2016-11-11T12:16:15-06:00 2015-12-31 990 2015-01-01 930391573 GOOD SAMARITAN HOSPITAL CORVALLIS GOOD 5417684773 C/O SHS ACCOUNTING PO BOX 3000 CORVALLIS OR 973393000 DANIEL SMITH VP FINANCE/CFO 5417684773 2016-11-09 2015 2017-02-10 21:41:12Z GOOD SAMARITAN REGIONAL MEDICAL CTR BECKY PAPE 3600 NW SAMARITAN DR CORVALLIS OR 97330 396725598 0 X WWW.SAMHEALTH.ORG X 1948 OR TO IMPROVE THE HEALTH AND WELL BEING OF THE COMMUNITY THROUGH ITS MEDICAL AND SURGICAL HOSPITAL. 11 9 2485 337 264278 0 1054619 6731496 325920895 370433780 973496 1018014 3464197 4303874 331413207 382487164 334474 316084 0 0 177147666 194098591 0 0 271684 156824903 171843081 334307043 366257756 -2893836 16229408 170488288 181252375 93703835 88077021 76784453 93175354 X GOOD SAMARITAN HOSPITAL, CORVALLIS (GSH) ACHIEVES ITS MISSION OF IMPROVING THE HEALTH AND WELL BEING OF THE COMMUNITY THROUGH ITS MEDICAL AND SURGICAL HOSPITAL AND HEALTHCARE CLINICS PROVIDING OUTPATIENT CARE SERVICES AT SEVERAL AREA LOCATIONS.GSH IS A MEMBER OF SAMARITAN HEALTH SERVICES (SHS), A REGIONAL NETWORK OF HOSPITALS, PHYSICIANS AND SENIOR CARE FACILITIES. THE NETWORK, FORMED IN THE LATE 1990'S, SERVES APPROXIMATELY 290,000 RESIDENTS IN LINN, BENTON, LINCOLN AND PORTIONS OF POLK AND MARION COUNTIES IN OREGON. IT IS LOCALLY OWNED, AND ITS BOARDS OF DIRECTORS INCLUDE HOSPITAL LEADERS, PHYSICIANS AND COMMUNITY REPRESENTATIVES. GSH PROVIDES HEALTHCARE SERVICES REGARDLESS OF RACE, COLOR, CREED, SEX, NATIONAL ORIGIN, DISABILITY OR AGE. THE MISSION OF GSH IS TO ENHANCE COMMUNITY HEALTH AND ACHIEVE HIGH VALUE THROUGH QUALITY SERVICES ACROSS A CONTINUUM OF CARE. THE COLLECTIVE VISION OF THE SHS SYSTEM IS TO BE A VALUES-DRIVEN ORGANIZATION GOVERNED BY COMMUNITY MEMBERS, PHYSICIANS AND O 0 0 335418734 371769066 GOOD SAMARITAN HOSPITAL CORVALLIS (GSH), THE LARGEST HOSPITAL IN LINN, BENTON AND LINCOLN COUNTIES, OFFERS MORE THAN 22 MEDICAL SPECIALTIES INCLUDING COMPREHENSIVE CANCER CARE, A FULL-SERVICE CARDIOLOGY AND VASCULAR SURGERY PROGRAM, A SLEEP LAB, NEUROSURGERY AND OTHER REGIONAL SERVICES. GSH HAS MORE THAN 2,000 EMPLOYEES AND 250 VOLUNTEERS SERVING THE MEDICAL NEEDS OF THE COMMUNITY. IT IS LICENSED TO OPERATE 188 BEDS AND IS ONE OF ONLY THREE 'LEVEL 2' TRAUMA CENTERS IN THE STATE. DURING 2015, GSH SERVED 9,451 INPATIENTS, HAD 27,678 EMERGENCY DEPARTMENT VISITS, PERFORMED 9,845 SURGERIES AND DELIVERED 1,068 BABIES. IN ADDITION, GSH PERFORMED 85,300 IMAGING PROCEDURES, HAD 33,774 HOME HEALTH VISITS, AND HAD 217,268 PHYSICIAN CLINIC VISITS. 316084 316084 GRANTS AND ASSISTANCE PROVIDED BY GOOD SAMARITAN HOSPITAL CORVALLIS TO VARIOUS ORGANIZATIONS AND INDIVIDUALS TO BENEFIT THE COMMUNITY. SEE PART IX, LINES 1 AND 2 AND RELATED SCHEDULE I FOR MORE DETAILS. 335734818 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 1 0 1 1 0 1 2485 1 1 1 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 OR X SAMARITAN HEALTH SERVICES 5417684773 PO BOX 3000 CORVALLIS OR 973393000 RICHARD CRONK MD BOARD CHAIR 1.00 2.00 X X 0 0 0 JUDY LIST BOARD VICE CHAIR 1.00 1.00 X X 0 0 0 REVEREND SIMON JUSTICE BOARD SECRETARY 1.00 X X 0 0 0 NANCY SEIFERT BOARD TREASURER 1.00 X X 0 0 0 CLIFFORD HALL MD BOARD MEMBER 1.00 X 0 900 0 BISHOP MICHAEL HANLEY BOARD MEMBER 1.00 X 0 0 0 TIM HENNESSY BOARD MEMBER 1.00 X 0 4960 0 SHIRLEY PETERSON BOARD MEMBER 1.00 1.00 X 0 0 0 STEFAN SPANN MD BOARD MEMBER 1.00 X 0 1650 0 ERIC THOMPSON BOARD MEMBER 1.00 X 0 0 0 STEVE UERLINGS BOARD MEMBER 1.00 2.00 X 0 0 0 BECKY PAPE COO (JAN - NOV) / CEO (DEC) 30.00 10.00 X 0 340865 53257 DANIEL SMITH VP FINANCE / CFO 2.00 38.00 X 0 436557 88384 LARRY MULLINS DHA CEO (JAN - NOV) / CEO SHS 10.00 30.00 X 0 1465392 47400 CAROLINE FISHER MD VP SMH MEDICAL DIRECTOR (MAR - DEC) 40.00 X 323420 0 51354 RYAN COMBS VP PRIMARY CARE SPEC PRACTICES 40.00 X 205331 0 38748 SCOTT WILSON VP ANCILLARY SUPPORT SVCS 40.00 X 182619 0 41034 WILLIAM HOWDEN VP NURSING 40.00 X 181247 0 35153 MICHAEL MAY MD VP SMH MEDICAL DIRECTOR (JAN - FEB) 39.00 1.00 X 151752 1200 19795 LUIS VELA DO PHYSICIAN 40.00 X 896278 0 50158 DONALD PENNINGTON DO PHYSICIAN 40.00 X 711038 0 53130 TOSHIO NAGAMOTO MD PHYSICIAN 40.00 X 682799 0 50582 JEFF HSING MD PHYSICIAN 40.00 X 647412 0 49973 DANA PENNER MD PHYSICIAN 40.00 X 623186 0 52446 STEVEN JASPERSON FORMER CEO / VP SO. CALIFORNIA OPS 0.00 40.00 X 0 476259 46642 4605082 2727783 678056 327 1 1 0 0 6731496 6731496 NET PATIENT REVENUE 622110 363046093 363046093 RETAIL PHARMACY 446110 6833368 6833368 OTHER PATIENT REVENUE 622110 554319 554319 370433780 608812 608812 1040642 292360 748282 748282 748282 13923241 354082 13422362 445759 500879 -91677 409202 409202 342231 77953 264278 264278 CAFETERIA 722210 1956028 1956028 MEDICAL DIRECTOR FEES 900099 318263 318263 PSYCH PILOT PROGRAM 900099 200816 200816 816207 816207 3291314 382487164 371769066 264278 3722324 269633 269633 46451 46451 1230453 1006799 223654 146800169 143298532 3420325 81312 11090558 10828213 256253 6092 24437307 23859247 564637 13423 10540104 10290779 243535 5790 19617 19617 54585 1400 53185 2284 2284 9908853 9656590 208347 43916 56946 13847 31134 11965 12610749 12155084 385579 70086 17403388 16790880 612508 5429742 5307203 122539 592195 563502 25003 3690 784558 781174 3384 5092900 4913657 179243 9770010 9566210 203184 616 4558064 4147034 411030 MEDICAL SUPPLIES 51594603 51594603 PURCHASED SERVICES 35947243 12644705 23269701 32837 DUES, TAXES, & LICENSES 18017344 17996991 18396 1957 366257756 335734818 30251254 271684 12102 11109 1071389 823575 42347735 48289711 182919 196114 6556040 7468394 1899245 1676419 229020357 129051701 96074746 99968656 16845632 16486395 281180 281180 5217300 6050822 170488288 181252375 19678063 25831630 1192186 1257377 3708000 3708000 2340607 1126425 66784979 56153589 93703835 88077021 X 76784453 93175354 76784453 93175354 170488288 181252375 X 16229408 -1305728 1467221 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 6118410 136267 -233344 289157 5732176 6035183 61783 214664 193220 6118410 5430883 269432 578249 243381 6035183 4758581 316843 543063 187604 5430883 4975845 106549 -131912 191901 4758581 0.19880 0.80120 0 1 1 2051610 2051610 149196616 71284400 77912216 3070929 803148 2267781 65084029 52216112 12867917 9617173 4748041 4869132 99968656 PROFESSIONAL LIABILITY RESERVE 2521000 OTHER LIABILITIES 1533172 PAYABLE TO CONTRACTUAL AGENCIES 5036703 MINIMUM PENSION LIABILITY 38209399 ACCRUED INTEREST 1213205 ACCOUNTS PAYABLE-AFFILIATES 7640110 56153589 X PART V, LINE 4: THE BOARD-DESIGNATED AND GENERAL ENDOWMENTS ARE USED FOR GENERAL HOSPITAL SUPPORT. THE BERNIER ENDOWMENT IS USED FOR STAFF CONTINUING EDUCATION. THE ERKKILA ENDOWMENT IS USED FOR HEALTH AND HUMAN PERFORMANCE RESEARCH AND REHABILITATION. THE MULLINS SCHOLARSHIP ENDOWMENT IS USED TO SUPPORT EDUCATIONAL SCHOLARSHIPS. THE PASTEGA HOUSE ENDOWMENT IS USED TO HELP UNDERWRITE THE OPERATING COSTS OF THE MARIO PASTEGA GUEST HOUSE. THE VRTISKA ENDOWMENT IS USED TO SUPPORT THE HOSPITAL'S LABORATORY FOR EDUCATIONAL PURPOSES. THE WISH ENDOWMENT IS USED FOR HOSPITAL-BASED PROGRAMS SUPPORTING WOMEN'S AND CHILDREN'S HEALTH. THE HALL ENDOWMENT IS USED TO PROVIDE GRADUATE MEDICAL EDUCATIONAL OPPORTUNITIES IN THE AREA OF PRIMARY AND INTERNAL MEDICINE. PART X, LINE 2: FOOTNOTE DISCLOSURE FROM THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS: U.S. GENERALLY ACCEPTED ACCOUNTING PRINCIPLES REQUIRE THE SHS' MANAGEMENT TO EVALUATE TAX POSITIONS AND RECOGNIZE A TAX LIABILITY (OR ASSET) IF SHS HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE INTERNAL REVENUE SERVICE. MANAGEMENT HAS ANALYZED TAX POSITIONS TAKEN BY SHS AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2015, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY (OR ASSET) OR DISCLOSURE IN THE FINANCIAL STATEMENTS. SHS IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. SHS' MANAGEMENT BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO 2012. 1 1 X 1 X 225.000000000000 1 X 1 1 1 0 1 1 16 12976 4342632 4342632 0.01190 11 82217 73586447 55716342 17870105 0.04880 27 95193 77929079 55716342 22212737 0.06070 11 16843 521536 2484 519052 0.00140 5 19365 18263411 9280420 8982991 0.02450 13 54448 22411907 12669373 9742534 0.02660 11 22853 720166 183493 536673 0.00150 40 113509 41917020 22135770 19781250 0.05400 67 208702 119846099 77852112 41993987 0.11470 2 1385 24363 24363 0.00010 1 31 1796 1796 0.00000 3 1416 26159 26159 0.00010 0 893135 203635 61317903 63889337 -2571434 X 1 1 1 CORVALLIS MED BLDGS LLC REAL PROPERTY RENTAL 0.54500 0.21500 2 HULL IMAGING LLC IMAGING SERVICES 0.60000 0.40000 3 SAMARITAN ENDOSCOPY CENTER MEDICAL SERVICES 0.66670 0.33330 4 CORVALLIS MRI A JV IMAGING SERVICES 0.50000 0.50000 5 CASCADE VIEW MEDICAL OFFICE BUILDING LLC REAL PROPERTY RENTAL 0.26300 0.73700 1 1 GOOD SAMARITAN HOSPITAL CORVALLIS 3600 NW SAMARITAN DRIVE CORVALLIS OR 97330 WWW.SAMHEALTH.ORG STATE LICENSE: 14-1074 X X X X GOOD SAMARITAN HOSPITAL CORVALLIS 1 0 0 1 X X X X X X X X 13 1 0 1 1 X HTTP://WWW.SAMHEALTH.ORG/COMMUNITYSUPPORT X X 1 15 1 HTTP://WWW.SAMHEALTH.ORG/COMMUNITYSUPPORT 0 0 1 X 225.000000000000 300.000000000000 X X X 1 1 X X X X 1 X WWW.SAMHEALTH.ORG X WWW.SAMHEALTH.ORG X WWW.SAMHEALTH.ORG X X X X X 1 X 0 X X X X X 1 X 0 0 GOOD SAMARITAN HOSPITAL, CORVALLIS PART V, SECTION B, LINE 5: THE STAFF FROM THE COMMUNITY HEALTH PROMOTION DEPARTMENT AND OTHER EMPLOYEES OF GOOD SAMARITAN HOSPITAL PARTICIPATED IN THE COMMUNITY-WIDE BENTON COUNTY COMMUNITY HEALTH ASSESSMENT PROCESS DURING 2012 AND 2013. THE OVERALL GSH COMMUNITY HEALTH NEEDS ASSESSMENT IS ADOPTED FROM THE BENTON COUNTY COMMUNITY HEALTH ASSESSMENT AND COMMUNITY HEALTH IMPROVEMENT PLAN; HOWEVER IN CONSULTATION WITH THE EPIDEMIOLOGIST FROM BENTON COUNTY HEALTH DEPARTMENT, ADDITIONAL INFORMATION WAS GATHERED THAT IS SPECIFIC TO THE GSH SERVICE AREA AND IS INCLUDED IN THE CHNA. PERSONS CONSULTED FOR THE HOSPITAL'S CHNA WERE BENTON COUNTY HEALTH DEPARTMENT, COMMUNITY OUTREACH INC., BENTON EAST LINN HEALTH CENTER, OREGON STATE UNIVERSITY, SAMARITAN HEALTH PLANS, WESTERN UNIVERSITY-COMP NORTHWEST, LINN-BENTON COMMUNITY COLLEGE, CORVALLIS SCHOOL DISTRICT, LINN-BENTON COUNTY HEALTH EQUITY ALLIANCE, OLD MILL CENTER FOR CHILDREN AND FAMILIES, PARENT ENHANCEMENT PROGRAM, STRENGTHENING RURAL FAMILIES, LOVE INC, CHURCH OF THE GOOD SAMARITAN, OREGON CASCADES WEST COUNCIL OF GOVERNMENTS, SAMARITAN INTERCOMMUNITY HEALTH NETWORK, DEPARTMENT OF HUMAN SERVICES, OREGON HEALTH AUTHORITY, COMMUNITY SERVICES CONSORTIUM, CORVALLIS CLINIC, MONROE SCHOOL DISTRICT, ALSEA SCHOOL DISTRICT, PHILOMATH SCHOOL DISTRICT, LINN-BENTON HISPANIC ADVISORY COUNCIL, BENTON COUNTY ORAL HEALTH COALITION AND COMMUNITY MEMBERS. GOOD SAMARITAN HOSPITAL, CORVALLIS PART V, SECTION B, LINE 6B: BENTON COUNTY COMMISSION ON CHILDREN AND FAMILIES, BENTON COUNTY HEALTHY COMMUNITIES COALITION, BENTON COUNTY LBGTQ HEALTH COALITION, BENTON COUNTY HEALTHY COMMUNITIES COALITION, BENTON COUNTY PUBLIC HEALTH ADVISORY AND PLANNING COMMITTEE, BENTON LINN HEALTH EQUITY ALLIANCE, BENTON LINN HEALTHY AGING COALITION, CENTER AGAINST RAPE AND DOMESTIC VIOLENCE, CASA LATINOS UNIDOS DE BENTON COUNTY, COAST TO THE CASCADES COMMUNITY WELLNESS NETWORK, CRECIENDO EN SALUD - HEALTHY KIDS HEALTHY COMMUNITIES, MENTAL HEALTH ADDICTION AND DEVELOPMENTAL DISABILITIES ADVISORY COMMITTEE, OREGON FOOD BANK, OREGON STATE UNIVERSITY EXTENSION - LINN & BENTON COUNTIES, OREGON STATE UNIVERSITY PUBLIC HEALTH, ORGANIZATION LATINAS UNIDOS, TEN RIVERS FOODWEB, THE PARTNERSHIP: TO REDUCE EXCESSIVE AND UNDERAGE DRINKING, UNITED WAY OF BENTON AND LINCOLN COUNTIES, VOCEROS DE SALUD, WILLAMETTE NEIGHBORHOOD HOUSING GOOD SAMARITAN HOSPITAL, CORVALLIS PART V, SECTION B, LINE 7D: COPIES OF THE CHNA WERE EMAILED TO KEY COMMUNITY PARTNERS AND DISTRIBUTED DURING LOCAL COALITION MEETINGS. GOOD SAMARITAN HOSPITAL, CORVALLIS PART V, SECTION B, LINE 11: GSH IS ADDRESSING THE SIGNIFICANT NEEDS IDENTIFIED IN THE MOST RECENT COMMUNITY HEALTH NEEDS ASSESSMENTS THROUGH MULTIPLE STRATEGIES. FIRST, GSH PROVIDES GRANT FUNDING TO LOCAL COMMUNITY AGENCIES THAT ADDRESS ONE OR MORE OF THE PRIORITIES IDENTIFIED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT AND IS INCLUDED IN THE HOSPITAL'S COMMUNITY BENEFIT PLAN. SECOND, THE HOSPITAL STAFF SERVE ON COMMUNITY ADVISORY BOARDS AND COALITIONS TO ADDRESS THE MOST PRESSING NEEDS IN THE COMMUNITY. AND FINALLY, THE HOSPITAL IS PROVIDING WORKSHOPS, CLASSES AND SUPPORT GROUPS TO ADDRESS THE HIGHEST HEALTH CONCERNS IDENTIFIED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT. BECAUSE SEVERAL NEEDS TO IMPROVE HEALTH WERE IDENTIFIED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT, GSH DOES NOT HAVE THE FINANCES OR RESOURCES TO ADDRESS ALL THE NEEDS. GOOD SAMARITAN HOSPITAL, CORVALLIS PART V, SECTION B, LINE 15E: REGISTRATION REFERS UNINSURED AND/OR LOW INCOME PATIENTS TO THE ONSITE PATIENT FINANCIAL ADVOCATE AND A THIRD PARTY VENDOR WHO CONTACTS THE PATIENTS TO ASSESS THEIR FINANCIAL STATUS AND NEEDS. GOOD SAMARITAN HOSPITAL, CORVALLIS PART V, SECTION B, LINE 20E: PRESUMPTIVE CHARITY DETERMINATION / SCREENING GOOD SAMARITAN HOSPITAL, CORVALLIS PART V, SECTION B, LINE 22D: THE HOSPITAL FACILITY USED THE LOOK-BACK METHOD TO CALCULATE AGB (AMOUNTS GENERALLY BILLED). THIS CALCULATION DETERMINES THE MAXIMUM AMOUNT THAT CAN BE CHARGED TO FAP-ELIGIBLE INDIVIDUALS, AND IS BASED ON THE AVERAGE AMOUNT ACCEPTED AS PAYMENT IN FULL FOR THE COMBINATION OF MEDICARE AND COMMERCIALLY INSURED PATIENTS. 33 1 - SAMARITAN PASTEGA REGIONAL CANCER CTR 441 NW ELKS DR CORVALLIS OR 97330 RADIATION ONCOLOGY 2 - SAMARITAN ORTHOPEDICS CLINIC 3620 NW SAMARITAN DR STE 202 CORVALLIS OR 97330 MEDICAL CLINIC - OUTPATIENT 3 - SAMARITAN HEART & VASC - VASC SURGERY 3615 NW SAMARITAN DR STE 201 CORVALLIS OR 97330 MEDICAL CLINIC - OUTPATIENT 4 - SAMARITAN SURGICAL SPECIALISTS 3615 NW SAMARITAN DR STE 201 CORVALLIS OR 97330 MEDICAL CLINIC - OUTPATIENT 5 - SAMARITAN GYN & SURGICAL ASSOCIATES 400 NW WALNUT BLVD STE 300 CORVALLIS OR 97330 MEDICAL CLINIC - OUTPATIENT 6 - SAMARITAN INTERNAL MEDICINE 3521 NW SAMARITAN DR STE 201 CORVALLIS OR 97330 MEDICAL CLINIC - OUTPATIENT 7 - SAMARITAN NEUROSURGERY 3615 NW SAMARITAN DR STE 210 CORVALLIS OR 97330 MEDICAL CLINIC - OUTPATIENT 8 - SAMARITAN FAMILY MEDICINE 3517 NW SAMARITAN DR STE 201 CORVALLIS OR 97330 MEDICAL CLINIC - OUTPATIENT 9 - MAMMOGRAPHY CLINIC 3615 NW SAMARITAN DR CORVALLIS OR 97330 MAMMOGRAPHY CLINIC 10 - SAMARITAN KIDNEY SPECIALISTS 3615 NW SAMARITAN DR STE 203 CORVALLIS OR 97330 MEDICAL CLINIC - OUTPATIENT 11 - SAMARITAN PEDIATRICS 777 NW 9TH ST STE 320 CORVALLIS OR 97330 MEDICAL CLINIC - OUTPATIENT 12 - SAMARITAN URGENT CARE CENTER 5234 SW PHILOMATH BLVD CORVALLIS OR 97333 MEDICAL CLINIC - OUTPATIENT 13 - SAMARITAN RHEUMATOLOGY 3620 NW SAMARITAN DR STE 203 CORVALLIS OR 97330 MEDICAL CLINIC - OUTPATIENT 14 - SAMARITAN ENDOSCOPY CENTER 3509 NW SAMARITAN DR STE 201 CORVALLIS OR 97330 ENDOSCOPY CENTER 15 - CORVALLIS MRI 3615 NW SAMARITAN DR STE 101 CORVALLIS OR 97330 IMAGING SERVICES 16 - SAMARITAN OBSTETRICS & GYN 3640 NW SAMARITAN DR STE 270 CORVALLIS OR 97330 MEDICAL CLINIC - OUTPATIENT 17 - SAMARITAN MENTAL HEALTH - CORVALLIS 3509 NW SAMARITAN DR CORVALLIS OR 97330 MENTAL HEALTH SERVICES 18 - SAMARITAN PLASTICRECON SURG - HAVARD 996 NW CIRCLE BLVD STE 103 CORVALLIS OR 97330 MEDICAL CLINIC - OUTPATIENT 19 - SAMARITAN HEMATOLOGY & ONCOLOGY 501 NW ELKS DR CORVALLIS OR 97330 RADIATION ONCOLOGY 20 - SAMARITAN ORTHOPEDICS - DR VELA 3620 NW SAMARITAN DR STE 201 CORVALLIS OR 97330 MEDICAL CLINIC - OUTPATIENT 21 - SAMARITAN MENTAL HEALTH - ALBANY 1052 SW 29TH ST ALBANY OR 97321 MENTAL HEALTH SERVICES 22 - SAMARITAN INFECTIOUS DISEASE 3640 NW SAMARITAN DR STE 210 CORVALLIS OR 97330 MEDICAL CLINIC - OUTPATIENT 23 - SAMARITAN UROLOGY 990 NW CIRCLE BLVD STE 102 CORVALLIS OR 97330 MEDICAL CLINIC - OUTPATIENT 25 - OUTPATIENT SURGERY 3620 NW SAMARITAN DR CORVALLIS OR 97330 AMBULATORY SURGERY 26 - SAMARITAN WEIGHT MGMT & METABOLIC SURG 3517 NW SAMARITAN DR STE 100 CORVALLIS OR 97330 MEDICAL CLINIC - OUTPATIENT 27 - SAMARITAN FAMILY MEDICINE SOUTHWEST 5234 SW PHILOMATH BLVD CORVALLIS OR 97333 MEDICAL CLINIC - OUTPATIENT 28 - SAMARITAN PHYSICAL REHAB - CORVALLIS 3580 NW SAMARITAN DRIVE CORVALLIS OR 97330 MEDICAL CLINIC - OUTPATIENT 29 - SAMARITAN OCC MED - ALBANY 2615 WILLETTA ST SW STE C2 ALBANY OR 97321 MEDICAL CLINIC - OUTPATIENT 30 - SAMARITAN OCC MED - LEBANON 100 MULLINS DRIVE STE B2 LEBANON OR 97355 MEDICAL CLINIC - OUTPATIENT 31 - SAMARITAM OCC MED - CORVALLIS 5234 SW PHILOMATH BLVD STE B CORVALLIS OR 97333 MEDICAL CLINIC - OUTPATIENT 32 - SAMARITAN OB & GYN RESIDENT CLINIC 3517 NW SAMARITAN DR STE 202 CORVALLIS OR 97330 MEDICAL CLINIC - OUTPATIENT 33 - SAMARITAN MENTAL HEALTH FAMILY CTR 3517 NW SAMARITAN DR STE 101 CORVALLIS OR 97330 MEDICAL CLINIC - OUTPATIENT 34 - SAMARITAN ATHLETIC MEDICINE 845 SW 30TH ST CORVALLIS OR 97330 MEDICAL CLINIC - OUTPATIENT PART I, LINE 6A: THE FILING ORGANIZATION SUBMITS AN ANNUAL COMMUNITY BENEFIT REPORT TO THE STATE OF OREGON. IN ADDITION, THE PARENT ORGANIZATION, SAMARITAN HEALTH SERVICES (SHS) PROVIDES AN ANNUAL REPORT TO THE COMMUNITY THAT INCLUDES COMMUNITY BENEFIT REPORTING FOR THE SYSTEM AS A WHOLE. PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS REPORTED IN SCHEDULE H, PART I, LINE 7A AND 7B IS A COST-TO-CHARGE RATIO DERIVED USING WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES FROM THE SCHEDULE H INSTRUCTIONS. FOR LINE 7G, A COMBINATION OF THE COST-TO-CHARGE RATIO AND COST ACCOUNTING SYSTEM CALCULATIONS IS USED SINCE NOT ALL SERVICES ARE TRACKED IN THE COST ACCOUNTING SYSTEM. PART I, LINE 7G: PHYSICIAN CLINICS MEETING THE DEFINITION OF SUBSIDIZED HEALTH SERVICES WERE INCLUDED IN THE REPORTING FOR LINE 7G. CONSISTENT WITH THE LATEST SCHEDULE H INSTRUCTIONS, PHYSICIAN CLINIC ACTIVITY FOR 2015 HAS BEEN COMBINED WITH ASSOCIATED HOSPITAL SERVICES IN DETERMINING WHETHER THE SERVICES WERE PROVIDED AT A LOSS. PRIOR TO 2015, HOSPITAL SERVICES ASSOCIATED WITH OUR PHYSICIAN CLINICS HAD NOT BEEN COMBINED FOR PURPOSES OF THIS CALCULATION. THE EFFECT OF THIS CHANGE IS A REDUCTION IN OVERALL SUBSIDIZED HEALTH SERVICES REPORTED IN 2015 AS COMPARED TO PRIOR YEARS. THE PORTION OF NET COMMUNITY BENEFIT EXPENSE RELATED TO PHYSICIAN CLINICS, COMBINED WITH ASSOCIATED HOSPITAL ACTIVITY, THAT IS BEING COUNTED AS SUBSIDIZED HEALTH SERVICES IN 2015 IS $7,269,846. PART II, COMMUNITY BUILDING ACTIVITIES: GSH PROVIDES SERVICES AND ACTIVITIES THAT ARE CLASSIFIED AS COMMUNITY BUILDING TO PROMOTE THE HEALTH OF BENTON COUNTY. RECOGNIZING THAT THE HEALTH OF A COMMUNITY ENCOMPASSES MULTIPLE FACTORS, GSH LEADERSHIP AND STAFF ARE INVOLVED IN A VARIETY OF ACTIONS THAT WORK TO IMPROVE COMMUNITY OUTCOMES. DURING 2015, GSH SERVED AS THE LEAD AGENCY TO CONDUCT DISASTER PREPAREDNESS DRILLS WITH LOCAL AGENCIES IN BENTON COUNTY. THIS INCLUDED HOLDING REGULAR COMMUNITY MEETINGS TO REVIEW AND UPDATE THE COMMUNITY DISASTER PREPAREDNESS PLAN, IDENTIFY DISASTER DRILL DATES, ORGANIZE THE DISASTER PREPAREDNESS DRILL AND RECRUITING AND TRAINING COMMUNITY VOLUNTEERS TO SERVE AS VICTIMS DURING THE DRILL. GSH BELIEVES THAT TRAINED AND COMPETENT STAFF IN ALL ASPECTS OF THE ORGANIZATION PROMOTES COMMUNITY HEALTH. GSH ACTIVELY PARTICIPATES IN WORKFORCE DEVELOPMENT IN PARTNERSHIP WITH OREGON STATE UNIVERSITY, LINN-BENTON COMMUNITY COLLEGE AND WESTERN UNIVERSITY-COMP NW TO RECRUIT, TRAIN AND RETAIN HEALTHCARE WORKERS AT ALL LEVELS. GSH ALSO HOSTS LOCAL EVENTS SUPPORTED BY THE HOSPITAL'S FOUNDATION AND OTHER DEPARTMENTS IN THE ORGANIZATION. ANNUAL EVENTS SUCH AS SENIOR HEALTH FAIRS, FESTIVAL LATINO, CHILDREN'S HEALTH FAIRS, BENTON COUNTY FAIR AND PROJECT HOMELESS CONNECT ARE A FEW EXAMPLES OF HOW GSH PROMOTES THE HEALTH OF THE COMMUNITY. GSH ALSO PROVIDES OPPORTUNITIES FOR COMMUNITY MEMBERS TO OBTAIN TRAINING ON CIVIC AND CULTURAL ISSUES THAT IMPACT HEALTH. SOME OF THE TRAINING OPPORTUNITIES INCLUDE GRANT WRITING, ORGANIZATIONAL SUSTAINABILITY, AND BOARD DEVELOPMENT. GSH STAFF SERVE ON MANY LOCAL COALITIONS AND BOARDS THAT PROMOTE THE HEALTH OF THE COMMUNITY. BOARD AFFILIATIONS INCLUDE, BUT ARE NOT LIMITED TO, COMMUNITY OUTREACH INC., OREGON CASCADES WEST COUNCIL OF GOVERNMENTS, AND THE UNITED WAY OF BENTON AND LINCOLN COUNTIES. ADDITIONALLY GSH STAFF SERVE ON THE OREGON HEALTH POLICY ADVISORY BOARD, THE OREGON HEALTH RESOURCES COMMISSION, THE MEDICAID ADVISORY COMMITTEE, THE OREGON ASSOCIATION OF HOSPITALS AND HEALTH SYSTEMS AND REGIONAL BOARDS THAT ADDRESS HEALTH CARE ISSUES. PART III, LINE 2: BAD DEBT EXPENSE IS RECORDED FOR THOSE PATIENTS WHO DO NOT QUALIFY FOR FINANCIAL ASSISTANCE AND DO NOT PAY AFTER REPEATED ATTEMPTS TO COLLECT PAYMENT, INCLUDING INFORMING THEM OF THE OPPORTUNITY TO COMPLETE A FINANCIAL ASSISTANCE APPLICATION. IF INDEPENDENT EVIDENCE INDICATES THAT THE PATIENT IS UNABLE TO PAY, SHS MAY CHOOSE TO CLASSIFY DELINQUENT ACCOUNTS AS "PRESUMPTIVE CHARITY" RATHER THAN BAD DEBT. PATIENT PAYMENTS (OR RECOVERIES) ON ACCOUNTS THAT WERE PREVIOUSLY WRITTEN OFF AS BAD DEBT ARE RECORDED AS A REDUCTION TO BAD DEBT EXPENSE. PART III, LINE 3: LINE 3 REPRESENTS AN ESTIMATE OF THE AMOUNT INCLUDED IN BAD DEBT EXPENSE (LINE 2) THAT REASONABLY COULD BE ATTRIBUTABLE TO PATIENTS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY, BUT FOR WHOM THE ORGANIZATION WAS NOT ABLE TO OBTAIN SUFFICIENT INFORMATION TO MAKE A DETERMINATION. THE METHODOLOGY USED TO ESTIMATE THIS POTENTIAL FINANCIAL ASSISTANCE IS BASED ON FINANCIAL ASSISTANCE APPLICATIONS DENIED DUE TO INCOMPLETE DOCUMENTATION, MULTIPLIED BY THE AVERAGE FINANCIAL ASSISTANCE WRITE-OFF FOR APPROVED APPLICATIONS. PART III, LINE 4: GOOD SAMARITAN HOSPITAL (GSH) IS THE LARGEST OF FIVE HOSPITALS OF SAMARITAN HEALTH SERVICES (SHS). AS A NETWORK, SHS PREPARES ITS FINANCIAL STATEMENTS ON A CONSOLIDATED BASIS. BAD DEBT EXPENSE IS DESCRIBED IN FOOTNOTE 1(O) ENTITLED "PROVISION FOR BAD DEBTS AND ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS", FOUND ON PAGE 12 OF THE 2015 SHS CONSOLIDATED FINANCIAL STATEMENTS. PART III, LINE 8: TOTAL MEDICARE ALLOWABLE COSTS REPORTED ON PART III, SECTION B, LINE 6 IS CALCULATED BY UTILIZING WORKSHEET A IN THE SCHEDULE H INSTRUCTIONS IN CONJUNCTION WITH AMOUNTS TAKEN DIRECTLY FROM THE FILING ORGANIZATION'S MEDICARE COST REPORT (CALCULATED BASED ON A COST-TO-CHARGE RATIO). CARING FOR MEDICARE PATIENTS FULFILLS A COMMUNITY NEED, AS THESE PATIENTS TYPICALLY HAVE LOW OR FIXED INCOMES AND GOVERNMENT REIMBURSEMENT IS NOT SUFFICIENT TO COVER THE COSTS OF PROVIDING CARE FOR THESE PATIENTS. MEDICARE PATIENTS ARE A GROWING SEGMENT OF THE LOCAL POPULATION, AND MANY ARE BECOMING INCREASINGLY DEPENDENT ON OUR HOSPITAL AND NON-PROFIT AFFILIATES TO PROVIDE FOR THEIR CARE, ESPECIALLY AS OTHER FOR-PROFIT HEALTHCARE PROVIDERS IN THE COMMUNITY DISCONTINUE ACCEPTING MEDICARE PATIENTS.THE AMOUNT OF MEDICARE SHORTFALL SHOWN ON LINE 7 OF PART III, SECTION B, IS UNDERSTATED. THIS IS PRIMARILY DUE TO THE FACT THAT THE MEDICARE COST REPORT INCLUDES ACTIVITY FOR MEDICARE FEE-FOR-SERVICE PATIENTS BUT NOT MEDICARE MANAGED CARE PATIENTS. MEDICARE MANAGED CARE ACCOUNTS FOR ROUGHLY HALF OF OUR MEDICARE ACTIVITY. IN ADDITION, CERTAIN COSTS OF PROVIDING HEALTHCARE SERVICES, SUCH AS PHYSICIAN COMPENSATION, ARE NOT ALLOWABLE ON THE MEDICARE COST REPORTS. THEREFORE, THE AMOUNT OF MEDICARE SHORTFALL SHOWN ON LINE 7 IS SMALLER THAN THE SHORTFALL CALCULATION USING REVENUE AND COST DATA FOR ALL MEDICARE PATIENT ACTIVITY, AS FOLLOWS:NET REV RECEIVED FROM MEDICARE (ALL MEDICARE PATIENT PROGRAMS):116,803,732MEDICARE COSTS (BASED ON A COST-TO-CHARGE RATIO): 134,619,341UNPAID COST OF PROVIDING SERVICES TO ALL MEDICARE PATIENTS: -17,815,609 PART III, LINE 9B: PER HOSPITAL GUIDELINES, IF A PATIENT IS DETERMINED TO QUALIFY FOR FINANCIAL ASSISTANCE PRIOR TO SENDING AN ACCOUNT TO COLLECTIONS, THE FINANCIAL ASSISTANCE WRITE-OFF IS PROCESSED AND NO COLLECTION ATTEMPT IS MADE. IF AN ACCOUNT IS ALREADY IN COLLECTIONS AND MEDICAID ELIGIBILITY IS DEEMED ACTIVE DURING THE ACCOUNT DATE OF SERVICE, NO FURTHER COLLECTION ATTEMPT WILL BE MADE. PART VI, LINE 2: GOOD SAMARITAN HOSPITAL (GSH) ACTIVELY PARTICIPATES IN ASSESSING THE HEALTH NEEDS OF THE COMMUNITY. EVERY THREE YEARS, AS REQUIRED BY FEDERAL AND STATE LAW, GSH CONDUCTS A COUNTYWIDE HEALTH NEEDS ASSESSMENT IN CONJUNCTION WITH THE UNITED WAY OF BENTON COUNTY, THE CITY OF CORVALLIS, BENTON COUNTY HEALTH DEPARTMENT, BENTON COUNTY FEDERALLY QUALIFIED HEALTH CENTER, OREGON STATE UNIVERSITY, WESTERN UNIVERSITY-COMP NORTHWEST, LINN-BENTON COMMUNITY COLLEGE AND OTHER COMMUNITY PARTNERS. THE PROCESS INCLUDES EXAMINING PRIMARY DATA COLLECTED THROUGH SURVEYS, FOCUS GROUPS, COMMUNITY FORUMS AND PERSONAL INTERVIEWS WITH COMMUNITY MEMBERS WHO RESIDE THROUGHOUT BENTON COUNTY. SECONDARY DATA IS GATHERED FROM FEDERAL, STATE AND LOCAL AGENCIES THAT ADDRESS HEALTH NEEDS OF CHILDREN, YOUTH AND FAMILIES. THE INFORMATION IS REVIEWED BY THE STAFF, PARTNERS AND COMMUNITY MEMBERS TO PRIORITIZE THE HEALTH CARE NEEDS FOR BENTON COUNTY. EACH YEAR GSH BOARD AND VARIOUS INTERNAL AND EXTERNAL COMMITTEES REVIEW THE PRIORITIES TO ENSURE WE ARE CONTINUING TO ADDRESS THE NEEDS OF THE COMMUNITY. PART VI, LINE 3: GSH IS COMMITTED TO PROVIDING THE HIGHEST QUALITY HEALTH CARE SERVICES TO ALL, REGARDLESS OF THEIR ABILITY TO PAY. IF QUALIFICATIONS ARE MET, PATIENTS' CARE MAY BE PROVIDED FREE OR AT A REDUCED COST. THE DETERMINATION IS BASED IN PART ON POVERTY INCOME GUIDELINES ISSUED BY THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. PATIENTS WHO REGISTER FOR AN INPATIENT, OUTPATIENT, CLINICAL OR EMERGENCY SERVICE RECEIVE BOTH VERBAL AND WRITTEN INFORMATION ON FINANCIAL ASSISTANCE. PATIENTS WHO ARE IDENTIFIED AS SELF-PAY OR UNINSURED ARE SCREENED THROUGH PRESUMPTIVE ELIGIBILITY QUESTIONS TO DETERMINE IF THEY ARE ELIGIBLE FOR THE OREGON HEALTH PLAN MEDICAID ASSISTANCE PROGRAM(OHP). EXTENDED STAY AND INPATIENTS WHO ARE DEEMED ELIGIBLE FOR OHP ARE AUTOMATICALLY ASSIGNED TO A FINANCIAL COUNSELOR AS PART OF THE CHECK-IN PROCESS. DURING THE PATIENT STAY OR PRIOR TO DISCHARGE, THE FINANCIAL COUNSELOR MEETS WITH THE PATIENT TO ASSIST WITH COMPLETING AND SUBMITTING THEIR OHP APPLICATION PACKET TO THE OREGON HEALTH AUTHORITY OFFICE. OUTPATIENT, CLINICAL AND EMERGENCY SERVICE PATIENTS WHO ARE DEEMED ELIGIBLE FOR OHP IS ALSO ASSIGNED A FINANCIAL COUNSELOR WHO PROVIDES THEM WITH THE OHP APPLICATION PACKET AND THEIR CONTACT INFORMATION IF THEY REQUIRE ASSISTANCE TO COMPLETE THE FORMS. THE FINANCIAL COUNSELOR CONTACTS THE PATIENT VIA TELEPHONE OR EMAIL AFTER 24 HOURS TO ANSWER QUESTIONS, PROVIDE SUPPORT AND ENSURE THAT THE APPLICATION HAS BEEN SUBMITTED. ANY PATIENT WHO IS SELF-PAY OR UNINSURED AND NOT DEEMED ELIGIBLE FOR OHP IS PROVIDED A FINANCIAL ASSISTANCE APPLICATION PACKET AND ASSIGNED A FINANCIAL COUNSELOR. THE FINANCIAL COUNSELOR REVIEWS THE APPLICATION PACKET AND PROVIDES INFORMATION TO THE PATIENT ON MULTIPLE FINANCIAL SUPPORT OPTIONS INCLUDING A NO-INTEREST PAYMENT PLAN OR FINANCIAL ASSISTANCE FOR THOSE AT OR BELOW 300% OF THE FEDERAL POVERTY LEVEL GUIDELINES.ALL APPLICATION MATERIALS ARE AVAILABLE IN BOTH ENGLISH AND SPANISH AND INTERPRETATIVE SERVICES ARE AVAILABLE FOR NON-ENGLISH SPEAKING PATIENTS THROUGH VARIOUS ELECTRONIC DEVICES. GSH ALSO INFORMS AND EDUCATES PATIENTS AND COMMUNITY MEMBERS REGARDING FINANCIAL ASSISTANCE THROUGH A VARIETY OF METHODS. PAMPHLETS ARE AVAILABLE IN THE HOSPITAL WAITING AREAS, CLINIC WAITING ROOMS, VISITING ROOMS AND AT THE INFORMATION DESKS. FLYERS ARE POSTED AT THE SPECIALTY CLINICS, THE MAIN ENTRANCE OF THE HOSPITAL AND IN THE EMERGENCY DEPARTMENT. FINANCIAL ASSISTANCE INFORMATION IS ALSO POSTED ON THE HOSPITAL'S WEBSITE, INCLUDING THE FINANCIAL ASSISTANCE POLICY AND APPLICATION. PART VI, LINE 4: GSH PRIMARILY SERVE RESIDENTS OF BENTON COUNTY. ESTABLISHED BY THE PROVISIONAL LEGISLATURE IN 1847, BENTON COUNTY OCCUPIES 679 SQUARE MILES OF THE CENTRAL WILLAMETTE VALLEY. BENTON COUNTY IS BORDERED ON THE EAST BY THE WILLAMETTE RIVER AND LINN COUNTY, WITH LINCOLN COUNTY ON THE WEST, POLK COUNTY ON THE NORTH, AND BY LANE COUNTY ON THE SOUTH. THE CITY OF CORVALLIS IS THE COUNTY SEAT FOR BENTON COUNTY AND IS HOME TO OREGON STATE UNIVERSITY. ALTHOUGH THE MAJORITY OF RESIDENTS LIVE IN CORVALLIS OR OTHER INCORPORATED CITIES IN THE COUNTY, APPROXIMATELY 21% OF RESIDENTS LIVE IN RURAL BENTON COUNTY. THESE RURAL COMMUNITIES INCLUDE ALSEA, KINGS VALLEY, WREN, BLODGETT, SUMMIT AND BELLFOUNTAIN. PORTIONS OF BENTON COUNTY HAVE DESIGNATIONS OF MEDICALLY UNDERSERVED AREAS AND MEDICALLY UNDERSERVED POPULATIONS ACCORDING TO THE HEALTH RESOURCES AND SERVICES ADMINISTRATION, WITH GSH BEING THE ONLY HOSPITAL LOCATED IN BENTON COUNTY. THE CHARTS BELOW DESCRIBE THE DEMOGRAPHICS OF BENTON COUNTY:RACE/ETHNICITY POPULATIONWHITE/CAUCASIAN 87.1%BLACK/AFRICAN AMERICAN 0.9%AMERICAN INDIAN/ALASKA NATIVE 0.7%ASIAN AND PACIFIC ISLANDER 5.4%HISPANIC 6.4%OTHER 2.7%REPORTING TWO OR MORE RACES 3.6%SOURCE: U.S. CENSUS BUREAU, 2010 CENSUS, PUBLIC LAW 94-171 SUMMARY FILEHEALTH AND SOCIAL INDICATORS ARE USED TO GENERALIZE THE CONDITIONS OF BENTON COUNTY:HEALTH AND SOCIAL INDICATORS TOTALSMEDIAN INCOME $49,338UNEMPLOYMENT 5.3%POVERTY 18.9%HOMELESSNESS(ADULTS) 306*EARLY PRENATAL CARE 78.2%IMMUNIZATIONS 53.8%UNINSURED CHILDREN 5.3%CHILD CARE SLOTS 22/100CHILD ABUSE 11.1/1000EARLY CHILDHOOD OBESITY 20.6%CHILDREN ON FREE AND REDUCED LUNCH 38.3%CHILDREN ENROLLED WITH A DENTAL CARE ORGANIZATION 89.3%HOMELESS STUDENTS 261TEEN PREGNANCY 8.1/1000HIGH SCHOOL GRADUATION RATES 72%JUVENILE ARRESTS 11/10008TH GRADE ALCOHOL USE 13.7%8TH GRADE DRUG USE 6.4%*THERE IS NO ACCURATE WAY TO COUNT THE NUMBER OF HOMELESS PEOPLE IN A COUNTY. HOMELESS DATA IS BASED ON LOCAL AGENCIES SERVING BENTON COUNTY DURING 2015.THE INFORMATION LISTED ABOVE WAS OBTAINED FROM VARIOUS LOCAL, STATE AND FEDERAL DATABASES USING THE MOST RECENT AVAILABLE DATA BETWEEN THE YEARS 2012 - 2015. PART VI, LINE 5: GSH'S GOVERNING BOARD IS COMPRISED OF LOCAL-AREA RESIDENTS. THE MAJORITY OF THE BOARD MEMBERS ARE INDEPENDENT, MEANING THEY AND THEIR FAMILY MEMBERS ARE NOT EMPLOYEES OF GSH NOR DO THEY HAVE ANY SIGNIFICANT BUSINESS RELATIONSHIPS WITH GSH. GSH EXTENDS ITS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. GSH APPLIES SURPLUS FUNDS TO IMPROVE PATIENT CARE, MEDICAL EDUCATION AND RESEARCH. GSH INVESTS IN UPDATING EQUIPMENT, TECHNOLOGY AND FACILITIES TO IMPROVE PATIENT CARE. GSH IS ACCREDITED FOR CONTINUING MEDICAL EDUCATION AND OFFERS WEEKLY PROGRAMS FOR AREA PHYSICIANS AND OTHER HEALTH PROFESSIONALS. THE CENTER FOR HEALTH RESEARCH AND QUALITY, A DEPARTMENT OF GSH'S PARENT COMPANY, SAMARITAN HEALTH SERVICES (SHS), PROVIDES ADMINISTRATIVE OVERSIGHT FOR HEALTH AND CLINICAL RESEARCH, QUALITY IMPROVEMENT PROJECTS AND STUDIES, AND OTHER SPONSORED ACTIVITIES FOR GSH AND ITS AFFILIATED HOSPITALS. PART VI, LINE 6: "BUILDING HEALTHIER COMMUNITIES TOGETHER" IS THE COMMITMENT OF, AND THE MOTIVATION FOR, SAMARITAN HEALTH SERVICES (SHS), A NETWORK OF OREGON HOSPITALS, PHYSICIANS, AND SENIOR CARE FACILITIES THAT SERVES THE HEALTH CARE NEEDS OF PEOPLE IN THE MID-WILLAMETTE VALLEY AND THE CENTRAL OREGON COAST.AS THE INDIVIDUAL ENTITIES OF SHS CAME TOGETHER TO BUILD HEALTHIER COMMUNITIES, THEY WERE DRAWN BY A SHARED MISSION "TO ENHANCE COMMUNITY HEALTH AND ACHIEVE HIGH VALUE THROUGH QUALITY SERVICES ACROSS THE CONTINUUM OF CARE." THAT MEANS SHS LOOKS CAREFULLY AT LOCAL HEALTH CARE NEEDS, AND IT GIVES THOUGHTFUL CONSIDERATION TO THE MOST EFFECTIVE WAYS TO MEET THOSE NEEDS. THE RESULT IS A RICH MIX OF LOCAL AND CENTRALIZED REGIONAL SERVICES WHICH PROVIDE HIGH VALUE AND EXCELLENT HEALTHCARE FOR PEOPLE AT ALL STAGES OF THEIR LIVES. SERVICES ARE PROVIDED TO ALL INDIVIDUALS, REGARDLESS OF THEIR ABILITY TO PAY. THE COLLECTIVE VISION OF SHS IS TO SUCCESSFULLY OPERATE AS A VALUES-DRIVEN, CHURCH-RELATED ORGANIZATION GOVERNED BY A PARTNERSHIP OF COMMUNITY MEMBERS, PHYSICIANS AND OTHER HEALTH CARE PROVIDERS. SHS SEEKS TO LEAD COLLABORATIVE EFFORTS AMONG PROVIDERS, EMPLOYERS, HEALTH PLANS AND CONSUMERS WHO SHARE SIMILAR GOALS AND VALUES TO MEET THE CHALLENGES OF THE FUTURE.GSH IS THE FLAGSHIP HOSPITAL OF SHS. IT PRIMARILY SERVES RESIDENTS OF BENTON COUNTY. OTHER AFFILIATED HOSPITALS ARE ALBANY GENERAL HOSPITAL AND SAMARITAN LEBANON COMMUNITY HOSPITAL, SERVING RESIDENTS OF LINN COUNTY, AND SAMARITAN NORTH LINCOLN HOSPITAL AND SAMARITAN PACIFIC COMMUNITIES HOSPITAL, SERVING RESIDENTS OF LINCOLN COUNTY. PART VI, LINE 7, REPORTS FILED WITH STATES OR 1 COMMUNITY OUTREACH 865 REIMAN AVENUE CORVALLIS OR 97330 930602094 501(C)(3) 107796 MEDICAL, DENTAL, MENTAL HEALTH CLINICS OLD MILL CENTER 1650 SW 45TH PLACE CORVALLIS OR 97333 930722603 501(C)(3) 15000 COUNSELING, MENTAL HEALTH, AND PARENT EDUCATION ALBANY HELPING HANDS PO BOX 2252 ALBANY OR 97321 931244271 501(C)(3) 5600 SUPPORT FOR HOMELESS PEOPLE CENTER AGAINST RAPE & DOMESTIC VIOLENCE PO BOX 914 CORVALLIS OR 97339 930792125 501(C)(3) 20500 TRANSITIONAL HOUSING SERVICES FOR DOMESTIC VIOLENCE SURVIVORS BENTON COUNTY HEALTH DEPARTMENT 530 NW 27TH ST CORVALLIS OR 97330 936002285 GOV'T 22050 EMER. DENTAL SERVICES TO UNINSURED AND UNDERINSURED ADULTS THROUGH A VOUCHER PROG. STRENGTHENING RURAL FAMILIES PO BOX 1528 PHILOMATH OR 97370 202934930 501(C)(3) 8500 ORGANIZING DENTAL VAN SERVICES IN RURAL COMMUNITIES LOVE IN THE NAME OF CHRIST OF BENTON COUNTY PO BOX 270 CORVALLIS OR 97339 931326307 501(C)(3) 5950 PROVIDING TRANSPORTATION AND MEDICAL CO-PAYS FOR UNINSURED AND HOMELESS ADULTS BOYS AND GIRLS CLUB OF CORVALLIS INC 1112 NW CIRCLE BLVD CORVALLIS OR 97330 237153987 501(C)(3) 50000 YOUTH DEVELOPMENT FOR SCHOOL-AGED CHILDREN JACKSON STREET YOUTH SHELTER INC PO BOX 285 CORVALLIS OR 97339 931269503 501(C)(3) 10000 OFFERING SHELTER AND CASE MANAGEMENT FOR HOMELESS YOUTH 9 TRANSPORTATION 230 14527 MEDICAL ASSISTANCE 1 75 BOOK MEDICAL SUPPLIES SHELTER 1 95 MEALS FOR FAMILY MEMBERS OF PATIENTS 286 2881 BOOK MEALS ACCOMODATIONS - PASTEGA HOUSE 6403 28873 BOOK TEMPORARY HOUSING FOR HEALTH CARE RECIPIENTS PART I, LINE 2: AGENCIES IN THE COMMUNITY ARE INVITED TO SUBMIT GRANT PROPOSALS THROUGH AN APPLICATION PROCESS. A COMMITTEE REVIEWS THE APPLICATIONS TO DETERMINE IF THE FUNDS REQUESTED WILL BE USED TO ADDRESS THE ORGANIZATION'S ESTABLISHED COMMUNITY HEALTH PRIORITIES, IDENTIFIED NEEDS, AND SUPPORTS THE ORGANIZATION'S MISSION. ONCE APPROVED AND FUNDED, AGENCIES MUST SUBMIT A COMPLETE ANNUAL REPORT DESCRIBING HOW THE FUNDS WERE USED, THE NUMBER OF CLIENTS SERVED, AND HOW OUTCOMES WERE ACHIEVED. X 1 1 1 1 0 1 0 0 0 0 0 BECKY PAPE COO (JAN - NOV) / CEO (DEC) 0 300950 0 37000 0 2915 0 21760 0 31497 0 394122 0 0 DANIEL SMITH VP FINANCE / CFO 0 350633 0 77000 0 8924 0 56843 0 31541 0 524941 0 0 LARRY MULLINS DHA CEO (JAN - NOV) / CEO SHS 0 679857 0 242000 0 543535 0 21760 0 25640 0 1512792 0 225675 CAROLINE FISHER MD VP SMH MEDICAL DIRECTOR (MAR - DEC) 320596 0 2000 0 824 0 21760 0 29594 0 374774 0 0 0 RYAN COMBS VP PRIMARY CARE SPEC PRACTICES 176879 0 21000 0 7452 0 16433 0 22315 0 244079 0 0 0 SCOTT WILSON VP ANCILLARY SUPPORT SVCS 163807 0 4500 0 14312 0 13789 0 27245 0 223653 0 0 0 WILLIAM HOWDEN VP NURSING 173399 0 7000 0 848 0 13635 0 21518 0 216400 0 0 0 MICHAEL MAY MD VP SMH MEDICAL DIRECTOR (JAN - FEB) 40265 1200 0 0 111487 0 10533 0 9262 0 171547 1200 0 0 LUIS VELA DO PHYSICIAN 894036 0 1000 0 1242 0 19356 0 30802 0 946436 0 0 0 DONALD PENNINGTON DO PHYSICIAN 586513 0 111582 0 12943 0 21760 0 31370 0 764168 0 0 0 TOSHIO NAGAMOTO MD PHYSICIAN 487790 0 175740 0 19269 0 21760 0 28822 0 733381 0 0 0 JEFF HSING MD PHYSICIAN 535602 0 111270 0 540 0 21760 0 28213 0 697385 0 0 0 DANA PENNER MD PHYSICIAN 380678 0 223856 0 18652 0 21760 0 30686 0 675632 0 0 0 STEVEN JASPERSON FORMER CEO / VP SO. CALIFORNIA OPS 0 386534 0 0 0 89725 0 21760 0 24882 0 522901 0 0 PART I, LINE 1A IN CONNECTION WITH ITS EMPLOYEE WELLNESS PROGRAM, THE ORGANIZATION HAS A GYM/FITNESS FACILITY BENEFIT THAT IS AVAILABLE TO ALL EMPLOYEES WHO WORK AT LEAST 32 HOURS PER MONTH. IF AN EMPLOYEE PARTICIPATES AT A NON-SAMARITAN GYM, REIMBURSEMENT IS MADE FOR FEES. REIMBURSEMENT DOES NOT EXCEED $300 PER YEAR AND IS INCLUDED IN THE EMPLOYEE'S TAXABLE WAGES AND IS SUBJECT TO FEDERAL/STATE WITHHOLDING TAX. NO PERSONS LISTED ON PART VII RECEIVED THIS TAXABLE GYM BENEFIT IN 2015. IF AN EMPLOYEE PARTICIPATES AT A SAMARITAN FITNESS CENTER (SAMFIT), MEMBERSHIP IS FREE OF CHARGE (PROVIDED AS A NONTAXABLE FRINGE BENEFIT). TWO KEY EMPLOYEES RECEIVED THE SAMFIT BENEFIT DURING 2015. PART I, LINE 3 THE CHIEF EXECUTIVE OFFICER IS EMPLOYED AND PAID BY A RELATED ORGANIZATION. THE RELATED ORGANIZATION CONDUCTS A COMPENSATION ANALYSIS EACH YEAR TO COMPARE COMPENSATION OF ALL PAID POSITIONS TO MARKET SURVEYS OF COMPENSATION FOR SIMILAR POSITIONS IN OTHER ORGANIZATIONS. PERIODICALLY, THE RELATED ORGANIZATION WILL ALSO USE WRITTEN EMPLOYMENT CONTRACTS, FORM 990 OF OTHER ORGANIZATIONS, AND INDEPENDENT COMPENSATION CONSULTANTS TO DETERMINE THE COMPENSATION OF THE CHIEF EXECUTIVE OFFICER. PART I, LINES 4A-B 4.A. MICHAEL MAY, MD, A KEY EMPLOYEE, RECEIVED $34,108 IN TAXABLE COMPENSATION, AND $4,721 IN NON-TAXABLE BENEFITS PURSUANT TO HIS SEPARATION FROM THE FILING ORGANIZATION. 4.B. THE ORGANIZATION MAINTAINS A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN. UNDER THIS PLAN, LARRY MULLINS, DHA AND DANIEL SMITH ACCRUED DEFERRED COMPENSATION BENEFITS DURING 2015. LARRY MULLINS, DHA RECEIVED A PAYMENT IN 2015 FROM THIS PLAN, WHICH IS INCLUDED IN HIS 2015 COMPENSATION ON SCHEDULE J AND FORM 990. $225,675 OF THIS PAYMENT WAS ACCRUED IN PRIOR YEARS AND WAS ALSO INCLUDED IN COMPENSATION DISCLOSED IN PRIOR YEARS AS REQUIRED ON SCHEDULE J AND FORM 990. DANIEL SMITH RECEIVED NO PAYMENTS FROM HIS PLAN IN 2015. PART I, LINE 5 VARIOUS PHYSICIAN COMPENSATION METHODOLOGIES ARE UTILIZED AND, DEPENDING ON SPECIALTY, RELATIVE VALUE UNITS (RVU'S) MAY BE USED IN DETERMINING A PORTION OF OR ALL OF THEIR COMPENSATION. TANIA MAY FAM MBR, M. MAY 146152 EMP BY ORG 0 JACOB SMITH FAM MBR, D. SMITH 13132 EMP BY ORG 0 FORM 990, PART VI, SECTION A, LINE 1 TWO NON-EMPLOYEE BOARD MEMBERS OF THE FILING ORGANIZATION ARE NOT INDEPENDENT DUE TO BUSINESS TRANSACTIONS WITH A RELATED ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 6 GOOD SAMARITAN HOSPITAL CORVALLIS HAS A SOLE CORPORATE MEMBER, SAMARITAN HEALTH SERVICES, INC., WHICH IS A SECTION 501(C)(3) TAX-EXEMPT ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A GOOD SAMARITAN HOSPITAL CORVALLIS ELECTS MEMBERS OF ITS BOARD OF DIRECTORS. THOSE ELECTED MEMBERS ARE THEN SUBMITTED TO THE SOLE CORPORATE MEMBER FOR APPROVAL. FORM 990, PART VI, SECTION A, LINE 7B THE SOLE CORPORATE MEMBER HAS SEVERAL RESERVED POWERS OVER THE ORGANIZATION. THESE RESERVED POWERS INCLUDE, BUT ARE NOT LIMITED TO, APPROVAL AT CERTAIN THRESHOLD LEVELS: THE BORROWING OF FUNDS, MERGERS AND ACQUISITIONS, AND SALES OR TRANSFERS OF ASSETS. IN ADDITION, THE SOLE CORPORATE MEMBER MUST APPROVE ANY CHANGE IN THE MISSION OF THE ORGANIZATION, THE ANNUAL BUDGET, AND ANY AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE ORGANIZATION'S FINAL FORM 990 (INCLUDING REQUIRED SCHEDULES), AS ULTIMATELY FILED WITH THE IRS, WAS PROVIDED TO EACH VOTING MEMBER OF THE SAMARITAN HEALTH SERVICES (SHS) AUDIT AND COMPLIANCE COMMITTEE PRIOR TO ITS FILING WITH THE IRS. SHS IS A 501(C)(3) CORPORATION AND IS THE SOLE MEMBER OF THE FILING ORGANIZATION. SHS'S CHIEF FINANCIAL OFFICER CONDUCTED THE FORM 990 REVIEW WITH THE COMMITTEE AND PROVIDED TIME FOR QUESTIONS FROM THE GROUP. A FORMAL REPORT OF THIS COMMITTEE HAS BEEN MADE TO THE FULL BOARD OF DIRECTORS OF SHS. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBER CONFLICTS OF INTEREST: THE MEMBERS OF THE BOARD MUST ANNUALLY COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE, WHICH REQUIRES DISCLOSURE OF ANY CONFLICTS OR POTENTIAL CONFLICTS OF INTEREST. THE COMPLETED QUESTIONNAIRES ARE REVIEWED BY THE CHIEF FINANCIAL OFFICER AND CORPORATE COMPLIANCE OFFICER. IF A CONFLICT IS DISCLOSED THAT COULD PROHIBIT A MEMBER FROM SERVING ON THE BOARD, THIS IS EVALUATED BY THE AUDIT AND COMPLIANCE COMMITTEE OF THE SAMARITAN HEALTH SERVICES (SHS) BOARD OF DIRECTORS TO DETERMINE WHETHER THE MEMBER SHOULD CONTINUE TO SERVE ON THE BOARD. IF A CONFLICT IS DISCLOSED THAT DOES NOT PROHIBIT A MEMBER FROM SERVING ON THE BOARD, THE CONFLICT IS MANAGED THROUGH A PROCESS SET FORTH IN THE ORGANIZATION'S BYLAWS. THE BYLAWS PROHIBIT ANY BOARD MEMBER FROM VOTING ON AN ACTION WHERE AN INDIVIDUAL MEMBER HAS A CONFLICT OF INTEREST. EMPLOYEE CONFLICTS OF INTEREST: THE SHS CODE OF ETHICS AND CONDUCT POLICY REQUIRES THAT ALL SHS EMPLOYEES COMPLETE AN ANNUAL DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST. THROUGH THE HUMAN RESOURCES SOFTWARE, PERFORMANCE MANAGER, THE DISCLOSURE REQUIREMENT NOTICE IS ASSIGNED TO ALL EMPLOYEES AND BY YEAR END ALL TASKS ARE TO BE COMPLETED. IF THERE IS A PERCEIVED CONFLICT OF INTEREST IT IS REVIEWED BY THE CORPORATE COMPLIANCE OFFICER, LEGAL COUNSEL AND/OR SENIOR MANAGEMENT. ACTUAL CONFLICTS OF INTEREST ARE REVIEWED AND DISCUSSED BY THE AUDIT AND COMPLIANCE COMMITTEE OF THE SAMARITAN HEALTH SERVICES BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION COMMITTEE OF SAMARITAN HEALTH SERVICES, INC. ANNUALLY ENGAGES AN INDEPENDENT CONSULTANT TO ASSIST IT IN PROVIDING COMPARABLE MARKET DATA FOR THE CEO/CEO SHS. THIS ANALYSIS INCLUDES REGIONAL AND NATIONAL DATA AS TO COMPARABLE COMPENSATION FOR SIMILARLY QUALIFIED PERSONS IN FUNCTIONALLY COMPARABLE POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS. THIS INFORMATION IS USED BY THE COMPENSATION COMMITTEE IN ITS DELIBERATIONS REGARDING THE CEO/CEO SHS' COMPENSATION WHICH IS DOCUMENTED IN THE COMMITTEE'S MINUTES. PHYSICIAN EMPLOYEE COMPENSATION, INCLUDING PHYSICIANS WHO ARE BOARD MEMBERS, IS REVIEWED AT LEAST ANNUALLY BY SENIOR MANAGEMENT. THIS REVIEW INCLUDES COMPARISON WITH PUBLISHED PHYSICIAN COMPENSATION STUDIES. FOR ALL OTHER EMPLOYEES, THE ORGANIZATION PERFORMS AN ANALYSIS EACH YEAR TO COMPARE COMPENSATION OF ALL PAID POSITIONS TO MARKET SURVEYS OF COMPENSATION FOR SIMILAR POSITIONS IN OTHER ORGANIZATIONS. FORM 990, PART VI, SECTION C, LINE 19 FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. SYSTEM-WIDE SUMMARIZED DATA IS ALSO PROVIDED IN THE ANNUAL REPORT TO THE COMMUNITY. THIS REPORT IS MADE AVAILABLE IN ALL KIOSKS AND HIGH-TRAFFIC AREAS OF ALL HOSPITALS AND PHYSICIAN CLINICS, AS WELL AS COMMUNITY PLACES SUCH AS THE PUBLIC LIBRARY. IT IS ALSO DISTRIBUTED TO THE BOARDS OF DIRECTORS AND DIRECTLY MAILED TO DONORS AND NEW RESIDENTS IN THE COMMUNITY. ADDITIONALLY, THE REPORT IS MADE AVAILABLE AT ALL EVENTS, COMMUNITY OUTREACH PROJECTS, AND SCREENINGS ATTENDED THROUGHOUT THE YEAR. GOVERNING DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: DISTRIBUTIONS TO MINORITY INTEREST CONSOLIDATED JVS -1,148,000. INCREASE IN MINIMUM PENSION LIABILITY 2,492,500. OTHER CHANGES 122,721. 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