2017-05-05T13:13:30-05:00 2016-06-30 KPMG LLP 55 SECOND STREET SUITE 1400 SAN FRANCISCO CA 94105 990 2015-07-01 941439787 Sierra Nevada Memorial - Miners Hospital Inc % LARA HARROWFINANCE DEPT SIER 5302746099 185 BERRY STREET SUITE 300 SAN FRANCISCO CA 94107 CAROLYN CANADY CFO 5302746099 2017-04-24 true VALERIE J BALL P00178114 4159635100 2017-05-01 2015 2021-01-29 14:40:06Z Carolyn Canady 155 Glasson Way Grass Valley CA 95945 211599731 false X www.SNMH.Org X 1934 CA TO CONTRIBUTE TO THE WELLNESS OF OUR COMMUNITY THROUGH THE PROVISION OF QUALITY SERVICES DELIVERED IN A COMPASSIONATE AND COST-EFFECTIVE MANNER. 11 9 973 94 7672 -2014 1003110 693819 148797515 152838258 7492224 5677937 641210 775973 157934059 159985987 5422875 7565667 0 0 90326370 98152219 0 0 0 61100968 65489223 156850213 171207109 1083846 -11221122 251963383 232844651 33385953 34322609 218577430 198522042 X TO CONTRIBUTE TO THE WELLNESS OF OUR COMMUNITY THROUGH THE PROVISION OF QUALITY SERVICES DELIVERED IN A COMPASSIONATE AND COST-EFFECTIVE MANNER,COLLABORATING WITH OTHERS IN THE COMMUNITY TO IMPROVE QUALITY OF LIFE. false false 142296996 7565667 152833703 SIERRA NEVADA MEMORIAL HOSPITAL'S MISSION IS TO CONTRIBUTE TO THE WELLNESS OF OUR COMMUNITY THROUGH THE PROVISION OF QUALITY SERVICES DELIVERED IN A COMPASSIONATE AND COST-EFFECTIVE MANNER, COLLABORATING WITH OTHERS IN THE COMMUNITY TO IMPROVE THE QUALITY OF LIFE. THE HOSPITAL OFFERS A WIDE RANGE OF SERVICES AND SPECIALTIES TO ACCOMMODATE THE GROWING NEEDS OF WESTERN NEVADA COUNTY. AS THE SOLE ACUTE CARE PROVIDER IN OUR SERVICE AREA, SIERRA NEVADA MEMORIAL HOSPITAL TREATS ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. SIERRA NEVADA MEMORIAL HOSPITAL IS LICENSED WITH 104 ACUTE BEDS, SPECIALIZING IN ORTHOPEDICS, ONCOLOGY AND GENERAL MEDICAL SERVICE. SERVICES PROVIDED IN FISCAL YEAR 2016 INCLUDED 152,762 OUTPATIENT VISITS, 30,515 EMERGENCY VISITS, AND 2,444 INPATIENT AND OUTPATIENT SURGERIES. SIERRA NEVADA MEMORIAL HOSPITAL'S LIST OF INPATIENT, OUTPATIENT AND SUPPORT SERVICES IS QUITE EXHAUSTIVE. INPATIENT SERVICES INCLUDE ACUTE MEDICAL/SURGICAL CARE; INTENSIVE CARE; PHARMACY; ORTHOPEDIC AND GENERAL SURGERY; AND WOMEN & INFANT CARE UNIT. OUTPATIENT SERVICES: AMBULATORY TREATMENT CENTER; CARDIAC REHABILITATION; CARDIOPULMONARY; DIAGNOSTIC IMAGING; LABORATORY; OUTPATIENT SURGERY CENTER; NUEROLOGICAL REHABILITATION SERVICES; WOUND CARE CENTER; AMBULANCE; CANCER CENTER; AND EMERGENCY SERVICES. 142296996 true true false true false false false false false true true true false false true true false true false false false false false false false false true true true false true true true false false false false false false false true false false false false false false true false false false true 117 0 true 973 true true true false false false false false false false false false X 11 9 false false false false true true true true true false false false true true true true true false false true true CA X LARA HARROWFINANCE DEPT 9168512104 3400 DATA DRIVE Rancho Cordova CA 95670 Dale Creighton Board Member 2.0 0.0 X 0 0 0 Monty East Board Member 2.0 0.0 X 0 0 0 Stacy Fore DDS Board Member 2.0 0.0 X 0 0 0 Alex Klistoff MD Board Member 2.0 0.0 X 0 0 0 Scott Robertson Board Member 2.0 0.0 X 0 0 0 Kevin Vaziri Board Member 2.0 40.0 X 0 619760 93288 Alan Wong Board Member 2.0 0.0 X 1500 0 0 Katherine A Medeiros CEO/ Service Area Leader 40.0 0.0 X X 0 518947 80837 Kathryn Rappath Board Vice Chair 2.0 0.0 X X 0 0 0 Edward Sylvester Board Chair 2.0 0.0 X X 0 0 0 Michele White Board Secretary 2.0 0.0 X X 0 0 0 Carolyn Canady CFO/Board Treasurer 40.0 0.0 X 239544 0 44495 Brian Evans VP, CMO 40.0 0.0 X 282203 0 54287 Jill McWilliams VP/CNE 40.0 0.0 X 223238 0 41786 Debbie L Plass VP Operations 40.0 0.0 X 187603 0 44548 Gregory T Smith Registered Nurse 40.0 0.0 X 242899 0 53402 Jonathan D Stone Director of Pharmacy 40.0 0.0 X 203070 0 50224 William S Swindling Pharmacist 40.0 0.0 X 201331 0 24868 Tzvetan I Tzvetanov Physicist 40.0 0.0 X 276890 0 47051 Gail A Van Vleck Charge Nurse IP/OP Surgery 40.0 0.0 X 225084 0 40980 2083362 1138707 575766 252 false true false COGENT HEALTHCARE OF CA PO BOX 645037 CINCINNATI OH 452645037 Medical Services 2627606 TRIMEDX LLC 5451 LAKEVIEW PKWY S DR INDIANAPOLIS IN 46268 Management services 1565614 SIERRA NEVADA ANESTHESIA 1020 MCCOURTNEY RD SUITE A GRASS VALLEY CA 95949 Medical Services 1191982 ARAMARK HEALTHCARE 27310 NETWORK PL CHICAGO IL 606731273 Management food/faci 1023276 DELPHI OF TEAM HEALTH 2600 UNIVERSITY PARKWAY CORALVILLE IA 522413212 Medical Services 890485 34 X 610615 36310 46894 693819 PATIENT NET OF CHARITY & BAD DEBT 900099 81482412 81482412 MEDICARE/MEDICAID PAYMENTS 900099 69183694 69183694 MEANINGFUL USE INCENTIVES (EHR) 900099 492246 492246 GS HIO MAINTENANCE 900099 452364 452364 RISK POOL PAYMENT REVENUE 900099 452515 452515 775027 770472 4555 152838258 2302621 2302621 0 0 2626 2626 0 2626 2626 54957490 31305 51613478 3344012 31305 3375316 3375316 0 1189 266 923 923 0 REBATES AND REFUNDS 900099 189829 189829 CAFETERIA/CATERING 722320 190842 3117 187725 FINANCE CHARGES 900099 180195 180195 211558 211558 772424 159985987 152833703 7672 6450793 X 7561167 7561167 4500 4500 0 0 1117924 1018863 99061 200374 200374 70905612 64472818 6432794 4562044 4203364 358680 16424790 15132960 1291830 4941475 4552809 388666 0 76730 76730 35224 35224 49369 49369 0 721321 721321 26258315 19127357 7130958 669306 13034 656272 2983760 2001742 982018 10815244 673981 10141263 0 1611619 1550227 61392 266359 168182 98177 0 37555 29258 8297 679457 679327 130 0 6109407 6038806 70601 800976 800976 MEDICAL SUPPLIES 13643607 13639233 4374 0 FOOD & OTHER EXPENSES 420568 326572 93996 0 DUES & SUBSCRIPTIONS 136965 30364 106601 0 LICENSES & TAXES 146333 71082 75251 0 27108 27108 171207109 142296996 28910113 0 X 6388 6128 2264536 4979028 0 0 28887452 22389577 0 0 0 0 473610 485482 1940027 1984663 5766887 6563055 128367583 86897718 41879527 41469865 111818708 65353626 53246572 83988750 5679676 5624477 0 0 0 0 251963383 232844651 15705874 17957996 0 0 266436 216137 4334365 4334365 0 0 0 0 413203 326521 0 0 12666075 11487590 33385953 34322609 X 214817106 194794622 2392646 2359742 1367678 1367678 218577430 198522042 251963383 232844651 X -11221122 -8801362 -32904 X X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 49369 49369 false PART II-B, LINE 1 SCHEDULE C, PART II-B, LINE 1 LOBBYING EXPENDITURES PAID DIRECTLY BY THE FILING ORGANIZATION FOR ANNUAL MEMBERSHIP DUES: AMERICAN COLLEGE OF HEALTHCARE EXECUTIVES $3 ASTRO $145 LOBBYING EXPENDITURES PAID BY THE PARENT ORGANIZATION FOR ANNUAL MEMBERSHIP DUES WHERE EXPENSES ARE ALLOCATED TO THE HOSPITAL: CATHOLIC HEALTH ASSOCIATION $745 AMERICAN HOSPITAL ASSOCIATION $1,628 HOSPITAL ASSOCIATION OF SOUTHERN CALIFORNIA $7,614 CALIFORNIA ASSOCIATION FOR HEALTH SERVICES AT HOME $60 VISITING NURSE ASSOCIATION OF AMERICA $205 CALIFORNIA HOSPITAL ASSOCIATION $38,879 340 B HEALTH $90 TOTAL EXPENDITURES PAID TO ORGANIZATIONS $49,369 2362497 -388783 1973714 2296400 0 66097 2362497 1367108 570 928722 2296400 1351797 15311 0 1367108 1599745 61959 -309907 1351797 0.69000 0.31000 false true true 1140153 1140153 63603486 43008985 20594501 289591 289591 0 52951006 40632379 12318627 10383347 2966763 7416584 41469865 POOLED INVESTMENTS 83988750 F 83988750 0 DUE TO RELATED PARTIES 8918468 PENSION PAYABLE 2569122 11487590 X Sch D, PART V, LINE 4 The endowment funds are intended to be used to support Alzheimer's research, the Cancer Center, the Cardiac program and other hospital program needs. Sch D, PART X, LINE 2 DIGNITY HEALTH REVIEWS ITS TAX POSITIONS ANNUALLY AND HAS DETERMINED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS THAT REQUIRE RECOGNITION IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. true true X true X true X 500. true true false true true 2716 1093146 161232 931914 0.00540 32376 36987855 31633607 5354248 0.03130 0 0 0 0 0.00000 35092 38081001 31794839 6286162 0.03670 22 9089 765477 0 765477 0.00450 1 10 95 0 95 0.00000 1 131 24818 0 24818 0.00010 0 0 0 0 0.00000 6 177 1335639 0 1335639 0.00780 30 9407 2126029 0 2126029 0.01240 30 44499 40207030 31794839 8412191 0.04910 2 125 66718 0 66718 0.00040 1 0 398 0 398 0.00000 3 125 67116 0 67116 0.00040 true 1626203 0 44179482 67648288 -23468806 X true true GRASS VALLEY OP SURG AMBULATORY SURGERY CENTER 0.228 0.0 0.3159 1 1 Sierra Nevada Memorial-Miners Hospita 155 Glasson Way Grass Valley CA 95945 http://www.snmh.org/index.htm 230000152 X X X Sierra Nevada Memorial-Minors Hosp 1 false false true X X X X X X X X X 15 true true false true X SEE SECTION C X true 15 true SEE SECTION C false true X 200. 500. X X X X true true X X X X true X SEE SECTION C X www.snmh.org X SEE SECTION C X X X X X true X false X X X X true X false false SCH H, PART V SCHEDULE H, PART V, SECTION B, LINE 5 COMMUNITY INPUT AND PRIMARY DATA ON HEALTH NEEDS WERE OBTAINED VIA INTERVIEWS WITH SERVICE PROVIDERS AND COMMUNITY KEY INFORMANTS AND THROUGH FOCUS GROUPS WITH MEDICALLY UNDERSERVED, LOW-INCOME, AND MINORITY POPULATIONS. TRANSCRIPTS AND NOTES FROM INTERVIEWS AND FOCUS GROUPS WERE ANALYZED TO LOOK FOR THEMES AND TO DETERMINE IF A HEALTH NEED WAS IDENTIFIED AS SIGNIFICANT AND/OR A PRIORITY TO ADDRESS. PARTICIPANTS INCLUDED THE COUNTY PUBLIC HEALTH DEPARTMENT AND PUBLIC AND NON-PROFIT AGENCIES, COMMUNITY MEMBERS AND SERVICE PROVIDERS; A COMPLETE LIST OF KEY INFORMANT INTERVIEW DATA SOURCES, AREAS OF EXPERTISE AND POPULATIONS SERVED, ALONG WITH LISTS OF FOCUS GROUPS WITH PARTICIPANT DEMOGRAPHIC INFORMATION IS IN THE CHNA REPORT APPENDICES. SCHEDULE H, PART V, SECTION B, LINE 6A MERCY HOSPITAL OF FOLSOM, MERCY GENERAL HOSPITAL, METHODIST HOSPITAL OF SACRAMENTO, MERCY SAN JUAN MEDICAL CENTER, WOODLAND MEMORIAL HOSPITAL, UC DAVIS MEDICAL CENTER, KAISER PERMANENTE, SUTTER MEDICAL CENTER SCHEDULE H, PART V, SECTION B, LINE 7A https://www.dignityhealth.org/-/media/cm/media/documents/CHNA/CHNA-SNMH-20 16.ashx?la=en SCHEDULE H, PART V, SECTION B, LINE 10A https://www.dignityhealth.org/-/media/cm/media/documents/CHNA/CHNA-SNMH-20 16.ashx?la=en SCHEDULE H, PART V, SECTION B, LINE 11 SIERRA NEVADA MEMORIAL WILL ADDRESS THE 2016 CHNA SIGNIFICANT HEALTH NEEDS OF: ACCESS TO BEHAVIORAL HEALTH; ACCESS TO HIGH QUALITY HEALTH CARE; AND CHRONIC DISEASE PREVENTION, MANAGEMENT, AND TREATMENT. BEHAVIORAL HEALTH INCLUDES INDICATORS RELATED TO MENTAL HEALTH AND SUBSTANCE USE. THE HOSPITAL IS ADDRESSING THESE NEEDS IN NUMEROUS WAYS DESCRIBED IN DETAIL IN THE IMPLEMENTATION STRATEGY, WHICH IS WIDELY AVAILABLE TO THE PUBLIC ONLINE. PROGRAMS INCLUDE: INTEGRATED CARE COORDINATION FOR FAMILY WELLNESS; MENTAL HEALTH CRISIS SUPPORT PARTNERSHIP; CRISIS STABILIZATION UNIT; TELE-PSYCHIATRIC CARE; CLASSES ADDRESSING MENTAL HEALTH; PENN VALLEY SATELLITE LAB AND X-RAY CLINIC; CANCER NURSE NAVIGATOR; EMERGENCY DEPARTMENT NAVIGATION; ALZHEIMERS OUTREACH PROGRAM; FALLS PREVENTION PROGRAM; HEART FAILURE PROGRAM; DIABETES MANAGEMENT AND PREVENTION WORKSHOPS; WELLNESS CLASSES ADDRESSING PREVENTION AND HEALTH MANAGEMENT; CANCER SCREENINGS; HEALTH FAIRS; TAXI VOUCHER PROGRAM; ANTI-HUMAN TRAFFICKING INITIATIVE; AND HOMELESS OUTREACH PROJECT. SIERRA NEVADA MEMORIAL, AS A RURAL COMMUNITY HOSPITAL, DOES NOT HAVE THE CAPACITY OR RESOURCES TO ADDRESS ALL PRIORITY HEALTH ISSUES IDENTIFIED IN NEVADA COUNTY. THE HOSPITAL IS NOT DIRECTLY ADDRESSING THE FOLLOWING PRIORITIES, ALTHOUGH PROGRAMS ARE IN PLACE TO ASSIST COMMUNITY RESIDENTS IN LIMITED CAPACITY: AFFORDABLE AND ACCESSIBLE TRANSPORTATION; SAFE, CRIME AND VIOLENCE FREE COMMUNITIES; ACTIVE LIVING AND HEALTH EATING; AND BASIC NEEDS. IN ADDITION, THE HOSPITAL WILL CONTINUE TO SEEK COLLABORATIVE OPPORTUNITIES THAT ADDRESS NEEDS THAT HAVE NOT BEEN SELECTED AS PRIORITIES. THE HOSPITAL IS NOT ADDRESSING POLLUTION-FREE LIVING AND WORKING ENVIRONMENTS, AS THIS PRIORITY IS BEYOND THE CAPACITY AND EXPERTISE OF SIERRA NEVADA MEMORIAL. SCHEDULE H, PART V, SECTION B, LINE 16A, 16B AND 16C https://www.dignityhealth.org/Service%20Areas/sacramento/patients-and-visi tors/for-patients/billing-information/payment-assistance SCHEDULE H, PART V, SECTION B, LINE 16I ADDITIONAL MEASURES TAKEN TO PUBLICIZE DIGNITY HEALTH'S FINANCIAL ASSISTANCE POLICY INCLUDE THE PROVISION OF BROCHURES EXPLAINING AVAILABLE GOVERNMENT SPONSORED PROGRAMS AND THE FINANCIAL ASSISTANCE POLICY, A COPY OF THE FINANCIAL ASSISTANCE APPLICATION, A TELEPHONE NUMBER FOR PATIENTS TO REQUEST FURTHER INFORMATION ABOUT THE PROGRAM, AVAILABLITY OF INFORMATION IN LANGUAGES OTHER THAN ENGLISH, CONTACT INFORMATION FOR FINANCIAL COUNSELORS OR OTHER REPRESENTATIVES WHO CAN PROVIDE INFORMATION.THE FACILITY'S WEB SITE ALSO CONTAINS THE FINANCIAL ASSISTANCE POLICY, PLAIN LANGUAGE SUMMARY OF THE POLICY, APPLICATION, BILLING AND COLLECTION POLICY, A DESCRIPTION OF THE AMOUNT GENERALLY BILLED AND A LISTING OF PROVIDERS AT EACH FACILITY THAT ARE COVERED AND NOT COVERED BY THE FINANICAL ASSISTANCE POLICY. CONTACT INFORMATION CAN ALSO BE FOUND ON EACH FACILITYS WEB PAGE. SCHEDULE H, PART V, SECTION B, LINE 22D THE MAXIMUM CHARGE THAT MAY BE BILLED TO A PATIENT WHO IS ELIGIBLE FOR FINANCIAL ASSISTANCE UNDER THE FINANCIAL ASSISTANCE POLICY IS KNOWN AS THE AMOUNT GENERALLY BILLED (AGB). NO PATIENT ELIGIBLE FOR FINANCIAL ASSISTANCE WILL BE CHARGED MORE THAN THE AGB FOR THE ELIGIBLE SERVICE(S) PROVIDED TO THE PATIENT. DIGNITY HEALTH CALCULATES THE AGB ON A FACILITY-BY-FACILITY USING THE "LOOKBACK" METHOD BY MULTIPLYING THE "GROSS CHARGES" FOR ANY ELIGIBLE SERVICES THAT IT PROVIDES BY AGB PERCENTAGES WHICH ARE BASED UPON PAST CLAIMS ALLOWED UNDER MEDICARE AND PRIVATE INSURANCE AS SET FORTH IN FEDERAL LAW. 1 GRASS VALLEY SURGERY CENTER 408 Sierra College Drive GRASS VALLEY CA 95945 OUTPATIENT SURGERY CENTER SCH H, Part I, Lines 7 & 7B, column (f) Line 7B, column (f) BEGINNING IN 2009, THE STATE OF CALIFORNIA ESTABLISHED PROVIDER FEE PROGRAMS. THESE PROGRAMS ARE FUNDED BY QUALITY ASSURANCE FEES PAID BY PARTICIPATING HOSPITALS AND MATCHING FEDERAL FUNDS. SIERRA NEVADA MEMORIAL HOSPITAL RECOGNIZED FEE-FOR-SERVICE SUPPLEMENTAL PAYMENTS OF $10.48 MILLION DURING THE YEAR REFLECTED UNDER THE MEDICAID PROGRAM AS DIRECT OFFSETTING REVENUE (PART I, LINE 7B, COLUMN D). THIS NET REDUCTION IN THE COST OF THE MEDICAID PROGRAM IS DRIVING THE DECREASE IN THE OVERALL COST OF COMMUNITY BENEFIT EXPENSE AS A PERCENT OF TOTAL EXPENSES WHEN COMPARED TO PRIOR YEARS. LINE 7I COLUMN C THE CALIFORNIA HOSPITAL ASSOCIATION CREATED A PRIVATE PROGRAM, THE CALIFORNIA HEALTH FOUNDATION AND TRUST ("CHFT"), ESTABLISHED FOR SEVERAL PURPOSES, INCLUDING AGGREGATING AND DISTRIBUTING FINANCIAL RESOURCES TO SUPPORT CHARITABLE ACTIVITIES AT VARIOUS HOSPITALS AND HEALTH SYSTEMS IN CALIFORNIA. DURING THE YEAR, SIERRA NEVADA MEMORIAL HOSPITAL RECORDED A PLEDGE TO A GRANT FUND ESTABLISHED BY CHFT IN THE AMOUNT $0.17 MILLION. THE GRANT IS REPORTED UNDER OTHER BENEFITS (PART I, LINE 7I, COLUMN C), AS CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS. SCH H, PART I, LINE 7 FOR PURPOSES OF CALCULATING THE AMOUNTS PROVIDED IN THE TABLE, SNMMH USES A COST ACCOUNTING SYSTEM THAT COMBINES RELATIVE VALUE UNITS (RVU) AND COST TO CHARGE RATIOS (CCR) TO ALLOCATE COSTS TO THE PATIENT LEVEL. THE COST ACCOUNTING SYSTEM ALGORITHM ALLOCATES TOTAL OPERATING EXPENSES TO THE PROCEDURE CHARGE CODE LEVEL BASED UPON AN RVU FOR PROCEDURES THAT HAVE BEEN STUDIED AND ASSIGNED AN RVU, OR BASED UPON A CCR FOR UNSTUDIED PROCEDURES THAT DO NOT HAVE AN RVU ASSIGNED. WHEN A CCR IS USED, THE SYSTEM CALCULATES THAT CCR ON A DEPARTMENTAL SPECIFIC BASIS AT EACH INDIVIDUAL HOSPITAL WHERE THE SERVICES WERE PROVIDED. THE CALCULATION IS SIMILAR TO THE WORKSHEET 2 OF SCHEDULE H, RATIO OF PATIENT CARE COST TO CHARGES, EXCEPT IT IS CALCULATED ON A DEPARTMENTAL SPECIFIC BASIS, NOT IN THE AGGREGATE. THE ALLOCATED PROCEDURE CHARGE CODE LEVEL COSTS ARE THEN ROLLED UP TO THE PATIENT LEVEL BASED UPON THE BILLED PROCEDURE CHARGE CODES ASSOCIATED WITH THOSE SERVICES PROVIDED TO EACH SPECIFIC PATIENT. THIS IS DONE FOR ALL PATIENT SEGMENTS INCLUDING INPATIENT, OUTPATIENT, EMERGENCY DEPARTMENT, PRIVATE INSURANCE, MEDICAID, MEDICARE, UNINSURED AND SELF PAY. THE COST ACCOUNTING SYSTEM IS UTILIZED TO DETERMINE THE UNREIMBURSED COST OF MEDICAID AND OTHER MEANS-TESTED GOVERNMENT PROGRAMS. THE COST OF CHARITY CARE IS CALCULATED BY APPLYING THE CCR DERIVED FROM THE COST ACCOUNTING SYSTEM ON A PER FACILITY BASIS, TO THE CHARGES INCURRED ON PATIENTS THAT QUALIFY FOR CHARITY CARE AT THE RESPECTIVE FACILITY. THE ACTUAL COST IS REPORTED FOR OTHER COMMUNITY BENEFIT ACTIVITIES SUCH AS COMMUNITY HEALTH IMPROVEMENT SERVICES, COMMUNITY BENEFIT OPERATIONS, HEALTH PROFESSIONS EDUCATION, SUBSIDIZED HEALTH SERVICES, RESEARCH AND CASH AND IN-KIND DONATIONS. SCH H, PART II - COMMUNITY BUILDING ACTIVITIES ADVOCACY TO IMPROVE THE HEALTH STATUS OF THE UNDERSERVED AND THE QUALITY OF LIFE FOR RESIDENTS IN NEVADA COUNTY IS A PRIORITY. SIERRA NEVADA MEMORIAL HOSPITAL IS INVOLVED IN VARIOUS ORGANIZATIONS TO REPRESENT THE NEEDS OF THE UNDERSERVED, DEVELOP INITIATIVES FOR HEALTHIER COMMUNITIES, AND ENHANCE THE OVERALL ECONOMY OF THE COMMUNITY. SIGNIFICANT VOLUNTEER TIME IS SPENT SERVING THE COMMUNITY IN THIS CAPACITY ON THE BOARDS OF ORGANIZATIONS THAT INCLUDE: -MINERS/WESTERN SIERRA CLINIC -GRASS VALLEY CHAMBER OF COMMERCE -COMMUNITY RECOVERY RESOURCES -ROTARY OF GRASS VALLEY -ROTARY OF NEVADA COUNTY SOUTH -THE FRIENDSHIP CLUB -ELDERCARE PROVIDERS -ECONOMIC RESOURCE COUNCIL THE HOSPITAL ALSO PARTICIPATES IN FUNDRAISING EVENTS TO SUPPORT MEANINGFUL HEALTH IMPROVEMENT PROGRAMS AND SERVICES BY COMMUNITY BASED NONPROFIT ORGANIZATIONS. SCH H, PART III SCHEDULE H, PART III, LINE 2 THE AMOUNT OF THE ORGANIZATION'S BAD DEBT AT COST IS DETERMINED BY APPLYING THE CCR (SEE ABOVE) TO PATIENT CHARGES THAT ARE DEEMED TO BE UNCOLLECTIBLE. THIS AMOUNT REPRESENTS THE COST OF SERVICES PROVIDED TO PATIENTS WHO ARE UNABLE OR REFUSE TO PAY THEIR BILLS AND DO NOT QUALIFY FOR FREE OR DISCOUNTED CARE, GOVERNMENT SPONSORED PROGRAMS OR OTHER PAYMENT ASSISTANCE, AND ARE OTHERWISE UNINSURED. AS NOTED IN PART I, LINE 3B, SNMMH PROVIDES FREE OR DISCOUNTED CARE TO UNINSURED OR UNDER-INSURED INDIVIDUALS THAT FALL INTO THREE CATEGORIES; UNDER 200%, 201%-350% OR 351%-500% OF THE FEDERAL POVERTY LEVEL. DIGNITY HEALTH ALSO PROVIDES PATIENTS OPTIONS FOR PROMPT PAY DISCOUNTS, AND INTEREST-FREE EXTENDED PAYMENT PLANS FOR PATIENTS WHO HAVE DEMONSTRATED GOOD FAITH AND ARE COOPERATING IN RESOLVING THEIR HOSPITAL BILLS. ALL ACCOUNTS FOR ELIGIBLE UNINSURED PATIENTS AT ALL DIGNITY HEALTH FACILITIES RECEIVE AN AUTOMATIC UNINSURED DISCOUNT OF 30%. THE EXPECTED PATIENT PAYMENT AMOUNT ON THE PATIENT'S BILL REFLECTS THIS DISCOUNT. DISCOUNTS ARE ACCOUNTED FOR AS DEDUCTIONS FROM REVENUE, NOT AS BAD DEBT EXPENSE. SCHEDULE H, PART III, LINE 3 SNMMH MAKES EVERY EFFORT IN DETERMINING IF A PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE UPON ADMISSION. SNMMH FOLLOWS DIGNITY HEALTH'S FINANCIAL ASSISTANCE POLICY. THIS FINANCIAL ASSISTANCE POLICY IS COMMUNICATED TO PATIENTS UPON ADMISSION AND IS AVAILABLE IN THE LANGUAGES PRIMARILY SPOKEN IN THE COMMUNITY. IT IS ALSO POSTED IN VARIOUS COMMON AREAS OF THE HOSPITAL, SUCH AS EMERGENCY ROOMS, URGENT CARE CENTERS, ADMITTING AND REGISTRATION DEPARTMENTS, HOSPITAL BUSINESS OFFICES LOCATED ON FACILITY CAMPUSES, AND OTHER PUBLIC PLACES, AND IS PROVIDED UPON BILLING IF ELIGIBILITY IS NOT PREVIOUSLY DETERMINED. ELIGIBILITY IS REEVALUATED AS NEEDED AND AMOUNTS ARE CLASSIFIED AS CHARITY AS SOON AS ELIGIBILITY IS KNOWN. DIGNITY HEALTH ALSO UTILIZES A PAYMENT ASSISTANCE RANK ORDERING (PARO) SCORING SYSTEM TO ASSIST IN DETERMINING IF A PATIENT MAY QUALIFY FOR FINANCIAL ASSISTANCE EVEN THOUGH THEY HAVE NOT APPLIED FOR IT. PARO IS A METHODOLOGY THAT APPLIES CONSISTENT SCREENING AND APPLICATION STANDARDS TO ALL PATIENTS UTILIZING HISTORICAL DATA TO DEVELOP A PREDICTIVE MODEL FOR HEALTHCARE PAYMENT ASSISTANCE. IN ITS DEVELOPMENT, SPECIAL ATTENTION WAS PAID TO THOSE SOCIOECONOMIC FACTORS THAT MIGHT ADVERSELY AFFECT THOSE PATIENTS DESERVING THE MOST ATTENTION. OTHER CRITERIA ARE ALSO UTILIZED TO ENSURE THAT NO SERVICES THAT HAVE QUALIFIED AS FINANCIAL ASSISTANCE WERE REPORTED AS BAD DEBT. AS SUCH, SNMH DOES NOT BELIEVE THAT ANY AMOUNTS INCLUDED IN PART III, LINE 2, ARE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY, AND THEREFORE, NO PORTION OF BAD DEBT EXPENSE IS INCLUDED AS COMMUNITY BENEFIT EXPENSE. SCHEDULE H, PART III, LINE 4 THE FOLLOWING IS AN EXCERPT FROM DIGNITY HEALTH AND ITS SUBORDINATE CORPORATIONS' CONSOLIDATED ANNUAL AUDITED FINANCIAL STATEMENTS FOR THE YEAR ENDED JUNE 30, 2016, RELATED TO ACCOUNTS RECEIVABLE AND ALLOWANCES FOR CHARITY AND DOUBTFUL ACCOUNTS: PATIENT ACCOUNTS RECEIVABLE AND NET PATIENT SERVICE REVENUE ARE REPORTED AT THE NET REALIZABLE AMOUNT FROM PATIENTS, THIRD-PARTY PAYORS, AND OTHERS FOR SERVICES RENDERED. SNMMH MANAGES ITS COLLECTION RISK BY REGULARLY REVIEWING ITS ACCOUNTS AND CONTRACTS AND BY PROVIDING APPROPRIATE ALLOWANCES. RESERVES FOR CHARITY AND UNCOLLECTIBLE AMOUNTS HAVE BEEN ESTABLISHED AND ARE NETTED AGAINST PATIENT ACCOUNTS RECEIVABLE IN THE CONSOLIDATED BALANCE SHEET. SCHEDULE H, PART III, LINE 8 SNMMH PREPARES MEDICARE COST REPORTS IN A MANNER THAT COMPORTS WITH PROVIDER REIMBURSEMENT MANUAL (PRM) 15-1, 2150FF AND PRM 15-2, 1000FF. AS SUCH, THE FOLLOWING LANGUAGE PER THE PRM 15-1 DESCRIBES THE COMPUTATION OF COSTS PER THE MEDICARE COST REPORT: TOTAL ALLOWABLE COSTS OF A PROVIDER ARE APPORTIONED BETWEEN PROGRAM BENEFICIARIES AND OTHER PATIENTS SO THAT THE SHARE BORNE BY THE PROGRAM IS BASED UPON ACTUAL SERVICES RECEIVED BY PROGRAM BENEFICIARIES. THE RATIO OF COVERED BENEFICIARY CHARGES TO TOTAL PATIENT CHARGES FOR THE SERVICES OF EACH ANCILLARY DEPARTMENT IS APPLIED TO THE COST OF THE DEPARTMENT. ADDED TO THIS AMOUNT IS THE COST OF ROUTINE SERVICES FOR PROGRAM BENEFICIARIES, DETERMINED ON THE BASIS OF A SEPARATE AVERAGE COST PER DIEM FOR ALL PATIENTS FOR GENERAL ROUTINE PATIENT CARE AREAS. ANOTHER FACTOR TO BE CONSIDERED IS A SEPARATE AVERAGE COST PER DIEM FOR EACH INTENSIVE CARE UNIT, CORONARY CARE UNIT, AND OTHER SPECIAL CARE INPATIENT HOSPITAL UNITS. DIGNITY HEALTH BELIEVES THAT THE ENTIRE MEDICARE SHORTFALL OF $895 MILLION, AS REPORTED BELOW IN PART VI, LINE 6, CONSTITUTES COMMUNITY BENEFIT. THE IRS COMMUNITY BENEFIT STANDARD INCLUDES THE PROVISION OF CARE TO THE ELDERLY AND MEDICARE PATIENTS. MEDICARE SHORTFALLS MUST BE ABSORBED BY DIGNITY HEALTH HOSPITALS IN ORDER TO CONTINUE TREATING THE ELDERLY IN OUR COMMUNITIES. THE HOSPITALS PROVIDE CARE REGARDLESS OF THIS SHORTFALL AND THEREBY RELIEVE THE FEDERAL GOVERNMENT OF THE BURDEN OF PAYING THE FULL COST FOR MEDICARE BENEFICIARIES. THIS SHORTFALL INCLUDES $23.5 MILLION REPORTED ON PART III, SECTION B, LINE 7, PRIMARILY FOR FEE FOR SERVICE MEDICARE PATIENTS, AS WELL AS THE UNREIMBURSED PORTION OF MEDICARE MANAGED CARE AND MEDICARE CAPITATED PROGRAMS FOR SNMMH. SCHEDULE H, PART III, LINE 9B SNMMH ENSURES THAT PATIENT ACCOUNTS ARE PROCESSED FAIRLY AND CONSISTENTLY. SNMMH'S COLLECTION POLICY CONTAINS PROVISIONS THAT PROHIBIT THE COLLECTION OF AMOUNTS DUE FROM PATIENTS WHO THE ORGANIZATION KNOWS QUALIFY FOR FINANCIAL ASSISTANCE. ACCOUNTS WITH INCORRECT OR INCOMPLETE DEMOGRAPHIC INFORMATION ARE ASSIGNED TO A COLLECTION AGENCY IF THE SNMMH OR BILLING COMPANY RETAINED BY SNMMH IS UNABLE TO OBTAIN AN UPDATED ADDRESS THROUGH SKIP TRACING OR OTHER MEANS. FOR PATIENTS WHO HAVE AN APPLICATION PENDING FOR EITHER GOVERNMENT-SPONSORED FINANCIAL ASSISTANCE OR FOR ASSISTANCE UNDER SNMMH'S FINANCIAL ASSISTANCE POLICY, OR WHERE THE PATIENT IS ATTEMPTING IN GOOD FAITH TO SETTLE AN OUTSTANDING BILL WITH THE FACILITY VIA PAYMENT PLANS, SNMMH WILL NOT KNOWINGLY SEND THAT PATIENT'S BILL TO AN OUTSIDE COLLECTION AGENCY. LEGAL ACTION WILL NOT BE PURSUED TO COLLECT DEBTS FROM PATIENTS WHO HAVE QUALIFIED FOR CHARITY OR ARE COOPERATING IN GOOD FAITH TO RESOLVE THEIR DEBT. ON SELF-PAY ACCOUNTS THAT DO NOT MEET THE CRITERIA NOTED ABOVE, THE INITIAL DETERMINATION OF ASSIGNMENT TO A COLLECTION AGENCY WILL VARY DEPENDING ON THE NATURE OF THE ACCOUNT WITH THE FINAL DECISION BEING AT THE DISCRETION OF THE HOSPITAL PATIENT FINANCIAL ASSISTANCE DEPARTMENT. UPON ASSIGNMENT OF SUCH A PATIENT ACCOUNT TO A COLLECTION AGENCY, SNMMH REQUIRES THE AGENCY TO COMPLY WITH THE FAIR DEBT COLLECTION PRACTICES ACT. Sch H, Part VI, Line 2 - Needs Assessment THE HOSPITAL IS ADDRESSING PRIORITY NEEDS IDENTIFIED IN THE NEEDS ASSESSMENT, FOCUSING ON ACCESS TO CARE AS A PRIORITY NEED AND BY IMPLEMENTING A CHRONIC DISEASE SELF-MANAGEMENT PROGRAM. NEEDS ARE ALSO ASSESSED EACH YEAR WORKING WITH COMMUNITY ORGANIZATIONS DURING OUR COMMUNITY GRANTS PROGRAM. SIERRA NEVADA MEMORIAL HOSPITAL ENGAGED VALLEY VISION, INC. TO CONDUCT AN ASSESSMENT OF THE HEALTH NEEDS OF THE RESIDENTS LIVING IN THE SERVICE AREA. THE ASSESSMENT WAS CONDUCTED OVER A PERIOD OF EIGHTEEN MONTHS, BEGINNING IN JANUARY 2015 AND CONCLUDED IN JUNE 2016 USING A MIXED METHOD DATA COLLECTION APPROACH THAT INCLUDED PRIMARY DATA SUCH AS KEY INFORMANT INTERVIEWS, COMMUNITY FOCUS GROUPS, AND COMMUNITY ASSET ASSESSMENTS. SECONDARY DATA INCLUDED HEALTH OUTCOMES, DEMOGRAPHIC DATA, BEHAVIORAL DATA AND ENVIRONMENTAL DATA. SNMMH LEADERSHIP REVIEWED AND COMPARED THE FINDINGS OF THE ASSESSMENT WITH COMMUNITY BENEFIT PROGRAMS AND SERVICES CURRENTLY BEING OFFERED BY THE HOSPITAL AND DETERMINED SNMMH IS RESPONDING TO A NUMBER OF PRIORITY NEEDS. SNMMH LEADERSHIP HAS CONSTRUCTED AN ACTION PLAN AND IS WORKING WITH COMMUNITY PARTNERS TO FURTHER ADDRESS THE NEEDS INDENTIFIED IN THE ASSESSMENT. Sch H, Part VI, Line 3- Patient Education of Eligibility for ASSISTANCE COMMUNICATION OF THE FINANCIAL ASSISTANCE PROGRAM TO PATIENTS AND THE PUBLIC: INFORMATION ABOUT THE ORGANIZATION'S FINANCIAL ASSISTANCE PROGRAM AND A CONTACT NUMBER ARE MADE AVAILABLE TO PATIENTS AND THE PUBLIC. PATIENTS ARE INFORMED OF THE FACILITY'S FINANCIAL ASSISTANCE PROGRAM VIA SIGNAGE IN ALL ADMITTING AREAS AND IN VARIOUS COMMON AREAS OF THE HOSPITAL. FINANCIAL ASSISTANCE PROGRAM INFORMATION NOTICES ARE POSTED IN THE EMERGENCY AND ADMITTING DEPARTMENTS AND AT OTHER PUBLIC PLACES AS THE HOSPITAL FACILITY MAY ELECT. SUCH INFORMATION IS PROVIDED IN THE PRIMARY LANGUAGES SPOKEN IN THE COMMUNITIES SNMMH SERVES. THE SIGNAGE INCLUDES NOTIFICATION THAT ALL UNINSURED PATIENTS RECEIVE AN UNINSURED DISCOUNT OF 30%, AND THAT FURTHER DISCOUNTS MAY BE PROVIDED UPON THE COMPLETION AND SUBMISSION OF A FINANCIAL ASSISTANCE APPLICATION OR WITH PROMPT PAYMENT. FINANCIAL ASSISTANCE INFORMATION, GOVERNMENT PROGRAM RESOURCE INFORMATION, TOOLS TO ASSIST PATIENTS IN FINDING HEALTH COVERAGE, ANSWERS TO FREQUENTLY ASKED BILLING QUESTIONS, AND OTHER SUCH INFORMATION CAN ALSO BE FOUND ON FACILITY'S WEBSITE AT https://www.dignityhealth.org/Service%20Areas/sacramento/patients-and-visi tors/for-patients/billing-information/payment-assistance. AT THE POINT OF REGISTRATION, BROCHURES ARE MADE AVAILABLE TO ALL PATIENTS EXPLAINING THE FACILITY'S FINANCIAL ASSISTANCE PROGRAM AND THE AVAILABILITY OF GOVERNMENT SPONSORED PROGRAMS. COPIES OF THE FINANCIAL ASSISTANCE APPLICATION ARE MADE AVAILABLE TO ALL UNINSURED PATIENTS IN ADDITION TO THE BROCHURE UPON ADMISSION TO THE FACILITY. IF FINANCIAL ASSISTANCE ELIGIBILITY IS NOT DETERMINED PRIOR TO BILLING, INITIAL BILLING STATEMENTS TO UNINSURED PATIENTS INCLUDE A REQUEST TO THE PATIENT TO PROVIDE ANY INSURANCE INFORMATION THAT WAS VALID FOR THE DATES OF SERVICE BILLED, A STATEMENT INFORMING PATIENTS WITHOUT INSURANCE COVERAGE THAT THEY MAY BE ELIGIBLE FOR A GOVERNMENT SPONSORED PROGRAM OR FACILITY FUNDED FINANCIAL ASSISTANCE, INSTRUCTIONS ON HOW TO APPLY FOR A GOVERNMENT PROGRAM OR FINANCIAL ASSISTANCE AND THE PROVISION OF SUCH APPLICATIONS. ADDITIONALLY, CONTRACT TERMS WITH COLLECTION VENDORS WORKING ON BEHALF OF DIGNITY HEALTH REQUIRE ALL INITIAL STATEMENTS TO UNINSURED PATIENTS TO INCLUDE VERBIAGE INFORMING PATIENTS OF THE FACILITY'S FINANCIAL ASSISTANCE PROGRAM AND A COPY OF THE FINANCIAL ASSISTANCE APPLICATION. ALSO, ANY MEMBER OF THE SNMMH FACILITY STAFF OR MEDICAL STAFF MAY MAKE REFERRALS OF PATIENTS FOR FINANCIAL ASSISTANCE. THE PATIENT, A FAMILY MEMBER, A CLOSE FRIEND OR AN ASSOCIATE OF THE PATIENT MAY ALSO MAKE A REQUEST FOR FINANCIAL ASSISTANCE. Sch H, Part VI Line 4: - Community Information PRIMARY SERVICE AREA: SIERRA NEVADA MEMORIAL HOSPITAL IS LOCATED WEST OF LAKE TAHOE IN THE SIERRA NEVADA MOUNTAINS, NEVADA COUNTY IS IN THE HEART OF CALIFORNIA'S HISTORIC GOLD COUNTRY. THE HOSPITALS SERVICE AREA ENCOMPASSES SEVEN ZIP CODES IN THE COMMUNITIES OF GRASS VALLEY, PENN VALLEY, ROUGH AND READY, NEVADA CITY, NORTH SAN JUAN AND WASHINGTON (95945, 95946, 95949, 95959, 95960, 95975, AND 95986). FOUR OF THE ZIP CODES HAD PORTIONS THAT WERE DESIGNATED HEALTH PROFESSIONAL SHORTAGE AREAS (HPSAS) FOR PRIMARY CARE. Total Population: 75,301 Race/Ethnicity: White - Non-Hispanic 87.0%; Black/African American - Non-Hispanic 0.6%; Hispanic or Latino 7.1%; Asian/Pacific Islander 1.4%; All Others 3.9% Median Income: $55,724 Unemployment: 4.7% No High School Diploma: 7.6% Medicaid: 25.9% Uninsured: 6.1% OTHER AREA HOSPITALS: 1 Sch H, Part VI, Line 5 - Promotion of Community Health SIERRA NEVADA MEMORIAL HOSPITAL OFFERS MEDICAL STAFF PRIVILEGES TO ANY QUALIFYING PHYSICIANS. THE HOSPITAL'S FIDUCIARY BOARD SERVES IN AN OVERSIGHT ROLE TO ENSURE THAT COMMUNITY BENEFIT PRACTICES AND PROGRAMS ARE ALIGNED WITH AND SUPPORT THE MISSION, POLICY AND PRIORITIES OF THE REGION AND THE ORGANIZATION. THE MAJORITY OF THE ORGANIZATION'S GOVERNING BODY RESIDES IN THE PRIMARY SERVICE AREA AND IS NOT EMPLOYED BY NOR CONTRACTED WITH THE ORGANIZATION. SNMMH UTILIZES A COMMUNITY NEEDS ASSESSMENT PROCESS THAT RESULTS IN A DOCUMENT DESCRIBING THE HEALTH CARE NEEDS OF THE SURROUNDING POPULATION. IN ADDITION A COMPANION DOCUMENT LISTING COMMUNITY HEALTH ASSETS IS PREPARED AND THEN COMPARED TO THE NEEDS ASSESSMENT. UNMET NEEDS ARE IDENTIFIED AND USED IN PLANNING FOR PHYSICIAN RECRUITMENT, ADDING NEW SERVICES AND PROGRAMS, AND OFFERING COMMUNITY EDUCATION. SIERRA NEVADA MEMORIAL HOSPITAL SPECIFICALLY SPONSORS AND TAKES AN ACTIVE ROLE IN PROGRAMS THAT ADDRESS PRIORITIES WITHIN ITS SERVICE AREA SUCH AS: - CHAMP (CONGESTIVE HEART ACTIVE MANAGEMENT PROGRAM) THAT PROVIDES A VITAL MEDICAL LINK TO HEART FAILURE PATIENTS WHEN THEY LEAVE THE HOSPITAL TO IMPROVE THEIR UNDERSTANDING AND ABILITY TO MANAGE THIS CHRONIC DISEASE, AND REDUCE THEIR RISK OF READMISSION. -FREE OR DISCOUNTED CARDIAC REHAB PROGRAMS TO THOSE WHO ARE UNABLE TO PAY AS A COMPLEMENTARY PROGRAM TO CHAMP. - WELLNESS EDUCATION PROGRAM THAT OFFERS A WIDE VARIETY OF CLASSES ADDRESSING HEALTH ISSUES INCLUDING DIABETES, CHRONIC DISEASE SELF-MANAGEMENT, SMOKING CESSATION, AGING, HEALTH COOKING, AND PRENATAL CARE. THE FEE IS DISCOUNTED OR ELIMINATED FOR THOSE WHO ARE UNABLE TO PAY. - FREE NUTRITIONAL COUNSELING BY A REGISTERED DIETICIAN FOR THOSE THAT ARE UNINSURED OR CAN'T AFFORD TO PAY. - ASSISTANCE TO ALZHEIMER'S PATIENTS AND THEIR CAREGIVERS/FAMILIES BY THE HOSPITAL'S HOME CARE DEPARTMENT. - CANCER SCREENINGS AND CANCER SUPPORT GROUPS. - TRAUMATIC BRAIN INJURY, STROKE AND OTHER SUPPORT GROUPS. - EDUCATIONAL TRAINING FOR THOSE ENTERING THE PROFESSIONAL AND MEDICAL HEALTH FIELD. SIERRA NEVADA MEMORIAL HOSPITAL ALSO PROVIDES ASSISTANCE TO UNINSURED PATIENTS FOR ENROLLMENT IN GOVERNMENT SPONSORED HEALTH INSURANCE PROGRAMS, AND FREE TRANSPORTATION TO THOSE IN NEED. Sch H, Part VI, Line 6 - Affiliated Health Care System SNMMH is affiliated with Dignity Health. Affiliates of Dignity Health promote the health of additional communities in Bakersfield, San Bernardino, San Francisco, San Andreas, and Grass Valley/Nevada City, California. These affiliates follow practices similar to those noted above in determining the unmet healthcare needs of their communities. Total unsponsored community benefit expense for Dignity Health and its subordinate corporations for the year ended June 30, 2016, is as follows: Persons Net Comm % of Served Benefit Exp excl Bad Debt Benefits for the Poor: Traditional Charity Care 140,490 96,453,000 0.8% Unpaid Costs of Medicaid/Medi-Cal 1,623,229 927,750,000 7.3% Other Means-tested Programs 275,647 7,027,000 0.1% Community Services: Community Health Services 371,669 44,816,000 0.4% Health Professions Education 84 48,000 0.0% Subsidized Health Services 321,882 47,172,000 0.4% Donations 108,977 22,245,000 0.2% Community Building Activities 6,090 1,679,000 0.0% Community Benefit Operations 65 8,030,000 0.1% Total Community Services for the poor 808,767 123,990,000 1.1% Total Benefits for the Poor 2,848,133 1,155,220,000 9.3% Benefits for the Broader Community: Community Services: Community Health Services 307,874 13,768,000 0.1% Health Professions Education 24,127 70,327,000 0.6% Subsidized Health Services 5,215 1,147,000 0.0% Research 565 7,370,000 0.1% Donations 36,410 6,544,000 0.1% Community Building Activities 16,623 2,724,000 0.0% Community Benefit Operations 28 1,318,000 0.0% Total Benefits for the Broader Community 390,842 103,198,000 0.8% Total Community Benefits 3,238,975 1,258,418,000 10.1% Unpaid Costs of Medicare 1,098,561 895,491,000 7.1% Total Community Benefits including Cost of Medicare 4,337,536 2,153,909,000 17.2% true Western Sierra Medical Clinic Inc 1345 Whispering Pines Lane Grass Valley CA 95945 942279011 501(c)(3) 180720 0 N/A N/A Community Health Sierra nevada Hospital Foundation 140 Litton Drive Grass Valley CA 95945 680005939 501(c)(3) 708068 0 N/A N/A Foundation Support California Health Foundation and Trust 1215 K Street Suite 800 Sacramento CA 95814 941498697 501(c)(3) 168313 0 N/A N/A Community Health Dignity Health Medical Foundation 3400 Data Drive Rancho Cordova CA 95670 680220314 501(c)(3) 6366234 0 N/A N/A Medical Fnd Support Nevada County Bahavioral Health Department 500 Crown Point Circle Suite 120 Grass Valley CA 95945 946000526 Govt 131178 0 N/A N/A Community Health 5 0 Part I, line 2 THE ORGANIZATION'S CFO REVIEWS FINANCIAL INFORMATION MONTHLY AND APPROVES THE GRANT PAYMENT BASED ON THAT REVIEW. THE GRANTS TO THE FOUNDATION ARE BASED ON ACTUAL EXPENSES, NOT TO EXCEED THE APPROVED BUDGET. false true false false false false false false false Kevin Vaziri Board Member 0 333364 0 275789 0 10607 0 52601 0 40687 0 713048 0 0 Katherine A Medeiros CEO/ Service Area Leader 0 296172 0 207397 0 15378 0 42233 0 38604 0 599784 0 0 Carolyn Canady CFO/Board Treasurer 196210 0 39502 0 3832 0 31981 0 12514 0 284039 0 0 0 Brian Evans VP, CMO 235066 0 47137 0 0 0 20601 0 33686 0 336490 0 0 0 Jill McWilliams VP/CNE 185658 0 37580 0 0 0 16424 0 25362 0 265024 0 0 0 Debbie L Plass VP Operations 156534 0 31069 0 0 0 21791 0 22757 0 232151 0 0 0 Gregory T Smith Registered Nurse 233860 0 500 0 8539 0 19966 0 33436 0 296301 0 0 0 Jonathan D Stone Director of Pharmacy 176195 0 26875 0 0 0 26835 0 23389 0 253294 0 0 0 William S Swindling Pharmacist 182777 0 5226 0 13328 0 23791 0 1077 0 226199 0 0 0 Tzvetan I Tzvetanov Physicist 263483 0 13407 0 0 0 44395 0 2656 0 323941 0 0 0 Gail A Van Vleck Charge Nurse IP/OP Surgery 224584 0 500 0 0 0 19895 0 21085 0 266064 0 0 0 PART I, LINE 3 SCHEDULE J, PART I, LINE 3 ALTHOUGH THE ORGANIZATION EMPLOYS PERSONNEL, THE ORGANIZATION RELIED ON A RELATED ORGANIZATION, DIGNITY HEALTH, THAT USED ONE OR MORE OF THE METHODS DESCRIBED IN SCHEDULE J, PART I, LINE 3, TO ESTABLISH THE ORGANIZATION'S SERVICE AREA LEADER'S COMPENSATION. SEE SCHEDULE O DISCLOSURE FOR FORM 990, PART VI, SECTION B, LINE 15A FOR ADDITIONAL INFORMATION. PART I, LINE 4a SCHEDULE J, PART I, LINE 4A THE ORGANIZATION'S KEY EMPLOYEES, CERTAIN OFFICERS AND HIGHLY COMPENSATED EMPLOYEES PARTICIPATE IN A SEVERANCE PLAN THAT PROVIDES MARKET-STANDARD COMPENSATION PAYMENTS OF UP TO 6 MONTHS OF BASE COMPENSATION, DEPENDING ON THE EXECUTIVE'S POSITION, IN THE EVENT OF A POSITION ELIMINATION OR OTHER INVOLUNTARY TERMINATION, IN ACCORDANCE WITH THE GUIDELINES OF THE PLAN. NO PAYMENTS PURSUANT TO THE PLAN ARRANGEMENT OCCURRED DURING 2015. PART I, LINE 4b CERTAIN LISTED PERSONS are eligible to participate in one of two non-qualified 457(f) plans that are subject to substantial risk of forfeiture, as required by the IRS. The 2007 Executive Deferred Compensation Plan is for executives hired prior to June 30, 2006. The benefit is intended to bridge the difference, if any, between the benefit provided under the Dignity Health Excess Benefit Plan had benefit service not been frozen at January 1, 2008, and the benefits provided from all other qualified and non-qualified plans. Benefits vest under this 457(f) plan at the later of the date the participant attains age 62 or is credited with 15 years of service. The 2010 Executive Deferred Compensation Plan is for certain officers and key employees, primarily those who are not eligible to participate in the Dignity Health Excess Benefit Plan or the 2007 Executive Deferred Compensation Plan described above. This benefit provides an annual accrual of 10% of total compensation and is payable annually on July 1 once vested, which is age 62 with 5 years of service; the plan also allows for special awards. NO PAYMENTS WERE MADE UNDER THIS PLAN DURING 2015. Compensation amounts for the supplemental nonqualified retirement plans discussed above are reported as deferred compensation in the year accrued (Schedule J, Part II, column C) and are reflected again as reportable compensation in the year paid (Schedule J, Part II, column B(iii)). PART II - SUPPLEMENTAL DISCLOSURES THE ORGANIZATION'S EXECUTIVE COMPENSATION PHILOSOPHY is designed to assist the organization in attracting and retaining the caliber of executives required to enable to fulfill its mission of providing high quality healthcare for all persons regardless of their ability to pay for services, improving the quality of life in the communities it serves, promoting patient and employee satisfaction, and ensuring financial stability. A substantial portion of executive compensation is performance based and is linked to organizational goals approved in advance by the Human Resources and Compensation Committee. These goals include attainment of annual and long-term financial performance, certain healthcare quality standards and the organization's commitment to serving the poor and disenfranchised in the communities it serves. Total compensation, which includes base salary, annual and long-term incentive compensation, is established to approximate the prevailing market conditions for executives of companies of similar size, revenues and complexity. A CALIFORNIA HEALTH FACILITIES FINANCING AUTHORITY 521598225 13033FTN0 2004-05-19 150000000 BOND A: CUSIP 13033FTN0-SEE PRT VI false false true B CALIFORNIA HEALTH FACILITIES FINANCING AUTHORITY 521643828 13033FYE4 2005-11-10 200000000 BOND B: CUSIP 13033FYE4-SEE PRT VI false false true A 0 0 2000000 0 0 0 0 0 0 2000000 0 0 2005 false false true true B 0 0 2334365 0 0 0 0 0 0 2334365 0 0 2008 false false true true A false true true true true true 0.00100 0.00300 0.00400 false false 0.00000 false true B false true true true true true 0.00100 0.00300 0.00400 false false 0.00000 false true A false false false true true false 0 false 0 true true B false false false true true false 0 false 0 true true A true B true BOND A: CUSIP 13033FTN0 PART I, COLUMN (C) THE CHFFA 2004 SERIES J BONDS WERE EXCHANGED IN NOVEMBER 2009 FOR THE CHFFA 2009 SERIES H BONDS IN AN EXCHANGE PURSUANT TO NOTICE 2008-41 THAT WAS NOT TREATED AS A NEW ISSUANCE FOR PURPOSES OF SECTIONS 103 AND 141-150 OF THE INTERNAL REVENUE CODE. PART I, COLUMN (E) THE DIFFERENCE BETWEEN THE ISSUE PRICE IN PART I, COLUMN (E) AND PART II, LINE 3 IS PRIMARILY A RESULT OF THE fact that the COMPOSITE BOND ISSUE WAS A POOLED FINANCING ISSUE. THE FULL ISSUE PRICE OF WHICH IS SHOWN IN PART I, COLUMN (E). IN COMPARISON, THE AMOUNT OF PROCEEDS SHOWN IN PART II, LINE 3 REFLECTS ONLY THE PORTION OF THE BOND ISSUE BORROWED BY SIERRA NEVADA HOSPITAL AND CURRENTLY OUTSTANDING. A SMALL PART OF THE DIFFERENCE BETWEEN THE ISSUE PRICE AND PROCEEDS IS DUE TO INVESTMENT EARNINGS. PART I, COLUMN (F) FINANCE ACQUISITION OF MEDICAL EQUIPMENT AND CONSTRUCTION AND RENOVATION OF HOSPITAL FACILITIES. PART II, LINE 3 IN MAY 2013, ALL OF THE LOANS ORIGINATED WITH PROCEEDS OF THE BONDS MATURED AND WERE REPAID TO THE ISSUER. OF SUCH REPAYMENTS, SIERRA NEVADA MEMORIAL HOSPITAL BORROWED THE SUM OF $2,000,000 TO FINANCE THE CONSTRUCTION/RENOVATION OF FACILITIES AND THE ACQUISITION OF MEDICAL EQUIPMENT AT VARIOUS HOSPITALS. ALTHOUGH THE FACILITIES ORIGINALLY FINANCED WITH PROCEEDS OF THE BONDS WERE SUBSTANTIALLY COMPLETED IN THE YEAR INDICATED, REPAYMENTS OF THE LOANS ORIGINATED WITH PROCEEDS OF THE BONDS WERE AND/OR WILL BE RECYCLED INTO NEWLY ORIGINATED LOANS CONTINGENT ON DEMAND BY PARTICULAR BORROWERS AT THE TIME OF A LOAN REPAYMENT. COMPLETION DATES OF PROJECTS FINANCED OR TO BE FINANCED WITH SUCH RECYCLED AMOUNTS ARE NOT INDICATED. PART IV, LINE 2C THE CALCULATION FOR COMPUTING NO REBATE DUE WAS PERFORMED ON 6/30/2016. BOND B: CUSIP 13033FYE4 PART I, COLUMN (E) THE DIFFERENCE BETWEEN THE ISSUE PRICE IN PART I, COLUMN (E) AND PART II, LINE 3 IS PRIMARILY A RESULT OF THE fact that the COMPOSITE BOND ISSUE WAS A POOLED FINANCING ISSUE. THE FULL ISSUE PRICE OF WHICH IS SHOWN IN PART I, COLUMN (E). IN COMPARISON, THE AMOUNT OF PROCEEDS SHOWN IN PART II, LINE 3 REFLECTS ONLY THE PORTION OF THE BOND ISSUE BORROWED BY SIERRA NEVADA HOSPITAL AND CURRENTLY OUTSTANDING. A SMALL PART OF THE DIFFERENCE BETWEEN THE ISSUE PRICE AND PROCEEDS IS DUE TO INVESTMENT EARNINGS. PART I, COLUMN (F) FINANCE ACQUISITION OF MEDICAL EQUIPMENT AND CONSTRUCTION AND RENOVATION OF HOSPITAL FACILITIES. PART IV, LINE 2C THE CALCULATION FOR COMPUTING NO REBATE DUE WAS PERFOMED ON 1/28/2015. LEANNA KLISTOFF FAMILY MEMBER, A KLISTOFF 103974 EMPLOYMENT false SCHEDULE L, PART IV A KLISTOFF IS A BOARD MEMBER OF THE FILING ORGANIZATION. FORM 990, PART VI, VII, XI and XII FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS A SOLE CORPORATE MEMBER, DIGNITY HEALTH, A 501(C)(3) EXEMPT ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A THE CORPORATE MEMBER CAN ELECT ONE MEMBER AND APPOINT TWO OTHER MEMBERS IF NOMINATED BY THE BOARD. FORM 990, PART VI, SECTION A, LINE 7B RESERVED RIGHTS OF THE CORPORATE MEMBER INCLUDE ADOPTION OF MISSION AND PHILOSOPHY STATEMENTS, AMENDMENT OR RESTATEMENT OF ARTICLES OF INCORPORATION AND BYLAWS, DISSOLUTION OF THE CORPORATION, ACQUISITION OF ANOTHER CORPORATION, CREATION OF A NEW SUBSIDIARY, MERGER OR CONSOLIDATION WITH ANOTHER CORPORATION, PARTICIPATION AS A GENERAL OR LIMITED PARTNER IN ANY VENTURE, INCURRING LONG-TERM INDEBTEDNESS IN EXCESS OF NORMAL OPERATING REQUIREMENTS, RATIFICATION OF BOARD MEMBER APPOINTMENTS AND DISMISSALS, SELECTION AND REMOVAL OF INDEPENDENT AUDITORS, AND TRANSACTIONS OUTSIDE THE ORDINARY COURSE OF BUSINESS. FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION'S CFO REVIEWED THE FORM 990. IN ADDITION, IN THE PROCESS OF PREPARATION, THE FORM 990 WAS REVIEWED BY FINANCE AND ACCOUNTING (REGIONAL DIGNITY HEALTH MANAGEMENT AND CORPORATE TAX DEPARTMENT), WHICH WORKED CLOSELY WITH AN INDEPENDENT ACCOUNTING FIRM ENGAGED TO REVIEW THE RETURN. DUE TO TIMING, THE FORM 990 WILL BE SHARED WITH THE ORGANIZATION'S BOARD SUBSEQUENT TO FILING WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS ADOPTED DIGNITY HEALTH'S CONFLICTS OF INTEREST POLICY. Under such policies, the EVP/General Counsel is responsible for collecting, reviewing and validating annual disclosures of all covered persons (i.e., Board and Board Committee members, officers and executive leadership, key employees, management personnel at the vice president level and above, and any other personnel at his or her discretion). All covered persons are required to disclose real or potential conflicts arising from the business, financial and personal interests held by such covered persons or their family members. Covered persons are required to disclose to their superiors and to relevant decision makers any interest that may present a conflict, or the appearance of a conflict of interest. Such disclosure is required on a transactional basis at the time such conflicts arise, when an individual becomes a covered person, and annually thereafter. Each covered person is required to certify at least annually that he/she: (1) has received a copy of the policy applicable to his/her position; (2) has read the policy and understands said policy; and (3) agrees to comply with all requirements of the policy, including completing the conflicts of interest disclosure statement as required by the policy. The President/CEO and EVP/General Counsel prepare annual reports of reported conflicts of interest, which are provided to the Board of Directors, Committee Chairs, and key leaders of the organization to enable responsible individuals to monitor and manage disclosed conflicts of interest and assure decisions are made in the organization's best interests. The procedures for addressing a conflict of interest related to a proposed transaction include, but are not limited to, the following: (1) the conflicting interest is fully disclosed to the Board of Directors, members of Board Committees with subject matter jurisdiction and any other relevant decision-makers; (2) the interested person responds to factual questions related to the substance of the transaction or arrangement being considered, after which he/she shall leave the meeting; (3) the interested person is excluded from the discussion and approval of such transaction; (4) if warranted, alternatives to the proposed transaction are investigated, and competitive bids or comparable valuations are obtained; (5) the transaction or action is approved by a majority of disinterested persons, consistent with any requirements of bylaws or policies; and (6) any conflicting issues arising during the course of a board meeting which cannot be resolved may be referred to an independent committee of the Board of Directors. There are similar conflicts of interest provisions under the Standards of Conduct, which are applicable to all employees and which are administered by the VP/Corporate Compliance Officer who has reporting responsibility to the President/CEO as well as to the Audit and Compliance Committee of the Board of Directors. FORM 990, PART VI, SECTION B, LINE 15A ALTHOUGH THE ORGANIZATION EMPLOYS PERSONNEL, THE SERVICE AREA LEADER IS COMPENSATED BY DIGNITY HEALTH. FOR 2015, DIGNITY HEALTH'S Human Resources and Compensation Committee approves, consistent with the organization's philosophy and principles, the annual performance goals and criteria to be used in determining merit increases and variable compensation criteria for officers and key executives. The Human Resources and Compensation Committee also engages outside legal counsel as necessary and qualified independent compensation and benefits specialists (independent experts) to review, analyze and provide benchmarking data for the total compensation and benefits packages of officers and key executives. Appropriate comparable data is obtained from the independent experts, (e.g., total economic benefits paid by similarly situated organizations, both taxable and tax-exempt, for similar job responsibilities). Key deliberations of the Committee are documented in meeting minutes which are approved at the next Committee meeting and provided to the Board of Directors. The documentation of the deliberations includes (a) the terms of the transaction approved and the date approved; (b) the members of the Committee who were present during discussion of the approved transaction and those who voted on it; and (c) the comparability data obtained and relied upon by the Committee and how the data was obtained. FORM 990, PART VI, SECTION B, LINE 15B COMPENSATION OF OTHER OFFICERS AND KEY EMPLOYEES IS BASED ON A COMPREHENSIVE EVALUATION FOCUSING ON ALL ASPECTS OF THE INCUMBENT'S ASSIGNED DUTIES AND ASSESSED PERFORMANCE IN CARRYING OUT THE PHILOSOPHY AND MISSION OF SNMMH. ADDITIONALLY, COMPARATIVE DATA AND MARKET SURVEYS REGARDING COMPENSATION IN THE SURROUNDING MARKETPLACE ARE CONSIDERED. FORM 990, PART VI, SECTION C, LINE 19 FEDERAL TAX LAWS DO NOT MANDATE THAT THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY BE MADE AVAILABLE FOR PUBLIC INSPECTION. FORM 990 AND THE COPY OF AUDITED FINANCIAL STATEMENTS ATTACHED TO IT ARE MADE AVAILABLE UPON REQUEST. THE AUDITED FINANCIAL STATEMENTS ARE ALSO AVAILABLE ON OUR WEBSITE. FORM 990, PART XI, LINE 9 INTEREST IN NET ASSETS OF AN UNCONSOLIDATED FOUNDATION; (32,904) FORM 990, PART XII, LINE 3B THE ORGANIZATION'S FEDERAL AWARDS WERE INCLUDED IN DIGNITY HEALTH'S CONSOLIDATED OMB CIRCULAR A-133 AUDITED SCHEDULE OF FEDERAL EXPENDITURES. SAFE HARBOR ELECTION DISCLOSURE Tangible Property Regulation Statement Section 1.263(A)-1(F) de minimis safe harbor election Taxpayer is making the de minimis safe harbor election under Treasury Regulation 1.263(A)-1(F) for all eligible amounts paid or incurred during the taxable year. FORM 990 PART IX LINE 11G DESCRIPTION:ADMINISTRATIVE SERVICES TOTAL FEES:4286410 FORM 990 PART IX LINE 11G DESCRIPTION:MEDICAL SERVICES TOTAL FEES:10091674 FORM 990 PART IX LINE 11G DESCRIPTION:MAINTENANCE/REPAIRS/JANITORIAL TOTAL FEES:3263932 FORM 990 PART IX LINE 11G DESCRIPTION:PROFESSIONAL CONSULTING TOTAL FEES:1540798 FORM 990 PART IX LINE 11G DESCRIPTION:LAUNDRY& LINE SVCS TOTAL FEES:413637 FORM 990 PART IX LINE 11G DESCRIPTION:STORAGE & SHREDDING SVCS TOTAL FEES:102531 FORM 990 PART IX LINE 11G DESCRIPTION:REVENUE CYCLE SERVICES TOTAL FEES:4387507 FORM 990 PART IX LINE 11G DESCRIPTION:OTHER PURCHASED SERVICES TOTAL FEES:2171826 Sierra Nevada Memorial Hospital Fdtn 140 Litton Drive Grass Valley CA 95945 680005939 Fundraising CA 501(c)(3) 11;type 3 NA false Dignity Health 185 Berry Street San Francisco CA 94107 941196203 Hospital CA 501(c)(3) 3 NA false false true true false false false false false false false false false true false false true false false true NA