2019-11-08T19:40:19-06:00 2018-12-31 910189318 Moss Adams LLP 3121 W March Ln Ste 200 Stockton CA 952192367 990 2018-01-01 941639901 Ukiah Adventist Hospital UKIA 9164060000 275 Hospital Drive Ukiah CA 95482 Ryan Quattlebaum Treasurer 9164060000 2019-11-06 1 Tracy S Paglia P00366884 2099556100 2019-11-06 172.9.161.112 2019-11-06 23:17:20 PS P F565611BDA9E00D03FA055086BAA92DB14EC1355 2CA4604677747A1B8287DC7DD1B2F222DAF5CAE3 2018 2020-03-31 21:24:44Z Adventist Health Ukiah Valley Gwen Matthews 275 Hospital Drive Ukiah CA 95482 202794673 0 1071 X www.adventisthealth.org/ukiah-valley/ X 1967 CA Living God's love by inspiring health, wholeness and hope. 12 10 915 35 0 0 1085638 637022 173925889 200406296 1491630 1674506 64431 32232 176567588 202750056 161065 443311 0 0 56688316 65742706 0 0 294286 96548146 116478675 153397527 182664692 23170061 20085364 182267697 207274569 73509876 78431384 108757821 128843185 X Living God's love by inspiring health, wholeness and hope. 0 0 153934836 443311 200406296 See Schedule O 153934836 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 915 1 0 0 0 0 0 1 1 0 0 0 0 0 0 X 12 10 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 CA X Jay Lipps VP System Controller 9167465932 PO Box 619135 Roseville CA 95661 X Banks David Director 0.00 4.00 X 0 27620 0 Cherry Robert Director 0.00 4.00 X 0 25126 0 Davis Andrew Director 0.00 4.00 X 0 24002 0 Freedman John Director 0.00 4.00 X 0 718 0 Gabriel Melody Director thru 12/2018 0.00 4.00 X 0 20464 0 Graham Ricardo Director 0.00 4.00 X 0 1442 0 Heinrich Kerry Director 0.00 4.00 X 0 20485 0 Innocent Larry Director 0.00 4.00 X 0 31885 0 Pedersen James Director thru 07/2018 0.00 4.00 X 0 3625 0 Reiner Richard Director 0.00 4.00 X 0 27964 0 Reiner Scott Dir/Chair 0.00 50.00 X X 0 2458436 44472 Rippey Wesley Director thru 05/2018 0.00 50.00 X 0 623943 47568 Salazar Velino Director 0.00 4.00 X 0 1542 0 Wing Bill Dir/Vice Chair/Asst Secr 0.00 50.00 X X 0 1875311 49315 Jobe Meredith Secretary 0.00 50.00 X 0 666615 38328 Matthews Gwen President 50.00 0.00 X 0 674861 16539 Quattlebaum Ryan Treasurer 50.00 0.00 X 0 237512 33980 Wagner Jack Asst Secr thru 03/2018 0.00 50.00 X 0 1332908 34076 Byrnes John Medical Officer, NCR 10.00 40.00 X 0 501269 14905 Eller Jeff President, NCR 10.00 40.00 X 0 1176550 38127 Lang Kevin Finance Officer, NCR 10.00 40.00 X 0 563108 0 Lonto Robert VP HR, NCR 0.00 50.00 X 0 359348 46556 Ploss David Medical Director 50.00 0.00 X 0 518492 24422 Reppert Joseph CFO, NCR 50.00 0.00 X 0 953615 46846 Van Housen Heather Patient Care Exec 0.00 50.00 X 0 309781 66 Weis David VP Operations 0.00 50.00 X 0 248194 44921 Bartolomie Jill Director, RN 50.00 0.00 X 179326 0 22313 Kilkenny Martha Nurse Practitioner 50.00 0.00 X 182496 0 18435 Petersen Lisa RN, Nurse lead 50.00 0.00 X 281874 0 30875 Rehm Donna RN 50.00 0.00 X 234778 0 40046 Spencer Lindsey Patient Care Exec 50.00 0.00 X 220966 0 40133 McDonald Edward Former Treas/Asst Secr 0.00 50.00 X 0 338302 20694 Poole Aaron Former Treas/Asst Secr 0.00 50.00 X 0 327164 41356 1099440 13350282 693973 154 1 1 0 Herrero Builders Inc 2100 Oakdale Avenue San Francisco CA 94124 Construction 11442549 Pacific Redwood Medical Services Inc 242 Hospital Drive Suite B Ukiah CA 95482 Medical services 2614003 Bivens Medical Corporation 20105 Geisendorfer Applegate CA 95703 Medical services 2463650 Pacific Redwood Medical Group Inc PO Box 2800 Ukiah CA 95482 Medical services 2190747 Locumtenenscom LLC PO Box 405547 Atlanta GA 30384 Medical services 1718428 39 33075 10000 75636 518311 637022 Patient service revenue 621110 199138834 199138834 Other program revenue 900099 836117 836117 Dietary 722210 285155 285155 Rent medical office bldg 531120 134140 134140 Medical records revenue 621990 12050 12050 200406296 1674013 1674013 493 0 493 493 493 29215 33075 11625 17590 17590 47634 32992 14642 14642 202750056 200406296 0 1706738 X 443311 443311 50380039 46921857 3329053 129129 1252694 1148013 100826 3855 10514804 10195241 298000 21563 3595169 3406593 179702 8874 9590787 1135538 8455249 162221 162221 40522 40522 16281 16281 66080150 57561866 8413143 105141 362479 362479 1199311 919315 271962 8034 7331305 1548403 5778070 4832 6819322 5710873 1108449 344066 241644 100864 1558 61677 33309 28368 573854 571854 1000 1000 3075151 3075151 54121 53958 163 Patient care supplies 20298900 20195047 103853 Rental/lease costs equi 846059 831426 14633 Sales taxes 65337 65337 -442868 -140181 -312987 10300 182664692 153934836 28435570 294286 804521 117196 72740524 71725081 15268465 16040043 2672796 3010203 306375 267252 120812707 41421760 59408731 79390947 3762091 3850194 500000 500000 172586 172586 26631608 32201067 182267697 207274569 13960859 15119395 59549017 63311989 73509876 78431384 X 103346893 127072956 5410928 1770229 108757821 128843185 182267697 207274569 20085364 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 16281 16281 0 Part II-B, Line 1: The Hospital belongs to industry and professional associations for which a portion of the membership dues is used for lobbying activities. 5410928 567262 3220 13744 4197437 1770229 5268630 798626 193575 4820 845083 5410928 4179423 1348696 259489 5268630 3563283 663489 1870 49219 4179423 2087526 1515900 1487 41630 3563283 0.00000 0.00000 1.00000 0 0 1276873 1276873 39353492 19177456 20176036 1075597 1075597 0 24441542 21168707 3272835 54665203 54665203 79390947 Receivables from third-party payors 27577637 Receivables from related organizations 4204881 Other receivables 418549 32201067 Payables to related organizations 44746109 Payables to third party payors 16372622 Workers' compensation liability 2177326 MOB deposits 10702 Other current liabilities 5230 63311989 Part V, Line 4: Board-designated and temporarily restricted endowment funds are for specified operating and capital projects. The funds are released as project costs are expended. Golf tournament 42122 33075 9047 195 4558 3038 Colors for cancer fun run 12721 12721 3696 54843 33075 21768 195 4558 6734 11487 10281 1 1 X 1 X 1 X 1 1 0 1 1 2760233 2760233 0.01530 2760233 2760233 0.01530 941756 23070 918686 0.00510 309874 309874 0.00170 3677162 19979 3657183 0.02020 133410 14120 119290 0.00070 5062202 57169 5005033 0.02770 7822435 57169 7765266 0.04300 3467 3467 0.00000 3468 3468 0.00000 336052 336052 0.00190 342987 342987 0.00190 1 798107 368406 46797652 52444923 -5647271 X 1 1 1 Hospital Dr Med Plaza Assn Property management 0.33000 0.00000 0.67000 1 1 Adventist Health Ukiah Valley 275 Hospital Drive Ukiah CA 95482 See Form 990, Pg 1, Item J 110000095 X X X Adventist Health Ukiah Valley 1 0 0 1 X X X X X X X X X 16 1 1 1 1 X See Sch H Part VI - Needs Assessment X See Sch H Part VI - Needs Assessment X 1 18 1 See Sch H Part VI - Needs Assessment 0 1 X 200.000000000000 400.000000000000 X X X X 1 1 X X X X 1 X Sch H, Part VI-Patient Educ X Sch H, Part VI-Patient Educ X Sch H, Part VI-Patient Educ X X X X X X 1 X 0 X X X X 1 X 0 0 Adventist Health Ukiah Valley Part V, Section B, Line 5: The 2016 CHNA data collection process can be summarized as follows: Review of prior CHNA reporting effortsCollection of most recently available demographic, socioeconomic and health indicator dataData gathering was accomplished by using a widely-distributed community health survey and conducting key informant interviews.Community Health Survey: was provided to Mendocino County residents online as well as in hardcopy format. A total of 1,486 residents completed the Community Health Survey; 1,402 were completed in English, and 84 in Spanish.Key Informant Interviews: sixteen key stakeholders in the community were interviewed, including representatives of county and city government, healthcare, the courts, nonprofits, media, health and human services, and private business. Interviews were conducted in person or by phone. The questions were also provided in hardcopy format for written response. While an effort was made to have diverse representation, the opinions provided by the key informants are not necessarily representative of the county as a whole.Participants in this effort included the following stakeholders: County and city government officials with public health responsibilities, hospital executives, Health and Human Services representatives, one judge, one media representative, and several private business and nonprofit leaders who serve the community with social, health, or educational support services. These key stakeholders were selected by the workgroup because they would provide a unique perspective on the health of the community, health care delivery systems in place and overall conditions that influence health behaviors. Adventist Health Ukiah Valley Part V, Section B, Line 6a: Ukiah Valley Medical Center partnered with Frank R. Howard Memorial Hospital to produce the 2016 CHNA. Adventist Health Ukiah Valley Part V, Section B, Line 6b: Ukiah Valley Medical Center collaborated with the Alliance for Rural Community Health (ARCH), Mendocino County Health and Human Services Agency, and North Coast Opportunities to prepare the 2016 Community Health Needs Assessment. Adventist Health Ukiah Valley Part V, Section B, Line 11: Our 2016 CHNA identified three areas of significant needs: mental health, childhood obesity and family wellness, and childhood trauma. The main goal was to improve the overall health and wellness of our communities through provision of services, community collaboration and innovation. Priority Need 1 - Mental health: County-wide mental health consciousness is reflected in a proactive, no-shame view of the issues. Communities, agencies, and schools take a comprehensive approach to care and case management. People with mental illnesses and their families and health practitioners have access to needed treatment and case management resources across the continuum of care. Our main goals are: (a) to educate the community about mental illness to reduce stigma and increase resilience; (b) to expand treatment and case management options and access; and (c) to improve prevention for all residents and all mental health conditions. Interventions:1. Homeless/Street Medicine Outreach: Addresses the complex care of patients with high impact social determinants of health. A team of staff and volunteers bring healthcare to homeless individuals and families in the Ukiah area. Scheduled clinic referrals from Mendocino County Health Clinic and Rural Health Clinics are made to homeless shelters, medical respite units, social services, Project Sanctuary, Manzanita and Mendocino County Aids and Viral Hepatitis Network (MCAVHN). In addition, an RN case manager was placed in the Emergency Department (ED) and the EDie/PreManage software has been implemented in the ED to provide exchange of critical information, facilitate coordination of care and alignment with the plan of care across the continuum. Number of Community Members Served by the Outreach Team: 650. 2. LiveWell Programing - launched in 2017, the Live Well Program is focused on helping patients address their chronic disease using the tools of lifestyle change. A team including the patient works to determine specific health goals and map a plan including fitness training, nutrition counseling, behavioral health counseling, diabetes education, pain management and more. This program is open to all through self-referral or provider referral. Number of Community Members Served in the Live Well Clinic: 716.3. Vertical Change Platform: In 2018, the AHUV Street Medicine team began working with a program called Vertical Change. This health record program allows for care coordination across organizations for the purpose of expediting appropriate care. With grants from the Community Foundation, AHUV was able to create a platform to share Vertical Change with interested agencies within the Ukiah Valley. During 2018, 130 clients through the Health and Human Services Department's Whole Person Care Program were signed up in Vertical Care and plans have been made to extend the program to other interested agencies in May of 2019. Number of Community Members Served by the Vertical Change Platform: 130.4. Pharmacy for Street Medicine: Working with the AHUV Pharmacy staff, the Street Medicine Team was able to create a program where basic medicines were included in the team backpacks for use at community pop-up clinics. Medicines such as stool softener and antibiotics are now available to patients at the clinics reducing their need to access emergency departments. Number of Community Members Served in the Pharmacy for Street Medicine Program: 19.Priority Need 2 - Childhood obesity and family wellness: We strive for healthy, active children in healthy families and wide access to healthy food and safe recreational opportunities. Our main goals are: (a) to increase public awareness of relevant community programs and resources and (b) to change the health environment at workplace, recreation, and community meeting venues, offering access to healthy foods. While metrics for fifth grade students at a healthy or under-weight remained the same, Mendocino County saw an almost 1.5% increase in the number of seventh graders who were physically fit. This, along with a slight increase in metrics for ninth grade students at a healthy or under-weight indicates a shift in overall health among our youth.Interventions: 1. Healthy Mendocino: Family Wellness & Childhood Obesity Team. AHUV is an active member of the Family Wellness & Childhood Obesity Action team with the goal to help improve the quality of life in Mendocino County for children and families. AHUV has sponsored the Kids Triathlon Swimming, biking and running for all levels of fitness to help fight childhood obesity and encourage physical activity in Mendocino County. Number of Community Members Served: 300.2. Ukiah on Ice: Partnership with the City of Ukiah to host an open-air ice-skating rink downtown Ukiah. The rink was used by individual citizens, ice hockey teams and area schools for field trips. Number of Community Members Served: 2,000.3. Children's Health Fair: A free children's health fair with the goal to connect local families with community resources that have a positive impact on the lives of their children and families. A bilingual event, this health fair includes screenings for diabetes, vision, hearing, and an emphasis on healthy eating with interactive community partner booths. Number of Community Members Served: 300.4. Food with Friends: Making the most of summer bounty from the garden. Sharing easy and healthy recipes. Staying hydrated during the summer months. Number of Community Members Served: 200.5. Colors for Cancer Fun Run/Walk: A family fun event to educate and raise awareness of cancer benefiting the Focus on Healing program. Number of Community Members Served: 240.Priority Need 3 - Childhood trauma: All children need to grow up in stable and supportive families, and all families must have support in times of crisis. Our main goals are: (a) to educate community members and leaders about the impact of adverse childhood experiences; (b) to increase support for at-risk families, including parents struggling with substance abuse and (c) to develop and promote local policies that strive to prevent childhood trauma. Based on statistics from the University of California at Berkeley our total population of children in child welfare programs did not change although, as would be expected the age ratios changed. Most pronounced was the increase of under one-year old's from 11 to 20. Interventions:1. Community Christmas: AHUV hosts a Christmas dinner and party for identified families who otherwise would not have the means to provide for their children and those in their care. Number of Community Members Served: 21.2. Dream It Be It: A free program hosted by Soroptimist International of Ukiah in partnership with AHUV and other community partners to provide a day-long workshop for at-risk teen girls focused on empowerment and career readiness. Number of Community Members Served: 60.3. Health Careers Exploration Summer Institute: A program designed to promote the advancement of health care workforce through quality education and service. AHUV partnered with Ukiah Unified School District to introduce local high school students to a career in the health care field. Students participated in a three-week course to observe the roles and responsibilities, scope of practice and educational requirement of 10 different hospital rotations. Number of Community Members Served: 10.Priority Areas Not Addressed:All needs were met from our CHNA.Adventist Health recognized the health needs of our community that may not be part of the CHNA. Interventions to address those needs include:1. Focus on Healing programing is a community service provided to any community member going through the cancer experience by bringing healing arts and support for healing through animal assisted therapy available to patients, staff, visitors and the public with stress reduction and Caring/Ceres Kitchen which provides nutritious meals to cancer patients and families by providing food prepared by students and volunteers. Total number of community members served: 1,361.2. Diabetes Education. Monthly classes in English and Spanish are open to anyone in the community that has been diagnosed with diabetes. Family members and support members are welcome to join and learn how to manage their diabetes and stay healthy. Education and free screenings are a major component of the interventions. Number of community members served: 1,765.3. Organ Donation Registry. The creation of an AHUV campaign to partner with local high school and community organizations to build the organ donor bank for organ, eye and tissue donations. Number of community members served: 830. 27 1 - Advanced Wound Center 415 Hospital Drive Ukiah CA 95482 Wound care center 2 - Ukiah Adventist Health Pavilion Surgica 245 Hospital Drive Suite 100 Ukiah CA 95482 Radiology 3 - Ukiah Adventist Hospital - Outpatient Pa 245 Hospital Drive Ukiah CA 95482 Outpatient surgery 4 - Ukiah Valley Pain Management Clinic 260 Hospital Drive Suite 107 Ukiah CA 95482 Rural health clinic 5 - Outpatient Physician Services-Dora-ENT 1165 S Dora Street Suite C-2 Ukiah CA 95482 Hospital-based outpatient clinic 6 - Lakeport Cardiology 475 N Forbes Street Lakeport CA 95453 Hospital-based outpatient clinic 7 - Ukiah Valley Cardiology Clinic 115 Hospital Drive Ukiah CA 95482 Cardiology 8 - Ukiah Valley Internal MedicineAllergy C 260 Hospital Drive Suite 103 Ukiah CA 95482 Rural health clinic 9 - Outpatient Physician Services 246 Hospital Drive Suite 248-B Ukiah CA 95482 Ophthalmology 10 - Rehabilitation Clinic 271 Observatory Avenue Ukiah CA 95482 Physical and speech therapies 11 - Lakeport Internal Medicine 487 S Main Street Lakeport CA 95453 Rural health clinic 12 - Fort Bragg Family Practice Center 850 Sequoia Circle Fort Bragg CA 95437 Rural health clinic 13 - Ukiah Adventist Hospital - Job Care 232 B Hospital Drive Ukiah CA 95482 Job care 14 - The Cancer Treatment & Infusion Center 260 Hospital Drive Suite 207 Ukiah CA 95482 Rural health clinic 15 - Gastroenterology Clinic 234 Hospital Drive Suite A B Ukiah CA 95482 HBOIC-GI 16 - Ukiah Valley General Surgery 246 Hospital Drive Ukiah CA 95482 Hospital-based outpatient clinic 17 - Phlebotomy Draw Station 260 Hospital Drive Suite 109 Ukiah CA 95482 Laboratory draw station 18 - Ukiah Valley Urology Clinic 260 Hospital Drive Suite 201 Ukiah CA 95482 Rural health clinic 19 - Physical Therapy at Redwood Health Club 3101 S State Street Ukiah CA 95453 Physical therapy 20 - Ukiah Valley Rural Health 1050 N State Street Ukiah CA 95482 Rural health clinic 21 - Ukiah Valley Rural Health Center-Dora-Op 1165 S Dora Street Suite B-1 Ukiah CA 95482 Hospital-based outpatient clinic 22 - Ukiah Valley Rural Health Center Lakepor 487 S Main Street Lakeport CA 95453 Rural health clinic 23 - Mendocino Radiology 1165 S Dora Street Suite D Ukiah CA 95482 Radiology 24 - Ukiah Valley Rural Health Center 260 Hospital Drive Suite 102 Ukiah CA 95482 Pain management 25 - Ukiah Valley Behavioral Health Clinic 260 Hospital Drive Suite 101 Ukiah CA 95482 Rural health clinic 26 - Rapid Care at Ukiah Valley Rural Health 260 Hospital Drive Suite 204 Ukiah CA 95482 Pediatric care 27 - Rapid Care at Ukiah Rural Health Center 260 Hospital Drive Suite 209 Ukiah CA 95482 Family practice Part I, Line 7: The costs were determined by using a cost-to-charge ratio. The cost-to-charge computation is based on Hospital specific data included in the system-wide combined audited financial statements. The formula used for computation equals financial statement data as follows:Total expenses - (Provision for bad debts + Other revenue + Interest income)/Gross patient chargesUkiah Valley Medical Center is located in a medically underserved area and participates in a quality assurance fee program with the State of California to fund certain Medi-Cal coverage expansions. The state redistributes funds to hospitals that provide patient care to a higher proportion of indigent and medically underprivileged patients, who otherwise would most likely not have access to physicians and other medical services. The community benefit analysis includes receipts from this redistribution that are used to assist in partially offsetting the significant costs associated with providing patient care to this population group. The program may or may not continue in the future based on the State of California's regulations and policies and the approval of the federal government. Part II, Community Building Activities: The Hospital is involved in numerous community building activities which promote the health of the communities it serves. Numerous community concerns are addressed, including health improvement, education, poverty, workforce development and access to care. We also encourage our employees to serve on community collaboration boards, health advocacy programs, and physical improvement projects to promote the health of the communities we serve. In addition, we work with neighborhood programs, including schools, work sites and safety net providers to promote health and wellness and prevent disease. These activities are not included elsewhere on Schedule H. Part III, Line 2: Uncollected patient accounts are analyzed using written patient financial services policies that apply standard procedures for all patient accounts. The result of the analysis is what is recognized as bad debt expense. For example, all self-pay patients receive a discount. If the discounted account is unpaid after collection efforts, the unpaid balance is classified as bad debt. The cost-to-charge ratio described for Part I, Line 7 is multiplied times the Hospital's bad debt expense. The resulting figure has been reported as bad debts at cost on Part III, Line 2. Part III, Line 3: The portion of the bad debts attributed to charity care as reported on Part III, Line 3 was calculated by an independent third-party consulting firm. This is an estimate of additional charity care that would have been granted if patients had cooperated by furnishing family financial information. A statistically valid sampling of patient accounts written-off was evaluated. The evaluation used various factors to determine which patients would have been eligible for charity care. Had the Hospital obtained sufficient information from all patients who qualified for financial assistance, these additional accounts would have been recorded as charity care instead of bad debt. Part III, Line 4: The system-wide audited combined financial statements do not contain a footnote describing bad debt expense. Part III, Line 8: The Medicare cost report apportions the hospital's costs on the basis of inpatient days and ancillary and outpatient charges to establish the costing methodology. Healthcare delivery by hospitals is a complex, highly regulated business in the United States. Healthcare unit cost inflation is driven by compliance with ever-expanding regulatory requirements, shortages of highly skilled labor and evolving medical and information technology. The health care "market basket" is unrelated to that of the average individual consumer.Since the 1997 Balanced Budget Act, Medicare annual payment updates have fallen behind actual healthcare cost inflation to the point that Medicare payments to many U.S. hospitals are well below the cost of providing care. These unreimbursed costs are a community benefit for seniors and others in the community as these individuals are continuing to receive care without which many would become dependent on other governmental resources such as Medicaid. The benefit to the community for healthier Medicare recipients is no different than those benefits the community realizes for uninsured and underinsured patients who are eligible for partial and full charity care. Medicare is a safety net for seniors and others. Without Medicare coverage, many individuals would undoubtedly qualify for charity care.In addition to the mismatch between Medicare payment increases and healthcare cost inflation, the highly complex Medicare payment systems and formulas produce disparate payment levels from one hospital to another for the same service. These disparate payment levels create disparate results within groups of hospitals.Reconciliation of Medicare Revenue from the Hospital's Medicare Cost Report to GL: Revenue Rec. *Medicare Cost Report Revenue 46,797,652Prior Year Settlements 1,096,495Cost Report Reimbursable Bad Debts 673,604Estimates and Accrual Variances (147,822)Other 4,667,806 Total Medicare Revenue 53,087,735*Note: The Medicare Cost Report revenue does not include the bad debt reimbursement. The Cost Report revenue does include the patient co-pay and deductible amounts. Adding the bad debt reimbursement would have duplicated the revenue already accounted for in the co-pay and deductible amounts. Part III, Line 9b: When a patient has requested screening for charity care, the Hospital must immediately cease collection activity and place the account in a charity pending status. If 100% charity is approved, the entire account balance is written off to charity care. If the patient has a sliding scale liability based on the federal poverty guidelines, they are billed only for that liability. If the patient fails to pay their after-charity liability, they are assigned to a collection agency with an identifier that indicates to the agency that the patient is "low income and the following criteria must be followed by the agency:1. They may not report the patient to a credit bureau2. They may not file a lawsuit to recover the outstanding liability3. They may not charge interest Part III - Other Community Benefit: Adventist Health recognized the health needs of our community that may not be part of the CHNA. Interventions to address those needs include:1. Focus on Healing programing is a community service provided to any community member going through the cancer experience by bringing healing arts and support for healing through animal assisted therapy available to patients, staff, visitors and the public with stress reduction, Caring/Ceres Kitchen provides nutritious meals to cancer patients and families by providing food prepared by students and volunteers and Pet therapy is available at no cost to assist patients, staff, visitors and public with stress reduction and healing. Total number of community members served: 1,073.2. Diabetes Education. Monthly classes in English and Spanish are open to anyone in the community that has been diagnosed with diabetes. Family members and support members are welcome to join and learn how to manage their diabetes and stay healthy. Education and free screenings are a major component of the interventions. Number of community members served: 509.3. Smoking Cessation Classes are no cost for community members based on the American Lung Association guidelines. Number of community members served is 37. Part VI, Line 2: The Hospital's 2016 CHNA, the 2019 Community Health Plan (CHP) Update for fiscal year 2018, the 2018 Community Health Plan (CHP) Update for fiscal year 2017, and the 2016 Implementation Strategy (adopted in May 2017), that includes the 2016 CHP, are posted on the Hospital's website at: https://www.adventisthealth.org/about-us/community-benefit/ The CHNA, Implementation Strategy and the CHPs are also available on the Adventist Health Corporate website at:https://www.adventisthealth.org/about-us/community-benefit/https://www.adventisthealth.org/Pages/About-Us/Community-Health-Needs-Assessments.aspxHospital leadership serves on a variety of community boards and committees focused on addressing community-specific needs, allowing for ongoing responsiveness to the health care needs of the community and collaboration with local agencies and organizations, enabling maximum effectiveness through collective impact. Committee/Board Participation includes: Cancer Resource Centers of Mendocino County, Chronic Disease Self-Management, Community Foundation of Mendocino County, FIRST5 Mendocino, Ford Street Project, Healthy Mendocino and HHSA Advisory Board, Mendocino County AIDS/Viral Hepatitis Network, Potter Valley Youth and Community Center, Redwood Children Services, and Ukiah Valley Trails Group. Part VI, Line 3: The plain language summary of the Financial Assistance Policy (FAP) is posted along with the complete FAP policy and FAP Application on the Hospital's website at: https://www.adventisthealth.org/ukiah-valley/patient-resources/financial-services/financial-assistance/These documents are available in multiple languages. At the time of registration, patients who are uninsured and underinsured are provided information about government healthcare programs. Patients are also orally informed of their right to request charity assistance. Signs are displayed in the patient business office, patient registration areas and the emergency room in multiple languages informing patients of this right as well. The Hospital also provides a brochure during the registration process that explains the hospital billing and collection procedures, and how to request financial assistance. In addition, every billing statement sent to patients contains information on how to request financial assistance. Part VI, Line 4: The Hospital is situated in the city of Ukiah, the county seat and largest city of Mendocino County, with a population of approximately 16,000. The hospital's primary service area, however, consists of nearly the entire rural county, which spans over 3,500 square miles. Small, geographically isolated communities make up a large part of the county's nearly 88,000 residents. The county is predominately agricultural and tourist based and is known for several unique features including the beauty of the northern California coastal terrain and a favorable climate. The Hospital serves a very high percentage of Medicare and Medicaid patients compared to otherhospitals across the country. A very large transient population is also present in Ukiah and surrounding areas. In 2014, the county's population was 66% White, 24% Hispanic/Latino, 6% Native American, 2% Asian, and 1% African American. It is expected that between 2010 and 2060, the Hispanic/Latino population will increase to 37% of the county population, while Whites will decrease from to 48% of the county population.Mendocino County experiences significant housing issues, including a lack of affordable housing, overcrowding, and homelessness. The County Health Rankings estimate that about 28% of the county population lives in substandard housing, or in crowded conditions. In addition, over one-half of Mendocino County residents who rent (52%) pay more than a third (35%) of their total income for rent. Part VI, Line 5: Our Hospital's mission is, "Living God's love by inspiring health, wholeness and hope." Our community benefit work is rooted deep within our mission and merely an extension of our mission and service. We have also incorporated our community benefit work to be an integral component of improving the "Triple Aim." The "Triple Aim" concept broadly known and accepted within health care includes:1) Improve the experience of care for our residents.2) Improve the health of populations.3) Reduce the per capita costs of health care.Our strategic investments in our community are focused on a more planned, proactive approach to community health. The basic issue of good stewardship is making optimal use of limited charitable funds. Defaulting to charity care in our emergency rooms for the most vulnerable is not consistent with our mission. An upstream and more proactive and strategic allocation of resources enables us to help low income populations avoid preventable pain and suffering; in turn allowing the reallocation of funds to serve an increasing number of people experiencing health disparities. Hospitals and health systems are facing continuous challenges during this historic shift in our health system. Given today's state of health, where cost and heartache is soaring, now more than ever, we believe we can do something to change this. These challenges include a paradigm shift in how hospitals and health systems are positioning themselves and their strategies for success in a new payment environment. This will impact everyone in a community and will require shared responsibility among all stakeholders.As hospitals move toward population health management, community health interventions are a key element in achieving the overall goals of reducing the overall cost of health care, improving the health of the population, and improving access to affordable health services for the community both in outpatient and community settings. The key factor in improving quality and efficiency of the care hospitals provide is to include the larger community they serve as a part of their overall strategy.Population health is not just the overall health of a population, but also includes the distribution of health. Overall health could be quite high if the majority of the population is relatively healthy even though a minority of the population is much less healthy. Ideally such differences would be eliminated or at least substantially reduced.Community health can serve as a strategic platform to improve the health outcomes of a defined group of people, concentrating on three correlated stages:1) The distribution of specific health statuses and outcomes within a population;2) Factors that cause the present outcomes distribution; and3) Interventions that may modify the factors to improve health outcomes.Improving population health requires effective initiatives to:1) Increase the prevalence of evidence-based preventive health services and preventive health behaviors,2) Improve care quality and patient safety, and3) Advance care coordination across the health care continuum.We will work together with our community to ensure the community health improvements are identified and then targeted for programs to influence behaviors to obtain improved health within the whole community. Part VI, Line 6: The Hospital is a member of Adventist Health, a health care system which provides healthcare services in diverse markets within the Western United States. A member hospital may share some services with other member hospitals in its geographic area, such as clinical, management and support services. Using today's technology, hospitals outside the geographic area are able to provide support through remote services such as telepharmacy and robotics surgery. The Corporate Office provides important shared administrative support for member hospitals' rural health clinics and home care agencies, quality of care, other clinical needs, financing and risk management, and shared clinical and financial information technology. As many experienced and new physicians search for alternatives to independent practice, there is also corporate administrative support for hospital affiliated medical groups that engage physicians through employment or other contracts. This provides stability and growth of qualified physicians across many specialties, which is very important to make healthcare services available and to maintain and improve health within the communities served by all member hospitals. Part VI, Line 7, Reports Filed With States CA 1 Alex Rorabaugh Recreation Center 1640 S State Street Ukiah CA 95482 943273691 Gov't 7500 ARRC Event Sponsorship CA Health Fund & Trust 1215 K Street Suite 800 Sacramento CA 95814 941498697 501(c)(3) 324831 Public health grant: Health services un/underinsured patients City of Ukiah 411 Clay Street Ukiah CA 95482 946000446 Gov't 25300 Sponsorship for Ukiah on Ice & Kids Triathalon Mendocino College Foundation 1000 Hensley Ukiah CA 95482 680040876 501(c)(3) 51750 Nursing Program Mendocino County AIDS Volunteer Network PO Box 1350 Ukiah CA 95482 680159027 501(c)(3) 7000 MCAVHN Event of the Heart 2018 Mendocino County Office of Education PO Box 45 Redwood Valley CA 95470 946002711 Gov't 10400 Outdoor Education Project, and Snack program North Coast Opportunities 413 N State Street Ukiah CA 95482 941671958 501(c)(3) 10000 Ukiah Symphony 2018, and Caring Kitchen Ukiah Senior Center 497 Leslie Street Ukiah CA 95482 237258082 501(c)(3) 5000 Senior Center Ride Program Donation 8 0 Part I, Line 2: Charitable support and assistance is provided with no reporting required by recipient. X X X X 1 1 0 0 0 0 0 0 0 Reiner Scott Dir/Chair 0 1339257 0 747881 0 371298 0 16682 0 27790 0 2502908 0 289242 Rippey Wesley Director thru 05/2018 0 565539 0 0 0 58404 0 20249 0 27319 0 671511 0 0 Wing Bill Dir/Vice Chair/Asst Secr 0 1015353 0 603273 0 256685 0 16682 0 32633 0 1924626 0 191758 Jobe Meredith Secretary 0 419684 0 111013 0 135918 0 16682 0 21646 0 704943 0 59224 Matthews Gwen President 0 378556 0 149560 0 146745 0 0 0 16539 0 691400 0 0 Quattlebaum Ryan Treasurer 0 187962 0 27982 0 21568 0 8891 0 25089 0 271492 0 0 Wagner Jack Asst Secr thru 03/2018 0 180671 0 414342 0 737895 0 11182 0 22894 0 1366984 0 0 Byrnes John Medical Officer, NCR 0 346875 0 25000 0 129394 0 0 0 14905 0 516174 0 0 Eller Jeff President, NCR 0 699892 0 344777 0 131881 0 16682 0 21445 0 1214677 0 118827 Lang Kevin Finance Officer, NCR 0 563108 0 0 0 0 0 0 0 0 0 563108 0 0 Lonto Robert VP HR, NCR 0 254747 0 60037 0 44564 0 16682 0 29874 0 405904 0 0 Ploss David Medical Director 0 392592 0 7100 0 118800 0 20882 0 3540 0 542914 0 0 Reppert Joseph CFO, NCR 0 686470 0 152446 0 114699 0 16682 0 30164 0 1000461 0 0 Van Housen Heather Patient Care Exec 0 221606 0 44090 0 44085 0 0 0 66 0 309847 0 0 Weis David VP Operations 0 158965 0 40082 0 49147 0 13054 0 31867 0 293115 0 0 Bartolomie Jill Director, RN 168571 0 7963 0 2792 0 9875 0 12438 0 201639 0 0 0 Kilkenny Martha Nurse Practitioner 182343 0 0 0 153 0 8938 0 9497 0 200931 0 0 0 Petersen Lisa RN, Nurse lead 272828 0 0 0 9046 0 16682 0 14193 0 312749 0 0 0 Rehm Donna RN 227166 0 0 0 7612 0 13939 0 26107 0 274824 0 0 0 Spencer Lindsey Patient Care Exec 24375 0 0 0 196591 0 12081 0 28052 0 261099 0 0 0 McDonald Edward Former Treas/Asst Secr 0 21099 0 0 0 317203 0 1047 0 19647 0 358996 0 0 Poole Aaron Former Treas/Asst Secr 0 261059 0 27658 0 38447 0 16682 0 24674 0 368520 0 0 Part I, Lines 4a-b Severance payments are made based upon agreements between certain qualifying employees and Adventist Health Services/West. Details of the terms and conditions of the severance agreements are available to the IRS upon request. McDonald, Edward - severance payment - $302,307 Wagner, Jack - severance payment - $598,810 The Supplemental Executive Retirement Plan (SERP) is a defined contribution plan designed to encourage the participants continued employment with Adventist Health and is subject to the participants satisfying specified substantial risks of forfeiture. The SERP benefit distribution occurs when the executive achieves 30 years of Adventist health care service, 20 of which are to be as an executive and at least 10 are to be with Adventist Health System/West, and reaches age 60. Until that time, the SERP benefit is at risk to the creditors of Adventist Health. The SERP benefit is designed to help the executive receive employer-provided retirement benefit income equal to 60% of pre-retirement income. A flexible benefits plan (CAA) is offered to groups of highly-compensated employees meeting certain criteria. The participants are provided with an amount equivalent to 41 percent of their base compensation, less the value of their corporate provided benefits. The balance is set aside for nonvested deferred compensation that is subject to substantial risk of forfeiture and is at risk to the creditors of Adventist Health. Payouts occur according to the participants' payment elections after all substantial risks of forfeiture have lapsed. Eller, Jeff - $118,827 Jobe, Meredith - $59,224 Reiner, Scott - $289,242 Wing, Bill - $191,758 Form 990, Part III, Line 4a Ukiah Adventist Hospital (AHUV) provides quality medical health care regardless of race, creed, sex, national origin, handicap, age, or ability to pay. Although reimbursement for services rendered is critical to the operation and stability to AHUV, the Hospital recognizes that not all individuals possess the ability to pay for essential medical services. Adventist Health's vision is to enhance the health of the communities where we live and serve, by engaging our communities and our patients in a new definition of and partnership for personal community health. In keeping with this commitment to serve all members of the community, the following will be considered when individuals who need health care cannot pay: - providing free care and/or subsidized care - providing care to persons covered by governmental programs at below cost - providing health/wellness activities and community education programs Not only does AHUV provide low cost care to individuals covered by government-programs and those unable to afford healthcare, it also helps patients find and access private and governmental resources for healthcare benefits. AHUV recognizes below-cost reimbursement as charity and uncompensated care in meeting its mission to the entire community. The unreimbursed cost of providing care to these patients in 2018 was $2,760,233. The following Inpatient services that were provided to all our patients. These services included: - 724 Babies delivered - 652 Surgeries performed - 11,929 Patient days The following Outpatient services that were provided to all our patients. These services included: - 29,784 Emergency department visits - 3,293 Outpatient surgeries performed - 103,637 Outpatient visits - 127,077 Clinic visits AHUV recognizes it has an obligation to provide human services above and beyond its role as a healing facility. The following community benefits demonstrate the tangible ways in which the organization is fulfilling its mission. The total unreimbursed cost of these community benefits in 2018 was $5,005,033. Adventist Health's mission statement of Living God's love by inspiring health, wholeness and hope is coupled with a vision to transform the health experience of our communities through collaborative programs, community investments and community outreach. We are inspired by the healing ministry as represented by the life of Jesus Christ and believe we are called to live out our mission intentionally in the communities we serve. In the small towns, suburbs and inner cities we serve, we continue our journey to provide quality healthcare until every person made in God's image has experienced the best health today, hope for tomorrow, and God's love that endures forever. Websites for our community benefit information: https://www.adventisthealth.org/about-us/community-benefit/ Form 990, Part VI, Section A, line 6 The Hospital is organized as a public benefit corporation and operates as a not-for-profit hospital. The sole corporate member is Adventist Health System/West, a California not-for-profit public benefit corporation that operates as a public charity. The Hospital operates as an affiliate of Adventist Health System/West. Form 990, Part VI, Section A, line 7a The Hospital Bylaws define its Board of Directors to be the same individuals who are members of the Adventist Health System/West Board of Directors. Form 990, Part VI, Section A, line 7b The sole corporate member, Adventist Health System/West, must approve all changes to the Articles of Incorporation and Bylaws. Form 990, Part VI, Section B, line 11b This Form 990 including all supporting schedules was prepared by a public accounting firm, reviewed by the System Controller and Market Finance Officer, and shared by electronic communication with the Hospital's Board of Directors prior to filing. Form 990, Part VI, Section B, line 12c During the first quarter of each year, the annual conflict of interest questionnaire is sent to board members, hospital officers, key employees and department directors for completion and signature. The questionnaire is accompanied by a letter of explanation, to illustrate examples of a conflict and to remind the recipient that if any perceived conflict should arise before the next annual questionnaire, he/she is to notify the CEO immediately. The Corporate General Counsel distributes, collects, and reviews for signatures the COIs for all applicable Corporate employees and the board. In addition, the hospital's administration is responsible for keeping record to ensure all hospital-based individuals with director and above positions have submitted their COIs. The Corporate General Counsel reviews all the disclosures on the board and Corporate employees' COIs. Corporate General Counsel retains the COIs for the board members. The officers and key employees' COIs are kept in their personnel files. Further inquiries on any potential significant conflicts are made as needed. Conflicts are documented and reviewed with the Board. Form 990, Part VI, Section B, line 15 The Hospital Board of Directors has established a Compensation Committee to oversee the executive compensation program. This committee is composed of independent directors with no conflicts of interest. The committee performs the following functions: recommends a total compensation philosophy to the board; assures compliance with the board-approved philosophy; meets annually to review comparability data from outside consultants; recommends any adjustments to current executive compensation, including salary ranges for hospital CEOs and CFOs, that would be indicated by the data; evaluates executive performance against annual goals; recommends appropriate incentive awards to the board for approval; follows a diligent process that meets regulatory requirements for a rebuttable presumption of reasonableness; records committee deliberations and decisions in timely minutes; selects, engages and supervises any consultant hired to advise and provide comparability data. The board-approved executive compensation philosophy specifies that salary ranges will be established for hospital CEOs and executives, with midpoints aligned with the 50th percentile of comparable system hospital data, and having a 50 percent spread from minimum to maximum. A hospital CEO has a maximum potential incentive of 30 or 35 percent of base salary based upon size and scope of hospital. (Incentive potential is industry norm) Other hospital executives have a maximum potential incentive of 25 to 30 percent of base salary. Form 990, Part VI, Section C, line 19 The Hospital does not make its governing documents publicly available, beyond required filings of Articles of Incorporation with the Secretary of State. The Hospital does not make its Conflict of Interest Policy available upon request, but does file monthly/quarterly summary financial reports with the state health-planning agency. Form 990, Part VII: In recognition of the time commitment directors make to serve on the Adventist Health System/West boards and committees, directors receive compensation when their employment agreements with their employers allow such payments. For those whose employers do not allow accepting compensation for board service, the funds are directly distributed to charitable organizations as mandated by their employment agreements. In addition, amounts paid for taxable benefits are also reported. Form 990, Part IX, line 11g Physician professional fees: Program service expenses 26,867,630. Management and general expenses 141,810. Fundraising expenses 0. Total expenses 27,009,440. Other medical professional fees: Program service expenses 4,440. Management and general expenses 24,347. Fundraising expenses 0. Total expenses 28,787. Consulting and other management fees: Program service expenses 243,902. Management and general expenses 382,188. Fundraising expenses 0. Total expenses 626,090. Other professional fees non-medical: Program service expenses 23,814. Management and general expenses 51,225. Fundraising expenses 0. Total expenses 75,039. Contract labor: Program service expenses 2,494,173. Management and general expenses 34,972. Fundraising expenses 0. Total expenses 2,529,145. Purchased medical services: Program service expenses 22,019,956. Management and general expenses 0. Fundraising expenses 0. Total expenses 22,019,956. Repairs and maintenance: Program service expenses 1,068,940. Management and general expenses 110,259. Fundraising expenses 0. Total expenses 1,179,199. All other purchased services: Program service expenses 4,850,644. Management and general expenses 799,456. Fundraising expenses 105,141. Total expenses 5,755,241. Revenue cycle fees: Program service expenses -11,633. Management and general expenses 6,868,886. Fundraising expenses 0. Total expenses 6,857,253. Adventist Health Clearlake Hospital Inc 15630 18th Avenue Clearlake CA 95422 680395149 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Adventist Health Medical Center Tehachapi 1100 Magellan Drive Tehachapi CA 93561 812240617 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Adventist Health Physicians Network PO Box 619135 Roseville CA 95661 680357690 Medical foundation CA 501(c)(3) Line 12b, II Adventist Health SystemWest 0 Adventist Health SystemWest PO Box 619135 Roseville CA 95661 953484589 Integrated health system CA 501(c)(3) Line 10 N/A 0 Castle Medical Center 640 Ulukahiki Street Kailua HI 96734 990107330 Hospital HI 501(c)(3) Line 3 Adventist Health SystemWest 0 Feather River Hospital PO Box 619135 Roseville CA 95661 941101228 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Fremont-Rideout Health Group 989 Plumas Street Yuba City CA 95991 942917251 Acute care hospital CA 501(c)(3) Line 12b, II Stone Point Health 0 Glendale Adventist Medical Center 1509 Wilson Terrace Glendale CA 91206 951816017 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Hanford Community Hospital 115 Mall Drive Hanford CA 93230 940535360 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Lodi Memorial Hospital Association Inc 975 S Fairmont Avenue Lodi CA 95240 941044474 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Northwest Medical Foundation of Tillamook 1000 Third Street Tillamook OR 97141 930622075 Hospital OR 501(c)(3) Line 3 Adventist Health SystemWest 0 Paradise Valley Hospital PO Box 619135 Roseville CA 95661 951816034 Discontinued operations CA 501(c)(3) Line 1 Adventist Health SystemWest 0 Portland Adventist Medical Center 10123 SE Market Street Portland OR 97216 930429015 Hospital OR 501(c)(3) Line 3 Adventist Health SystemWest 0 Reedley Community Hospital 372 Cypress Avenue Reedley CA 93654 453220509 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Rideout Memorial Hospital 989 Plumas Street Yuba City CA 95991 941387866 Acute care hospital CA 501(c)(3) Line 3 Fremont-Rideout Health Group 0 St Helena Hospital 10 Woodland Road St Helena CA 94574 941279779 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 San Joaquin Community Hospital 2615 Chester Avenue Bakersfield CA 93301 952294234 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Simi Valley Hospital & Health Care Services 2975 N Sycamore Drive Simi Valley CA 93065 956064971 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Sonora Community Hospital 1000 Greenley Road Sonora CA 95370 941415069 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Stone Point Health PO Box 619135 Roseville CA 95661 823763347 Supporting organization CA 501(c)(3) Line 12b, II Adventist Health SystemWest 0 United Com-Serve 989 Plumas Street Yuba City CA 95991 943015356 Skilled nursing/assisted living/home health CA 501(c)(3) Line 12b, II Fremont-Rideout Health Group 0 Walla Walla General Hospital PO Box 619135 Roseville CA 95661 910617726 Hospital - closed July 2017 WA 501(c)(3) Line 3 Adventist Health SystemWest 0 Western Health Resources PO Box 619135 Roseville CA 95661 953867863 Home care CA 501(c)(3) Line 10 Adventist Health SystemWest 0 White Memorial Medical Center 1720 Cesar E Chavez Avenue Los Angeles CA 90033 952282647 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Willits Hospital Inc 1 Marcela Drive Willits CA 95490 680108919 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 South Coast Medical Center PO Box 619135 Roseville CA 95661 952037291 Wind down after sale of hospital CA N/A C 0 0 0 1 0 1 0 0 0 0 0 0 1 1 0 1 1 1 0 0