2018-11-14T15:05:45-06:00 2017-12-31 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2017-01-01 910545036 TRI-STATE MEMORIAL HOSPITAL TRI- 5097585511 1221 HIGHLAND AVENUE CLARKSTON WA 99403 SCOT ATTRIDGE CFO 5097585511 2018-11-14 1 TERRI REXRODE CPA MST P00096513 9206620016 2018-11-13 74.87.127.216 2018-11-14 07:43:37 CS P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 A43ECD1EE6AF4781A69F6BFA161A98BDE8FA2C07 2017 2019-02-21 02:37:17Z SCOT ATTRIDGE 1221 HIGHLAND AVENUE CLARKSTON WA 99403 82752325 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 13 556 68 -428306 -428306 405369 289611 70764991 80809717 614557 1039648 1161104 75804 72946021 82214780 28079 49495 0 0 32205583 38059482 0 0 252510 37887979 39476205 70121641 77585182 2824380 4629598 82047376 87332722 28830278 27844092 53217098 59488630 X 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. 1 0 63995498 49495 79807398 THE HOSPITAL PROVIDED 4,191 DAYS OF CARE TO 1,233 PATIENTS IN 2017. IN ADDITION, THE HOSPITAL PROVIDED APPROXIMATELY 314,298 OUTPATIENT VISITS IN THE EMERGENCY ROOM, RENTAL DIALYSIS, SURGICAL, AND OTHER PATIENT SERVICE CENTERS. THE HOSPITAL PROVIDED APPROXIMATELY $1,822,000 IN CHARITABLE SERVICES TO PATIENTS UNABLE TO PAY FOR HEALTHCARE SERVICES. 63995498 1 1 0 1 0 0 0 0 0 1 1 0 0 1 0 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 0 0 0 1 47 0 556 1 1 1 0 0 0 0 0 0 0 0 0 X 13 13 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 0 0 X SCOT ATTRIDGE 5097585511 1221 HIGHLAND AVENUE CLARKSTON WA 99403 K DAVID HAGEN BOARD MEMBER 1.00 X 0 0 0 E WAYNE DAY MD PRESIDENT 1.00 X X 0 0 0 JACK SEEH SECRETARY/TREASURER 1.00 X X 0 0 0 RICK WASEM BOARD MEMBER 1.00 X 0 0 0 SCOTT ARNONE BOARD MEMBER 1.00 X 0 0 0 JOHN MANNSCHRECK MD - TERMED BOARD MEMBER 1.00 X 0 0 0 LARAE MERRIL BOARD MEMBER 1.00 X 0 0 0 STEVE CLAASSEN VICE PRESIDENT 1.00 X X 0 0 0 DICK FLERCHINGER BOARD MEMBER 1.00 X 0 0 0 MIKE MARTIN BOARD MEMBER 1.00 X 0 0 0 DAN KLAVEANO BOARD MEMBER 1.00 X 0 0 0 DON MCQUARY BOARD MEMBER 1.00 X 0 0 0 DEBRA R AUSMAN BOARD MEMBER 1.00 X 0 0 0 JOHN RUDOLPH MD BOARD MEMBER 1.00 X 0 0 0 DONALD WEE CEO 40.00 X 319674 0 33251 ALEX TOWN CFO 40.00 X 143877 0 19588 SCOT ATTRIDGE CFO 40.00 X 23372 0 1123 M LYNDON DIETER PHYSICIAN 40.00 X 416056 0 37432 LEROY SMITH PHYSICIAN 40.00 X 643271 0 16106 RICHARD ZOBELL PHYSICIAN 40.00 X 502736 0 25835 CRAIG FLINDERS PHYSICIAN 40.00 X 463135 0 19552 BHUPESH RATHOD PHYSICIAN 40.00 X 509298 0 9862 3021419 0 162749 43 0 1 0 PATHOLOGIST REGIONAL LAB P O BOX 956 LEWISTON ID 83501 LAB/BLOOD WORK 4034373 CLARKSTON EMERGENCY PHYSICIANS P O BOX 189 CLARKSTON WA 99403 ER PHYSICIANS 2035608 TWIN CITY RADIOLOGY PO BOX 136 CLARKSON WA 99403 RADIOLOGY PHYSICIAN SERVICES 1227250 RURAL PHYSICIANS GROUP 10023 BRYCE ROSE AVE LAS VEGAS NV 89148 HOSPITAL PHYSICIANS 762328 MEDEFIS CONSOLIDATED PO BOX 5068 NEW YORK NY 10087 TRAVELING STAFF/LOCUMS 442361 12 289611 289611 NET PATIENT SERVICE 621400 78202288 78202288 OTHER OPERATING REVENUE 623000 1109076 1109076 340B REVENUE 621400 913128 913128 CAFETERIA REVENUE 909999 397758 397758 MOB RENTAL INCOME 621400 187467 187467 80809717 989473 989473 108834 537545 -428711 -428711 -428306 -405 50175 0 50175 50175 50175 EHR INCENTIVE 900099 837541 837541 INVESTMENT IN JOINT VENTU 621300 15092 15092 INCOME ON INVESTMENT IN SUBSIDIAR 900099 -348118 -348118 504515 82214780 79807398 -428306 2546077 X 49495 49495 540885 540885 30587360 28039142 2380224 167994 934123 853915 67151 13057 3352678 2980527 354653 17498 2644436 2368440 255459 20537 67403 67403 275686 275686 12788189 12122228 665961 331087 331087 13127139 12171253 952690 3196 123361 28446 94915 3044227 2376359 644325 23543 619114 619114 4344975 4344975 493688 493688 BAD DEBT 1311015 1311015 CONTINUING EDUCATION 361484 261147 100337 DUES AND SUBSCRIPTIONS 114507 23848 90659 2474330 1895923 571722 6685 77585182 63995498 13337174 252510 11791960 8481016 5263582 9447593 7650692 9074220 1711938 1861466 470933 522792 79603705 43022430 37030459 36581275 7263260 10263078 3272412 2907674 3384400 3384400 4207740 4809208 82047376 87332722 9408735 10522993 2585271 1654882 12043770 11665682 4792502 4000535 28830278 27844092 X 49042504 54675027 2614655 3245403 1559939 1568200 53217098 59488630 82047376 87332722 X 4629598 815276 826658 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 71621 71621 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. 3024844 657838 3682682 2794652 230192 3024844 2637354 220000 62702 2794652 2566632 80000 70048 26667 52659 2637354 1995974 118680 492667 27284 13405 2566632 0.00000 0.40000 0.60000 0 1 1 2451085 2451085 39342846 16741189 22601657 1079344 248300 831044 36212831 26032941 10179890 517599 517599 36581275 INTEREST IN NET ASSETS OF THE FOUNDATION 4545737 INVESTMENT IN UNCONSOLIDATED AFFILIATES 22761 LAND HELD FOR FUTURE EXPANSION 240710 4809208 X 81428053 -1311015 -1311015 82739068 -524288 -524288 82214780 76798455 524288 524288 76274167 1311015 1311015 77585182 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. THE HOSPITAL IS ALSO ENGAGED, TO A LIMITED EXTENT, IN CERTAIN ACTIVITIES SUBJECT TO TAXATION AS UNRELATED BUSINESS INCOME (UBI). INCOME TAXES ON UBI ARE NOT SIGNIFICANT. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE -1,311,015. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -524,288. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 524,288. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,311,015. 1 1 X 1 X 1 X 1 1 0 1 1 887257 51153 836104 0.01100 7394985 7411353 0 0.00000 8282242 7462506 836104 0.01100 14603 14603 0.00020 14603 14603 0.00020 8296845 7462506 850707 0.01120 32428 32428 0.00040 32428 32428 0.00040 1 638416 30733025 30921230 -188205 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 16 1 0 0 1 X WWW.TRISTATEHOSPITAL.ORG/ABOUT X 1 17 1 WWW.TRISTATEHOSPITAL.ORG/ABOUT 0 1 X 100.000000000000 300.000000000000 X X X X 1 1 X X X 1 X HTTP://TRISTATEHOSPITAL.ORG/PATIENT-INFORMATION/POLICIES/FINANCIAL-ASSISTAN X HTTP://TRISTATEHOSPITAL.ORG/PATIENT-INFORMATION/POLICIES/FINANCIAL-ASSISTAN X HTTP://TRISTATEHOSPITAL.ORG/PATIENT-INFORMATION/POLICIES/FINANCIAL-ASSISTAN 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 PARTNERSHIP WITH THE ASOTIN COUNTY HEALTH DISTRICT, THE IDAHO NORTH CENTRAL PUBLIC HEALTH DISTRICT AND KEY COMMUNITY AND CIVIC GROUPS:CHARLOTTE ASH, SNAKE RIVER COMMUNITY CLINIC AND NIMIIPUU HEALTH CENTER, MARY ACKERMAN, ASOTIN COUNTY FOOD BANK, KELLY CARLSTROM, BOYS AND GIRLS CLUB, BRADY WOODBURY, ASOTIN COUNTY HEALTH DISTRICT, SHERRY GREENUP, ASOTIN COUNTY AGING AND DISABILITY, DALE BONFIELD, SUPERINTENDENT ASOTIN-ANATONE SCHOOL DISTRICT, COMMUNITY ACTION PARTNERSHIP, UNITED WAY, AND QUALITY BEHAVIORAL HEALTH. TRI-STATE MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: THE FACILITY IDENTIFIED NUMEROUS COMMUNITY NEEDS IN THEIR COMMUNITY HEALTH NEEDS ASSESSMENT. DUE TO THE WIDE RANGE OF NEEDS AND THE FACILITY'S LIMITED RESOURCES, THE FACILITY IS UNABLE TO ADDRESS ALL OF THE NEEDS IDENTIFIED. GIVEN THE FACILITY'S AREAS OF EXPERTISE AND RESOURCES AVAILABLE, THE FACILITY WILL FOCUS ON THE FOLLOWING NEEDS:- INCREASING ACCESS TO AFFORDABLE HEALTHCARE BY SUPPORTING ACTIVE ENROLLMENT IN MEDICAID EXPANSION AND EXCHANGE.- REDUCING THE IMPACT OF OBESITY AND OTHER CHRONIC HEALTH CONDITIONS BY PROVIDING/PARTNERING WITH COMMUNITY ORGANIZATIONS TO DEVELOP COMMUNITY EDUCATION CLASSES AIMED AT HEALTH LIFESTYLES AND MANAGING HEALTH CONDITIONS. PART I, LINE 7: THE COST-TO-CHARGE RATIO USED WAS DERIVED BASED ON THE FILED 2016 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 $ 1,311,015. 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 2016 TRI-STATE HOSPITAL CONTRIBUTED $8,325 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. TRI-STATE MEMORIAL HOSPITAL ALSO CONTRIBUTED OVER $5,000 TO THE INTERLINK VOLUNTEER ORGANIZATION THAT PROVIDES VOLUNTEERS THROUGH THE SURROUNDING COMMUNITIES TO PROVIDE ASSISTANCE WITH MEDICAL TRANSPORTATION, BUILDING WHEELCHAIR ACCESSIBLE RAMPS AND MOVING SUPPORT. 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 LEWIS-CLARK STATE COLLEGE, THE TINA'S HOPE FOR A CURE, LC LEGANDS, CLARKSTON ROTARY CLUB, INLAND NORTHWEST BLOOD CENTER, ASOTIN COUNTY AQUATIC CENTER, TWIN COUNTY UNITED WAY, QUALITY BEHAVIORAL HEALTH, LEWIS CLARK ANIMAL SHELTER, WA-ID VOLUNTEER CENTER AND THE ASOTIN COUNTY FAIR. 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 $1,311,015 FOR THE YEAR ENDED DECEMBER 31, 2017. 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 2017 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 2009 TRI-STATE MEMORIAL HOSPITAL ASSESSED THE NEEDS OF THE COMMUNITIES IT SERVES BY PARTICIPATING IN THE LOCAL ACCESS TO CARE COMMITTEE. THIS COMMITTEE REPRESENTS A MAJORITY OF HEALTH CARE ORGANIZATIONS IN THE COMMUNITY, INCLUDING ST. JOSEPH REGIONAL MEDICAL CENTER, VALLEY MEDICAL CENTER, AREA AGENCY ON AGING, IDAHO DEPARTMENT OF HEALTH AND WELFARE, WASHINGTON STATE, ASOTIN COUNTY HEALTH DISTRICT, NORTH CENTRAL IDAHO DISTRICT HEALTH, NIMIPOO INDIAN HEALTH SERVICES, QUALITY BEHAVIORAL HEALTH, THE UNITED WAY, AND THE COMMUNITY HEALTH ASSOCIATION OF SPOKANE. THE PURPOSE OF THE COMMITTEE IS TO BRING ADMINISTRATORS TOGETHER TO DISCUSS THE MAJOR HEALTH ISSUES AND ACCESS TO HEALTH CARE ISSUES IN THE COMMUNITY. THE WORK OF THIS COMMUNITY HELPED ESTABLISH A FEDERALLY QUALIFIED HEALTH CENTER IN 2009 AND CONTINUES TO ASSESS THE NEEDS OF THE PATIENTS IN THE 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: TRI STATE MEMORIAL HOSPITAL SERVES PATIENTS IN A 10 COUNTY REGION OF SOUTHEASTERN WASHINGTON, NORTHEASTERN OREGON AND NORTH CENTRAL IDAHO. THERE ARE APPROXIMATELY 165,000 PATIENTS IN THE SERVICE AREA. 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, PEDIATRIC CLINIC, UROLOGY CLINIC, RHEUMATOLOGY CLINIC, AND PAIN CLINIC. THE HOSPITAL OPERATES WITH OVER 475 FULL AND PART-TIME EMPLOYEES, 74 VOLUNTEERS AND 247 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) 8475 PARTNERSHIP FOR KIDS, ANNUAL CAMPAIGN, SCHOLARSHIPS, GRILLED CHEESE PROGRAM SNAKE RIVER COMMUNITY CLINIC 215 10TH STREET LEWISTON ID 83501 311726460 501(C)(3) 10000 FREE MEDICAL CLINIC FOR THE UNINSURED AND MEDICALLY NEEDY 2 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 DONALD WEE CEO 279712 0 23000 0 16962 0 14628 0 18623 0 352925 0 0 0 ALEX TOWN CFO 140185 0 3692 0 0 0 11708 0 7880 0 163465 0 0 0 M LYNDON DIETER PHYSICIAN 408364 0 0 0 7692 0 18080 0 19352 0 453488 0 0 0 LEROY SMITH PHYSICIAN 643271 0 0 0 0 0 0 0 16106 0 659377 0 0 0 RICHARD ZOBELL PHYSICIAN 502736 0 0 0 0 0 7979 0 17856 0 528571 0 0 0 CRAIG FLINDERS PHYSICIAN 463135 0 0 0 0 0 0 0 19552 0 482687 0 0 0 BHUPESH RATHOD PHYSICIAN 509298 0 0 0 0 0 2164 0 7698 0 519160 0 0 0 A WASHINGTON HEALTH CARE AUTHORITY 911108929 2014-07-17 13200000 MEDICAL OFFICE BUILDING ADDITION 0 0 0 A 378104 13200000 189169 12988122 2015 1 0 0 1 A 0 0 0 0 0.04000 0.04000 0 0 1 A 0 1 0 0 0 0 0 0 1 A 0 MIKE MARTIN BOARD MEMBER 176674 INSURANCE BROKER - OWNER OF MARTIN INSURANCE 0 FORM 990, PART III, LINE 2 IN JULY 2017 OPENED A MINOR CARE. IN JUNE 2017 OPENED A PULMONOLOGY PRACTICE. IN APRIL 2017 OPENED A PODIATRY PRACTICE. FORM 990, PART VI, SECTION B, LINE 11B A COPY IS PROVIDED TO THE CFO FOR REVIEW PRIOR TO FILING. THE BOARD AUTHORIZES THE CFO TO REVIEW AND APPROVE THE 990. THE FINAL 990 IS FILED AFTER CFO APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION IS AWARE THAT THE POTENTIAL FOR CONFLICT OF INTEREST EXISTS FOR DECISION-MAKERS AT ALL LEVELS WITHIN THE HOSPITAL. THIS INCLUDES MEMBERS OF THE GOVERNING BOARD, ADMINISTRATION, THE MEDICAL STAFF, AND ALL OTHER EMPLOYEES. 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. A DISINTERESTED PERSON OR COMMITTEE SHALL INVESTIGATE ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT. IF THE TRANSACTION OR ARRANGEMENT IS NOT ADVANTAGEOUS WITH A NON CONFLICT OF INTEREST PARTY, A VOTE OF MAJORITY WILL OCCUR TO DETERMINE IF THE HOSPITAL SHOULD ENTER INTO THE TRANSACTION OR ARRANGEMENT WITH THE CONFLICT OF INTEREST BUSINESS OR INDIVIDUAL. 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 3,962,593. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,962,593. ER PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 2,035,608. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,035,608. RADIOLOGY PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 1,199,008. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,199,008. HOSPITALIST PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 684,768. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 684,768. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 4,240,251. MANAGEMENT AND GENERAL EXPENSES 665,961. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,906,212. FORM 990, PART XI, LINE 9: TEMPORARILY RESTRICTED - NET GRANT FUNDS RECEIVED 33,648. TEMPORARILY RESTRICTED - RELEASED FOR OPERATIONS -34,557. TEMPORARILY RESTRICTED - INTEREST INCOME 281. TEMPORARILY RESTRICTED - CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION 903,638. TEMPORARILY RESTRICTED - NET ASSETS RELEASED FROM RESTRICTIONS - FOUNDATION -272,262. INTERCOMPANY TRANSFERS 195,910. FORM 990, PART XII, LINE 2C: THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. 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