2015-08-12T15:21:38-05:00 2014-09-30 930623286 AKT LLP 5665 SW MEADOWS RD SUITE 200 LAKE OSWEGO OR 97035 990 2013-10-01 431960221 WEST VALLEY HOSPITAL WEST 5035615200 525 SOUTHEAST WASHINGTON STREET DALLAS OR 97338 JAMES PARR CHIEF FINANCIAL OFFICER 5035615150 2015-08-05 1 JOYLYN M ANKENEY CPA P00366587 5036204489 2015-08-05 2013 2016-03-07 17:11:31Z ROBERT BRANNIGAN 525 SOUTHEAST WASHINGTON STREET DALLAS OR 97338 24510740 0 X WWW.WESTVALLEYHOSPITAL.ORG X 2002 OR TO IMPROVE THE HEALTH AND WELL BEING OF THE PEOPLE IN THE COMMUNITIES WE SERVE. 13 11 186 40 20050 12449 118950 61774 23457657 24445873 2634 -3907 0 0 23579241 24503740 0 15557 0 0 12256542 12583050 0 0 0 10222003 9928633 22478545 22527240 1100696 1976500 15412885 16501146 10101407 9347237 5311478 7153909 TO IMPROVE THE HEALTH AND WELL BEING OF THE PEOPLE IN THE COMMUNITIES WE SERVE. 0 0 12474589 20522012 WEST VALLEY HOSPITAL IS A CRITICAL ACCESS HOSPITAL SERVING THE RURAL POLK COUNTY REGION WITH A POPULATION OF 98,000. SERVICES INCLUDE: DIAGNOSTIC IMAGING PROCEDURES 18,286, EMERGENCY DEPARTMENT VISITS 12,351, INPATIENT ADMISSIONS 164, LABORATORY TESTS/DRAWS 107,016, SURGERIES 474. 5326579 3533674 WEST VALLEY HOSPITAL PROVIDES HEALTHCARE TO PEOPLE IN OUR COMMUNITY REGARDLESS OF THEIR ABILITY TO PAY. IN FY 2014, THE COST OF SERVICES PROVIDED AS A COMMUNITY BENEFIT TOTALED $1,792,905. THIS FIGURE CONSISTED OF $636,581 IN COSTS TO PROVIDE CHARITY CARE TO INDIVIDUALS WHO CANNOT AFFORD TO PAY AND $1,156,324 IN UNDERPAYMENT BY MEDICAID AS THE AMOUNT PAID UNDER THE PROGRAM WAS LESS THAN THE COST TO PROVIDE THE SERVICES. WEST VALLEY HOSPITAL DOES NOT PURSUE LEGAL ACTION FOR NON-PAYMENT OF BILLS AGAINST CHARITY CARE PATIENTS WHO HAVE DEMONSTRATED THAT THEY HAVE NEITHER SUFFICIENT INCOME NOR ASSETS TO MEET THEIR FINANCIAL OBLIGATIONS. 1148393 15557 370137 WEST VALLEY HOSPITAL ACTIVELY PARTICIPATES IN COMMUNITY HEALTH IMPROVEMENT SERVICES. IN FY 2014, WEST VALLEY HOSPITAL GAVE $85,000 FOR UNFUNDED OR UNDERFUNDED HEALTH SERVICES, INCLUDING IMPROVING ACCESS TO CARE THROUGH PHYSICIAN RECRUITING, COMMUNITY HEALTH EDUCATION AND PREVENTION PROGRAMS. THE HOSPITAL HAS AN ACTIVE SPEAKERS BUREAU PROVIDING FREE HEALTH LECTURES TO COMMUNITY GROUPS. HEALTH SCREENINGS, SUPPORT GROUPS AND EDUCATION CLASSES ARE OFFERED ON AN ON-GOING BASIS. WEST VALLEY HOSPITAL SUBSIDIZES THE COST OF PROVIDING SERVICES TO THE COMMUNITY AT A FINANCIAL LOSS IN THE AMOUNT OF OVER $660,000. WEST VALLEY HOSPITAL PROVIDES CASH AND IN-KIND DONATIONS TO COMMUNITY PROGRAMS, THE LARGEST OF WHICH IS THE CONNECTIONS VAN WHICH PROVIDES TRANSPORTATION SERVICES TO PATIENTS NEEDING MEDICAL SERVICES. 18949561 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 29 0 1 186 1 1 1 0 0 0 0 0 0 0 0 0 X 13 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OR X X SALEM HOSPITAL 5035615200 890 OAK STREET SE SALEM OR 97301 KATHERINE KEENE TRUSTEE 9.00 X 0 0 0 BRUCE CARTER MD TRUSTEE 5.90 X 0 0 0 KENNETH SHERMAN JR TRUSTEE 5.90 X 0 0 0 DAVID ELMGREN MD TRUSTEE 5.90 X 0 0 0 BONNIE DRIGGERS RN TRUSTEE 5.90 X 0 0 0 ALAN WYNN SECRETARY/TREASURER 5.00 X X 0 0 0 ALAN COSTIC CHAIRPERSON 5.00 X X 0 0 0 LANE SHETTERLY TRUSTEE 5.90 X 0 0 0 ROBERT WELLS VICE-CHAIR 10.00 X X 0 0 0 J BART MCMULLAN MD TRUSTEE 5.00 X 0 0 0 ROBERT WACHTER MD TRUSTEE 2.00 X 0 39190 0 THERESA HASKINS TRUSTEE 5.00 X 0 0 0 PAM VUKOVICH TRUSTEE 5.90 X 0 0 0 NORMAN GRUBER PRESIDENT 40.00 X 0 870161 257947 AARON CRANE CHIEF FIN. & STRATEGY OFFICER 40.00 X 0 530260 75272 PAMELA CORTEZ DIR. OF CLINICAL OPERATIONS 40.00 X 219937 0 42011 ROBERT BRANNIGAN CHIEF ADMIN OFFICER WVH/VP 40.00 X 0 349531 59468 ALISON SMITH MD GENERAL SURGEON 40.00 X 417317 0 64179 LISA JEFFERS ASSISTANT NURSE MANAGER 40.00 X 139300 0 22914 CHARLES ESSEX MD PHYSICIAN 40.00 X 250685 0 53992 JOHN HADLEY MD PHYSICIAN 40.00 X 219033 0 47812 REBECCA LUCAS MD ER PHYSICIAN 40.00 X 285890 0 50017 1532162 1789142 673612 6 0 1 0 SALEM RADIOLOGY CONSULTANTS PC PO BOX 12989 SALEM OR 97309 RADIOLOGY SERVICES 429850 EMCARE INC 7032 COLLECTION CTR DR CHICAGO IL 60693 EMERGENCY ROOM COVERAGE 265157 CTM MANAGEMENT 476 NW HILLCREST LOOP MCMINNVILLE OR 97128 CRNA COVERAGE 233235 SHIFTWISE US BANK CORP TRUST 1800 SW 1ST AVE STE 510 PORTLAND OR 97201 WORKFORCE MANAGEMENT 114670 GE MEDICAL SYSTEMS 2727 NW 29TH AVE PORTLAND OR 97210 SUPPORT SERVICES 101696 5 59440 2334 61774 NET PATIENT REVENUE 621110 13609547 13609547 LABORATORY 621500 8613360 8593310 20050 PHARMACY 621300 2108090 2108090 NUTRITION SERVICES 900099 64805 64805 OTHER HOSPITAL SERVICES 900099 50071 50071 24445873 3093 3093 7000 -7000 -7000 -7000 24503740 24425823 20050 -3907 15557 15557 269707 269707 9744970 8658156 1086814 544336 470604 73732 1350162 1168135 182027 673875 582596 91279 25743 25743 1602537 1571806 30731 16548 16548 1909356 343681 1565675 27905 3923 23982 592309 580819 11490 36300 19962 16338 13368 11473 1895 1118746 1118746 199306 199306 PATIENT SUPPLIES 2185020 2185020 BAD DEBT 1688716 1688716 OTHER PURCHASED SERVICE 442919 311109 131810 DUES 19712 10103 9609 50148 9849 40299 22527240 18949561 3577679 0 299 299 431693 350110 2744270 2750145 331349 370066 128636 157939 20402586 8066346 11732034 12336240 0 275900 44604 260447 15412885 16501146 2562285 3049941 7539122 6297296 10101407 9347237 X 5270570 7106273 40908 47636 5311478 7153909 15412885 16501146 X 1976500 -134069 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 40908 3808 2920 0 47636 122681 4345 3956 90074 40908 65975 53985 5864 3143 122681 62724 3251 65975 57619 5977 3376 4248 62724 1.00000 0 1 1 342155 342155 13052664 4493630 8559034 5740727 3550146 2190581 1267040 22570 1244470 12336240 DUE TO MEDICARE/MEDICAID 354464 OTHER LONG-TERM ACCRUALS 2322 EST. LIABILITY FOR MALPRACTICE INSURANCE 198789 EST. POST-RETIREMENT BENEFITS 429870 DUE TO SALEM HOSPITAL 5311851 6297296 X 24362943 -140797 -140797 24503740 0 24503740 22520512 -6728 -6728 22527240 0 22527240 PART V, LINE 4: ENDOWMENT FUNDS ARE HELD BY WEST VALLEY HOSPITAL FOUNDATION FOR WEST VALLEY HOSPITAL SUPPORT. PART X, LINE 2: UNCERTAIN TAX POSITIONS FROM THE NOTES TO CONSOLIDATED FINANCIAL STATEMENTS ISSUED FOR SALEM HEALTH AND RELATED COMPANIES: THE CORPORATION, SALEM, WEST VALLEY, SHF, WVHF, WVPS, AND WVIC ARE TAX-EXEMPT ORGANIZATIONS PURSUANT TO INTERNAL REVENUE CODE (IRC) SECTION 501(C)(3). AS SUCH, ONLY UNRELATED BUSINESS INCOME IS SUBJECT TO FEDERAL OR STATE INCOME TAXES. THE CORPORATION ACCOUNTS FOR UNCERTAINTY IN INCOME TAXES IN ACCORDANCE WITH FASB ASC 740-10, INCOME TAXES-IMPLEMENTATION GUIDANCE ON ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES AND DISCLOSURE AMENDMENTS FOR NONPUBLIC ENTITIES. MANAGEMENT HAS NOT RECORDED A PROVISION AS UNRELATED BUSINESS INCOME, IF ANY, IS IMMATERIAL TO THE CONSOLIDATED FINANCIAL STATEMENTS. U.S. GENERALLY ACCEPTED ACCOUNTING PRINCIPLES REQUIRE THE CORPORATION TO EVALUATE TAX POSITIONS TAKEN BY THE CORPORATION AND RECOGNIZE A TAX LIABILITY (OR ASSET) IF THE CORPORATION HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS. MANAGEMENT HAS ANALYZED TAX POSITIONS TAKEN BY THE CORPORATION AND HAS CONCLUDED THAT AS OF SEPTEMBER 30,2014 THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY (OR ASSET) OR DISCLOSURE IN THE CONSOLIDATED FINANCIAL STATEMENTS. THE CORPORATION IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. THE CORPORATION MANAGEMENT BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO FISCAL YEAR 2009. PART XI, LINE 2D - OTHER ADJUSTMENTS: REVENUE NETTED WITH EXPENSES CHANGE IN POST RETIREMENT BENEFIT OBLIGATION -140,797. PART XII, LINE 2D - OTHER ADJUSTMENTS: REVENUE NETTED WITH EXPENSES CHANGE IN BENEFICIAL INTEREST IN FOUNDATION -6,728. 1 1 X 1 X 1 X 1 1 1 0 1 1 5268 636581 636581 0.03050 10183 4689998 3533674 1156324 0.05550 15451 5326579 3533674 1792905 0.08600 1815 34753 3546 31207 0.00150 49 53571 53571 0.00260 1029997 366591 663406 0.03180 1136 23992 23992 0.00120 3000 1142313 370137 772176 0.03710 18451 6468892 3903811 2565081 0.12310 30 20788 20788 0.00100 30 20788 20788 0.00100 0 1688716 1502957 3526348 3454212 72136 X 1 1 1 1 WEST VALLEY HOSPITAL 525 SOUTHEAST WASHINGTON ST DALLAS OR 97338 X X X WEST VALLEY HOSPITAL 1 1 X X X X X X X X X 13 1 1 1 X WWW.WESTVALLEYHOSPITAL.ORG X X X X X X X X X X 0 0 1 1 200.000000000000 1 400.000000000000 1 X X X X X X 1 1 X X X X X X 1 0 X X X X 1 X 0 0 WEST VALLEY HOSPITAL PART V, SECTION B, LINE 3: WEST VALLEY HOSPITAL COLLABORATED WITH THE MARION AND POLK COUNTY HEALTH DEPARTMENTS IN PUBLICATION OF THE COMMUNITY HEALTH NEEDS REPORT. WEST VALLEY HOSPITAL COMMUNITY BENEFIT ACTIVITIES ARE PROVIDED TO ADDRESS IDENTIFIED HEALTH NEEDS.PARTNERING AGENCIES ARE LISTED IN POLK COUNTY COMMUNITY HEALTH NEEDS REPORT AND CHIP PUBLICATION AND INCLUDE:-THE CONFEDERATED TRIBES OF GRAND RONDE-DEPARTMENT OF HEALTH AND HUMAN SERVICES, STATE OF OREGON-EVANGELICAL BIBLE CHURCH-I LOVE ME DIABETES TASK FORCE-MARION COUNTY CHILD DEVELOPMENT BOARD-MARION AND POLK COUNTY PUBLIC HEALTH SERVICES-MARION-POLK MEDICAL SOCIETY-POLK COUNTY MENTAL HEALTH-OREGON CHILD DEVELOPMENT COALITION-OREGON HEALTH AND SCIENCES UNIVERSITY-OREGON HEALTH AUTHORITY-OREGON STATE UNIVERSITY EXTENSION SERVICE-PERFORMANCE MANAGEMENT PROGRAM-POLK COUNTY HEALTH ADVISORY BOARD-RED CROSS OF THE MID-WILLAMETTE VALLEY-RURAL METRO AMBULANCE-UNITED WAY OF THE MID-WILLAMETTE VALLEY-WESTERN OREGON UNIVERSITY-WESTERN OREGON UNIVERSITYS HEALTH AND WELLNESS CENTER-WILLAMETTE VALLEY HOSPICE-WVP HEALTH AUTHORITY-YMCAIN ADDITION, AS THE HOSPITAL BOARD OF TRUSTEES REVIEWED THE RICH SOURCES OF SECONDARY DATA, THE COLLABORATIVE HEALTH REPORT AND WORK OF THE CHIP, IT BECAME APPARENT THAT LIMITED PRIMARY DATA WAS AVAILABLE. LIKEWISE, THERE WAS LITTLE UNDERSTANDING OF PERCEIVED NEED FROM HEALTH SYSTEM PROVIDERS. IN 2012, THE BOARD ORGANIZED A SERIES OF FIVE FOCUS GROUPS TO HELP FURTHER UNDERSTAND THE NEEDS OF THE COMMUNITY. THE FOCUS GROUP PARTICIPANTS INCLUDED EMERGENCY DEPARTMENT AND URGENT CARE PROVIDERS, SAFETY NET PROVIDERS, PRIMARY CARE PROVIDERS, MENTAL AND BEHAVIORAL HEALTH PROVIDERS AND SENIOR SERVICES AGENCY REPRESENTATIVES. THE GOAL WAS TO GAIN FIRST-HAND KNOWLEDGE OF THE CHALLENGES WITHIN THE CURRENT HEALTH SYSTEM IN PROVIDING SERVICES FOR VULNERABLE POPULATIONS. WEST VALLEY HOSPITAL PART V, SECTION B, LINE 4: THE CHNA WAS DONE IN COLLABORATION WITH SALEM HOSPITAL WEST VALLEY HOSPITAL PART V, SECTION B, LINE 6I: WEST VALLEY HOSPITAL COMMUNITY BENEFIT ACTIVITY TO ADDRESS AREAS OF NEED IN POLK COUNTYHEALTH NEED: ACCESS TO MEDICAL AND MENTAL HEALTH SERVICES COMMUNITY BENEFIT ACTIVITIES TO ADDRESS THIS NEED:-DEVELOPMENT AND PARTICIPATION IN THE WILLAMETTE VALLEY COORDINATED CARE ORGANIZATION (CCO)-RECRUITMENT OF PRIMARY CARE PROVIDERS TO SERVE POLK COUNTIES-SPONSORSHIP OF THE DALLAS FREE MEDICAL CLINIC-SUPPORT OF PROGRAMS THAT PROVIDE TRANSPORTATION TO MEDICAL SERVICES-DEVELOPMENT OF THE HEALTHCARE WORKFORCEHEALTH NEED: CHRONIC DISEASE PREVENTION AND SELF MANAGEMENT COMMUNITY BENEFIT ACTIVITIES TO ADDRESS THIS NEED:-IMPLEMENT COUNTY-WIDE COMMUNITY HEALTH IMPROVEMENT PLANS WITH PRIMARY FOCUS OF OBESITY PREVENTION-IMPROVE ACCESS TO PRIMARY CARE MEDICAL HOMES FOR RESIDENTS OF POLK COUNTY-FUND SAFETY NET SERVICES IN POLK COUNTY-OFFER CHRONIC DIABETES PREVENTION AND SELF MANAGEMENT PROGRAMS TO UNDERSERVED COMMUNITIES AND INDIVIDUALS-PROVIDE IN-KIND SUPPORT AND MEETING ROOMS FOR COMMUNITY SUPPORT GROUPSHEALTH NEED: CANCER SCREENINGSCOMMUNITY BENEFIT ACTIVITIES TO ADDRESS THIS NEED:WEST VALLEY HOSPITAL PARTNERS WITH SALEM GASTROENTEROLOGY OF SALEM EACH YEAR IN A MONTH-LONG COLON CANCER AWARENESS CAMPAIGN TO ENCOURAGE MORE PEOPLE TO RECEIVE COLON CANCER SCREENING.-500 STOOL TESTING KITS DISTRIBUTED THROUGHOUT THE COMMUNITY AT VARIOUS LOCATIONS INCLUDING WEST SALEM CLINIC AND DALLAS FREE MEDICAL CLINIC.-PARTNER WITH POLK COUNTY HEALTH DEPARTMENT TO PROVIDE MAMMOGRAMS FOR WOMEN WHO DO NOT QUALIFY FOR OTHER PROGRAMS OR ASSISTANCEHEALTH NEED: EARLY PRENATAL CARE COMMUNITY BENEFIT ACTIVITIES TO ADDRESS THIS NEED:THIS NEED IS DIRECTLY LINKED TO ACCESS TO HEALTH SERVICES AND INCLUDES:-DEVELOPMENT AND PARTICIPATION IN THE WILLAMETTE VALLEY COORDINATED CARE ORGANIZATION-SPONSORSHIP OF DALLAS FREE CLINIC -SUPPORT PROGRAMS THAT PROVIDE TRANSPORTATION TO MEDICAL SERVICES-RECRUITMENT OF PRIMARY CARE PROVIDERS TO SERVE POLK COUNTYHEALTH NEED: POOR MENTAL HEALTH DAYSCOMMUNITY BENEFIT ACTIVITIES TO ADDRESS THIS NEED:THIS HEALTH NEED IS ALSO LINKED TO ACCESS TO HEALTH SERVICES. MENTAL HEALTH SCREENING, DIAGNOSIS AND TREATMENT IS KEY TO IMPROVING MENTAL HEALTH DAYS. COMMUNITY BENEFIT ACTIVITIES TO ADDRESS THIS NEED:-DEVELOPMENT AND PARTICIPATION IN THE WILLAMETTE VALLEY COORDINATED CARE ORGANIZATION (CCO)-RECRUITMENT OF PRIMARY CARE PROVIDERS TO SERVE POLK COUNTIES-SPONSORSHIP OF THE DALLAS FREE MEDICAL CLINIC-SUPPORT OF PROGRAMS THAT PROVIDE TRANSPORTATION TO MEDICAL SERVICES-DEVELOPMENT OF THE HEALTHCARE WORKFORCEHEALTH NEED: PREVALENCE OF TEEN MARIJUANA USECOMMUNITY BENEFIT ACTIVITIES TO ADDRESS THIS NEED:PROVIDE CASH AND IN-KIND SUPPORT TO SERVICE INTEGRATION TEAMS IN POLK COUNTY. THE GOAL OF SERVICE INTEGRATION IS TO PROVIDE COORDINATED COMMUNITY RESOURCES AND INFORMATION TO FAMILIES AND INDIVIDUALS IN POLK COUNTY. THE GOAL IS ACCOMPLISHED BY MEETING WITH AREA PARTNERS ON A REGULAR BASIS TO BUILD RELATIONSHIPS, SHARE SERVICES AND RESOURCES, AND BRAINSTORM WAYS TO OFFER ASSISTANCE AND IDENTIFY GAPS IN SERVICES.HEALTH NEED: SOCIAL DETERMINATES OF HEALTHTHE SOCIAL DETERMINANTS OF HEALTH TOPIC AREA WITHIN HEALTHY PEOPLE 2020 IS DESIGNED TO IDENTIFY WAYS TO CREATE SOCIAL AND PHYSICAL ENVIRONMENTS THAT PROMOTE GOOD HEALTH FOR ALL. ALL AMERICANS DESERVE AN EQUAL OPPORTUNITY TO MAKE CHOICES THAT LEAD TO GOOD HEALTH. BUT TO ENSURE THAT ALL AMERICANS HAVE THAT OPPORTUNITY, ADVANCES ARE NEEDED NOT ONLY IN HEALTH CARE, BUT ALSO IN FIELDS SUCH AS EDUCATION, CHILDCARE, HOUSING, BUSINESS, LAW, MEDIA, COMMUNITY PLANNING, TRANSPORTATION, AND AGRICULTURE. MAKING THESE ADVANCES INVOLVES WORKING TOGETHER TO:-EXPLORE HOW PROGRAMS, PRACTICES, AND POLICIES IN THESE AREAS AFFECT THE HEALTH OF INDIVIDUALS, FAMILIES, AND COMMUNITIES.-ESTABLISH COMMON GOALS, COMPLEMENTARY ROLES, AND ONGOING CONSTRUCTIVE RELATIONSHIPS BETWEEN THE HEALTH SECTOR AND THESE AREAS.-MAXIMIZE OPPORTUNITIES FOR COLLABORATION AMONG STATE-, AND LOCAL-LEVEL PARTNERS RELATED TO SOCIAL DETERMINANTS OF HEALTH.COMMUNITY BENEFIT ACTIVITIES TO ADDRESS THIS NEED:-COMMUNITY EVENT SPONSORSHIP-SALEM HEALTH LEADERS PARTICIPANT IN COMMUNITY ACTION AGENCIES-EDUCATION CLASSES AND EVENTS TO BIRTH OUTCOME-TOBACCO CESSATION, EDUCATION AND AWARENESS-HEALTHCARE WORKFORCE DEVELOPMENT-OUTREACH TO LOW INCOME COMMUNITIES-CAREGIVER SUPPORT WEST VALLEY HOSPITAL PART V, SECTION B, LINE 7: NOT ALL IDENTIFIED NEEDS ARE BEING ADDRESSED IN THE HOSPITALS COMMUNITY BENEFIT PLAN. TEEN PREGNANCY AND ADULT BINGE DRINKING IN POLK COUNTY WILL NOT BE ADDRESSED.THE MARION COUNTY CHIP IDENTIFIED TEEN PREGNANCY AS A HEALTH PRIORITY AREA. THE COUNTY HEALTH DEPARTMENT IS TAKING THE LEAD TO ADDRESS THIS HEALTH NEED AND DATA SHOWS SIGNIFICANT IMPROVEMENT IN THIS HEALTH INDICATOR SINCE 2007, WHEN THE RATE WAS 43.0 PREGNANCIES PER 1,000 FEMALES AGED 15 -17. FROM 2010 THROUGH 2011 THE RATE DROPPED FROM 30.6 TO 23.2 PER 1,000. LIKEWISE, POLK COUNTY TEEN PREGNANCIES ARE 16.4 PREGNANCIES PER 1,000 FEMALES AGED 15-17 AND RATES CONTINUE TO SHOW SIGNIFICANT IMPROVEMENT SINCE 2007 WHEN THE RATE WAS REPORTED AT 20.5 PREGNANCIES PER 1,000 FEMALES AGED 15-17. WEST VALLEY HOSPITAL WILL CONTINUE TO MONITOR IMPROVEMENT AND PARTNER WITH KEY AGENCIES TO SUSTAIN IMPROVEMENT. IN POLK COUNTY 16.5 PERCENT OF ADULT MALES REPORTED BINGE DRINKING AT LEAST ONCE DURING THE 30 DAYS PRIOR TO THE SURVEY. BINGE DRINKING IS DEFINED AS FIVE OR MORE DRINKS ON ONE OCCASION. WHILE COMMUNITY PARTNERING AGENCIES IDENTIFIED BINGE DRINKING AS A HEALTH PRIORITY, THE HEALTHY PEOPLE 2020 NATIONAL HEALTH TARGET IS TO REDUCE THE PROPORTION OF ADULTS AGED 18 YEARS AND OLDER ENGAGING IN BINGE DRINKING DURING THE PAST 30 DAYS TO 24.3 PERCENT. POLK COUNTY DATA SHOWS ADULT MALE BINGE DRINKING WELL BELOW THE NATIONAL TARGET. WEST VALLEY HOSPITAL PART V, SECTION B, LINE 20D: THE AMOUNTS CHARGED TO PATIENTS ELIGIBLE UNDER THE FAP ARE DISCOUNTED AT TWO STEPS. THE FIRST STEP IS THAT ALL SELF-PAY PATIENTS RECEIVE A 15% DISCOUNT SO BILLED AMOUNTS ARE 85% OF GROSS CHARGES REGARDLESS OF FAP ELIGIBILITY. PATIENTS ELIGIBLE UNDER THE VERY FIRST TIER OF THE FAP, THOSE RECEIVING THE SMALLEST DISCOUNT, RECEIVE AN ADDITIONAL 20% DISCOUNT OFF THE AMOUNTS BILLED TO SELF-PAY PATIENTS (THE 85% OF GROSS CHARGES AMOUNT). THIS SECOND DISCOUNT MEANS THAT PATIENTS ELIGIBLE UNDER THE FAP ARE LIMITED TO BILLINGS AT A DISCOUNTED RATE OF 68%. THE HOSPITAL CALCULATES AGB USING THE LOOKBACK METHOD PRESCRIBED IN PROPOSED REGULATIONS (REG-130266-11). AS THE PROPOSED REGULATIONS DETAIL, AGB IS CALCULATED UNDER THIS METHOD BY DIVIDING THE SUM OF CLAIMS PAID TO THE HOSPITAL FACILITY BY THE SUM OF THE ASSOCIATED GROSS CHARGES FOR THOSE CLAIMS. THE AGB PERCENTAGES CALCULATED ARE BASED ON ALL CLAIMS THAT HAVE BEEN PAID IN FULL TO THE HOSPITAL FACILITY FOR EMERGENCY AND OTHER MEDICALLY NECESSARY CARE BY BY MEDICARE FEE-FOR-SERVICE AND ALL PRIVATE HEALTH INSURERS (INCLUDING MEDICARE ADVANTAGE) TOGETHER AS THE PRIMARY PAYER OF THESE CLAIMS. THE AMOUNT CONSIDERED PAID INCLUDES PAYMENTS FROM INSURER, MEDICARE AND AMOUNTS PAID BY THE INDIVIDUALS UNDER CO-INSURANCE, CO-PAYMENTS AND DEDUCTIBLES. THE MOST RECENT CALCULATION WAS BASED ON THE FISCAL YEAR ENDED 9/30/13. THE CALCULATION SHOWED THAT AMOUNTS GENERALLY BILLED ("AGB") WAS DISCOUNTED AT A RATE OF 32% FROM GROSS CHARGES DURING THE PERIOD ANALYZED, IN OTHER WORDS PAYMENTS WERE MADE AT AN AVERAGE RATE OF 68% OF GROSS CHARGES. THE DISCOUNTS UNDER THE FAP WILL BE REVIEWED WITHIN 45 DAYS OF EACH FISCAL YEAR END TO ENSURE THAT EACH YEAR THE POLICY IS UPDATED TO REFLECT CURRENT AGB AMOUNTS. 1 MONMOUTH MEDICAL CENTER 512 E MAIN ST 300 MONMOUTH OR 97361 CLINIC PART I, LINE 3C: IT IS THE POLICY OF WEST VALLEY HOSPITAL TO PROVIDE FINANCIAL COUNSELING TO PATIENTS REGARDING THEIR FINANCIAL OBLIGATION AT THE EARLIEST OPPORTUNITY POSSIBLE. WEST VALLEY HOSPITAL PROVIDES A VARIETY OF OPTIONS TO ASSIST PATIENTS IN RESOLVING THEIR ACCOUNTS, INCLUDING: OREGON HEALTH PLAN (OHP) SCREENING, CHARITY ASSISTANCE, MEDICAL FINANCING CARDS, LOANS, AND EXTENDED PAYMENT PLANS. DISCOUNTS MAY BE AVAILABLE ON THE NET BALANCE FOR PATIENTS AT OR BELOW 400% OF THE FEDERAL POVERTY LEVEL. PATIENTS AT OR BELOW 200% OF THE POVERTY LEVEL ARE ELIGIBLE FOR 100% CHARITY ASSISTANCE.THE HOSPITAL CONSIDERS BOTH INCOME AND/OR ASSETS AVAILABLE TO PAY PATIENT'S MEDICAL EXPENSES.1. THE HOSPITAL WILL MULTIPLY THE FAMILY INCOME BY 30%2. THE HOSPITAL WILL DETERMINE THE PATIENT'S ALLOWABLE MEDICAL EXPENSES3. THE HOSPITAL WILL COMPARE 30% OF THE FAMILY INCOME TO THE TOTAL OF THE PATIENT'S ALLOWABLE MEDICAL EXPENSES. IF THE TOTAL OF THE ALLOWABLE MEDICAL EXPENSES IS GREATER THAN 30% OF THE FAMILY INCOME, THEN THE PATIENT MEETS THE CATASTROPHIC CHARITY CARE QUALIFICATION. THE HOSPITAL WILL LIMIT PATIENT LIABILITY FOR MEDICAL EXPENSES TO 30% OF THE FAMILY'S INCOME. AMOUNTS THAT EXCEED THIS LIMIT WILL BE ELIGIBLE FOR CHARITY CARE.FOR EXAMPLE: FAMILY INCOME OF $70,000 PER YEAR AND MEDICAL EXPENSES OF $45,000. THIRTY-PERCENT OF THE FAMILY'S ANNUAL INCOME IS $21,000; THE FAMILY'S MEDICAL EXPENSES OF $45,000 EXCEED THIS AMOUNT. THE FAMILY SHOULD THEREFORE BE ELIGIBLE FOR A CHARITY WRITE-OFF OF $24,000.ORASSET TESTASSETS CONSIDERED AVAILABLE TO PAY PATIENT'S MEDICAL EXPENSES1. EQUITY IN A REAL ESTATE, OTHER THAN THE PATIENT'S PERSONAL RESIDENCE, SECURITIES OR OTHER ASSETS (E.G.. RENTAL PROPERTY, AGRICULTURAL USE) IS CONSIDERED AVAILABLE TO PAY THE PATIENT'S MEDICAL EXPENSES.2. $201,000 REPRESENTS THE MEDIAN VALUE OF A HOME IN SALEM, OREGON AS OF AUGUST 2010. THE HOSPITAL CONSIDERS THIS AMOUNT TO BE PROTECTED FROM CONSIDERATION AS A FUNDING SOURCE. EQUITY IN A PATIENT'S PERSONAL RESIDENCE OVER AND ABOVE $201,000 WILL BE CONSIDERED AS AVAILABLE TO PAY MEDICAL LIABILITIES.3. THE CATASTROPHIC LIMIT UNDER THIS TEST WILL BE ESTABLISHED AT 100% OF THE EQUITY IN REAL PROPERTY OVER AND ABOVE THE FIRST $201,000 IN A PRIMARY RESIDENCE, AND 100% OF THE EQUITY IN OTHER REAL PROPERTY PRODUCING INCOME.FOR EXAMPLE: $280,000 (MARKET VALUE) - $100,000 (MORTGAGE) = $180,000 (NET VALUE); THEREFORE, $201,000 (PROTECTED SO EQUITY WOULD NOT BE CONSIDERED) PART I, LINE 7: NET COMMUNITY BENEFIT EXPENSE IS CALCULATED BY TOTAL COSTS OF CARE PROVIDED LESS THE DIRECT, OFFSETTING NET REVENUES FOR THOSE SERVICES. THE COSTS TO PROVIDE CHARITY CARE AND MEDICAID SERVICES DISCLOSED IN LINE 7, COLUMN (C) LINES (A) AND (B), RESPECTIVELY, ARE DETERMINED BY APPLYING THE COST TO CHARGE RATIO AS DETERMINED IN WORKSHEET 2 TO THE FULL BILLED CHARGES FOR THE SERVICES RENDERED. NET COMMUNITY BENEFIT EXPENSE FOR THE COSTS FOR SUBSIDIZED HEALTH SERVICES DISCLOSED IN PART I, LINE 7(G) USES AN INTERNAL COSTING SYSTEM WHEREBY DIRECT AND INDIRECT EXPENSES ARE ALLOCATED TO DISCRETE OFFSETTING NET REVENUES FOR EACH SERVICE. OVERHEAD COSTS ARE ALLOCATED TO REVENUE GENERATING SERVICES BASED ON UTILIZATION STATISTICS SUCH AS SQUARE FOOTAGE FOR MAINTENANCE COSTS. PART I, LINE 7G: MARION AND POLK COUNTY MUA/HPSA DESIGNATION, HEALTH ASSESSMENT DATA SETS AND MARION POLK RESIDENT (2008) SURVEY RESULTS DEMONSTRATE HEALTHCARE ACCESS PROBLEMS, SPECIFICALLY LACK OF PHYSICIANS WILLING TO TAKE MEDICARE AND OREGON HEALTH INSURANCE (MEDICAID). LIKEWISE, ACCESS TO HEALTHCARE WAS ALSO ONE OF THE TOP THREE COMMUNITY HEALTH CONCERNS CITED BY PROVIDERS SURVEY RESPONDENTS. WHILE REGION 3, WHICH INCLUDES MARION, BENTON, LANE, LINN AND POLK COUNTIES, HAS 94 (OR 111) PRIMARY CARE PROVIDERS PER 100,000 POPULATION, ONLY 86 (OR 98) OF THOSE ACCEPT MEDICARE, AND OF THOSE 86, ONLY A PORTION ARE ACTUALLY ACCEPTING NEW PATIENTS. A SIMILAR SITUATION EXISTS FOR OREGON HEALTH PLAN; EVEN WHEN PEOPLE HAVE COVERAGE, THEY MAY NOT HAVE ACCESS TO ESTABLISHING CARE WITH A LOCAL MEDICAL PROVIDER. TO EASE THIS ACCESS BURDEN, WEST VALLEY HOSPITAL HAS SUBSIDIZED PHYSICIAN PRACTICES AND REPORTS THESE SUBSIDIES IN PART 1, LINE 7, COLUMN (F). PART I, LN 7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM TOTAL EXPENSE THAT WAS INCLUDED IN FORM 990, PART IX, LINE 25, COLUMN (A), BUT REMOVED FROM THIS FIGURE FOR THE PURPOSES OF CALCULATING THE PERCENTAGE IN SCHEDULE H, PART I, LINE 7, COLUMN (F) WAS $1,688,716. PART III, LINE 4: EFFECTIVE OCTOBER 1, 2011, THE HOSPITALS ADOPTED FASB ISSUED ACCOUNTING STANDARDS UPDATE (ASU) NO. 2011-07, HEALTH CARE ENTITIES (TOPIC 954): PRESENTATION AND DISCLOSURE OF PATIENT SERVICE REVENUE, PROVISION FOR BAD DEBTS, AND THE ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR CERTAIN HEALTH CARE ENTITIES. THE ADOPTION OF THIS ASU RESULTED IN A RECLASSIFICATION OF BAD DEBT EXPENSE FROM AN OPERATING EXPENSE TO BE A REDUCTION IN DERIVING NET PATIENT SERVICE REVENUE. COST OF BAD DEBT EXPENSE ESTIMATED AS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE FINANCIAL ASSISTANCE POLICY ON LINE 3 IS CALCULATED BY SUBTOTALING THE BAD DEBT AMOUNTS BY ZIP CODE. AMOUNTS WRITTEN OFF FOR ZIP CODES WHOSE MEDIAN HOUSEHOLD INCOME FALLS AT OR BELOW 200% OF FEDERAL POVERTY GUIDELINES ARE INCLUDED ON THIS LINE. PART III, LINE 9B: IF THERE IS AN INDICATION THAT A PATIENT MAY BE UNABLE TO PAY THEIR BILL, A FINANCIAL QUESTIONNAIRE IS GIVEN OR SENT TO THE PATIENT. UPON RECEIPT OF THE COMPLETED QUESTIONNAIRE, THE PATIENT FINANCIAL COUNSELOR WILL DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE AND NOTIFY THE PATIENT REGARDING THEIR ELIGIBILITY FOR DISCOUNTS UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. ELIGIBILITY IS DETERMINED BASED ON THE QUESTIONNAIRE AND SUPPORTING DOCUMENTATION IN ACCORDANCE TO THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. PART VI, LINE 2: WEST VALLEY HOSPITAL("WVH"), AS PART OF SALEM HEALTH, THE POLK COUNTIES, PUBLIC HEALTH MANAGER WORKED WITH THE SALEM HOSPITAL COMMUNITY BENEFIT DIRECTOR TO GATHER COMMUNITY PARTNERS FOR REVIEW OF HEALTH INDICATORS AND TO PRIORITIZE NEEDS. A PRIORITIZED DESCRIPTION OF THE COMMUNITY HEALTH NEEDS IDENTIFIED IN THE POLK COUNTY COMMUNITY HEALTH REPORT AND THE SALEM HEALTH WEB-BASED, POLK COUNTY INDICATOR TOOLS ARE INCLUDED IN THE COMMUNITY HEALTH IMPROVEMENT PLAN (CHIP). THE CHIP REPORTS ALSO DESCRIBE THE PROCESS AND CRITERIA USED IN PRIORITIZING HEALTH NEEDS. THE CHIP PLANNING COMMITTEES CHOSE KEY HEALTH INDICATORS THAT MOST ADVERSELY AFFECTED THE COMMUNITY AT LARGE FROM THE HEALTH REPORT AND DASHBOARD FINDINGS.IN POLK COUNTY, THE CHIP PLANNING COMMITTEE CHOSE NINE KEY HEALTH INDICATORS THAT MOST ADVERSELY AFFECTED THE COMMUNITY AT LARGE FROM THE HEALTH REPORT AND DASHBOARD FINDINGS. THE REVIEW RESULTED IN THE FOLLOWING RANKINGS, LISTED IN ORDER OF RECEIVING THE MOST EXPRESSED CONCERN TO LEAST THE EXPRESSED CONCERN: TEENS WHO ARE OBESE; POOR MENTAL HEALTH DAYS; ADULTS WHO ARE OBESE; MOTHERS WHO RECEIVE EARLY PRENATAL CARE; TEEN PREGNANCY RATES; LOW-INCOME PRESCHOOL OBESITY; MALE ADULTS WHO BINGE DRINK; CANCER SCREENINGS AND PREVALENCE; AND TEEN MARIJUANA USE.THE NINE INDICATORS WERE PRESENTED TO REPRESENTATIVES FROM COMMUNITY PARTNERING AGENCIES AT THE POLK COMMUNITY HEALTH ASSESSMENT LAUNCH IN LATE 2011. THE GROUP WAS INSTRUCTED TO SELECT THREE TO FOUR FOCUS AREAS. INDICATORS SELECTED INCLUDED TEENS WHO ARE OBESE, ADULTS WHO ARE OBESE, AND LOW-INCOME PRESCHOOL OBESITY. ALL THREE INDICATORS FOCUSED ON THE ISSUE OF OBESITY. DESPITE THE FACILITATORS ENCOURAGEMENT TO THINK BROADLY, THE COMMUNITY STRONGLY SUPPORTED THE SINGLE ISSUE OF OBESITY, DUE, AMONG OTHER THINGS, TO THE IMPACT ON OTHER HEALTH ISSUES. THE COMMUNITY HEALTH IMPROVEMENT PLAN WORKGROUP AGREED THAT TARGETING THE HIGH RATE OF OBESITY IN POLK COUNTY WOULD HAVE A TREMENDOUS POSITIVE IMPACT DUE TO THE VARIETY OF HEALTH ISSUES DIRECTLY RELATED TO OBESITY INCLUDING: MOBILITY, CHRONIC CONDITIONS, WORKABILITY, SELF-ESTEEM, STRESS, AND PHYSICALITY. ALTHOUGH THE POLK COUNTY CHIP IDENTIFIED NINE HEALTH INDICATORS AND CHOSE TO FOCUS ON THOSE RELATED TO OBESITY, THE HOSPITAL DATA DASHBOARD INCLUDES SOCIAL DETERMINANTS OF HEALTH AS WELL. IN POLK COUNTY, EDUCATIONAL (3RD GRADE READING, AND 8TH GRADE MATH PROFICIENCY), GROCERY STORE DENSITY, AND VIOLENT CRIME RATE NEGATIVELY INFLUENCE HEALTH. THEREFORE, THESE FOUR INDICATORS WERE ALSO IDENTIFIED AS AREAS OF NEED.IN ADDITION, THE HOSPITAL WILL FOCUS RESOURCES AND ALIGN COMMUNITY BENEFIT WORK TO IMPACT SOCIAL DETERMINANTS OF HEALTH IDENTIFIED IN THE CHNA. THE PUBLIC HEALTH DEPARTMENT AND HOSPITAL RECOGNIZE THE IMPORTANCE OF EACH OF THE HEALTH INDICATORS AND ARE COMMITTED TO IMPACT AS MANY HEALTH MEASURES AS POSSIBLE THROUGH DIRECT CONTRIBUTION, COMMUNITY COLLABORATION, AND PARTNERSHIP. PART VI, LINE 3: IT IS THE POLICY OF WEST VALLEY HOSPITAL TO PROVIDE FINANCIAL COUNSELING TO PATIENTS REGARDING THEIR FINANCIAL OBLIGATION AT THE EARLIEST OPPORTUNITY POSSIBLE. WEST VALLEY HOSPITAL PROVIDES A VARIETY OF OPTIONS TO ASSIST PATIENTS IN RESOLVING THEIR ACCOUNTS, INCLUDING: OREGON HEALTH PLAN (OHP) SCREENING, CHARITY ASSISTANCE, MEDICAL FINANCING CARDS, LOANS, AND EXTENDED PAYMENT PLANS. DISCOUNTS MAY BE AVAILABLE ON THE NET BALANCE FOR PATIENTS AT OR BELOW 400% OF THE FEDERAL POVERTY LEVEL. PATIENTS AT OR BELOW 200% OF THE POVERTY LEVEL ARE ELIGIBLE FOR 100% CHARITY ASSISTANCE.ALL UNINSURED PATIENTS WITH BALANCES OVER $500 ARE SCREENED FOR ELIGIBILITY THROUGH THE OREGON HEALTH PLAN (OHP), CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA) ELIGIBILITY, AND/OR ELIGIBILITY INTO THE FAMILY HEALTH INSURANCE ASSISTANCE PLAN (FHIAP) PROGRAM.WEST VALLEY HOSPITAL OR ITS REPRESENTATIVE WILL REVIEW THE PATIENT'S CURRENT RESOURCES AND WORK WITH HIM/HER TO GAIN ELIGIBILITY FOR ANY OF THESE PROGRAMS AS APPROPRIATE.PATIENTS THAT ARE NOT ELIGIBLE FOR OHP OR THE OTHER PROGRAMS LISTED ABOVE, AND HAVE FINANCIAL CONSTRAINTS THAT INHIBIT THEIR ABILITY TO PAY, WILL BE ASSESSED FOR EITHER CHARITY CARE OR A FINANCIAL DISCOUNT.INFORMATION ON THE HOSPITAL'S CHARITY CARE & FINANCIAL POLICY SHALL BE MADE PUBLICLY AVAILABLE IN THE FOLLOWING MANNER:- NOTICES ARE POSTED IN KEY AREAS OF THE HOSPITAL, INCLUDING ADMITTING, THE EMERGENCY DEPARTMENT, OUTPATIENT DEPARTMENT REGISTRATION AREAS, AND THE BUSINESS OFFICE. - THE CONDITIONS OF ADMISSION FORM INFORMS THE PATIENT OF THEIR RIGHT TO APPLY FOR CHARITY CARE. - WRITTEN INFORMATION SHALL BE AVAILABLE IN ENGLISH AND SPANISH. THE HOSPITAL WILL PROVIDE THE APPROPRIATE INTERPRETATION SERVICES FOR ALL PATIENTS WHO DO NOT SPEAK ENGLISH. - FRONT-LINE STAFF IS TRAINED TO ANSWER CHARITY CARE QUESTIONS EFFECTIVELY AND WILL DIRECT ANY QUESTIONS THAT CANNOT BE ANSWERED TO BUSINESS OFFICE STAFF IN A TIMELY MANNER. - THIS POLICY IS POSTED ON WEST VALLEY HOSPITAL'S WEBSITE. WRITTEN INFORMATION ABOUT THIS POLICY IS MADE AVAILABLE TO ANY PERSON WHO REQUESTS THE INFORMATION. - THE FIRST PATIENT STATEMENT WILL INCLUDE A NOTICE THAT CHARITY CARE AND/OR FINANCIAL ASSISTANCE IS AVAILABLE. PART VI, LINE 4: WEST VALLEY HOSPITAL IS A CRITICAL ACCESS HOSPITAL SERVING THE COMMUNITY OF POLK COUNTY, OREGON. WEST VALLEY HOSPITAL, THE ONLY HOSPITAL IN POLK COUNTY, OFFERS SERVICES BEYOND WHAT YOU MIGHT EXPECT FROM A SMALL-TOWN HOSPITAL. IN ADDITION TO MANY OUTPATIENT SURGERIES, THE MRI CAPABILITY TOPS AN IMAGING SERVICE THAT INCLUDES A NEW MAMMOGRAPHY SUITE. THE HOSPITAL PRIDES ITSELF ON PROVIDING LOW WAIT TIME AT ITS ROUND-THE-CLOCK EMERGENCY DEPARTMENT. SEVERAL CARDIOLOGISTS, UROLOGISTS, ORTHOPEDISTS AND GENERAL SURGEONS DO SEE PATIENTS AT WEST VALLEY HOSPITAL FOR PRELIMINARY AND FOLLOW-UP APPOINTMENTS. POLK COUNTY POPULATION ESTIMATE IN 2014 WAS 76,794 WITH PERSONS UNDER THE AGE OF 18 YEARS MAKING UP 23.6% OF THE POPULATION AND THOSE OVER 65 YEARS 15.8% OF THE POPULATION. 12.6% OF POLK COUNTY RESIDENTS ARE HISPANIC OR LATINO, 0.7% BLACK OR AFRICAN AMERICAN, 2.4% AMERICAN INDIAN AND ALASKA NATIVE. 79.9% ARE WHITE, NOT HISPANIC OR LATINO. OVERALL 14.6% OF PERSONS, AND 18.9% OF CHILDREN LIVE BELOW THE FEDERAL POVERTY LEVEL IN POLK COUNTY PART VI, LINE 5: WEST VALLEY HOSPITAL, AS A PART OF SALEM HEALTH, IS GOVERNED BY AN ALL-VOLUNTEER COMMUNITY-BASED BOARD OF TRUSTEES (BOARD). WEST VALLEY HOSPITAL LEADERSHIP AND HEALTH SYSTEM EXECUTIVE STAFF SERVE ON COMMUNITY NON-PROFIT ADVISORY BOARDS AND PROFESSIONAL ASSOCIATIONS. THE ORGANIZATION EXTENDS MEDICAL STAFF PRIVILEGES TO QUALIFIED PHYSICIANS IN ITS COMMUNITY AND PROVIDES FREE OFFICE SPACE AND OTHER IN-KIND SUPPORT SERVICES TO NON-PROFIT ORGANIZATIONS. WEST VALLEY HOSPITAL PROVIDES FINANCIAL SUPPORT AND SPONSORSHIP TO NONPROFIT ORGANIZATIONS. BY LEVERAGING HOSPITAL RESOURCES AND WORKING IN COLLABORATIVE PARTNERSHIPS, THE HOSPITAL IS ABLE TO PROVIDE BENEFITS THAT REACH BEYOND HEALTHCARE DELIVERY AND POSITIVELY IMPACT THE SOCIAL DETERMINANTS OF HEALTH. PART VI, LINE 6: SALEM HEALTH IS AN OREGON NONPROFIT CORPORATION AND A TAX-EXEMPT ORGANIZATION DESCRIBED IN SECTION 501(C)(3) OF THE CODE. SALEM HEALTH IS THE "PARENT" CORPORATION AND SOLE CORPORATE MEMBER OF SALEM HOSPITAL, SALEM HOSPITAL FOUNDATION, WEST VALLEY HOSPITAL, WEST VALLEY HOSPITAL FOUNDATION, WILLAMETTE VALLEY INSURANCE CORPORATION, AND WILLAMETTE VALLEY PROFESSIONAL SERVICES. ALL ENTITIES WITHIN THE PARENT CORPORATION ARE SEPARATE NONPROFIT CORPORATIONS.WEST VALLEY HOSPITAL IS ALSO AN OREGON NON-PROFIT CORPORATION. WEST VALLEY HOSPITAL, FORMERLY NAMED VALLEY COMMUNITY HOSPITAL, IS LOCATED IN DALLAS, OREGON, AND BECAME A CONTROLLED SUBSIDIARY OF SALEM HEALTH IN 2002. THE CORPORATION ALSO DOES BUSINESS UNDER THE NAME "WEST VALLEY HOSPITAL, A PART OF SALEM HEALTH." IT IS DESIGNATED AS A CRITICAL ACCESS HEALTH CENTER WITH 25 LICENSED BEDS. WEST VALLEY HOSPITAL, AS PART OF SALEM HEALTH, IS GOVERNED BY AN ALL-VOLUNTEER COMMUNITY-BASED BOARD OF TRUSTEES (BOARD). THE BOARD HAS THE RESPONSIBILITY FOR THE DEVELOPMENT AND OVERSIGHT OF SALEM HEALTH VALUES, VISION, PURPOSE AND LONG-TERM STRATEGY. THROUGH THESE DOCUMENTS, THE COMMUNITY BENEFIT STEERING COMMITTEE ASSESSES AND REAFFIRMS WEST VALLEY HOSPITAL'S COMMUNITY BENEFIT COMMITMENTS AND CONNECTIONS WITH COMMUNITY NEEDS AND PRIMARY CONSTITUENCIES. THE COMMUNITY BENEFIT PLAN ASSURES MEASUREMENT AND COMPARISON OF WEST VALLEY HOSPITAL'S COMMUNITY ACTIVITIES TO EVOLVING NORMS AND OVERSEES THE CLEAR AND ACCURATE COMMUNICATION OF THESE ACTIVITIES TO KEY CONSTITUENCIES. PART VI, LINE 7, REPORTS FILED WITH STATES OR 0 POLK COUNTY SERVICE INTEGRATION TEAMS 750 S 5TH STREET INDEPENDENCE OR 97351 936000869 COUNTY 15000 IMPROVE SOCIAL DETERMINATES OF HEALTH X X X X X 0 1 0 0 0 1 1 1 0 NORMAN GRUBER PRESIDENT 0 760325 0 95710 0 14126 0 219125 0 38822 0 1128108 0 0 AARON CRANE CHIEF FIN. & STRATEGY OFFICER 0 462111 0 55230 0 12919 0 47318 0 27954 0 605532 0 0 PAMELA CORTEZ DIR. OF CLINICAL OPERATIONS 192093 0 27498 0 346 0 18976 0 23035 0 261948 0 0 0 ROBERT BRANNIGAN CHIEF ADMIN OFFICER WVH/VP 0 315509 0 26681 0 7341 0 34131 0 25337 0 408999 0 0 ALISON SMITH MD GENERAL SURGEON 391212 0 21580 0 4525 0 38164 0 26015 0 481496 0 0 0 LISA JEFFERS ASSISTANT NURSE MANAGER 120866 0 18250 0 184 0 6440 0 16474 0 162214 0 0 0 CHARLES ESSEX MD PHYSICIAN 234803 0 12028 0 3854 0 24894 0 29098 0 304677 0 0 0 JOHN HADLEY MD PHYSICIAN 200866 0 15592 0 2575 0 25217 0 22595 0 266845 0 0 0 REBECCA LUCAS MD ER PHYSICIAN 283705 0 1291 0 894 0 25433 0 24584 0 335907 0 0 0 PART I, LINE 4B SOME OF THE HOSPITAL'S OFFICERS AND EMPLOYEES RECEIVE DEFERRED COMPENSATION UNDER A 457(F) NONQUALIFIED PLAN. THIS COMPENSATION IS INCLUDED IN COMPENSATION REPORTED IN PART II. THE TOTAL NONQUALIFIED PORTION OF EACH PERSONS DEFERRED COMPENSATION IS: NORMAN GRUBER 295,710 ($95,710 INCLUDED IN OTHER REPORTABLE COMPENSATION AND $200,000 INCLUDED IN DEFERRED COMPENSATION) AARON CRANE 66,649 ($35,905 INCLUDED IN OTHER REPORTABLE COMPENSATION AND $30,743 INCLUDED IN DEFERRED COMPENSATION) ROBERT BRANNIGAN 20,106 (INCLUDED IN DEFERRED COMPENSATION) ALISON SMITH 43,234 ($21,580 INCLUDED IN OTHER REPORTABLE COMPENSATION AND $21,654 INCLUDED IN DEFERRED COMPENSATION) CHARLES ESSEX 23,671 ($12,028 INCLUDED IN OTHER REPORTABLE COMPENSATION AND $11,643 INCLUDED IN DEFERRED COMPENSATION) JOHN HADLEY 27,594 ($15,592 INCLUDED IN OTHER REPORTABLE COMPENSATION AND $12,002 INCLUDED IN DEFERRED COMPENSATION) REBECCA LUCAS 12,699 ($1,291 INCLUDED IN OTHER REPORTABLE COMPENSATION AND $11,408 INCLUDED IN DEFERRED COMPENSATION) PART I, LINE 6 CERTAIN PHYSICIANS RECEIVE INCENTIVE COMPENSATION IN ACCORDANCE WITH THEIR EMPLOYMENT AGREEMENTS WITH SALEM HOSPITAL. AMOUNTS NOTED ON SCHEDULE J PART II COLUMN (II) REFLECT PAYMENTS EARNED BY THESE PHYSICIAN EMPLOYEES IN SUCH AGREEMENTS. ADDITIONALLY, FOR KEY EMPLOYEES AND MANAGEMENT OF SALEM HOSPITAL THE BOARD OF TRUSTEES HAS APPROVED AN ANNUAL LEADERSHIP INCENTIVE PROGRAM THAT PROVIDES FOR INCENTIVE PAYMENTS BASED ON OBJECTIVE CRITERIA RELATED TO QUALITY AND SAFETY, ENGAGEMENT, PATIENT SATISFACTION AND FINANCIAL PERFORMANCE. AMOUNTS NOTED ON SCHEDULE J PART II COLUMN (II) REFLECT PAYMENTS EARNED UNDER THE LEADERSHIP INCENTIVE PLAN. PART I, LINE 7 THE GOVERNANCE COMMITTEE OF THE BOARD OF TRUSTEES, IN CONSULTATION WITH INDEPENDENT COMPENSATION CONSULTANTS, REVIEWS CEO TOTAL COMPENSATION AND PERFORMANCE ANNUALLY. AS PART OF THE COMMITTEE'S ACTIONS, A NON-FIXED BONUS MAY BE AWARDED TO THE CEO. IN THIS YEAR THE NON-FIXED PAYMENT WAS PAID UNDER THE 457(F) NONQUALIFIED PLAN AND IS INCLUDED IN DEFERRED COMPENSATION REPORTED IN PART II. FORM 990, PART VI, SECTION B, LINE 11 THE GOVERNANCE COMMITTEE OF THE BOARD OF TRUSTEES REVIEWS THE 990. IT IS THEN FORWARDED TO THE ENTIRE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION B, LINE 12C ON AN ANNUAL BASIS THE SECRETARY OF THE HOSPITAL SHALL SEND TO EACH PERSON WHO IS A TRUSTEE, OFFICER, OR MEMBER OF A COMMITTEE, AND TO THOSE EMPLOYEES OF THE HOSPITAL AS THE BOARD MAY DETERMINE, A COPY OF THE POLICY REGARDING CONFLICTS OF INTEREST, TOGETHER WITH A QUESTIONNAIRE INQUIRING AS TO CONFLICTS, TO BE COMPLETED AND RETURNED TO THE SECRETARY BY THE TRUSTEE, OFFICER, COMMITTEE MEMBER OR EMPLOYEE PRIOR TO THE BEGINNING OF EACH CALENDAR YEAR. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION FOR THE CEO IS REVIEWED ON AN ANNUAL BASIS. THE GOVERNANCE COMMITTEE ENGAGES AN OUTSIDE CONSULTANT TO DO A MARKET REVIEW AND COMPARISON. THE CONSULTANT WORKS DIRECTLY WITH THE GOVERNANCE COMMITTEE CHAIR AS WELL AS HUMAN RESOURCES TO COMPLETE THE ASSESSMENT AND MAKE A RECOMMENDATION. THE FINAL RECOMMENDATION IS BROUGHT BEFORE THE BOARD IN EXECUTIVE SESSION FOR FINAL APPROVAL. FORM 990, PART VI, SECTION C, LINE 19 THE CONFLICT OF INTEREST POLICY AND GOVERNING DOCUMENTS ARE AVAILABLE ON THE HOSPITAL WEBSITE. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST (FAS 136) 6,728. CHANGE IN POST RETIREMENT BENEFIT -140,797. SALEM HOSPITAL 890 OAK STREET SE SALEM OR 97301 930579722 HOSPITAL OR 501(C)(3) 3 SALEM HEALTH 0 SALEM HOSPITAL FOUNDATION 890 OAK STREET SE SALEM OR 97301 237002687 SUPPORTS SALEM HOSPITAL OR 501(C)(3) 11 TYPE 1 SALEM HEALTH 0 SALEM HOSPITAL AUXILIARY 890 OAK STREET SE SALEM OR 97301 931081113 SUPPORTS SALEM HOSPITAL OR 501(C)(3) 9 N/A 0 SALEM HEALTH 890 OAK STREET SE SALEM OR 97301 930823471 LEASES LAND TO SALEM HOSPITAL OR 501(C)(3) 11 TYPE 1 N/A 0 WEST VALLEY HOSPITAL FOUNDATION 525 SOUTHEAST WASHINGTON STREET DALLAS OR 97338 931298564 SUPPORTS WEST VALLEY HOSPITAL OR 501(C)(3) 11 TYPE 1 SALEM HEALTH 0 WILLAMETTE VALLEY INSURANCE COMPANY 745 FORT STREET HONOLULU HI 96813 201836190 CAPTIVE INSURANCE HI 501(C)(3) 11 TYPE 1 SALEM HEALTH 0 WILLAMETTE VALLEY PROFESSIONAL SERVICES 890 OAK STREET SE SALEM OR 97301 753175249 BILLING SERVICE FOR PROFESSIONAL SERVICES OR 501(C)(3) 3 SALEM HEALTH 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 0 0