2013-08-15T12:10:36-05:00 2012-12-31 911194016 Clark Nuber PS 10900 NE 4th Suite 1700 Bellevue WA 98004 990 2012-01-01 931003750 PROVIDENCE WILLAMETTE FALLS MEDICAL FOUNDATION PROV 5038936460 1500 DIVISION STREET OREGON CITY OR 97045 Tiffany Gillespie 5038936460 2013-08-15 1 Sara Elizabeth J Hyre CPA P00235495 4254544919 2012 2016-02-24 21:20:13Z Tiffany Gillespie 1500 DIVISION STREET OREGON CITY OR 97045 702377 0 X www.providencefoundations.org/foundations/pages/ X 1989 OR Support Programs & Activities of Providence Willamette Falls Medical Center. 13 13 0 67 0 0 816268 297684 0 0 -14479 254518 -8680 29846 793109 582048 351702 221784 0 0 340276 98038 2000 0 95147 97143 89424 791121 409246 1988 172802 8234552 9004147 3424 5562 8231128 8998585 X As People of Providence, we reveal God's love for all, especially the poor and vulnerable, through our compassionate service.Support programs of Providence Willamette Falls Medical Center. 0 0 72384 72384 0 Payments to, or on behalf of, Providence Willamette Falls Medical Center to provide for hospital related programs such as charity care support, equipment purchases such as wheel chairs, play equipment in physical therapy, patient room white message boards, birthplace medical cart, hospice staff development and training of volunteers, Founders' Art Gallery display and scholarships for parent child programs. 125000 125000 0 Funding to Clackamas Volunteers in Medicine for the Founders Clinic, a clinic providing health care for low-income uninsured patients. 20000 20000 0 Donation to Childrens Center of Clackamas County, a center to support and medically assess children who are victims of abuse or neglect. 3500 3500 0 Donation to Clackamas County Art Alliance to provide for the selection and display of art pieces in our Founders Gallery. This display is managed by the Clackamas County Arts Alliance and provides local artists and our patients and staff with high quality art for viewing and reflection. 900 900 0 Donation to Oregon Cancer Ski-Out, a fundraiser in the fight against cancer. 4400 4400 221784 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 X 2 0 1 0 0 0 0 0 0 1 1 0 0 0 0 X 13 13 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 OR X Steve Cassell 5032154773 1235 NE 47th ST 260 Portland OR 97213 X Pam Bloom 3.00 0.00 X X 0 0 0 The Honorable Ron Thom 1.00 0.00 X X 0 0 0 Rob Hoover 1.00 0.00 X X 0 0 0 Dan Fowler 1.00 0.00 X X 0 0 0 Norma Barney 1.00 0.00 X 0 0 0 The Honorable Robert Herndon 1.00 0.00 X 0 0 0 Sherrie Henson 1.00 0.00 X 0 0 0 Charles Hickman MD 1.00 0.00 X 0 0 0 Kevin Krueger 0.20 0.00 X 0 0 0 David Lindquist MD 1.00 0.00 X 0 0 0 Greg Rogers 0.50 0.00 X 0 0 0 Denis Ryan 1.00 0.00 X 0 0 0 Jeff Sumpter 1.00 0.00 X 0 0 0 Alex Crooks Res 712 0.20 0.00 X 0 0 0 Rich Cook 0.20 0.00 X 0 0 0 Bob McEahern MD Res 712 0.20 0.00 X 0 0 0 Ray Smucker MD Res 712 0.20 0.00 X 0 235195 29624 P Michael Drake Thru 212 40.00 0.00 X 0 84172 4388 Marilyn Speirn 10.00 40.00 X 0 163361 25918 0 482728 59930 0 0 1 0 0 60998 123356 113330 297684 254518 254518 12555 60998 23264 -10709 -10709 2800 0 2800 2800 134820 97065 37755 37755 582048 0 0 284364 221784 221784 72855 21856 50999 25183 7555 17628 56689 56689 976 293 683 12016 12016 9395 2123 7272 150 45 105 4712 1414 3298 Dues & Subscriptions 4170 1251 2919 Oregon Form CT-12 993 993 323 96 227 409246 221784 92315 95147 748424 754696 53617 31755 19145 6376 3165 17943 12574 7375978 8214371 459 196 8234552 9004147 3424 5208 0 354 3424 5562 X 4381327 4809763 1701870 1969254 2147931 2219568 8231128 8998585 8234552 9004147 X 172802 594654 1 X X 0 1 X 1 0 X X X 0 0 0 PH&S - OR dba Providence Willamette Falls Medical Center 930426018 3 1 1 1 72384 1 72384 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 6850804 71637 480845 60183 7343103 6870936 48253 -48640 19745 6850804 3032082 3394728 444126 6870936 2658917 1479 371686 3032082 3122185 28276 60595 552139 2658917 0.60000 0.30000 0.10000 0 0 0 Due To Affiliates 354 354 X Description of Intended Use of Endowment Funds: Part V, Line 4: The intended use of the endowments are to provide for program enhancements, facility improvements, equipment upgrades and/or other advancement support to the Medical Center's operations. Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: Accounting principles generally accepted in the United States of America require the Foundations' management to evaluate tax positions taken by the Foundations and recognize a tax liability (or asset) if the Foundation 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 Foundations and has concluded that as of December 31, 2012, there are no uncertain positions taken or expected to be taken that would require recognition of a liability (or asset) or disclosure in the combined financial statements. Gala 53703 46348 7355 3500 3016 200 1786 Golf Tournament 19850 14650 5200 13790 972 73553 60998 12555 17290 3016 200 2758 23264 -10709 1 Clackamas Volunteers in Medicine 700 Molalla St Oregon City OR 97045 371621141 501(C)(3) 125000 Community Health Needs PH&S - OR dba Providence Willamette Falls Medical Center 1500 Division St Oregon City OR 97045 930426018 501(C)(3) 72384 Funding for operations and capital Children's Center of Clackamas County 1713 Penn Lane Oregon City OR 97045 753027143 501(C)(3) 20000 Community Child Welfare 3 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: Since Foundation distributions are made to an affiliated company, Willamette Falls Hospital, the Foundation has access to the Hospital's financial records and reviews them for appropriate use of the funds. The appropriation of funds to Clackamas Volunteers in Medicine was used for the establishment of the Founders Clinic in Oregon City, Oregon. Services are provided to low-income uninsured in Clackamas County by volunteer medical professionals free of charge to those who qualify. Status reports are provided by a physician who sits on the Foundation Board as well as the Clinic Board. Reports are provided to the Board on a quarterly basis. The Foundation receives an Annual Report from the Children's Center. 1 0 0 0 0 0 0 0 0 Ray Smucker MD Res 712 0 227070 0 8125 0 0 0 9822 0 19802 0 264819 0 0 Marilyn Speirn 0 158682 0 4679 0 0 0 12726 0 13192 0 189279 0 0 Part I, Line 4a SEVERANCE 1) P. Michael Drake - $37,377 Part I, Line 8 FORM 990, SCHEDULE J, PART II - EXECUTIVE PERFORMANCE AWARDS PROGRAM The Providence Executive Performance Awards Program provides a lump sum award annually as a percent of the executive's base pay. Percent opportunities are aligned with our total compensation philosophy as outlined in Part VI, Section B, Line 15 (Process for determining compensation of top management, officers & key employees). The performance award is based on the level of accomplishment of annual system objectives and personal objectives. In 2012, 50 percent of the participant awards were based on pre-determined organizational goals consistent with Providence's five strategic priorities of: mission driven, financially responsible, people centered, service oriented and quality focused. In 2012 the percent allocation for each of these strategic priorities was: Mission driven 10% Financially responsible 10% People centered 10% Service oriented 10% Quality focused 10%. To ensure affordability of the program, the organization (system, region or entity) must meet a threshold of 50 percent of budgeted net operating income. Supplemental Information Part III COMPENSATION Dr. Smucker was compensated for his medical services provided at Molalla Medical Clinic, a Physician Family Practice of Providence Medical Group. Marilyn Speirn was compensated for her Interim Director responsibilities by the Oregon Regional Shared Services. None of her compensation was allocated to the Foundation. Form 990, Part VI, Section A, line 6 The Corporate Member of the Foundation is Providence Health & Services - Oregon, a not-for-profit corporation. Form 990, Part VI, Section A, line 7a The Corporate Member has the power to approve the number of Directors, appoint the Board of Directors of the Foundation and remove such Directors at any time with or without cause. Form 990, Part VI, Section A, line 7b The following powers are reserved exclusively to the Corporate Member: * Adopt and amend the Articles of Incorporation and the Bylaws of the Foundation after consultation with the Foundation's Board of Directors. * Approve the merger, consolidation, or affiliation of the Foundation with another corporation, organization or program, or the dissolution of the Foundation. * Approve any strategic plan of the Foundation. * Approve the annual fundraising plan including special events, annual, capital and planned giving activities. * Approve the acceptance of any gift that carries conditions or limitations or any gift restricted to services, programs or facilities not currently offered or approved to be offered by the Corporate Member's Board. * Develop and implement investment policies and/or guidelines that will be used by the Foundation in determining appropriate investments. Form 990, Part VI, Section B, line 11 The Form 990 is prepared internally by experienced staff and reviewed by external tax advisors. The Foundation Director will review the Form 990 in detail. Once approved, an electronic copy of the Form 990 is emailed to the Board prior to filing with the IRS. Form 990, Part VI, Section B, line 12c Providence Health & Services maintains a conflict of interest policy that applies to board members and management of all Providence-related organizations. The purpose of the policy is to guide and direct those serving the Providence Health & Services corporations and other legal entities so they can (1) fulfill their fiduciary responsibilities and exercise stewardship in ways that promote and protect the best interests of Providence and, (2) avoid situations that create a conflict, or the appearance of a conflict, between the interests of an individual associated with Providence and Providence. On an annual basis, each board member and management level employee must complete and submit an updated conflict of interest statement. Conflict of interest disclosures are reviewed by the System Integrity Department working in conjunction with the Department of Legal Affairs. If it is determined that an actual conflict exists, appropriate follow-up action is taken with the individual to rectify the conflict. Form 990, Part VI, Section B, line 15 It is Providence's intention to make financial information accessible and transparent. Although the filing of Form 990 provides insight into how Providence achieves its Mission, delivers its programs and stewards its finances, deciphering the information directly from Form 990 can be challenging. The following paragraphs provide further information about the process we use to determine compensation for top management, officers and key employees. Providence has a single fiduciary Board, with responsibility for financial oversight associated with fulfillment of the Providence Mission, developing system policies, protecting the assets entrusted to the organization and overseeing the strategic and operational affairs of Providence's legal entities. Providence also maintains a network of community ministry boards with responsibility for quality of care oversight, community relations, advocacy and community needs assessments. Providence has a consistent compensation philosophy for all of its employees, including our senior executives. Salaries for senior executives are determined by the Providence Board's Human Resources Committee and approved by the full Board of Directors, none of whom is a Providence employee. The Board retains an independent consultant each year to review salaries of those in the most significant leadership roles in the organization. Part of the consultant's role is to review an extensive array of compensation surveys of large, not-for-profit health care systems in the United States. Providence is one of the larger health systems in the country, and as such, the Board benchmarks executive compensation against other large, not-for-profit health systems whose revenue is similar to that of Providence. Base salaries for Providence executives are set at the median level of the market, as identified by the independent consultant and reviewed with the Human Resources Committee. Performance incentives allow executives to earn additional compensation if they achieve specific organizational and individual goals for furthering Providence operating principles - advancing the Providence Mission and core values, meeting benchmarks for charity care, achieving quality targets, delivering top-rated customer satisfaction, meeting employee satisfaction goals and reaching financial performance objectives. The Board of Directors conducts a thorough process to ensure performance incentives are aligned with appropriate practices for not-for-profit health care systems. The Board's process for executive compensation fully complies with IRS standards and mirrors the best practices recommended in the "Report to Congress and the Nonprofit Sector on Governance, Transparency, and Accountability" submitted to the Senate Finance Committee by the Panel on the Nonprofit Sector. The Foundation Executive Director is compensated by a related organization which uses a market based compensation program utilizing several independent third party compensation market surveys to establish pay ranges for the position. The related organization then establishes the individual rate of pay within the range based on relevant experience, skills and competencies. The rate offered to the Executive Director at the time of hire was determined through discussion between the Regional CEO, Regional Director of HR and the Administrative Director of HR. The ranges and rate of pay are reviewed on an annual basis by Regional HR. Form 990, Part VI, Section C, line 19 Public disclosure of governing documents, conflict of interest policy and 990 filings are made available to the public upon written request. The Health System consolidated financial statements are available on our public Internet site www2.providence.org. All governing policies including the conflict of interest policy, as well as 990 filings are available to employees on the Intranet site. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Rounding 1. EMPLOYEE COMPENSATION FORM 990, PART I, LINE 5 & PART V, LINE 2A The employees working at the Foundation are paid by Providence Health & Services - Oregon EIN# 51-0216587. Therefore, no W-2s are issued by the reporting organization. Marilyn Speirn, Interim Foundation Director, was compensated primarily for her duties in the role of Regional Director of the Oregon Foundations. VOLUNTEERS Form 990, Part I, Line 6 In addition to our Board, Foundation volunteers serve on a variety of committees, event committees and task forces that focus on securing new gifts, renewing gifts and managing the financial assets of the Foundation. This includes a just concluded 3 year initiative to fund a new Free Clinic for the uninsured in our community. The new Free Clinic is now open and serving patients. In addition, the Foundation funded various smaller projects that provided program or equipment support to the hospital. AUDIT & COMPLIANCE Form 990, Part XII, Line 2c The Providence Health & Services Audit and Compliance Committee assists the Board of Directors with the oversight of the integrity of the financial statements and reporting, the audit process and the internal financial controls and policies; compliance with ethical, legal and regulatory standards and requirements; the independence, qualifications and performance of the internal and external auditors; investment committee; and informs the Board of Directors of critical risk areas and recommended mitigation. AFFILIATION AGREEMENT FORM 990, SCHEDULE R - RELATED ORGANIZATIONS On February 1, 2012, Providence Health & Services (the Health System) and Swedish Health Services (Swedish) effected an affiliation Agreement, which integrated the operations of the two health systems. The Health System and Swedish have affiliated to create a fully integrated, nonprofit, charitable health care system serving the communities throughout Western Washington. No cash or other purchase consideration was transferred to effect the affiliation. 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