2011-08-15T16:28:53-05:00 2010-09-30 Moss Adams LLP 805 SW Broadway 1200 Portland OR 97205 990 2009-10-01 930281321 SILVERTON HOSPITAL SILV 5038731500 342 FAIRVIEW STREET SILVERTON OR 97381 JEFF FRITSCHE 5038731500 2011-08-04 1 Wendy Campos 5032421447 2009 2016-02-24 21:20:13Z RICHARD CAGEN 342 FAIRVIEW STREET SILVERTON OR 97381 111387020 0 X WWW.SILVERTONHOSPITAL.ORG X 1918 OR Through Silverton Hospital Network we come together to improve the health of our communities. Recognizing our responsibility for careful use of resources, it is our misson to encourage wellness and deliver quality health care, to organize ourselves as a collaborative team fostering integrity, accountability and innovation, and to create an environment that promotes compassion and recognizes the dignity of all, with sensitivity to the values and cultures of those who entrust us with their care. 11 10 932 286 1495092 -1497869 434091 153905 96060170 101000335 128992 25603 3665350 3746819 100288603 104926662 104476 111590 0 52699533 54884334 0 0 44435041 46855009 97239050 101850933 3049553 3075729 60187424 62227077 19507938 18299135 40679486 43927942 Through Silverton Hospital Network we come together to improve the health of our communities. Recognizing our responsibility for careful use of resources, it is our misson to encourage wellness and deliver quality health care, to organize ourselves as a collaborative team fostering integrity, accountability and innovation, and to create an environment that promotes compassion and recognizes the dignity of all, with sensitivity to the values and cultures of those who entrust us with their care. 0 0 100899574 111590 103255441 GENERAL HOSPITAL INPATIENT AND OUTPATIENT CARE AND EDUCATION FOR PATIENTS IN THE LOCAL COMMUNITY, INCLUDING MEDICARE AND MEDICAID PATIENTS AND CHARITY CARE. CHARGES WRITTEN OFF DUE TO INADEQUATE REIMBURSEMENT - $53.7 MILLION. CHARGES FORGONE FOR CHARITY CARE - $12.1 MILLION. 100899574 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 1 0 1 1 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 1 0 0 1 100 0 1 932 1 1 1 0 0 0 0 1 1 0 0 0 11 10 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 0 OR X JEFF FRITSCHE CFO 5038731548 342 FAIRVIEW STREET SILVERTON OR 97381 GARY SIMON 2.00 X X 0 0 0 GAYLE GOSCHIE 2.00 X X 0 0 0 JOHN WEBSTER 2.00 X X 0 0 0 CORY CROSS 2.00 X X 0 0 0 DAVE BUCK 2.00 X 0 0 0 BOB ENGLE 2.00 X 0 0 0 FRANK GOLDEN MD 2.00 X 0 0 0 DARCY RUEF 2.00 X 0 0 0 CLINT SANFORD MD 2.00 X 0 0 0 BETH DAVISSON 2.00 X 0 0 0 JANE WYNN 2.00 X 0 0 0 WILLIAM WINTER 40.00 X 876110 0 20028 JEFF LORENZ 40.00 X 242744 0 35413 ROB JOHNSON 40.00 X 142411 0 9703 JEFF FRITSCHE 40.00 X 0 0 0 TERRI MERRITT WORDEN 40.00 X 139175 0 15260 DAVID THORSETT MD 40.00 X 646561 0 24978 DAVID FORSYTHE MD 40.00 X 483224 0 27910 ROBERT CHISHOLM MD 36.00 X 419505 0 28151 RICHARD BLOCK MD 40.00 X 411527 0 34416 KENNETH KOLARSKY MD 40.00 X 364310 0 14057 3725567 0 209916 72 0 1 0 Providence Health System - Oregon 47th Ave Suite 260 Portland OR 97213 Billing Services 1052733 ProvidenceSilverton Rehab LLC PO BOX 3290 portland OR 97208 Patient Services 473153 Shiftwise PO Box 70870 St Paul MN 55170 Staffing 338672 Netscript Inc 235 CR 3520 Clarksville AR 72830 Transcription 281046 Donald Graham MD 127 Del Prado Lake Oswego OR 97035 Physician 280673 9 3379 150526 23919 153905 PATIENT SERVICES 621990 101000335 101000335 101000335 104993 104993 6353219 3590 6436009 190 -82790 3400 -79390 -79390 20780 3379 24159 -3379 -3379 OTHER OPERATING REV 900099 3696452 2201360 1495092 INCOME FROM SUBSIDIARY 900099 53746 53746 3750198 104926662 103255441 1495092 22224 111590 111590 1307231 629123 678108 43261931 43261931 1605382 1605382 5734598 5734598 2975192 2937819 37373 153895 153895 81983 81983 5875603 5875603 218013 218013 728128 728128 397495 397495 3547568 3547568 77832 77832 155624 155624 379686 379686 3913527 3913527 764320 764320 CHARITY CARE 12094170 12094170 SUPPLIES 11673890 11673890 BAD DEBT EXPENSE 5033353 5033353 OTHER 1327711 1327711 Equipment Rent 432211 432211 101850933 100899574 951359 0 6937053 8370163 14382272 13610102 141945 98518 1758705 1751521 1266817 1011981 64765053 36485029 30158231 28280024 30886 206197 5511515 8898571 60187424 62227077 9665604 9356656 8623685 8072652 280822 937827 869827 19507938 18299135 X 40679486 43927942 40679486 43927942 60187424 62227077 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2768949 2768949 29795033 11872380 17922653 779035 514277 264758 31029705 24098372 6931333 392331 392331 28280024 OTHER RECEIVABLES 109134 OTHER ASSETS 123882 ASSETS LIMITED AS TO USE 8665555 8898571 ESTIMATED MEDICAL MALPRACTICE LIABILITY 869827 869827 Part X: Description of Uncertain Tax Positions Under FIN 48: The Hospital adopted the provisions of Financial Accounting Standards Board (FASB) Accounting Standards Codification (ASC) 740-10, Accounting for Uncertainty in Income Taxes, on October 1, 2007. The Hospital had no unrecognized tax benefits at September 30, 2010 and at September 30, 2009. The Hospital recognizes interest accrued and penalties related to unrecognized tax benefits as an administrative expense. During the years ended September 30, 2010 and 2009, the Hospital recognized no interest and penalties. WELLSPRING HEART GOLF TOURNAMENT 24159 3379 20780 24159 24159 3379 20780 24159 24159 -3379 1 1 1 X 1 X 1 1 0 1 1 4043 4177673 109556 4068117 0.04200 17497 14783789 13923403 860386 0.00890 21540 18961462 14032959 4928503 0.05090 34 37050 1288092 192236 1095856 0.01130 21 161 208386 0 208386 0.00220 1 9031 426901 0 426901 0.00440 17 12722 278521 79 278442 0.00290 73 58964 2201900 192315 2009585 0.02080 73 80504 21163362 14225274 6938088 0.07170 2 100 7097 0 7097 0.00010 4 583 17668 0 17668 0.00020 5 1379 11766 50 11716 0.00010 9 1145 84274 0 84274 0.00090 20 3207 120805 50 120755 0.00130 1 5033353 1693069 6473694 8154605 -1680911 X 1 1 SILVERTON HOSPITAL

342 FAIRVIEW STREET SILVERTON OR 97381

X X X Part III, Line 4: THE ORGANIZATION UTILIZES A COST ACCOUNTING SYSTEM FOR DETERMINING THE ASSOCIATED COST OF PROVIDING SERVICES TO PATIENTS WITHOUT INSURANCE THAT ARE SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS. THAT PERCENTAGE IS THEN APPLIED TO THE TOTAL BAD DEBT EXPENSE PER THE GENERAL LEDGER (BASED ON CHARGES) TO DETERMINE THE ASSOCIATED COST. COLLECTIONS FROM THE PATIENT/GUARANTOR ARE NETTED AGAINST THAT COST TO DETERMINE A NET COST.ANY COLLECTIONS RECEIVED ON ACCOUNTS THAT WERE WRITTEN OFF TO BAD DEBT (EITHER PARTIALLY OR IN FULL) WERE NETTED AGAINST THE COST OF PROVIDING THE SERVICES TO THE PATIENT IN ORDER TO DETERMINE A NET COST.THE ORGANIZATION CURRENTLY DOES NOT HAVE THE SYSTEMS NECESSARY TO REASONABLY ESTIMATE THE AMOUNT OF BAD DEBT EXPENSE THAT COULD BE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY.THE HOSPITAL REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYORS, PATIENTS AND OTHERS. THE HOSPITAL PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTIONS INFORMATION AND EXISTING ECONOMIC CONDITIONS. AS A SERVICE TO THE PATIENT, THE HOSPITAL BILLS THIRD-PARTY PAYORS DIRECTLY AND BILLS THE PATIENT WHEN THE PATIENT'S LIABILITY IS DETERMINED. PATIENT ACCOUNTS RECEIVABLE ARE DUE IN FULL WHEN BILLED. ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT. Part III, Line 8: SILVERTON HOSPITAL'S MISSION IS TO PROVIDE QUALITY HEALTHCARE SERVICES AND LEADERSHIP IN PROMOTING HEALTH IMPROVEMENT TO ALL PERSONS IN ITS SERVICE AREA ON A NON-DISCRIMINATORY BASIS AND WITHOUT REGARD TO ABILITY TO PAY. IN KEEPING WITH ITS COMMITMENT TO SERVE ALL MEMBERS OF THE COMMUNITY, THE HOSPITAL PROVIDES CARE TO INDIVIDUALS COVERED BY THE MEDICARE PROGRAM IN SPITE OF THE FACT THAT THE COST OF PROVIDING THOSE SERVICES EXCEEDS THE REVENUE RECEIVED. THE SHORTFALL THAT THE HOSPITAL WAS REQUIRED TO ABSORB TOTALED $2,424,430 (INCLUDING SHORTFALL ARISING FROM MEDICARE ADVANTAGE). THIS CONTINUED COMMITMENT SHOULD BE TREATED AS A COMPONENT OF THE HOSPITAL'S COMMUNITY BENEFIT.IN ADDITION TO PROVIDING SERVICES TO MEDICARE BENEFICIARIES UNDER THE TRADITIONAL FEE FOR SERVICE PROGRAM, THE ORGANIZATION ALSO PROVIDES SERVICES TO MEDICARE BENEFICIARIES THROUGH VARIOUS MEDICARE ADVANTAGE PLANS. THE ORGANIZATION REALIZED A SHORTFALL OF COSTS IN EXCESS OF NET REVENUE OF $553,594 FOR BENEFICIARIES COVERED THROUGH MEDICARE ADVANTAGE PLANS, IN ADDITION TO THE SHORTFALLS REPORTED ABOVE ATTRIBUTABLE TO MEDICARE FEE FOR SERVICE BENEFICIARIES.THE ORGANIZATION UTILIZES A COST ACCOUNTING SYSTEM FOR DETERMINING THE ASSOCIATED COST OF PROVIDING SERVICES TO PATIENTS BY INDIVIDUAL PATIENT ACCOUNT. THE ACCOUNTS ARE THEN AGGREGATED FOR ALL PATIENT SEGMENTS BOTH BY TYPE OF SERVICE (INPATIENT, OUTPATIENT, EMERGENCY, ETC) AS WELL AS BY PAYOR (PRIVATE INSURANCE, MEDICARE, MEDICAID, SELF PAY, ETC) IN ORDER TO DETERMINE THE COST OF PROVIDING SERVICES TO ALL PATIENTS.THE COSTING METHODOLOGY USED FOR DETERMINING MEDICARE ALLOWABLE COSTS IS THAT REQUIRED BY CMS IN PREPARATION OF FORM CMS-2552. Part III, Line 9b: SILVERTON HOSPITAL NETWORK STRIVES TO PROVIDE ACCURATE AND TIMELY SERVICE WHEN BILLING AN INSURANCE COMPANY OR PATIENT DIRECTLY. EVERY BILL AND STATEMENT INCLUDES INFORMATION ABOUT HOW TO CONTACT FINANCIAL REPRESENTATIVES AND ARRANGE PAYMENT PLANS. WE ARE COMMITTED TO FINDING WAYS TO HELP EVERY PATIENT PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE RESPONSIBLE WITHOUT EXPERIENCING AN OVERWHELMING FINANCIAL BURDEN. IN ADDITION TO MAKING OUR BILLING PROCESS EASY TO UNDERSTAND AND ENSURING READY ACCESS TO CHARITY CARE AND FINANCIAL ASSISTANCE, WE ARE ABLE TO PROVIDE PATIENT COST INFORMATION IN ADVANCE OF SERVICES OR TREATMENT. Part VI, Line 2: WE REVIEWED NATIONAL, STATE AND LOCAL HEALTH NEEDS ASSESSMENTS, GOALS AND ACTION PLANS TO IDENTIFY THE NEEDS OF OUR COMMUNITY AND INCORPORATED THOSE NEEDS INTO OUR CURRENT PLANS. WE ALSO WORK WITH LOCAL NOT-FOR-PROFIT COMMUNITY ORGANIZATIONS AND LOCAL SCHOOLS TO IDENTIFY ADDITIONAL NEEDS. FINALLY, WE RECEIVE DIRECT REQUESTS (VIA E-MAIL, CALLS, LETTERS) FROM STATE, LOCAL AND NOT-FOR-PROFIT GROUPS/ORGANIZATIONS ASKING US TO ASSIST THEM IN MEETING OTHER HEALTH NEEDS. Part VI, Line 3: ALL PATIENTS INQUIRING ABOUT FINANCIAL ASSISTANCE AND/OR CHARITY CARE ARE REFERRED TO THE FINANCIAL COUNSELORS WHERE THE PATIENT IS THEN PROVIDED WITH DETAILED INFORMATION ON THE APPLICATION AND REQUIREMENTS NEEDED TO SUPPORT CHARITY CARE ELIGIBILITY AND DETERMINATION. Part VI, Line 4: SILVERTON HOSPITAL NETWORK DEFINES ITS PRIMARY SERVICE AREA BY THE FOLLOWING ZIPCODES: 97381, 97362, 97071, 97038, 97375, 97026, 97032, 97303, 97305, 97373 AND 97317. THIS INCLUDES THE CITIES OF SILVERTON, MT. ANGEL, WOODBURN, GERVAIS, HUBBARD, SCOTTS MILLS, ST. BENEDICT, MOLALLA, KEIZER AND PARTS OF SALEM. OUR COVERAGE STRETCHES OVER BOTH MARION AND CLACKAMAS COUNTIES. RESIDENTS OF OUR COMMUNITY ARE PRIMARILY CAUCASIAN AND HISPANIC. THERE IS A LARGE MIGRANT WORKER POPULATION IN THIS AREA AND SOME OF OUR SERVICE AREA INCLUDES MEDICALLY UNDERSERVED AREAS AS WELL AS HEALTH PROFESSIONAL SHORTAGE AREAS. IN ADDITION, WE HAVE AN UNCHARACTERISTICALLY LARGE POPULATION OF SENIORS IN SOME PORTIONS OF OUR SERVICE AREA, SPECIFICALLY IN WOODBURN AND THE SURROUNDING AREAS. Part VI, Line 5: PHYSICAL IMPROVEMENTS AND HOUSING: SUPPORTING THE DEVELOPMENT OF A LOCAL SENIOR CENTER PROMOTES THE HEALTH OF OUR COMMUNITY BY PROVIDING SHELTER, PHYSICAL ACTIVITY, SOCIAL INTERACTION, SENSE OF COMMUNITY AND EDUCATION TO OUR LOCAL SENIORS. THESE THINGS ARE ALL KNOWN TO ATTRIBUTE TO HEALTH AND WELLNESS. STAFF SERVING ON COMMUNITY HOUSING BOARDS AND WITH LOCAL LANGUAGE GROUPS BETTERS COMMUNITY HEALTH BY USING HEALTH EXPERTISE TO BETTER THE ROOT CAUSES OF POVERTY AND HOMELESSNESS.ECONOMIC DEVELOPMENT: PARTICIPATION IN LOCAL CHAMBERS OF COMMERCE AND ECONOMIC DEVELOPMENT GROUPS BETTERS COMMUNITY HEALTH BY SUPPORTING THE GROWTH OF JOBS IN OUR COMMUNITY, ENABLING THE UNEMPLOYED TO FIND WORK, AND FROM THAT, THE ABILITY TO AFFORD HEALTHCARE AND FOOD/SHELTER FOR THEIR FAMILIES.COMMUNITY SUPPORT: BY FINANCIALLY SUPPORTING AND DONATING FUNDS/SPACE TO THE LOCAL BOYS AND GIRLS CLUB AND VARIOUS SCHOOLS IN OUR SERVICE AREA, SHN BETTERS COMMUNITY HEALTH BY SUPPORTING THOSE PLACES WHICH GIVE CHILDREN A SAFE PLACE FOR PHYSICAL ACTIVITY, ACCESS TO BETTER NUTRITION, AND ACCESS TO FREE HEALTH SERVICES LIKE NURSES AND COUNSELING.WORKFORCE DEVELOPMENT: SHN STAFF ROUTINELY ALLOW STUDENTS TO JOB SHADOW THEM WHILE THEY WORK, OFFER TOURS OF THE HOSPITAL TO YOUNG CHILDREN, AND PARTICIPATE IN HIGH SCHOOL CAREER FAIRS. THROUGH THIS PARTICIPATION, THE HOSPITAL NETWORK HOPES TO EDUCATE LOCAL YOUTH ABOUT HEALTHCARE CAREERS, THE IMPORTANCE OF GOING TO COLLEGE, AND THE HOSPITAL PROCESS IN HOPES THAT THEY WILL FEEL SAFE IN A HEALTHCARE ENVIRONMENT AND POSSIBLY PURSUE A HEALTHCARE CAREER. OREGON CURRENTLY HAS A LARGE SHORTAGE OF HEALTHCARE WORKERS. OR 1 SILVERTON AREA SENIORS 402 E Main St Silverton OR 97381 931180119 501(C)(3) 5000 Support the welfare of Silverton seniors SILVERTON AREA COMMUNITY AID 421 S Water St Silverton OR 97381 930884237 501(C)(3) 1000 4604 fmv food donation Supply food for the needy SALUD MEDICAL CENTER 3896 Beverly Ave NE SALEM OR 97305 911019392 501(C)(3) 42432 Community Medical Care WOODBURN KIWANIS PO BOX 1046 WOOdburn OR 97071 936037102 501(C)(3) 7050 fmv room rentals Provide meeting place to plan community activities AMERICAN CANCER SOCIETY PO BOX 22538 OKLAHOMA CITY OK 73123 841316555 501(C)(3) 12853 sponsorship of a relay for life team ROTARY INTERNATIONAL WOODBURN PO BOX 247 Woodburn OR 97071 936032666 501(C)(4) 13224 fmv room rentals Provide meeting place to plan community activities 5 1 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: The grants and assistance provided to local organizations are considered to be donation-type contributions. Such contributions are generally made to section 501(c)(3) tax-exempt organizations. 1 X X X 0 1 0 0 0 0 0 0 0 WILLIAM WINTER 330801 0 150 0 545159 0 17948 0 2080 0 896138 0 0 0 JEFF LORENZ 227594 0 15150 0 0 0 18008 0 17405 0 278157 0 0 0 ROB JOHNSON 142261 0 150 0 0 0 3329 0 6374 0 152114 0 0 0 TERRI MERRITT WORDEN 129025 0 10150 0 0 0 0 0 15260 0 154435 0 0 0 DAVID THORSETT MD 646411 0 150 0 0 0 7573 0 17405 0 671539 0 0 0 DAVID FORSYTHE MD 483074 0 150 0 0 0 12650 0 15260 0 511134 0 0 0 ROBERT CHISHOLM MD 419355 0 150 0 0 0 11900 0 16251 0 447656 0 0 0 RICHARD BLOCK MD 411377 0 150 0 0 0 16831 0 17585 0 445943 0 0 0 KENNETH KOLARSKY MD 364180 0 130 0 0 0 0 0 14057 0 378367 0 0 0 Part I, Line 4b: William Winter, President, participated in a supplemental nonqualified retirement plan during the tax year. The Hospital created a trust to fully secure the obligation, and its assets were subject to the claims of the Hospital's general creditors until the funds were distributed to the individual. The trust was closed during the tax year and Mr. Winter received payments from the plan in the amount of $545,159 during calendar year 2009, shown in Part II above as W-2 other compensation. HOSPITAL FACILITY AUTHORITY - SILVERTONOR 931074291 2006-10-26 10097600 CAPITAL IMPROVEMENTS AND EQUIPMENT ACQUISITIONS 0 0 10097600 3966670 97600 6033330 2008 1 0 1 1 0 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 1 JEFF FRITSCHE HOSPITAL CFO/EMPLOYEE OF MANAGEMENT COMPANY PROVIDING SERVICES TO HOSPITAL 239799 JEFF FRITSCHE IS THE CFO OF THE HOSPITAL BY CONTRACT WITH A THIRD-PARTY MANAGEMENT COMPANY AND IS AN EMPLOYEE OF THAT MANAGEMENT COMPANY; THE MANAGEMENT COMPANY PROVIDES VARIOUS SERVICES TO THE HOSPITAL, WHICH INCLUDE THE CFO POSITION. THE TRANSACTION AMOUNT IS THE AMOUNT THE HOSPITAL PAID THE MANAGEMENT COMPANY FOR FINANCIAL SERVICES. 0 BOB ENGLE HOSPITAL BOARD MEMBER/OWNER OF PARTNERSHIP LEASING PROPERTY TO HOSPITAL 2176935 Bob Engle is a greater than 5% owner of 3 partnerships, which each lease property to the hospital. The transaction amount is total lease payments paid to the 3 partnerships during the fiscal year. 0 Form 990, Part VI, Section A, line 3 THE HOSPITAL CONTRACTS WITH A THIRD-PARTY NONPROFIT CORPORATION TO PROVIDE VARIOUS MANAGEMENT SERVICES, INCLUDING FINANCIAL SERVICES (INCLUDING THE CFO POSITION), GROUP PURCHASING AND PATIENT ACCOUNTING SERVICES. Form 990, Part VI, Section B, line 11 Form 990 is presented to the finance committee for review and approval. this committee includes governing board members, and all board members are invited to attend. Form 990, Part VI, Section B, line 12c The conflict of interest policy is sent out annually for officers, directors, trustees and key employees to review the policy and complete the conflict of interest statement. Any conflicts are brought to the board and handled according to the procedure stated in the conflict of interest policy. Form 990, Part VI, Section B, line 15 Legal counsel developed a process to determine compensation of the CEO, which includes comparability data and development of a compensation grid. Comparability data was used from Northwest executive compensation survey and a standard process was followed in determining compensation for key employees. Form 990, Part VI, Section C, line 19 Governing documents, conflict of interest policy and financial statements are made available to the public upon request. MID-VALLEY MEDICAL MANAGEMENT COMPANY LLC 342 FAIRVIEW STREET SILVERTON OR 97381 800612509 MANAGEMENT OF THE CATHETERIZATION LAB AT SILVERTON HOSPITAL OR N/A RELATED 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 MID-VALLEY MEDICAL MANAGEMENT COMPANY LLC B 76500