2018-05-15T12:35:20-05:00 2017-06-30 930623286 ALDRICH CPAS AND ADVISORS LLP 5665 SW MEADOWS RD SUITE 200 LAKE OSWEGO OR 97035 990 2016-07-01 431960221 SALEM HEALTH WEST VALLEY SALE 5038141938 525 SOUTHEAST WASHINGTON ST DALLAS OR 97338 JAMES PARR CHIEF FINANCIAL OFFICER 5038141938 2018-05-08 1 JOYLYN M ANKENEY CPA P00366587 5036204489 2018-04-30 69.30.50.66 2018-05-08 08:44:03 PD P 8DEF7001EF646B25FB6D4B1C1546779B4D96824C DB5FA997F7011B499C38FB840EA7688578FDB970 2016 2021-01-29 14:40:06Z JAMES PARR 525 SOUTHEAST WASHINGTON ST DALLAS OR 97338 30059050 0 X WWW.SALEMHEALTH.ORG X 2002 OR WE STRIVE TO IMPROVE THE HEALTH AND WELL BEING OF THE PEOPLE AND COMMUNITY WE SERVE. 11 9 205 24 37625 18761 20515 100432 22060474 29956551 965 -25706 0 0 22081954 30031277 0 15000 0 0 10432993 14826949 0 0 0 8662218 12266351 19095211 27108300 2986743 2922977 18155305 21433845 3560774 3843842 14594531 17590003 X TO IMPROVE THE HEALTH AND WELL BEING OF THE PEOPLE IN THE COMMUNITIES WE SERVE. 0 0 12830254 24246695 SALEM HEALTH WEST VALLEY IS A CRITICAL ACCESS HOSPITAL SERVING THE RURAL POLK COUNTY REGION WITH A POPULATION OF 98,000. SERVICES INCLUDE: DIAGNOSTIC IMAGING PROCEDURES 19,274, EMERGENCY DEPARTMENT VISITS 14,742, INPATIENT ADMISSIONS 137, LABORATORY TESTS/DRAWS 125,901, SURGERIES 720. 6942640 4844757 SALEM HEALTH WEST VALLEY PROVIDES HEALTHCARE TO PEOPLE IN OUR COMMUNITY REGARDLESS OF THEIR ABILITY TO PAY. IN THE 12 MONTHS ENDED 6/30/17, THE COST OF SERVICES PROVIDED AS A COMMUNITY BENEFIT TOTALED $2,097,883. THIS FIGURE CONSISTED OF $388,577 IN COSTS TO PROVIDE CHARITY CARE TO INDIVIDUALS WHO CANNOT AFFORD TO PAY AND $1,709,306 IN UNDERPAYMENT BY MEDICAID AS THE AMOUNT PAID UNDER THE PROGRAM WAS LESS THAN THE COST TO PROVIDE THE SERVICES. SALEM HEALTH WEST VALLEY DOES NOT PURSUE LEGAL ACTION FOR NON-PAYMENT OF BILLS AGAINST CHARITY CARE PATIENTS WHO HAVE DEMONSTRATED THAT THEY HAVE NEITHER SUFFICIENT INCOME NOR ASSETS TO MEET THEIR FINANCIAL OBLIGATIONS. 2055264 15000 827474 SALEM HEALTH WEST VALLEY ACTIVELY PARTICIPATES IN COMMUNITY HEALTH IMPROVEMENT SERVICES. IN THE 12 MONTHS ENDED 6/30/17, SALEM HEALTH WEST VALLEY GAVE $186,557 FOR UNFUNDED OR UNDERFUNDED HEALTH SERVICES, INCLUDING IMPROVING ACCESS TO CARE THROUGH PHYSICIAN RECRUITING, COMMUNITY HEALTH EDUCATION AND PREVENTION PROGRAMS. THE HOSPITAL HAS AN ACTIVE SPEAKERS BUREAU PROVIDING FREE HEALTH LECTURES TO COMMUNITY GROUPS. HEALTH SCREENINGS, SUPPORT GROUPS AND EDUCATION CLASSES ARE OFFERED ON AN ON-GOING BASIS. SALEM HEALTH WEST VALLEY SUBSIDIZES THE COST OF PROVIDING SERVICES TO THE COMMUNITY AT A FINANCIAL LOSS IN THE AMOUNT OF OVER $1,018,795. SALEM HEALTH WEST VALLEY PROVIDES CASH AND IN-KIND DONATIONS TO COMMUNITY PROGRAMS, THE LARGEST OF WHICH IS THE CONNECTIONS VAN WHICH PROVIDES TRANSPORTATION SERVICES TO PATIENTS NEEDING MEDICAL SERVICES. 21828158 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 31 0 1 205 1 1 1 0 0 0 0 0 0 0 0 0 X 11 9 0 0 1 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OR X X SALEM HEALTH 5038141938 890 OAK STREET SE SALEM OR 97301 BONNIE DRIGGERS RN CHAIRPERSON 5.00 X X 0 0 0 KATHERINE KEENE VICE CHAIR 4.25 X X 0 0 0 ALAN K WYNN SECRETARY/TREASURER 5.25 X X 0 0 0 JOHN COMBES MD TRUSTEE 5.25 X 0 0 0 THERESA HASKINS TRUSTEE 3.50 X 0 0 0 ROB KELLY MD TRUSTEE 5.00 X 0 0 0 JOHN LATTIMER TRUSTEE 5.00 X 0 0 0 KENNETH SHERMAN JR TRUSTEE 7.00 X 0 0 0 NANCY REYES-MOLYNEUX MD TRUSTEE 5.25 X 0 0 0 LANE SHETTERLY TRUSTEE 7.00 X 0 0 0 ROBERT WELLS PAST CHAIRMAN 5.25 X 0 0 0 CHERYL NESTER WOLFE CEO & PRESIDENT 6.00 34.00 X 0 730298 72614 JAMES PARR CHIEF FINANCIAL OFFICER 3.00 37.00 X 0 439053 81331 BRUCE RODGERS CHIEF ADMIN OFFICER 40.00 X 203140 0 48383 JENNIFER BROADUS DIR, WV CLINICAL OPERATIONS 40.00 X 154284 0 25081 ALISON SMITH MD GENERAL SURGEON 40.00 X 430772 0 53362 CHARLES ESSEX MD FAMILY PRACTITIONER 40.00 X 279529 0 61251 JOHN HADLEY MD FAMILY PRACTITIONER 40.00 X 268843 0 53192 CELIA WALLIS RN BSN STAFF NURSE 36.00 X 146523 0 35807 TIFFANY DUELL PHARMACIST 40.00 X 140273 0 33123 1623364 1169351 464144 25 0 1 0 SALEM RADIOLOGY CONSULTANTS PC PO BOX 12989 SALEM OR 97309 CONTRACT LABOR 777348 EMCARE INC 7032 COLLECTION CTR DR CHICAGO IL 60693 CONTRACT LABOR 277052 CTM MANAGEMENT 476 NW HILLCREST LOOP MCMINNVILLE OR 97128 CONTRACT LABOR 270330 AMN LOS ANGELES PO BOX 56157 LOS ANGELES CA 900746157 CONTRACT LABOR 151050 WILLAMETTE ORTHOPEDIC GROUP LLC 1600 STATE ST SALEM OR 97301 CONTRACT LABOR 132967 5 42910 57522 100432 NET PATIENT REVENUE 621110 18494786 18494786 LABORATORY 621500 6956049 6918424 37625 PHARMACY 621300 4279708 4279708 OTHER HOSPITAL SERVICES 900099 127455 127455 NUTRITION SERVICES 900099 98553 98553 29956551 2067 2067 27773 -27773 -27773 -27773 30031277 29918926 37625 -25706 15000 15000 469811 469811 11549185 9730262 1818923 652846 528527 124319 1356716 1098361 258355 798391 646356 152035 25966 25966 1408067 1377431 30636 10901 10901 2661104 513760 2147344 42964 2298 40666 754692 729488 25204 67020 25579 41441 19691 16800 2891 140 140 1367815 1367815 167386 167386 UBI TAX 5600 5600 PATIENT SUPPLIES 2574865 2561838 13027 BAD DEBT 2380276 2380276 OTHER PURCHASED SERVICE 704480 666981 37499 75384 75384 27108300 21828158 5280142 0 300 301 278117 212009 3116523 3564260 367033 423388 49696 73787 24617027 10420165 12312982 14196862 275900 275900 1754754 2687338 18155305 21433845 2603456 2466694 957318 1377148 3560774 3843842 X 14553776 17546946 40755 43057 14594531 17590003 18155305 21433845 X 2922977 72495 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 40755 2302 43057 45073 1503 -5821 40755 47636 13814 -9077 7300 45073 40908 3808 2920 47636 122681 4345 3956 90074 40908 1.00000 0 1 1 342155 342155 18048591 6561613 11486978 6188879 3829876 2359003 37402 28676 8726 14196862 BENEFICIAL INTEREST IN FOUNDATION 43057 DUE FROM SALEM HEALTH 2532134 OTHER LONG TERM ASSETS 112147 2687338 DUE TO MEDICARE/MEDICAID 425719 OTHER LONG-TERM ACCRUALS 14482 LIABILITY FOR MALPRACTICE INSURANCE 150488 POST-RETIREMENT BENEFITS 236459 DUE TO SALEM HEALTH HOSPITALS & CLINICS 550000 1377148 X 30101469 70192 70192 30031277 0 30031277 27105997 -2303 -2303 27108300 0 27108300 PART V, LINE 4: ENDOWMENT FUNDS ARE HELD BY WEST VALLEY HOSPITAL FOUNDATION FOR SALEM HEALTH WEST VALLEY SUPPORT. PART X, LINE 2: UNCERTAIN TAX POSITIONS FROM THE NOTES TO CONSOLIDATED FINANCIAL STATEMENTS ISSUED FOR SALEM HEALTH HOSPITALS AND CLINICS AND RELATED COMPANIES: THE CORPORATION ("SALEM HEALTH HOSPITALS AND CLINICS"), SALEM HEALTH, SALEM HEALTH WEST VALLEY, SHF, WVHF, SHPS, AND WVIC ARE TAX-EXEMPT ORGANIZATIONS PURSUANT TO INTERNAL REVENUE CODE (IRC) SECTION 501(C)(3). AS SUCH, ONLY UNRELATED BUSINESS INCOME IS SUBJECT TO FEDERAL OR STATE INCOME TAXES. THE CORPORATION ACCOUNTS FOR UNCERTAINTY IN INCOME TAXES IN ACCORDANCE WITH FASB ASC 740-10, INCOME TAXES-IMPLEMENTATION GUIDANCE ON ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES AND DISCLOSURE AMENDMENTS FOR NONPUBLIC ENTITIES. MANAGEMENT HAS NOT RECORDED A PROVISION AS UNRELATED BUSINESS INCOME, IF ANY, IS IMMATERIAL TO THE CONSOLIDATED FINANCIAL STATEMENTS. U.S. GENERALLY ACCEPTED ACCOUNTING PRINCIPLES REQUIRE THE CORPORATION TO EVALUATE TAX POSITIONS TAKEN BY THE CORPORATION AND RECOGNIZE A TAX LIABILITY (OR ASSET) IF THE CORPORATION HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS. MANAGEMENT HAS ANALYZED TAX POSITIONS TAKEN BY THE CORPORATION AND HAS CONCLUDED THAT AS OF JUNE 30,2017 THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY (OR ASSET) OR DISCLOSURE IN THE CONSOLIDATED FINANCIAL STATEMENTS. THE CORPORATION IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. THE CORPORATION MANAGEMENT BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO FISCAL YEAR 2011. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN POST RETIREMENT BENEFIT OBLIGATION 70,192. PART XII, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN BENEFICIAL INTEREST IN FOUNDATION -2,303. 1 1 X 1 X 300.000000000000 1 X 1 1 1 0 1 1 3126 388577 388577 0.01570 14723 6554063 4844757 1709306 0.06910 17849 6942640 4844757 2097883 0.08480 6683 132827 31309 101518 0.00410 42 85039 85039 0.00340 1814960 796165 1018795 0.04120 40 22438 22438 0.00090 6765 2055264 827474 1227790 0.04960 24614 8997904 5672231 3325673 0.13440 5452 5452 0.00020 5452 5452 0.00020 0 2380276 1866065 3831456 3762036 69420 X 1 1 1 1 SALEM HEALTH WEST VALLEY 525 SOUTHEAST WASHINGTON ST DALLAS OR 97338 14-1461 X X X SALEM HEALTH WEST VALLEY 1 0 0 1 X X X X X X X X X 15 1 0 1 1 X WWW.SALEMHEALTH.ORG X X 1 15 1 WWW.SALEMHEALTH.ORG/ABOUT/COMMUNITY/COMMUNITY-HEALTH-NEEDS-ASSESSMENT 0 1 X 300.000000000000 400.000000000000 X X X X X X 1 1 X X X X 1 X HTTP://WWW.SALEMHEALTH.ORG/ABOUT/CHARITY-CARE-AND-FINANCIAL-POLICY X HTTP://WWW.SALEMHEALTH.ORG/ABOUT/CHARITY-CARE-AND-FINANCIAL-POLICY X HTTP://WWW.SALEMHEALTH.ORG/ABOUT/CHARITY-CARE-AND-FINANCIAL-POLICY X X X X X X 1 X 1 X X 1 X 0 0 SALEM HEALTH WEST VALLEY PART V, SECTION B, LINE 3J: A POLK COUNTY COMPREHENSIVE NEEDS ASSESSMENT WAS CONDUCTED IN TAX YEAR 2015. THE NEEDS ASSESSMENT DESCRIBES THE COMMUNITY SERVED BY THE HOSPITAL AND THE DEMOGRAPHICS OF THE COMMUNITY. IT DOES NOT DESCRIBE THE EXISTING HEALTH CARE FACILITIES AND RESOURCES WITHIN THE COMMUNITY THAT ARE AVAILABLE TO RESPOND TO NEEDS. THE MARION AND POLK COUNTY HEALTH CARE SYSTEM CAPACITY AND ACCESS ASSESSMENT CONTAINS HEALTH CARE FACILITY AND RESOURCE INFORMATION. THE CAPACITY AND ACCESS ASSESSMENT IS UPDATED ANNUALLY. THE LATEST CHNA AND HEALTH CARE SYSTEM CAPACITY AND ACCESS ASSESSMENTS ARE PUBLISHED TO THE SALEM HEALTH WEBSITE AT WWW.SALEMHEALTH.ORG. THE NATIONAL MODEL, MOBILIZATION FOR ACTION THROUGH PLANNING AND PARTNERSHIPS OR MAPP WAS USED AS THE FRAMEWORK FOR THE COMMUNITY HEALTH ASSESSMENT. THE FOUR ASSESSMENTS OF THE MAPP FRAMEWORK INCLUDE: COMMUNITY THEMES AND STRENGTHS, LOCAL PUBLIC HEALTH SYSTEM ASSESSMENT, COMMUNITY HEALTH STATUS ASSESSMENT AND THE FORCES OF CHANGE ASSESSMENT.THE COMMUNITY THEMES AND STRENGTHS ASSESSMENT WAS CONDUCTED BY SURVEYING COMMUNITY PARTNERS WORKING IN SOCIAL, HEALTH, COMMUNITY, EDUCATIONAL AND CORRECTIONAL HEALTH SETTINGS AND THE COMMUNITY-AT-LARGE. THE SURVEYS USED IN POLK COUNTY CONSISTED OF THE SAME QUESTIONS AND USED THE 2011 COUNTY SURVEY AS A TEMPLATE. PAPER AND ELECTRONIC SURVEYS WERE ALLOCATED BASED ON POPULATION DISTRIBUTION THROUGHOUT OUR COMMUNITIES. THE COMMUNITY HEALTH STATUS ASSESSMENT WAS CONDUCTED BY COMPILING DATA FROM NATIONAL SURVEILLANCE SYSTEMS LIKE THE BEHAVIOR RISK FACTOR SURVEILLANCE SURVEY AND OREGON HEALTHY TEENS AS WELL AS STATE AND LOCAL DATA FROM BIRTH AND DEATH CERTIFICATES. IN ADDITION, A SERIES OF COMMUNITY CAFES WERE CONDUCTED ACROSS POLK COUNTY TO IDENTIFY HEALTH PRIORITIES.SALEM HEALTH WEST VALLEY HOSTED COMMUNITY CAFES AND REPRESENTATIVES FROM POLK COUNTY PUBLIC HEALTH, PRESENTED CHNA FINDINGS TO THE SALEM HEALTH COMMUNITY BENEFIT COMMITTEE OF THE BOARD OF TRUSTEES IN NOVEMBER 2015. THE POLK COUNTY HEALTH REPORTS WAS PUBLISHED IN DECEMBER 2015 AND CAN BE FOUND ON THE SALEM HEALTH WEBSITE. WWW.SALEMHEALTH.ORG. THE DOCUMENT INFORMED THE DEVELOPMENT OF THE COMMUNITY BENEFIT IMPLEMENTATION STRATEGY FOR REPORTING YEARS 2015 - 2017, ALSO AVAILABLE ON THE WEBSITE.THE IMPACT OF ACTIONS TAKEN TO ADDRESS THE SIGNIFICANT HEALTH NEEDS IDENTIFIED IN THE HOSPITAL FACILITIES PRIOR CHNAS CAN BE FOUND ON THE COMMUNITY HEALTH IMPROVEMENT PARTNERS (CHIP) ANNUALLY REPORT. THE CHIP IS COORDINATED BY THE POLK COUNTY PUBLIC HEALTH DEPARTMENT AND IS PUBLISHED ON THEIR WEBPAGE AT HTTP://WWW.CO.POLK.OR.US/PH/CHA/CHIP. SALEM HEALTH WEST VALLEY PART V, SECTION B, LINE 5: THE NATIONAL MODEL, MOBILIZATION FOR ACTION THROUGH PLANNING AND PARTNERSHIPS OR MAPP WAS USED AS THE FRAMEWORK FOR THE COMMUNITY HEALTH ASSESSMENT. THE FOUR ASSESSMENTS OF THE MAPP FRAMEWORK INCLUDE: COMMUNITY THEMES AND STRENGTHS, LOCAL PUBLIC HEALTH SYSTEM ASSESSMENT, COMMUNITY HEALTH STATUS ASSESSMENT AND THE FORCES OF CHANGE ASSESSMENT.THE COMMUNITY THEMES AND STRENGTHS ASSESSMENT WAS CONDUCTED BY SURVEYING COMMUNITY PARTNERS WORKING IN SOCIAL, HEALTH, COMMUNITY, EDUCATIONAL AND CORRECTIONAL HEALTH SETTINGS AND THE COMMUNITY-AT-LARGE. THE SURVEYS USED IN POLK COUNTIES CONSISTED OF THE SAME QUESTIONS AND USED THE 2011 MARION COUNTY SURVEY AS A TEMPLATE. PAPER AND ELECTRONIC SURVEYS WERE ALLOCATED BASED ON POPULATION DISTRIBUTION THROUGHOUT OUR COMMUNITIES. THE COMMUNITY HEALTH STATUS ASSESSMENT WAS CONDUCTED BY COMPILING DATA FROM NATIONAL SURVEILLANCE SYSTEMS LIKE THE BEHAVIOR RISK FACTOR SURVEILLANCE SURVEY AND OREGON HEALTHY TEENS AS WELL AS STATE AND LOCAL DATA FROM BIRTH AND DEATH CERTIFICATES. IN ADDITION, AS SERIES OF COMMUNITY CAFES WERE CONDUCTED ACROSS POLK COUNTY TO IDENTIFY HEALTH PRIORITIES.SALEM HEALTH WEST VALLEY HOSPITAL HOSTED COMMUNITY CAFES AND REPRESENTATIVES FROM POLK COUNTY PUBLIC HEALTH, PRESENTED CHNA FINDINGS TO THE SALEM HEALTH COMMUNITY BENEFIT COMMITTEE OF THE BOARD OF TRUSTEES IN NOVEMBER 2015. SALEM HEALTH WEST VALLEY PART V, SECTION B, LINE 6A: SALEM HEALTH WEST VALLEY IS A CRITICAL ACCESS HOSPITAL AND THE ONLY HOSPITAL POLK COUNTY. SALEM HEALTH SERVES BOTH MARION AND POLK COUNTY, THEREFORE, SALEM HEALTH PARTICIPATED IN THE CHNA AND DEVELOPMENT OF THE COMMUNITY BENEFIT IMPLEMENTATION PLAN. SALEM HEALTH WEST VALLEY PART V, SECTION B, LINE 6B: THE HOSPITAL FACILITY'S CHNA WAS CONDUCTED WITH COMMUNITY ACTION AGENCY, THE EARLY LEARNING HUB, INC, MARION COUNTY HEALTH DEPARTMENT, POLK COUNTY HEALTH DEPARTMENT, OREGON STATE UNIVERSITY, COOPERATIVE EXTENSION, UNITED WAY, WVP HEALTH AUTHORITY AND WILLAMETTE VALLEY COMMUNITY HEALTH. SALEM HEALTH WEST VALLEY PART V, SECTION B, LINE 7D: THE HOSPITAL MADE THE CHNA WIDELY AVAILABLE TO THE COMMUNITY. ALL PARTNERS DESCRIBED IN SECTION B, LINE 6B WERE PROVIDED WITH EXECUTIVE SUMMARY DOCUMENTS FOR DISTRIBUTION TO COMMUNITY MEMBERS FREE OF CHARGE. THE FULL ASSESSMENT ARE POSTED TO HOSPITAL AND COUNTY WEBSITES. SALEM HEALTH WEST VALLEY PART V, SECTION B, LINE 2: THE HOSPITAL WAS NOT ACQUIRED OR PLACED INTO SERVICE AS A TAX-EXEMPT HOSPITAL IN THE CURRENT TAX YEAR OR THE IMMEDIATELY PRECEDING TAX YEAR 2016. SALEM HEALTH WEST VALLEY PART V, SECTION B, LINE 11: PRIORITY AREAS ADDRESSED IN THE 2015 ASSESSMENT INCLUDE: EARLY PRENATAL CARE, DEPRESSION SCREENING, OBESITY AND TOBACCO USE.SALEM HEALTH WEST VALLEY HOSPITAL IS AN ACTIVE MEMBER OF THE COMMUNITY HEALTH IMPROVEMENT PARTNERSHIP AND HAS REPRESENTATION ON THE PRENATAL CARE TASK FORCE ADDRESSING EARLY PRENATAL CARE. BABIES BORN TO MOTHERS WHO DO NOT RECEIVE PRENATAL CARE ARE THREE TIMES MORE LIKELY TO HAVE A LOW BIRTH WEIGHT AND FIVE TIMES MORE LIKELY TO DIE THAN THOSE BORN TO MOTHERS WHO DO GET CARE. EARLY PRENATAL CARE (I.E. CARE IN THE FIRST TRIMESTER OF A PREGNANCY) ALLOWS WOMEN AND THEIR HEALTH CARE PROVIDERS TO IDENTIFY AND, WHEN POSSIBLE, TREAT OR CORRECT HEALTH PROBLEMS AND HEALTH-COMPROMISING BEHAVIORS THAT CAN BE PARTICULARLY DAMAGING DURING THE INITIAL STAGES OF FETAL DEVELOPMENT. INCREASING THE NUMBER OF WOMEN WHO RECEIVE PRENATAL CARE, AND WHO DO SO EARLY IN THEIR PREGNANCIES, CAN IMPROVE BIRTH OUTCOMES AND LOWER HEALTH CARE COSTS BY REDUCING THE LIKELIHOOD OF COMPLICATIONS DURING PREGNANCY AND CHILDBIRTH.THE HEALTHY PEOPLE 2020 NATIONAL HEALTH TARGET IS TO INCREASE THE PROPORTION OF PREGNANT WOMEN WHO RECEIVE PRENATAL CARE IN THE FIRST TRIMESTER TO 77.9%. POLK COUNTY MEETS THE TARGET AT 79.7%. ADULT OBESITY RATES IN POLK COUNTIES REMAIN ABOVE STATE AND NATIONAL AVERAGES AND ABOVE THE HP2020 GOAL OF 30.5%. LATEST RATES IN POLK COUNTY ARE 31.4%. SALEM HEALTH WEST VALLEY, PARTNERS WITH THE POLK COUNTY PUBLIC HEALTH DEPARTMENT AND OFFERS 5210, AN OBESITY PREVENTION PROGRAM AND SCHOOLS ACROSS POLK COUNTY.PSYCHOLOGICAL DISTRESS CAN AFFECT ALL ASPECTS OF OUR LIVES. OCCASIONAL DOWN DAYS ARE NORMAL, BUT PERSISTENT MENTAL/EMOTIONAL HEALTH PROBLEMS SHOULD BE EVALUATED AND TREATED BY A QUALIFIED PROFESSIONAL. FOR THIS REASON, SALEM HEALTH WEST VALLEY PROVIDES DEPRESSION SCREENING IN INPATIENT AND EMERGENCY ROOM SETTINGS. PRIMARY CARE CLINICS CONDUCT THE PHQ 9. POLK COUNTY RESIDENTS ON AVERAGE EXPERIENCE 4.4 POOR MENTAL HEALTH DAYS PER MONTH, WHICH IS HIGHER THAN THE US AVERAGE VALUE OF 3.7 DAYS.TOBACCO IS THE AGENT MOST RESPONSIBLE FOR AVOIDABLE ILLNESS AND DEATH IN AMERICA TODAY. ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND PREVENTION, TOBACCO USE BRINGS PREMATURE DEATH TO ALMOST HALF A MILLION AMERICANS EACH YEAR, AND IT CONTRIBUTES TO PROFOUND DISABILITY AND PAIN IN MANY OTHERS. THE WORLD HEALTH ORGANIZATION STATES THAT APPROXIMATELY ONE-THIRD OF ALL TOBACCO USERS IN THIS COUNTRY WILL DIE PREMATURELY BECAUSE OF THEIR DEPENDENCE ON TOBACCO. POLK COUNTY HAS SEEN A SIGNIFICANT INCREASE IN TOBACCO USE FROM 2010 TO 2013. WITH A HIGH SMOKING PREVALENCE THERE IS ALSO A GREATER EXPOSURE TO SECONDHAND SMOKE FOR NON-SMOKERS, WHICH CAN CAUSE OR EXACERBATE A WIDE RANGE OF ADVERSE HEALTH EFFECTS SUCH AS CANCER, RESPIRATORY INFECTIONS, AND ASTHMA.THE HEALTHY PEOPLE 2020 NATIONAL HEALTH TARGET IS TO REDUCE THE PROPORTION OF ADULTS AGED 18 YEARS AND OLDER WHO SMOKE CIGARETTES TO 12.0%. LATEST POLK COUNTY DATA SHOWS A RATE OF 16.4% COUNTY OF ITS RESIDENTS REPORTING TOBACCO USE. SALEM HEALTH WEST VALLEY IS A SMOKE FREE CAMPUS. THE HOSPITAL SCREENS 100% OF PATIENTS FOR TOBACCO USE AND PROVIDES ALL TOBACCO USERS WITH COMMUNITY CESSATION RESOURCE INFORMATION. SALEM HEALTH WEST VALLEY PART V, SECTION B, LINE 13B: SALEM HEALTH FINANCIAL MATRIX IS BASED ON INCOME AS A PERCENT OF FEDERAL POVERTY LEVEL. SALEM HEALTH WEST VALLEY PART V, SECTION B, LINE 13H: CRITERIA CONSIDERED IN DETERMINING ELIGIBILITY INCLUDE, BUT ARE NOT LIMITED TO: 1. THE HOUSEHOLD'S GROSS INCOME. 2. HOUSEHOLD'S ASSETS OTHER THAN PRIMARY RESIDENCE --EQUITY IN A REAL ESTATE (OTHER THAN THE PATIENT/GUARANTOR'S PRIMARY RESIDENCE), SECURITIES OR OTHER ASSETS ARE CONSIDERED AVAILABLE TO PAY THE PATIENT'S MEDICAL EXPENSES AND SHOULD BE INCLUDED IN THE INCOME CALCULATION --THE INCOME FROM INCOME-PRODUCING REAL PROPERTY SHOULD BE USED IN THE CALCULATION RATHER THAN THE EQUITY. --INDIVIDUAL RETIREMENT ACCOUNTS (IRAS) OR OTHER RETIREMENT FUNDS WILL NOT BE INCLUDED IN HOUSEHOLD ASSETS; HOWEVER DISTRIBUTIONS FROM THOSE FUNDS WILL BE CONSIDERED INCOME. 3. FAMILY SIZE (PERSONS LEGALLY RESPONSIBLE FOR THE PATIENT BILL AND THEIR DEPENDENTS) 4. THE FAMILY'S MONTHLY OUT OF POCKET EXPENSES FOR MEDICAL SUPPLIES AND SERVICES. 5. ELIGIBILITY MAY BE CONTINGENT UPON PATIENT COOPERATION WITH THE APPLICATION PROCESS. *THE DEFINITION OF 'HOUSEHOLD'S GROSS INCOME' INCLUDES THE COMBINED GROSS MONTHLY INCOME OF ALL PERSONS LEGALLY RESPONSIBLE FOR PATIENT BILL OR BALANCE.HOUSEHOLD INCOMES UP TO 400% OF THE ANNUAL FEDERAL POVERTY GUIDELINES (FPG) WILL BE ELIGIBLE FOR FINANCIAL ASSISTANCE AS OUTLINED BELOW AND IN THE FPG FINANCIAL MATRIX: FINANCIAL MATRIX INCOME AS A PERCENTAGE OF FEDERAL POVERTY LEVEL PERCENTAGE DISCOUNT 0-300% 100% 301-400% 65%** ALL OTHER UNINSURED SEE OTHER SELF-PAY DISCOUNT POLICY SALEM HEALTH WEST VALLEY PART V, SECTION B, LINE 15E: PATIENT MUST PROVIDE TWO OF THE FOLLOWING DOCUMENTS TO SUPPORT THE INCOME CLAIMS ON THE APPLICATION. -THREE MONTHS INCOME VERIFICATION IN THE FORM OF PAY STUBS, BANK DEPOSITS, ETC. -SOCIAL SECURITY DETERMINATION LETTERS. -THE PRIOR YEAR'S TAX RETURNS OR 4506T-EZ -A "BASIC NEEDS" LETTER THAT INDICATES HOW PERSONS WITH NO INCOME ARE MEETING THEIR DAY TO DAY BASIC LIVING NEEDS. "BASIC NEEDS" LETTER MUST ONLY BE CONSIDERED A SECONDARY SUPPORTING DOCUMENT AFTER THE FINANCIAL COUNSELOR OR CLERK VALIDATES THE INFORMATION. AS OUTLINED IN SALEM HEALTH'S CONDITION OF ADMISSION, A CREDIT BUREAU REPORT OR A CHARITY SCORING VENDOR MAY BE REQUESTED TO VALIDATE INFORMATION PROVIDED ON THE FINANCIAL ASSISTANCE APPLICATION. SALEM HEALTH WEST VALLEY MAY ACCEPT INFORMATION PROVIDED ON AN OHP APPLICATION, OHP ELIGIBILITY, PROBATE ESTATES DETERMINATION, DOCUMENTATION OF HOMELESS STATUS, OR RELIABLE THIRD PARTY CREDIT INFORMATION AS A SUBSTITUTE FOR THE FINANCIAL FORMS. OHP INFORMATION WILL BE CONSIDERED VALID 30 DAYS PRIOR TO ADMISSION AND 90 DAYS POST DISCHARGE. APPROVED SOURCES OF DOCUMENTATION FOR HOMELESS STATUS INCLUDE CHART NOTES, DISCHARGE PLANS, OR DISCHARGE SUMMARIES ENTERED INTO OUR HEALTH INFORMATION SYSTEM BY CARE PROVIDERS OR THE PATIENT INDICATING THEY ARE HOMELESS DURING THE REGISTRATION PROCESS. FINANCIAL ASSISTANCE GRANTED BASED ON THIRD PARTY INFORMATION RATHER THAN A FINANCIAL ASSISTANCE APPLICATION DOES NOT EXTEND TO FUTURE DATES OF SERVICE AND WOULD NEED TO BE REEVALUATED BASED ON INFORMATION AVAILABLE AT THAT TIME. APPLICATION PROCESS & ELIGIBILITY DETERMINATION A REQUEST FOR FINANCIAL ASSISTANCE MAY BE MADE BEFORE, DURING, OR AFTER THE PROVISION OF CARE. THE HOSPITAL HAS DEVELOPED AN APPLICATION PROCESS FOR DETERMINING INITIAL INTEREST IN AND QUALIFICATION FOR FINANCIAL ASSISTANCE. REQUESTS FOR FINANCIAL ASSISTANCE WILL BE ACCEPTED FROM THE PATIENT DIRECTLY, OR OTHERS ON THE PATIENT'S BEHALF. THIS COULD INCLUDE BUT IS NOT LIMITED TO, THE PATIENT'S REPRESENTATIVE, OR HOSPITAL STAFF. -FINANCIAL ASSISTANCE POLICY, PLAIN LANGUAGE SUMMARY AND APPLICATIONS MAY BE DOWNLOADED FROM OUR WEBSITE: HTTP://WWW.SALEMHEALTH.ORG/ABOUT/CHARITY-CARE-AND-FINANCIAL-POLICY -PAPER COPIES OF THE FINANCIAL ASSISTANCE POLICY, PLAIN LANGUAGE SUMMARY AND APPLICATIONS ARE AVAILABLE IN THE EMERGENCY DEPARTMENT, IN REGISTRATION AREAS AND AT PATIENT FINANCIAL SERVICES, 550 HAWTHORNE AVE SE, SUITE 200, SALEM OR 97301 -PAPER COPIES OF THE FINANCIAL ASSISTANCE POLICY, PLAIN LANGUAGE SUMMARY AND APPLICATIONS MAY BE REQUESTED BY MAIL FROM: FINANCIAL COUNSELING, SALEM HEALTH, PO BOX 14001, SALEM OR 97309-9976 OR VIA TELEPHONE BY CALLING 503-562-4357 SALEM HEALTH WEST VALLEY PART V, SECTION B, LINE 16J: INFORMATION ON THE HOSPITAL'S FINANCIAL ASSISTANCE IS BE MADE PUBLICLY AVAILABLE FREE OF CHARGE IN THE FOLLOWING MANNER: 1. NOTICES ARE POSTED IN KEY AREAS OF THE HOSPITAL, INCLUDING ADMITTING, THE EMERGENCY DEPARTMENT, OUTPATIENT DEPARTMENT REGISTRATION AREAS, AND PATIENT FINANCIAL SERVICES. 2. THE CONDITIONS OF ADMISSION FORM INFORMS THE PATIENT OF THEIR RIGHT TO APPLY FOR FINANCIAL ASSISTANCE. 3. WRITTEN INFORMATION IS AVAILABLE IN ENGLISH, SPANISH, RUSSIAN AND VIETNAMESE. THE HOSPITAL WILL PROVIDE THE APPROPRIATE INTERPRETATION SERVICES FOR PATIENTS/GUARANTORS WHO DO NOT SPEAK ENGLISH. 4. FRONT-LINE STAFF ARE TRAINED TO ANSWER FINANCIAL ASSISTANCE QUESTIONS EFFECTIVELY AND WILL DIRECT ANY THAT CANNOT BE ANSWERED TO FINANCIAL COUNSELOR'S IN A TIMELY MANNER. 5. THIS POLICY IS POSTED ON SALEM HEALTH'S WEB SITE. WRITTEN INFORMATION ABOUT THIS POLICY WILL BE MADE AVAILABLE UPON REQUEST. 6. ALL PATIENT BILLING STATEMENTS INCLUDES A NOTICE THAT FINANCIAL ASSISTANCE IS AVAILABLE AND CONTACT INFORMATION IF THEY WANT TO LEARN MORE. SALEM HEALTH WEST VALLEY PART V, SECTION B, LINE 18E: IT IS THE POLICY OF SALEM HEALTH WEST VALLEY TO PURSUE COLLECTION OF PATIENT BALANCES FROM PATIENTS WHO HAVE THE ABILITY TO PAY FOR SERVICES. SALEM HEALTH WEST VALLEY MAKES REASONABLE EFFORTS TO IDENTIFY PATIENTS WHO MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE. COLLECTION PROCEDURES ARE APPLIED CONSISTENTLY AND FAIRLY FOR ALL PATIENTS REGARDLESS OF INSURANCE STATUS. ALL COLLECTION PROCEDURES WILL COMPLY WITH APPLICABLE LAWS AND WITH SALEM HEALTH'S MISSION. FOR THOSE PATIENTS UNABLE TO PAY ALL OR A PORTION OF THEIR OPEN BALANCES, THE FINANCIAL ASSISTANCE POLICY WILL BE FOLLOWED. COLLECTION AGENCIES AND/OR LAW FIRMS MAY BE ENLISTED AFTER REASONABLE COLLECTION AND PAYMENT OPTIONS HAVE BEEN EXHAUSTED. AGENCIES MAY HELP RESOLVE ACCOUNTS WHERE PATIENTS ARE UNCOOPERATIVE IN MAKING PAYMENTS, HAVE NOT MADE APPROPRIATE PAYMENTS, OR HAVE BEEN UNWILLING TO PROVIDE REASONABLE FINANCIAL AND OTHER DATA TO SUPPORT THEIR REQUEST FOR FINANCIAL ASSISTANCE. COLLECTION AGENCY AND LAW FIRM STAFF WILL UPHOLD THE CONFIDENTIALITY AND INDIVIDUAL DIGNITY OF EACH PATIENT. ALL AGENCIES AND LAW FIRMS WILL COMPLY WITH ALL APPLICABLE LAWS INCLUDING HIPAA REQUIREMENTS FOR HANDLING PROTECTED HEALTH INFORMATION. SALEM HEALTH WEST VALLEY PART V, SECTION B, LINE 19E: SALEM HEALTH WEST VALLEY WILL NOTIFY INDIVIDUALS THAT FINANCIAL ASSISTANCE IS AVAILABLE TO ELIGIBLE INDIVIDUALS AT LEAST 30 DAYS PRIOR TO PURSUING EXTRAORDINARY COLLECTIONS ACTIONS (EAC) AS TO OBTAIN PAYMENT FOR THE CARE PROVIDED BY THE HOSPITAL. ECAS FOR HOSPITAL SERVICES WILL NOT COMMENCE FOR A PERIOD OF AT LEAST 240 DAYS AFTER THE DATE OF THE FIRST POST-DISCHARGE BILLING STATEMENT AND 30 DAYS AFTER THE HOSPITAL OR AUTHORIZED THIRD PARTY PROVIDES WRITTEN NOTICE OF ECAS THE HOSPITAL PLANS TO INITIATE FOR THE APPLICABLE MEDICALLY NECESSARY OR EMERGENCY MEDICAL CARE. SALEM HEALTH WEST VALLEY PART V, SECTION B, LINE 20E: SALEM HEALTH WEST VALLEY WILL NOTIFY INDIVIDUALS THAT FINANCIAL ASSISTANCE IS AVAILABLE TO ELIGIBLE INDIVIDUALS AT LEAST 30 DAYS PRIOR TO PURSUING EXTRAORDINARY COLLECTIONS ACTIONS AS TO OBTAIN PAYMENT FOR THE CARE PROVIDED BY THE HOSPITAL BY DOING THE FOLLOWING: 1. PROVIDE WRITTEN NOTICE TO THE INDIVIDUAL INDICATING THAT FINANCIAL ASSISTANCE IS AVAILABLE TO ELIGIBLE INDIVIDUALS, INDICATING THAT SALEM HEALTH, WEST VALLEY INTENDS TO INITIATE OR HAVE A THIRD PARTY INITIATE TO OBTAIN PAYMENT FOR THE CARE, AND PROVIDES A DEADLINE AFTER WHICH ECAS MAY BE PURSUED AND WHICH IS NO LATER THAN 30 DAYS AFTER THE DATE OF THIS WRITTEN NOTICE 2. PROVIDE THE INDIVIDUAL A PLAIN LANGUAGE SUMMARY OF THE FINANCIAL ASSISTANCE POLICY WITH THE WRITTEN NOTICE 3. MAKE REASONABLE EFFORTS TO ORALLY NOTIFY INDIVIDUALS ABOUT THE SALEM HEALTH'S FINANCIAL ASSISTANCE POLICY. 4 1 - MONMOUTH MEDICAL CENTER 512 E MAIN ST 300 MONMOUTH OR 97361 CLINIC 2 - SALEM HEALTH WEST VALLEY MEDICAL CLINIC 555 SE WASHINGTON ST DALLAS OR 97338 CLINIC 3 - CENTRAL SCHOOL-HEALTH CLINIC 1601 MONMOUTH ST STE 100 INDEPENDENCE OR 97351 CLINIC 4 - SALEM HEALTH WEST VALLEY SPECIALTY CLIN 591 SE CLAY ST DALLAS OR 97338 CLINIC PART I, LINE 3C: CRITERIA CONSIDERED IN DETERMINING ELIGIBILITY INCLUDE, BUT ARE NOT LIMITED TO: -THE HOUSEHOLD'S* GROSS INCOME. -HOUSEHOLD'S ASSETS OTHER THAN PRIMARY RESIDENCE --EQUITY IN A REAL ESTATE (OTHER THAN THE PATIENT/GUARANTOR'S PRIMARY RESIDENCE), SECURITIES OR OTHER ASSETS ARE CONSIDERED AVAILABLE TO PAY THE PATIENT'S MEDICAL EXPENSES AND SHOULD BE INCLUDED IN THE INCOME CALCULATION --THE INCOME FROM INCOME-PRODUCING REAL PROPERTY SHOULD BE USED IN THE CALCULATION RATHER THAN THE EQUITY. --INDIVIDUAL RETIREMENT ACCOUNTS (IRAS) OR OTHER RETIREMENT FUNDS WILL NOT BE INCLUDED IN HOUSEHOLD ASSETS; HOWEVER DISTRIBUTIONS FROM THOSE FUNDS WILL BE CONSIDERED INCOME. -FAMILY SIZE (PERSONS LEGALLY RESPONSIBLE FOR THE PATIENT BILL AND THEIR DEPENDENTS) -THE FAMILY'S MONTHLY OUT OF POCKET EXPENSES FOR MEDICAL SUPPLIES AND SERVICES. -ELIGIBILITY MAY BE CONTINGENT UPON PATIENT COOPERATION WITH THE APPLICATION PROCESS. *THE DEFINITION OF 'HOUSEHOLD'S GROSS INCOME' INCLUDES THE COMBINED GROSS MONTHLY INCOME OF ALL PERSONS LEGALLY RESPONSIBLE FOR PATIENT BILL OR BALANCE.SUPPORTING DOCUMENTATION MAY INCLUDE THE FOLLOWING: PATIENT MUST PROVIDE TWO OF THE FOLLOWING DOCUMENTS TO SUPPORT THE INCOME CLAIMS ON THE APPLICATION. -THREE MONTHS INCOME VERIFICATION IN THE FORM OF PAY STUBS, BANK DEPOSITS, ETC. -SOCIAL SECURITY DETERMINATION LETTERS. -THE PRIOR YEAR'S TAX RETURNS OR 4506T-EZ -A "BASIC NEEDS" LETTER THAT INDICATES HOW PERSONS WITH NO INCOME ARE MEETING THEIR DAY TO DAY BASIC LIVING NEEDS. BASIC NEEDS" LETTER MUST ONLY BE CONSIDERED A SECONDARY SUPPORTING DOCUMENT AFTER THE FINANCIAL COUNSELOR OR CLERK VALIDATES THE INFORMATION. AS OUTLINED IN SALEM HEALTH'S CONDITION OF ADMISSION, A CREDIT BUREAU REPORT OR A CHARITY SCORING VENDOR MAY BE REQUESTED TO VALIDATE INFORMATION PROVIDED ON THE FINANCIAL ASSISTANCE APPLICATION. SALEM HEALTH WEST VALLEY MAY ACCEPT INFORMATION PROVIDED ON AN OHP APPLICATION, OHP ELIGIBILITY, PROBATE ESTATES DETERMINATION, DOCUMENTATION OF HOMELESS STATUS, OR RELIABLE THIRD PARTY CREDIT INFORMATION AS A SUBSTITUTE FOR THE FINANCIAL FORMS. OHP INFORMATION WILL BE CONSIDERED VALID 30 DAYS PRIOR TO ADMISSION AND 90 DAYS POST DISCHARGE. APPROVED SOURCES OF DOCUMENTATION FOR HOMELESS STATUS INCLUDE CHART NOTES, DISCHARGE PLANS, OR DISCHARGE SUMMARIES ENTERED INTO OUR HEALTH INFORMATION SYSTEM BY CARE PROVIDERS OR THE PATIENT INDICATING THEY ARE HOMELESS DURING THE REGISTRATION PROCESS. FINANCIAL ASSISTANCE GRANTED BASED ON THIRD PARTY INFORMATION RATHER THAN A FINANCIAL ASSISTANCE APPLICATION DOES NOT EXTEND TO FUTURE DATES OF SERVICE AND WOULD NEED TO BE REEVALUATED BASED ON INFORMATION AVAILABLE AT THAT TIME. PART I, LINE 7: FINANCIAL ASSISTANCE, MEDICAID AND COSTS OF OTHER MEANS-TESTED GOVERNMENT PROGRAMS ACCOUNT FOR A LARGE PORTION OF SALEM HEALTH WEST VALLEY'S COMMUNITY BENEFIT CONTRIBUTION. ENSURING THAT COMMUNITY MEMBERS HAVE ACCESS TO EMERGENCY, PRIMARY CARE AND OTHER HEALTH SERVICES REGARDLESS OF ABILITY TO PAY, ALIGNS WITH THE HOSPITAL MISSION AND COMMITMENT TO SERVE THOSE LIVING IN POLK COUNTIES. SALEM HEALTH WEST VALLEY IS DEEPLY EMBEDDED IN THE TIGHT KNIT COMMUNITIES OF POLK COUNTY. HOSPITAL LEADERS WORK HAND IN HAND WITH REPRESENTATIVES FROM GOVERNMENT AGENCIES AND OTHER NON-PROFITS TO ASSESS AND ADDRESS COMMUNITY NEEDS. FOUR COMMUNITY WIDE TASK FORCES ARE IN PLACE TO ADDRESS THE FOUR HEALTH NEEDS DEEMED MOST CRITICAL IN POLK COUNTY. THOSE ARE EARLY CHILDHOOD HEALTH INCLUDING PRENATAL CARE, TOBACCO AND SUBSTANCE ABUSE, DEPRESSION SCREENING AND OBESITY PREVENTION. THE HOSPITAL'S DIRECTOR OF COMMUNITY BENEFIT ATTENDS TASK FORCE MEETINGS AND LOOKS FOR WAYS TO LEVERAGE HOSPITAL RESOURCES TO IMPACT HEALTH OUTCOMES. HOSPITAL LEADERS VOLUNTEER TIME TO SERVE ON COMMUNITY NON-PROFIT BOARDS AND ATTEND REGIONAL COLLABORATIVE WORKGROUPS THAT ADDRESS SOCIAL DETERMINANTS OF HEALTH. EXAMPLES INCLUDE, BOARD POSITIONS ON THE EARLY LEARNING HUB, WITH A FOCUS ON KINDERGARTEN READINESS; THE MID-WILLAMETTE VALLEY HOMELESS INITIATIVE; AND SALEM KEIZER SPECIAL TRANSPORTATION ADVISORY GROUP, WHICH PROVIDES GRANT FUNDS TO SUPPORT THE SALEM HEALTH WEST VALLEY CONNECTIONS VAN PROGRAM.THE HOSPITAL PROVIDES TRAINING FOR NURSING STUDENTS AND EMERGING HEALTH CARE PROFESSIONS. ITS HEALTH CAREER EXPLORATION PROGRAMS PROVIDES A LEARNING OPPORTUNITY FOR HIGH SCHOOL STUDENTS IN DISTRICTS THAT FALL WITHIN THE HOSPITAL CATCHMENT AREA IN POLK COUNTIES. SCHOLARSHIPS ARE AWARDED TO HIGH SCHOOL STUDENTS ANNUALLY. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 2,380,276. PART III, LINE 2: BAD DEBT EXPENSE IS PRIMARILY ESTIMATED BASED UPON THE HOSPITALS' HISTORICAL COLLECTION EXPERIENCE, THE AGE OF THE PATIENT'S ACCOUNT, THE PATIENT'S ECONOMIC ABILITY TO PAY, AND THE EFFECTIVENESS OF COLLECTION EFFORTS. PATIENT ACCOUNTS RECEIVABLE BALANCES ARE ROUTINELY REVIEWED IN CONJUNCTION WITH HISTORICAL COLLECTION RATES AND OTHER ECONOMIC CONDITIONS THAT MIGHT ULTIMATELY AFFECT THE COLLECTABILITY OF PATIENT ACCOUNTS WHEN CONSIDERING THE ADEQUACY OF THE AMOUNTS RECORDED IN THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. ACTUAL WRITE-OFFS HISTORICALLY HAVE APPROXIMATED MANAGEMENT'S EXPECTATIONS. PART III, LINE 3: BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE UNDER SALEM HEALTH'S FINANCIAL ASSISTANCE POLICY, IS ESTIMATED BASED ON DATA FROM OUR PATIENT ACCOUNTING SYSTEM. THIS DATA IS THEN COMPARED AND MATCHED TO MEDIAN HOUSEHOLD INCOME CENSUS DATA BY ZIP CODE TO DETERMINE THE ESTIMATED BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE. PART III, LINE 4: EFFECTIVE OCTOBER 1, 2011, THE HOSPITALS ADOPTED FASB ISSUED ACCOUNTING STANDARDS UPDATE (ASU) NO. 2011-07, HEALTH CARE ENTITIES (TOPIC 954): PRESENTATION AND DISCLOSURE OF PATIENT SERVICE REVENUE, PROVISION FOR BAD DEBTS, AND THE ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR CERTAIN HEALTHCARE ENTITIES. THE ADOPTION OF THIS ASU RESULTED IN A RECLASSIFICATION OF BAD DEBT EXPENSE FROM AN OPERATING EXPENSE TO BE A REDUCTION IN DERIVING NET PATIENT SERVICE REVENUE. THE ALLOWANCES FOR DOUBTFUL ACCOUNTS ARE PRIMARILY ESTIMATED BASED UPON THE HOSPITALS' HISTORICAL COLLECTION EXPERIENCE, THE AGE OF THE PATIENT'S ACCOUNT, THE PATIENT'S ECONOMIC ABILITY TO PAY, AND THE EFFECTIVENESS OF COLLECTION EFFORTS. PATIENT ACCOUNTS RECEIVABLE BALANCES ARE ROUTINELY REVIEWED IN CONJUNCTION WITH HISTORICAL COLLECTION RATES AND OTHER ECONOMIC CONDITIONS THAT MIGHT ULTIMATELY AFFECT THE COLLECTABILITY OF PATIENT ACCOUNTS WHEN CONSIDERING THE ADEQUACY OF THE AMOUNTS RECORDED IN THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. ACTUAL WRITE-OFFS HISTORICALLY HAVE APPROXIMATED MANAGEMENT'S EXPECTATIONS. PART III, LINE 9B: THE BILLING AND COLLECTIONS ADMINISTRATIVE HOUSE-WIDE POLICY AND PROCEDURE STATES, "IF A PATIENT SUBMITS A COMPLETE APPLICATION FOR FINANCIAL ASSISTANCE AFTER AN ACCOUNT HAS BEEN REFERRED FOR COLLECTION ACTIVITY, SALEM HEALTH WEST VALLEY WILL SUSPEND THE ECAS UNTIL THE PATIENT'S APPLICATION HAS BEEN PROCESSED AND NOTIFY THE PATIENT OF DETERMINATION. IF AN INDIVIDUAL IS FOUND TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE, ANY ECAS WILL BE REVERSED. PART VI, LINE 2: A COMPREHENSIVE NEEDS ASSESSMENT WAS CONDUCTED IN TAX YEAR 2015. THE NEEDS ASSESSMENT DESCRIBES THE COMMUNITY SERVED BY THE HOSPITAL AND THE DEMOGRAPHICS OF THE COMMUNITY. IN ADDITION TO THE NEEDS ASSESSMENT, THE MARION AND POLK COUNTY HEALTH CARE SYSTEM CAPACITY AND ACCESS ASSESSMENT CONTAINS HEALTH CARE FACILITY AND RESOURCE INFORMATION. THE CAPACITY AND ACCESS ASSESSMENT IS UPDATED ANNUALLY. THE CHNA AND HEALTH CARE SYSTEM CAPACITY AND ACCESS ASSESSMENTS ARE PUBLISHED TO THE SALEM HEALTH WEBSITE AT WWW.SALEMHEALTH.ORG. THE HOSPITAL EXECUTIVE TEAM MEMBERS INTENTIONALLY SERVE ON NON-PROFIT BOARDS AND ATTEND COALITION MEETINGS THAT AIM TO IMPROVE THE SOCIAL DETERMINANTS OF HEALTH IN POLK COUNTY. THESE ORGANIZATIONS AND TEAMS SERVE VULNERABLE POPULATIONS AND PROVIDE CRITICAL INSIGHT INTO THE NEEDS OF THE COMMUNITY FROM THOSE THAT PROVIDE DIRECT CARE AND SERVICES. PART VI, LINE 3: SALEM HEALTH WEST VALLEY SCREENS UNINSURED PATIENTS FOR ELIGIBILITY THROUGH THE OREGON HEALTH PLAN (OHP/MEDICAID), WORKERS COMPENSATION, THIRD PARTY LIABILITIES, CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA), OR ANY OTHER POTENTIAL FUNDING SOURCE AT THE POINT OF SCHEDULING, PATIENT REGISTRATION OR WHILE INPATIENT. THE HOSPITAL OR ITS REPRESENTATIVE WILL REVIEW THE PATIENT'S CURRENT RESOURCES AND WORK WITH HIM/HER TO GAIN ELIGIBILITY FOR ANY OF THESE PROGRAMS AS APPROPRIATE. PATIENTS THAT ARE NOT ELIGIBLE FOR OHP OR THE OTHER PROGRAMS LISTED ABOVE, AND HAVE FINANCIAL CONSTRAINTS THAT INHIBIT THEIR ABILITY TO PAY, WILL BE ASSESSED FOR A FINANCIAL ASSISTANCE. INFORMATION REGARDING THE HOSPITAL'S FINANCIAL ASSISTANCE IS MADE PUBLICLY AVAILABLE IN THE FOLLOWING MANNER: 1. NOTICES ARE POSTED IN KEY AREAS OF THE HOSPITAL, INCLUDING ADMITTING, THE EMERGENCY DEPARTMENT, OUTPATIENT DEPARTMENT REGISTRATION AREAS, AND PATIENT FINANCIAL SERVICES. 2. THE CONDITIONS OF ADMISSION FORM INFORMS THE PATIENT OF THEIR RIGHT TO APPLY FOR FINANCIAL ASSISTANCE. 3. WRITTEN INFORMATION SHALL BE AVAILABLE IN ENGLISH, SPANISH, RUSSIAN AND VIETNAMESE. THE HOSPITAL WILL PROVIDE THE APPROPRIATE INTERPRETATION SERVICES FOR PATIENTS/GUARANTORS WHO DO NOT SPEAK ENGLISH. 4. FRONT-LINE STAFF WILL BE TRAINED TO ANSWER FINANCIAL ASSISTANCE QUESTIONS EFFECTIVELY AND WILL DIRECT ANY THAT CANNOT BE ANSWERED TO FINANCIAL COUNSELOR'S IN A TIMELY MANNER. 5. THIS POLICY WILL BE POSTED ON SALEM HEALTH'S WEB SITE. WRITTEN INFORMATION ABOUT THIS POLICY WILL BE MADE AVAILABLE UPON REQUEST. 6. ALL PATIENT BILLING STATEMENTS WILL INCLUDE A NOTICE THAT FINANCIAL ASSISTANCE IS AVAILABLE AND CONTACT INFORMATION IF THEY WANT TO LEARN MORE. PART VI, LINE 4: SALEM HEALTH WEST VALLEY SERVES POLK COUNTYIN 2016, THERE WERE 79,291 PEOPLE AND 28,458 HOUSEHOLDS RESIDING IN THE POLK COUNTY. THE RURAL COMMUNITY HAD A POPULATION DENSITY OF 101.8 INHABITANTS PER SQUARE MILE (39.3/KM2). THERE WERE 31,166 HOUSING UNITS. THE RACIAL MAKEUP OF THE COUNTY WAS 90.7% WHITE, 2.6% AMERICAN INDIAN, 2.0% ASIAN, 0.9% BLACK OR AFRICAN AMERICAN, 0.4% PACIFIC ISLANDER AND 3.5% FROM TWO OR MORE RACES. THOSE OF HISPANIC OR LATINO ORIGIN MADE UP 13% OF THE POPULATION. 7.5% OF THE POPULATION IS FOREIGN BORN. THE AVERAGE HOUSEHOLD SIZE WAS 2.62. 5.9% OF THE POPULATION ARE UNDER THE AGE OF 5 YEARS, 23.5% ARE UNDER THE AGE OF 18 AND 16.4% ARE OVER THE AGE OF 65 YEARS. THE MEDIAN INCOME FOR A HOUSEHOLD IN POLK COUNTY IS $52,821. THE PER CAPITA INCOME FOR THE COUNTY WAS $23,967. ABOUT 13.7% OF THE POPULATION LIVE BELOW THE POVERTY LINE. ACCORDING TO THE U.S. CENSUS BUREAU, MARION COUNTY HAS A TOTAL AREA OF 744 SQUARE MILES (1,930 KM2), OF WHICH 741 SQUARE MILES (1,920 KM2) IS LAND AND 3.1 SQUARE MILES (8.0 KM2) (0.4%) IS WATER. THE MAJOR INDUSTRIES OF THE COUNTY ARE AGRICULTURE, FOREST PRODUCTS, MANUFACTURING, AND EDUCATION. POLK COUNTY HAS THE SECOND-LARGEST AREA DEVOTED TO VITICULTURE IN OREGON, AT 1,322 ACRES (5.35 KM2). PART VI, LINE 5: SALEM HEALTH WEST VALLEY SUPPORTS THE CONNECTIONS VAN PROGRAM. IN 2016, THE HOSPITAL PURCHASED A NEW VAN TO HELP PATIENTS IN RURAL COMMUNITIES' ACCESS HEALTH SERVICES. PAID STAFF COORDINATE RIDES AND AT TIMES WILL DRIVE THE VAN, WHEN THE VOLUNTEER DRIVERS ARE UNAVAILABLE. THE VAN PROVIDES RIDES FREE OF CHARGE TO LOW INCOME, MEDICALLY FRAGILE COMMUNITY MEMBERS. SALEM HEALTH WEST VALLEY, FUNDS POLK COUNTY SERVICE INTEGRATION. SERVICE INTEGRATION TEAMS (SITS) AIM TO TRANSFORM HEALTH BY COORDINATING AND ALIGNING SERVICES THAT ADDRESS THE NEEDS OF INDIVIDUALS, FAMILIES AND COMMUNITY, THUS IMPROVING THE CONTEXT IN WHICH PEOPLE LIVE. SALEM HEALTH WEST VALLEY STAFF AND LEADERS ROUTINELY ATTEND SERVICE INTEGRATION TEAM MEETINGS AND THE HOSPITAL PROVIDES FUNDING TO ADDRESS THE SOCIAL DETERMINANTS OF HEALTH IN POLK COUNTY. PART VI, LINE 6: SALEM HEALTH WEST VALLEY, AS PART OF SALEM HEALTH HOSPITALS AND CLINICS, WAS AFFILIATED WITH OREGON HEALTH SCIENCE UNIVERSITY (OHSU) AND TUALITY HEALTHCARE. CHANGES IN PRIORITIES AND PROCESSES REQUIRING COURSE CORRECTIONS ARE COMMON IN THE FIRST YEARS OF AN AFFILIATION AND THE CONCLUSION WAS REACHED BY BOTH THE CORPORATION AND OHSU THAT THE JMA WAS NOT WORKING IN THE WAY ORIGINALLY INTENDED. THE PARTIES RECOGNIZED THE NEED FOR A TRANSITION. AS A RESULT, THE CORPORATION AND OHSU ENTERED IN TO A TRANSITION AGREEMENT THAT TERMINATED THE JMA EFFECTIVE MAY 4, 2017 WITH EACH PARTY REASSUMING OVERSIGHT AND FULL MANAGEMENT OF THEIR OWN CLINICAL ENTERPRISES AND THE CORPORATION TRANSFERRING ITS INTEREST IN OHSU PARTNERS TO OHSU. PART VI, LINE 7, REPORTS FILED WITH STATES OR 1 POLK COUNTY SERVICE INTEGRATION TEAMS 182 SW ACADEMY STREET 220 DALLAS OR 97338 936002310 GOVERNMENT 15000 IMPROVE SOCIAL DETERMINATES OF HEALTH 1 PART I, LINE 2: SERVICE INTEGRATION TEAM FUNDS ARE RESTRICTED TO BE USED FOR COMMUNITY BENEFIT ELIGIBLE EXPENSES THAT ARE LINKED TO AN ESTABLISHED COMMUNITY NEED THAT HAS BEEN IDENTIFIED IN THE CHNA. IN THIS CASE, THE NEED IS SOCIAL DETERMINANTS OF HEALTH AND THE HOSPITAL PUBLISHED COMMUNITY BENEFIT IMPLEMENTATION PLAN CALLS FOR SUPPORT OF SITS IN POLK COUNTY. X X X X X 0 1 0 0 0 1 1 1 0 CHERYL NESTER WOLFE CEO & PRESIDENT 0 579665 0 143292 0 7341 0 57385 0 15229 0 802912 0 0 JAMES PARR CHIEF FINANCIAL OFFICER 0 398813 0 38833 0 1407 0 45500 0 35831 0 520384 0 0 BRUCE RODGERS CHIEF ADMIN OFFICER 182863 0 19438 0 839 0 24252 0 24131 0 251523 0 0 0 JENNIFER BROADUS DIR, WV CLINICAL OPERATIONS 139915 0 14240 0 129 0 13110 0 11971 0 179365 0 0 0 ALISON SMITH MD GENERAL SURGEON 394543 0 31704 0 4525 0 38937 0 14425 0 484134 0 0 0 CHARLES ESSEX MD FAMILY PRACTITIONER 264081 0 11455 0 3993 0 29125 0 32126 0 340780 0 0 0 JOHN HADLEY MD FAMILY PRACTITIONER 246787 0 17949 0 4107 0 28484 0 24708 0 322035 0 0 0 CELIA WALLIS RN BSN STAFF NURSE 146039 0 0 0 484 0 12595 0 23212 0 182330 0 0 0 TIFFANY DUELL PHARMACIST 140128 0 0 0 145 0 9896 0 23227 0 173396 0 0 0 PART I, LINE 4B SOME OF THE HOSPITAL'S EMPLOYEES RECEIVE DEFERRED COMPENSATION UNDER A 457(F) NONQUALIFIED PLAN. THIS COMPENSATION IS INCLUDED IN COMPENSATION REPORTED IN PART II. THE TOTAL NONQUALIFIED PORTION OF EACH PERSONS DEFERRED COMPENSATION IS: CHERYL NESTER WOLFE $79,653 ($39,493 INCLUDED IN BONUS & INCENTIVE COMPENSATION AND $40,160 INCLUDED IN DEFERRED COMPENSATION) JAMES PARR $28,275 (INCLUDED IN DEFERRED COMPENSATION) ALISON SMITH $49,424 ($27,712 INCLUDED IN OTHER REPORTABLE COMPENSATION AND $21,712 INCLUDED IN DEFERRED COMPENSATION) CHARLES ESSEX 23,355 ($11,455 INCLUDED IN OTHER REPORTABLE COMPENSATION AND $11,900 INCLUDED IN DEFERRED COMPENSATION) JOHN HADLEY 27,025 ($14,948 INCLUDED IN OTHER REPORTABLE COMPENSATION AND $12,077 INCLUDED IN DEFERRED COMPENSATION) BRUCE RODGERS 11,367 (INCLUDED IN DEFERRED COMPENSATION) PART I, LINE 6 CERTAIN PHYSICIANS RECEIVE INCENTIVE COMPENSATION IN ACCORDANCE WITH THEIR EMPLOYMENT AGREEMENTS WITH SALEM HEALTH. AMOUNTS NOTED ON SCHEDULE J PART II COLUMN (II) REFLECT PAYMENTS EARNED BY THESE PHYSICIAN EMPLOYEES IN SUCH AGREEMENTS. ADDITIONALLY, FOR KEY EMPLOYEES AND MANAGEMENT OF SALEM HEALTH THE BOARD OF TRUSTEES HAS APPROVED AN ANNUAL LEADERSHIP INCENTIVE PROGRAM THAT PROVIDES FOR INCENTIVE PAYMENTS BASED ON OBJECTIVE CRITERIA RELATED TO QUALITY AND SAFETY, ENGAGEMENT, PATIENT SATISFACTION AND FINANCIAL PERFORMANCE. AMOUNTS NOTED ON SCHEDULE J PART II COLUMN (II) REFLECT PAYMENTS EARNED UNDER THE LEADERSHIP INCENTIVE PLAN. PART I, LINE 7 THE GOVERNANCE COMMITTEE OF THE BOARD OF TRUSTEES, IN CONSULTATION WITH INDEPENDENT COMPENSATION CONSULTANTS, REVIEWS CEO TOTAL COMPENSATION AND PERFORMANCE ANNUALLY. AS PART OF THE COMMITTEE'S ACTIONS, A NON-FIXED BONUS MAY BE AWARDED TO THE CEO. IN THIS YEAR THE NON-FIXED PAYMENT WAS PAID UNDER THE 457(F) NONQUALIFIED PLAN AND IS INCLUDED IN DEFERRED COMPENSATION REPORTED IN PART II. FORM 990, PART VI, SECTION A, LINE 4 ARTICLES WERE AMENDED, EFFECTIVE AS OF JULY 1, 2016, IN ORDER TO CHANGE ORGANIZATION'S NAME. UPDATED NAME WAS REFLECTED ON THE PRIOR YEAR FORM 990. FORM 990, PART VI, SECTION B, LINE 11B THE GOVERNANCE COMMITTEE OF THE BOARD OF TRUSTEES REVIEWS THE 990. IT IS THEN FORWARDED TO THE ENTIRE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION B, LINE 12C ON AN ANNUAL BASIS THE SECRETARY OF THE HOSPITAL SHALL SEND TO EACH PERSON WHO IS A TRUSTEE, OFFICER, OR MEMBER OF A COMMITTEE, AND TO THOSE EMPLOYEES OF THE HOSPITAL AS THE BOARD MAY DETERMINE, A COPY OF THE POLICY REGARDING CONFLICTS OF INTEREST, TOGETHER WITH A QUESTIONNAIRE INQUIRING AS TO CONFLICTS, TO BE COMPLETED AND RETURNED TO THE SECRETARY BY THE TRUSTEE, OFFICER, COMMITTEE MEMBER OR EMPLOYEE PRIOR TO THE BEGINNING OF EACH CALENDAR YEAR. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION FOR THE CEO IS REVIEWED ON AN ANNUAL BASIS. THE GOVERNANCE COMMITTEE ENGAGES AN OUTSIDE CONSULTANT TO DO A MARKET REVIEW AND COMPARISON. THE CONSULTANT WORKS DIRECTLY WITH THE GOVERNANCE COMMITTEE CHAIR AS WELL AS HUMAN RESOURCES TO COMPLETE THE ASSESSMENT AND MAKE A RECOMMENDATION. THE FINAL RECOMMENDATION IS BROUGHT BEFORE THE BOARD IN EXECUTIVE SESSION FOR FINAL APPROVAL. FORM 990, PART VI, SECTION C, LINE 19 THE CONFLICT OF INTEREST POLICY AND GOVERNING DOCUMENTS ARE AVAILABLE ON THE HOSPITAL WEBSITE. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST (FAS 136) 2,303. CHANGE IN POST RETIREMENT BENEFIT 70,192. FORM 990, PART XII, LINE 2C THERE HAVE NOT BEEN ANY CHANGES FROM THE PREVIOUS YEAR. SALEM HEALTH 890 OAK STREET SE SALEM OR 97301 930579722 HOSPITAL OR 501(C)(3) LINE 3 SALEM HEALTH HOSPITALS AND CLINICS 0 SALEM HEALTH FOUNDATION 890 OAK STREET SE SALEM OR 97301 237002687 SUPPORTS SALEM HOSPITAL OR 501(C)(3) LINE 12A, I SALEM HEALTH HOSPITALS AND CLINICS 0 SALEM HOSPITAL AUXILIARY 890 OAK STREET SE SALEM OR 97301 931081113 SUPPORTS SALEM HOSPITAL OR 501(C)(3) LINE 10 N/A 0 SALEM HEALTH HOSPITALS AND CLINICS 890 OAK STREET SE SALEM OR 97301 930823471 LEASES LAND TO SALEM HOSPITAL OR 501(C)(3) LINE 12A, I N/A 0 WEST VALLEY HOSPITAL FOUNDATION 525 SOUTHEAST WASHINGTON STREET DALLAS OR 97338 931298564 SUPPORTS WEST VALLEY HOSPITAL OR 501(C)(3) LINE 12A, I SALEM HEALTH HOSPITALS AND CLINICS 0 WILLAMETTE VALLEY INSURANCE COMPANY 745 FORT STREET HONOLULU HI 96813 201836190 CAPTIVE INSURANCE HI 501(C)(3) LINE 12A, I SALEM HEALTH HOSPITALS AND CLINICS 0 SALEM HEALTH PROFESSIONAL SERVICES 890 OAK STREET SE SALEM OR 97301 753175249 BILLING SERVICE FOR PROFESSIONAL SERVICES OR 501(C)(3) LINE 3 SALEM HEALTH HOSPITALS AND CLINICS 0 OHSU PARTNERS 3303 SW BOND AVE STE 6100 PORTLAND OR 97239 475584608 HEALTHCARE SYSTEM MANAGEMENT OR N/A POPULATION HEALTH ALLIANCE 601 SW 2ND AVE STE 1940 PORTLAND OR 97204 471546023 POPULATION HEALTH DATA MANAGEMENT OR N/A WILLAMETTE VALLEY COMMUNITY HEALTH 2995 RYAN DRIVE SE STE 200 SALEM OR 97301 455540852 COORDINATED CARE ORGANIZATION OR N/A 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 0 0