2017-11-14T18:30:05-06:00 2016-12-31 930418710 DELAP LLP 5885 MEADOWS ROAD NO 200 LAKE OSWEGO OR 97035 990 2016-01-01 930415219 SANTIAM MEMORIAL HOSPITAL SANT 5037692175 1401 N 10TH AVENUE STAYTON OR 973831311 TERRY FLETCHALL CEO 5037692175 2017-11-13 1 MARK E EKLUND CPA P00156145 5036974118 2017-11-13 76.14.192.226 2017-11-13 09:29:00 PS P BED54D2DEB6E9258230C084D8939139CD33CD9C2 A037F773A43E5D098BFBF49CACF0A7B31F1836C7 2016 2021-01-29 14:40:06Z TERRY FLETCHALL 1401 N 10TH AVENUE STAYTON OR 973831311 47005063 0 X WWW.SANTIAMHOSPITAL.ORG X 1950 OR GENERAL ACUTE HEALTH CARE HOSPITAL SERVING SANTIAM COMMUNITIES 9 9 451 15 0 0 163242 25444 42319756 46284802 24294 142244 306269 223649 42813561 46676139 38853 43618 0 0 24071350 26978191 0 0 0 16983573 18043488 41093776 45065297 1719785 1610842 56699850 58737185 32216050 32538033 24483800 26199152 SANTIAM MEMORIAL HOSPITAL'S MISSION IS TO PROVIDE QUALITY HEALTH CARE TO PERSONS SUFFERING FROM ILLNESS, INJURIES, OR DISABILITIES AND TO PROMOTE THE GENERAL HEALTH AND WELFARE OF THE COMMUNITY THROUGH EDUCATION, SUPPORT, AND MEDICAL SERVICES. 0 0 39683384 43618 46331951 ACUTE HOSPITAL CARE: PATIENT DAYS 3,201, NURSERY DAYS 126, AMBULANCE TRIPS 1,967, OUTPATIENT DAYS 43,121, REFERENCE LABORATORY 135,527. 39683384 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 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 1 1 0 0 0 1 84 0 451 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OR X X TERRY FLETCHALL 5037692175 1401 N 10TH AVENUE STAYTON OR 97383 RON ETZEL SECRETARY 3.00 X X 0 0 0 VICTOR KINTZ DIRECTOR 3.00 X 0 0 0 MARYANN MEREDITH VICE PRESIDENT 3.00 X X 0 0 0 MIKE ODENTHAL DIRECTOR 3.00 X 0 0 0 RANDY MICKEY PRESIDENT 3.00 X X 0 0 0 GEORGE LONG DIRECTOR 3.00 X 0 0 0 JUANITA CULVER DIRECTOR 3.00 X 0 0 0 NORM RAUSCHER DIRECTOR 3.00 X 0 0 0 TERRY FLETCHALL CEO 50.00 X 269713 0 54088 MAGGIE HUDSON CFO/COO 50.00 X 223748 0 40309 GENNY BALDWIN CHIEF NURSING OFFICER 50.00 X 169001 0 22127 JOHN HOFFMAN M.D. 40.00 X 401159 0 28208 JOHN SILVER M.D. 40.00 X 381156 0 27397 SUSAN TAYLOR M.D. 40.00 X 301165 0 19488 KALSANG PHUNTSHOG M.D. 32.00 X 286791 0 28208 NICOLAS J STRATTON M.D. 40.00 X 401159 0 27397 2433892 0 247222 36 0 1 0 ROBERT L JACQUES MD 5419 SW SCHOLLS FERRY ROAD PORTLAND OR 97225 HOSPITALIST 424695 STEPHEN P MOON MD 16788 SW SARALA ST ALOHA OR 97007 EMERGENCY ROOM PHYSICIAN 302405 MILLER NASH LLP PO BOX 3585 PORTLAND OR 97208 LEGAL SERVICES 284050 OMAC ADVERTISING 2573 12TH STREET SE SALEM OR 97302 ADVERTISING SERVICES 256841 EDWARD HC JUNN MD 9742 NW SKYVIEW DR PORTLAND OR 97231 EMERGENCY ROOM PHYSICIAN 245393 13 25444 25444 PATIENT SERVICE REVENUE - NET 622110 45836841 45836841 K-1, INCOME FROM CCO 900099 481967 481967 ELECTRONIC HLTH RECORDS 990009 -34006 -34006 46284802 37923 37923 49900 103864 -53964 -53964 -53964 160907 168474 164885 60175 -3978 108299 104321 104321 CAFETERIA REVENUE 722210 176500 176500 OTHER MISC. REVENUE 900099 101113 101113 277613 46676139 46331951 0 318744 43618 43618 776681 776681 20197178 19234506 962672 538692 495714 42978 4054145 3429588 624557 1411495 1266795 144700 102566 102566 248899 248899 3527242 2851645 675597 717089 717089 553444 143275 410169 332090 332090 1815334 1815334 63 63 2182943 2114644 68299 256728 34571 222157 SUPPLIES 6102767 6102767 CLINIC EXPENSE 1550623 1550623 EQUIPMENT MAINTENANCE 546489 552571 -6082 MISCELLANEOUS 57678 44831 12847 49533 2902 46631 45065297 39683384 5381913 0 240 240 11050030 11725228 4899968 6139086 309916 263681 1316628 1368540 832676 632887 55801493 22721778 33502045 33079715 998415 1192874 272728 272728 3268203 3013065 249001 1049141 56699850 58737185 3446791 3819725 27711460 26864456 1057799 1853852 32216050 32538033 X 24483800 26199152 24483800 26199152 56699850 58737185 X 1610842 43473 61037 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 330620 1144800 1475420 1864409 36082071 10836664 27109816 619850 521309 98541 10000 15603719 11363805 4249914 146024 146024 33079715 EST 3RD PARTY PAYOR SETTLEMENTS 52000 OTHER LONG-TERM LIABILITIES 1801852 1853852 X 46780649 43473 550000 593473 46187176 488963 488963 46676139 45065297 0 45065297 0 45065297 PART X, LINE 2: IT IS MANAGEMENT'S BELIEF THAT NONE OF THE HOSPITAL'S ACTIVITIES HAVE GENERATED MATERIAL UNRELATED BUSINESS INCOME; THEREFORE, NO PROVISION FOR INCOME TAXES HAS BEEN MADE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. INCOME TAX POSITIONS THAT MEET A "MORE-LIKELY-THAN-NOT" RECOGNITION THRESHOLD ARE MEASURED AT THE LARGEST AMOUNT OF INCOME TAX BENEFIT THAT IS MORE THAN 50% LIKELY TO BE REALIZED UPON SETTLEMENT WITH THE APPLICABLE TAXING AUTHORITY. THE PORTION OF THE BENEFITS ASSOCIATED WITH INCOME TAX POSITIONS TAKEN THAT EXCEEDS THE AMOUNT MEASURED AS DESCRIBED ABOVE WOULD BE REFLECTED AS A LIABILITY FOR UNRECOGNIZED INCOME TAX BENEFITS IN THE HOSPITAL'S CONSOLIDATED BALANCE SHEETS ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. INTEREST AND PENALTIES ASSOCIATED WITH UNRECOGNIZED INCOME TAX BENEFITS WOULD BE CLASSIFIED AS INCOME TAXES IN THE HOSPITAL'S CONSOLIDATED STATEMENTS OF OPERATIONS AND CHANGES IN UNRESTRICTED NET ASSETS. THERE WERE NO UNRECOGNIZED INCOME TAX BENEFITS, NOR ANY INTEREST AND PENALTIES ASSOCIATED WITH UNRECOGNIZED INCOME TAX BENEFITS, ACCRUED OR EXPENSED AS OF AND FOR THE YEARS ENDED DECEMBER 31, 2016 AND 2015. PART XI, LINE 2D - OTHER ADJUSTMENTS: DISTRIBUTIONS, WILLAMETTE VALLEY COMMUNITY HEALTH, LLC 550,000. PART XI, LINE 4B - OTHER ADJUSTMENTS: REVENUE FROM K-1, WILLAMETTE VALLEY COMMUNITY HEALTH, LLC 488,963. 1 1 1 X 1 X 1 1 1 0 1 1 1538 670329 670329 0.01490 9442458 7878489 1563969 0.03470 1538 10112787 7878489 2234298 0.04960 3133 248835 6580 242255 0.00540 175183 175183 0.00390 43618 43618 0.00100 3133 467636 6580 461056 0.01030 4671 10580423 7885069 2695354 0.05990 1 2015016 4114231 5778576 -1664345 X 1 1 1 1 SANTIAM MEMORIAL HOSPITAL 1401 N 10TH AVENUE STAYTON OR 973831311 WWW.SANTIAMHOSPITAL.ORG 14-0709 X X X SANTIAM MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 15 1 1 0 1 X WWW.SANTIAMHOSPITAL.ORG 1 16 1 HTTP://SANTIAMHOSPITAL.ORG/RESOURCES.PHP 0 1 X 200.000000000000 300.000000000000 X X X X 1 1 X X 1 X HTTP://WWW.SANTIAMHOSPITAL.ORG/PAT_FINANCIAL.PHP X HTTP://WWW.SANTIAMHOSPITAL.ORG/PAT_FINANCIAL.PHP X HTTP://WWW.SANTIAMHOSPITAL.ORG/PAT_FINANCIAL.PHP X X X X X X 1 X 0 X X X 1 X 0 0 SANTIAM MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: CONSULTED WITH MARION COUNTY DEPARTMENT OF HEALTH AND OTHER COMMUNITY MEMBERS REGARDING THE NEEDS OF STAYTON AND SURROUNDING AREAS SERVED. SANTIAM MEMORIAL HOSPITAL PART V, SECTION B, LINE 6A: SALEM HEALTH SYSTEM, SILVERTON HOSPITAL NETWORK SANTIAM MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: CHIP PLANNING IMPLEMENTED IN 2016 12 1 - SUBLIMITY MEDICAL CLINIC 114 SE CHURCH ST SUBLIMITY OR 97325 PHYSICIAN CLINIC 2 - AUMSVILLE MEDICAL CLINIC 205 MAIN ST AUMSVILLE OR 97325 PHYSICIAN CLINIC 3 - SANTIAM MEDICAL CLINIC 280 S FIRST AVENUE MILL CITY OR 97360 PHYSICIAN CLINIC 4 - CASCADE MEDICAL CLINIC 1375 N 10TH AVENUE STE B STAYTON OR 97383 PHYSICIAN CLINIC 5 - SANTIAM PULMONARY CLINIC 1401 N 10TH AVENUE STE B STAYTON OR 97383 PHYSICIAN CLINIC 6 - SANTIAM INTERNAL MEDICINE CLINIC 1401 N 10TH AVENUE STE 200 STAYTON OR 97383 PHYSICIAN CLINIC 7 - SANTIAM ORTHOPAEDIC CLINIC 1369 N 10TH AVENUE STAYTON OR 97383 PHYSICIAN CLINIC 8 - SANTIAM WOMEN'S CLINIC 1373 N 10TH AVENUE STAYTON OR 97383 PHYSICIAN CLINIC 8 - SANTIAM MEDICAL ASSOCIATES 1401 N 10TH AVENUE STE 100 STAYTON OR 97383 PHYSICIAN CLINIC 9 - SANTIAM SURGERY CLINIC 1371 N 10TH AVENUE STAYTON OR 97383 PHYSICIAN CLINIC 10 - STAYTON FAMILY PRACTICE 1375 N 10TH AVE SUITE A STAYTON OR 97383 PHYSICIAN CLINIC 11 - NORTH SANITAM PODIATRY CLINIC 1375 N 10TH AVE SUITE B STAYTON OR 97383 PHYSICIAN CLINIC PART III, LINE 4: [NOTE: SEE PAGES 9-10 OF THE FINANCIAL STATEMENTS]PATIENT ACCOUNTS RECEIVABLE AND ALLOWANCE FOR DOUBTFUL ACCOUNTS:THE COLLECTION OF RECEIVABLES FROM THIRD-PARTY PAYORS AND PATIENTS IS THE HOSPITAL'S PRIMARY SOURCE OF CASH AND IS CRITICAL TO ITS OPERATING PERFORMANCE. WHEN THE HOSPITAL PROVIDES CARE TO PATIENTS, IT DOES NOT REQUIRE COLLATERAL; HOWEVER, IT MAINTAINS AN ESTIMATED ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE PRIMARY COLLECTION RISKS RELATE TO UNINSURED PATIENT ACCOUNTS AND PATIENT ACCOUNTS FOR WHICH THE PRIMARY INSURANCE PAYOR HAS PAID, BUT THE PATIENT IS RESPONSIBLE FOR THE REMAINING AMOUNT OUTSTANDING (GENERALLY DEDUCTIBLES AND CO PAYMENTS). THE HOSPITAL DOES NOT MAINTAIN A SIGNIFICANT ALLOWANCE FOR DOUBTFUL ACCOUNTS RELATED TO PATIENT ACCOUNTS RECEIVABLE FROM THIRD-PARTY PAYORS, NOR HAS IT HISTORICALLY HAD SIGNIFICANT BAD DEBT WRITE-OFFS OF PATIENT ACCOUNTS RECEIVABLE FROM THIRD-PARTY PAYORS. HOWEVER, FOR SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL RECORDS THE RELATED PATIENT SERVICE REVENUE AND PATIENT ACCOUNTS RECEIVABLE NET OF CONTRACTUAL DISCOUNTS AND ALLOWANCES. FOR PATIENT ACCOUNTS RECEIVABLE DUE FROM SELF-PAY PATIENTS - WHICH INCLUDE BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL - THE HOSPITAL RECORDS A SIGNIFICANT ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IS ESTIMATED BASED PRIMARILY UPON THE HOSPITAL'S HISTORICAL COLLECTION EXPERIENCE, THE AGE OF PATIENTS' ACCOUNTS, MANAGEMENT'S ESTIMATE OF ITS PATIENTS' 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 WHICH MIGHT ULTIMATELY AFFECT THE COLLECTABILITY OF PATIENT ACCOUNTS WHEN CONSIDERING THE ADEQUACY OF THE AMOUNTS RECORDED IN THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE DIFFERENCE BETWEEN THE HOSPITAL'S STANDARD RATES (OR THE DISCOUNTED RATES, IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. RECOVERIES OF AMOUNTS CHARGED OFF ARE ADDED TO THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. ACTUAL WRITE-OFFS HAVE HISTORICALLY BEEN WITHIN MANAGEMENT'S EXPECTATIONS. SIGNIFICANT CHANGES IN PAYOR MIX, BUSINESS OFFICE OPERATIONS, ECONOMIC CONDITIONS, OR TRENDS IN FEDERAL AND STATE GOVERNMENTAL HEALTH CARE COVERAGE COULD AFFECT THE HOSPITAL'S COLLECTION OF PATIENT ACCOUNTS RECEIVABLE, CASH FLOWS, AND RESULTS OF OPERATIONS.SIGNIFICANT CONCENTRATIONS OF GROSS PATIENT ACCOUNTS RECEIVABLE AS OF DECEMBER 31, 2016 AND 2015 WERE APPROXIMATELY AS FOLLOWS: 2016 2015MEDICARE 37% 41%OREGON HEALTH PLAN (OHP) AND MEDICAID 18 18COMMERCIAL INSURANCE AND OTHER THIRD-PARTY PAYORS 34 26SELF-PAY 11 15 100% 100% THE HOSPITAL'S ALLOWANCE FOR DOUBTFUL ACCOUNTS REPRESENTED 58% AND 56% OF GROSS SELF-PAY PATIENT ACCOUNTS RECEIVABLE AS OF DECEMBER 31, 2016 AND 2015, RESPECTIVELY. THE FOLLOWING IS A SUMMARY OF THE ACTIVITY IN THE HOSPITAL'S ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR THE YEARS ENDED DECEMBER 31, 2016 AND 2015: 2016 2015BALANCE - BEGINNING OF YEAR $1,173,000 $1,134,000PROVISION FOR BAD DEBTS 2,015,016 1,382,961ACCOUNTS WRITTEN OFF - NET OF RECOVERIES (1,876,016) (1,343,961)BALANCE - END OF YEAR $1,312,000 $1,173,000 PART III, LINE 9B: FINANCIAL ASSISTANCE IS GRANTED ON A SLIDING SCALE. IF AMOUNT DEEMED TO BE PAYABLE BY THE PATIENT IS DELINQUENT, THE PATIENT IS SENT TO COLLECTION AGENCY FOR THE PORTION OUTSTANDING. PART VI, LINE 7, REPORTS FILED WITH STATES OR 0 FAMILY BUILDING BLOCKS 383 N 3RD AVE STAYTON OR 97383 931233373 501(C)3 5000 THIS ORGANIZATION SUPPORTS THE COMMUNITY IN PREVENTING CHILD ABUSE BY WORKING WITH HIGH RISK CHILDREN AND FAMILIES. MEDICAL FOUNDATION OF MARION AND POLK COUNTIES 2295 RYAN DR SE 100 SALEM OR 97301 931261633 501(C)3 5500 THIS ORGANIZATION HELPS PROVIDE ACCESS TO PRESCRIPTION MEDICATIONS AND HEALTHCARE FOR MEMBER OF THE COMMUNITY, ESPECIALLY THE WORKING UNDERPRIVILEDGED. THIS ORGANIZATION HELPS PROVIDE ACCESS TO PRESCRIPTION MEDICATIONS AND HEALTHCARE FOR MEMBER OF THE COMMUNITY, ESPECIALLY THE WORKING UNDERPRIVILEDGED. THIS ORGANIZATION HELPS PROVIDE ACCESS TO PRESCRIPTION MEDICATIONS AND HEALTHCARE FOR MEMBER OF THE COMMUNITY, ESPECIALLY THE WORKING UNDERPRIVILEDGED. THIS ORGANIZATION HELPS PROVIDE ACCESS TO PRESCRIPTION MEDICATIONS AND HEALTHCARE FOR MEMBER OF THE COMMUNITY, ESPECIALLY THE WORKING UNDERPRIVILEDGED. X X X 0 1 0 0 0 1 0 0 0 TERRY FLETCHALL CEO 232945 0 22470 0 14298 0 41107 0 12981 0 323801 0 0 0 MAGGIE HUDSON CFO/COO 188605 0 11816 0 23327 0 19241 0 21068 0 264057 0 0 0 GENNY BALDWIN CHIEF NURSING OFFICER 118065 0 11816 0 39120 0 11070 0 11057 0 191128 0 0 0 JOHN HOFFMAN M.D. 399998 0 1161 0 0 0 7950 0 20258 0 429367 0 0 0 JOHN SILVER M.D. 379995 0 1161 0 0 0 7950 0 19447 0 408553 0 0 0 SUSAN TAYLOR M.D. 300004 0 1161 0 0 0 7950 0 11538 0 320653 0 0 0 KALSANG PHUNTSHOG M.D. 285630 0 1161 0 0 0 7950 0 20258 0 314999 0 0 0 NICOLAS J STRATTON M.D. 399998 0 1161 0 0 0 7950 0 19447 0 428556 0 0 0 PART I, LINE 4B TERRY FLETCHALL, CEO - $25,000 CONTRIBUTED TO 457(B) & 457(F) SUPPLEMENTAL RETIREMENT PLAN IN 2016. FORM 990, PART VI, SECTION A, LINE 6 THE HOSPITAL HAS APPROXIMATELY 400 MEMBERS. FORM 990, PART VI, SECTION A, LINE 7A THE HOSPITAL MEMBERS VOTE ON SELECTING THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS REVIEWED BY THE DIRECTORS AND OFFICERS. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF DIRECTORS, KEY EMPLOYEES AND CHIEF OF STAFF ARE REQUIRED TO SIGN AN ANNUAL CONFLICT OF INTEREST STATEMENT ATTESTING TO THEIR COMPLIANCE. FORM 990, PART VI, SECTION B, LINE 15 SMH USES A THIRD PARTY COMPENSATION AND BENEFIT SERVICE: OLNEY & ASSOCIATES. THE SURVEY PROVIDES DATA ON HOSPITAL KEY EMPLOYEE COMPENSATION AND BENEFITS BASED ON BED SIZE, GEOGRAPHIC REGION, ADMISSIONS AND GROSS REVENUE. THE BOARD OF DIRECTORS REVIEW COMPENSATION AND BENEFITS FOR THE CEO (TERRY FLETCHALL), COO/CFO (MAGGIE HUDSON) AND CHIEF NURSING OFFICER(GENNY BALDWIN). THE CEO'S CONTRACT IS THROUGH THE HOSPITAL APPROVED BY THE BOARD AND THE CHIEF NURSING OFFICER AND COO/CFO CONTRACTS ARE WITH THE HOSPITAL APPROVED BY THE CEO. FORM 990, PART VI, SECTION C, LINE 19 SANTIAM MEMORIAL HOSPITAL MAKES COPIES OF ITS GOVERNING DOCUMENTS AND AUDITED FINANCIAL STATEMENTS AVAILABLE UPON REQUEST. THE AUDITED FINANCIAL STATEMENTS ARE ALSO AVAILABLE BY CONTACTING THE STATE OF OREGON DEPARTMENT OF JUSTICE. THE CONFLICT OF INTEREST POLICY IS NOT AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 9: REVENUE FROM WILLAMETTE VALLEY COMMUNITY HEALTH, LLC 61,037. SANTIAM MEDICAL GROUP LLC 1401 N 10TH AVENUE STAYTON OR 97383 462570877 TO PROVIDE OUTPATIENT MEDICAL SERVICES AT VARIOUS CLINIC LOCATIONS OR 12644653 9869124 SANTIAM MEMORIAL HOSPITAL SANTIAM MEMORIAL HOSPITAL AUXILIARY 1401 N 10TH AVENUE STAYTON OR 97383 237399406 OPERATION OF GIFT SHOP AT THE HOSPITAL OR 501(C)(3) LINE 3 0 SANTIAM HEALTHCARE ALLIANCE INC 1401 N 10TH AVENUE STAYTON OR 97383 HOSPITAL OR 501(C)(3) LINE 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 SANTIAM MEMORIAL HOSPITAL AUXILIARY N