2013-05-03T17:17:20-05:00 2012-06-30 KPMG LLP 55 SECOND STREET SUITE 1400 SAN FRANCISCO CA 94105 990 2011-07-01 951643373 Community Hospital of San Bernardino % DAVE EVANS FINANCE DEPT COMM 9088876333 1805 Medical Center Drive San Bernardino CA 92411 Darryl VandenBosch 2013-05-03 true 4159635100 2011 2016-02-25 16:41:14Z DARRYL VANDENBOSCH CFO 1805 MEDICAL CNTR DRIVE SAN BERNARDINO CA 92411 201056359 false X WWW.dignityhealth.ORG X 1938 CA Community Hospital of San Bernardino is committed to furthering the healing ministry of Jesus, and to providing high-quality, affordable healthcare to the community we serve. 16 9 1654 93 0 609137 1038794 196791336 199115964 56577 23318 862375 878283 198319425 201056359 1486148 1353088 0 0 122272435 127298124 0 0 0 88510573 91239175 212269156 219890387 -13949731 -18834028 63903035 78269563 88099865 121300421 -24196830 -43030858 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 200943466 1353088 199115964 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 442 beds and currently has 360 beds available. The hospital had 90,816 total patient days, 14,455 admissions, and 48,117 emergency room visits. Inpatient services: acute patient care; maternal child care; mental health care; neurological care; and a variety of outpatient care. 200943466 true true false true false false false false false false true false false false true false false true false false false false false false false false true true true true true true true false false false false true false false false true false false false false false true true true false false true 12 0 true 1654 true false false false false false false false false false false X 16 9 false false false false true true true true true false false false true true true true true false false false CA X DAVE EVANS FINANCE DEPT 9098876333 1805 MEDICAL CTR DRIVE SAN BERNARDINO CA 92411 X Steven Barron 1.0 X 0 641553 74017 Dr Alvaro Bolivar 1.0 X 213556 0 0 Paulette Brown Ph D 1.0 X 0 0 0 Dr Betty Daniels 1.0 X 0 0 0 Dr Hendrik DeJager 1.0 X 0 0 0 Bruce Ermann MD 1.0 X 0 252801 26422 Richard Gonzalez Esq 1.0 X 0 0 0 Margaret Hill 1.0 X 0 0 0 Dr Bharti Jain 28.0 X X 0 0 0 Albert Karnig PhD 1.0 X 0 0 0 Frank Lyman 1.0 X X 0 0 0 Peggy Merryman 1.0 X 0 0 0 Dr Vellore Muraligopal 1.0 X 0 0 0 John Nolan Esq 1.0 X 0 0 0 Marvin O'Quinn 1.0 X 0 2991707 441153 Dr Paul Ryan 1.0 X 12000 0 0 Elizabeth Shih 1.0 X 0 1703310 154085 Susan Whitten 1.0 X 0 433014 65434 Marvin Reiter CPA 1.0 X X 0 0 0 June Collison 40.0 X 0 0 0 Jack Ivie 40.0 X 331392 0 21428 Diane Nitta 40.0 X 782750 0 38808 Edward Sorenson 40.0 X 437491 0 28433 Darryl VandenBosch 20.0 X 0 323805 42744 Geraldine C Fike 40.0 X 226004 0 24763 Kimiko Ford 40.0 X 226318 0 37895 Stan Rucker 40.0 X 0 269809 27244 David J Evans 40.0 X 194269 0 35569 LAWRENCE LAWLER 40.0 X 213806 0 37834 Marc Marchetti 40.0 X 218065 0 35192 Rosilyn Nolan 40.0 X 183732 0 31877 Marie R Orpilla 40.0 X 232983 0 34004 3272366 6615999 1156902 225 false true false AMERICAN VITALCARE INC PO BOX 502096 ST LOUIS MO 631502096 Subacute care svc 1577997 SAFEWAY CONSTRUCTION 1474 N MILLER DR COLTON CA 923242457 Contractor 1244743 ANGELICA TEXTILE SERVICES 925 S 8TH ST COLTON CA 92324 LAUNDRY SERVICES 991364 AXIOM PAIN MANAGEMENT INC 1800 N MEDICAL CENTER DR SAN BERNARDINO CA 92411 Medical Services 990083 METROPOLITAN FAMILY MED GROUP 742 W HIGHLAND AVE SAN BERNARDINO CA 92405 Medical Services 946565 33 744000 250377 44417 1038794 PATIENT REVENUE/CHARITY CARE 900099 86339473 86339473 0 0 MEDICARE/MEDICAID PAYMENTS 900099 108955909 108955909 0 0 EHR INCENTIVE 900099 3144511 3144511 0 0 MEDICAL OFFICE BUILDING 900099 665415 665415 0 0 EDUCATION 900099 10656 10656 0 0 199115964 23318 0 0 23318 0 0 0 0 0 0 CAFETERIA 900099 481089 0 481089 GIFT SHOPS 900099 239164 0 239164 DISCOUNT ON PURCHASES 900099 46253 0 46253 111777 0 111777 878283 201056359 199115964 0 901601 1303599 1303599 49489 49489 0 0 2583520 2484265 99255 246000 246000 95123645 90271752 4851893 5748095 5116998 631097 16359774 14573133 1786641 7237090 6448247 788843 0 75896 75896 81983 81983 10314 10314 0 0 18408591 11840068 6568523 304158 11722 292436 5677740 5485853 191887 7665664 6839516 826148 0 2054402 1807874 246528 143920 114437 29483 0 121082 53270 67812 3272675 3272675 0 3916956 3329413 587543 3865440 3865440 MEDI-CAL PROVIDER FEE 13944250 13944250 0 0 BAD DEBT 15368332 15368332 0 0 MEDICAL SUPPLIES 12990443 12990443 0 0 FOOD SUPPLIES 1137714 1137714 0 0 2199615 388976 1810639 219890387 200943466 18946921 0 7625 7125 2800517 261696 13480 43687 21769319 23791700 195000 129841 0 0 1956785 1981374 1955954 2437451 8034004 24365104 104216243 78997908 27137101 25218335 0 0 0 0 0 0 0 0 33250 33250 63903035 78269563 18918376 26095300 0 0 8409609 0 2000000 2000000 0 0 0 0 0 0 0 0 58771880 93205121 88099865 121300421 X -24196830 -43030858 0 0 0 0 -24196830 -43030858 63903035 78269563 -18834028 X false true true X true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 10314 10314 false PART II-B, LINE 1i Lobbying expenditures paid by the Parent organization for annual membership dues where expenses are allocated to the hospital: American Hospital Association $ 1,118 Catholic Health Association $ 1,566 Hospital Association of So. California $ 7,286 National Association of Home Care and Hospice $ 53 California Hospice and Palliative Care Association $ 16 Safety Net Hospitals for Pharmaceutical Access $ 275 ======= TOTAL EXPENDITURES $10,314 ======= 799341 799341 76579450 61465580 15113870 25878834 17351592 8527242 958618 180736 777882 25218335 0 DUE TO RELATED PARTIES 87052208 PENSION PAYABLE 5223358 DEFERRED COMPENSATION 160628 ASSET RET OBLIG LIABILITY 768927 93205121 true true X true X true X 500. true true false true true 790 4857458 0 4857458 0.02380 43522 131011995 121193640 9818355 0.04800 620 3140809 1176317 1964492 0.00960 44932 139010262 122369957 16640305 0.08140 19 21633 1931431 22348 1909083 0.00930 0 0 0 0 0.00000 0 0 0 0 0.00000 0 0 0 0 0.00000 7 5633 1636968 0 1636968 0.00800 26 27266 3568399 22348 3546051 0.01730 26 72198 142578661 122392305 20186356 0.09870 0 0 0 0 0.00000 0 0 0 0 0.00000 0 0 0 0 0.00000 0 0 0 0 0.00000 0 0 0 0 0.00000 1 3 186359 0 286359 0.00090 0 0 0 0 0.00000 0 0 0 0 0.00000 0 0 0 0 0.00000 1 3 186359 0 286359 0.00090 true 3424765 0 21526506 23745983 -2219477 X true true 1 1 Community Hospital of San Bernardino

1805 Medical Center Dr San Barnardino CA 92411

X X X Community Hospital of San Bernardino 1 true true 200. true 500. true X X X X X X true true X X X X X X true false true X false false 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) is $15,368,332 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 $13.9 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 $30.4 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 $1.3 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 provides financial and in-kind support for community building activities. The following addresses the coalition building activity. Coalition Building: CHSB recognizes the community need for affordable office/work space for non-profit organization who share a mission the advance sustainable action plans that address solutions for documented community needs in the areas of health, environment and social welfare. With the objective of partnering with non-profit organizations to advance these needs, CHSB provides free office space for these agencies to operate. Schedule H, Part III, Line 4 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 at or below 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. The expected patient payment amount on the patient's bill reflects this discount. 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 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. CHSB also utilizes a Payment Assistance Rank Ordering (PARO) scoring system to assist in determining if a patient may qualify for financial 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 financial assistance. In its development, special attention was paid to those socio-economic 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 are 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 financial assistance policy. The following is an excerpt from Dignity Health and its subordinate corporations' consolidated annual audited financial statements for the year ended June 30, 2012, 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 $519.9 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. The hospitals provide 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 $2.2 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 V, Section B, Line 13g 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 facilitys financial assistance program and the availability of government sponsored programs; 3. All initial statements to uninsured patients includes verbiage informing patients of the facilitys 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 facilitys financial assistance program, access to the application, and contact information is available on the facilitys webpage. Schedule H, Part V, Section B, Line 19d 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. 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 2008 a Community Needs Assessment (CNA) 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, eight focus groups were conducted with residents of communities in the CHSB primary service area. Five of the groups were conducted in English and three 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 CNA 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. Payment 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. It is Dignity Health's policy that at the time of patient billing, CHSB provides to all uninsured patients the same billing information concerning services and charges provided to all other patients who receive care at CHSB. 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 thirteen (13) zip codes concentrated in the following cities: Bloomington, Colton, Fontana, Highland, Rialto and San Bernardino. The Inland Empire has been severely impacted by the recession. Within the service area, unemployment had risen to 16.2% in 2010. The data indicate that within the CHSB Service Area, poverty increased markedly for the population at or below 200% of the Federal Poverty Level. Many of the neighborhoods served by CHSB have close to half of the residents living at or below 200% of the Federal Poverty Level. In San Bernardino 92410, over two-thirds of the population is at this level of poverty (67.7%), followed closely by San Bernardino 92411 (63.3%) and San Bernardino 92408 (61.1%). In San Bernardino 92401, 83% of individuals live at or below the 200% poverty level. Contributing to the dismal earning potential of its residents, the community has a low education rate. Of the population age 25 and over, 32.1% have less than a high school diploma, more than double the state rate of 14.9%. Furthermore, for 26.9% of area adults, high school graduation was their highest level of educational attainment. Only 12.7% of the population holds a Bachelor's Degree or greater. Confirming the difficult economics of the region, in July 2012 the City of San Bernardino filed for Chapter 9 bankruptcy protection. This action will exacerbate the ability of non-profits to aid the most vulnerable in our community. The following reflects demographics for the primary service area: " Population: 660,751 " Diversity: Hispanic (66.4%), Caucasian (16.5%), African American (10.5%), Asian & Pacific Islander (4.6%), all others (2.1%) " Average Income: $57,112 " Uninsured: 27.27% " Unemployment: 8.3% " No High School Diploma: 32.1% " Renters: 36% " CNI Score: 4.8 " MediCal Patients: 25.41% " Other Area Hospitals: 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). Portions of the following zip codes served by the hospital fall in a MUA: 92401, 92404, 92405, 92335 and 92336. When reviewing Community Grant proposals, special attention is paid to organizations serving these areas. 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, 2012, is as follows: Persons Net Comm % of Served Benefit Exp excl Bad Debt Benefits for the Poor: Traditional Charity Care 108,530 188,380,000 2.0% Unpaid Costs of Medicaid/Medi-Cal 1,060,508 571,491,000 6.0% Other Means-tested Programs 280,517 66,067,000 0.7% Community Services: Community Health Services 525,831 53,467,000 0.6% Health Professions Education 86 27,000 0.0% Subsidized Health Services 193,751 28,297,000 0.3% Donations 155,219 33,140,000 0.3% Community Building Activities 12,811 1,623,000 0.0% Community Benefit Operations 3,884 8,911,000 0.1% Total Community Services for the poor 891,582 125,465,000 1.3% Total Benefits for the Poor 2,341,137 951,403,000 10.0% Benefits for the Broader Community: Community Services: Community Health Services 585,949 17,034,000 0.2% Health Professions Education 68,974 69,132,000 0.7% Subsidized Health Services 9,430 2,210,000 0.0% Research 26,281 30,049,000 0.3% Donations 165,149 7,584,000 0.1% Community Building Activities 38,641 3,138,000 0.0% Community Benefit Operations 87 1,446,000 0.0% Total Benefits for the Broader Community 894,511 130,593,000 1.3% Total Community Benefits 3,235,648 1,081,996,000 11.3% Unpaid Costs of Medicare 1,116,214 519,981,000 5.4% Total Community Benefits including Cost of Medicare 4,351,862 1,601,977,000 16.7% STATE FILING OF COMMUNITY BENEFIT REPORT 990 SCHEDULE H, PART VI CA, true California Health Foundation and Trust 1215 K Street Ste 800 Sacramento CA 95814 941498697 501(c)(3) 1278110 0 N/A N/A Service for the Poor healthcare Catholic Charities 1450 N D Street San Bernardino CA 92405 953516461 501(c)(3) 25489 0 N/A N/A Religious Community 2 0 Provision of food 4262 49489 cost food/meal Part I, Line 2 The hospital is a 501(c)(3) organization that uses a software package to document grant funding, to monitor and report program outcomes and to formulate criteria for grant selections. true true false false false false false false false Steven Barron 0 396189 0 226846 0 18518 0 36512 0 37505 0 715570 0 0 Dr Alvaro Bolivar 213556 0 0 0 0 0 0 0 0 0 213556 0 0 0 Bruce Ermann MD 0 235518 0 14539 0 2744 0 14509 0 11913 0 279223 0 0 Marvin O'Quinn 0 869909 0 1817959 0 303839 0 390406 0 50747 0 3432860 0 0 Elizabeth Shih 0 623398 0 788373 0 291539 0 104121 0 49964 0 1857395 0 253744 Susan Whitten 0 260577 0 160603 0 11834 0 32162 0 33272 0 498448 0 0 Jack Ivie 272167 0 50271 0 8954 0 18676 0 2752 0 352820 0 0 0 Diane Nitta 202496 0 213905 0 366349 0 32566 0 6242 0 821558 0 0 0 Edward Sorenson 168162 0 0 0 269329 0 19437 0 8996 0 465924 0 0 0 Darryl VandenBosch 0 263242 0 48524 0 12039 0 25465 0 17275 0 366545 0 0 Geraldine C Fike 184454 0 33699 0 7851 0 12435 0 12328 0 250767 0 0 0 Kimiko Ford 188369 0 36256 0 1693 0 20465 0 17430 0 264213 0 0 0 Stan Rucker 0 216187 0 40384 0 13238 0 14886 0 12358 0 297053 0 0 David J Evans 173277 0 12997 0 7995 0 18347 0 17222 0 229838 0 0 0 LAWRENCE LAWLER 179905 0 33556 0 345 0 20596 0 17238 0 251640 0 0 0 Marc Marchetti 179865 0 33842 0 4358 0 18025 0 17167 0 253257 0 0 0 Rosilyn Nolan 162829 0 12393 0 8510 0 14679 0 17198 0 215609 0 0 0 Marie R Orpilla 229180 0 1326 0 2477 0 16893 0 17111 0 266987 0 0 0 Sch J-1 Alvaro Bolivar's compensation is for Chief of Staff Services provided to the organization. Dr. Bharti Jain's and Dr. Paul Ryan's compensation is for medical Services provided to the organization. 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 The organization's certain officers, key employees and its highest compensated employees 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. Payments pursuant to the plan arrangement for two officers occurred during 2011; D Nitta, $322,193 and E. Sorenson, $187,808. Schedule J, PART I, LINE 4b Certain listed persons are eligible to participate in one of two 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 under this formula 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 2011. 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 2011 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 2011. Certain officers and key employees participate in the Dignity Health Supplemental Executive Retention/Retirement Plan, a nonqualified supplemental benefit plan which in 2002 was offered to members of the executive management team by the Dignity Health Board of Directors and would be paid only if the executives stayed with the organization for a specified number of years as the primary purpose of this plan is to provide for the retention and retirement of the participants. The executive management team was recruited from stable careers in organizations from across the country and from various industries to engineer and lead a financial and operational turnaround after the organization had lost nearly $1 billion in net operating performance. The calculation for the payments to each executive is based on the value of a final average pay annuity benefit based on retirement age and service years to the organization. Distribution occurs each July 1 if the plan formula warrants a payment. Vested amounts are reported as deferred compensation in the year vesting occurs (column C) and are reflected again as reportable compensation in the year paid (column B(iii)). Payments made during 2011 pursuant to this plan include $253,744 to E. Shih. 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 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 the compensation and benefits 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. CALIFORNIA HEALTH FACILITIES FINANCING AUTHORITY 521598225 13033FTN0 2004-05-19 150000000 NEW MONEY TO FUND VARIOUS PROJECTS false false true 0 0 2004025 0 0 0 0 0 0 2004025 0 0 2005 false false true true false true true true true true 0.00000 0.00000 0.00000 true false true false 0 false 0 true false X BOND A, CUSIP 13033FTN0 0 THE DIFFERENCE BETWEEN THE ISSUE PRICE IN PART 1(E) AND PART II LINE 3 IS DUE TO INVESTMENT EARNINGS. COMMUNITY HOSPITAL OF SAN BERNARDINO (CHSB) AS A SEPARATE ENTITY RECEIVED $2 MILLION OF THE $150 MILLION CHFFA 2004JK POOL BONDS. PART III, LINE 3A ALTHOUGH THERE ARE MANAGEMENT OR SERVICE CONTRACTS THAT MAY GENERATE PRIVATE USE, CHSB HAS POLICIES AND PROCEDURES IN PLACE THAT REQUIRE SUCH CONTRACT BE IN COMPLIANCE WITH REVENUE PROCEDURE 97-13. PART III, LINE 3B ALTHOUGH THERE ARE RESEARCH AGREEMENTS WHICH MAY RESULT IN PRIVATE USE, CHSB HAS POLICIES AND PROCEDURES IN PLACE THAT REQUIRE SUCH CONTRACT BE IN COMPLIANCE WITH REVENUE PROCEDURE 2007-47. PART IV LINE 1 ARBITRAGE CALCULATIONS WERE PERFORMED BY ARBITRAGE CONSULTANT AND THERE WAS NO REBATABLE ARBITRAGE LIABILITY SO NO FORM 8038-T FILED. Alvara Bolivar MD physician loan X 195000 129841 false true true 129841 BHARTI JAIN MD INC BM, B JAIN IS SOLE OWNER 246000 MEDICAL SERVICES false FORM 990, PART VI through PART XII 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 11a The organization's CFO 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. The Organization's Board is charged with monitoring proposed or ongoing transactions for conflicts of interest and addressing any potential or actual conflicts. Pursuant to these policies, an annual conflict of interest disclosure statement, aimed at determining any family and business relationships and transactions, or other transactions that may pose a potential conflict, is distributed to all covered persons (e.g., board members, officers and executive leadership, key employees and all management personnel whose responsibilities include business decisions which may give rise to conflicts of interest). Covered persons are also required to disclose real or potential conflicts at the time such conflicts arise. When an individual becomes a covered person and annually thereafter, each covered person is required to submit an updated disclosure statement and to sign a statement affirming that he/she: (1) has received a copy of the policy applicable to their 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 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 must be approved by a majority of disinterested persons, based on certain criteria; 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. FORM 990, PART VI, SECTION B, LINE 15A Although the organization employs personnel, the President's compensation is set by a related organization, Dignity Health. For 2011, 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 2011 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 and financial statements be made available for public inspection. The organization makes its financial statements available on its website and upon request. 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. HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Steven Barron TITLE:Director HOURS:40 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Bruce Ermann MD TITLE:Director HOURS:40 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Dr Bharti Jain TITLE:Director/Secretary Nov-Dec2011 HOURS:28 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Marvin O'Quinn TITLE:Director HOURS:40 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Elizabeth Shih TITLE:Director HOURS:40 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Susan Whitten TITLE:Director HOURS:40 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Darryl VandenBosch TITLE:VP/CFO HOURS:20 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 false true false false false false false false false false true false false false false true false COMMUNITY HOSP OF SAN BERNARDINO FOUNDATION c 744000 SEE Part VI Schedule R, Part V, line 2 column (c) Line 1c 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.