2022-11-14T13:43:14-06:00 2021-12-31 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2021-01-01 910545036 TRI-STATE MEMORIAL HOSPITAL TRI- 5097585511 1221 HIGHLAND AVENUE CLARKSTON WA 99403 KYM CLIFT CEO 5097585511 2022-11-10 1 KYM CLIFT 999009999 TERRI REXRODE CPA MST P00096513 9206620016 2022-11-10 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z KYM CLIFT 1221 HIGHLAND AVENUE CLARKSTON WA 99403 123111827 0 X WWW.TRISTATEHOSPITAL.ORG X 1955 WA TRI-STATE MEMORIAL HOSPITAL, A 62 BED LICENSED NOT-FOR-PROFIT COMMUNITY OWNED HOSPITAL, IS CURRENTLY OPERATING AS A 25 BED CRITICAL ACCESS HOSPITAL. THE HOSPITAL SERVES A 10 COUNTY REGION IN THREE STATES (WASHINGTON, OREGON, AND IDAHO). 13 11 806 41 -440571 0 6291600 8984083 96458039 113772198 467822 1759582 -245215 -2480743 102972246 122035120 18478 7800 0 0 49354757 54802223 0 0 0 48158038 53776228 97531273 108586251 5440973 13448869 106154327 107847750 39247491 27866101 66906836 79981649 FROM OUR FIRST DAY OF OPERATION UNTIL TODAY, WE ARE PROUD TO SAY THAT OUR MISSION HAS ALWAYS REMAINED THE SAME: THE PATIENT IS OUR FIRST PRIORITY. 0 0 96863527 7800 109728516 THE HOSPITAL PROVIDED 4,579 DAYS OF CARE TO 1,093 PATIENTS IN 2021. IN ADDITION, THE HOSPITAL PROVIDED APPROXIMATELY 324,484 OUTPATIENT VISITS IN THE EMERGENCY ROOM, RENTAL DIALYSIS, SURGICAL, AND OTHER PATIENT SERVICE CENTERS. THE HOSPITAL PROVIDED APPROXIMATELY $1,397,000 IN CHARITABLE SERVICES TO PATIENTS UNABLE TO PAY FOR HEALTHCARE SERVICES. 96863527 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 0 1 0 1 56 0 806 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 13 11 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 0 0 X TERESA GALL 5097585511 1221 HIGHLAND AVENUE CLARKSTON WA 99403 CRAIG FLINDERS PHYSICIAN 40.00 X 542392 0 33859 LEROY SMITH PHYSICIAN 40.00 X 539945 0 20146 ELINA CHERNYAK PHYSICIAN 40.00 X 515033 0 16048 TALMADGE CAVINESS PHYSICIAN 40.00 X 494217 0 26564 LEIF KANOOTH PHYSICIAN 40.00 X 445307 0 26784 JOHN RUDOLPH MD BOARD MEMBER 40.00 X 374245 0 27444 KIMBERLY BLEWETT BOARD MEMBER 40.00 X 239373 0 27554 KYM CLIFT CEO 40.00 X 216750 0 2653 DONALD WEE CEO (THRU MARCH) 40.00 X 150473 0 22141 JIM HEILSBERG CFO 40.00 X 134423 0 510 DON MCQUARY PRESIDENT 1.00 X X 0 0 0 MIKE MARTIN VICE PRESIDENT 1.00 X X 0 0 0 DAN KLAVEANO SECRETARY/TREASURER 1.00 X X 0 0 0 SCOTT ARNONE BOARD MEMBER 1.00 X 0 0 0 DEBRA R AUSMAN BOARD MEMBER 1.00 X 0 0 0 STEVE CLAASSEN BOARD MEMBER 1.00 X 0 0 0 E WAYNE DAY MD BOARD MEMBER 1.00 X 0 0 0 DICK FLERCHINGER BOARD MEMBER 1.00 X 0 0 0 K DAVID HAGEN BOARD MEMBER 1.00 X 0 0 0 PAUL JELINEK BOARD MEMBER 1.00 X 0 0 0 RICK WASEM BOARD MEMBER 1.00 X 0 0 0 3652158 0 203703 75 0 1 0 PATHOLOGISTS REGIONAL LAB PO BOX 956 LEWISTON ID 83501 LAB SERVICES 4718538 NAC ARCHITECTURE 1203 WEST RIVERSIDE AVE SPOKANE WA 99201 ENGINEERING SERVICES 1769768 SPRING RIVER EMERGENCY PO BOX 645948 CINCINNATI OH 45264 EMERGENCY ROOM PHYSICIANS 1750330 TWIN CITY RADIOLOGY PO BOX 136 CLARKSTON WA 99403 RADIOLOGY PHYSICIANS 1575828 MEDEFIS CONSOLIDATED PO BOX 5068 NEW YORK NY 10087 LOCUM STAFF & PHYSICIANS 908238 17 7754944 1229139 8984083 NET PATIENT SERVICE 621400 110552759 110552759 340B REVENUE 621400 1348871 1348871 MOB RENTAL INCOME 621400 96952 96952 1773616 1773616 113772198 1889171 1889171 432638 873209 -440571 -440571 -440571 73909 0 203498 73909 -203498 -129589 -129589 INCOME ON INVESTMENT IN SUBSIDIAR 900099 -4043682 -4043682 2003510 2003510 -2040172 122035120 109728516 -440571 3763092 X 7800 7800 1195568 668617 526951 43268480 37421818 5846662 1161197 941777 219420 5886490 4963946 922544 3290488 2722819 567669 38100 38100 61473 18950 42523 17492767 15983897 1508870 381811 239034 142777 2179175 1744373 434802 70596 70596 3781216 3781216 790875 790875 MEDICAL SUPPLIES 23227812 23227812 BAD DEBT 1775475 1775475 304B EXPENSES 903163 903163 LICENSES AND TAXES 593742 593742 2480023 1007617 1472406 108586251 96863527 11722724 0 9677679 12963524 9385657 2913964 10734506 14863061 2552469 2785321 637298 799779 95178834 59935540 32078322 35243294 31244668 27292181 111069 124585 3384400 3384400 6348259 7477641 106154327 107847750 7916702 9545252 11114272 203188 412402 20013329 17908447 39247491 27866101 X 60561041 72507734 6345795 7473915 66906836 79981649 106154327 107847750 X 13448869 693247 56759 -1124062 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4084 4084 0 PART II-B, LINE 1: THE FACILITY PAYS DUES TO THE WASHINGTON STATE HOSPITAL ASSOCIATION, THE NATIONAL RURAL HEALTH ASSOCIATION AND THE IDAHO HOSPITAL ASSOCIATION. A PERCENTAGE OF THESE DUES WERE USED FOR LOBBYING ON BEHALF OF HEALTH CARE ORGANIZATIONS. 5704063 33538 1107194 1046449 5798346 4868807 124950 907885 197579 5704063 3489793 507510 871504 4868807 3682682 -192889 3489793 3024844 657838 3682682 0.00000 0.08934 0.91066 0 1 1 2572686 2572686 41377038 22908419 18468619 1079344 261063 818281 45044224 36766058 8278166 5105542 5105542 35243294 INTEREST IN NET ASSETS OF THE FOUNDATION 7236931 LAND HELD FOR FUTURE EXPANSION 240710 7477641 PPP LOAN 1298386 THIRD PARTY PAYOR SETTLEMENTS PAYABLE 487030 REFUNDABLE ADVANCES 11727677 INVESTMENT IN SUBSIDIARIES 4395354 17908447 X PART V, LINE 4: THE FOUNDATION'S ARTICLES OF INCORPORATION PROVIDE THAT ALL FUNDS RAISED, EXCEPT FOR FUNDS REQUIRED FOR OPERATION OF THE FOUNDATION, SHALL BE DISTRIBUTED TO OR HELD PRIMARILY FOR THE BENEFIT OF THE HOSPITAL OR THE HOSPITAL'S MISSION IN THE COMMUNITY. THE HOSPITAL ALSO HOLDS PERMANENTLY AND TEMPORARILY DONOR-RESTRICTED ENDOWMENT FUNDS. PART X, LINE 2: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE ORGANIZATION DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED ON EXAMINATION BY THE TAXING AUTHORITIES BASED ON THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THE TAX POSITION IS NOT RECOGNIZED IN THE CONSOLIDATED FINANCIAL STATEMENTS. 1 1 X 1 X 1 X 1 1 0 1 1 652708 23262 629446 0.00590 11816770 10219173 1597597 0.01500 12469478 10242435 2227043 0.02090 6282 6282 0.00010 6282 6282 0.00010 12475760 10242435 2233325 0.02100 15650 15650 0.00010 15650 15650 0.00010 1 819430 0 64350418 63713285 637133 X 1 1 1 1 TRI-STATE MEMORIAL HOSPITAL 1221 HIGHLAND AVENUE CLARKSTON WA 99403 WWW.TRISTATEHOSPITAL.ORG H-108 X X X X TRI-STATE MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 19 1 0 0 1 X HTTP://TSMH.ORG/COMMUNITY-NEEDS-ASSESSMENT/ X 1 20 1 HTTP://TSMH.ORG/COMMUNITY-NEEDS-ASSESSMENT/ 0 1 X 100.000000000000 300.000000000000 X X X X 1 1 X X X 1 X HTTPS://TRISTATEHOSPITAL.ORG/POLICIES-BILLING/ X HTTPS://TRISTATEHOSPITAL.ORG/POLICIES-BILLING/ X HTTPS://TRISTATEHOSPITAL.ORG/POLICIES-BILLING/ X X X X 1 X 0 X X X 1 X 0 0 TRI-STATE MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: THE CHNA WAS PREPARED IN PARTICIPATION AND SUPPORT WITH THE SE WASHINGTON HEALTH PARTNERSHIP AND THE GREATER COLUMBIA ACCOUNTABLE COMMUNITIES OF HEALTH. THEIR FINDINGS AND PRIORITIES INFORMED OUR OWN PROCESS. OTHER ORGANIZATIONS THAT CONTRIBUTED THEIR TIME AND PERSPECTIVES THE THIS CHNA THROUGH KEY INFORMATION SURVEYS INCLUDE: CITY OF CLARKSTON, CITY OF LEWISTON, THE ASOTIN COUNTY HEALTH DISTRICT, LOCAL SCHOOL DISTRICTS, TWIN COUNTY UNITED WAY, THE SALVATION ARMY-LEWISTON, NORTHWEST CHILDREN'S HOME, THE YWCA, TSMH FAMILY PRACTICE, LEWIS-CLARK VALLEY CHAMBER OF COMMERCE, THE LOCAL BEHAVIORAL HEALTH AND AGING AND DISABILITY PROVIDERS AS WELL AS OTHER KEY EMPLOYERS AND CIVIC LEADERS IN THE LEWIS-CLARK VALLEY COMMUNITY. TRI-STATE MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: TSMH HAS ELECTED TO CONTINUE TO BUILD OFF THE PREVIOUS CHNA PRIORITIES. WE HAVE SELECTED AS OUR OVERALL PRIORITY SUPPORT INDIVIDUALS AND FAMILIES THROUGH ACCESS TO CARE AND COMPREHENSIVE PRIMARY-CARE BASED PREVENTIVE WELLNESS PROGRAMMING. SPECIFIC STRATEGIES THAT CONTINUE INCLUDE RECRUIT ADDITIONAL PRIMARY CARE PROVIDERS, CONTINUE GROWTH OF BEHAVIORAL HEALTH SERVICES, DEVELOP AND OFFER LOWER COST MEANS OF ACCESSING CARE (I.E. VIRTUAL CARE), PARTNER WITH COMMUNITY ORGANIZATIONS TO EDUCATE, INFORM AND SUPPORT YOUTH AND ADULTS AROUND HEALTHY LIVING. STRATEGIES BEING CONSIDERED INCLUDE ENHANCED MENTAL/BEHAVIORAL HEALTH STRATEGIES: RECRUIT ADDITIONAL MENTAL HEALTH CARE PROVIDERS, INCLUDING MID-LEVEL PROVIDERS IMPROVE RATE OF SCREENING FOR MENTAL HEALTH AND SUBSTANCE ABUSE DISORDERS IN PRIMARY CARE, AND RATE OF REFERRALS FOR MENTAL HEALTH/SUBSTANCE ABUSE DISORDERS PARTNER WITH LOCAL ORGANIZATIONS TO IMPLEMENT COMMUNITY-BASED SUICIDE PREVENTION STRATEGIESCHILDREN AND YOUTH WORK WITH PARTNERS TO IMPLEMENT STRATEGIES TO REDUCE CHILDHOOD FOOD INSECURITY, INCLUDING FOOD BACKPACKS IN SCHOOLS AND IN-KIND DONATIONS TO LOCAL FOOD BANKS WORK WITH SCHOOLS AND LOCAL BUSINESSES TO IMPLEMENT AND EVALUATE ANTI-VAPING CAMPAIGNS AND TOOLKITS 13 1 - TSMH IPC 1119 HIGHLAND AVENUE SUITE 11 CLARKSTON WA 99403 PROVIDER BASED CLINIC 2 - TSMH RHEUM CLINIC 1119 HIGHLAND AVENUE SUITE 3 CLARKSTON WA 99403 PROVIDER BASED CLINIC 3 - TSMH CMC CLINIC 1534 17TH STREET LEWISTON ID 83501 NON-PROVIDER BASED CLINIC 4 - TSMH FAMILY PRACTICE CLARKSTON 1119 HIGHLAND AVENUE SUITE 10 CLARKSTON WA 99403 PROVIDER BASED CLINIC 5 - TSMH WOUND CARE & PODIATRY 1221 HIGHLAND AVENUE SUITE 7 CLARKSTON WA 99403 PROVIDER BASED CLINIC 6 - TSMH LEW FP CLINIC 2841 JUNIPER DRIVE 2 LEWISTON ID 83501 NON-PROVIDER BASED CLINIC 7 - TSMH MINOR CARE CLINIC 1267 BELMONT WAY CLARKSTON WA 99403 PROVIDER BASED CLINIC 8 - TSMH UROLOGY 1119 HIGHLAND AVENUE SUITE 1 CLARKSTON WA 99403 PROVIDER BASED CLINIC 9 - TSMH SLEEP LAB 1119 HIGHLAND AVENUE SUITE 8 CLARKSTON WA 99403 PROVIDER BASED CLINIC 10 - TSMH BEHAVIORAL HEALTH CLINIC 1119 HIGHLAND AVENUE SUITE 6 CLARKSTON WA 99403 PROVIDER BASED CLINIC 11 - TSMH NEPHR CLINIC 1221 HIGHLAND AVENUE SUITE 5 CLARKSTON WA 99403 PROVIDER BASED CLINIC 12 - TSMH FAMILY PULMONOLOGY CLINIC 1119 HIGHLAND AVENUE SUITE 2 CLARKSTON WA 99403 PROVIDER BASED CLINIC 13 - TSMH GENERAL SURGERY 1119 HIGHLAND AVENUE SUITE 4 CLARKSTON WA 99403 PROVIDER BASED CLINIC PART I, LINE 7: THE COST-TO-CHARGE RATIO USED WAS DERIVED BASED ON THE FILED 2020 MEDICARE COST REPORT. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 1,743,768. PART II, COMMUNITY BUILDING ACTIVITIES: TRI-STATE MEMORIAL HOSPITAL HELPS PROMOTE THE HEALTH OF THE COMMUNITIES IT SERVES BY PROVIDING SUPPORT AMONGST A NUMBER OF LOCAL CHARITIES, FOOD BANKS AND OTHER AGENCIES. IN 2021 TRI-STATE HOSPITAL CONTRIBUTED $7,500 TO THE BOYS AND GIRLS CLUBS OF THE LEWIS-CLARK VALLEY WHICH THEY USED FOR THE PARTNERSHIP FOR KIDS, THE ANNUAL CAMPAIGN, THE GRILLED CHEESE PROGRAM AND MEDICAL SUPPLIES/FIRST AID DONATIONS. THE WORLD SERIES OF NAIA BASEBALL IS PLAYED IN LEWISTON AND TRI-STATE MEMORIAL HOSPITAL SPONSORED THAT EVENT AND SPONSORED THE MEDICAL TENT AND REFRESHMENTS FOR ALL MEDICAL VOLUNTEERS FOR THIS EVENT. ADDITIONALLY, TRI-STATE MEMORIAL HOSPITAL GAVE DONATIONS TO THE WASHINGTON POISON CONTROL, VALLEY VISION, AND FIELD OF DREAMS. TRI-STATE MEMORIAL HOSPITAL CONTINUES TO FIND WAYS TO SUPPORT THE COMMUNITIES IT SERVES IN BROAD AND EXPANDING WAYS, TRYING TO REACH ALL PATIENTS FROM ADOLESCENCE TO ADULTHOOD. PART III, LINE 2: THE ORGANIZATION'S BAD DEBT EXPENSE AT COST WAS ESTIMATED BY MULTIPLYING THE BAD DEBT EXPENSE BY THE ORGANIZATION'S COST-TO-CHARGE RATIO. PART III, LINE 3: THE FACILITY REPORTS BAD DEBT EXPENSE IN ACCORDANCE WITH HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION STATEMENT NUMBER 15, SO NONE OF THE BAD DEBT EXPENSE REPORTED ON SCHEDULE H, PART III, LINE 2 IS ESTIMATED TO BE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE FACILITY'S FINANCIAL ASSISTANCE POLICY. PART III, LINE 4: WHILE THE FACILITY DOES NOT HAVE A NOTE REGARDING BAD DEBT EXPENSE IN ITS FINANCIAL STATEMENTS, THE AMOUNT OF BAD DEBT EXPENSE FOR EACH YEAR IS DISCLOSED ON THE FACILITY'S STATEMENTS OF REVENUE AND EXPENSES. THE AMOUNT OF BAD DEBT EXPENSE REPORTED WAS $1,743,768 FOR THE YEAR ENDED DECEMBER 31, 2021. THE COSTING METHODOLOGY USED TO DETERMINE THE COST OF BAD DEBT IS BASED ON THE FACILITY'S CALCULATED COST-TO-CHARGE RATIO. PART III, LINE 8: THE FACILITY IS DESIGNATED AS A CRITICAL ACCESS HOSPITAL AND IS REIMBURSED BY MEDICARE AT APPROXIMATELY 99% OF MEDICARE'S COSTS.THE TOTAL REVENUE RECEIVED FROM MEDICARE AND RELATED MEDICARE ALLOWABLE COSTS WERE DERIVED FROM THE FACILITY'S FILED 2021 MEDICARE COST REPORT. PART III, LINE 9B: THE FULL PATIENT BALANCE FOR THOSE KNOWN TO QUALIFY FOR CHARITY CARE WILL BE EVALUATED FOR FINANCIAL ASSISTANCE ELIGIBILITY AS FOLLOWS: THEY QUALIFY FOR A 100% DISCOUNT IF THE PATIENT'S GROSS FAMILY INCOME IS AT OR BELOW 100% OF THE CURRENT FEDERAL POVERTY GUIDELINES, THEY QUALIFY FOR A 75% DISCOUNT IF THE PATIENT'S GROSS FAMILY INCOME IS AT OR BETWEEN 101% TO 200% OF THE CURRENT FEDERAL POVERTY GUIDELINES, AND THEY QUALIFY FOR A 35% DISCOUNT IF THE PATIENT'S GROSS FAMILY INCOME IS AT OR BETWEEN 201% TO 300% OF THE CURRENT FEDERAL POVERTY GUIDELINES.THE HOSPITAL MAY CHOOSE TO GRANT FINANCIAL ASSISTANCE BASED SOLELY UPON THE INITIAL DETERMINATION OF THE PATIENT. ANY PATIENTS WHO ARE ON STATE ASSISTANCE, ARE UNEMPLOYED, DISABLED, TRANSIENT OR INCOMPETENT MAY BE VALID "PRIMA-FACIE" CANDIDATES. IN SUCH CASES, THE HOSPITAL MAY NOT COMPLETE FULL VERIFICATION OR DOCUMENTATION OF ANY REQUESTS.UNINSURED AND UNDERINSURED WASHINGTON AND IDAHO PATIENTS MAY QUALIFY FOR A DISCOUNT. DETERMINATION WILL BE MADE BY TSMH ADMINISTRATION UPON PATIENT'S COMPLETION OF THE SPECIAL CONSIDERATION FINANCIAL ASSISTANCE APPLICATION AND THE SPECIFIED SUPPORTING DOCUMENTATION AS PROOF OF SEVERE FINANCIAL HARDSHIP OF PERSONAL LOSS FROM TIME OF REQUEST BASED ON ECONOMIC SITUATION. THE COLLECTION PRACTICE FOR PATIENTS KNOWN TO QUALIFY FOR CHARITY CARE IS AS FOLLOWS: 75% OF THE PATIENT'S BILL IS ADJUSTED OFF IF THE PERSON IS BETWEEN 101-200% OF THE FPL TO CHARITY CARE AND THE REMAINING 25% IS THE PATIENT'S RESPONSIBILITY. IF THE PATIENT IS UP TO 100% OF THE FPL THEN 100% OF THE PATIENT'S BILL IS ADJUSTED OFF AS CHARITY CARE. THIS POLICY IS APPLIED TO ALL PATIENTS THAT HAVE COMPLETED A FINANCIAL ASSISTANCE APPLICATION AND WHOSE INCOMES LEVELS HAVE BEEN VERIFIED. PATIENTS ARE ALSO IDENTIFIED WHO MAY BE ELIGIBLE FOR ASSISTANCE BEYOND THE HOSPITAL THROUGH MEDICAID OR COUNTY AID. PART VI, LINE 2: IN 2019 THE CHNA WAS PREPARED IN PARTICIPATION AND SUPPORT WITH THE SE WASHINGTON HEALTH PARTNERSHIP AND THE GREATER COLUMBIA ACCOUNTABLE COMMUNITIES OF HEALTH. THEIR FINDINGS AND PRIORITIES INFORMED OUR OWN PROCESS. OTHER ORGANIZATIONS THAT CONTRIBUTED THEIR TIME AND PERSPECTIVES THE THIS CHNA THROUGH KEY INFORMATION SURVEYS INCLUDE: CITY OF CLARKSTON, CITY OF LEWISTON, THE ASOTIN COUNTY HEALTH DISTRICT, LOCAL SCHOOL DISTRICTS, TWIN COUNTY UNITED WAY, THE SALVATION ARMY-LEWISTON, NORTHWEST CHILDREN'S HOME, THE YWCA, TSMH FAMILY PRACTICE, LEWIS-CLARK VALLEY CHAMBER OF COMMERCE, THE LOCAL BEHAVIORAL HEALTH AND AGING AND DISABILITY PROVIDERS AS WELL AS OTHER KEY EMPLOYERS AND CIVIC LEADERS IN THE LEWIS-CLARK VALLEY COMMUNITY. PART VI, LINE 3: FINANCIAL BROCHURES ARE SENT WITH ITEMIZED STATEMENTS TO ALL UNINSURED PATIENTS. AT THE TIME PATIENT MAKES CONTACT, THE PATIENT FINANCIAL COUNSELOR WILL:1. DISCUSS THE HOSPITAL GUIDELINE FOR REIMBURSEMENT OF HOSPITAL SERVICES.2. THE 10% DISCOUNT IS OFFERED TO UNINSURED PATIENTS WHEN BALANCE IS PAID IN FULL. 3. ESTABLISH A PAYMENT CONTRACT IN ORDER TO RESOLVE THE ACCOUNT BALANCE WITHIN APPLICABLE GUIDELINES. THE MINIMUM ACCEPTABLE PAYMENT IS $50 OR 5% (WHICHEVER IS GREATER).4. IDENTIFY A PATIENT WHO MAY BE ELIGIBLE FOR ASSISTANCE TO INCLUDE BUT NOT LIMITED TO MEDICAID OR COUNTY AID FOR THE STATE THE PATIENT RESIDES.5. DETERMINE IF HOUSEHOLD INCOME MEETS OR FALLS BELOW THE CURRENT YEAR'S POVERTY GUIDELINES THEN EXPLAIN TSMH FINANCIAL ASSISTANCE PROGRAM. PART VI, LINE 4: TSMH IS LOCATED IN THE LEWIS-CLARK VALLEY (THE VALLEY), AT THE CONFLUENCE OF THE SNAKE AND CLEARWATER RIVERS IN THE SOUTHEASTERN MOST CORNER OF WASHINGTON STATE. THE CITY OF CLARKSTON IS CONTIGUOUS TO THE CITY OF LEWISTON IN NEIGHBORING NEZ PERCE COUNTY IN IDAHO. TSMH SERVES RESIDENTS OF BOTH ASOTIN COUNTY AND ADJOINING NEZ PERCE COUNTY. COLLECTIVELY, THESE TWO COUNTIES ACCOUNT FOR CLOSE TO 80% OF TSMH'S PATIENTS AND ARE CONSIDERED THE SERVICE AREA COMMUNITY (COMMUNITY). PART VI, LINE 5: THE HOSPITAL PERFORMS SURGERIES REQUIRING INPATIENT STAYS AND ALSO SAME DAY OPERATIONS, NOT REQUIRING A HOSPITAL STAY. OUTPATIENT SERVICES INCLUDE RENAL DIALYSIS CENTERS IN CLARKSTON, WA, WOUND HEALING & HYPERBARIC CENTER, SLEEP DIAGNOSTIC CENTER, AND A 24 HOUR PHYSICIAN STAFFED EMERGENCY DEPARTMENT. OTHER OUTPATIENT SERVICES INCLUDE A NEPHROLOGY CENTER, PRIMARY CARE CLINIC, INTERNAL MEDICINE CLINIC, GENERAL SURGERY CLINIC, UROLOGY CLINIC, RHEUMATOLOGY CLINIC, AND PAIN CLINIC. THE HOSPITAL OPERATES WITH OVER 657 FULL AND PART-TIME EMPLOYEES, 41 VOLUNTEERS AND 325 PHYSICIANS ON STAFF. TRI-STATE HOSPITAL FOUNDATION IS A NON-PROFIT ORGANIZATION WHICH BENEFITS THE HEALTH CARE NEEDS OF THE COMMUNITY SERVED BY THE HOSPITAL. GIFTS TO THE FOUNDATION ARE USED TO PURCHASE SPECIALIZED EQUIPMENT THAT HELP EXPAND SERVICES PROVIDED BY THE HOSPITAL TO THE COMMUNITY. 1 BOYS & GIRLS CLUBS OF THE LEWIS-CLARK VALLEY 1021 BURRELL AVE LEWISTON ID 83501 826001432 501(C)(3) 7500 0 PARTNERSHIP FOR KIDS, ANNUAL CAMPAIGN, SCHOLARSHIPS, GRILLED CHEESE PROGRAM 1 0 PART I, LINE 2: THE HOSPITAL RECEIVES AND REVIEWS DETAILED REPORTS PROVIDED BY THE CHARITABLE ORGANIZATIONS THAT RECEIVE GRANT FUNDS FROM THE HOSPITAL. THE HOSPITAL IS ABLE TO SUBSTANTIATE THE PROPER USE OF THE FUNDS THROUGH THE REPORTS PROVIDED BY THE CHARITABLE ORGANIZATIONS. X X X X X X 0 0 0 0 0 0 0 0 0 CRAIG FLINDERS PHYSICIAN 542392 0 0 0 0 0 11600 0 22259 0 576251 0 0 0 LEROY SMITH PHYSICIAN 539945 0 0 0 0 0 0 0 20146 0 560091 0 0 0 ELINA CHERNYAK PHYSICIAN 304560 0 210473 0 0 0 3700 0 12348 0 531081 0 0 0 TALMADGE CAVINESS PHYSICIAN 494217 0 0 0 0 0 2900 0 23664 0 520781 0 0 0 LEIF KANOOTH PHYSICIAN 445307 0 0 0 0 0 5944 0 20840 0 472091 0 0 0 JOHN RUDOLPH MD BOARD MEMBER 363160 0 11085 0 0 0 10053 0 17391 0 401689 0 0 0 KIMBERLY BLEWETT BOARD MEMBER 239373 0 0 0 0 0 8724 0 18830 0 266927 0 0 0 KYM CLIFT CEO 212250 0 0 0 4500 0 0 0 2653 0 219403 0 0 0 DONALD WEE CEO (THRU MARCH) 148348 0 0 0 2125 0 12421 0 9720 0 172614 0 0 0 MIKE MARTIN BOARD MEMBER 284262 INSURANCE BROKER - OWNER OF MARTIN INSURANCE 0 FORM 990, PART VI, SECTION B, LINE 11B A COPY IS PROVIDED TO THE CEO FOR REVIEW PRIOR TO FILING. THE BOARD AUTHORIZES THE CEO TO REVIEW AND APPROVE THE 990. THE FINAL 990 IS FILED AFTER CEO APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C IT IS THE ORGANIZATION'S POLICY TO REQUEST THE DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST SO THAT APPROPRIATE ACTION MAY BE TAKEN TO ENSURE THAT SUCH CONFLICT DOES NOT INAPPROPRIATELY INFLUENCE IMPORTANT DECISIONS. THE HOSPITAL REVIEWS ITS RELATIONSHIP AND ITS STAFF'S RELATIONSHIPS WITH OTHER CARE PROVIDERS, EDUCATIONAL INSTITUTIONS, AND PAYERS TO ENSURE THAT THOSE RELATIONSHIPS ARE WITHIN LAW AND REGULATION AND DETERMINE IF CONFLICTS OF INTEREST EXIST. BOARD MEMBERS ARE REQUIRED TO SUBMIT AN ANNUAL DISCLOSURE FORM. BOARD MEMBERS, ADMINISTRATION AND MEDICAL STAFF LEADERS ARE REQUIRED TO DISCLOSE POTENTIAL CONFLICTS RELATED TO DECISIONS THAT ARISE DURING THE COURSE OF THE YEAR ON A CASE-BY-CASE BASIS. THE GOVERNING BOARD, SENIOR MANAGEMENT, OR THE MEDICAL EXECUTIVE COMMITTEE WILL REVIEW POTENTIAL CONFLICTS AND TAKE APPROPRIATE ACTION. IN THE EVENT A POTENTIAL CONFLICT OF INTEREST HAS A DIRECT IMPLICATION FOR PATIENT CARE, THE INSTITUTION MAY CONVENE AN ETHICS COMMITTEE TO ASSIST IN THE RESOLUTION OF THE ISSUE. FORM 990, PART VI, SECTION B, LINE 15A COMPENSATION IS DETERMINED BASED ON FAIR MARKET VALUE. TSMH USES NATIONAL AND REGIONAL BENCHMARKS (MILLIMAN SURVEY & STATE OF IDAHO). BASED ON THESE COMPARISONS, THE BOARD OF DIRECTORS DETERMINES THE COMPENSATION FOR THE CEO AND THE CEO DETERMINES THE COMPENSATION FOR THE REMAINING EMPLOYEES OF THE FACILITY. THE BOARD HAS FULL DETERMINATION OF THE CEO'S COMPENSATION. DECISIONS ARE MADE BY THOSE WITHOUT CONFLICT AND THE DECISIONS ARE DOCUMENTED. FORM 990, PART VI, SECTION C, LINE 19 TRI-STATE MEMORIAL HOSPITAL'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G LAB PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 4,558,386. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,558,386. MAINTENANCE SERVICES: PROGRAM SERVICE EXPENSES 1,497,364. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,497,364. TRAVELING STAFF: PROGRAM SERVICE EXPENSES 1,016,290. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,016,290. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 6,196,146. MANAGEMENT AND GENERAL EXPENSES 1,508,870. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 7,705,016. PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 2,715,711. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,715,711. FORM 990, PART XI, LINE 9: TEMPORARILY RESTRICTED - NET GRANT FUNDS RECEIVED 43,195. TEMPORARILY RESTRICTED - RELEASED FOR OPERATIONS -44,459. TEMPORARILY RESTRICTED - INTEREST INCOME 2. TEMPORARILY RESTRICTED - CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION 1,129,382. TEMPORARILY RESTRICTED - NET ASSETS RELEASED FROM RESTRICTIONS - FOUNDATION -2,346,902. INTERCOMPANY TRANSFERS 94,720. 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