2022-02-15T16:09:23-08:00 2021-03-31 990 2020-04-01 930618975 LEGACY MERIDIAN PARK HOSPITAL LEGA 5034155600 19300 SW 65TH AVENUE TUALATIN OR 97062 ANNA L LOOMIS CFO & TREASURER 2022-02-15 ANNA L LOOMIS 999009999 2 AAL1 IAL1 FAL1 2020 2022-09-23 18:48:47Z KATHRYN CORREIA 19300 SW 65TH AVENUE TUALATIN OR 97062 261054650 false X WWW.LEGACYHEALTH.ORG X 1973 OR Legacy Meridian Park Hospital (LMPH), established in 1973, is a community hospital in Tualatin, OR. LMPH is South Metro's most sophisticated medical center and provides the personal touch of a community hospital along with a variety of specialized services. 17 13 0 24 86360 249993 371438 274283143 260517004 -6467026 46108 70751 66181 268136861 261000731 0 0 110727571 111679072 0 0 125174872 122360557 235902443 234039629 32234418 26961102 479530781 531167310 37722930 62398357 441807851 468768953 Legacy Meridian Park Hospital (LMPH), established in 1973, is a community hospital in Tualatin, OR, south of Portland with 150 licensed beds. LMPH serves the needs of the fast growing communities of Tualatin, Tigard, Wilsonville, Sherwood, West Linn, and Lake Oswego. LMPH offers outpatient diagnostic, angiography, and MRI/MRA, a total joint, diagnostic and interventional cardiac cath, a nationally recognized stroke program, cancer treatment, intensive and intermediate care units, a family birth center, and pediatric and ambulatory care units in the emergency department. LMPH 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 ach false false 177689926 260517031 In support of its mission, LMPH 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 2021, LMPH provided financial assistance on approximately 5,491 patient accounts (of which 683 accounts received discounts totaling 100% of costs) and resulted in LMPH incurring roughly $3,785,507 in uncompensated costs associated with this program. In addition to charity care, LMPH provides services under various states' Medicaid programs for financially needy patients and Medicare beneficiaries programs for which the cost of treating these patients exceeds the government payments received. During fiscal year 2021, LMPH incurred approximately $8,815,700 and $18,534,800 in uncompensated costs attributable to Medicaid and Medicare programs, respectively. LMPH 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 $836,900 during fiscal year 2021.LMPH is part of Legacy, which collectively provided over $42 million, $258 million, $191 million, and $7 million in uncompensated care attributable to its financial assistance, Medicaid, Medicare, and other government programs, respectively, in fiscal year 2021. In addition, Legacy provided over $21 million in other community benefit activities during fiscal year 2021. 177689926 true true false true false false false false false true true true false false true false false true false false false false false false false false true true false false 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 false OR X X ANNA LOOMIS 5034155600 1919 NW LOVEJOY STREET PORTLAND OR 97209 KATHRYN CORREIA President & CEO 0.00 40.00 X X 0 1828174 62132 TRENT S GREEN SR VP 0.00 40.00 0 984100 78481 ANNA LOOMIS CFO & TREASURER 0.00 40.00 X X 0 945032 46582 BRYCE HELGERSON SR VP 0.00 40.00 0 738723 104095 LEWIS L LOW MD SR VP 0.00 40.00 0 746920 69162 JONATHAN E AVERY HOSPITAL PRESIDENT 40.00 0.00 688363 0 97140 JOHN J KENAGY SR VP 0.00 40.00 0 676875 88776 SONJA O STEVES SR VP 0.00 40.00 0 574772 127479 MELINDA J MULLER MD SR VP INTERIM 0.00 40.00 0 507985 108917 ROBERT E DEWITT FORMER SR. VP & SECRETARY 0.00 0.00 0 504774 18636 CHRISTOPHER THOMING MD CLINICAL VP 20.00 20.00 427008 25403 53421 ANITA N IYENGER SR VP 0.00 40.00 0 410454 60096 MAUREEN A BRADLEY SR VP 0.00 40.00 0 388955 73838 CAROL A BRADLEY FORMER SR. VP 0.00 0.00 0 406321 31375 ANNE T GREER Secretary 0.00 40.00 X X 0 353676 60712 MELINDA C STIBAL VP 40.00 0.00 309348 0 47542 JONATHAN HILL MD BOARD DIRECTOR 3.00 40.00 X 0 296477 37731 ERIC J MACEVOY MD MEDICAL DIRECTOR 40.00 0.00 272838 0 54791 POMPY Z GOSWAMI PHYSICIAN 40.00 0.00 272442 0 51184 GWEN J GREWE MD MEDICAL DIRECTOR 40.00 0.00 258964 0 58499 BRIAN M BEDOLLA MD MEDICAL DIRECTOR 40.00 0.00 247140 0 51806 LESLIE ROOT MD BOARD DIRECTOR 4.00 40.00 X 0 201390 26242 CHARLES WILHOITE Chairman 4.00 0.00 X X 0 22500 0 DAVID RAMUS VICE CHAIR 4.00 0.00 X X 0 17500 0 GAYLE GOSCHIE BOARD DIRECTOR 3.00 0.00 X 0 12500 0 NANCY R LOCKE BOARD DIRECTOR 4.00 0.00 X 0 12500 0 LYNN T GUST BOARD DIRECTOR 3.00 0.00 X 0 12500 0 JEFFREY BARBER BOARD DIRECTOR 3.00 0.00 X 0 7908 0 JEFFREY D FULLMAN MD BOARD DIRECTOR 3.00 0.00 X 0 7500 0 NANCY HORTON BOARD DIRECTOR 3.00 0.00 X 0 7500 0 SAMIR DESAI MD BOARD DIRECTOR 3.00 0.00 X 0 7500 0 JACK A FRIEDMAN BOARD DIRECTOR 3.00 0.00 X 0 7500 0 LISA FREEDMAN BOARD DIRECTOR 3.00 0.00 X 0 7500 0 JERRY D PETTY BOARD DIRECTOR 3.00 0.00 X 0 7500 0 EDGAR NAVAS BOARD DIRECTOR 3.00 0.00 X 0 7500 0 PATRICK REITEN BOARD DIRECTOR 3.00 0.00 X 0 7500 0 BISHOP DIANA AKIYAMA BOARD DIRECTOR 3.00 0.00 X 0 0 0 BISHOP LAURIE L CAESAR BOARD DIRECTOR 3.00 0.00 X 0 0 0 2476103 9735439 1408637 271 true true false ECHO VISION INC 7214 NE 72ND PL VANCOUVER WA 98662 MEDICAL SERVICES 496020 WAVE FORM SYSTEMS INC PO BOX 35142 SEATTLE WA 98124 MEDICAL SERVICES 324375 SURGICAL INSTRUMENT SERVICE CO 151 N BRANDON DRIVE GLENDALE HEIGHTS IL 60139 MEDICAL SERVICES 277205 RENAL CARE GROUP NORTHWEST INC PO BOX 749959 LOS ANGELES CA 90074 MEDICAL SERVICES 260884 OREGON ANESTHESIOLOGY GROUP PC 847 NE WASHINGTON ST STE 700 PORTLAND OR 97205 MEDICAL SERVICES 228105 10 371438 371438 CAFE & GIFT SHOP 931001 931001 PATIENT PROGRAM REV 259499643 259499643 PHARMACY 86360 86360 260517004 27 27 0 0 66181 66181 66181 66181 100000 53919 46081 46081 46081 0 0 0 0 261000731 259499643 86360 1043290 0 0 0 0 1502441 1303603 198838 0 84812957 75098689 9714268 4926900 4376363 550537 13590744 12007779 1582965 6846030 5940005 906025 0 63660 63660 0 0 0 0 2666530 2666530 0 35803832 34957776 846056 0 0 1847238 1073220 774018 5446 4661 785 0 0 535837 458569 77268 0 6254967 5352993 901974 3043872 2844202 199670 ADMINISTRATIVE SERVICES FEES 35770032 35770032 CONTRACT SERVICES 14966447 10645818 4320629 PROVIDER TAX 13787836 13787836 BAD DEBTS 7286550 7286550 328310 -114668 442978 234039629 177689926 56349703 0 333673 707590 0 0 28307535 30970426 0 0 0 3632236 3717557 127151 123373 181150714 146443907 35911969 34706807 0 404118388 453841730 0 0 7099829 7099827 479530781 531167310 16981086 42281948 20741844 20116409 37722930 62398357 X 441807851 468768953 441807851 468768953 479530781 531167310 26961102 X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false X 285875 285875 209894189 2077339064 209894189 2077624939 1000000 1000000 250000 250000 false 2000000 2000000 2000000 2000000 8000000 12000000 296586 316588 402167 285875 1301216 500000 500000 500000 500000 2000000 3000000 3173958 634376 242645 4050979 5999285 -2563071 -67066 195190 3173958 5852078 206601 12267 71663 5999283 5544718 368737 83402 144780 5852077 4223199 1319261 79354 77096 5544718 false true true 153922 153922 85542546 72064924 13477622 8292605 2592997 5699608 86707398 71785986 14921412 454243 454243 34706807 453841730 I/C AFFILIATE DEBT 19497142 MPP NONCURRENT WORKERS' COMP LIABILITIES 9151 NONCURRENT ENVIRONMENTAL OBILGATION 189954 NONCURRENT WORKERS' COMP LIABILITY 420162 20116409 259717000 -46674 -46674 259763674 1237057 1237057 261000731 232926000 -46936 -46936 232972936 1066693 1066693 234039629 Part V, Line 4: Intended uses of the endowment fund. Endowment funds disclosed in Part V are used to improve the healthcare of the community as designated by the donors. Meridian Park Medical Foundation (MPMF) maintains all charitable gifts including endowment funds for the benefit of LMPH and it's programs. In 2021, the MPMF board of trustees approved the dissolution of MPMF and a merger of the Foundations assets into the Legacy Health Foundation (LHF). All assets of MPMF 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 $357572 MEDICAL STAFF INCOME $378247 FOUNDATION CAPITAL CONTRIBUTION $13866 PROGRAM SERVICE REVENUE $487372 Part XII, Line 4b: Other revenue amounts included on 990 but not included in F/S MEDICAL STAFF EXPENSE $221749 FOUNDATION CONTRIBUTION $357572 PROGRAM SERVICE REVENUE $487372 true true X true X 300.000000000 true X true true true false true true 3785507 3785507 0.01620 26834680 18018979 8815701 0.03770 30620187 18018979 12601208 0.05390 177652 177652 0.00080 245672 245672 0.00100 413622 413622 0.00180 836946 836946 0.00360 31457133 18018979 13438154 0.05750 false 7286550 4590527 37329631 49596362 -12266731 X true true 1 1 LEGACY MERIDIAN PARK HOSPITAL 19300 SW 65TH AVENUE TUALATIN OR 97062 www.legacyhealth.org 14-1336 X X X LEGACY MERIDIAN PARK HOSPITAL 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 MERIDIAN PARK HOSPITAL - Part V, Section B, Line 5 In 2020, Legacy Meridian Park 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 Meridian Park 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).Our work included the following community partners: 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 MERIDIAN PARK HOSPITAL - Part V, Section B, Line 6a In addition to Legacy Healths five hospitals which includes Legacy Meridian Park 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 MERIDIAN PARK HOSPITAL - Part V, Section B, Line 11 The FY2021 Legacy Meridian Park CHNA identified health-related needs across the quad county region. Legacy Meridian Park 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 Meridian Park 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 Meridian Park 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 Meridian Park Medical Center is confident these needs are being addressed by other community organizations. Legacy Meridian Park 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 Meridian Park 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 I, Line 7 - Explanation of Costing Methodology 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 2 - Methodology Used To Estimate Bad Debt Expense LMPH 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, LMPH 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 demographic profile of household income and average household size in the zip code areas around the hospital. 63% of Households in the LMPH service area would qualify for financial assistance with incomes under 400% of the Federal Poverty Guidelines using this methodology. Part III, Line 4 - Bad Debt Expense The footnote that explains 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 $92,260,703 and $110,795,489 respectively. This results in a total Medicare shortfall of $18,534,785.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 The described CHNA provides the primary source for assessing needs. Senior leadership, in conjunction with the Board of Directors, continually assesses the needs of the communities it serves through a compilation of primary and secondary market research (qualitative and quantitative), medical staff input, reviewing national trends and practices, working with local foundations and funders regarding their assessments, and working with local community-based partners to understand their needs. The goal is to understand the needs and develop programs specific to 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 these assessments is the development of both long-term and fiscal year plans that are supported by a yearly budget that is proposed by staff and approved by the Board of Directors. Community Benefit staff as well as Legacy representatives on nonprofit and community based boards serving communities at risk also provide ongoing informal feedback regarding needs. These are then aligned to the community health needs identified in the formal CHNA. The region served by Legacy Meridian Park Hospital (LMPH), 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, LMPH has been and will remain committed to addressing these issues to improve the health of all residents in the community, including equity among ethnically diverse populations. Part VI, Line 3 - Patient Education of Eligibility for Assistance LMPH 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, LMPH's financial assistance program, and public assistance programs, such as Medicaid. In support of its mission, LMPH 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 based on eligibility for insurance coverage, household income, qualified assets, catastrophic medical events, or other information supporting a patients inability to pay for services provided. Specifically, LMPH 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, patients qualified assets (e.g., 25% of household assets) and other catastrophic or economic circumstances are considered in determining eligibility for charity care.In addition to financial counselors and social workers, Legacy Meridian Park 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 Meridian Park Financial Assistance Program. Legacy Meridian Park website also has information about the availability of financial assistance. Legacy Meridian Park 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 Meridian Park requires the use of a collection agency, those agencies are required to provide a telephone number that patients can 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. LMPH 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. Part VI, Line 4 - Community Information LMPH is located in Tualatin, Oregon and straddles the Clackamas and Washington County border. As a full service hospital in the south metro area, the hospitals primary service area includes the fast-growing communities of Tualatin, Tigard, Wilsonville, Sherwood, West Linn, Canby and Lake Oswego. The five mile radius is predicated on the assumption that this includes approximately 80 percent of the hospital's discharges. Primary service area zip codes include :97002, 97007, 97008, 97013, 97032, 97034-97235, 97140, 97062, 97068, 97070, 97223-97224, 97071, 97045, 97219, 97132, and 97038. Legacy added two clinics located in Woodburn and Canby. While these communities are not within LMPH's five mile primary service area, the clinics are considered as part of LMPH's communities. Since there are only a few large employers located in the area, most residents commute to other cities for employment.The majority population lives in Clackamas and Washington counties which showed an estimated population of approximately 1,019,779 in 2019. The LMPMC primary service area was 81.1 percent non-Hispanic white, 9 percent Hispanic, 1.2 percent African American, 4.9 percent Asian, 3.7 percent bi-racial, and 0.3 percent Native American in Clackamas county. Washington county which is also included in the LMPMC primary service area had 64.6 percent non-Hispanic white, 2.5 percent African American, 11.7 percent Asian, 4.5 percent bi-racial, and 0.5 percent Native American. The prevalence of speaking a language other than English at home continues to increase year over year, particularly in Washington County where 24.8 percent of the population falls into this cohortas compared with 12.1 percent in Clackamas County. Spanish is the most common language spoken, with Vietnamese and Chinese also prevalent.Across Clackamas and Washington Counties 2012-2016, individuals who identified as African American/Black, Hispanic/Latino, Native American/Alaska Native, Native Hawaiian/Pacific Islander, and Two or More Races had lower median per capital incomes than White or Asian groups.The LMPH primary service area is also served by Providence St. Vincent Medical Center, a tertiary hospital located just north of the primary service northern boundary. Community-based Providence Willamette Falls Hospital located in Clackamas County is beyond the primary service area, but serves some of the overlapping area. Located in far west Washington County is community-based Tuality Hospital. It is outside the service area, but in the same primary service area county. Kaiser Permanente has a strong presence with clinics and a hospital in Clackamas' Sunnyside area. In 2013, Kaiser also opened a hospital in mid-Washington County.The Dignity Health and Truven Health Community Needs Index (CNI) is accepted as the national standard in identifying communities with health disparities and comparing relative need. CNI for the Legacy Meridian Park service area shows highest need in close proximity to Meridian Park: 97008-Beaverton.Southwest Clackamas County includes a Medically Underserved Areas (MUA)beyond the primary service area. Clackamas County Health Department Clinics are FQHCs, but are located across the Willamette River in areas further from Legacy Meridian Park. Legacy Medical Group Clinic in Canby is a designated Rural Health Center. One volunteer staffed safety net clinic, now under the umbrella of SW Community Health Center, is located in central Washington County; Legacy provides a financial donation and board representation to the center. Federally Qualified Health Centers (FQHC) are located in central and west Washington County--Virginia Garcia Memorial Health Clinic (multiple sites) and Neighborhood Health Center. A local non-profit, Project Access NOW, links uninsured low-income individuals to no-cost healthcare services. All of the health systems in the metro area are very involved with this program. Legacy Health provides cash donations as well as clinical services.While the Affordable Care Act has significantly lowered the uninsured rate in Oregon, longstanding income disparities in the Legacy Meridian Park service area underscore the ongoing need for safety net services, which are detailed in the separate Community Health Improvement Plan (CHIP) document which can be found on the organizations website.In FY21, LMPH provided $3.8 million in charity care; total unreimbursed costs of care for people in need amounted to $31.1 million. Part VI, Line 5 - Promotion of Community Health Legacy Meridian Park collaborates with other health care providers, community-based organizations, business and the public on projects to improve the health of the community. Non-cash donations of resources include clinical and non-clinical services and items, e.g., screenings and support services, internships, information and referral services and health fairs. Legacys warehouse located in NW Portland is open to nonprofit organizations to obtain surplus equipment and furniture. In addition, conference room space is made available at no charge to local nonprofits for Board and community meetings.Clinical staff is involved with local communities through many child safety programs. In 1986, nurses in Meridian Parks sister hospital, Legacy Emanuel Hospitals Level I Trauma Center, developed the Trauma Nurses Talk Tough (TNTT) program. The American Hospital Association awarded the TNTT program its NOVA Award. On average every month TNTT offers 12 court ordered classes, two senior falls prevention classes, and multiple school, parent, and young driver safety education classes. Last year, Legacy Emanuel staff fit and distributed 900 low-cost helmets and safety gear to children, of which 70% were donated. Randall Injury Prevention staff provide targeted bedside education to families who have experienced a traumatic injury. Team members also provide online infant CPR classes, virtual car safety seat evaluations and education on home safety.The COVID-19 pandemic continued surging across the U.S. in FY21. The pandemic presented unforeseen challenges within our communities and heightened the need for community benefit. The economic implications of COVID-19 have constrained the availability of resources and required Legacy to redirect funding and develop new strategies in response to emerging community needs. Legacy responded to the significant needs of our communities from setting up mass vaccines sites, to working with community-based organizations to repurposing grants to respond to the immediate impacts of the pandemic.Legacy joined our local health care partners to support the effort of providing safe, fast, and equitable vaccinations across our communities. Most vaccinations came through large clinics at mass vaccination sites as well as Legacy affiliate hospitals. The clinics were often run by our staff who contributed their time to support the effort. About 1,570 Legacy staff volunteered for about 8,300 shifts and contributed almost 50,000 hours across seven vaccination settings. Part VI, Line 6 - Affilated Health Care System LMPH is a subsidiary of Legacy Health (Legacy). Legacy is an integrated health system based in Portland, Oregon and primarily operates six acute care hospitals and dedicated childrens care offered at Randall Childrens Hospital at Legacy Emanuel, and related services (e.g., physician practices, hospice, preferred provider network) in the four-county metro area of Portland and SW Washington, and Marion County. In addition, Legacy is a collaborative partner with Unity Center for Behavioral Health.The Legacy Board is comprised of community and business leaders as well as representatives of the medical staff. The LMPH medical staff is open, with physicians submitting credentialing information reviewed according to LMPH policies and standards. As the health needs of communities surrounding our hospitals is changing, Legacy continues to identify investments for underserved populations. In FY2021, grants totaling $1.08 million were provided to community-based organizations to strengthen organizational capacity and support programs and initiatives that address health equity, access to care, behavioral health, and COVID-19 education and outreach.Recognizing that education, employment, and income inequities exist for communities of color, and that health professions are lacking in diversity, Legacy established the Health Occupation Profession and Education program (HOPE, formerly Youth Employment in Summer). Each year between 5-15 students of ethnically diverse communities receive paid summer employment in departments where they work with health professionals. Students are paid between $13-17 per hour and may work up to 400 hours during the summer. HOPE students also receive college scholarships between $3,000 and $10,000 annually. Students remain in the program if they remain in school and pursue health careers. Some students remain in the program as long as seven years and graduate with a range of degrees from imaging tech to bachelors in nursing, to medical residents. Most students are the first in their family to go to college. While not all the HOPE students were able to work due to supplemental employment pauses due to COVID-19, we were able to provide two limited internships and provide all the HOPE students with their education scholarships.In the fall of 2018, Legacy in collaboration with 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 to respond 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. In 2021, eleven clinics were invited to apply and were each awarded $50,000 in funding. Grantees had access to $100,000 over two years. Clinics received training and individual technical assistance in various areas of organizational development for community supported clinics.Legacy also provided cash donations to local health and human service, education, economic development and civic organizations. Donations focus on organizations with year-round relationships through programs and board representationspecifically focused organizations addressing disparities. Examples include Virginia Garcia Memorial Health Center, Latino Network, Ronald McDonald Charities, Free Clinic of SW Washington, Silverton Area Community Aid, Trillium Family Services, National Alliance on Mental Illness Oregon, Native American Youth and Family Center, and Basic Rights Oregon. Part VI, Line 7 - States Filing of Community Benefit Report OR true true false true true true true false true true ANITA N IYENGER SR VP 366611 48185 -4342 35919 24177 470550 ANNA LOOMIS CFO & TREASURER 698377 249915 -3260 14250 32332 991614 26293 ANNE T GREER Secretary 287532 64949 1195 39087 21625 414388 BRIAN M BEDOLLA MD MEDICAL DIRECTOR 231591 20360 -4811 20201 31605 298946 BRYCE HELGERSON SR VP 566173 147785 24765 88143 15952 842818 13437 CAROL A BRADLEY FORMER SR. VP 406321 31451 -76 437696 CHRISTOPHER THOMING MD CLINICAL VP 398550 25788 28781 -323 -385 14250 36218 2953 477476 28356 ERIC J MACEVOY MD MEDICAL DIRECTOR 253421 26235 -6818 28840 25951 327629 GWEN J GREWE MD MEDICAL DIRECTOR 238683 23258 -2977 27695 30804 317463 JOHN J KENAGY SR VP 498198 134864 43813 51967 36809 765651 33935 JONATHAN E AVERY HOSPITAL PRESIDENT 535600 127812 24951 60221 36919 785503 JONATHAN HILL MD BOARD DIRECTOR 280000 12520 3957 11400 26331 334208 KATHRYN CORREIA President & CEO 1354597 468527 5050 22730 39402 1890306 87021 LESLIE ROOT MD BOARD DIRECTOR 144244 57380 -234 22831 3411 227632 LEWIS L LOW MD SR VP 475903 181297 89720 45862 23300 816082 46391 MAUREEN A BRADLEY SR VP 317132 66752 5071 53547 20291 462793 MELINDA C STIBAL VP 257412 53245 -1309 14318 33224 356890 MELINDA J MULLER MD SR VP INTERIM 407848 96755 3382 70510 38407 616902 POMPY Z GOSWAMI PHYSICIAN 228517 44823 -898 31821 19363 323626 ROBERT E DEWITT FORMER SR. VP & SECRETARY 504774 18636 523410 SONJA O STEVES SR VP 452690 120822 1260 103312 24167 702251 30627 TRENT S GREEN SR VP 780820 206375 -3095 40574 37907 1062581 18765 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 2020, Dr. Hill received compensation related to his duties as Medical Director 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 2020.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 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 toexecutives 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.Sch J, Part II, Column Breakdown of W-2 or Misc-1099 (Cont):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.The Legacy Health Board approved the goals and long-term objectives for the Executive Long-Term Incentive Plan effective April 1, 2017 for 3 years ending on March 31, 2020. The plan was discretionary and could be terminated at any time. The purpose of the Plan was to achieve market share growth in key areas identified in Legacy Healths strategic plan. Targets for operating margins and clinical quality were required over the three-year period and all goals were measured at March 31, 2020. The plan was funded and paid out in August 2020 after approval from the Legacy Health Compensation Committee and the Legacy Health Board. The final payout is included in the Executive compensation reported as deferred on the FY2018, FY2019 and FY2020 990.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 Merdian Park Hospital. 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 received a memorandum with draft 990 returns for Legacy and Legacy Emanuel Hospital & Health Center highlighting key areas and requesting feedback. Questions from the Board Audit and Compliance Committee are answered and changes made where appropriate. Any significant differences in disclosure from the draft 990 to the final 990 return for other affiliated entities, including Legacy Meridian Park Hospital are provided to the Board Audit and Compliance Committee. Depending on the deadline for the 990 return filing and the Board Audit and Compliance Committee meeting this discussion may take place following the filing of the return. 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 LMPH's financial results.When changes are made to the LMPH Articles or Bylaws, LMPH 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. Form 990, Part IV, question 12 Legacy has an audit of its consolidated financial statement which includes consolidating schedules highlighting LMPH'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 LMPH is 1,287. Form 990, Part X LMPH 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, Silverton Health, and Legacy Visiting Nurse Association. 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