2015-11-05T18:12:26-06:00 2014-12-31 930418710 DELAP LLP 5885 MEADOWS ROAD NO 200 LAKE OSWEGO OR 97035 990 2014-01-01 930415219 SANTIAM MEMORIAL HOSPITAL SANT 5037692175 1401 N 10TH AVENUE STAYTON OR 973831311 TERRY FLETCHALL CEO 5037692175 2015-11-05 1 MARK E EKLUND CPA P00156145 5036974118 2015-11-05 2014 2016-04-25 22:37:26Z TERRY FLETCHALL 1401 N 10TH AVENUE STAYTON OR 973831311 39955604 0 X WWW.SANTIAMHOSPITAL.ORG X 1950 OR GENERAL ACUTE HEALTH CARE HOSPITAL SERVING SANTIAM COMMUNITIES 9 9 371 0 0 0 18817 101829 35601394 39452907 32919 23341 222179 253262 35875309 39831339 0 0 0 0 21851502 22111426 0 0 0 16966682 18672524 38818184 40783950 -2942875 -952611 60110228 56074029 34382875 32868011 25727353 23206018 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 31784064 39545238 ACUTE HOSPITAL CARE: PATIENT DAYS 3,408, NURSERY DAYS 175, AMBULANCE TRIPS 1,906, OUTPATIENT DAYS 38,264, REFERENCE LABORATORY 132,883. 31784064 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 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 80 0 1 371 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 DIRECTOR 3.00 X 0 0 0 ELAINE HANSEN VICE PRESIDENT 3.00 X X 0 0 0 VICTOR KINTZ PRESIDENT 3.00 X X 0 0 0 MARYANN MEREDITH SECRETARY 3.00 X X 0 0 0 MIKE ODENTHAL DIRECTOR 3.00 X 0 0 0 RANDY MICKEY DIRECTOR 3.00 X 0 0 0 GEORGE LONG DIRECTOR 3.00 X 0 0 0 DENNIS LULAY DIRECTOR 3.00 X 0 0 0 FRANCIS HENDRICKS DIRECTOR 3.00 X 0 0 0 TERRY FLETCHALL CEO 50.00 X 255722 0 36624 MAGGIE HUDSON CFO/COO 50.00 X 215998 0 34965 GENNY BALDWIN CHIEF NURSING OFFICER 50.00 X 188246 0 35380 JOHN HOFFMAN M.D. 40.00 X 401046 0 41084 JOHN SILVER M.D. 40.00 X 381043 0 40033 SUSAN TAYLOR M.D. 40.00 X 301052 0 39983 LORI BORELLA M.D. 32.00 X 287518 0 30891 NICOLAS J STRATTON M.D. 40.00 X 401046 0 25341 2431671 0 284301 24 0 1 0 MILLER NASH LLP PO BOX 3585 PORTLAND OR 97208 LEGAL SERVICES 897147 ROBERT L JACQUES MD 1401 N 10TH AVE STAYTON OR 973831311 HOSPITALIST 469847 STEPHEN P MOON MD 1401 N 10TH AVE STAYTON OR 973831312 EMERGENCY ROOM PHYSICIAN 288770 STEVEN M VETS DO 1401 N 10TH AVE STAYTON OR 973831312 EMERGENCY ROOM PHYSICIAN 283535 CHARLES H STRINGHAM MD 1401 N 10TH AVE STAYTON OR 973831311 EMERGENCY ROOM PHYSICIAN 279967 14 50000 39893 11936 101829 PATIENT SERVICE REVENUE - NET 622110 37510444 37510444 K-1, INCOME FROM CCO 900099 1544864 1544864 ELECTRONIC HLTH RECORDS 990009 397599 397599 39452907 43509 43509 77900 95105 -17205 -17205 -17205 8992 0 29160 8992 -29160 -20168 -20168 CAFETERIA REVENUE 722210 160931 160931 OTHER MISC. REVENUE 900099 109536 109536 270467 39831339 39545238 0 184272 786250 786250 15943509 14965358 978151 396526 396526 3815813 2849247 966566 1169328 954288 215040 153271 153271 181082 181082 3969018 2115355 1853663 393306 393306 106325 106325 249657 249657 401283 401283 1556903 1556903 2477444 2477444 256859 33759 223100 SUPPLIES 5348042 5224581 123461 CLINIC EXPENSE 1446261 1435117 11144 MISCELLANEOUS 756412 141524 614888 EQUIPMENT RENT & MAINTE 662868 585055 77813 713793 204527 509266 40783950 31784064 8999886 0 238 240 13025489 7805480 5260029 5247171 189221 521612 1212379 1226173 516437 749985 53913741 18322937 37434432 35590804 643702 695334 272728 272728 1139666 3530220 415907 434282 60110228 56074029 6799390 3527071 26460308 28471150 1123177 869790 34382875 32868011 X 25727353 23206018 25727353 23206018 60110228 56074029 X -952611 -23180 -1545544 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 330620 1091087 1421707 1866107 36084059 8280019 29670147 619850 487834 132016 10000 13833201 9555084 4288117 9320 69497 78817 35590804 EST 3RD PARTY PAYOR SETTLEMENTS 142508 OTHER LONG-TERM LIABILITIES 727282 869790 X 38262615 -23180 -23180 38285795 1545544 1545544 39831339 40783950 0 40783950 0 40783950 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, 2014 AND 2013. PART XI, LINE 4B - OTHER ADJUSTMENTS: REVENUE FROM K-1, WILLAMETTE VALLEY COMMUNITY HEALTH, LLC 1,545,544. 1 1 1 X 1 X 1 1 1 0 1 1 450 419910 419910 0.01030 21751 8993294 6232996 2760298 0.06770 32375 17314040 13143631 4170409 0.10230 54576 26727244 19376627 7350617 0.18030 3977 160309 11909 148400 0.00360 981477 727726 253751 0.00620 21875 21875 0.00050 3977 1163661 739635 424026 0.01030 58553 27890905 20116262 7774643 0.19060 1 2037522 4066749 5686659 -1619910 X 1 1 1 1 SANTIAM MEMORIAL HOSPITAL 1401 N 10TH AVENUE STAYTON OR 973831311 X X X SANTIAM MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 12 1 1 0 1 X WWW.SANTIAMHOSPITAL.ORG 1 13 1 HTTP://SANTIAMHOSPITAL.ORG/RESOURCES.PHP 0 0 1 X 150.000000000000 250.000000000000 X X X X 1 1 1 X X 1 X 0 1 X 0 1 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 2012 SANTIAM MEMORIAL HOSPITAL PART V, SECTION B, LINE 22D: ALL PATIENTS ARE CHARGED AT THE SAME GROSS CHARGES. SANTIAM MEMORIAL HOSPITAL PART V, SECTION B, LINE 24: ALL PATIENTS ARE BILLED THE SAME GROSS CHARGES REGARDLESS OF INSURANCE STATUS. ALL PATIENTS ARE GIVEN A 10% DISCOUNT FOR PAYMENT OVER $ 500. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY SANTIAM MEMORIAL HOSPITAL PART V, SECTION B, LINE 16C WEBSITE: HTTP://WWW.SANTIAMHOSPITAL.ORG/PAT_FINANCIAL.PHP 8 SUBLIMITY MEDICAL CLINIC 114 SE CHURCH ST SUBLIMITY OR 97325 PHYSICIAN CLINIC AUMSVILLE MEDICAL CLINIC 205 MAIN ST AUMSVILLE OR 97325 PHYSICIAN CLINIC SANTIAM MEDICAL CLINIC 280 S FIRST AVENUE MILL CITY OR 97360 PHYSICIAN CLINIC CASCADE MEDICAL CLINIC 1375 N 10TH AVENUE STE B STAYTON OR 97383 PHYSICIAN CLINIC SANTIAM PULMONARY CLINIC 1401 N 10TH AVENUE STE 200 STAYTON OR 97383 PHYSICIAN CLINIC SANTIAM INTERNAL MEDICINE CLINIC 1401 N 10TH AVENUE STE 200 STAYTON OR 97383 PHYSICIAN CLINIC SANTIAM ORTHOPAEDIC CLINIC 1369 N 10TH AVENUE STAYTON OR 97383 PHYSICIAN CLINIC SANTIAM WOMEN'S CLINIC 1373 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, $2,037,522, 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 X X X 0 0 0 1 0 0 0 0 0 TERRY FLETCHALL CEO 239164 0 1048 0 15510 0 24605 0 12019 0 292346 0 0 0 MAGGIE HUDSON CFO/COO 178997 0 1048 0 35953 0 18359 0 16606 0 250963 0 0 0 GENNY BALDWIN CHIEF NURSING OFFICER 183745 0 1048 0 3453 0 22880 0 12500 0 223626 0 0 0 JOHN HOFFMAN M.D. 399998 0 1048 0 0 0 7800 0 33284 0 442130 0 0 0 JOHN SILVER M.D. 379995 0 1048 0 0 0 7800 0 32233 0 421076 0 0 0 SUSAN TAYLOR M.D. 300004 0 1048 0 0 0 7800 0 32183 0 341035 0 0 0 LORI BORELLA M.D. 287518 0 0 0 0 0 7800 0 23091 0 318409 0 0 0 NICOLAS J STRATTON M.D. 399998 0 1048 0 0 0 5531 0 19810 0 426387 0 0 0 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 -1,545,544. SANTIAM MEDICAL GROUP LLC 1401 N 10TH AVENUE STAYTON OR 97383 462570877 TO PROVIDE OUTPATIENT MEDICAL SERVICES AT VARIOUS CLINIC LOCATIONS OR 9101180 8154396 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 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 SANTIAM MEMORIAL HOSPITAL AUXILIARY N