2012-11-13T16:54:48-06:00 2011-12-31 930623286 AKT LLP 5665 SW MEADOWS RD SUITE 200 LAKE OSWEGO OR 97035 990 2011-01-01 931329784 SAMARITAN PACIFIC HEALTH SERVICES SAMA 5415744824 930 SW ABBEY STREET NEWPORT OR 97365 DANIEL B SMITH 5415744824 2012-11-08 0 JOYLYN ANKENEY P00366587 5036204489 2011 2016-02-24 21:20:13Z SAMARITAN PACIFIC COMMUNITIES HOSP DAVID C BIGELOW 930 SW ABBEY STREET NEWPORT OR 97365 69920805 0 X WWW.SAMHEALTH.ORG X 2001 OR SAMARITAN PACIFIC HEALTH SERVICES (SPHS) ACHIEVES ITS MISSION OF IMPROVING THE HEALTH AND WELL BEING OF THE COMMUNITY THROUGH ITS CRITICAL-ACCESS HOSPITAL AND HEALTHCARE CLINICS PROVIDING OUTPATIENT CARE SERVICES AT SEVERAL AREA LOCATIONS. 6 4 582 99 733446 -185410 1331186 1151890 66461008 62065554 13654 5669863 395883 482673 68201731 69369980 612445 607512 0 0 37125468 37898497 0 0 228461 28222105 25711038 65960018 64217047 2241713 5152933 21111877 26500056 12466681 12701927 8645196 13798129 X SAMARITAN PACIFIC HEALTH SERVICES (SPHS) IS A MEMBER OF SAMARITAN HEALTH SERVICES (SHS), A REGIONAL NETWORK OF HOSPITALS, PHYSICIANS AND SENIOR CARE FACILITIES. THE NETWORK, FORMED IN THE LATE 1990'S, SERVES APPROXIMATELY 290,000 RESIDENTS IN LINN, BENTON, LINCOLN AND PORTIONS OF POLK AND MARION COUNTIES IN OREGON. IT IS LOCALLY OWNED, AND ITS BOARDS OF DIRECTORS INCLUDE HOSPITAL LEADERS, PHYSICIANS AND COMMUNITY REPRESENTATIVES. SPHS PROVIDES HEALTHCARE SERVICES REGARDLESS OF RACE, COLOR, CREED, SEX, NATIONAL ORIGIN, DISABILITY OR AGE. THE MISSION OF SPHS IS TO ENHANCE COMMUNITY HEALTH AND ACHIEVE HIGH VALUE THROUGH QUALITY SERVICES ACROSS A CONTINUUM OF CARE. THE COLLECTIVE VISION OF THE SHS SYSTEM IS TO BE A VALUES-DRIVEN ORGANIZATION GOVERNED BY COMMUNITY MEMBERS, PHYSICIANS AND OTHER HEALTH CARE PROVIDERS. SHS SEEKS TO BE THE FIRST CHOICE OF CONSUMERS IN THE REGION AND TO LEAD COLLABORATIVE EFFORTS AMONG THOSE WHO SHARE SIMILAR GOALS. 0 0 54301919 61039663 PROGRAM SERVICES:SAMARITAN PACIFIC HEALTH SERVICES (SPHS) INCLUDES A CRITICAL-ACCESS HOSPITAL AND SEVERAL MEDICAL CLINICS PROVIDING HEALTH CARE FOR RESIDENTS AND TOURISTS THROUGHOUT A 270-SQUARE-MILE AREA IN LINCOLN COUNTY. SPHS HAS OVER 500 EMPLOYEES AND 90 VOLUNTEERS. DURING 2011, SPHS SERVED 1,438 INPATIENTS, HAD 12,606 EMERGENCY DEPARTMENT VISITS, PERFORMED 2,064 SURGERIES, AND DELIVERED 190 BABIES. IN ADDITION, SPHS PERFORMED 25,878 IMAGING PROCEDURES, HAD 4,856 HOME HEALTH AND 4,622 HOSPICE VISITS, AND HAD 51,538 PHYSICIAN CLINIC VISITS. 526546 526546 350276 SEE SCHEDULE OTHE SENIOR COMPANION PROGRAM IS A PROGRAM SPONSORED, IN PART, BY SAMARITAN PACIFIC HEALTH SERVICES. THE PURPOSE OF THE PROGRAM IS TO IMPROVE THE LIVES OF FRAIL ELDERLY AND YOUNGER DISABLED NEIGHBORS ALLOWING THEM TO STAY IN THEIR OWN FAMILIAR SURROUNDINGS FOR AS LONG AS SAFELY POSSIBLE. A SENIOR COMPANION PROVIDES COMPANIONSHIP AND TRANSPORTATION TO APPOINTMENTS, SOCIAL EVENTS, OR PERSONAL ERRANDS. THE SENIOR COMPANION PROGRAM SERVED 215 PEOPLE IN 2011.THE FOSTER GRANDPARENT PROGRAM USES SENIOR VOLUNTEERS AGE 55 AND OLDER TO HELP CHILDREN IN SCHOOLS, CHILD CARE CENTERS AND HEAD START CLASSROOMS. FOSTER GRANDPARENT VOLUNTEERS ENCOURAGE CHILDREN WITH ONE-ON-ONE SUPPORT BY LISTENING TO A CHILD READ, HAVING LUNCH WITH A CHILD OR LISTENING TO A CHILD TALK ABOUT A NEW CONCEPT OR IDEA. THE PROGRAM SERVED 1000 CHILDREN IN 2011. 77285 77285 GRANTS:GRANTS MADE BY SAMARITAN PACIFIC HEALTH SERVICES TO VARIOUS ORGANIZATIONS TO BENEFIT THE COMMUNITY. SEE PART IX, LINE 1, AND RELATED SCHEDULE I FOR GRANTS GREATER THAN $5,000. 54905750 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 1 87 0 1 582 1 1 1 0 0 0 0 0 0 0 0 0 X 6 4 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 OR X X SAMARITAN PACIFIC HEALTH SERVICES 5415744824 930 SW ABBEY STREET NEWPORT OR 97365 X LARRY A MULLINS DHA 6.00 X X 0 685646 697289 DAVID TRIEBES 1.00 X X 0 337203 61343 SUSAN WOODRUFF 1.00 X 0 0 0 STEPHEN BURNS MD 1.00 X 0 0 0 BONNIE SAXTON 1.00 X X 0 0 0 KEITH HARCOURT MD 1.00 X 0 0 0 DAVID C BIGELOW 40.00 X 0 216520 45822 DANIEL B SMITH 6.00 X 0 320608 51431 FRED V SCHNEIDER MD 40.00 X 251379 0 40367 GERALD BUTLER MD 40.00 X 466745 0 31751 RICHARD NORTH MD 40.00 X 330007 0 40831 DAVID A LARSEN MD 40.00 X 323172 0 45950 JERRY FLAMING DO 40.00 X 232974 0 24365 1604277 1559977 1039149 43 0 1 0 WAMPLER LARRY DO 611 SE 3RD STREET NEWPORT OR 97365 MEDICAL SERVICES 1216985 CENTRAL COAST INTERNAL MEDICINE 775 SW 9TH ST STE B NEWPORT OR 97365 HOSPITALIST SERVICES 837287 PETERSON MICHAEL MD PO BOX 1985 NEWPORT OR 97365 MEDICAL SERVICES 322945 COMPHEALTH PO BOX 972651 DALLAS TX 753972651 EMPLOYMENT SERVICES 310069 LEGACY LABORATORY SERVICES LLC PO BOX 5337 PORTLAND OR 97228 LAB SERVICES 184277 12 1106992 44898 1151890 NET PATIENT SVC REV 900099 57448450 57444143 4307 DURABLE MEDICAL EQP 446199 4617104 3887965 729139 62065554 23670 23670 165377 45254 120123 120123 120123 5802835 156642 5646193 5646193 5646193 487553 348929 138624 138624 CAFETERIA 722210 166095 166095 DISTRICT ADMIN SVCS 900099 31500 31500 RELEASE OF INFORMATION 561000 26331 26331 223926 69369980 61389939 733446 6094705 77285 77285 530227 530227 28520078 26573725 1819219 127134 1445235 1346605 92188 6442 5286068 4925320 337184 23564 2647116 2466464 168852 11800 137291 137291 6500 6500 5189623 5185274 4349 13148 688 12460 2073422 1913610 138354 21458 1265696 1265696 1229848 1108179 111662 10007 131167 121809 6454 2904 108717 90099 18618 31466 31466 1170646 1143688 25928 1030 915212 825520 89692 MEDICAL SUPPLIES 7934434 7934434 PURCHASED SERVICES 5405360 608826 4780080 16454 DUES, TAXES, & LICENSES 98508 53997 43343 1168 64217047 54905750 9082836 228461 161284 297295 3186080 899792 8441909 7121729 92949 62047 68400 2514403 2216255 183841 155825 10089610 5965411 5069684 4124199 388889 370370 1103740 11153242 21111877 26500056 4954251 5263588 12975 26125 942531 622834 6556924 6789380 12466681 12701927 X 8645196 13798129 8645196 13798129 21111877 26500056 5152933 0 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1347002 375541 971461 8657436 5589870 3067566 85172 85172 4124199 OTHER RECEIVABLES/ASSETS 732038 ACCOUNTS RECEIVABLE - AFFILIATES 10421204 11153242 CONTRACTUAL REIMB OBLIGATIONS 1164731 PROFESSIONAL LIABILITY RESERVES 288000 WORKING CAPITAL RESERVES 4879683 OTHER RESERVES 456966 6789380 69369980 64217047 5152933 5152933 69761517 391537 391537 69369980 0 69369980 64608584 391537 391537 64217047 0 64217047 PART XII, LINE 2D - OTHER ADJUSTMENTS: EXPENSES NETTED WITH REV PER T/R 391,537. PART XIII, LINE 2D - OTHER ADJUSTMENTS: EXPENSES NETTED WITH REV PER T/R 391,537. 1 1 X 1 X 1 X 1 1 0 1 1 14 3810 2053387 2053387 0.03200 6 27880 8965975 9086824 -120849 0.00000 20 31690 11019362 9086824 1932538 0.03200 14 3321 375729 216334 159395 0.00250 4 98 252891 252891 0.00390 17 64664 16463826 11273659 5190167 0.08080 9 899 108143 108143 0.00170 44 68982 17200589 11489993 5710596 0.08890 64 100672 28219951 20576817 7643134 0.12090 3 1450 251957 133942 118015 0.00180 1 52 22583 22583 0.00040 4 1502 274540 133942 140598 0.00220 0 2441961 48636 16905775 16741410 164365 X 1 1 1 1 SAMARITAN PACIFIC HEALTH SERVICES

930 SW ABBEY STREET NEWPORT OR 97365

X X X X SAMARITAN PACIFIC HEALTH SERVICES 1 1 1 150.000000000000 1 200.000000000000 1 X X X X X X 1 1 X X X 1 0 1 X 0 0 10 SAMARITAN WALDPORT CLINIC

150 SW ARROW ST WALDPORT OR 97394

MEDICAL CLINIC - OUTPATIENT SAMARITAN PACIFIC WOMENS HEALTH GROUP

775 SW 9TH ST STE H NEWPORT OR 97365

MEDICAL CLINIC - OUTPATIENT SAMARITAN DEPOE BAY CLINIC

531 NW HWY 101 STE A DEPOE BAY OR 97341

MEDICAL CLINIC - OUTPATIENT SAMARITAN PACIFIC SURGICAL ASSOCIATES

929 SW BAY ST NEWPORT OR 97365

MEDICAL CLINIC - OUTPATIENT SAMARITAN TOLEDO CLINIC

199 NW BUSINESS HWY 20 TOLEDO OR 97391

MEDICAL CLINIC - OUTPATIENT SAMARITAN PACIFIC INTERNAL MEDICINE

1010 SW COAST HWY STE 201 NEWPORT OR 97365

MEDICAL CLINIC - OUTPATIENT SAMARITAN ORTHOPEDIC SURGEONS

1010 SW COAST HWY STE 101 NEWPORT OR 97365

MEDICAL CLINIC - OUTPATIENT SAMARITAN PACIFIC ENT & ALLERGY

904 SW BAY ST NEWPORT OR 97365

MEDICAL CLINIC - OUTPATIENT SAMARITAN OCCUPATIONAL MED - NEWPORT

775 SW 9TH ST STE E NEWPORT OR 97365

MEDICAL CLINIC - OUTPATIENT SAMARITAN PACIFIC WALK-IN CLINIC

775 SW 9TH ST STE F NEWPORT OR 97365

MEDICAL CLINIC - OUTPATIENT PART I, LINE 6A: THE FILING ORGANIZATION SUBMITS AN ANNUAL COMMUNITY BENEFIT REPORT TO THE STATE OF OREGON. IN ADDITION, THE PARENT ORGANIZATION, SAMARITAN HEALTH SERVICES (SHS) PROVIDES AN ANNUAL REPORT TO THE COMMUNITY THAT INCLUDES COMMUNITY BENEFIT REPORTING FOR THE SYSTEM AS A WHOLE. PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS REPORTED IN SCHEDULE H, PART I, LINE 7A AND 7B IS A COST-TO-CHARGE RATIO DERIVED USING WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES FROM THE SCHEDULE H INSTRUCTIONS. FOR LINE 7G, A COMBINATION OF THE COST-TO-CHARGE RATIO AND COST ACCOUNTING SYSTEM CALCULATIONS IS USED SINCE NOT ALL SERVICES ARE TRACKED IN THE COST ACCOUNTING SYSTEM. PART I, LINE 7G: PHYSICIAN CLINICS MEETING THE DEFINITION OF SUBSIDIZED HEALTH SERVICES WERE INCLUDED IN THE REPORTING FOR LINE 7G. THE PORTION OF NET COMMUNITY BENEFIT EXPENSE RELATED TO THESE CLINICS IS $2,068,579. PART II: SPHS PROVIDES SERVICES AND ACTIVITIES THAT ARE CLASSIFIED AS COMMUNITY BUILDING. SPHS LEADS DISASTER PREPAREDNESS DRILLS WITH LOCAL AGENCIES AND STAFF PARTICIPATION IN SUPPORT SERVICES FOR HOMELESS FAMILIES IN THE COMMUNITY. SPHS STAFF SERVE ON MANY LOCAL COALITIONS AND BOARDS THAT PROMOTE THE HEALTH OF THE COMMUNITY. THE NURSING STAFF SPENDS MANY HOURS SPEAKING TO LOCAL FAITH GROUPS AND RECRUITING PARISH NURSES. PART III, LINE 4: THE COSTING METHODOLOGY USED TO CALCULATE BAD DEBT EXPENSE (AT COST) ON LINE 2 OF PART III IS BASED ON THE FACILITY COST-TO-CHARGE RATIO, IN CONJUNCTION WITH WORKSHEET A FROM THE SCHEDULE H, PART III INSTRUCTIONS.LINE 3 REPRESENTS AN ESTIMATE OF THE AMOUNT OF COST INCLUDED IN LINE 2 (BAD DEBT EXPENSE AT COST) THAT REASONABLY COULD BE ATTRIBUTABLE TO PATIENTS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE ORGANIZATION'S CHARITY CARE POLICY, BUT FOR WHOM THE ORGANIZATION WAS NOT ABLE TO OBTAIN SUFFICIENT INFORMATION TO MAKE A DETERMINATION. THE METHODOLOGY USED TO ESTIMATE THIS POTENTIAL CHARITY CARE COST IS BASED ON FINANCIAL ASSISTANCE APPLICATIONS DENIED DUE TO INCOMPLETE DOCUMENTATION, MULTIPLIED BY THE AVERAGE CHARITY CARE WRITE-OFF FOR APPROVED APPLICATIONS.SAMARITAN PACIFIC HEALTH SERVICES (SPHS) IS ONE OF FIVE HOSPITALS OF SAMARITAN HEALTH SERVICES (SHS). AS A NETWORK, SHS PREPARES ITS FINANCIAL STATEMENTS ON A CONSOLIDATED BASIS. FOOTNOTE 1(O) FROM THE AUDITED CONSOLIDATED FINANCIAL STATEMENTS ENTITLED "PROVISION FOR BAD DEBTS AND ALLOWANCE FOR DOUBTFUL ACCOUNTS" DESCRIBES BAD DEBT EXPENSE AS FOLLOWS: "ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, SHS ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDE PATIENTS WITHOUT INSURANCE), SHS RECORDS A PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. FOR THIRD-PARTY RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, SHS ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, WHICH PRIMARILY RELATES TO SELF-PAY PATIENT BALANCES THAT WILL REMAIN AFTER PAYMENTS FROM THE THIRD-PARTY PAYOR HAVE BEEN COLLECTED. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS." PART III, LINE 8: TOTAL MEDICARE ALLOWABLE COSTS REPORTED ON PART III, SECTION B, LINE 6 IS CALCULATED BY UTILIZING WORKSHEET B IN THE SCHEDULE H INSTRUCTIONS IN CONJUNCTION WITH AMOUNTS TAKEN DIRECTLY FROM THE FILING ORGANIZATION'S MEDICARE COST REPORT. THE COST REPORT INCLUDES ACTIVITY FOR MEDICARE FEE-FOR-SERVICE PATIENTS BUT NOT MEDICARE MANAGED CARE PATIENTS. PART III, LINE 9B: PER HOSPITAL GUIDELINES, IF A PATIENT IS DETERMINED TO QUALIFY FOR FINANCIAL ASSISTANCE PRIOR TO SENDING AN ACCOUNT TO COLLECTIONS, THE CHARITY WRITE-OFF IS PROCESSED AND NO COLLECTION ATTEMPT IS MADE. IF AN ACCOUNT IS ALREADY IN COLLECTIONS AND MEDICAID ELIGIBILITY IS DEEMED ACTIVE DURING THE ACCOUNT DATE OF SERVICE, NO FURTHER COLLECTION ATTEMPT WILL BE MADE. SAMARITAN PACIFIC HEALTH SERVICES PART V, SECTION B, LINE 19D: THE MAXIMUM AMOUNT CHARGED BY THE HOSPITAL FACILITY TO FAP-ELIGIBLE INDIVIDUALS IS SET TO BE LESS THAN THE AVERAGE OF ALL NEGOTIATED COMMERCIAL INSURANCE RATES. PART VI, LINE 2: SAMARITAN PACIFIC HEALTH SERVICES (SPHS) ACTIVELY PARTICIPATES IN ASSESSING THE HEALTH NEEDS OF THE COMMUNITY. IN CONJUNCTION WITH THE LINCOLN COUNTY HEALTH AND HUMAN SERVICES DEPARTMENT, LINCOLN COUNTY FEDERALLY QUALIFIED HEALTH CENTER, LINCOLN COUNTY UNIFIED SCHOOL DISTRICT, OREGON COAST COMMUNITY COLLEGE, UNITED WAY OF LINCOLN COUNTY, THE LINCOLN COUNTY COMMISSION ON CHILDREN AND FAMILIES AND OTHER COMMUNITY PARTNERS, THE SAMARITAN NORTH LINCOLN HOSPITAL COMMUNITY HEALTH IMPROVEMENT PARTNERSHIP (CHIP) COORDINATOR AND OTHER SPHS EMPLOYEES ACTIVELY PARTICIPATED IN A COMMUNITY HEALTH ASSESSMENT DURING 2010. THIS PROCESS INCLUDED EXAMINING PRIMARY DATA COLLECTED THROUGH TELEPHONE SURVEYS, FOCUS GROUPS, COMMUNITY FORUMS AND PERSONAL INTERVIEWS WITH SEVERAL COMMUNITY MEMBERS FROM THROUGHOUT LINCOLN COUNTY. SECONDARY DATA WAS GATHERED FROM STATE AND LOCAL AGENCIES THAT ADDRESS HEALTH NEEDS OF CHILDREN, YOUTH AND FAMILIES. AS A RESULT OF THE COMMUNITY HEALTH ASSESSMENT, SPHS IS ABLE TO UPDATE THE ANNUAL COMMUNITY BENEFIT PLAN THAT OUTLINES GOALS AND OBJECTIVES AND SERVICES THAT EXPAND ACROSS THE SAMARITAN HEALTH SERVICES SYSTEM AND RESPOND TO COMMUNITY NEEDS. PART VI, LINE 3: SPHS IS COMMITTED TO PROVIDING THE HIGHEST QUALITY HEALTH CARE SERVICES TO ALL, REGARDLESS OF THEIR ABILITY TO PAY. IF QUALIFICATIONS ARE MET, PATIENTS' CARE MAY BE PROVIDED FREE OR AT A REDUCED COST. THE DETERMINATION IS BASED IN PART ON POVERTY INCOME GUIDELINES ISSUED BY THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. ONCE A COMPLETED FINANCIAL QUESTIONNAIRE HAS BEEN SUBMITTED, INDIVIDUALS/FAMILIES AT OR BELOW 200 PERCENT OF THE ESTABLISHED FEDERAL POVERTY LEVEL (FPL) COULD BE ELIGIBLE TO RECEIVE FREE OR DISCOUNTED CARE (CHARITY CARE).THE ORGANIZATION INFORMS AND EDUCATES PATIENTS AND COMMUNITY MEMBERS BY PUBLISHING INFORMATION REGARDING ALL FINANCIAL ASSISTANCE OPTIONS ON ITS WEBSITE, IN ADDITION TO IN PERSON AT THE REGISTRATION AREA, AND THROUGH CLEARLY IDENTIFIED MATERIALS LOCATED IN THE REGISTRATION AREA. PART VI, LINE 4: SAMARITAN PACIFIC HEALTH SERVICES (SPHS) OPERATES SAMARITAN PACIFIC COMMUNITIES HOSPITAL (SPCH), A CRITICAL-ACCESS HOSPITAL LOCATED IN NEWPORT THAT PRIMARILY SERVES THE RESIDENTS IN SOUTHERN LINCOLN COUNTY. LOCATED ON A PRIMARILY RURAL PORTION OF OREGON'S CENTRAL COAST, LINCOLN COUNTY IS HOME TO 46,034 (U.S. CENSUS) RESIDENTS. WITHIN LINCOLN COUNTY, THE LARGE TRIBAL POPULATION IS DISPROPORTIONATELY BURDENED BY HEALTH INEQUITIES. THERE ARE 4,769 ENROLLED TRIBAL MEMBERS OF THE CONFEDERATED TRIBES OF SILETZ INDIANS, OF WHICH 22% LIVE IN LINCOLN COUNTY. LINCOLN COUNTY LACKS A MAJOR METROPOLITAN AREA AND CONSISTS OF MANY SMALL COMMUNITIES SCATTERED THROUGHOUT THE REGION. NEWPORT IS THE COUNTY SEAT AND HAS A POPULATION OF 9,989. LINCOLN CITY IS THE SECOND LARGEST TOWN AND HAS A POPULATION OF 7,930. THE MEDIAN INCOME FOR LINCOLN COUNTY IS $50,600, WITH 16% LIVING BELOW THE FEDERAL POVERTY LEVEL. AS OF DECEMBER 2011, THE OREGON EMPLOYMENT DEPARTMENT REPORTED A 9.4% UNEMPLOYMENT RATE FOR LINCOLN COUNTY. THIRTY-EIGHT PERCENT OF THE POPULATION LIVES IN RURAL UNINCORPORATED AREAS AND 25% OF RESIDENTS ARE UNINSURED. SAMARITAN NORTH LINCOLN HOSPITAL, LOCATED IN LINCOLN CITY, IS THE SISTER HOSPITAL IN NORTHERN LINCOLN COUNTY SERVING LOCAL RESIDENTS. LINCOLN COUNTY IS DESIGNATED AS MEDICALLY UNDERSERVED POPULATION AND THE MIGRANT SEASONAL FARMWORKER POPULATION HAS BEEN DESIGNATED A PRIMARY MEDICAL CARE HEALTH PROVIDER SHORTAGE AREA BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION. THE SILETZ COMMUNITY HEALTH CLINIC, WHICH SERVES THE 3,666-ACRE RESERVATION OF THE CONFEDERATED TRIBES OF SILETZ INDIANS, IS A DESIGNATED HEALTH PROVIDER SHORTAGE AREA. PART VI, LINE 5: SPHS'S GOVERNING BOARD IS COMPRISED OF LOCAL-AREA RESIDENTS AND OFFICERS OF AFFILIATED ORGANIZATIONS. THE MAJORITY OF THE BOARD MEMBERS ARE INDEPENDENT, MEANING THEY AND THEIR FAMILY MEMBERS ARE NOT EMPLOYEES OF SPHS NOR DO THEY HAVE SIGNIFICANT BUSINESS RELATIONSHIPS WITH SPHS. SPHS EXTENDS ITS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. SPHS APPLIES SURPLUS FUNDS TO IMPROVE PATIENT CARE, MEDICAL EDUCATION AND RESEARCH. SPHS INVESTS IN UPDATING EQUIPMENT, TECHNOLOGY AND FACILITIES TO IMPROVE PATIENT CARE. SPHS IS ACCREDITED FOR CONTINUING MEDICAL EDUCATION AND OFFERS FREQUENT PROGRAMS FOR AREA PHYSICIANS AND OTHER HEALTH PROFESSIONALS. THE CENTER FOR HEALTH RESEARCH AND QUALITY, A DEPARTMENT OF SPHS'S PARENT COMPANY, SAMARITAN HEALTH SERVICES (SHS), PROVIDES ADMINISTRATIVE OVERSIGHT FOR HEALTH AND CLINICAL RESEARCH, QUALITY IMPROVEMENT PROJECTS AND STUDIES AND OTHER SPONSORED ACTIVITIES FOR SPHS AND ITS AFFILIATED HOSPITALS. SPHS ALSO PROVIDES SCHOLARSHIPS FOR STUDENTS AND EMPLOYEES IN HEALTH OCCUPATIONS AND CONTRIBUTES FINANCIALLY TO THE OREGON COAST COMMUNITY COLLEGE. PART VI, LINE 6: "BUILDING HEALTHIER COMMUNITIES TOGETHER" IS THE COMMITMENT OF, AND THE MOTIVATION FOR, SAMARITAN HEALTH SERVICES (SHS), A NETWORK OF OREGON HOSPITALS, PHYSICIANS, AND SENIOR CARE FACILITIES THAT SERVES THE HEALTH CARE NEEDS OF PEOPLE IN THE MID-WILLAMETTE VALLEY AND THE CENTRAL OREGON COAST.AS THE INDIVIDUAL ENTITIES OF SHS CAME TOGETHER TO BUILD HEALTHIER COMMUNITIES, THEY WERE DRAWN BY A SHARED MISSION "TO ENHANCE COMMUNITY HEALTH AND ACHIEVE HIGH VALUE THROUGH QUALITY SERVICES ACROSS THE CONTINUUM OF CARE." THAT MEANS SHS LOOKS CAREFULLY AT LOCAL HEALTH CARE NEEDS, AND IT GIVES THOUGHTFUL CONSIDERATION TO THE MOST EFFECTIVE WAYS TO MEET THOSE NEEDS. THE RESULT IS A RICH MIX OF LOCAL AND CENTRALIZED REGIONAL SERVICES WHICH PROVIDE HIGH VALUE AND EXCELLENT HEALTHCARE FOR PEOPLE AT ALL STAGES OF THEIR LIVES. SERVICES ARE PROVIDED TO ALL INDIVIDUALS, REGARDLESS OF THEIR ABILITY TO PAY. THE COLLECTIVE VISION OF SHS IS TO SUCCESSFULLY OPERATE AS A VALUES-DRIVEN, CHURCH-RELATED ORGANIZATION GOVERNED BY A PARTNERSHIP OF COMMUNITY MEMBERS, PHYSICIANS AND OTHER HEALTH CARE PROVIDERS. SHS SEEKS TO LEAD COLLABORATIVE EFFORTS AMONG PROVIDERS, EMPLOYERS, HEALTH PLANS AND CONSUMERS WHO SHARE SIMILAR GOALS AND VALUES TO MEET THE CHALLENGES OF THE FUTURE.SAMARITAN PACIFIC COMMUNITIES HOSPITAL IS ONE OF TWO LINCOLN COUNTY CRITICAL ACCESS HOSPITALS OF SHS PRIMARILY SERVING RESIDENTS OF SOUTH LINCOLN COUNTY. OTHER AFFILIATED HOSPITALS ARE GOOD SAMARITAN HOSPITAL SERVING RESIDENTS OF BENTON COUNTY, SAMARITAN ALBANY GENERAL HOSPITAL AND SAMARITAN LEBANON COMMUNITY HOSPITAL, SERVING RESIDENTS OF LINN COUNTY, AND SAMARITAN NORTH LINCOLN HOSPITAL, SERVING RESIDENTS OF NORTH LINCOLN COUNTY. REPORTS FILED WITH STATES PART VI, LINE 7 OR 1 OCCC - FOUNDATION 400 SE COLLEGE WAY NEWPORT OR 97366 931290953 501(C)(3) 25000 NURING PROGRAM SUPPORT PACIFIC COMMUNITIES HEALTH DISTRICT PO BOX 873 NEWPORT OR 97365 930603489 GOV'T 21035 CAPITAL PURCH FOR USE IN HOSPITAL FACILITIES 2 SENIOR COMPANION PROGRAM 215 275606 BOOK WAGES, BUILDING, UTILITES, AND SUPPLIES FOSTER GRANDPARENT PROGRAM 1000 250940 BOOK WAGES, BUILDING, UTILITES, AND SUPPLIES TRANSPORTATION ASSISTANCE 28 2181 SCHOLARSHIPS 2 1500 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: AGENCIES IN THE COMMUNITY ARE INVITED TO SUBMIT GRANT PROPOSALS THROUGH AN APPLICATION PROCESS. A COMMITTEE REVIEWS THE APPLICATIONS TO DETERMINE IF THE FUNDS REQUESTED WILL BE USED TO ADDRESS THE ORGANIZATION'S ESTABLISHED COMMUNITY HEALTH PRIORITIES, IDENTIFIED NEEDS, AND SUPPORTS THE ORGANIZATION'S MISSION. ONCE APPROVED AND FUNDED, AGENCIES MUST SUBMIT A COMPLETE ANNUAL REPORT DESCRIBING HOW THE FUNDS WERE USED, THE NUMBER OF CLIENTS SERVED, AND HOW OUTCOMES WERE ACHIEVED. X 1 1 X X X X 0 1 0 1 0 0 0 0 0 LARRY A MULLINS DHA 0 578681 0 6000 0 100965 0 672392 0 24897 0 1382935 0 0 DAVID TRIEBES 0 285814 0 22950 0 28439 0 34264 0 27079 0 398546 0 0 DAVID C BIGELOW 0 173536 0 21813 0 21171 0 17548 0 28274 0 262342 0 0 DANIEL B SMITH 0 285276 0 28000 0 7332 0 20228 0 31203 0 372039 0 0 FRED V SCHNEIDER MD 247295 0 2500 0 1584 0 20228 0 20139 0 291746 0 0 0 GERALD BUTLER MD 455998 0 4560 0 6187 0 20228 0 11523 0 498496 0 0 0 RICHARD NORTH MD 324586 0 3154 0 2267 0 20228 0 20603 0 370838 0 0 0 DAVID A LARSEN MD 319170 0 3600 0 402 0 20228 0 25722 0 369122 0 0 0 JERRY FLAMING DO 229446 0 2292 0 1236 0 14267 0 10098 0 257339 0 0 0 PART I, LINE 1A IN CONNECTION WITH ITS EMPLOYEE WELLNESS PROGRAM, THE ORGANIZATION HAS A GYM REIMBURSEMENT BENEFIT THAT IS AVAILABLE TO ALL EMPLOYEES WHO WORK AT LEAST 32 HOURS PER MONTH. THE EMPLOYEE MUST ATTEND THE GYM FOR 6 CONSECUTIVE MONTHS, AT LEAST 50 TIMES, IN ORDER TO QUALIFY FOR REIMBURSEMENT. THIS GYM REIMBURSEMENT BENEFIT IS INCLUDED IN THE EMPLOYEE'S TAXABLE WAGES AND IS SUBJECT TO STATE/FEDERAL WITHHOLDING TAX. ONE BOARD MEMBER, WHO IS ALSO AN EMPLOYEE OF A RELATED ORGANIZATION, AND TWO HIGHEST PAID EMPLOYEES RECEIVED THIS BENEFIT IN 2011. PART I, LINE 4B 4.B. THE ORGANIZATION MAINTAINS SUPPLEMENTAL NONQUALIFIED RETIREMENT PLANS. UNDER THESE PLANS, LARRY A. MULLINS, DHA, ACCRUED DEFERRED COMPENSATION BENEFITS DURING 2011. NO PAYMENTS WERE MADE TO HIM FROM THESE PLANS IN 2011. PART I, LINE 5 VARIOUS PHYSICIAN COMPENSATION METHODOLOGIES ARE UTILIZED AND, DEPENDING ON SPECIALTY, RELATIVE VALUE UNITS (RVU'S) MAY BE USED IN DETERMINING A PORTION OF OR ALL OF THEIR COMPENSATION. JERRY FLAMING DO RECRUITMENT PACKAGE X 30000 19374 0 1 1 DAVID LARSEN MD RECRUITMENT PACKAGE X 80000 73575 0 1 1 92949 FORM 990, PART VI, SECTION A, LINE 6 SAMARITAN PACIFIC HEALTH SERVICES HAS A SOLE CORPORATE MEMBER, SAMARITAN HEALTH SERVICES, INC., WHICH IS A SECTION 501(C)(3) TAX-EXEMPT ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A SAMARITAN PACIFIC HEALTH SERVICES ELECTS MEMBERS OF ITS BOARD OF DIRECTORS. THOSE ELECTED MEMBERS ARE THEN SUBMITTED TO THE SOLE CORPORATE MEMBER FOR APPROVAL. FORM 990, PART VI, SECTION A, LINE 7B THE SOLE CORPORATE MEMBER HAS SEVERAL RESERVED POWERS OVER THE ORGANIZATION. THESE RESERVED POWERS INCLUDE, BUT ARE NOT LIMITED TO, APPROVAL AT CERTAIN THRESHOLD LEVELS: THE BORROWING OF FUNDS, MERGERS AND ACQUISITIONS, AND SALES OR TRANSFERS OF ASSETS. IN ADDITION, THE SOLE CORPORATE MEMBER MUST APPROVE ANY CHANGE IN THE MISSION OF THE ORGANIZATION, THE ANNUAL BUDGET, AND ANY AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE ORGANIZATION'S FINAL FORM 990 (INCLUDING REQUIRED SCHEDULES), AS ULTIMATELY FILED WITH THE IRS, WAS PROVIDED TO EACH VOTING MEMBER OF THE SAMARITAN HEALTH SERVICES (SHS) AUDIT AND COMPLIANCE COMMITTEE PRIOR TO ITS FILING WITH THE IRS. SHS IS A 501(C)(3) CORPORATION AND IS THE SOLE MEMBER OF THE FILING ORGANIZATION. SHS'S CHIEF FINANCIAL OFFICER CONDUCTED THE FORM 990 REVIEW WITH THE COMMITTEE AND PROVIDED TIME FOR QUESTIONS FROM THE GROUP. A FORMAL REPORT OF THIS COMMITTEE HAS BEEN MADE TO THE FULL BOARD OF DIRECTORS OF SHS. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBER CONFLICTS OF INTEREST: THE MEMBERS OF THE BOARD MUST ANNUALLY COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE, WHICH REQUIRES DISCLOSURE OF ANY CONFLICTS OR POTENTIAL CONFLICTS OF INTEREST. THE COMPLETED QUESTIONNAIRES ARE REVIEWED BY THE CHIEF FINANCIAL OFFICER AND CORPORATE COMPLIANCE OFFICER. IF A CONFLICT IS DISCLOSED THAT COULD PROHIBIT A MEMBER FROM SERVING ON THE BOARD, THIS IS EVALUATED BY THE AUDIT AND COMPLIANCE COMMITTEE OF THE SAMARITAN HEALTH SERVICES (SHS) BOARD OF DIRECTORS TO DETERMINE WHETHER THE MEMBER SHOULD CONTINUE TO SERVE ON THE BOARD. IF A CONFLICT IS DISCLOSED THAT DOES NOT PROHIBIT A MEMBER FROM SERVING ON THE BOARD, THE CONFLICT IS MANAGED THROUGH A PROCESS SET FORTH IN THE ORGANIZATION'S BYLAWS. THE BYLAWS PROHIBIT ANY BOARD MEMBER FROM VOTING ON AN ACTION WHERE AN INDIVIDUAL MEMBER HAS A CONFLICT OF INTEREST. EMPLOYEE CONFLICTS OF INTEREST: THE SHS CODE OF ETHICS AND CONDUCT POLICY REQUIRES THAT ALL SHS EMPLOYEES COMPLETE AN ANNUAL DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST. THROUGH THE HUMAN RESOURCES SOFTWARE, PERFORMANCE MANAGER, THE DISCLOSURE REQUIREMENT NOTICE IS ASSIGNED TO ALL EMPLOYEES AND BY YEAR END ALL TASKS ARE TO BE COMPLETED. IF THERE IS A PERCEIVED CONFLICT OF INTEREST IT IS REVIEWED BY THE CORPORATE COMPLIANCE OFFICER, LEGAL COUNSEL AND/OR SENIOR MANAGEMENT. ACTUAL CONFLICTS OF INTEREST ARE REVIEWED AND DISCUSSED BY THE AUDIT AND COMPLIANCE COMMITTEE OF THE SAMARITAN HEALTH SERVICES BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. SYSTEM-WIDE SUMMARIZED DATA IS ALSO PROVIDED IN THE ANNUAL REPORT TO THE COMMUNITY. THIS REPORT IS MADE AVAILABLE IN ALL KIOSKS AND HIGH-TRAFFIC AREAS OF ALL HOSPITALS AND PHYSICIAN CLINICS, AS WELL AS COMMUNITY PLACES SUCH AS THE PUBLIC LIBRARY. IT IS ALSO DISTRIBUTED TO THE BOARDS OF DIRECTORS AND DIRECTLY MAILED TO DONORS AND NEW RESIDENTS IN THE COMMUNITY. ADDITIONALLY, THE REPORT IS MADE AVAILABLE AT ALL EVENTS, COMMUNITY OUTREACH PROJECTS, AND SCREENINGS ATTENDED THROUGHOUT THE YEAR. GOVERNING DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. LARRY A. MULLINS, DHA PART VII - COMPENSATION EXPLANATION DR. MULLINS WORKED 40 HOURS PER WEEK FOR SEVERAL RELATED ORGANIZATIONS. HIS COMPENSATION WAS PAID BY A RELATED ORGANIZATION FOR WORK DONE FOR THE FILING ORGANIZATION AND SEVERAL RELATED ORGANIZATIONS. DAVID TRIEBES PART VII - COMPENSATION EXPLANATION MR. TRIEBES WORKED 40 HOURS PER WEEK FOR SEVERAL RELATED ORGANIZATIONS. HIS COMPENSATION WAS PAID BY A RELATED ORGANIZATION FOR WORK DONE FOR THE FILING ORGANIZATION AND SEVERAL RELATED ORGANIZATIONS. DAVID C. BIGELOW PART VII - COMPENSATION EXPLANATION MR. BIGELOW'S COMPENSATION WAS PAID BY A RELATED ORGANIZATION FOR WORK DONE FOR THE FILING ORGANIZATION. DANIEL B. SMITH PART VII - COMPENSATION EXPLANATION MR. SMITH WORKED 40 HOURS PER WEEK FOR SEVERAL RELATED ORGANIZATIONS. HIS COMPENSATION WAS PAID BY A RELATED ORGANIZATION FOR WORK DONE FOR THE FILING ORGANIZATION AND SEVERAL RELATED ORGANIZATIONS. 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