, OFFICERS, AND KEY EMPLOYEES ANNUALLY. ALL BOARD MEMBERS, OFFICERS, AND KEY EMPLOYEES MUST SIGN AND DATE THE CONFLICT OF INTEREST POLICY ACKNOWLEDGEMENT, QUESTIONNAIRE, AND DISCLOSURE STATEMENT. ANY POTENTIAL OR ACTUAL CONFLICTS OF INTEREST AT THE BOARD OR OFFICER LEVEL ARE DISCUSSED AT THE BOARD MEETING. ACTUAL CONFLICTS OF INTEREST ARE ADDRESSED, DOCUMENTED, AND FILED IN THE CONFIDENTIAL PERSONNEL FILE. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION OF ALL OFFICERS WAS REVIEWED WITH COMPARABILITY DATA BY A THIRD-PARTY CONSULTANT. THE RESULTS OF THE STUDY WERE REVIEWED AND DISCUSSED AT A BOARD OF TRUSTEES' MEETING. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL INFORMATION REPORTED IN THE 990 ARE AVAILABLE UPON REQUEST AT THE HOSPITAL. FORM 990, PART IX, LINE 11G PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 20,004,713. MANAGEMENT AND GENERAL EXPENSES 1,865,866. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 21,870,579. FORM 990, PART XI, LINE 9: DEFINED BENEFIT RETIREMENT PLAN ADJUSTMENT 6,479,372. INCOME FROM PROVIDER TRUST K-1 -1,003. BARGAIN PURCHASE OF BUILDING 45,000. FROM 990, PART XI, LINE 2C: THE BOARD OF TRUSTEE FINANCE COMMITTEE ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT, REVIEW, AND SELECTION OF AN INDEPENDENT AUDIT FIRM. TRADITIONALLY, A THREE YEAR CONTRACT WITH A SELECTED AUDIT FIRM IS APPROVED. ANNUALLY, A SPECIAL BOARD MEETING IS HELD AND THE AUDIT FIRM PRESENTS THE AUDITED FINANCIAL STATEMENTS TO THE BOARD OF TRUSTEES. DURING THE MEETING, THE BOARD MEMBERS ARE GIVEN THE OPPORTUNITY TO ASK QUESTIONS WITHOUT MANAGEMENT PRESENT. FOLLOW-UP INFORMATION ON THE MANAGEMENT LETTER RECOMMENDATIONS IS ALSO PRESENTED SEMI-ANNUALLY TO THE BOARD FINANCE COMMITTEE. FORM 990, PART III, LINE 4A: STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS MISSION STATEMENT: THE MISSION OF COLUMBIA MEMORIAL HOSPITAL IS TO PROVIDE EXCELLENCE, LEADERSHIP, AND COMPASSION IN THE ENHANCEMENT OF HEALTH FOR THOSE WE SERVE. UTILIZATION STATISTICES: YEAR ENDING 2021 AVAILABLE BEDS 25 ADMISSIONS 1,826 PATIENT DAYS 5,386 OBSERVATIONS 627 AVERAGE LENGTH OF STAY (IN DAYS) 2.95 OCCUPANCY RATE 59.0% DELIVERIES 249 EMERGENCY ROOM VISITS 13,192 URGENT CARE VISITS 13,604 OUTPATIENT VISITS (NET OF ER) 245,805 SURGICAL CASES: 3,012 PLANETREE DESIGNATION THE HOSPITAL HAS ADOPTED A PHILOSOPHY OF PROVIDING PATIENT-CENTERED CARE THROUGHOUT ITS FACILITIES. IN 2000, THE HOSPITAL JOINED AN ORGANIZATION CALLED PLANETREE, INC ("PLANETREE") AS AN AFFILIATE MEMBER. PLANETREE PARTNERS WITH HEALTHCARE ORGANIZATIONS AROUND THE WORLD TO DEVELOP AND ADVANCE PATIENT CENTERED APPROACHES TO CARE. IN 2013, THE HOSPITAL BECAME ONLY THE SECOND HOSPITAL IN OREGON TO ACHIEVE THE PRESTIGIOUS PLANETREE DESIGNATION STATUS. PLANETREE-DESIGNATION REPRESENTS THE HIGHEST LEVEL OF ACHIEVEMENT IN PATIENT/PERSON-CENTERED CARE BASED ON EVIDENCE AND STANDARDS, ACCORDING TO PLANETREE. PLANETREE-DESIGNATED HOSPITALS MUST DEMONSTRATE THEIR COMMITMENT AND SUCCESSFUL ADOPTION OF THE PATIENT CENTERED CARE PRINCIPLES BY PASSING A RIGOROUS SURVEY PROCESS, PERFORMED BY PLANETREE EVERY THREE YEARS. COLUMBIA MEMORIAL HOSPITAL WAS AWARDED RE-DESIGNATION FOR ANOTHER THREE YEARS IN NOVEMBER 2016 AT THE ANNUAL PLANTREE CONFERENCE. THE HOSPITAL HAS MAINTAINED PLANETREE DESIGNATION BY CREATING AN ORGANIZATIONAL CULTURE COMMITTED TO PROVIDING THE LATEST IN MEDICAL TECHNOLOGY IN A HEALING, NURTURING ENVIRONMENT THAT ENCOURAGES A PATIENT'S INVOLVEMENT IN THE CARE THAT THEY RECEIVE. THE HOSPITAL CONTINUALLY STRIVES TO OFFER PEACEFUL, COMFORTABLE SURROUNDINGS, WARM AND SUPPORTIVE CAREGIVERS, ACCESS TO HEALTH INFORMATION ALTERNATIVE THERAPIES, AND EDUCATION TO HELP PATIENTS GET WELL FASTER AND STAY WELL LONGER. COLUMBIA MEMORIAL HOSPITAL RECENT ACCREDITATIONS: 1. HEALTHCARE FACILITIES ACCREDITATION PROGRAM (HFAP) - NATIONALLY RECOGNIZED ACCREDITATION - ORGANIZATION WITH DEEMING AUTHORITY FROM THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) 2. COMMISSION OF OFFICE LABORATORY ACCREDITATION (COLA) - LABORATORY ACCREDITATION 3. AMERICAN COLLEGE OF RADIOLOGY MAMMOGRAPHY QUALITY STANDARDS ACT (ACR/MSQA) - IMAGING SERVICES/MAMO ACCRED. 4. INTER-SOCIETAL ACCREDITATION COMMISSION (IAC) - ECHOCARDIOGRAPHY ACCREDITATION 5. AMERICAN ASSOCIATION OF CARDIOVASULAR REHABILITATION (AACVP) - CARDIAC REHABILITATION ACCREDITATION 6. AMERICAN ASSOC. FOR RESPIRATORY CARE QUALITY RESPIRATORY CARE RECOGNITION (AARC'S QRCR) RESPIRATORY THERAPY ACCREDITATION INFORMATION TECHNOLOGY: THE HOSPITAL'S INVESTMENT IN THE HEALTHCARE INFORMATION TECHNOLOGY ALONG WITH THE NESESSARY HUMAN RESOURCES AND ASSOCIATED PROCESS CHANGE HAVE RESULTED IN IMPROVED CLINICAL OPERATIONS, QUALITY, PATIENT SAFETY, AND OVERALL EFFICIENCY. THE HOSPITAL RECEIVED THE MOST WIRED AWARD FROM THE AMERICAN HOSPITAL ASSOCIATION IN NINE CONSECUTIVE YEARS OF 2011-2019 AND IN 2021. THE HOSPITAL HAS ALSO ACHIEVED COMPLIANCE WITH THE AMERICAN RECOVERY AND REINVESTMENT ACT OF 2009 MEANINGFUL USE OF HEALTHCARE IT CRITERIA BOTH STAGE 1 AND STAGE 2. SINCE 2012, THE HOSPITAL HAS REALIZED MEANINGFUL USE INCENTIVE REVENUES OF APPROXIMATELY $3,164,000. THE HOSPITAL INVESTED IN AN INDUSTRY LEADING BUSINESS INTELLIGENCE PLATFORM WHICH IS UTILIZED IN OPTIMIZING OPERATIONS AND FINANCIAL PERFORMANCE. CMH MEDICAL GROUP: THE HOSPITAL OWNS AND OPERATES A NUMBER OF PROVIDER-BASED PRIMARY, URGENT CARE, AND SPECIALTY CARE CLINICS ORGANIZED AND COLLECTIVELY KNOWN AS THE CMH MEDICAL GROUP. THE CLINICS OPERATE IN 3 SEPERATE ASTORIA LOCATIONS AND 1 WARRENTON AND 1 IN SEASIDE OREGON. THE WARRENTON AND SEASIDE LOCATIONS OPERATES AS A PROVIDER-BASED LOCASTIONS AND EXPANDING THE CAPACITY TO PROVIDE PRIMARY CARE SERVICES FOR THE COMMUNITY. THERE ARE SEVENTY-THREE (73) PHYSICIANS AND MID-LEVEL PROVIDERS EMPLOYED WITHIN THE CMH MEDICAL GROUP IN ELEVEN (11) DIFFERENT MEDICAL SPECIALTIES. THESE SPECIALTIES INCLUDE: GENERAL SURGERY, PEDIATRICS, PRIMARY CARE, URGENT CARE, UROLOGY, ENDOCRINOLOGY, ORTHOPEDICS, PODIATRY, AND WOMEN'S HEALTHCARE, ONCOLOGY, AND CARDIOLOGY IN COLLABORATION WITH OHSU. CLINICAL COLLABORATIONS: IN ORDER TO ENHANCE THE SERVICES THAT THE HOSPITAL PROVIDES TO THE COMMUNITY, THE HOSPITAL ESTABLISHED A CLINICAL ALLIANCE WITH OHSU IN 2010. THROUGH THIS ALLIANCE, THE HOSPITAL AND OHSU INITIALLY CREATED THE CMH/OHSU CANCER CARE CENTER WHICH WAS DEDICATED TO PROVIDING COMPREHENSIVE, INTER-DISCIPLINARY, CONSULTATIVE, AND ONGOING ONCOLOGY AND HEMATOLOGY CARE. IN 2011, THE HOSPITAL AND OHSU ESTABLISHED THE CMH/OHSU CARDIOLOGY CLINIC, WHICH PROVIDES COMPREHENSIVE CARE FOR A RANGE OF HEART HEALTH AND HEART DIISEASE PREVENTION NEEDS IN THE COMMUNITY. SINCE 2011, THE ALLIANCE HAS BROADENED SUBSTANTIALLY AND NOW INCLUDES CLINICAL OVERSIGHT AND STAFFING OF THE HOSPITAL'S EMERGENCY DEPARTMENT, GENERAL SURGERY AND RESIDENCY PROGRAMS, TELEMEDICINE, A WOMEN'S HEART HEALTH PROJECT AND CONTINUING MEDICAL EDUCATION. IN TOTAL, THERE ARE APPROXIMATELY FORTY-SIX (46) OHSU PHYSICIANS WORKING FULL-TIME IN THE HOSPITAL'S FACILITIES. JOINT OPERATING AGREEMENT: IN THE FIRST QUARTER OF 2015, THE HOSPITAL ENTERED INTO A JOINT OPERATING AGREEMENT (JOA) WITH OHSU THROUGH THE OHSU KNIGHT CANCER INSTITUTE TO BETTER SERVE THE ONCOLOGY CARE NEEDS OF ASTORIA AND SURROUNDING COMMUNITIES IN OREGON AND SOUTHWEST WASHINGTON. A BOND WAS SECURED IN JULY OF 2016 TO PROVIDE FOR THE FINANCING OF A 19,000 SQUARE-FOOT, TWO-STORY COMPREHENSIVE CANCER TREATMENT CENTER AND EQUIPMENT. CONSTRUCTION ON THE CANCER TREATMENT CENTER BEGAN IN AUGUST OF 2016 AND WAS COMPLETED IN THE FALL OF 2017. THE JOA AND ADDITIONAL SPACE AND EQUIPMENT PROVIDED CMH THE OPPORTUNITY TO EXPAND SERVICES TO INCLUDE RADIATION THERAPY IN ADDITION TO MEDICAL ONCOLOGY AND INFUSION THERAPY SERVICES. COLUMBIA MEMORIAL HOSPITAL & OHSU KNIGHT CANCER COLLABORATION IS THE ONLY PROVIDER ON THE NORTH OREGON COAST THAT PROVIDES RADIATION THERAPY SERVICES. CMH FOUNDATION: THE HOSPITAL BENEFITS FORM SUBSTANTIAL COMMUNITY SUPPORT. THE FOUNDATION PROVIDES A DIRECT LINK TO THE REGION'S NEED FOR COMPASSIONATE HEALTH CARE BY SUPPORTING THE ENHANCEMENT OF THE HOSPITAL'S PROGRAMS AND SERVICES. THE FOUNDATION WAS INCORPORATED IN 1991 BY A GROUP OF CITIZENS TO SERVE AS THE BRIDGE BETWEEN THE COMMUNITY AND THE HOSPITAL TO ENCOURAGE FINANCIAL SUPPORT OF HEALTH PROGRAMS AND SERVICES. THE FOUNDATION IS A DEDICATED FUND DEVELOPMENT ENITY THAT HAS SUCCESSFULLY RAISED OVER $5,000,000. IN 2010, THE FOUNDATION CONTRIBUTED $500,000 TO THE HOSPITAL TO ASSIST WITH THE SURGERY CENTER RENOVATION. THIS SUPPORT CONTINUED WITH A $185,000 DONATION IN 2012 FOR THE CONTINUED EXPANSION OF THE CANCER CENTER AND HAS RAISED AN ADDITION OF $2,000,000 TO BENEFIT THAT PROGRAM. THE FOUNDATION FOCUSES ON WORKING WITH DONORS WHO WISH TO MAKE MAJOR AND PLANNED GIFTS IN SUPPORT OF THE HOSPITAL. IN SOME CASES, THE FOUNDATION WILL RAISE FUNDS TO SUPPORT A VARIETY OF PRIORITIES AS IDENTIFIED BY THE HOSPITAL AND IN PARTNERSHIP WITH DONORS. THE FOUNDATION PROVIDES OPPORTUNITIES FOR DONORS TO SUPPORT A MISSION THAT MATCHES THEIR OWN INTERESTS SUCH AS PROVIDING EQUIPMENT, CREATING PROGRAMS TO SERVE THE COMMUNITY OR FUNDING THE FUTURE ENDOWMENT. 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