2023-02-15T13:01:40-08:00 2022-03-31 990 2021-04-01 930591528 LEGACY MOUNT HOOD MEDICAL CENTER LEGA 5034155600 24800 SE STARK ST GRESHAM OR 97030 ANNA L LOOMIS CFO & TREASURER 2023-02-15 ANNA L LOOMIS 999009999 2 AAL1 IAL1 FAL1 2021 2023-03-07 01:45:13Z KATHRYN CORREIA 24800 SE STARK ST GRESHAM OR 97030 199289116 false X WWW.LEGACYHEALTH.ORG X 1922 OR Legacy Mount Hood Medical Center (LMHMC) was founded in 1922 and is a community hospital in Gresham, OR. LMHMC offers a wide range of services including family birth, diagnostic services, cancer treatment, surgery and emergency services. 17 13 0 178 28454 543518 60135 163197549 199228962 175457 -8694 0 163916524 199280403 1200 252592 0 81909343 98208942 0 0 84588719 95294600 166499262 193756134 -2582738 5524269 153604509 154359908 59344691 54586320 94259818 99773588 Legacy Mount Hood Medical Center (LMHMC) was founded in 1922 and is a community hospital in Gresham, Oregon with 115 licensed beds. LMHMC offers a wide range of services including family birth, diagnostic services, cancer treatment, surgery and emergency services. LMHMC is part of Legacy Health (Legacy).Our mission:Our legacy is good health for our people, our patients, our communities, and our world. We will work as a team to demonstrate our values:Respect - Treat all people with respect and compassion Service - Put the needs of our patients and their families first Quality - Deliver outstanding clinical services within healing environments Excellence - Set high standards and achieve them Responsibility - Be good stewards of our resources, ensuring access to care for all Innovation - Be progressive in our thinking and actions Leadership - Serve as a role model of good health and good citizenship false false 146164009 252592 199228962 LMHMC provides inpatient and outpatient healthcare services to the communities it serves. In support of its mission, LMHMC voluntarily provides medically necessary patient care services that are discounted or free of charge to persons who have insufficient resources and/or who are uninsured. During fiscal year 2022, LMHMC provided financial assistance on approximately 8,879 patient accounts (of which 1,472 accounts received discounts totaling 100% of costs) and resulted in LMHMC incurring roughly $5,115,100 in uncompensated costs associated with this program. In addition to charity care, LMHMC provides services under various states' Medicaid programs for financially needy patients, Medicare beneficiaries and other government programs for which the cost of treating these patients exceeds the government payments received. During fiscal year 2022, LMHMC incurred approximately $14,290,600, $17,736,700 and $932,100 in uncompensated costs attributable to Medicaid, Medicare, and other government programs, respectively. LMHMC also provides a variety of other community benefit activities such as medical education, donations to other charitable entities, research, and other health improvement services which totaled roughly $1,328,700 during fiscal year 2022.LMHMC is part of Legacy, which collectively provided over $40 million, $292 million, $265 million, and $13 million in uncompensated care attributable to its financial assistance, Medicaid, Medicare, and other government programs, respectively, in fiscal year 2022. In addition, Legacy provided over $26 million in other community benefit activities during fiscal year 2022. 146164009 true true false true false false false false false false true true false false true false false true false false false false false false false false true true true true true false false false false false false false false false false false false false true true false false false true 0 0 false 0 true true false false false false false false 0 false false false false false false false X 17 13 false true false false true true true true true false false true true true true true true true true true true OR X X ANNA LOOMIS 5034155600 1919 NW LOVEJOY STREET PORTLAND OR 97209 KATHRYN CORREIA President & CEO 0.00 40.00 X X 0 1725220 86479 TRENT S GREEN SR VP 0.00 40.00 0 1065077 92568 BRYCE R HELGERSON SR VP 0.00 40.00 0 767254 136117 ANNA LOOMIS CFO & TREASURER 0.00 40.00 X X 0 837787 61371 GRETCHEN M NICHOLS HOSPITAL PRESIDENT 0.00 40.00 0 653713 97704 JOHN J KENAGY SR VP 0.00 40.00 0 611138 98640 SONJA O STEVES SR VP 0.00 40.00 0 576338 122473 ANITA N IYENGER SR VP 0.00 40.00 0 568644 91017 MELINDA J MULLER MD SR VP 0.00 40.00 0 520082 99838 ALEXANDER GLADNEY SECRETARY 0.00 40.00 X X 0 478951 23664 MAUREEN A BRADLEY SR VP 0.00 40.00 0 395289 79546 ANNE T GREER SECRETARY 0.00 40.00 X X 0 327633 61731 LAURA E OSTROM MD PHYSICIAN 40.00 0.00 304463 0 62601 JONATHAN HILL MD BOARD DIRECTOR 3.00 40.00 X 0 312647 40814 SETH R PODOLSKY MD SR VP 0.00 40.00 0 333096 14782 TANYA R SHANKS-CONNORS VP CNO 40.00 0.00 273865 0 51595 ARUNA JAYARAM MD PHYSICIAN 40.00 0.00 255536 0 63517 LISA G GOREN SR VP 0.00 40.00 0 264726 49559 KECIA M KELLY DNP SR VP 0.00 40.00 0 272754 20783 SHEVYLL S TAN MD PHYSICIAN 40.00 0.00 240035 0 45189 BRENDA SHERMAN RN REGISTERED NURSE 40.00 0.00 236869 0 45542 MICHELLE L JOHN PHYSICIAN 40.00 0.00 220445 0 40904 LESLIE ROOT MD BOARD DIRECTOR 3.00 40.00 X 0 222197 27116 ROBERT E DEWITT FORMER SR. 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Endowment funds disclosed in Part V are used to improve the healthcare of the community as designated by the donors. Mount Hood Medical Center Foundation (MHMCF) maintains all charitable gifts including endowment funds for the benefit of LMHMC and it's programs. In 2021, the MHMCF board of trustees approved the dissolution of MHMCF and a merger of the Foundations assets into the Legacy Health Foundation (LHF). All assets of MHMCF as of March 31, 2021, were transferred to LHF, with all original donor restrictions preserved.Income from permanently restricted net assets is accounted for in accordance with the donors' instructions.Legacy follows the guidance in the Uniform Prudent Management of Institutional Funds Act (UPMIFA) in determining the net asset classification of all donor-restricted endowment funds. In accordance with UPMIFA and board policy, assets classified as permanent endowments in accordance with donor intent are only utilized for current period expenditures to the extent that earnings on the endowment exceed the original fair value of the donation. To the extent earnings on endowment funds exceed identified expenditures on which to apply those earnings, the earnings are classified as temporarily restricted net assets. Legacy has adopted investment and spending policies for endowment assets to provide a predictable stream of funding to programs supported by its endowment and to maintain the value of the endowment assets. Asset allocation is reviewed quarterly with respect to: i) Legacy's tolerance for risk based on its financial condition and need for cash from investments to support operations; ii) expected asset class return, risk and correlation characteristics; iii) changes in accounting guidance or tax law and iv) changes in bond covenants or other restrictions.Legacy's spending practices are intended to comply with donor's wishes and meet all applicable laws and regulations. Spending must be for a purpose that is consistent with the documented intent of the donor, and may not exceed the amounts annually determined by Legacy. Factors that are considered in addressing the annual spending allocation are: i) market value of the fund relative to the principal of the gift and ii) the level of spending in prior years.From time to time, the fair value of assets associated with individual donor-restricted endowment funds may fall below the level that the donor or UPMIFA requires Legacy to retain as a fund of perpetual duration. Deficiencies of this nature are reported as a reduction to unrestricted net assets and are excluded from the performance indicator. Part XI, Line 4b: Other revenue amounts included on 990 but not included in F/S FOUNDATION CONTRIBUTION $59091 ROUNDING $275 MEDICAL STAFF INCOME $160819 GAIN / LOSS OF SALE OF ASSETS $-8695 FOUNDATION CAPITAL CONTRIBUTION $1044 PROGRAM SERVICE REVENUE $559869 Part XII, Line 4b: Other revenue amounts included on 990 but not included in F/S FOUNDATION CONTRIBUTION $59091 ROUNDING $-581 MEDICAL STAFF EXPENSE $6450 GAIN / LOSS OF SALE OF ASSETS $-8695 PROGRAM SERVICE REVENUE $559869 true true X true X 300.000000000 true X true true true false true true 5115136 5115136 0.02640 49241238 34950624 14290614 0.07380 2829617 1897475 932142 0.00480 57185991 36848099 20337892 0.10500 442952 442952 0.00230 619142 619142 0.00320 266616 266616 0.00140 1328710 1328710 0.00690 58514701 36848099 21666602 0.11190 false 4892585 3865142 23427061 29561252 -6134191 X true true 1 1 LEGACY MT HOOD MEDICAL CENTER 24800 SE STARK STREET GRESHAM OR 97030 www.legacyhealth.org 14-1337 X X X LEGACY MT HOOD MEDICAL CENTER 1 false false true X X X X X X X X X 20 true true true true X www.legacyhealth.org true 21 true www.legacyhealth.org false false true X 300.0000 400.0000 X X X X X true true X X X true X www.legacyhealth.org X www.legacyhealth.org X www.legacyhealth.org X X X X X X true X false X X X X true X false false Facility: LEGACY MT HOOD MEDICAL CENTER - Part V, Section B, Line 5 In 2020, Legacy Mount Hood Medical Center participated with seven other hospital systems, four county health departments and one coordinated care organization in the four-county regional 2019 Healthy Columbia Willamette Collaborative (HCWC) Community Health Needs Assessment (CHNA) which was used as a base for the Legacy Emanuel Community Health Needs Assessment. The results of Legacys Community Needs Assessment can be found at www.legacyhealth.org.The HCWC CHNA is regional and developed to improve efficiency and effectiveness and also to help meet the requirements of the ACA and Public Health Accreditation. HCWC prioritized community input and lived experiences of priority populations and leaders from community-based organizations across the region. Volunteer participants shared their insights on the vision, strengths, challenges, and needs of their communities in town halls and listening sessions. Four town halls were conductedone in each countyand community-based organizations hosted 18 community listening sessions across the quad-county region, with more than 200 participants. In the 2019 CHNA, HCWC also reviewed population data (health-related behaviors, morbidity, mortality); medical data from local Coordinated Care Organizations (CCO) (most frequent conditions Medicaid-covered individuals sought care for); and hospital data (uninsured patients seen in the emergency department for conditions that could have been managed in primary or ambulatory care settings).The following organizations were surveyed or interviewed.Adelante MujeresAntFarmASACCascade AIDS Project Aging WellCentral City ConcernCommunity Partnership for Affordable HousingCity of Lake OswegoClackamas Behavioral Health DivisionClackamas County Aging Services Advisory CouncilClackamas County Community Action BoardClackamas County Disaster ManagementClackamas County Public Health DivisionClackamas County Social ServicesClackamas WorkforceClark County Community ServicesClark County Public HealthCoalition of Community Health ClinicsEstacada Community CenterFaith Organization in Multnomah CountyFriendly HouseIndividual Facilitators, Arabic CommunityIndividual Facilitator, FarmworkersIraqi Society of OregonLatino NetworkMicronesian Islander CommunityMomentum AllianceNAMI, Clackamas CountyNAYA Family CenterNorthwest Family ServicesOutside InOregon AIDS Education & Training CenterOregon Community Health Workers AssociationOregon Dairy and Nutrition CouncilOregon Food BankOregon Health Equity AllianceOregon Office on Disability and HealthOregon Oral Health CoalitionPacific Islander CoalitionPlanned ParenthoodProject Access NOWProvidence ElderPlaceQuest Center for Integrative HealthSW WA Accountable Community of HealthSociety of St. Vincent de PaulVeterans of Foreign WarsVibrant Future Coalition/NW Family ServicesYMCA of Columbia Willamette Facility: LEGACY MT HOOD MEDICAL CENTER - Part V, Section B, Line 6a In addition to Legacy Healths five hospitals which includes Legacy Mount Hood Medical Center, the other seven hospital systems in the metro area that participated in the Healthy Columbia Willamette Collaborative Community Health Needs Assessment were: Adventist Health, Kaiser Permanente, Oregon Health & Science University, Peace Health Southwest Medical Center, Providence Health & Services and Tuality Health Care. Facility: LEGACY MT HOOD MEDICAL CENTER - Part V, Section B, Line 11 The FY2021 Legacy Mount Hood CHNA identified health-related needs across the quad county region. Legacy Mount Hood grouped the health needs identified in the 2019 Healthy Columbia Willamette Collaborative Community Health Assessment into two broad categories of need: Access to Health Care Chronic ConditionsIn addition to identified health-related needs across the quad county region, Legacy Mount Hood Medical Center heard through community members that discrimination, racism and trauma impact the health and well-being of communities and should be addressed as part of all programming and projects (HCWC CHNA 2019). Legacy Mount Hood Medical Centers Community Health Improvement Plan highlights the health equity strategies for this improvement plan cycle.The priority areas identified in this implementation plan will be addressed through health service delivery, health education and outreach, community partnerships, community investments, and funding for evidence-based health programs and services.No singular hospital facility can address all the issues present in our community. Through our partnerships in the Quad County, Legacy Mount Hood Medical Center is confident these needs are being addressed by other community organizations. Legacy Mount Hood Medical Centers top priority continues to be a focus on the issues which have the greatest impact on the health of the community and where we can affect the most change.Details on the specific initiatives Legacy Mount Hood is undertaking to address these priority issues can be found in the Community Health Improvement Plan (CHIP), which can be found on the organizations website at www.legacyhealth.org. Part III, Line 2 - Methodology Used To Estimate Bad Debt Expense LMHMC uses many different approaches to inform and educate patients on the availability of financial assistance as is described later in Part VI of Schedule H. Still, many patients do not respond to requests for information or provide appropriate documentation to benefit from financial assistance. As a result, LMHMC must report these amounts as bad debt. A portion of bad debt expense should be considered as charity care, using reasonable methodologies to analyze the information. Part III, Line 3 - Methodology of Estimated Amount & Rationale for Including in Community Benefit The estimated amount of bad debt expenses attributable to charity care policy was calculated using the FY2021 demographic profile of household income and average household size in the zip code areas around the hospital. 79% of Households in the LMHMC service area would qualify for financial assistance with incomes under 400% of the Federal Poverty Guidelines under this methodology. Part III, Line 4 - Bad Debt Expense The footnote that describes the Legacy bad debt expense can be found on Page 9 of the attached audited financial statements. Part III, Line 8 - Explanation Of Shortfall As Community Benefit The entire Medicare shortfall should be considered a community benefit. Medicare shortfalls must be absorbed by the hospital in order to continue treating the elderly in the community served by the hospital. The hospital provides care regardless of this shortfall and thereby relieves the federal government of the burden of paying the full cost for Medicare beneficiaries. The Medicare amounts listed in Part III Section B. on lines 5, 6, and 7 do not represent all of the organization's revenues and costs associated with its participation in Medicare programs. The methodology used in reporting in Part III Section B Medicare is inconsistent with the other sections in Schedule H, as the instructions limit Medicare revenues and allowable cost to those from only the Medicare Cost Report. Revenue and costs from Medicare Part C patients, Part B physician services billed by the organization, and clinical laboratory services weren't included. In addition, hospitals incur other costs to provide care that Medicare does not allow in the cost report, such as Physician Call pay to ensure adequate physician coverage for the ED. The total revenues and costs attributable to all Medicare services are $57,896,444 and $75,633,189 respectively. This results in a total Medicare shortfall of $17,736,745.Costing Methodology (Part III, Line 8).Medicare allowable costs were calculated using the costing methodologies in the Medicare Cost Report. The cost report arrives at total allowable hospital cost through a cost finding process that includes direct cost allocations and a step-down allocation of indirect or overhead costs. Inpatient operating costs are composed of general inpatient routine and ICU unit costs derived from cost per diems, as well as inpatient ancillary service costs that utilize cost to charge ratios to arrive at cost. Apportionment of cost applicable to hospital outpatient services is through the application of cost to charge ratios. This excludes other costs incurred to provide services of the hospital to the community that the cost report deems as unallowable costs, such as Physician on-call pay. Part III, Line 9b - Provisions On Collection Practices For Qualified Patients Legacy provides care without charge or at amounts less than its established rates to patients who meet certain criteria under its financial assistance policy. Since Legacy does not pursue collection of amounts determined to qualify as charity care, they are excluded from net patient service revenues. Part VI, Line 2 - Needs Assessment Legacy Senior leadership, in conjunction with the Community Benefit staff works with local community-based partners to understand the needs of the community. The goal is to develop programs specific to the needs of the community. Involvement is both proactive and responsive - a leadership role in initiating programs as well as being readily available as a collaborative partner when the community asks. The outcome of this work is the development of both long-term and fiscal year plans. These are then aligned to the community health needs identified in the formal CHNA. The region served by the Legacy Mount Hood, along with most of Oregon, is experiencing significant challenges in population growth, economic development, education and health care. Recognizing that social and economic determinants impact health, Legacy Mount Hood has been and will remain committed to addressing these issues to improve the health of all residents in the community and ensure equity among ethnically diverse populations. Part VI, Line 3 - Patient Education of Eligibility for Assistance Legacy Mount Hood employs financial counselors and social workers that assist patients in obtaining coverage for their healthcare needs. This includes assistance with workers compensation, motor vehicle accident policies, COBRA, veterans assistance, Legacys financial assistance program, and public assistance programs, such as Medicaid. In support of its mission, Legacy Mount Hood provides medically necessary patient care services that are discounted or free of charge to persons who have insufficient resources and/or who are uninsured. The criteria for charity care are determined based on eligibility for insurance coverage, household income, catastrophic medical events, or other information supporting a patients inability to pay for services provided. Specifically, Legacy Mount Hood provides an uninsured discount of 35% to self-pay patients with no coverage. Additional discounts, on a sliding scale, are available to patients whose household income is less than 400% of the federal poverty level. For patients whose household income is at or below 300% of the federal poverty level, a full subsidy is available. In addition to the household income criteria, other catastrophic or economic circumstances are considered in determining eligibility for charity care. In addition to financial counselors and social workers, Legacy Mount Hood makes every effort to communicate its Financial Assistance Program to all patients. This includes signage in main admitting areas of the hospital and brochures explaining financial assistance in all patient care areas, translated for patients/individuals with limited English proficiency (LEP). Financial counselors are available to assist patients in understanding and applying for available resources, including the Legacy Mount Hood Financial Assistance Program. Legacy Mount Hoods website also has information about the availability of financial assistance. Legacy Mount Hood offers financial assistance customer service Monday through Friday, as well as the availability of voicemail so patients can leave confidential, detailed messages during non-business hours. Patients are encouraged to sign up for MyHealth, a secure online tool to access their medical record. Using their MyHealth account they can correspond with a financial counselor via email. Finally, all of Legacys billing statements include information regarding the availability of financial assistance. If Legacy Mount Hood requires the use of a collection agency, those agencies are required to provide a telephone number for patients to call to request financial assistance. Annual education is provided to all billing and admitting staff, so they can be kept informed of and speak with knowledge about current financial assistance policies and options. Legacy Mount Hood provides copies of the latest policies in main admitting areas, as well as with the hospital financial counselor, online via the website and through MyHealth. Legacy Mount Hood also partners with Project Access NOW, a community-based organization that aims to improve the health of our community by creating access to care and services for those in need. The Premium Assistance program serves low-income, uninsured or underinsured; participants receive assistance with monthly insurance premiums to help lower additional out-of-pocket expenses and are provided education on how to utilize insurance once covered. Part VI, Line 4 - Community Information Legacy Mount Hood Medical Center is a full-service hospital in East Multnomah County and offers advanced care and expertise in robotic-assisted surgery, cancer treatment and gastrointestinal care. Legacy Mount Hoods services include emergency care, maternity, surgery radiology, breast health, cardiac rehabilitation and orthopedic services. Legacy Mount Hood is located in Gresham, 25 miles east of downtown Portland. The primary service area is Multnomah County and includes the cities/towns of Gresham, Troutdale, Fairview, Corbett and Wood Village and extends from the Columbia River in the north to Estacada in the south, and from S.E. 122nd Ave. in the west to Mt. Hood in the east.The demographic data that informed Legacy Mount Hood's CHNA/CHIP for FY22 is from 2012-2016. The population estimate of the primary service area for Legacy Mount Hood was 778,193. The primary service area was 78.2% white, 11.1% Hispanic or Latino, 6.9% Asian, 5.4% Black/African American, 0.8% American Indian/Alaska Native, 0.6% Native Hawaiian and Other Pacific Islander, and 5.2% of two or more races. Foreign-born population represents 13.9% of the community and languages other than English account for 19.7%. In Multnomah County, while White individuals median per capita income was $36,751, Native Hawaiians/Pacific Islanders had the lowest median per capita income at $15,905 followed by Native Americans/Alaska Natives at $16,534, Hispanics/Latinos and two or more races at $17,335, African Americans/Blacks at $17,805, and Asian Americans at $27,896.In FY22, Legacy Mount Hood Medical Center provided $5.1 million in charity care and $38 million in total unpaid costs of care for those in need. Part VI, Line 5 - Promotion of Community Health The Legacy Health system is involved in several activities and provides a wide variety of services that engage community members and promote community health. For example, the Legacy Health Board is comprised of volunteer community leaders, hospital administrators and representatives of the Lutheran and Episcopal churches who guide Legacys efforts in meeting its mission of providing good health for our people, our patients, our communities and our world. The Community-Based Advisory Committee (CBAC) assists the Community Benefit department with the development and implementation of the Community Health Needs Assessments (CHNAs) and Community Health Implementation Plans (CHIPs) for each Legacy Medical Center. Legacy Community Benefit and the CBAC work closely with the Healthy Columbia and Willamette Collaborative and other partners in the Portland metropolitan area (Clackamas, Multnomah, Washington counties in Oregon and Clark County in SW Washington) to assess community needs and describe how the Legacy Mount Hood Medical Center will address these needs and evaluate the effectiveness of its efforts within its service community.The Legacy Mount Hood Medical Center gives in-kind lab donations to safety net clinics in their service areas. Non-cash donations of clinical and non-clinical services and items, e.g., screenings and support services, internships, information and referral services, and health fairs, also are provided. Legacy Healths supply warehouse is open to local non-profit organizations to obtain surplus equipment and furniture. In addition, free office and conference space and other infrastructure services are made available to local non-profit organizations in the Legacy Good Samaritan service area for a variety of uses. In addition, Legacy provides training for interns and residents through its nationally accredited graduate medical education program, Legacy Health supports over 500 employed and visiting medical trainees annually across many disciplines. Health professions training ranged from nursing, occupational and physical therapy, and radiography to public health, lab assistant, emergency medical technician, and many others. Legacy also partners with schools to provide training and education for nursing and other health professionals.Legacy Mount Hoods medical staff is open, with physicians submitting credentialing information that is reviewed according to Legacy Health policies and standards.Legacy Mount Hood collaborates with other health care providers, community-based organizations, business and the public on projects to improve the health of the community. One example of clinically based partnerships includes, among others: CARES NW (Child Abuse Response and Evaluation Services), a collaboration among four health systems Kaiser Permanente, OHSU Doernbecher Childrens Hospital, Providence Childrens Health and Randall Childrens Hospital at Legacy Emanuel; Legacy Emanuel serves as the employer and donates the infrastructure. Additionally, the first collaborative medical initiative of its kind in the Pacific Northwest, Unity Center for Behavioral Health, is a joint effort between Adventist Health, Kaiser Permanente, Oregon Health & Science University and Legacy Health, providing psychiatric emergency services. Legacy has collaborated with more than a dozen community mental health partners in developing this new psychiatric center. Part VI, Line 6 - Affilated Health Care System The Legacy Mount Hood Medical Center is a subsidiary of Legacy Health. Legacy Health (Legacy) is an integrated health system headquartered in Portland, Oregon. Legacy operates six acute care hospitals, provides dedicated childrens care at the Randall Childrens Hospital at Legacy Emanuel, Unity Center for Behavioral Health and offers related services (e.g., physician practices, hospice, preferred provider network) in the four-county metro area of Portland, Oregon (Clackamas, Multnomah, Washington counties in Oregon and Clark County in SW Washington) and in Marion County, Oregon, which is approximately 50 miles south of Portland. Legacy Health conducts system-wide projects and activities to improve the health of its service communities. For example, Legacy's policy of providing care regardless of an individuals ability to pay makes it one of the region's largest providers of uncompensated care. As the health needs of communities surrounding our hospitals are frequently changing, Legacy Health continues to identify investments for underserved populations. For example, in FY2022, Legacy contributed over one million dollars ($1,027,420.00) to two health care collaboratives (Project Access NOW and the Health Systems Access to Care Fund) that ensure access to culturally responsive primary and specialty health services for community members in Legacy service areas.In response to the lack of diversity within health professions and the persistent inequities in education, employment, and income among communities of color, Legacy Health established the Health Occupation Profession and Education program (HOPE, formerly Youth Employment in Summer) to provide work experiences through paid summer internships in the health care professions for underserved students of color. The primary goal of the program is to increase the number of underserved persons of color entering health care careers and to promote greater diversity in health care professions. Each summer between 5-15 students from ethnically diverse communities participate in the program. Students are paid between $15-18 per hour and may work up to 400 hours within available clinical and non-clinical departments across the Legacy Health system. Students meet weekly with a mentor and/or attend workshops to ensure the needs of the student and the department are being met.Students who perform well during the summer internship qualify for college tuition assistance ranging from $3,000 to $10,000 annually. These successful students also may continue in the HOPE program the following summer if they maintain the educational requirements for the program. Some students have remained in the program for seven years. Program alumni graduate with a range of degrees including imaging technology, nursing, and medicine. Most students are the first in their family to go to college. At all sites, Legacy Health trains interns and residents through its nationally accredited graduate medical education program and partners with local nursing and other health professional schools and programs to provide practical training and education.Legacy Health also collaborates with and supports other health care systems, public health agencies and community-based organizations to improve the health of the community. For example, in the fall of 2018, Legacy Health, Kaiser Permanente NW, PeaceHealth and Providence Health & Services came together to create the Health Systems Access to Care Fund through the Oregon Community Foundation. The goal of this fund is to strengthen the capacity and infrastructure for community clinics that are expanding and/or adapting their current models in response to the changing needs of patient populations due to ongoing healthcare reform, Medicaid transformation, and the increasing pressure on the safety net for access to care. Community clinics in Oregon and SW Washington were awarded multiyear grants up to $50,000. In 2022, eleven clinics continued existing work focused on four main areas which included assuring easy access to care, improving quality of care, strengthening leadership and enhancing data collection. Finally, Legacy Community Benefit supports organizations and partnerships in the Legacy Medical Centers service communities whose work addresses community-identified needs and aligns with the objectives and strategies of each Medical Centers Community Health Implementation Plan. In FY2022, Community Benefit funded 18 community-based organizations ($668,500.00) that promoted workforce development and educational attainment and addressed behavioral health issues within the communities served by Legacy Health. Part VI, Line 7 - States Filing of Community Benefit Report OR false MEDICAL TEAMS INTERNATIONAL 14150 SW MILTON CT TIGARD OR 97224 930878944 501(c)(3) 0 10504 COST SUPPLIES FOR DISASTER ASSISTANCE 1 0 PATIENT NEEDS FOR SAFE DISCHARGE 219704 TRANSPORTATION PATIENT NEEDS FOR SAFE DISCHARGE 22384 HOUSING, SHELTER, TRANSPORTATION true true false true true true true false true true ALEXANDER GLADNEY SECRETARY 363462 104500 10989 8376 15288 502615 ANITA N IYENGER SR VP 571791 1000 -4147 58583 32434 659661 ANNA LOOMIS CFO & TREASURER 839668 1000 -2881 24841 36530 899158 ANNE T GREER SECRETARY 308319 16063 3251 38546 23185 389364 ARUNA JAYARAM MD PHYSICIAN 213744 42773 -981 50370 13147 319053 BRENDA SHERMAN RN REGISTERED NURSE 195370 46469 -4970 23038 22504 282411 BRYCE R HELGERSON SR VP 764766 1000 1488 120126 15991 903371 CAROL A BRADLEY FORMER SR. VP 117186 24178 141364 GRETCHEN M NICHOLS HOSPITAL PRESIDENT 595875 1000 56838 58867 38837 751417 JOHN J KENAGY SR VP 612001 1000 -1863 54945 43695 709778 JONATHAN HILL MD BOARD DIRECTOR 282130 25600 4917 11600 29214 353461 KATHRYN CORREIA President & CEO 1718633 1000 5587 43448 43031 1811699 KECIA M KELLY DNP SR VP 210096 43500 19158 6928 13855 293537 LAURA E OSTROM MD PHYSICIAN 308329 7726 -11592 32587 30014 367064 LESLIE ROOT MD BOARD DIRECTOR 159240 63269 -312 23204 3912 249313 LISA G GOREN SR VP 270000 1000 -6274 21764 27795 314285 MAUREEN A BRADLEY SR VP 358240 1000 36049 56478 23068 474835 MELINDA J MULLER MD SR VP 482812 42381 -5111 59793 40045 619920 MICHELLE L JOHN PHYSICIAN 202465 23460 -5480 21570 19334 261349 ROBERT E DEWITT FORMER SR. VP & SECRETARY 184437 15758 200195 SETH R PODOLSKY MD SR VP 288750 33500 10846 378 14404 347878 SHEVYLL S TAN MD PHYSICIAN 201263 44181 -5409 12286 32903 285224 SONJA O STEVES SR VP 571000 1000 4338 96808 25665 698811 TANYA R SHANKS-CONNORS VP CNO 251611 1000 21254 35467 16128 325460 TRENT S GREEN SR VP 1029518 1000 34559 53413 39155 1157645 Part I, Line 5b: Explanation of organization compensation based on revenues of related organization Physicians employed by Legacy affiliates are paid variable compensation based on quality, value, and production. Production is based upon the level of effort of services provided during the year measured by industry standard relative value units (RVU) and which generate revenue. Part I, Line 6b: Explanation of organization compensation contingent on net earnings from related or Legacy has an at-risk incentive compensation plan for management. The plan is based on meeting goals related to employee engagement, work processes, customer service, clinical quality, financial management, and certain key strategic tactics. In order to payout any at-risk incentive compensation, Legacy must exceed operating margin targets. Part I, Line 8: Amounts reported on 990 VII pursuant to initial contract exemption described in Regs Legacy enters into initial employment agreements with Executives that qualify under the initial contract exception. The Compensation Committee of the Board of Directors, none of whom is a Legacy employee, reviews the compensation for key executive positions. The Committee relies on comparable market data and all decisions are documented. Part III, Additional Information Sch J, Part 1, Question 3 Regarding Compensation PracticesDirectors for Legacy started receiving compensation for their services in August 2014. They also receive expense reimbursements related to their duties. Any expense reimbursements to board members are reviewed by the Director of Tax for determining 1099 tax reporting. In addition to the Board of Directors compensation, during 2021, Dr. Hill received compensation related to his duties as Clinical VP while Dr. Root received compensation for medical services provided at Legacy Emanuel Hospital. There was no other reportable compensation received by any board member during 2021.Executive compensation for Legacy is designed to recruit, retain and motivate qualified senior management personnel. The comprehensive compensation plan is designed for positions that have a significant impact on the high-level strategic and policy direction of Legacy and its affiliates. Base pay and total compensation (including incentive compensation) for similar positions is established at a level comparable to market compensation for healthcare organizations. External consultants are regularly used to review published compensation surveys of comparable organizations and comparable benchmark positions in the market. The Compensation Committee of the Board of Directors, none of whom is a Legacy employee, reviews the compensation for executive positions. The Committee oversees the system's governance procedures with respect to intermediate sanctions legislation and the evaluation of reasonableness of compensation. The Committee reports to the Board in sufficient detail to enable the entire Board to take such actions as are required to obtain the rebuttable presumption of reasonableness. The Compensation Committee also reviews tax-reporting disclosures.Sch J, Part II, Column Breakdown Of W-2 Or Misc-1099:Column B(i) - Base compensation consists of regular base pay including employee elected deferrals for retirement plans (403(b) and 457(b) plans).Column B(ii) - The incentive compensation program for Legacy is based on predetermined criteria and reviewed and approved by the Board. Bonuses are paid to key employees for interim duties outside their primary responsibilities (e.g. Acting in Capacity).Column B(iii) - Other compensation consists of deferred compensation amounts paid to executives during the current year and were reported on prior form 990 returns. These amounts include arrangements that contain elements of a substantial risk of forfeiture conditioned on continued employment, vesting and/or a noncompete provision upon termination of employment. Distributions from 457(b) plans, reported to the employee on a 1099-R, are also included as other compensation. In addition, imputed income for insurance, cell phone and other benefits is included in other compensation as well as any severance related payments.Column C - Deferred compensation includes the contributions to defined contribution plans, amounts deferred under the 457(f) plan including earnings, earnings in the 457(b) plan, and the value of the pension restoration plan. Earnings on the 457(f) and 457(b) include gains and losses on the underlying investments. The defined contribution plan is available to all employees as they become qualified to participate. The pension restoration plan provides executive pension benefits in excess of IRS mandated limits on eligible compensation to key executives. The benefits are unfunded and subject to forfeiture. Executive pension benefits are intended to make the executive's retirement benefit, as a proportion of their final average salary, comparable to all other employees, and are treated as income when paid.Column D - Nontaxable benefits include company paid health and welfare and long-term care and disability benefits under group plans.Column F - Current year compensation reported as deferred in prior years. Form 990, Part VI, Line 3: Description of Delegated Duties to Management Company Legacy Health (Legacy) provides management services for all of its affiliated companies which includes, accounting, purchasing, contracting, legal, human resources, information technology, billing, facilities, budgeting, transcription, security, public relations, strategic planning, organization development. Form 990, Part VI, Line 6: Explanation of Classes of Members or Shareholder Legacy Health is the sole member of Legacy Mount Hood Medical Center. Form 990, Part VI, Line 7a: How Members or Shareholders Elect Governing Body The Board of Directors includes the following members: (a) The Bishop of the Oregon Synod of the Evangelical Lutheran Church inAmerica (the "Oregon Synod") or the Bishop's designee, who shall serve ex officio;(b) The Bishop of the Episcopal Diocese of Oregon (the "Episcopal Diocese")or the Bishop's designee, who shall serve ex officio;(c) One (1) person elected by the Legacy Health Board of Directors pursuant to the process set forth in the Bylaws; provided, however, that such person shall be an active member of a Lutheran congregation in the Oregon Synod ("Lutheran Director");(d) One (1) person elected by the Legacy Health Board of Directors pursuant to the process set forth in the Bylaws; provided, however, that such person shall be an active member of an Episcopal congregation in the Episcopal Diocese known to his/her parish priest, or alternatively a member of the clergy in the Episcopal Diocese ("Episcopal Director"). Form 990, Part VI, Line 7b: Describe Decisions of Governing Body Approval by Members or Shareholders The election of Lutheran Director is subject to the approval by the Bishop of the Oregon Synod, who may object to the newly-elected director for any reason by delivering written notice to the Legacy President or the Chair of the Board of Directors no later than one week after the election. If the Bishop timely objects to the election of the new Lutheran Director, the election will be ineffective and that person will not be a director; otherwise, if no timely objection is received, that person shall be conclusively presumed to be the Lutheran Director for his/her full term or the remainder of an unexpired term to which elected. The election of the Episcopal Director is subject to approval by the Bishop of theEpiscopal Diocese, who may object to the newly elected director for any reason by delivering written notice to the Legacy President or Chair of the Board of Directors no later than one week after the election. The election of the Episcopal Director is also subject to approval by the Standing Committee of the Episcopal Diocese, who may object to the newly elected director only on the grounds that he/she is not an active member of an Episcopal congregation or a member of the Episcopal clergy in the Episcopal Diocese; such objection to be effected by delivering written notice to the Legacy President or Chair of the Board of Directors within five days after the next meeting of the Standing Committee or 45 days after the election, whichever isearlier. If the Bishop or Standing Committee timely object to the election of the new Episcopal Director, the election will be ineffective and that person will not be a director; otherwise, if no timely objection is received, that person shall be conclusively presumed to be the Episcopal Director for his/her full term or the remainder of an unexpired term to which elected. Form 990, Part VI, Line 11b: Form 990 Review Process The Legacy Board received a copy of the 990 return prior to filing. At the direction of the entire Board, the Board Compensation Committee reviewed the compensation disclosures and the Board Audit and Compliance Committee reviewed the 990 returns for Legacy and Legacy Emanuel Hospital & Health Center with Management prior to filing. Any key differences in disclosure for other affiliated entities, including Legacy Mount Hood Medical Center were discussed with the Board Audit and Compliance Committee. Form 990, Part VI, Line 12c: Explanation of Monitoring and Enforcement of Conflicts The following is a summary of Legacy's policy and procedures for conflict of interest disclosure, monitoring and resolution.All Legacy employees and non-employees in leadership positions (e.g., Board members, Foundation Trustees, Medical Directors) are required to disclose potential conflicts of interest as the conflict arises. All employees are required to disclose any conflict of interest per the Standard of Conduct policy. Certain groups have annual formal disclosure requirements, Executives and non-employees in leadership positions complete the Conflict Disclosure Statement from the Standards of Conduct policy annually. Officers, Directors, Trustees, Key and Highly Compensated employees are also required to complete a questionnaire covering business relationships, business transactions with interested parties, loans and grants. Conflict Disclosure Statements and questionnaires are returned to Legacy Corporate Compliance or Tax Departments for review of the disclosure. If a conflict is disclosed, or identified through any other means, Legacy Corporate Compliance ensures that management mitigates the risk (e.g., discontinues relationship with vendor, segregates responsibilities, recuses Board member from voting in area of conflict) and that the conflict and mitigation steps are reported to the appropriate level (e.g. Audit and Compliance Committee of the Board). Form 990, Part VI, Line 15b: Compensation Review and Approval Process for Officers and Key Employees The following describes the compensation practices of Legacy Health and its affiliates.Executive compensation for Legacy is designed to recruit, retain and motivate qualified senior leaders responsible for ensuring Legacy Health serves its mission and patients every day, and for ensuring a safe, inclusive and equitable workplace for all Legacy employees. The comprehensive compensation plan is designed for positions that have a significant impact on the high-level strategic and policy direction of Legacy and its affiliates, and are accountable for the effective day-to-day operation of the system.Base pay and total compensation (including incentive compensation) for similar positions is established at a level comparable to market compensation for healthcare organizations. External consultants are regularly used to review published compensation surveys of comparable organizations and comparable benchmark positions in the market. The Compensation Committee of the Board of Directors, none of whom is a Legacy employee, reviews the compensation for key executive positions. The Committee oversees the system's governance procedures with respect to the evaluation of reasonableness of compensation. The Committee reports to the Board in sufficient detail to enable the entire Board to take such actions as are required to obtain the rebuttable presumption of reasonableness. The Compensation Committee also reviews tax-reporting disclosures. Form 990, Part VI, Line 19: Other Organization Documents Publicly Available Legacy Health's audited and interim consolidated financial statements are publicly available on the Electronic Municipal Market Access(EMMA) (www.emma.msrb.org) and DAC Bond (www.dacbond.com) websites. Legacy's audited consolidated financial statements include consolidating schedules which highlights LMHMC's financial results.When changes are made to the LMHMC Articles or Bylaws, LMHMC discloses and attaches copies to the IRS Form 990, which are publicly available by request or on various public websites such as Guidestar(www.guidestar.org). Other governing documents are not available to the public. Other Changes In Net Assets Or Fund Balances - Other Decreases GIFT SHOP OPERATIONS FUND = -$10503 Other Changes In Net Assets Or Fund Balances - Other Increases Rounding = $4 Form 990, Part IV, question 12 Legacy has an audit of its consolidated financial statement which includes consolidating schedules highlighting LMHMC's financial results. Form 990, Part VI, question 2 Legacy Health System CPC, LLC (CPC) is a common pay agent for Legacy and its affiliates. The CPC files all required federal employment tax returns for Legacy and its affiliates. The number of employees reported on Form W-3 for LMHMC is 1,233. Form 990, Part X LMHMC participates in the Legacy investment pooled funds which include professionally managed equity and fixed income securities in both separately managed portfolios and commingled investment accounts. Investment returns are prorated according to each affiliate's share of the pool. Form 990, Schedule J Schedule J Reporting of Officers and Senior Management on Legacy Affilate Returns. The Legacy Officers, Senior Vice Presidents and other key employees may have responsibilities for the operations of the entire health system, including the affiliated entities. Their compensation is paid from and reported on the Legacy return(EIN 23-7426300). The compensation is reported again for informational purposes on related affiliated entity returns including, Legacy Emanuel Hospital & Health Center, Legacy Good Samaritan Hospital and Medical Center, Legacy Meridian Park Hospital, Legacy Mount Hood Medical Center, Legacy Salmon Creek Hospital, and Legacy Visiting Nurse Association. 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