2014-10-30T10:58:01-05:00 2013-12-31 930418710 DELAP LLP 5885 MEADOWS ROAD NO 200 LAKE OSWEGO OR 97035 990 2013-01-01 930415219 SANTIAM MEMORIAL HOSPITAL SANT 5037692175 1401 N 10TH AVENUE STAYTON OR 973831311 TERRY FLETCHALL CEO 5037692175 2014-10-29 1 MARK E EKLUND CPA P00156145 5036974118 2014-10-29 2013 2015-11-30 17:44:51Z TERRY FLETCHALL 1401 N 10TH AVENUE STAYTON OR 973831311 35976240 0 X WWW.SANTIAMHOSPITAL.ORG X 1950 OR GENERAL ACUTE HEALTH CARE HOSPITAL SERVING SANTIAM COMMUNITIES 9 9 361 18 0 0 22101 18817 35408269 35601394 43213 32919 154434 222179 35628017 35875309 0 0 0 0 18959075 21851502 0 0 0 14143943 16966682 33103018 38818184 2524999 -2942875 57094687 60110228 28227538 34382875 28867149 25727353 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 30393314 35659427 ACUTE HOSPITAL CARE: PATIENT DAYS 3,568, NURSERY DAYS 181, SWING BED DAYS 68, AMBULANCE TRIPS 1,734, OUTPATIENT DAYS 36,255, REFERENCE LABORATORY 135,301. 30393314 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 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 71 0 1 361 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 242520 0 78557 MAGGIE HUDSON CFO/COO 50.00 X 182039 0 57532 GENNY BALDWIN CHIEF NURSING OFFICER 50.00 X 167582 0 55726 JOHN HOFFMAN M.D. 40.00 X 398379 0 37645 JOHN SILVER M.D. 40.00 X 364095 0 29498 SUSAN TAYLOR M.D. 50.00 X 302954 0 36975 LORI BORELLA M.D. 32.00 X 276323 0 25226 FREDRICK CARLOCK M.D. 32.00 X 233873 0 35578 2167765 0 356737 8 0 1 0 ROBERT L JACQUES MD 1401 N 10TH AVE STAYTON OR 973831311 HOSPITALIST 450703 CHARLES H STRINGHAM MD 1401 N 10TH AVE STAYTON OR 973831311 ER PHYSICIAN 402077 DANNY SPARKS MD 1402 N 10TH AVE STAYTON OR 973831312 ER PHYSICIAN 253966 HEINZ MECHANICAL 2615 NW ST HELENS PORTLAND OR 97210 CONSTRUCTION SERVICES 197600 EDWARD JUNN MD 1402 N 10TH AVE STAYTON OR 973831312 ER PHYSICIAN 183075 5 18817 18817 ACUTE HOSPITAL CARE 900099 34284858 34284858 MEDICARE/MEDICAID PMTS 900099 29724520 29724520 ELECTRONIC HLTH RECORDS 990009 658367 658367 PROVISION FOR CHARITY 900099 -1526368 -1526368 CONTRACTUAL ALLOWANCES & ALLOWANC 900099 -33301362 -33301362 5761379 5761379 35601394 33174 33174 80500 91201 -10701 -10701 -10701 3375 6100 0 9730 3375 -3630 -255 -255 CAFETERIA REVENUE 722210 164146 164146 OTHER MISC. REVENUE 900099 68734 68734 232880 35875309 35659427 0 197065 766969 766969 15546397 14697368 849029 434338 398916 35422 3948127 2453151 1494976 1155671 954798 200873 221947 221947 97420 97420 15254 15254 3105980 1959455 1146525 254296 254296 93834 93834 327836 327836 379453 379453 1400149 1400149 2318731 2318731 359688 41041 318647 SUPPLIES 5288886 5175374 113512 CLINIC EXPENSE 1039635 1022108 17527 MISCELLANEOUS 762586 282036 480550 EQUIPMENT RENT & MAINTE 593491 512423 81068 707496 198460 509036 38818184 30393314 8424870 0 240 238 11609952 13025489 5920388 5260029 19132 189221 1142548 1212379 460618 516437 53345539 15911107 35140287 37434432 554404 643702 539574 0 1707544 1828301 57094687 60110228 5358787 6799390 22868751 26460308 0 1123177 28227538 34382875 X 28867149 25727353 28867149 25727353 57094687 60110228 X -2942875 34983 -231904 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 330620 1091087 1421707 1601014 35971373 6940022 30632365 619850 470537 149313 13683929 8500548 5183381 47666 47666 37434432 EST 3RD PARTY PAYOR SETTLEMENTS 344515 OTHER LONG-TERM LIABILITIES 778662 1123177 35678388 34983 34983 35643405 231904 231904 35875309 38818184 0 38818184 0 38818184 PART XI, LINE 4B - OTHER ADJUSTMENTS: REVENUE FROM WILLAMETTE VALLEY COMMUNITY HEALTH, LLC 231,904. 1 1 1 X 1 X 1 1 1 0 0 1 595 692103 692103 0.01780 2 89726 4343705 3488289 855416 0.02200 3 90321 5035808 3488289 1547519 0.03980 16 65062 6715 58347 0.00150 33069 33069 0.00090 16 98131 6715 91416 0.00240 19 90321 5133939 3495004 1638935 0.04220 1 3483382 2786706 4221963 6642015 -2420052 X 1 1 1 1 SANTIAM MEMORIAL HOSPITAL 1401 N 10TH AVENUE STAYTON OR 973831311 X X X SANTIAM MEMORIAL HOSPITAL 1 1 X X X X X X X X X 11 1 1 1 X 1 0 1 1 150.000000000000 1 250.000000000000 1 X X X X X 1 1 X X X X 1 X 0 1 X 0 1 SANTIAM MEMORIAL HOSPITAL PART V, SECTION B, LINE 3: 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 4: SALEM HEALTH SYSTEM, SILVERTON HOSPITAL NETWORK SANTIAM MEMORIAL HOSPITAL PART V, SECTION B, LINE 7: CHIP PLANNING IMPLEMENTED IN 2012 SANTIAM MEMORIAL HOSPITAL PART V, SECTION B, LINE 20D: ALL PATIENTS ARE CHARGED AT THE SAME GROSS CHARGES. SANTIAM MEMORIAL HOSPITAL PART V, SECTION B, LINE 22: ALL PATIENTS ARE BILLED THE SAME GROSS CHARGES REGARDLESS OF INSURANCE STATUS. ALL PATIENTS ARE GIVEN A 10% DISCOUNT FOR PAYMENT OVER $ 500. 7 SUBLIMITY MEDICAL CLINIC 114 SE CHURCH ST SUBLIMITY OR 97325 PHYSICIAN CLINIC AUMSVILLE MEDICAL CLINIC 205 MAIN ST AUMSVILLE OR 97325 PHYSICIAN CLINIC CASCADE MEDICAL CLINIC 1375 N 10TH AVENUE STE B STAYTON OR 97383 PHYSICIAN CLINIC SANTIAM MEDICAL CLINIC 280 S FIRST AVENUE MILL CITY OR 97360 PHYSICIAN CLINIC SANTIAM WOMEN'S CLINIC 1373 N 10TH AVENUE STAYTON OR 97383 PHYSICIAN CLINIC SANTIAM PULMONARY CLINIC 1401 N 10TH AVENUE STE 200 STAYTON OR 97383 PHYSICIAN CLINIC SANTIAM ORTHOPAEDIC CLINIC 1369 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, $3,483,382, 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 166163 0 64583 0 11774 0 37693 0 40864 0 321077 0 0 0 MAGGIE HUDSON CFO/COO 142352 0 33362 0 6325 0 16735 0 40797 0 239571 0 0 0 GENNY BALDWIN CHIEF NURSING OFFICER 138497 0 28085 0 1000 0 16060 0 39666 0 223308 0 0 0 JOHN HOFFMAN M.D. 397328 0 1051 0 0 0 7650 0 29995 0 436024 0 0 0 JOHN SILVER M.D. 363044 0 1051 0 0 0 0 0 29498 0 393593 0 0 0 SUSAN TAYLOR M.D. 301903 0 1051 0 0 0 7217 0 29758 0 339929 0 0 0 LORI BORELLA M.D. 275272 0 1051 0 0 0 7650 0 17576 0 301549 0 0 0 FREDRICK CARLOCK M.D. 232822 0 1051 0 0 0 7650 0 27928 0 269451 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 -231,904. SANTIAM MEDICAL GROUP LLC 1401 N 10TH AVENUE STAYTON OR 97383 462570877 TO PROVIDE OUTPATIENT MEDICAL SERVICES AT VARIOUS CLINIC LOCATIONS OR 4839909 6455242 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