2015-05-04T15:43:43-05:00 2014-06-30 KPMG LLP 55 SECOND STREET SUITE 1400 SAN FRANCISCO CA 94105 990 2013-07-01 951643373 Community Hospital of San Bernardino % SHANTRA WAYNE ACCT DEPT COMM 9088876333 1805 Medical Center Drive Suite San Bernardino CA 92411 DAVE EVANS CFO 9098061242 2015-05-01 true VALERIE J BALL P00178114 9098061242 2015-05-01 2013 2016-02-25 16:41:14Z JUNE COLLISON PRESIDENT 1805 MEDICAL CNTR DRIVE SAN BERNARDINO CA 92411 185729623 false X WWW.CHSB.ORG X 1938 CA Community Hospital of San Bernardino is committed to furthering the healing ministry of Jesus, and to providing affordable health care to the community we serve. 14 9 1632 150 0 802783 1295962 191134701 181985902 456565 474370 764394 1705389 193158443 185461623 2276546 2180494 0 0 129352536 124714445 0 0 0 84078218 76253011 215707300 203147950 -22548857 -17686327 72035842 65831563 137615557 149097605 -65579715 -83266042 X COMMUNITY HOSPITAL OF SAN BERNARDINO IS A NON-PROFIT, FULL-SERVICE, ACUTE CARE FACILITY IN BUSINESS TO PROVIDE ACUTE INPATIENT CARE, LONG-TERM CARE AND A WIDE RANGE OF ANCILLARY AND THERAPEUTIC CARE TO THE COMMUNITY WE SERVE. OUR VISION IS TO CREATE AND PROVIDE HEALTH CARE SOLUTIONS, AND MEET THE HEALTH CARE NEEDS OF OUR COMMUNITY. false false 171810821 2180494 181985902 COMMUNITY HOSPITAL OF SAN BERNARDINO'S MISSION IS TO CONTRIBUTE TO THE HEALTH OF THE COMMUNITY THROUGH THE PROVISION OF QUALITY SERVICES DELIVERED IN A COMPASSIONATE AND COST EFFECTIVE MANNER. THE HOSPITAL IS LICENSED FOR 446 BEDS AND CURRENTLY HAS 379 BEDS AVAILABLE. THE HOSPITAL HAD 91,061 TOTAL PATIENT DAYS, 13,690 ADMISSIONS, AND 56,794 EMERGENCY ROOM VISITS. INPATIENT SERVICES: ACUTE PATIENT CARE; MATERNAL CHILD CARE; MENTAL HEALTH CARE; NEUROLOGICAL CARE; AND A VARIETY OF OUTPATIENT CARE. 171810821 true true false true false false false false false false true false false false true true false true false false false false false false false false true true true true true true true false false false false false false false false false true false false false false true true true false false true 163 0 true 1632 true false false false false false false false false false false X 14 9 false false false true true true true true true false false false true true true true true false false true true CA X SHANTRA WAYNE ACCT DEPT 6022171894 3033 NORTH 3RD AVENUE PHOENIX AZ 85013 Steven Barron Director 1.0 40.0 X 0 935069 103200 Alvaro Bolivar MD Ex-officio Director 40.0 0.0 X 204550 0 0 Paulette Brown PhD Director (THRU 1/31/14) 1.0 0.0 X 0 0 0 Bruce Ermann MD Director 1.0 40.0 X 0 299031 45165 Richard Gonzalez Esq Director 1.0 0.0 X 0 0 0 Albert Karnig PhD Director 1.0 0.0 X 0 0 0 Deisell Martinez PhD Director 1.0 0.0 X 0 0 0 Vellore Muraligopal MD Director 1.0 0.0 X 0 0 0 Tony Myrell Director 1.0 0.0 X 0 0 0 Nitin Nanda MD Director 1.0 0.0 X 0 0 0 Marvin O'Quinn Director (THRU 1/31/14) 1.0 40.0 X 0 2899983 1122219 Rachelle Wenger Director 1.0 40.0 X 0 167152 33340 Susan Whitten Director 1.0 40.0 X 0 524511 82996 Margaret Hill PhD Vice Chair 1.0 0.0 X X 0 0 0 Peggy Merryman Secretary 1.0 0.0 X X 0 0 0 Marvin Reiter CPA Chairman 1.0 0.0 X X 0 0 0 June Collison Hospital President 40.0 0.0 X 0 476541 71660 Darryl VandenBosch VP/CFO 20.0 20.0 X 0 416895 50774 Geraldine C Fike VP/CNE 40.0 0.0 X 228695 0 33646 Kimiko Ford VP of Ancillary Svcs 40.0 0.0 X 232308 0 49446 Victoria Selby VP, Behavioral Health & Neuro 40.0 0.0 X 209223 0 31287 Diana M Ahearn Sr Director of Nursing 40.0 0.0 X 193890 0 26752 David J Evans Controller 40.0 0.0 X 215286 0 37714 Marc Marchetti VP Business Development 40.0 0.0 X 219393 0 38467 Lorena Wilson Medical Transcriber 40.0 0.0 X 228696 0 25668 Patricia Womack Director of Pharmacy 40.0 0.0 X 196939 0 19589 Jack Ivie Former COO 0.0 40.0 X 526687 0 60362 2455667 5719182 1832285 241 true true false AMERICAN VITALCARE LLC 680 S FOURTH ST LOUISVILLE KY 40202 Medical Services 1575046 PREMIER COMMUNITY ANESTHESIA 1580 MOHAVE DR COLTON CA 92324 Medical Services 1550004 SAFEWAY CONSTRUCTION 1474 N MILLER DR COLTON CA 923242457 Contractor 1484344 INPATIENT CONSULTANTS OF CALIFORNIA PO BOX 51465 LOS ANGELES CA 90051 Medical Services 777414 METROPOLITAN FAMILY MEDICAL GROUP 742 W HIGHLAND AVE SAN BERNARDINO CA 92405 Medical Services 357153 19 X 1167699 128263 84149 1295962 PATIENT REV NET OF CHARITY CARE AND BAD DEBT 900099 75302568 75302568 MEDICARE/MEDICAID PAYMENTS 900099 102260449 102260449 MEANINGFUL USE INCENTIVES (EHR) 900099 3626611 3626611 MEDICAL OFFICE BUILDING 900099 791189 791189 EDUCATION 900099 5085 5085 181985902 72370 0 72370 0 0 0 0 0 670000 268000 402000 402000 402000 0 0 0 INSURANCE FRAUD RECOVER 900099 850000 850000 CAFETERIA 900099 401958 401958 GIFT SHOPS 900099 185765 185765 267666 267666 1705389 185461623 181985902 0 2179759 X 2144792 2144792 35702 35702 0 0 1598023 1488734 109289 234505 234505 95216810 88281347 6935463 4982493 4683543 298950 15373120 12912838 2460282 7309494 6797829 511665 0 171095 171095 68004 68004 949053 949053 0 0 22698500 14746647 7951853 0 657619 34376 623243 4301969 3596779 705190 10331376 1329198 9002178 0 2512983 2214186 298797 131055 72327 58728 0 84099 58738 25361 6059859 6059859 0 3604710 3064003 540707 1978968 1978968 MEDICAL SUPPLIES 13413748 13412294 1454 0 MEDI-CAL PROVIDER FEE 6600553 6600553 0 0 FOOD SUPPLIES 1222504 1148382 74122 0 LICENSES AND TAXES 675360 518262 157098 0 791556 396959 394597 203147950 171810821 31337129 0 7325 7328 325066 253240 64361 0 22395606 21750798 62206 0 0 0 2177595 1821893 2624367 2475495 18047925 13108955 112368370 86027574 26298141 26340796 0 0 0 0 0 39808 0 0 33250 33250 72035842 65831563 21671660 16198384 0 0 0 0 2000000 2000000 0 0 0 0 0 0 0 0 113943897 130899221 137615557 149097605 X -65579715 -83266042 0 0 0 0 -65579715 -83266042 72035842 65831563 -17686327 X X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 949053 949053 false PART II-B, LINE 1i LOBBYING EXPENDITURES PAID BY THE PARENT ORGANIZATION FOR ANNUAL MEMBERSHIP DUES WHERE EXPENSES ARE ALLOCATED TO THE HOSPITAL: Hospital Association of Southern California $15,574 American Hospital Association $2,675 CALIFORNIA HOSPITAL COMMITTEE ON ISSUES $866,034 PEACH Inc $63,420 Catholic Health Association $1,258 Safety Net Hospitals $92 __________ Total $949,053 ========== 799341 799341 76579450 64867737 11711713 29647365 20925305 8722060 5342214 234532 5107682 26340796 0 DUE TO RELATED PARTIES 125167298 PENSION PAYABLE 4855649 DEFERRED COMPENSATION 12307 OTHER NON-CURRENT LIABILITY 863967 130899221 X PART X, LINE 2 - FIN 48 (ASC 740) FOOTNOTE DIGNITY HEALTH REVIEWS ITS TAX POSITIONS ANNUALLY AND HAS DETERMINED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS THAT REQUIRE RECOGNITION IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. true true X true X true X 500. true true false true true 1034 5490986 5490986 0.02700 53960 134782310 116357344 18424966 0.09070 1485 6330940 2553307 3777633 0.01860 56479 146604236 118910651 27693585 0.13630 15 25898 1293375 48567 1244808 0.00610 8 4189 1080564 1080564 0.00530 23 30087 2373939 48567 2325372 0.01140 23 86566 148978175 118959218 30018957 0.14770 1 838 145835 33242 112593 0.00060 1 838 145835 33242 112593 0.00060 true 3015529 37983907 44703528 -6719621 X true true 1 1 Community Hospital of San Bernardino 1805 Medical Center Drive San Bernadino CA 92411 240000198 X X X Community Hospital of San Bernardino 1 true X X X X X X X X X 13 true true true X SEE PART VI, SECTION C X X X X X X X false false true true 200. true 500. true X X X X X X X true true X X X X X X X true false X X X X true X false false SCHEDULE H, PART V, SECTION B, LINE 3 IN FY2014, COMMUNITY HOSPITAL OF SAN BERNARDINO (CHSB), IN COLLABORATION WITH ST. BERNARDINE MEDICAL CENTER, CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSMENT. BIEL CONSULTING, INC. WAS ENGAGED TO CONDUCT THE ASSESSMENT. TWENTY COMMUNITY STAKEHOLDERS, IDENTIFIED BY THE COMMUNITY BENEFIT INITIATIVE COMMITTEE, WERE CONTACTED AND ASKED TO PARTICIPATE IN THE NEEDS ASSESSMENT. INTERVIEW PARTICIPANTS INCLUDED LEADERS AND REPRESENTATIVES OF MEDICALLY UNDERSERVED, LOW-INCOME, AND MINORITY POPULATIONS. THOSE CONSULTED INCLUDE HEALTH CARE CONSUMERS AND REPRESENTATIVES OF NONPROFIT AND COMMUNITY-BASED ORGANIZATIONS, ACADEMIC EXPERTS, LOCAL GOVERNMENT OFFICIALS (INCLUIDNG THE LOCAL HEALTH DEPARTMENT), LOCAL SCHOOL DISTRICTS, HEALTH CARE PROVIDERS AND COMMUNITY HEALTH CENTERS. Additionally, SIX focus groups were conducted to obtain input from those who are direct recipients of services in the community and included members of medically underserved populations. SCHEDULE H, PART V, SECTION B, LINE 4 ST. BERNARDINE MEDICAL CENTER SCHEDULE H, PART V, SECTION B, LINE 5A http://www.dignityhealth.org/san-bernardino/who-we-are/serving-the-communi ty/community-health-needs-assessment-and-plan/health-needs-report SCHEDULE H, PART V, SECTION B, LINE 7 Significant health needs identified in the CHNA that are not addressed in the Implementation Strategy are community growth and enrichment (safety, homelessness, education, economic development) specific to adult populations. CHSB is strongly committed to breaking the cycle of phenomena (i.e. education, poverty, and employment) that impact the social determinants of health. Therefore its efforts at community growth and enrichment are targeted to youth. While recognizing that there are other valid concerns that impact the health of the community, the CBIC identified the hospital has limited resources. Therefore, the committee elected to focus on this issue specific to at-risk youth populations as there are existing programs in place through the facility or with community partners. SCHEDULE H, PART V, SECTION B, LINE 14G ALL LANGUAGE REGARDING THE POLICY IS COMMUNICATED TO PATIENTS VIA THE METHODS OUTLINED BELOW. 1. SIGNAGE IN ALL ADMITTING AREAS; 2. AT THE POINT OF REGISTRATION, ALL PATIENTS RECEIVE BROCHURES EXPLAINING THE FACILITY'S FINANCIAL ASSISTANCE PROGRAM AND THE AVAILABILITY OF GOVERNMENT SPONSORED PROGRAMS; 3. ALL INITIAL STATEMENTS TO UNINSURED PATIENTS INCLUDES VERBIAGE INFORMING PATIENTS OF THE FACILITY'S FINANCIAL ASSISTANCE PROGRAM AND A COPY OF THE FINANCIAL ASSISTANCE APPLICATION. A TELEPHONE NUMBER IS PROVIDED FOR PATIENTS TO REQUEST FURTHER INFORMATION ABOUT THE PROGRAM AND ASSISTANCE IS AVAILABLE IN LANGUAGES OTHER THAN ENGLISH; 4. INFORMATION ABOUT THE FACILITY'S FINANCIAL ASSISTANCE PROGRAM, ACCESS TO THE APPLICATION, AND CONTACT INFORMATION IS AVAILABLE ON THE FACILITY'S WEBPAGE. SCHEDULE H, PART V, SECTION B, LINE 20D PATIENTS WHO ARE APPLYING FOR DISCOUNTS UNDER THE DISCOUNT PROVISION OF HOSPITAL FAIR PRICING ACT - CALIFORNIA HEALTH AND SAFETY CODE 127400 WHOSE HOUSEHOLD INCOME IS AT OR BELOW 350% OF THE FPL ARE ELIGIBLE TO RECEIVE SERVICES AT THE HIGHEST AVERAGE RATE THE HOSPITAL WOULD RECEIVE FOR PROVIDING SERVICES FROM MEDICARE, MEDICAID, OR ANY OTHER GOVERNMENT-SPONSORED HEALTH PROGRAM OF HEALTH BENEFIT IN WHICH THE HOSPITAL PARTICIPATES, WHICHEVER IS GREATER. 1 Community Convalescent Center 1676 Medical Center Drive San Bernardino CA 92411 SKILLED NURSING Schedule H, Part I, Line 7, column (f) The amount of bad debt expense included on Form 990, Part IX, line 25, column (A), which is non-patient related bad debt expense, is $12,745 and has been subtracted for purposes of calculating the percentages in column (f). Schedule H, Part I, Line 7 FOR PURPOSES OF CALCULATING THE AMOUNTS PROVIDED IN THE TABLE, CHSB USES A COST ACCOUNTING SYSTEM THAT COMBINES RELATIVE VALUE UNITS (RVU) AND COST TO CHARGE RATIOS (CCR) TO ALLOCATE COSTS TO THE PATIENT LEVEL. THE COST ACCOUNTING SYSTEM ALGORITHM ALLOCATES TOTAL OPERATING EXPENSES TO THE PROCEDURE CHARGE CODE LEVEL BASED UPON AN RVU FOR PROCEDURES THAT HAVE BEEN STUDIED AND ASSIGNED AN RVU, OR BASED UPON A CCR FOR UNSTUDIED PROCEDURES THAT DO NOT HAVE AN RVU ASSIGNED. WHEN A CCR IS USED, THE SYSTEM CALCULATES THAT CCR ON A DEPARTMENTAL SPECIFIC BASIS AT THE HOSPITAL WHERE THE SERVICES WERE PROVIDED. THE CALCULATION IS SIMILAR TO THE WORKSHEET 2 OF SCHEDULE H, RATIO OF PATIENT CARE COST TO CHARGES, EXCEPT IT IS CALCULATED ON A DEPARTMENTAL SPECIFIC BASIS, NOT IN THE AGGREGATE. THE ALLOCATED PROCEDURE CHARGE CODE LEVEL COSTS ARE THEN ROLLED UP TO THE PATIENT LEVEL BASED UPON THE BILLED PROCEDURE CHARGE CODES ASSOCIATED WITH THOSE SERVICES PROVIDED TO EACH SPECIFIC PATIENT. THIS IS DONE FOR ALL PATIENT SEGMENTS INCLUDING INPATIENT, OUTPATIENT, EMERGENCY DEPARTMENT, PRIVATE INSURANCE, MEDICAID, MEDICARE, UNINSURED AND SELF PAY. THE COST ACCOUNTING SYSTEM IS UTILIZED TO DETERMINE THE UNREIMBURSED COST OF MEDICAID AND OTHER MEANS-TESTED GOVERNMENT PROGRAMS. THE COST OF CHARITY CARE IS CALCULATED BY APPLYING THE CCR DERIVED FROM THE COST ACCOUNTING SYSTEM ON A PER FACILITY BASIS, TO THE CHARGES INCURRED ON PATIENTS THAT QUALIFY FOR CHARITY CARE AT THE RESPECTIVE FACILITY. THE ACTUAL COST IS REPORTED FOR OTHER COMMUNITY BENEFIT ACTIVITIES SUCH AS COMMUNITY HEALTH IMPROVEMENT SERVICES, COMMUNITY BENEFIT OPERATIONS, HEALTH PROFESSIONS EDUCATION, SUBSIDIZED HEALTH SERVICES, RESEARCH AND CASH AND IN-KIND DONATIONS. Schedule H, Part I, line 7b, column (f) BEGINNING IN 2009, THE STATE OF CALIFORNIA ESTABLISHED PROVIDER FEE PROGRAMS. THESE PROGRAMS ARE FUNDED BY QUALITY ASSURANCE FEES PAID BY PARTICIPATING HOSPITALS AND MATCHING FEDERAL FUNDS. COMMUNITY HOSPITAL OF SAN BERNARDINO RECOGNIZED QUALITY ASSURANCE FEES DURING THE YEAR OF $6.6 MILLION WHICH ARE INCLUDED IN TOTAL COMMUNITY BENEFIT EXPENSE RELATED TO UNREIMBURSED MEDICAID (PART I, LINE 7B, COLUMN C), AND RECOGNIZED FEE-FOR-SERVICE SUPPLEMENTAL PAYMENTS OF $13.8 MILLION DURING THE YEAR REFLECTED UNDER THE MEDICAID PROGRAM AS DIRECT OFFSETTING REVENUE (PART I, LINE 7B, COLUMN D). THIS NET REDUCTION IN THE COST OF THE MEDICAID PROGRAM IS DRIVING THE DECREASE IN THE OVERALL COST OF COMMUNITY BENEFIT EXPENSE AS A PERCENT OF TOTAL EXPENSES WHEN COMPARED TO PRIOR YEARS. THE CALIFORNIA HOSPITAL ASSOCIATION CREATED A PRIVATE PROGRAM, THE CALIFORNIA HEALTH FOUNDATION AND TRUST ("CHFT"), ESTABLISHED FOR SEVERAL PURPOSES, INCLUDING AGGREGATING AND DISTRIBUTING FINANCIAL RESOURCES TO SUPPORT CHARITABLE ACTIVITIES AT VARIOUS HOSPITALS AND HEALTH SYSTEMS IN CALIFORNIA. DURING THE YEAR, COMMUNITY HOSPITAL OF SAN BERNARDINO RECORDED A PLEDGE TO A GRANT FUND ESTABLISHED BY CHFT IN THE AMOUNT $0.6 MILLION THE GRANT IS REPORTED UNDER OTHER BENEFITS (PART I, LINE 7I, COLUMN C), AS CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS. Schedule H, Part II - Community Building Activities CHSB staff provides resources and experiences that are generously shared with and sought by the community. Working collaboratively with community partners, the hospital provides leadership and advocacy, assists with local capacity building and participates in community-wide health planning through its involvement with organizations that address specific needs for a healthier and safer community including: * Healthy San Bernardino * Community Vital Signs (CVS) * Mobilizing Action through Planning and Partnership (MAPP) Work Group for CVS * Hospital Association of Southern California (HASC) Community Benefit Stakeholders Community Hospital of San Bernardino is dedicated to community building in the surrounding neighborhoods. CHSB actively partners with Healthy San Bernardino, a multi-agency collaboration devoted to advocating for community health improvement, especially in the areas of access to healthy food; safe streets and public spaces; schools, parks and open spaces; appropriate healthcare, wellness and prevention, including behavioral health; and personal awareness, motivation and responsibility with a community-wide sense of hope and purpose. As a member of the Hospital Association of Southern California (HASC) Community Benefit Stakeholders Committee, CHSB joined other local hospitals in establishing the goal of "displacing heart disease as the leading cause of death in San Bernardino County." Partners include: * American Heart Association * Arrowhead Regional Medical Center * Community Hospital of San Bernardino * Kaiser Permanente * Loma Linda University Health * Redlands Community Hospital * San Antonio Community Hospital * San Bernardino Dept. of Public Health * St. Bernardine Medical Center * St. Mary Medical Center (St. Joseph Health) SCHEDULE H, PART III, LINE 2 THE AMOUNT OF THE ORGANIZATION'S BAD DEBT AT COST IS DETERMINED BY APPLYING THE CCR (SEE ABOVE) TO PATIENT CHARGES THAT ARE DEEMED TO BE UNCOLLECTIBLE. THIS AMOUNT REPRESENTS THE COST OF SERVICES PROVIDED TO PATIENTS WHO ARE UNABLE OR REFUSE TO PAY THEIR BILLS AND DO NOT QUALIFY FOR FREE OR DISCOUNTED CARE, GOVERNMENT SPONSORED PROGRAMS OR OTHER FINANCIAL ASSISTANCE, AND ARE OTHERWISE UNINSURED. ANY PORTION OF A PATIENT BILL REMAINING AFTER APPLYING FINANCIAL, UNINSURED OR OTHER DISCOUNTS OR PAYMENTS RECEIVED ON THE ACCOUNT THAT ARE ULTIMATELY DETERMINED TO BE UNCOLLECTIBLE ARE WRITTEN OFF TO BAD DEBT. AS NOTED IN PART I, LINE 3, CHSB PROVIDES FREE OR DISCOUNTED CARE TO UNINSURED OR UNDER-INSURED INDIVIDUALS THAT FALL INTO THREE CATEGORIES; UNDER 200%, 201%-350% OR 351%-500% OF THE FEDERAL POVERTY LEVEL. CHSB ALSO PROVIDES PATIENTS OPTIONS FOR PROMPT PAY DISCOUNTS, DISCOUNTS FOR THE MEDICALLY INDIGENT, AND INTEREST-FREE EXTENDED PAYMENT PLANS FOR PATIENTS WHO HAVE DEMONSTRATED GOOD FAITH AND ARE COOPERATING IN RESOLVING THEIR HOSPITAL BILLS. ALL ACCOUNTS FOR ELIGIBLE UNINSURED PATIENTS RECEIVE AN AUTOMATIC UNINSURED DISCOUNT OF 25% FOR PATIENTS SEEN. THE EXPECTED PATIENT PAYMENT AMOUNT ON THE PATIENT'S BILL REFLECTS THIS DISCOUNT. SCHEDULE H, PART III, LINE 3 CHSB MAKES EVERY EFFORT IN DETERMINING IF A PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE UPON ADMISSION. CHSB FOLLOWS DIGNITY HEALTH'S FINANCIAL ASSISTANCE POLICY. THE FINANCIAL ASSISTANCE POLICY IS COMMUNICATED TO PATIENTS UPON ADMISSION AND IS AVAILABLE IN THE LANGUAGES PRIMARILY SPOKEN IN THE COMMUNITY. IT IS ALSO POSTED IN VARIOUS COMMON AREAS OF THE HOSPITAL, SUCH AS EMERGENCY ROOMS, URGENT CARE CENTERS, ADMITTING AND REGISTRATION DEPARTMENTS, HOSPITAL BUSINESS OFFICES LOCATED ON FACILITY CAMPUSES, AND OTHER PUBLIC PLACES, AND IS PROVIDED UPON BILLING IF ELIGIBILITY IS NOT PREVIOUSLY DETERMINED. ELIGIBILITY IS REEVALUATED AS NEEDED AND AMOUNTS ARE CLASSIFIED AS CHARITY AS SOON AS ELIGIBILITY IS KNOWN. DIGNITY HEALTH ALSO UTILIZES A PAYMENT ASSISTANCE RANK ORDERING (PARO) SCORING SYSTEM TO ASSIST IN DETERMINING IF A PATIENT MAY QUALIFY FOR PAYMENT ASSISTANCE EVEN THOUGH THEY HAVE NOT APPLIED FOR IT. PARO IS A METHODOLOGY THAT APPLIES CONSISTENT SCREENING AND APPLICATION STANDARDS TO ALL PATIENTS UTILIZING HISTORICAL DATA TO DEVELOP A PREDICTIVE MODEL FOR HEALTHCARE PAYMENT ASSISTANCE. IN ITS DEVELOPMENT, SPECIAL ATTENTION WAS PAID TO THOSE SOCIOECONOMIC FACTORS THAT MIGHT ADVERSELY AFFECT THOSE PATIENTS DESERVING THE MOST ATTENTION. OTHER CRITERIA ARE ALSO UTILIZED TO ENSURE THAT NO SERVICES THAT HAVE QUALIFIED AS FINANCIAL ASSISTANCE WERE REPORTED AS BAD DEBT. AS SUCH, CHSB DOES NOT BELIEVE THAT ANY AMOUNTS INCLUDED IN PART III, LINE 2, ARE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S PAYMENT ASSISTANCE POLICY, AND THEREFORE, NO PORTION OF BAD DEBT EXPENSE IS INCLUDED AS COMMUNITY BENEFIT EXPENSE. Schedule H, Part III, Line 4 THE FOLLOWING IS AN EXCERPT FROM DIGNITY HEALTH AND ITS SUBORDINATE CORPORATIONS' CONSOLIDATED ANNUAL AUDITED FINANCIAL STATEMENTS FOR THE YEAR ENDED JUNE 30, 2014, RELATED TO ACCOUNTS RECEIVABLE AND ALLOWANCES FOR CHARITY AND DOUBTFUL ACCOUNTS: PATIENT ACCOUNTS RECEIVABLE AND NET PATIENT SERVICE REVENUE ARE REPORTED AT THE NET REALIZABLE AMOUNT FROM PATIENTS, THIRD-PARTY PAYORS, AND OTHERS FOR SERVICES RENDERED. CHSB MANAGES ITS COLLECTION RISK BY REGULARLY REVIEWING ITS ACCOUNTS AND CONTRACTS AND BY PROVIDING APPROPRIATE ALLOWANCES. RESERVES FOR CHARITY AND UNCOLLECTIBLE AMOUNTS HAVE BEEN ESTABLISHED AND ARE NETTED AGAINST PATIENT ACCOUNTS RECEIVABLE IN THE CONSOLIDATED BALANCE SHEET. Schedule H, Part III, Line 8 CHSB PREPARES MEDICARE COST REPORTS IN A MANNER THAT COMPORTS WITH PROVIDER REIMBURSEMENT MANUAL (PRM) 15-1, 2150FF AND PRM 15-2, 1000FF. AS SUCH, THE FOLLOWING LANGUAGE PER THE PRM 15-1 DESCRIBES THE COMPUTATION OF COSTS PER THE MEDICARE COST REPORT: TOTAL ALLOWABLE COSTS OF A PROVIDER ARE APPORTIONED BETWEEN PROGRAM BENEFICIARIES AND OTHER PATIENTS SO THAT THE SHARE BORNE BY THE PROGRAM IS BASED UPON ACTUAL SERVICES RECEIVED BY PROGRAM BENEFICIARIES. THE RATIO OF COVERED BENEFICIARY CHARGES TO TOTAL PATIENT CHARGES FOR THE SERVICES OF EACH ANCILLARY DEPARTMENT IS APPLIED TO THE COST OF THE DEPARTMENT. ADDED TO THIS AMOUNT IS THE COST OF ROUTINE SERVICES FOR PROGRAM BENEFICIARIES, DETERMINED ON THE BASIS OF A SEPARATE AVERAGE COST PER DIEM FOR ALL PATIENTS FOR GENERAL ROUTINE PATIENT CARE AREAS. ANOTHER FACTOR TO BE CONSIDERED IS A SEPARATE AVERAGE COST PER DIEM FOR THE INTENSIVE CARE UNIT, CORONARY CARE UNIT, AND OTHER SPECIAL CARE INPATIENT HOSPITAL UNITS. DIGNITY HEALTH BELIEVES THAT THE ENTIRE MEDICARE SHORTFALL OF $674 MILLION, AS REPORTED BELOW IN PART VI, LINE 6, CONSTITUTES COMMUNITY BENEFIT. THE IRS COMMUNITY BENEFIT STANDARD INCLUDES THE PROVISION OF CARE TO THE ELDERLY AND MEDICARE PATIENTS. MEDICARE SHORTFALLS MUST BE ABSORBED BY DIGNITY HEALTH HOSPITALS IN ORDER TO CONTINUE TREATING THE ELDERLY IN OUR COMMUNITIES. CHSB PROVIDES CARE REGARDLESS OF THIS SHORTFALL AND THEREBY RELIEVE THE FEDERAL GOVERNMENT OF THE BURDEN OF PAYING THE FULL COST FOR MEDICARE BENEFICIARIES. THIS SHORTFALL INCLUDES $6.7 MILLION REPORTED ON PART III, SECTION B, LINE 7, PRIMARILY FOR FEE FOR SERVICE MEDICARE PATIENTS, AS WELL AS THE UNREIMBURSED PORTION OF MEDICARE MANAGED CARE AND MEDICARE CAPITATED PROGRAMS FOR CHSB. Schedule H, Part III, Line 9b AT TIME OF PATIENT BILLING, CHSB PROVIDES TO ALL PATIENTS INFORMATION CONCERNING SERVICES AND CHARGES PROVIDED. INFORMATION PROVIDED INCLUDES, PATIENT FINANCIAL ASSISTANCE INFORMATION, UNINSURED PATIENT DISCOUNT INFORMATION, INFORMATION REGARDING ELIGIBILITY ASSISTANCE FOR GOVERNMENT-SPONSORED HEALTHCARE AND PAYMENT ASSISTANCE. CHSB ENSURES THAT PATIENT ACCOUNTS ARE PROCESSED FAIRLY AND CONSISTENTLY. CHSB'S COLLECTION POLICY CONTAINS PROVISIONS THAT PROHIBIT THE COLLECTION OF AMOUNTS DUE FROM PATIENTS WHO THE ORGANIZATION KNOWS QUALIFY FOR FINANCIAL ASSISTANCE. ACCOUNTS WITH INCORRECT OR INCOMPLETE DEMOGRAPHIC INFORMATION ARE ASSIGNED TO A COLLECTION AGENCY IF CHSB OR THE BILLING COMPANY RETAINED BY CHSB IS UNABLE TO OBTAIN AN UPDATED ADDRESS THROUGH SKIP TRACING OR OTHER MEANS. FOR PATIENTS WHO HAVE AN APPLICATION PENDING FOR EITHER GOVERNMENT-SPONSORED FINANCIAL ASSISTANCE OR FOR ASSISTANCE UNDER CHSB'S PATIENT PAYMENT ASSISTANCE POLICY, OR WHERE THE PATIENT IS ATTEMPTING IN GOOD FAITH TO SETTLE AN OUTSTANDING BILL WITH THE FACILITY VIA PAYMENT PLANS, CHSB WILL NOT KNOWINGLY SEND THAT PATIENT'S BILL TO AN OUTSIDE COLLECTION AGENCY. LEGAL ACTION WILL NOT BE PURSUED TO COLLECT DEBTS FROM PATIENTS WHO HAVE QUALIFIED FOR CHARITY OR ARE COOPERATING IN GOOD FAITH TO RESOLVE THEIR DEBT. CHSB DOES NOT IMPOSE WAGE GARNISHMENTS OR LIENS ON PRIMARY RESIDENCES. ON SELF-PAY ACCOUNTS THAT DO NOT MEET THE CRITERIA NOTED ABOVE, THE INITIAL DETERMINATION OF ASSIGNMENT TO A COLLECTION AGENCY WILL VARY DEPENDING ON THE NATURE OF THE ACCOUNT WITH THE FINAL DECISION BEING AT THE DISCRETION OF EACH HOSPITAL PATIENT FINANCIAL ASSISTANCE DEPARTMENT. UPON ASSIGNMENT OF SUCH A PATIENT ACCOUNT TO A COLLECTION AGENCY, CHSB REQUIRES THE AGENCY TO COMPLY WITH THE FAIR DEBT COLLECTION PRACTICES ACT. Schedule H, Part VI, Line 2 - Needs Assessment THE PASSING OF CALIFORNIA'S COMMUNITY BENEFIT LAW (SB 697) CREATED A PROCESS AND MAJOR TOOL FOR CHSB TO DETERMINE ITS COMMUNITY BENEFIT PLAN, WHICH OUTLINES HOW THE HOSPITAL WILL GIVE BACK TO THE COMMUNITY IN THE FORM OF HEALTH CARE AND OTHER COMMUNITY SERVICES TO ADDRESS UNMET COMMUNITY HEALTH NEEDS. IN THE SPRING OF 2014 A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) WAS CARRIED OUT IN PARTNERSHIP WITH ST. BERNARDINE MEDICAL CENTER. IT INCORPORATES COMPONENTS OF PRIMARY DATA COLLECTION AND SECONDARY DATA ANALYSIS THAT FOCUS ON THE HEALTH AND SOCIAL NEEDS OF THE CHSB SERVICE AREA. ADDITIONALLY, SIX FOCUS GROUPS WERE CONDUCTED WITH RESIDENTS OF COMMUNITIES IN THE CHSB PRIMARY SERVICE AREA. FOUR OF THE GROUPS WERE CONDUCTED IN ENGLISH AND TWO IN SPANISH. THROUGH THE PARTICIPATION IN THIS NEEDS ASSESSMENT AND BENEFITS PLANNING PROCESS CHSB REMAINS COMMITTED TO PARTICIPATING IN COMMUNITY PROCESSES THAT UPDATE AND REFRESH THE ONGOING QUEST TO UNDERSTAND AND TO RESPOND TO THE COMMUNITY'S PRIORITIES FOR HEALTH AND QUALITY OF LIFE IMPROVEMENTS. THE CHNA CONTINUES TO BE A FOCAL POINT AND AN ESSENTIAL TOOL IN DEVELOPING THE STRATEGIC DIRECTION OF CHSB, ALONG WITH PARTICIPATORY AND SOLUTION FOCUSED PROCESSES WHICH HAVE TAKEN INVENTORY OF COMMUNITY ASSETS AND RESOURCES IN OUR COMMUNITY BY THE LATINO HEALTH COLLABORATIVE, THE AFRICAN AMERICAN HEALTH INSTITUTE, AND THE LOMA LINDA SCHOOL OF PUBLIC HEALTH. Schedule H, Part VI, Line 3 - Patient Education of Eligibility for Assistance COMMUNICATION OF THE FINANCIAL ASSISTANCE PROGRAM TO PATIENTS AND THE PUBLIC: INFORMATION ABOUT DIGNITY HEALTH'S FINANCIAL ASSISTANCE PROGRAM AND A CONTACT NUMBER ARE MADE AVAILABLE TO PATIENTS AND THE PUBLIC. PATIENTS ARE INFORMED OF THE FACILITY'S FINANCIAL ASSISTANCE PROGRAM VIA SIGNAGE IN ALL ADMITTING AREAS AND IN VARIOUS COMMON AREAS OF THE HOSPITAL. FINANCIAL ASSISTANCE PROGRAM INFORMATION NOTICES ARE POSTED IN THE EMERGENCY AND ADMITTING DEPARTMENTS AND AT OTHER PUBLIC PLACES AS THE HOSPITAL MAY ELECT. SUCH INFORMATION IS PROVIDED IN THE PRIMARY LANGUAGES SPOKEN IN THE COMMUNITIES THE HOSPITAL SERVES. THE SIGNAGE INCLUDES NOTIFICATION THAT ALL UNINSURED PATIENTS WITH ANNUAL INCOMES LESS THAN $250,000 RECEIVE AN UNINSURED DISCOUNT OF 25% FOR SERVICES PROVIDED AND THAT FURTHER DISCOUNTS MAY BE PROVIDED UPON THE COMPLETION AND SUBMISSION OF A FINANCIAL ASSISTANCE APPLICATION. FINANCIAL ASSISTANCE INFORMATION, GOVERNMENT PROGRAM RESOURCE INFORMATION, TOOLS TO ASSIST PATIENTS IN FINDING HEALTH COVERAGE, ANSWERS TO FREQUENTLY ASKED BILLING QUESTIONS, AND OTHER SUCH INFORMATION CAN ALSO BE FOUND ON DIGNITY HEALTH'S WEBSITE AT WWW.DIGNITYHEALTH.ORG. AT THE POINT OF REGISTRATION, ALL PATIENTS RECEIVE BROCHURES EXPLAINING THE FACILITY'S FINANCIAL ASSISTANCE PROGRAM AND THE AVAILABILITY OF GOVERNMENT SPONSORED PROGRAMS. UNINSURED PATIENTS RECEIVE COPIES OF THE FINANCIAL ASSISTANCE AND MEDICAID APPLICATIONS IN ADDITION TO THE BROCHURE UPON ADMISSION TO THE FACILITY. IF FINANCIAL ASSISTANCE ELIGIBILITY IS NOT DETERMINED PRIOR TO BILLING, INITIAL BILLING STATEMENTS TO UNINSURED PATIENTS INCLUDE A REQUEST TO THE PATIENT TO PROVIDE ANY INSURANCE INFORMATION THAT WAS VALID FOR THE DATES OF SERVICE BILLED, A STATEMENT INFORMING PATIENTS WITHOUT INSURANCE COVERAGE THEY MAY BE ELIGIBLE FOR A GOVERNMENT SPONSORED PROGRAM OR FACILITY FUNDED FINANCIAL ASSISTANCE, INSTRUCTIONS ON HOW TO APPLY FOR A GOVERNMENT PROGRAM OR FINANCIAL ASSISTANCE AND THE PROVISION OF SUCH APPLICATIONS. ADDITIONALLY, CONTRACT TERMS WITH COLLECTION VENDORS WORKING ON BEHALF OF DIGNITY HEALTH INCLUDES LANGUAGE REQUIRING ALL INITIAL STATEMENTS TO UNINSURED PATIENTS INCLUDE VERBIAGE INFORMING PATIENTS OF THE FACILITY'S FINANCIAL ASSISTANCE PROGRAM AND A COPY OF THE FINANCIAL ASSISTANCE APPLICATION. ALSO, ANY MEMBER OF CHSB FACILITY STAFF OR MEDICAL STAFF MAY MAKE REFERRALS OF PATIENTS FOR FINANCIAL ASSISTANCE. THE PATIENT OR A FAMILY MEMBER, A CLOSE FRIEND OR AN ASSOCIATE OF THE PATIENT MAY ALSO MAKE A REQUEST FOR FINANCIAL ASSISTANCE. Schedule H, Part VI, Line 4 - Community Information Community Hospital of San Bernardino is located in an area that has struggled economically for years, and has only seen the quality of life plummet with the recent national economic downturn. Eighty percent (80%) of discharges come from fifteen (15) zip codes concentrated in the following cities: Bloomington, Colton, Fontana, Highland, Rialto and San Bernardino. The Inland Empire continues to suffer the effects of the Great Recession of 2008. Within the service area, unemployment had risen as high as 16.6% in 2010 and by 2012 had dropped to 14.6%. Currently, 9.2% to 48.5% of the population lives at or below 100% of the Federal Poverty Level. In San Bernardino 92401, 88.5% of individuals live at or below the 200% poverty level, followed by 92411 (72.5%) and 92410 (71.0%). Contributing to the dismal earning potential of its residents, the community has a low education rate. While the high school graduation rate has improved slightly, of the population age 25 and over, 31.5% have less than a high school diploma, compared to the state rate of 19%. Furthermore, for 26.7% of area adults, high school graduation was their highest level of educational attainment. Confirming the difficult economics of the region, in July 2012 the City of San Bernardino filed for Chapter 9 bankruptcy protection. Crime has risen, businesses have fled and this past year recall efforts supported the recall of two city council members and the city attorney. The following reflects demographics for the primary service area: * Population: 702,088 * Diversity: Hispanic (64.8%), Caucasian (17.3%), African American (11.2%), Asian & Pacific Islander (4.6%), American Indian/Alaska Native (0.3%), Other Race/Multiracial (1.8%) * Median Household Income: $51,272 * Uninsured: 16.8% * Unemployment: 14.6% * No High School Diploma: 31.5% * Renters: 36.7% * CNI Score: 4.8 * MediCal Patients: 28.5% In addition to Community Hospital of San Bernardino and St. Bernardine Medical Center, other hospitals serving the area include: Arrowhead Regional Medical Center, Kaiser Permanente-Fontana, Loma Linda University Medical Center and Redlands Community Hospital. The Community Need Index (CNI) is a tool developed by Dignity Health to measure community need in a specific geography through analyzing the degree to which a community has the following health care access barriers: 1) Income Barriers, 2) Educational Barriers, 3) Cultural Barriers, 4) Insurance Barriers and 5) Housing Barriers. Communities with scores of "5" are more than twice as likely to need inpatient care for preventable conditions as communities with a score of "1". The median CNI score of the hospital's service area is 4.8 with six (6) of the zip code communities scoring a "5". Many of the neighborhoods served have been federally designated as a Medically Underserved Area (MUA). Schedule H, Part VI, Line 5 - Promotion of Community Health A MAJORITY OF THE CHSB'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE PRIMARY SERVICE AREA AND WHO ARE NEITHER EMPLOYEES, FAMILY MEMBERS NOR CONTRACTORS OF THE HOSPITAL. THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. CHSB RECOGNIZES THE IMPORTANCE OF COMMUNITY HEALTH AND PROMOTES COMMUNITY HEALTH BEYOND THE WALLS OF THE HOSPITAL THROUGH A VARIETY OF METHODS: COMMUNITY EDUCATION CLASSES ON A VARIETY OF TOPICS ARE OFFERED FREE OF CHARGE THROUGHOUT THE YEAR TO COMMUNITY MEMBERS; REFERRALS TO APPROPRIATE SOCIAL AGENCIES ARE MADE TO THOSE SEEKING ASSISTANCE; FREE FLU SHOTS; COLLABORATION WITH A VARIETY OF NON-PROFIT AGENCIES SHARING A MISSION OF HEALTH, ENVIRONMENT AND SOCIAL WELFARE; ACTIVE MEMBERSHIP ON ST. BERNARDINE MEDICAL CENTER'S COMMUNITY BENEFIT INITIATIVE COMMITTEE (CBIC) WHERE INPUT FROM KEY COMMUNITY STAKEHOLDERS IS CRITICAL IN REVIEWING THE NEEDS OF THE COMMUNITY AND ASSIST IN ESTABLISHING HEALTH PRIORITIES AND GOALS. CHSB REINVESTS ALL ITS OPERATING AND INVESTMENT INCOME IN HOSPITAL IMPROVEMENTS, TECHNOLOGY ENHANCEMENTS, COMMUNITY HEALTH PROGRAMS, AND EMPLOYEE BENEFITS. THIS ACTIVE REINVESTMENT MAKES IT POSSIBLE FOR US TO DELIVER ON OUR MISSION, INCLUDING ENSURING THAT EVERYONE HAS ACCESS TO HEALTH CARE. Schedule H, Part VI, Line 6 - Affiliated Health Care System CHSB is affiliated with Dignity Health. Affiliates of Dignity Health also promote the health of additional communities in Bakersfield, San Bernardino, San Francisco, San Andreas, and Grass Valley/Nevada City, California. These affiliates follow practices similar to those noted above in determining the unmet healthcare needs of their communities. The summary of Total unsponsored community benefit expense for Dignity Health and its subordinate corporations for the year ended June 30, 2014, is as follows: Persons Net Comm % of Served Benefit Exp excl Bad Debt Benefits for the Poor: Traditional Charity Care 118,274 175,717,000 1.7% Unpaid Costs of Medicaid/Medi-Cal 1,182,999 864,074,000 8.3% Other Means-tested Programs 269,323 51,389,000 0.5% Community Services: Community Health Services 434,278 39,122,000 0.4% Health Professions Education 54 24,000 0.0% Subsidized Health Services 108,604 27,467,000 0.3% Donations 128,428 19,579,000 0.2% Community Building Activities 4,623 1,508,000 0.0% Community Benefit Operations 2,886 6,793,000 0.1% Total Community Services for the poor 678,873 94,493,000 1.0% Total Benefits for the Poor 2,249,469 1,185,673,000 11.5% Benefits for the Broader Community: Community Services: Community Health Services 297,849 13,162,000 0.1% Health Professions Education 37,567 63,515,000 0.6% Subsidized Health Services 3,990 771,000 0.0% Research 408 23,158,000 0.2% Donations 31,034 9,080,000 0.1% Community Building Activities 7,068 3,716,000 0.0% Community Benefit Operations 21 1,110,000 0.0% Total Benefits for the Broader Community 377,937 114,512,000 1.1% Total Community Benefits 2,627,406 1,300,185,000 12.6% Unpaid Costs of Medicare 1,032,864 674,324,000 6.5% Total Community Benefits including Cost of Medicare 3,660,270 1,974,509,000 19.1% true California Health Foundation and Trust 1215 K Street Ste 800 Sacramento CA 95814 941498697 501(c)(3) 640683 N/A N/A Service for the poor Dignity Health 1980 Orange Tree Lane Redlands CA 92374 941196203 501(c)(3) 499878 0 N/A N/A COMMUNITY HEALTH Community Hospital Foundation 1805 Medical Center Drive San Bernadino CA 92411 953051931 501(c)(3) 998631 0 N/A N/A Foundation Support 3 0 Provision of food 1135 0 33610 cost food/meal Part I, Line 2 THE HOSPITAL USES A SOFTWARE PACKAGE TO DOCUMENT GRANT FUNDING, TO MONITOR AND REPORT PROGRAM OUTCOMES AND TO FORMULATE CRITERIA FOR GRANT SELECTIONS. false true false false false false false false false Steven Barron Director 0 387195 0 511976 0 35898 0 53943 0 49257 0 1038269 0 0 Alvaro Bolivar MD Ex-officio Director 204550 0 0 0 0 0 0 0 0 0 204550 0 0 0 Bruce Ermann MD Director 0 234781 0 44337 0 19913 0 16940 0 28225 0 344196 0 0 Marvin O'Quinn Director (THRU 1/31/14) 0 918044 0 1908776 0 73163 0 1056836 0 65383 0 4022202 0 0 Rachelle Wenger Director 0 128271 0 38276 0 605 0 14985 0 18355 0 200492 0 0 Susan Whitten Director 0 261025 0 250545 0 12941 0 38714 0 44282 0 607507 0 0 June Collison Hospital President 0 315210 0 148569 0 12762 0 35532 0 36128 0 548201 0 0 Darryl VandenBosch VP/CFO 0 299832 0 103479 0 13584 0 31869 0 18905 0 467669 0 0 Geraldine C Fike VP/CNE 179259 0 41127 0 8309 0 13496 0 20150 0 262341 0 0 0 Kimiko Ford VP of Ancillary Svcs 187426 0 43128 0 1754 0 21431 0 28015 0 281754 0 0 0 Victoria Selby VP, Behavioral Health & Neuro 188798 0 19523 0 902 0 12314 0 18973 0 240510 0 0 0 Diana M Ahearn Sr Director of Nursing 151949 0 30045 0 11896 0 11648 0 15104 0 220642 0 0 0 David J Evans Controller 190764 0 14609 0 9913 0 18798 0 18916 0 253000 0 0 0 Marc Marchetti VP Business Development 197802 0 20599 0 992 0 19664 0 18803 0 257860 0 0 0 Lorena Wilson Medical Transcriber 145727 0 74596 0 8373 0 16747 0 8921 0 254364 0 0 0 Patricia Womack Director of Pharmacy 174739 0 13967 0 8233 0 17249 0 2340 0 216528 0 0 0 Jack Ivie Former COO 322742 0 177387 0 26558 0 37652 0 22710 0 587049 0 0 0 Schedule J, Part I, Line 3 ALTHOUGH THE ORGANIZATION EMPLOYS PERSONNEL, THE ORGANIZATION RELIED ON A RELATED ORGANIZATION, DIGNITY HEALTH, THAT USED ONE OR MORE OF THE METHODS DESCRIBED IN SCHEDULE J, PART I, LINE 3, TO ESTABLISH THE ORGANIZATION'S PRESIDENT'S COMPENSATION. SEE SCHEDULE O DISCLOSURE FOR FORM 990, PART VI, SECTION B, LINE 15A FOR ADDITIONAL INFORMATION. Schedule J, PART I, LINE 4a CERTAIN LISTED PERSONS PARTICIPATE IN A SEVERANCE PLAN ESTABLISHED BY ITS SUPPORTED ORGANIZATION. THE PLAN PROVIDES MARKET-STANDARD COMPENSATION, RANGING FROM PAYMENTS OF 1 MONTH TO 2 YEARS OF BASE COMPENSATION, DEPENDING ON THE EXECUTIVE'S POSITION, IN THE EVENT OF A POSITION ELIMINATION OR OTHER INVOLUNTARY TERMINATION, IN ACCORDANCE WITH THE GUIDELINES OF THE PLAN. NO PAYMENTS WERE MADE UNDER THIS PLAN DURING 2013. Schedule J, PART I, LINE 4b CERTAIN LISTED PERSONS ARE ELIGIBLE TO PARTICIPATE IN ONE OF TWO DIGNITY HEALTH NON-QUALIFIED 457(F) PLANS THAT ARE SUBJECT TO SUBSTANTIAL RISK OF FORFEITURE, AS REQUIRED BY THE IRS. THE 2007 EXECUTIVE DEFERRED COMPENSATION PLAN IS FOR EXECUTIVES HIRED PRIOR TO JUNE 30, 2006. THE BENEFIT IS INTENDED TO BRIDGE THE DIFFERENCE, IF ANY, BETWEEN THE BENEFIT PROVIDED UNDER THE DIGNITY HEALTH EXCESS BENEFIT PLAN HAD BENEFIT SERVICE NOT BEEN FROZEN AT JANUARY 1, 2008, AND THE BENEFITS PROVIDED FROM ALL OTHER QUALIFIED AND NON-QUALIFIED PLANS. NO BENEFIT WILL VEST UNDER THIS 457(F) PLAN BEFORE THE ATTAINMENT OF AGE 62 OR THE COMPLETION OF 15 YEARS OF SERVICE. THE 2010 EXECUTIVE DEFERRED COMPENSATION PLAN IS FOR CERTAIN OFFICERS AND KEY EMPLOYEES WHO ARE NOT ELIGIBLE TO PARTICIPATE IN THE DIGNITY HEALTH EXCESS BENEFIT PLAN OR THE 2007 EXECUTIVE DEFERRED COMPENSATION PLAN DESCRIBED ABOVE. THIS BENEFIT PROVIDES AN ANNUAL ACCRUAL OF 10% OF TOTAL COMPENSATION AND IS PAYABLE ANNUALLY ON JULY 1 ONCE VESTED, WHICH IS AGE 62 WITH 5 YEARS OF SERVICE. NO PAYMENTS WERE MADE UNDER THIS PLAN DURING 2013. CERTAIN LISTED PERSONS PARTICIPATE IN THE DIGNITY HEALTH EXCESS BENEFIT PLAN, A NONQUALIFIED SUPPLEMENTAL BENEFIT PLAN LIMITED TO PARTICIPANTS IN THE DIGNITY HEALTH RETIREMENT PLAN WHOSE BENEFITS ARE AFFECTED BY THE LIMITATIONS IMPOSED BY SECTIONS 401(A)(17) AND 415 OF THE INTERNAL REVENUE CODE. BENEFIT SERVICE UNDER THIS PLAN WAS FROZEN AS OF JANUARY 1, 2008. NO PAYMENTS WERE MADE TO ANY LISTED PERSONS DURING 2013 PURSUANT TO THIS PLAN. CERTAIN LISTED PERSONS PARTICIPATE IN THE DIGNITY HEALTH KEY EMPLOYEE SHARE OPTION PLAN (KEYSOP), WHICH WAS FROZEN IN MAY 2002. THE KEYSOP PROGRAM WAS ESTABLISHED IN 2001 WITH THE PURPOSE OF PROVIDING ADDITIONAL COMPENSATION TO ELIGIBLE EMPLOYEES, COMMENSURATE WITH THEIR CONTRIBUTIONS TO THE SUCCESS OF DIGNITY HEALTH, IN A FORM THAT WOULD PROVIDE INCENTIVES AND REWARDS FOR MERITORIOUS PERFORMANCE AND ENCOURAGE THE RECIPIENTS' CONTINUANCE AS EMPLOYEES OF DIGNITY HEALTH. GRANTS OF OPTIONS COULD BE MADE TO ANY EMPLOYEE WHO WAS ELIGIBLE FOR THE COMPANY'S KEY EMPLOYEE RETENTION PROGRAM. NO PAYMENTS WERE MADE UNDER THIS PLAN DURING 2013. VESTED AMOUNTS FOR THE SUPPLEMENTAL NONQUALIFIED RETIREMENT PLANS DISCUSSED ABOVE ARE REPORTED AS DEFERRED COMPENSATION IN THE YEAR VESTING OCCURS (SCHEDULE J, PART II, COLUMN C) AND ARE REFLECTED AGAIN AS W-2 REPORTABLE COMPENSATION IN THE YEAR PAID (SCHEDULE J, PART II, COLUMN B(III)). PART II - SUPPLEMENTAL DISCLOSURES THE ORGANIZATION'S EXECUTIVE COMPENSATION PHILOSOPHY IS DESIGNED TO ASSIST THE ORGANIZATION IN ATTRACTING AND RETAINING THE CALIBER OF EXECUTIVES REQUIRED TO ENABLE THE ORGANIZATION TO FULFILL ITS MISSION OF PROVIDING HIGH QUALITY HEALTHCARE FOR ALL PERSONS REGARDLESS OF THEIR ABILITY TO PAY FOR SERVICES, IMPROVING THE QUALITY OF LIFE IN THE COMMUNITIES THE ORGANIZATION SERVES, PROMOTING PATIENT AND EMPLOYEE SATISFACTION, AND ENSURING FINANCIAL STABILITY. A SUBSTANTIAL PORTION OF EXECUTIVE COMPENSATION IS PERFORMANCE BASED AND IS LINKED TO ORGANIZATIONAL GOALS APPROVED IN ADVANCE BY DIGNITY HEALTH'S HUMAN RESOURCES AND COMPENSATION COMMITTEE. THESE GOALS INCLUDE ATTAINMENT OF ANNUAL AND LONG-TERM FINANCIAL PERFORMANCE, CERTAIN HEALTHCARE QUALITY STANDARDS AND THE ORGANIZATION'S COMMITMENT TO SERVING THE POOR AND DISENFRANCHISED IN THE COMMUNITIES IT SERVES. TOTAL COMPENSATION, WHICH INCLUDES BASE SALARY, ANNUAL AND LONG-TERM INCENTIVE COMPENSATION, IS ESTABLISHED TO APPROXIMATE THE PREVAILING MARKET CONDITIONS FOR EXECUTIVES OF COMPANIES OF SIMILAR SIZE AND REVENUE. A CALIFORNIA HEALTH FACILITIES FINANCING AUTHORITY 521598225 13033FTN0 2004-05-19 150000000 BOND A: CUSIP 13033FTN0 - SEE PART false false true A 0 0 2000000 0 0 0 0 0 0 2000000 0 0 2005 false false true true A false true true true true true 0.00400 0.00000 0.00400 false false 0.00000 false true A false false false true true false 0 false 0 true true A true BOND A: CUSIP 13033FTN0 PART I, COLUMN (C) THE CHFFA 2004 SERIES J BONDS WERE EXCHANGED IN NOVEMBER 2009 FOR THE CHFFA 2009 SERIES H BONDS IN AN EXCHANGE PURSUANT TO NOTICE 2008-41 THAT WAS NOT TREATED AS A NEW ISSUANCE FOR PURPOSES OF SECTIONS 103 AND 141-150 OF THE INTERNAL REVENUE CODE. PART I, COLUMN (E) THE DIFFERENCE BETWEEN THE ISSUE PRICE IN PART I, COLUMN (E) AND PART II, LINE 3 IS PRIMARILY A RESULT THAT THE COMPOSITE BOND ISSUE WAS A POOLED FINANCING ISSUE. THE FULL ISSUE PRICE OF WHICH IS SHOWN IN PART I, COLUMN (E). IN COMPARISON, THE AMOUNT OF PROCEEDS SHOWN IN PART II, LINE 3 REFLECTS ONLY THE PORTION OF THE BOND ISSUE BORROWED BY COMMUNITY HOSPITAL OF SAN BERNARDINO AND CURRENTLY OUTSTANDING. A SMALL PART OF THE DIFFERENCE BETWEEN THE ISSUE PRICE AND PROCEEDS IS DUE TO INVESTMENT EARNINGS. PART I, COLUMN (F) FINANCE ACQUISITION OF MEDICAL EQUIPMENT AND CONSTRUCTION AND RENOVATION OF HOSPITAL FACILITIES. PART II, LINE 3 IN MAY 2013, ALL OF THE LOANS ORIGINATED WITH PROCEEDS OF THE BONDS MATURED AND WERE REPAID TO THE ISSUER. OF SUCH REPAYMENTS, COMMUNITY HOSPITAL OF SAN BERNARDINO BORROWED THE SUM OF $2,000,000 TO FINANCE THE CONSTRUCTION/RENOVATION OF FACILITIES AND THE ACQUISITION OF MEDICAL EQUIPMENT AT VARIOUS HOSPITALS. ALTHOUGH THE FACILITIES ORIGINALLY FINANCED WITH PROCEEDS OF THE BONDS WERE SUBSTANTIALLY COMPLETED IN THE YEAR INDICATED, REPAYMENTS OF THE LOANS ORIGINATED WITH PROCEEDS OF THE BONDS WERE AND/OR WILL BE RECYCLED INTO NEWLY ORIGINATED LOANS CONTINGENT ON DEMAND BY PARTICULAR BORROWERS AT THE TIME OF A LOAN REPAYMENT. COMPLETION DATES OF PROJECTS FINANCED OR TO BE FINANCED WITH SUCH RECYCLED AMOUNTS ARE NOT INDICATED. PART IV, LINE 2C THE CALCULATION FOR COMPUTING NO REBATE DUE WAS PERFOMED ON 6/30/2014. X Other - Medical Equipment 5 84149 Average Market Value 1 false true false FORM 990, PART VI through PART XII FORM 990, PART VI, SECTION A, LINE 5 A former CHSB employee committed fraud through falsely documenting time cards and vendor service payments. That employee was charged and convicted of the grand theft. Other former employees complicit in the fraud are awaiting trial. Restitution from the former employees will be sought. The dollar amount of diversion is $1,605,497. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE CORPORATE MEMBER IS DIGNITY HEALTH, A 501(C)(3) EXEMPT ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A DIGNITY HEALTH, AS THE SOLE CORPORATE MEMBER, RATIFIES THE SELECTION OF MEMBERS AND THE DIGNITY HEALTH BOARD APPROVES NEW BOARD MEMBERS OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7B RESERVED RIGHTS OF THE CORPORATE MEMBER INCLUDE: ADOPTION OF MISSION & PHILOSOPHY STATEMENTS, AMENDMENT OR RESTATEMENT OF THE ARTICLES OF INCORPORATION AND BYLAWS; DISSOLUTION OF THE CORPORATION, ACQUIRE ANOTHER CORPORATION, OR CREATE A SUBSIDIARY; MERGING OR CONSOLIDATING WITH ANOTHER CORPORATION; PARTICIPATION AS A GENERAL OR LIMITED PARTNER IN ANY VENTURE; INCURRING LONG-TERM INDEBTEDNESS IN EXCESS OF NORMAL OPERATING REQUIREMENTS; RATIFICATION OF BOARD MEMBER APPOINTMENTS & DISMISSALS; SELECTION OR REMOVAL OF INDEPENDENT AUDITORS; TRANSACTIONS OUTSIDE THE ORDINARY COURSE OF BUSINESS. FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION'S CFO, SENIOR DIRECTOR OF FINANCE, AND CONTROLLER WORKED CLOSELY WITH THE PARENT ORGANIZATION AND AN INDEPENDENT ACCOUNTING FIRM ENGAGED TO REVIEW THE RETURN. THE BOARD OF DIRECTORS HAS DELEGATED THE REVIEW OF THE FORM 990 TO THE FINANCE COMMITTEE. MANAGEMENT PRESENTED THE DRAFT OF THE FORM 990 TO THE FINANCE COMMITTEE. THE DRAFT WAS COMPLETE EXCEPT IT EXCLUDED COMPENSATION INFORMATION FOR DIRECTORS WHO ARE ALSO KEY EXECUTIVES OF DIGNITY HEALTH, THE FILING ORGANIZATION'S SOLE MEMBER. COMPENSATION BY DIGNITY HEALTH TO THOSE DIRECTORS HAS BEEN REVIEWED BY THE COMPENSATION AND BENEFITS COMMITTEE OF THE DIGNITY HEALTH BOARD OF DIRECTORS. SUBSEQUENT TO ITS REVIEW, THE FINANCE AND INVESTMENT COMMITTEE REPORTED BACK TO THE BOARD REGARDING ITS REVIEW AND PROVIDED A DRAFT TO THE BOARD OF DIRECTORS, AGAIN EXCLUDING COMPENSATION FOR CERTAIN DIRECTORS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS ADOPTED DIGNITY HEALTH'S CONFLICTS OF INTEREST POLICY. UNDER SUCH POLICIES, THE EVP/GENERAL COUNSEL IS RESPONSIBLE FOR COLLECTING, REVIEWING AND VALIDATING ANNUAL DISCLOSURES OF ALL COVERED PERSONS (I.E., BOARD AND BOARD COMMITTEE MEMBERS, OFFICERS AND EXECUTIVE LEADERSHIP, KEY EMPLOYEES, MANAGEMENT PERSONNEL AT THE DIRECTOR LEVEL AND ABOVE, AND ANY OTHER PERSONNEL AT HIS OR HER DISCRETION). THE ORGANIZATION'S BOARD IS CHARGED WITH MONITORING PROPOSED OR ONGOING TRANSACTIONS FOR CONFLICTS OF INTEREST AND ADDRESSING ANY POTENTIAL OR ACTUAL CONFLICTS. ALL COVERED PERSONS ARE REQUIRED TO DISCLOSE REAL OR POTENTIAL CONFLICTS ARISING FROM BUSINESS, FINANCIAL AND PERSONAL INTERESTS HELD BY SUCH COVERED PERSONS OR THEIR FAMILY MEMBERS. COVERED PERSONS ARE REQUIRED TO DISCLOSE TO THEIR SUPERIORS AND TO RELEVANT DECISION MAKERS ANY INTEREST THAT MAY PRESENT A CONFLICT OR THE APPEARANCE OF A CONFLICT OF INTEREST. SUCH DISCLOSURE IS REQUIRED ON A TRANSACTIONAL BASIS AT THE TIME SUCH CONFLICTS ARISE, WHEN AN INDIVIDUAL BECOMES A COVERED PERSON, AND ANNUALLY THEREAFTER. EACH COVERED PERSON IS REQUIRED TO CERTIFY AT LEAST ANNUALLY THAT HE/SHE: (1) HAS RECEIVED A COPY OF THE POLICY APPLICABLE TO HIS/HER POSITION; (2) HAS READ THE POLICY AND UNDERSTANDS SAID POLICY; AND (3) AGREES TO COMPLY WITH ALL REQUIREMENTS OF THE POLICY, INCLUDING COMPLETING THE CONFLICTS OF INTEREST DISCLOSURE STATEMENT AS REQUIRED BY THE POLICY. THE PRESIDENT/CEO AND EVP/GENERAL COUNSEL PREPARE ANNUAL REPORTS OF REPORTED CONFLICTS OF INTEREST WHICH ARE PROVIDED TO THE BOARD OF DIRECTORS, COMMITTEE CHAIRS, AND KEY LEADERS OF THE ORGANIZATION TO ENABLE RESPONSIBLE INDIVIDUALS TO MONITOR AND MANAGE DISCLOSED CONFLICTS OF INTEREST AND ASSURE DECISIONS ARE MADE IN THE ORGANIZATION'S BEST INTERESTS. THE PROCEDURES FOR ADDRESSING ANY CONFLICT OF INTEREST RELATED TO A PROPOSED TRANSACTION INCLUDE, BUT ARE NOT LIMITED TO, THE FOLLOWING: (1) THE CONFLICTING INTEREST IS FULLY DISCLOSED TO THE BOARD; (2) THE INTERESTED PERSON RESPONDS TO FACTUAL QUESTIONS RELATED TO THE SUBSTANCE OF THE TRANSACTION OR ARRANGEMENT BEING CONSIDERED, AFTER WHICH HE/SHE SHALL LEAVE THE MEETING; (3) THE PERSON WITH THE CONFLICT OF INTEREST IS EXCLUDED FROM THE DISCUSSION AND APPROVAL OF SUCH TRANSACTION; (4) IF WARRANTED, ALTERNATIVES TO THE PROPOSED TRANSACTION ARE INVESTIGATED, AND COMPETITIVE BIDS OR COMPARABLE VALUATIONS ARE OBTAINED; (5) THE TRANSACTION OR ACTION IS APPROVED BY A MAJORITY OF DISINTERESTED PERSONS, AND CONSISTENT WITH ANY REQUIREMENTS OF BYLAWS OR POLICIES; AND (6) ANY CONFLICTING ISSUES ARISING DURING THE COURSE OF A BOARD MEETING WHICH CANNOT BE RESOLVED MAY BE REFERRED TO AN INDEPENDENT COMMITTEE OF THE BOARD OF DIRECTORS. THERE ARE ALSO CONFLICTS OF INTEREST PROVISIONS UNDER THE STANDARDS OF CONDUCT APPLICABLE TO ALL EMPLOYEES, AND WHICH ARE ADMINISTERED BY THE CHIEF COMPLIANCE OFFICER WHO HAS REPORTING RESPONSIBILITY TO THE AUDIT & COMPLIANCE COMMITTEE. FORM 990, PART VI, SECTION B, LINE 15A THE ORGANIZATION EMPLOYS PERSONNEL, HOWEVER, THE TOP MANAGEMENT OFFICIAL'S COMPENSATION IS SET BY A RELATED ORGANIZATION, DIGNITY HEALTH. FOR 2013, DIGNITY HEALTH'S COMPENSATION AND BENEFITS DEPARTMENT CONDUCTED AN ANNUAL REVIEW AND ANALYSIS TO PROVIDE BENCHMARKING DATA FOR THE TOTAL COMPENSATION AND BENEFITS PACKAGE OF THE PRESIDENT. APPROPRIATE COMPARABILITY DATA FOR SIMILAR JOBS IN PEER COMPANIES (BOTH TAXABLE AND TAX-EXEMPT) WAS OBTAINED FROM INDEPENDENT THIRD-PARTY SURVEY SOURCES. FORM 990, PART VI, SECTION B, LINE 15B FOR 2013 COMPENSATION, THE ORGANIZATION'S HUMAN RESOURCES DEPARTMENT CONDUCTED AN ANNUAL REVIEW AND ANALYSIS TO PROVIDE BENCHMARKING DATA FOR THE TOTAL COMPENSATION AND BENEFITS PACKAGE OF KEY EMPLOYEES. THE COMPENSATION FOR THESE INDIVIDUALS WAS BASED ON THE QUALIFICATION AND EXPERIENCE OF THE CANDIDATES. COMPENSATION IS ALSO REVIEWED ANNUALLY AS PART OF THE MERIT INCREASE PROCESS. FORM 990, PART VI, SECTION C, LINE 19 FEDERAL TAX LAWS DO NOT MANDATE THAT THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY BE MADE AVAILABLE FOR PUBLIC INSPECTION. THE FINANCIAL STATEMENTS ARE MADE AVAILABLE ON THE HOSPITAL WEBSITE AND UPON REQUEST. FORM 990, PART VII, SECTION A ALVARO BOLIVAR'S COMPENSATION IS FOR CHIEF OF STAFF SERVICES AND MEDICAL SERVICES PROVIDED TO THE ORGANIZATION. FORM 990, PART XII, LINE 3B THE ORGANIZATION'S FEDERAL AWARDS WERE INCLUDED IN DIGNITY HEALTH'S CONSOLIDATED OMB CIRCULAR A-133 AUDITED SCHEDULE OF FEDERAL EXPENDITURES. FORM 990 PART IX LINE 11G DESCRIPTION:ADMINISTRATIVE SERVICES TOTAL FEES:8088795 FORM 990 PART IX LINE 11G DESCRIPTION:MEDICAL FEES TOTAL FEES:6844626 FORM 990 PART IX LINE 11G DESCRIPTION:PROFESSIONAL/CONSULTING FEES TOTAL FEES:1545194 FORM 990 PART IX LINE 11G DESCRIPTION:REPAIRS & MAINTENANCE CONTRACT TOTAL FEES:3783263 FORM 990 PART IX LINE 11G DESCRIPTION:LAUNDRY & LINEN TOTAL FEES:976798 FORM 990 PART IX LINE 11G DESCRIPTION:OTHER PURCHASED SERVICES TOTAL FEES:1459824 Community Hospital Foundation 1805 Medical Center Drive San Bernardino CA 92411 953051931 Fund Raising CA 501(c)(3) 11; Type I CHSB true DIGNITY HEALTH 185 Berry Street San Francisco CA 94107 941196203 Hospital CA 501(c)(3) 3 NA false false true true false false false false false false false false false true false false false false false false COMMUNITY HOSPITAL SAN BERNARDINO FOUNDATION B 998631 SEE PART VII COMMUNITY HOSPITAL SAN BERNARDINO FOUNDATION c 1167699 Schedule R, Part V, line 2 COMMUNITY HOSPITAL OF SAN BERNARDINO (CHSB) IS SUPPORTED BY ONE FOUNDATION. AS A SUPPORTING ORGANIZATION, THE FOUNDATION OPERATES FOR THE BENEFIT OF, TO RAISE FUNDS FOR, OR TO CARRY OUT THE PURPOSES OF CHSB. AS A RESULT, PAYMENTS ARE MADE DIRECTLY TO CHSB FROM THE FOUNDATION OR DIRECTLY TO THE FOUNDATION FROM CHSB. AMOUNT REPORTED UNDER TRANSACTION TYPE "B" REPRESENT FUNDS EXPENDED BY CHSB ON BEHALF OF THE FOUNDATION FOR OPERATIONAL EXPENSES. AMOUNT REPORTED AS TRANSACTION TYPE "C" REPRESENT FUNDS RECEIVED FROM THE FOUNDATION AS GRANTS TO CHSB.