2016-11-14T16:39:57-06:00 2015-12-31 930418710 DELAP LLP 5885 MEADOWS ROAD NO 200 LAKE OSWEGO OR 97035 990 2015-01-01 930415219 SANTIAM MEMORIAL HOSPITAL SANT 5037692175 1401 N 10TH AVENUE STAYTON OR 973831311 TERRY FLETCHALL CEO 5037692175 2016-11-11 1 MARK E EKLUND CPA P00156145 5036974118 2016-11-11 2015 2017-02-10 21:41:12Z TERRY FLETCHALL 1401 N 10TH AVENUE STAYTON OR 973831311 43110182 0 X WWW.SANTIAMHOSPITAL.ORG X 1950 OR GENERAL ACUTE HEALTH CARE HOSPITAL SERVING SANTIAM COMMUNITIES 9 9 382 21 0 0 101829 163242 39452907 42319756 23341 24294 253262 306269 39831339 42813561 0 38853 0 0 22111426 24071350 0 0 0 18672524 16983573 40783950 41093776 -952611 1719785 56074029 56699850 32868011 32216050 23206018 24483800 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 35750295 38853 42468375 ACUTE HOSPITAL CARE: PATIENT DAYS 3,388, NURSERY DAYS 136, AMBULANCE TRIPS 2,021, OUTPATIENT DAYS 40,692, REFERENCE LABORATORY 130,940. 35750295 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 66 0 1 382 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 TERRY FLETCHALL 5037692175 1401 N 10TH AVENUE STAYTON OR 97383 RON ETZEL SECRETARY 1.00 X X 0 0 0 VICTOR KINTZ DIRECTOR 1.00 X 0 0 0 MARYANN MEREDITH VICE PRESIDENT 1.00 X X 0 0 0 MIKE ODENTHAL DIRECTOR 1.00 X 0 0 0 RANDY MICKEY PRESIDENT 1.00 X X 0 0 0 GEORGE LONG DIRECTOR 1.00 X 0 0 0 FRANCIS HENDRICKS DIRECTOR 1.00 X 0 0 0 TERRY FLETCHALL CEO 50.00 X 248345 0 83943 MAGGIE HUDSON CFO/COO 50.00 X 194005 0 36528 GENNY BALDWIN CHIEF NURSING OFFICER 50.00 X 188702 0 35680 JOHN HOFFMAN M.D. 40.00 X 398113 0 40517 JOHN SILVER M.D. 40.00 X 378110 0 40224 SUSAN TAYLOR M.D. 40.00 X 274802 0 31168 KALSANG PHUNTSHOG M.D. 40.00 X 249125 0 36288 NICOLAS J STRATTON M.D. 40.00 X 378065 0 40480 2309267 0 344828 32 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 10000 153242 163242 PATIENT SERVICE REVENUE - NET 622110 40940835 40940835 K-1, INCOME FROM CCO 900099 1261359 1261359 ELECTRONIC HLTH RECORDS 990009 117562 117562 42319756 32954 32954 69567 103812 -34245 -34245 -34245 181399 2750 190314 2495 -8915 255 -8660 -8660 OTHER MISC. REVENUE 900099 182864 182864 CAFETERIA REVENUE 722210 157650 157650 340514 42813561 42468375 0 181944 38853 38853 748478 748478 17527010 16598460 928550 480474 422474 58000 4036169 3246916 789253 1279219 1100826 178393 105080 105080 297877 297877 3454728 2659308 795420 488310 488310 446965 111374 335591 304831 304831 1856513 1856513 2363545 2300836 62709 213932 32218 181714 SUPPLIES 5678802 5678802 CLINIC EXPENSE 1089147 1089147 EQUIPMENT MAINTENANCE 598911 597890 1021 DUES & SUBSCRIPTIONS 52261 52261 32671 16678 15993 41093776 35750295 5343481 0 240 240 7805480 11050030 5247171 4899968 521612 309916 1226173 1316628 749985 832676 54239787 20737742 35590804 33502045 1008550 998415 272728 272728 3530220 3268203 121066 249001 56074029 56699850 3527071 3446791 28471150 27711460 869790 1057799 32868011 32216050 X 23206018 24483800 23206018 24483800 56074029 56699850 X 1719785 -43069 -398934 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 330620 1091087 1421707 1874688 36094641 9615643 28353686 619850 505045 114805 10000 14132199 10617054 3525145 9320 77382 86702 33502045 EST 3RD PARTY PAYOR SETTLEMENTS 143120 OTHER LONG-TERM LIABILITIES 914679 1057799 X 42371558 -43069 863000 819931 41551627 1261934 1261934 42813561 41093776 0 41093776 0 41093776 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, 2015 AND 2014. PART XI, LINE 2D - OTHER ADJUSTMENTS: DISTRIBUTIONS, WILLAMETTE VALLEY COMMUNITY HEALTH, LLC 863,000. PART XI, LINE 4B - OTHER ADJUSTMENTS: REVENUE FROM K-1, WILLAMETTE VALLEY COMMUNITY HEALTH, LLC 1,261,934. 1 1 1 X 1 X 1 1 1 0 1 1 369 198115 0 198115 0.00480 23626 9076482 7562390 1514092 0.03680 23995 9274597 7562390 1712207 0.04160 3700 108273 13832 94441 0.00230 220226 220226 0.00540 38853 38853 0.00090 3700 367352 13832 353520 0.00860 27695 9641949 7576222 2065727 0.05020 1 1382961 4256913 5786188 -1529275 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 13 1 HTTP://SANTIAMHOSPITAL.ORG/RESOURCES.PHP 0 0 1 X 200.000000000000 300.000000000000 X X X X 1 1 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 1 X 0 X 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 SANTIAM MEMORIAL HOSPITAL PART V, SECTION B, LINE 22D: DETERMINED BASED ON A LOOK-BACK METHODOLOGY USING ALL PAYER RATES. 10 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 200 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 PART III, LINE 4: THE COSTING METHODOLOGY USED TO DETERMINE THE AMOUNT ON LINE 2: THE GROSS BAD DEBT CHARGES, $1,382,961, WERE APPLIED TO THE PATIENT CARE COST TO CHARGES RATIO ESTABLISHED IN WORKSHEET 2. BAD DEBTS ARE DETERMINED AFTER THE PATIENT RECEIVED 4 STATEMENTS AFTER DATE OF SERVICE OR DATE OF PAYMENT BY INSURANCE. AFTER THE 4TH STATEMENT, THE PATIENT RECEIVES A LETTER EXPLAINING THAT THEIR ACCOUNT WILL BE TURNED OVER TO A COLLECTION AGENCY IF PAYMENT IS NOT RECEIVED BY THE END OF THE MONTH.THE COSTING METHODOLOGY USED TO DETERMINE THE AMOUNT ON LINE 3: THROUGH OBSERVATION OF CHARITY CARE COORDINATOR, 80% OF BAD DEBTS MAY HAVE QUALIFIED FOR CHARITY CARE BECAUSE OF 1) INCORRECT CONTRACT INFORMATION GIVEN TO HOSPITAL, 2) UNABLE OR UNWILLINGNESS TO FILL OUT AND COMPLETE CHARITY CARE FORMS AND SUPPORTING DOCUMENTATION AND 3) THE STIGMA ASSOCIATED WITH THE ACCEPTANCE OF CHARITY CARE. 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 231124 0 1100 0 16121 0 71443 0 12500 0 332288 0 0 0 MAGGIE HUDSON CFO/COO 183704 0 1100 0 9201 0 16270 0 20258 0 230533 0 0 0 GENNY BALDWIN CHIEF NURSING OFFICER 184045 0 1100 0 3557 0 23661 0 12019 0 224382 0 0 0 JOHN HOFFMAN M.D. 397013 0 1100 0 0 0 7950 0 32567 0 438630 0 0 0 JOHN SILVER M.D. 377010 0 1100 0 0 0 7950 0 32274 0 418334 0 0 0 SUSAN TAYLOR M.D. 273702 0 1100 0 0 0 7950 0 23218 0 305970 0 0 0 KALSANG PHUNTSHOG M.D. 248025 0 1100 0 0 0 5533 0 30755 0 285413 0 0 0 NICOLAS J STRATTON M.D. 376965 0 1100 0 0 0 7950 0 32530 0 418545 0 0 0 PART I, LINE 4B TERRY FLETCHALL, CEO - 457(B) & 457(F) SUPPLEMENTAL RETIREMENT PLAN $25,000 ACCRUED IN 2015 ARE PARTIALLY PAID THROUGH BASE COMPENSATION. A SEVERANCE PACKAGE OF $33,000 ACCRUED IN 2015 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 11 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 -398,934. SANTIAM MEDICAL GROUP LLC 1401 N 10TH AVENUE STAYTON OR 97383 462570877 TO PROVIDE OUTPATIENT MEDICAL SERVICES AT VARIOUS CLINIC LOCATIONS OR 10160545 8698621 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 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 SANTIAM MEMORIAL HOSPITAL AUXILIARY N SANTIAM MEMORIAL HOSPITAL AUXILIARY C 10000