2017-11-15T19:49:35-06:00 2016-12-31 910189318 Moss Adams LLP 2707 Colby Avenue Suite 801 Everett WA 982013510 990 2016-01-01 910568304 GRAYS HARBOR COMMUNITY HOSPITAL GRAY 3605328330 915 ANDERSON DRIVE ABERDEEN WA 98520 Tom Jensen CEO 3605328330 2017-11-15 1 Robert Grannum P00355876 4252597227 2017-11-15 98.173.108.220 2017-11-15 18:04:24 PS P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 A3F8860C7B3207B175A22DC4681C7B3212A2E7B5 2016 2017-02-10 21:41:12Z Tom Jensen 915 ANDERSON DRIVE ABERDEEN WA 98520 114226684 0 X WWW.GHCares.ORG X 1938 WA TO HEAL, COMFORT AND SERVE OUR COMMUNITY WITH COMPASSION. 7 7 868 57 0 0 3996353 2559299 109023706 102980824 224458 -198776 213655 153596 113458172 105494943 51343 83402 0 0 55272058 56795046 0 0 0 54089776 51839610 109413177 108718058 4044995 -3223115 114894663 109809129 74187056 72324637 40707607 37484492 X TO HEAL, COMFORT AND SERVE OUR COMMUNITY WITH COMPASSION. 0 0 83497122 83402 102646380 SEE FORM 990, SCHEDULE O FOR STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS. 83497122 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 1 167 0 1 868 1 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X Niall Foley 3605376143 915 ANDERSON DRIVE ABERDEEN WA 98520 Maryann Welch President 2.00 2.00 X X 0 6840 0 Robert Torgerson Secretary 1.00 1.00 X X 0 4560 0 Andrew Bickar Board Member 1.00 1.00 X 0 1938 0 Armando Juarez Jr Board Member 1.00 1.00 X 0 2052 0 Miles Longenbaugh Board Member 1.00 1.00 X 0 3534 0 Pete Scroggs Board Member 1.00 1.00 X 0 0 0 Becky Walsh Board Member 1.00 1.00 X 0 4446 0 Tom Jensen CEO 40.00 X 386119 0 46178 Joseph Vessey CFO 40.00 X 207953 0 19182 Cynthia Walsh CNO 40.00 X 183520 0 25266 Larry Kahl COO 40.00 X 183978 0 36204 Anne Marie Wong MD CMO 40.00 X 194370 0 27200 Erin Kawasaki DO Orthopedic Surgeon 40.00 X 494886 0 13681 Justin Marasigan DO Gastroenterologist 40.00 X 435573 0 11533 Charles Roberson MD Orthopedic Surgeon 40.00 X 361359 0 7968 Joseph Stengel DO Radiologist 40.00 X 347432 0 10320 Patrick Henderson DO Otolaryngologist 40.00 X 421427 0 35990 3216617 23370 233522 62 0 1 0 Northwest Emergency Physicians 3455 S 344TH WAY FEDERAL WAY WA 98001 PHYSICIAN Services 2921878 NATIONAL THERAPEUTIC ASSOCIATES 11623 ARBOR ST OMAHA NE 68144 Physical Therapy Services 2415932 CHG Companies dba CompHealth PO Box 972651 Dallas TX 75397 Physician Locums Services 643308 HEALOGICS WOUND CARE & HYPERBARIC SERVIC 3087 MOMENTUM PLACE CHICAGO IL 60689 Medical Services 539018 Gregory May MD Inc PS 1211 Skyview Drive Aberdeen WA 98520 Surgeon 528486 22 2346933 21943 190423 2559299 NET PATIENT REVENUES 624100 102328339 102328339 CAFETERIA 722210 334444 334444 OTHER HOSPITAL OPERATING REVENUE 624100 164556 164556 INVESTMENT INCOME JV 621500 153485 153485 102980824 29613 29613 368082 214486 153596 153596 153596 8288866 8511485 5770 -222619 -5770 -228389 -228389 105494943 102646380 0 289264 X 83402 83402 1309970 994288 315682 41814986 31738243 10076743 1772653 1345472 427181 7942936 6028816 1914120 3954501 3001530 952971 157563 119593 37970 136453 136453 30000 22770 7230 22017468 16711611 5305857 251298 190739 60559 1029701 781560 248141 83228 63171 20057 2095633 1590619 505014 74722 56715 18007 148126 112430 35696 1648358 1251130 397228 4448148 3376216 1071932 346448 262960 83488 SUPPLIES 10151834 7705404 2446430 BAD DEBT EXPENSE 4489694 4489694 MAINTENANCE CONTRACTS 1754192 1331460 422732 TAXES AND LICENSES 1573024 1193950 379074 1403720 1045349 358371 108718058 83497122 25220936 0 11042951 9706185 218192 190588 13783094 19450152 27703459 25683995 1854067 1845007 668802 525981 109502109 68972591 43763170 40529518 6348588 6543840 3687519 3528700 5824821 1805163 114894663 109809129 16456518 16489504 332260 286260 32270569 30339872 282965 168308 1250000 1250000 23594744 23790693 74187056 72324637 X 40707607 37484492 40707607 37484492 114894663 109809129 -3223115 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 54929 54929 0 Part II-B, Line 1: THE PORTION OF WASHINGTON STATE HOSPITAL ASSOCIATION DUES RELATED TO LOBBYING WAS $21,045. The portion of Association of Washington Public Hopsital Districts dues related to Lobbying was $3,884. PAYMENTS TO NAVIGATION GROUP WERE $30,000 FOR CONSULTATION IN support of transition to a public health district. 1702265 1702265 36051 68958530 36827683 32166898 638108 536150 101958 37786141 31608758 6177383 381014 381014 40529518 FV INTEREST RATE SWAP 23790693 23790693 X Part X, Line 2: The hospital, as a political subdivision of the state of Washington, is not subject to federal income taxes under section 115 of the Internal Revenue Code. 1 1 1 X 1 X 1 1 0 1 1 994696 994696 0.00950 33268345 28951368 4316977 0.04140 1536953 1259751 277202 0.00270 35799994 30211119 5588875 0.05360 22384 22384 0.00020 20612 7549 13063 0.00010 17906070 13663867 4242203 0.04070 19270 19270 0.00020 17968336 13671416 4296920 0.04120 53768330 43882535 9885795 0.09480 1 4489694 27130560 33751547 -6620987 X 1 1 1 Grays Harbor Imaging Stand Alone Imaging Facility 0.50000 0.50000 1 1 GRAYS HARBOR COMMUNITY HOSPITAL 915 ANDERSON DRIVE ABERDEEN WA 98520 X X X GRAYS HARBOR COMMUNITY HOSPITAL 1 0 0 0 1 1 50000 1 X 100.000000000000 300.000000000000 X X 1 1 X X X 1 X See Part V, Page 7 X http://www.ghcares.org/media/1013/financial_assistance.pdf X http://www.ghcares.org/media X X X X X X X 1 X 0 X X X X 1 X 0 0 GRAYS HARBOR COMMUNITY HOSPITAL Part V, Section B, Line 16j: notice OF our fap are printed on the billing invoice, posted throughout the facility and included in our 4-step pamphlet given to all patients upon registering for services. GRAYS HARBOR COMMUNITY HOSPITAL Part V, Section B, Line 24: The gross charges are consistent for all patients, regardless of ability to pay, as the bill is processed. As discounts are taken for insurance and Medicare at time of payment, adjustments are entered on the patient account for financial assistance approvals based on ability to pay. Part V, Section B, Line 16a http://www.ghcares.org/media/1219/ghch-charity-care-policy-and-procedure-12012016.doc 6 1 - REHAB VISIONS ELMA PHYSICAL THERAPY 575 East Main St elma WA 98541 PHYSICAL THERAPY PRACTICE 2 - Rehab Visions Physical Therapy 801 N Montesano St Ste 300 westport WA 98595 PHYSICAL THERAPY PRACTICE 3 - Pacific Internal Medicine 815 K St hoquiam WA 98550 PHYSICIANS PRACTICE 4 - Montesano Clinic 319 E Pioneer Ave montesano WA 98563 PHYSICIANS PRACTICE 5 - Harbor Pediatrics 615 F St aberdeen WA 98520 PHYSICIANS PRACTICE 6 - Grays Harbor Imaging 1108 Basich Blvd aberdeen WA 98520 MEDICAL IMAGING Part I, Line 7: A cost-to-charge ratio derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges was used. 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 $ 4,489,694. Part II, Community Building Activities: THE HOSPITAL PROVIDES THE GRAYS HARBOR COMMUNITY COLLEGE RN PROGRAM WITH A FREE CLINICAL TRAINING SITE AS WELL AS SKILLS LAB PRACTICE WITH OUR HIGH-FIDELITY HUMAN PATIENT SIMULATORS. THE HOSPITAL EDUCATION DEPARTMENT PARTNERS WITH TWIN HARBORS BRANCH SKILLS CENTER IN EDUCATING 10-20 LOCAL HIGH SCHOOL STUDENTS EACH YEAR WHO ARE INTERESTED IN ENTERING INTO THE HEALTHCARE FIELD. A MEMBER OF OUR MEDICAL STAFF SERVICES DEPARTMENT ACTS AS THE REGIONAL COORDINATOR FOR PACIFIC NORTHWEST UNIVERSITY IN PROVIDING CLINICAL ROTATION AND DIDACTIC SESSIONS. Part III, Line 2: THE ORGANIZATION'S BAD DEBT EXPENSE HAS THREE COMPONENTS; THE FIRST COMPONENT IS THE ACCOUNTS THAT ARE SENT TO A BILLING SERVICE FOR PAYMENT OVER TIME A PORTION OF WHICH IS CONSIDERED UNREALIZABLE. THE SECOND COMPONENT IS THE AMOUNT COLLECTED FROM COLLECTION EFFORTS. THE THIRD IS AN ESTIMATE OF A PORTION OF OUR ACCOUNTS RECEIVABLES THAT WILL BECOME BAD DEBT BASED ON EXPERIENCE AND ANY UNUSUAL CIRCUMSTANCES THAT MAY AFFECT THE ABILITY OF PATIENTS TO MEET THEIR OBLIGATIONS. AN ANALYSIS OF ACCOUNTS RECEIVABLE IS DONE TO DETERMINE WHICH ACCOUNTS ARE DEEMED UNCOLLECTIBLE. ACCOUNTS DEEMED UNCOLLECTIBLE ARE CHARGED AGAINST THIS ALLOWANCE. WHEN A PAYMENT IS RECEIVED ON A PATIENT ACCOUNT THAT WAS REPORTED A BAD DEBT, THE PAYMENT IS POSTED TO THE BAD DEBT RECOVERY GENERAL LEDGER ACCOUNT. Part III, Line 3: THE HOSPITAL DOES NOT HAVE SYSTEMS IN PLACE TO TRACK OR ESTIMATE BAD DEBT EXPENSE ATTRIBUTABLE TO ELIGIBLE PATIENTS. OUR CHAIRTY CARE PROCESS INVOLVES LOOKING AT PATIENTS' INCOME AND DEPENDENT STATUS ACCORDING TO WASHINGTON STATE GUIDELINES. OUR BAD DEBT EXPENSE IS THE RESULT OF SEEING PATIENTS REGARDLESS OF THEIR ABILITY TO PAY AND IS AN INDICATION OF THE LOCAL ECONOMY. THE UNEMPLOYEMENT RATE IN GRAYS HARBOR IS CURRENTLY THE HIGHEST IN WESTERN WASHINGTON. THIS IS ABSOLUTELY A COMMUNITY BENEFIT. Part III, Line 4: THE FOOTNOTE DISCUSSING BAD DEBT EXPENSE AND ALLOWANCE FOR DOUBTFUL ACCOUNTS IS ON PAGE 15 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS. Part III, Line 8: All of the medicare shortfall should be considered a community benefit. If costs are not fully reimbursed, but services associated with those costs must be provided, then it must be for the benefit of someone other than the provider, i.e. the community. To determine the amount of allowable costs reported, proprietary software approved by CMS is utilized to allocate overhead using the step down method. Part III, Line 9b: Patients without medical insurance benefits will explore payment alternatives with a Financial Counselor or Patient Account Representative. The Hospital provided financial counseling for those who will find those alternatives an extreme financial hardship. Charity care is provided and those individuals are encouraged to fill out an application. The Hospital shall provide final determination within 14 days of receipt of all application and documentation material.Patients that request charity are allowed time to complete the process and once we have all of the information needed to make a determination the account is "held" from collection activity and not expected to make a payment. Once a determination is made and if there is still a patient balance, the patient resumes being responsible for the balance of the account and expected to make payment arrangements if unable to pay in full. Part VI, Line 2: We utilize data and information pulled together by Grays Harbor County Public Health Department. This provides very good data on the state of our community's health and helps us establish priorities. Part VI, Line 3: GRAYS HARBOR COMMUNITY HOSPITAL EMPLOYS STATE CERTIFIED FINANCIAL COUNSELORS TO NAVIGATE PATIENTS THROUGH THE BILLING AND FINANCIAL ASSISTANCE ELIGIBILITY PROCESS. COUNSELORS CONTACT PATIENTS BY PHONE AND MAIL TO EXPEDITE SCREENING FOR FINANCIAL AID OR OTHER FEDERAL OR STATE GOVERNMENT PROGRAM ELIGIBILITY. THE FINANCIAL AID PROGRAM IS POSTED IN THE EMERGENCY ROOM AS WELL AS REGISTRATION. FINANCIAL ASSISTANCE INFORMATION IS PRINTED ON THE FIRST ITEMIZED STATEMENT AND ALL MONTHLY STATEMENTS ISSUED THEREAFTER. Part VI, Line 4: GRAYS HARBOR COMMUNITY HOSPITAL IS A NOT FOR PROFIT RURAL ACUTE CARE COMMUNITY HOSPITAL SERVING TWO COASTAL COUNTIES IN WASHINGTON STATE, GRAYS HARBOR AND PACIFIC COUNTY. ESTABLISHED IN 1945 IT PROVIDES SERVICES TO THE COMMUNITY PRIMARILY COMPOSED OF MEN, WOMEN, AND CHILDREN SUPPORTED BY TIMBER, FISHING, AND AGRICULTURAL INDUSTRIES. THE HOSPITAL IS LICENSED FOR 140 BEDS, WITH 105 CURRENTLY IN SERVICE. IT IS A LEVEL 3 TRAUMA CENTER THAT SERVES THE ENTIRE PACIFIC COAST OF WASHINGTON STATE. THE TWO CLOSEST HOSPITALS (OUTSIDE OF A CRITICAL ACCESS FACILITY) ARE LOCATED 47 AND 52 MILES EAST IN OLYMPIA. THE CLOSEST LEVEL 1 TRAUMA CENTER IS LOCATED 110 MILES NORTHEAST IN SEATTLE.GRAYS HARBOR COUNTY'S UNEMPLOYMENT RATE CONSISTENTLY TRENDS HIGHER THAN THE WASHINGTON STATE UNEMPLOYMENT RATE. THE CURRENT RATE AS OF SEPTEMBER 2017 IS 6.1% COMPARED TO 4.6% FOR THE STATE.IN 2014, THERE WERE 21,769 JOBS IN GRAYS HARBOR COUNTY COVERED BY UNEMPLOYMENT INSURANCE, WITH A TOTAL PAYROLL OF OVER $801.8 MILLION. THE AVERAGE ANNUAL WAGE IN 2014 WAS $36,834, WELL BELOW THE STATE'S AVERAGE ANNUAL WAGE OF $55,003. THE MEDIAN HOURLY WAGE IN 2014 WAS $18.60, BELOW THE SATES'S MEDIAN HOURLY WAGE OF $22.61.IN 2014, GRAYS HARBOR COUNTY'S POVERTY RATE OF 18.6 PERCENT WAS WELL ABOVE WASHINGTON STATE'S RATE OF 13.2 PERCENT AND THE NATION'S RATE OF 14.8 PERCENT, ACCORDING TO U.S CENSUS BUREAU QUICKFACTS.IN THE COUNTY, 86.5 PERCENT OF PERSONS AGE 25 OR OLDER WERE HIGH SCHOOL GRADUATES, COMPARED TO 90.2 PERCENT STATEWIDE. THE NUMBERS HOLDING A BACHELOR'S DEGREE OR HIGHER WERE 15 PERCENT COMPARED TO THE STATE'S 32.3 PERCENT. Part VI, Line 5: THE HOSPITAL IS GOVERNED BY A BOARD OF DIRECTORS THAT IS MADE UP OF MEMBERS ELECTED BY THE VOTERS AS COMMISSIONERS OF THE GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT #2 AND OPEN MEDICAL STAFF. THE HOSPITAL PROVIDES FREE MEETING SPACE TO ALCOHOLICS ANONYMOUS, NARCOTICS ANONYMOUS, OVEREATERS ANONYMOUS, DIABETES PREVENTION, AND FOSTER PARENT TRAINING, AMONG OTHERS. Part VI, Line 6: N/A Part VI, Line 7 N/A 1 GRAYS HARBOR PUBLIC HOSPITAL DISTRICT #2 915 ANDERSON DRIVE ABERDEEN WA 98520 383941437 Public Hospital Dist 83402 Support operating costs. 1 0 Part I, Line 2: The only grants are provided to the sole member, Grays County Public Hospital District #2 to support costs. Reports of the costs are provided to the organization and supporting records are maintained. X X X X 0 0 0 0 0 0 0 0 0 Tom Jensen CEO 328561 0 0 0 57558 0 10600 0 35578 0 432297 0 0 0 Joseph Vessey CFO 200595 0 0 0 7358 0 4320 0 14862 0 227135 0 0 0 Cynthia Walsh CNO 178123 0 0 0 5397 0 7111 0 18155 0 208786 0 0 0 Larry Kahl COO 175197 0 0 0 8781 0 7040 0 29164 0 220182 0 0 0 Anne Marie Wong MD CMO 194370 0 0 0 0 0 7950 0 19250 0 221570 0 0 0 Erin Kawasaki DO Orthopedic Surgeon 449254 0 45632 0 0 0 7950 0 5731 0 508567 0 0 0 Justin Marasigan DO Gastroenterologist 405259 0 30314 0 0 0 3750 0 7783 0 447106 0 0 0 Charles Roberson MD Orthopedic Surgeon 304981 0 56378 0 0 0 7950 0 18 0 369327 0 0 0 Joseph Stengel DO Radiologist 347432 0 0 0 0 0 0 0 10320 0 357752 0 0 0 Patrick Henderson DO Otolaryngologist 386215 0 35212 0 0 0 7950 0 28040 0 457417 0 0 0 A WASHINGTON HEALTH CARE FACILITIES AUTHORITY 911108929 93978EE65 2007-01-23 32400000 REFUNDING/FUNDING TO CONSTRUCT NEW EMERGENCY DEPARTMENT. 0 0 0 B WASHINGTON HEALTH CARE FACILITIES AUTHORITY 911108929 NONAVAILA 2011-12-18 12150000 EQUIPMENT PURCHASES AND CONSTRUCTION 0 0 0 A 32361173 2064310 635662 796952 10746270 13275369 2008 1 1 1 1 B 12150000 150000 11066561 933439 2015 0 0 1 1 A 0 0 1 1 0 0.02000 0.02000 0 0 1 B 0 0 0 0 0 0 1 A 1 1 1 PIPER JAFFREY 23.500000000000 0 0 0 0 1 B 0 0 0 1 1 0 0 0 1 A 1 B 1 Date Rebate Computation Performed Issuer Name: WASHINGTON HEALTH CARE FACILITIES AUTHORITY Date the Rebate Computation was Performed: 12/20/2011 FORM 990, PART III, LINE 4A: Grays Harbor Community Hospital provides quality health care services 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 of Grays Harbor Community Hospital, we recognize that not all individuals possess the ability to purchase essential medical services. Our mission "To Heal, Comfort, and Serve our Community with Compassion" encompasses the provision of health care services and education to any and all members of our community. Free care and/or subsidized care; care provided to persons covered by the governmental programs at below cost; and health activities and programs to support the community are considered where the need and/or an individual's inability to pay co-exists. During 2016, Grays Harbor Community Hospital cared for 3,408 inpatients and provided medical services to 104,907 outpatients. In alignment with our mission to the community, services are provided to all patients regardless of the ability to pay. To the extent reimbursement is below costs, Grays Harbor Community Hospital recognizes these amounts as charitable care in meeting its mission to the entire community. The un-reimbursed value for providing care to these patients was $994,697. Charity care is also provided through many reduced-priced services and free programs offered throughout the year. These are activities and services which Grays Harbor Community Hospital believes serve to meet bona fide community health needs. The community plays a major role through voluntary assistance in helping Grays Harbor Community Hospital provide quality services. In 2016, fifty-six (56) volunteers, provided 10,273 hours of service at a value of $202,289 for Grays Harbor Community Hospital. Areas of assistance included patient assistance, gift shop assistance, sewing, receptionists, administrative aides, etc. In conjunction with providing health care in the community, educational programs, clinics and activities were provided to physicians and office personnel, long term care facilities, community members, and schools in our surrounding area during 2016, including: Provided regular meeting facilities for nonprofit organizations and support groups for alcohol, drug and nutrition abuse including 7th Street Kids Community Theatre Group, Alcoholics Anonymous, Narcotics Anonymous, Back to Basics, Diabetes Prevention Program, Toastmasters, Adult Children of Alcoholics, AAPC Coders, Alanon, United Way, American Heart Association, American Cancer Society, Foster Parent Training, Gluten Free Living support group, Look Good, Feel Better, Breast Cancer support group, Narcotics Anonymous, National Alliance for Mental Illness, Overeaters Anonymous and TOPS International. Facilities are provided free of charge. Special community support was provided in 2016 which included - Free blood pressure screening - Free Chronic Disease Self-Management Program a 6-week workshop - Free Falls Assessments - Greater Grays Harbor, Inc. Volunteer Chairman and Membership Support - Career fairs for high schools and college students - Job shadowing for high school students students accompany and observe staff in the performance of their regular job duties - Falls Prevention programs for senior citizens - Business Week mentoring at local high schools - Public Relations and Women's Health presentations to local Civic Groups - Wound Healing, RehabVisions, Family Birth Center, HarborCrest and Emergency Department participation in local Greater Grays Harbor free public information EXPO - Instruction in Twin Harbors Professional Medical Careers high school program Contributed donations to numerous community support programs and projects: - Hoquiam High Schools Yearbook Support - The YMCA of Grays Harbor "Strong Kids" program - Hoquiam Logger's Playday - American Cancer Society Relay for Life - United Way of Grays Harbor - Union Gospel Mission Form 990, Part VI, Section A, line 6 The sole member of the Corporation is Grays Harbor Public Hospital District No. 2. Form 990, Part VI, Section A, line 7a As the sole member, the District has the right and power to appoint and remove all members of the Corporation's board of directors including the right to appoint the members of the District's Board of Commissioners as the sole members of the Corporation's board of directors. Form 990, Part VI, Section A, line 7b The District has the right and power to do the following: approve any amendments to the Corporation's article of incorporation or bylaws; approve any merger or consolidation of the Corporation; approve the sale, conveyance, mortgage, pledge, lease, exchange, gift, transfer or other disposition of any property or assets of the Corporation; approve the incurrence or guarantee of any indebtedness of the Corporation; appoint or remove the Corporation's chief executive officer; approve or amend the Corporation's annual operating and capital budget; approve or amend the annual operating or strategic plan for the Corporation or the Hospital; approve any action that would result in the Hospital's closure or the loss of the Hospital's license; and approve any decision to cease the Corporation's activities, dissolve the Corporation or distribute the assets of the Corporation. Form 990, Part VI, Section B, line 11b AFTER PREPARATION OF FORM 990, IT IS REVIEWED BY THE CFO AND SUBMITTED TO THE BOARD OF TRUSTEES PRIOR TO BEING FILED WITH THE INTERNAL REVENUE SERVICE. Form 990, Part VI, Section B, line 12c ANY CONTRACTUAL ARRANGEMENT, PARTNERSHIP, AGREEMENT OR FIDUCIARY RELATIONSHIP ENTERED INTO BY GRAYS HARBOR COMMUNITY HOSPITAL AND ANY OTHER PARTY THAT WILL AFFECT THE MISSION, VISION OR VALUES OF THE HOSPITAL, MUST RESPECT AND ABIDE BY THE POLICIES, PROCEDURES AND DIRECTIVES OF GRAYS HARBOR COMMUNITY HOSPITAL. IT IS THE POLICY OF GRAYS HARBOR COMMUNITY HOSPITAL THAT NO HEALTH CARE PROVIDER, EMPLOYEE, STAFF MEMBER OR OTHER HOSPITAL PERSONNEL SHOULD USE HIS OR HER POSITION OR ANY KNOWLEDGE GAINED AS A RESULT OF HIS OR HER POSITION, IN ANY MANNER SUCH THAT A CONFLICT DOES OR MAY ARISE BEETWEEN THE HOSPITAL'S INTERESTS AND HIS OR HER PERSONAL INTERESTS. A PERSON VIOLATING THIS POLICY MAY BE SUBJECT TO DISCIPLINARY ACTION IN ACCORDANCE WITH HUMAN RESOURCES POLICY. BOARD MEMBERS ANNUALLY SIGN CONFLICT OF INTEREST QUESTIONNAIRES AND THESE ARE REVIEWED BY THE COMPLIANCE DEPARTMENT FOR ANY POTENTIAL CONFLICTS OF INTEREST. IF A CONFLICT ARISES THE BOARD MEMBER MUST EXCUSE THEMSELVES FROM DISCUSSION OF AND VOTING ON THE ISSUE. IF A BOARD MEMBER IS AN OWNER IN A COMPANY THAT IS CAUSING THE CONFLICT OF INTEREST A CONTACT OF THE COMPANY OTHER THAN THE BOARD MEMBER MUST REPRESENT THE COMPANY IN NEGOTIATIONS WITH THE HOSPITAL FOR CONTRACTS AT FAIR MARKET VALUE. ESSENTIALLY THE BOARD MEMBER CANNOT BE INVOLVED IN THE TRANSACTION IN ANY WAY. Form 990, Part VI, Section B, line 15 In September 2013, a three-year contract was offered by the Board of Directors and signed by the CEO. That contract set forth salary levels for the years 2013 to 2016. At the time of the contract negotiations, salary survey information from the Washington State Hospital Association (WSHA) Executive survey, completed by Gallagher Benefits on the behalf of WSHA, had been provided to the Board of Directors. In 2014 we participated in the Milliman Northwest Health Care Executive Compensation Survey which gathered information on not only the CEO but also 27 other executive level positions. The survey results were given to the CEO by the Executive Director of Human Resources and utilized by the CEO in developing market-based salary information for the other executive level positions. Form 990, Part VI, Section C, line 19 THE ORGANIZATION MAKES ITS Audited financial statements, CONFLICT OF INTEREST POLICY, AND OTHER GOVERNANCE DOCUMENTS AVAILABLE UPON REQUEST. DOCUMENTS ARE MAINTAINED IN THE OFFICE OF THE CEO. COPIES MAY BE OBTAINED BY CONTACTING JOSEPH VESSEY, CFO. Form 990, Part IX, line 11g other Fees: Program service expenses 2,756,790. Management and general expenses 875,267. Fundraising expenses 0. Total expenses 3,632,057. Purchased Services: Program service expenses 6,709,986. Management and general expenses 2,130,389. Fundraising expenses 0. Total expenses 8,840,375. Professional Fees: Program service expenses 7,244,835. Management and general expenses 2,300,201. Fundraising expenses 0. Total expenses 9,545,036. GRAYS HARBOR COMMUNITY HOSPITAL PHYSICIAN SERVICES LLC 915 ANDERSON DRIVE ABERDEEN WA 98520 260767953 ESTABLISH AND MAINTAIN MEDICAL SERVICE CLINICS IN MONTESANO & HOQUIAM, WA WA 6229685 2600790 GRAYS HARBOR COMMUNITY HOSPITAL GRAYS HARBOR COMMUNITY HOSPITAL FOUNDATION 915 ANDERSON DRIVE ABERDEEN WA 98520 911122992 ADVOCACY AND FUNDRAISING SUPPORT SERVICES TO GRAYS HARBOR HOSPITAL WA 501(C)(3) Line 12a, I Grays Harbor Community Hospital 1 Grays Harbor Public Hospital District #2 915 ANDERSON DRIVE ABERDEEN WA 98520 383941437 To support health care for the Grays Harbor County community WA 501(c)(3) Line 6 N/A 0 Grays Harbor Imaging LLC 3417 ENSIGN RD NE OLYMPIA WA 98506 753083721 MEDICAL IMAGING WA N/A RELATED 153485 256972 0 1 0.50000 0 1 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 Grays harbor Public Hospital District #2 B 83402 cOST Grays harbor Public Hospital District #2 C 2260000 cOST GRAYS HARBOR COMMUNITY HOSPITAL FOUNDATION C 86933 COST Grays Harbor Imaging S 427500 cOST