2016-08-12T13:45:22-05:00 2015-09-30 930623286 AKT LLP 680 HAWTHORNE AVE SE 140 SALEM OR 97301 990 2014-10-01 930579722 SALEM HOSPITAL SALE 5038141938 890 OAK STREET SE SALEM OR 97301 JAMES PARR CHIEF FINANCIAL OFFICER 5038141938 2016-08-08 1 JOYLYN M ANKENEY CPA P00366587 5035857774 2016-08-08 2014 2016-09-27 15:27:22Z JAMES PARR 890 OAK STREET SE SALEM OR 97301 705501423 0 X WWW.SALEMHOSPITAL.ORG X 1970 OR TO IMPROVE THE HEALTH AND WELL BEING OF THE PEOPLE IN THE COMMUNITIES WE SERVE. 10 8 4643 377 3832349 838415 955967 971792 624694771 682835718 12885194 18432624 -1623352 1970549 636912580 704210683 496057 511839 0 0 314864958 340295913 0 0 0 282067536 294336205 597428551 635143957 39484029 69066726 1029796528 1058780244 404769196 395145843 625027332 663634401 TO IMPROVE THE HEALTH AND WELL-BEING OF THE PEOPLE AND COMMUNITIES WE SERVE. 0 0 115554677 326284573 SALEM HOSPITAL IS ONE OF THE LARGEST OF OREGON'S 59 ACUTE CARE HOSPITALS AND OPERATES THE BUSIEST EMERGENCY DEPARTMENT IN OREGON. THERE ARE 449 PRACTITIONERS, REPRESENTING 51 DIFFERENT SPECIALTIES. MORE THAN 350 VOLUNTEERS PROVIDE NON-MEDICAL SUPPORT FOR THE HOSPITAL. FISCAL YEAR ENDED 9/30/15 STATISTICS: BIRTHS - 3,269, DIAGNOSTIC IMAGING PROCEDURES - 170,512, ED VISITS - 103,849, INPATIENT ADMISSIONS - 25,260, LABORATORY PROCEDURES - 1,290,367, SURGERIES - 13,724. THE PRIMARY SERVICE AREA IS THE GREATER WILLAMETTE VALLEY WITH APPROXIMATELY 500,000 RESIDENTS. 429852704 343668248 SALEM HOSPITAL PROVIDES HEALTHCARE TO PEOPLE IN OUR COMMUNITY REGARDLESS OF THEIR ABILITY TO PAY. IN FY2015, THE COST OF SERVICES PROVIDED AS A COMMUNITY BENEFIT TOTALED $86.2 MILLION. THIS FIGURE CONSISTED OF $8.9 MILLION IN COSTS TO PROVIDE CHARITY CARE TO INDIVIDUALS WHO CANNOT AFFORD TO PAY; $39 MILLION IN UNDERPAYMENT BY MEDICAID AS THE AMOUNT PAID WAS LESS THAN THE COST TO PROVIDE THE SERVICES; AND $38.3 MILLION IN UNDERPAYMENT BY MEDICARE AS THE AMOUNT PAID WAS LESS THAN THE COST TO PROVIDE THE SERVICES. SALEM HOSPITAL DOES NOT PURSUE LEGAL ACTION FOR NON-PAYMENT OF BILLS AGAINST CHARITY CARE PATIENTS WHO HAVE DEMONSTRATED THAT THEY HAVE NEITHER SUFFICIENT INCOME NOR ASSETS TO MEET THEIR FINANCIAL OBLIGATIONS. 23842229 511839 11637229 SALEM HOSPITAL ACTIVELY PARTICIPATES IN COMMUNITY HEALTH IMPROVEMENT SERVICES. IN FY 2015, SALEM HOSPITAL GAVE $12.2 MILLION FOR UNFUNDED OR UNDERFUNDED HEALTH SERVICES, INCLUDING IMPROVING ACCESS TO CARE THROUGH PHYSICIAN RECRUITING, COMMUNITY HEALTH EDUCATION AND PREVENTION PROGRAMS. THE HOSPITAL HAS AN ACTIVE SPEAKERS BUREAU PROVIDING FREE HEALTH LECTURES TO COMMUNITY GROUPS. HEALTH SCREENINGS, SUPPORT GROUPS AND EDUCATION CLASSES ARE OFFERED ON AN ON-GOING BASIS. IN FY 2015, SALEM HOSPITAL PROVIDED MORE THAN $497 THOUSAND IN CASH AND IN-KIND DONATIONS TO COMMUNITY HEALTH PROGRAMS SUCH AS MEDASSIST AND PROJECT ACCESS, PSYCHIATRIC CRISIS CENTER AND THE SALEM FREE CLINIC. 569249610 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 350 0 1 4643 1 1 1 0 0 0 0 0 0 0 0 0 X 10 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 OR X X SALEM HOSPITAL 5038141938 890 OAK STREET SE SALEM OR 97301 KATHERINE L KEENE TRUSTEE 10.50 X 0 0 0 PAM VUKOVICH TRUSTEE 8.10 X 0 0 0 KENNETH SHERMAN JR TRUSTEE 4.00 X 0 0 0 BONNIE DRIGGERS RN TRUSTEE 6.30 X 0 0 0 THERESA HASKINS TRUSTEE 5.00 X 0 0 0 ALAN WYNN SECRETARY/TREASURER 3.00 X X 0 0 0 ROB KELLY MD TRUSTEE 8.10 X 0 0 0 LANE SHETTERLY TRUSTEE 9.00 X 0 0 0 ROBERT WELLS CHAIRPERSON 20.00 X X 0 0 0 NANCY REYES-MOLYNEUX MD TRUSTEE 7.00 X 0 0 0 NORMAN GRUBER CHIEF EXECUTIVE OFFICER 30.00 10.00 X 854799 0 359824 JAMES PARR AS OF 11114 CHIEF FINANCIAL OFFICER 30.00 10.00 X 267518 0 52372 AARON CRANE THRU 103114 CHIEF FINANCE AND STRATEGY OFFICER 30.00 10.00 X 481746 0 45607 ROBERT BRANNIGAN CHIEF ADMIN OFFICER WVH 10.00 30.00 X 350914 0 61875 LAURIE BARR VP HUMAN RESOURCES 30.00 10.00 X 331442 0 61564 BRENDA BUBLITZ VP SURGICAL SERVICES 30.00 10.00 X 188549 0 46867 MARTIN MORRIS THRU 2615 VP/CHIEF DEVELOPMENT OFFICER 5.00 35.00 X 302823 0 57922 CHERYL NESTER WOLFE CHIEF OPERATING OFFICER 30.00 10.00 X 586757 0 7254 CORT GARRISON CHIEF INFORMATION OFFICER 30.00 10.00 X 463435 0 79635 SARAH HORN CHIEF NURSING OFFICER 30.00 10.00 X 163441 0 41580 LEAH MITCHELL VP KAIZEN QUALITY & SAFETY 30.00 10.00 X 263204 0 47192 LORI JAMES-NIELSEN VP CHIEF STRATEGY OFFICER 30.00 10.00 X 249929 0 67173 JAYAPRAKASH REDDY MD PHYSICIAN 40.00 X 404689 0 58663 NICOLE VANDERHEYDEN MD PHYSICIAN 40.00 X 511496 0 79204 THYE SCHUYLER MD PHYSICIAN 40.00 X 457657 0 58822 PREETHI PRAKASH MD PHYSICIAN 40.00 X 412648 0 36327 SHERIF AL-HAWAREY MD PHYSICIAN 40.00 X 480037 0 39214 MARTHA ENRIQUEZ FORMER CHIEF NURSING OFFICER 30.00 10.00 X 352860 0 68353 WILLIAM HOLLOWAY MD FORMER CHIEF MEDICAL OFFICER 30.00 10.00 X 781952 0 65280 ANNE KOLLER FORMER CHIEF MARKETING OFFICER 30.00 10.00 X 144055 0 9343 8049951 0 1344071 256 1 1 0 OHSU PO BOX 574 PORTLAND OR 972070574 CONTRACT LABOR 2388240 SHIFTWISE PO BOX 70870 ST PAUL MN 55170 CONTRACT LABOR 2325087 EPIC SYSTEMS CORP PO BOX 88314 MILWAUKEE WI 532880314 CONSULTING SERVICES 2060890 OREGON ANESTHESIOLOGY GROUP 707 SW WASHINGTON ST STE 700 PORTLAND OR 972053523 CONTRACT LABOR 1578904 PEACEHEALTH LABORATORIES PO BOX 77003 SPRINGFIELD OR 97475 LABORATORY SERVICES 1403017 96 699078 272714 971792 NET PATIENT REVENUE 621110 656072515 656072515 OTHER HOSPITAL SERVICES 900099 17754814 17715569 39245 PHARMACY 446110 7343237 5019962 2323275 REGIONAL LAB 621500 1640682 184505 1456177 NUTRITION SERVICES 722210 24470 24470 682835718 18378083 18378083 674608 1290740 -616132 -616132 -616132 25941 28600 0 0 25941 28600 54541 54541 PASSTHROUGH INCOME 541900 2586681 2573029 13652 2586681 704210683 681590050 3832349 17816492 287257 287257 224582 224582 4761710 4761710 263963094 239079637 24883457 52648960 47376192 5272768 18922149 16866218 2055931 707694 707694 2307313 39867 2267446 361974 332375 29599 138200 138200 28820397 22046533 6773864 171770 289 171481 6928055 4779255 2148800 8448391 701148 7747243 14001503 11170205 2831298 1161687 566383 595304 1064937 592634 472303 12679399 12679399 38469437 38469437 723685 723685 PATIENT SUPPLIES 100110740 99665460 445280 0 PROVIDER TAX 35470286 35470286 BAD DEBTS 24726314 24726314 0 0 OTHER PURCHASED SERVICE 13072941 11633412 1439529 0 4971482 1111348 3860134 635143957 569249610 65894347 0 24005 23955 3387781 6279813 70343522 71162119 5218 0 9697318 2561826 6236713 6153634 8002433 7618392 936065912 481535017 445276526 454530895 450315165 474160005 12053859 14694650 24453988 21594955 1029796528 1058780244 70618815 71339123 306397614 296555251 551264 339797 27201503 26911672 404769196 395145843 X 622467140 661015081 2560192 2619320 625027332 663634401 1029796528 1058780244 X 69066726 -22946488 -7513169 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 50000 123324 173324 635020633 635193957 1000000 250000 0 0 1000000 1000000 1000000 3000000 4500000 126332 121166 173324 420822 250000 250000 250000 750000 1125000 50000 50000 SCHEDULE C, PART II-A SALEM HOSPITAL CONTRACTED WITH PUBLIC AFFAIRS COUNSEL TO KEEP THE HOSPITAL APPRISED OF BILLS IN THE STATE LEGISLATURE AND TO ENGAGE THE LEGISLATORS ON BEHALF OF THE HOSPITAL WHEN NECESSARY TO PROVIDE INFORMATION TO LEGISLATORS REGARDING THE IMPACT OF LEGISLATION ON THE HOSPITAL. ADDITIONALLY, THE HOSPITAL PAYS MEMBERSHIP DUES TO OAHHS AND AHA. A PORTION OF THE DUES TO THESE ORGANIZATIONS IS ALLOCATED TO LOBBYING ACTIVITY IN RELATION TO STATE AND NATIONAL HEALTHCARE ISSUES. 2560192 318689 -66873 192688 2619320 2073328 674913 154704 342753 2560192 2120674 160956 379362 587664 2073328 1785208 332125 494527 491186 2120674 1903809 -118601 1785208 0 1 1 9915235 23124460 33039695 5929821 536245415 217439805 324735431 988861 332723498 264095212 69617147 27138622 27138622 454530895 FAIR VALUE INTEREST RATE SWAP AGREEMENT 15991746 ACCRUED POST RETIREMENT HEALTHCARE BENEFITS 6247411 ACCRUED MALPRACTICE INSURANCE 2076182 ESTIMATED LIABILITY TO MEDICARE 2255141 DUE TO SALEM HEALTH 308163 OTHER LONG-TERM LIABILITIES 33029 26911672 X 691963969 -22946488 11325244 -11621244 703585213 625470 625470 704210683 645982944 11190782 11190782 634792162 351795 351795 635143957 PART V, LINE 4: ENDOWMENT FUNDS ARE HELD BY SALEM HOSPITAL FOUNDATION FOR SALEM HOSPITAL SUPPORT. PART X, LINE 2: UNCERTAIN TAX POSITIONS FROM THE NOTES TO CONSOLIDATED FINANCIAL STATEMENTS ISSUED FOR SALEM HEALTH AND RELATED COMPANIES: THE CORPORATION (SALEM HEALTH), SALEM HOSPITAL, WEST VALLEY HOSPITAL, SHF, WVHF, WVPS, AND WVIC ARE TAX-EXEMPT ORGANIZATIONS PURSUANT TO INTERNAL REVENUE CODE (IRC) SECTION 501(C)(3). AS SUCH, ONLY UNRELATED BUSINESS INCOME IS SUBJECT TO FEDERAL OR STATE INCOME TAXES. THE CORPORATION ACCOUNTS FOR UNCERTAINTY IN INCOME TAXES IN ACCORDANCE WITH FASB ASC 740-10, INCOME TAXES-IMPLEMENTATION GUIDANCE ON ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES AND DISCLOSURE AMENDMENTS FOR NONPUBLIC ENTITIES. MANAGEMENT HAS NOT RECORDED A PROVISION AS UNRELATED BUSINESS INCOME, IF ANY, IS IMMATERIAL TO THE CONSOLIDATED FINANCIAL STATEMENTS. ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE THE CORPORATION TO EVALUATE TAX POSITIONS TAKEN BY THE CORPORATION AND RECOGNIZE A TAX LIABILITY (OR ASSET) IF THE CORPORATION HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS. MANAGEMENT HAS ANALYZED TAX POSITIONS TAKEN BY THE CORPORATION AND HAS CONCLUDED THAT AS OF SEPTEMBER 30,2015 THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY (OR ASSET) OR DISCLOSURE IN THE CONSOLIDATED FINANCIAL STATEMENTS. THE CORPORATION IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. THE CORPORATION MANAGEMENT BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO FISCAL YEAR 2009. PART XI, LINE 2D - OTHER ADJUSTMENTS: REVENUE NETTED WITH EXPENSES 2,926,187. EXPENSE NETTED WITH REVENUE 5,093,858. CHANGE IN NET VALUE OF OTHER SECURITIES 3,305,199. PART XI, LINE 4B - OTHER ADJUSTMENTS: OTHER REVENUE NOT INCLUDED ON FINANCIAL STATEMENTS 625,470. PART XII, LINE 2D - OTHER ADJUSTMENTS: REVENUE NETTED WITH EXPENSES 2,926,187. CUMULATIVE EFFECT OF ADOPTION OF FAIR VALUE OPTION 3,170,737. EXPENSE NETTED WITH REVENUE 5,093,858. PART XII, LINE 4B - OTHER ADJUSTMENTS: CHANGE IN BENEFICIAL INTEREST IN FOUNDATION 59,127. CHANGE IN POSTRETIREMENT BENEFIT OBLIGATION 292,668. 1 1 X 1 X 1 X 1 1 1 0 1 1 33470 8902565 8902565 0.01460 150034 153711944 114683675 39028269 0.06390 183504 162614509 114683675 47930834 0.07850 160090 3339668 64058 3275610 0.00540 1848 1597096 1597096 0.00260 18189795 11573171 6616624 0.01080 219119 219119 0.00040 13191 496551 496551 0.00080 175129 23842229 11637229 12205000 0.02000 358633 186456738 126320904 60135834 0.09850 13246 13246 0.00000 13247 13247 0.00000 1280088 1280088 0.00210 1306581 1306581 0.00210 0 24726314 17865535 95550985 108540086 -12989101 X 1 1 1 1 SALEM HOSPITAL 890 OAK STREET SE SALEM OR 97301 X X X SALEM HOSPITAL 1 0 0 1 X X X X X X X X X 12 1 1 1 1 X WWW.SALEMHEALTH.ORG X 1 12 1 WWW.SALEMHEALTH.ORG/ABOUT/COMMUNITY/COMMUNITY-HEALTH-NEEDS-ASSESSMENT 0 0 1 X 200.000000000000 400.000000000000 X X X X X 1 1 X X X 1 X HTTPS://WWW.SALEMHOSPITALBILL.COM/FINANCIAL_ASSISTANCE.ASPX X HTTPS://WWW.SALEMHOSPITALBILL.COM/FINANCIAL_ASSISTANCE.ASPX X HTTPS://WWW.SALEMHOSPITALBILL.COM/FINANCIAL_ASSISTANCE.ASPX X X X X X 1 0 X X X X 1 X 0 0 SALEM HOSPITAL PART V, SECTION B, LINE 5: IN THE SUMMER OF 2014, MARION AND POLK HEALTH DEPARTMENTS BEGAN TO DISCUSS A VISION FOR A JOINT COMMUNITY HEALTH ASSESSMENT AND IMPROVEMENT PLAN. BOTH COUNTIES ENJOY WORKING WITH SIMILAR PARTNERS INCLUDING SALEM HEALTH, KAISER PERMANENTE, WILLAMETTE VALLEY COMMUNITY HEALTH, OSU EXTENSION, EARLY LEARNING HUB, INC., AND UNITED WAY.DRIVEN BY SHARED DATA NEEDS, SALEM AND WEST VALLEY HOSPITALS JOINED BY MARION AND POLK COUNTIES, BEGAN PLANNING FOR A JOINT COMMUNITY HEALTH ASSESSMENT IN SEPTEMBER 2014. SALEM HEALTH'S DIRECTOR OF COMMUNITY BENEFITS SERVED ON MARION POLK COMMUNITY HEALTH ASSESSMENT STEERING COMMITTEE, REPRESENTING WEST VALLEY AND SALEM HOSPITAL. THE STEERING COMMITTEE DEVELOPED A VISION TO ENSURE THE COMMUNITY HEALTH ASSESSMENT REPRESENTS THE WHOLE COMMUNITY BY LOOKING AT THE BROAD DEFINITION OF HEALTH INCLUDING THE COMMUNITY SYSTEM AND THE ENVIRONMENT.THE STEERING COMMITTEE SELECTED THE NATIONAL MODEL, MOBILIZATION FOR ACTION THROUGH PLANNING AND PARTNERSHIPS OR MAPP AS THE FRAMEWORK FOR THE COMMUNITY HEALTH ASSESSMENT. THE FOUR ASSESSMENTS OF THE MAPP FRAMEWORK INCLUDE: COMMUNITY THEMES AND STRENGTHS, LOCAL PUBLIC HEALTH SYSTEM ASSESSMENT (CONDUCTED IN 2013), COMMUNITY HEALTH STATUS ASSESSMENT AND THE FORCES OF CHANGE ASSESSMENT.THE COMMUNITY THEMES AND STRENGTHS ASSESSMENT WAS CONDUCTED BY SURVEYING COMMUNITY PARTNERS WORKING IN SOCIAL, HEALTH, COMMUNITY, EDUCATIONAL AND CORRECTIONAL HEALTH SETTINGS AND THE COMMUNITY-AT-LARGE. THE SURVEYS USED IN BOTH MARION AND POLK COUNTIES CONSISTED OF THE SAME QUESTIONS AND USED THE 2011 MARION COUNTY SURVEY AS A TEMPLATE. PAPER AND ELECTRONIC SURVEYS WERE ALLOCATED BASED ON POPULATION DISTRIBUTION THROUGHOUT OUR COMMUNITIES. THE COMMUNITY HEALTH STATUS ASSESSMENT WAS CONDUCTED BY COMPILING DATA FROM NATIONAL SURVEILLANCE SYSTEMS LIKE THE BEHAVIOR RISK FACTOR SURVEILLANCE SURVEY AND OREGON HEALTHY TEENS AS WELL AS STATE AND LOCAL DATA FROM BIRTH AND DEATH CERTIFICATES. IN ADDITION, AS SERIES OF COMMUNITY CAF S WERE CONDUCTED ACROSS MARION AND POLK COUNTY TO IDENTIFY HEALTH PRIORITIES.REPRESENTATIVES FROM MARION AND POLK COUNTY PUBLIC HEALTH, PRESENTED CHNA FINDINGS TO THE SALEM HEALTH COMMUNITY BENEFIT COMMITTEE OF THE BOARD OF TRUSTEES IN NOVEMBER 2015. THE MARION AND POLK COUNTY HEALTH REPORTS WAS PUBLISHED IN DECEMBER 2015 AND CAN BE FOUND ON THE SALEM HEALTH WEBSITE. WWW.SALEMHEALTH.ORG. THE DOCUMENT WILL INFORM THE DEVELOPMENT OF THE COMMUNITY BENEFIT IMPLEMENTATION STRATEGY FOR REPORTING YEARS 2015 - 2017. SALEM HOSPITAL PART V, SECTION B, LINE 6A: THE HOSPITAL FACILITY'S CHNA WAS CONDUCTED WITH SANTIAM HOSPITAL AND SILVERTON HEALTH. SALEM HOSPITAL PART V, SECTION B, LINE 6B: THE HOSPITAL FACILITY'S CHNA WAS CONDUCTED WITH COMMUNITY ACTION AGENCY, THE EARLY LEARNING HUB, INC, MARION COUNTY HEALTH DEPARTMENT, POLK COUNTY HEALTH DEPARTMENT, OREGON STATE UNIVERSITY, COOPERATIVE EXTENSION, UNITED WAY, WVP HEALTH AUTHORITY AND WILLAMETTE VALLEY COMMUNITY HEALTH. SALEM HOSPITAL PART V, SECTION B, LINE 11: 2014 IS THE LAST REPORTING YEAR FOR THE 2012- 2014 COMMUNITY BENEFIT IMPLEMENTATION PLAN. SALEM HOSPITAL CONTINUES TO WORK WITH COMMUNITY PARTNERS TO DECREASE THE RATE OF TEEN PREGNANCY, INCREASE THE RATE OF MOTHERS WHO RECEIVE EARLY PRENATAL CARE AND DECREASE THE PERCENTAGE OF ADULT OBESITY IN MARION COUNTY.IN POLK COUNTY, COMMUNITY MEMBERS AND REPRESENTATIVES FROM PARTNERING AGENCIES ARE WORKING COLLABORATIVELY WITH SALEM AND WEST VALLEY HOSPITALS TO DECREASE THE PREVALENCE OF OBESITY ACROSS ALL AGE RANGES.TEEN PREGNANCY RATES IN MARION COUNTY. SIGNIFICANT IMPROVEMENT HAS BEEN SEEN IN TEEN PREGNANCY RATES IN MARION COUNTY. SALEM HOSPITAL HAS COLLABORATED WITH SEVERAL AGENCIES TO IMPROVE THIS HEALTH PRIORITY. THE 2012 CHNA SET EARLY PRENATAL CARE AS A HEALTH PRIORITY. RATES IMPROVED IN 2012 AND 2013 BUT DROPPED IN IN 2014. TEEN AND LATINO MOTHERS DO NOT SEEK OR HAVE ACCESS TO EARLY PRENATAL CARE AT THE SAME RATES AS OLDER MOTHERS AND THOSE THAT IDENTIFY AS NON-HISPANIC, WHITE. TO ADDRESS THIS HEALTH PRIORITY, SALEM HOSPITAL COLLABORATES WITH THE SALEM KEIZER SCHOOL DISTRICT'S PROGRAM AT CHEMEKETA FOR PREGNANT AND PARENTING TEENS TO PROVIDE TEACHERS ON CHILDBIRTH TOPICS AND ALSO PROVIDE PRIVATE TOURS FOR THE TEENS THROUGH THEIR INSTRUCTOR. WE ATTEND HEALTH FAIRS AT CHEMEKETA FOR THIS GROUP A COUPLE OF TIMES A YEAR AND INCLUDE CAR SEAT DEMO AND INFORMATION. THE HOSPITAL COORDINATING OUTREACH TO TEENS. WE PUT OUT THE BROCHURES FOR THE OREGON MOTHERSCARE PROGRAM IN COOPERATION WITH THE MARION CO. HEALTH DEPT. THE HOSPITAL PROMOTES OREGON MOTHERSCARE. THE BOOT CAMP FOR NEW DADS REACHES THE TEEN DADS. WE POST ALL THESE CLASSES ON THE EARLY LEARNING HUB WEBSITE AND ALL THE AGENCIES ARE USING THIS WEB CALENDAR TO HELP PROMOTE THE CLASSES IN THE COMMUNITY. ADULT OBESITY RATES IN BOTH MARION AND POLK COUNTIES REMAIN ABOVE STATE AND NATIONAL AVERAGES AND ABOVE THE HP2020 GOAL OF 30.5%. SALEM AND WEST VALLEY HOSPITAL CONTINUE TO FOCUS ON OBESITY PREVENTION EFFORTS THROUGH HEALTH OUTREACH AND EDUCATION, SUPPORT OF PARTNERING AGENCIES WITH A SHARED GOAL TO DECREASE ADULT OBESITY, MEDICAL PROVIDER BMI SCREENING AND COMMUNITY HEALTH EDUCATION CENTER PROGRAMMING FOCUSING ON HEALTH PROMOTION AND PREVENTION OF CHRONIC DISEAS. SALEM HOSPITAL PART V, SECTION B, LINE 22D: SALEM HOSPITAL USED THE APPROVED LOOK-BACK AGB CALCULATION METHOD FROM THE REGULATIONS THAT INCLUDES MEDICARE AND COMMERCIAL PAYOR RATES. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY SALEM HOSPITAL PART V, SECTION B, LINE 16A WEBSITE: HTTPS://WWW.SALEMHOSPITALBILL.COM/FINANCIAL_ASSISTANCE.ASPX SALEM HOSPITAL PART V, SECTION B, LINE 16B WEBSITE: HTTPS://WWW.SALEMHOSPITALBILL.COM/FINANCIAL_ASSISTANCE.ASPX SALEM HOSPITAL PART V, SECTION B, LINE 16C WEBSITE: HTTPS://WWW.SALEMHOSPITALBILL.COM/FINANCIAL_ASSISTANCE.ASPX 8 REHABILITATION CENTER 2561 CENTER ST SE SALEM OR 97301 REHABILITATION LABORATORY PHLEBOTOMY SITE - HOPE 1600 STATE ST SALEM OR 97301 LABORATORY SERVICES COMPREHENSIVE PAIN CENTER 280 LIBERTY ST SE SUITE 320 SALEM OR 97301 PAIN MANAGEMENT REGIONAL LABORATORY 3300 STATE ST SALEM OR 97301 LABORATORY SERVICES WHP FAMILY MEDICINE KEIZER 550 DEITZ AVE NE KEIZER OR 97303 CLINIC WHP FAMILY MEDICINE RIVER ROAD S 2925 RIVER RD S SALEM OR 97302 CLINIC WHP FAMILY MEDICINE PARKSIDE 966 12TH STREET SE SALEM OR 97301 CLINIC WHP FAMILY MEDICINE WEST SALEM 1049 EDGEWATER ST NW SUITE 150 SALEM OR 97304 CLINIC PART I, LINE 3C: IT IS THE POLICY OF SALEM HOSPITAL TO PROVIDE FINANCIAL COUNSELING TO PATIENTS REGARDING THEIR FINANCIAL OBLIGATION AT THE EARLIEST OPPORTUNITY POSSIBLE. SALEM HOSPITAL PROVIDES A VARIETY OF OPTIONS TO ASSIST PATIENTS IN RESOLVING THEIR ACCOUNTS, INCLUDING: OREGON HEALTH PLAN (OHP) SCREENING, CHARITY ASSISTANCE, MEDICAL FINANCING CARDS, LOANS, AND EXTENDED PAYMENT PLANS. DISCOUNTS MAY BE AVAILABLE ON THE NET BALANCE FOR PATIENTS AT OR BELOW 400% OF THE FEDERAL POVERTY LEVEL. PATIENTS AT OR BELOW 200% OF THE POVERTY LEVEL ARE ELIGIBLE FOR 100% CHARITY ASSISTANCE.THE HOSPITAL CONSIDERS BOTH INCOME AND/OR ASSETS AVAILABLE TO PAY PATIENT'S MEDICAL EXPENSES1.THE HOSPITAL WILL MULTIPLY THE FAMILY INCOME BY 30%2.THE HOSPITAL WILL DETERMINE THE PATIENT'S ALLOWABLE MEDICAL EXPENSES3.THE HOSPITAL WILL COMPARE 30% OF THE FAMILY INCOME TO THE TOTAL OF THE PATIENT'S ALLOWABLE MEDICAL EXPENSES. IF THE TOTAL OF THE ALLOWABLE MEDICAL EXPENSES IS GREATER THAN 30% OF THE FAMILY INCOME, THEN THE PATIENT MEETS THE CATASTROPHIC CHARITY CARE QUALIFICATION. THE HOSPITAL WILL LIMIT PATIENT LIABILITY FOR MEDICAL EXPENSES TO 30% OF THE FAMILY'S INCOME. AMOUNTS THAT EXCEED THIS LIMIT WILL BE ELIGIBLE FOR CHARITY CARE.FOR EXAMPLE: FAMILY INCOME OF $70,000 PER YEAR AND MEDICAL EXPENSES OF $45,000. THIRTY-PERCENT OF THE FAMILY'S ANNUAL INCOME IS $21,000; THE FAMILY'S MEDICAL EXPENSES OF $45,000 EXCEED THIS AMOUNT. THE FAMILY SHOULD THEREFORE BE ELIGIBLE FOR A CHARITY WRITE-OFF OF $24,000.ORASSET TESTASSETS CONSIDERED AVAILABLE TO PAY PATIENT'S MEDICAL EXPENSES1. EQUITY IN A REAL ESTATE, OTHER THAN THE PATIENT'S PERSONAL RESIDENCE, SECURITIES OR OTHER ASSETS (E.G.. RENTAL PROPERTY, AGRICULTURAL USE) IS CONSIDERED AVAILABLE TO PAY THE PATIENT'S MEDICAL EXPENSES.2. $201,000 REPRESENTS THE MEDIAN VALUE OF A HOME IN SALEM, OREGON AS OF AUGUST 2010. THE HOSPITAL CONSIDERS THIS AMOUNT TO BE PROTECTED FROM CONSIDERATION AS A FUNDING SOURCE. EQUITY IN A PATIENT'S PERSONAL RESIDENCE OVER AND ABOVE $201,000 WILL BE CONSIDERED AS AVAILABLE TO PAY MEDICAL LIABILITIES.3. THE CATASTROPHIC LIMIT UNDER THIS TEST WILL BE ESTABLISHED AT 100% OF THE EQUITY IN REAL PROPERTY OVER AND ABOVE THE FIRST $201,000 IN A PRIMARY RESIDENCE, AND 100% OF THE EQUITY IN OTHER REAL PROPERTY PRODUCING INCOME.FOR EXAMPLE: $280,000 (MARKET VALUE) - $100,000 (MORTGAGE) = $180,000 (NET VALUE); THEREFORE, $201,000 (PROTECTED SO EQUITY WOULD NOT BE CONSIDERED) PART I, LINE 7: NET COMMUNITY BENEFIT EXPENSE IS CALCULATED BY TOTAL COSTS OF CARE PROVIDED LESS THE DIRECT, OFFSETTING NET REVENUES FOR THOSE SERVICES. THE COSTS TO PROVIDE CHARITY CARE AND MEDICAID SERVICES DISCLOSED IN LINE 7, COLUMN (C) LINES (A) AND (B), RESPECTIVELY, ARE DETERMINED BY APPLYING THE COST TO CHARGE RATIO AS DETERMINED IN WORKSHEET 2 TO THE FULL BILLED CHARGES FOR THE SERVICES RENDERED. NET COMMUNITY BENEFIT EXPENSE FOR THE COSTS FOR SUBSIDIZED HEALTH SERVICES DISCLOSED IN PART I, LINE 7(G) USES AN INTERNAL COSTING SYSTEM WHEREBY DIRECT AND INDIRECT EXPENSES ARE ALLOCATED TO DISCRETE OFFSETTING NET REVENUES FOR EACH SERVICE. OVERHEAD COSTS ARE ALLOCATED TO REVENUE GENERATING SERVICES BASED ON UTILIZATION STATISTICS SUCH AS SQUARE FOOTAGE FOR MAINTENANCE COSTS. PART I, LN 7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM TOTAL EXPENSE THAT WAS INCLUDED IN FORM 990, PART IX, LINE 25, COLUMN (A), BUT REMOVED FROM THIS FIGURE FOR THE PURPOSES OF CALCULATING THE PERCENTAGE IN SCHEDULE H, PART I, LINE 7, COLUMN (F) WAS $24,726,314. PART II, COMMUNITY BUILDING ACTIVITIES: IN 2014, SALEM HOSPITAL PROVIDED EXECUTIVE LEADERSHIP TO THE BOARD OF WALTON HOUSE, A RESPITE HOUSING PROVIDER. THE HEALTH EDUCATION DIVISION HOSTED AN ANNUAL UPDATE OF COMMUNITY BENEFIT ACTIVITIES FOR COMMUNITY PARTNERING AGENCIES. ACCESS TO CARE WAS IDENTIFIED AND PRIORITIZED AS A HEALTH NEED IN BOTH THE MARION AND POLK COUNTY COMMUNITY HEALTH REPORTS AND SALEM AND WEST VALLEY HOSPITALS ADDRESS THE NEED AS PART OF THE COMMUNITY BENEFIT IMPLEMENTATION STRATEGIES. MOREOVER, FOCUS GROUPS COORDINATED BY THE SALEM AND WEST VALLEY HOSPITAL BOARD OF TRUSTEES IDENTIFIED ACCESS TO CARE AS A SIGNIFICANT HEALTH CONCERN IN BOTH MARION AND POLK COUNTIES. FOCUS GROUP PARTICIPANTS STATED THAT LANGUAGE BARRIERS, LACK OF DENTAL HEALTH FUNDING, TRANSPORTATION, AND LIMITED ACCESS TO MENTAL HEALTH SERVICES ARE SIGNIFICANT ISSUES IN OUR COMMUNITY. A LIMITED NUMBER OF PROVIDERS WILL TAKE UNINSURED PATIENTS AND THOSE THAT DO, OFTEN CANNOT SEE THESE PATIENTS RIGHT AWAY. ALTHOUGH SOME CLINICS OFFER SAME DAY APPOINTMENTS AND EXTENDED HOURS, THE EMERGENCY DEPARTMENT IS SEEN AS THE SOURCE FOR AFTER-HOURS HEALTH CARE IN OUR COMMUNITY. PARTICIPANT SUGGESTED THAT THE HOSPITALS COULD EASE THE IDENTIFIED BURDENS BY CONTINUING TO RECRUIT MORE PROVIDERS WHO ARE WILLING TO ACCEPT UNINSURED AND UNDER-INSURED PATIENTS. TO EASE THE BURDEN OF ACCESS TO CARE AND TO ENSURE A WELL TRAINED HEALTH PROFESSIONAL WORKFORCE, SALEM HOSPITAL CONTINUES TO MAKE A SIGNIFICANT INVESTMENT IN PHYSICIAN RECRUITMENT AND MEDICAL WORK FORCE DEVELOPMENT. PART III, LINE 4: EFFECTIVE OCTOBER 1,2011, THE HOSPITALS ADOPTED FASB ISSUED ACCOUNTING STANDARDS UPDATE (ASU) NO. 2011-07, HEALTH CARE ENTITIES (TOPIC 954): PRESENTATION AND DISCLOSURE OF PATIENT SERVICE REVENUE, PROVISION FOR BAD DEBTS, AND THE ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR CERTAIN HEALTH CARE ENTITIES. THE ADOPTION OF THIS ASU RESULTED IN A RECLASSIFICATION OF BAD DEBT EXPENSE FROM AN OPERATING EXPENSE TO BE A REDUCTION IN DERIVING NET PATIENT SERVICE REVENUE. COST OF BAD DEBT EXPENSE ESTIMATED AS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE FINANCIAL ASSISTANCE POLICY ON LINE 3 IS CALCULATED BY SUBTOTALING THE BAD DEBT AMOUNTS BY ZIP CODE. AMOUNTS WRITTEN OFF FOR ZIP CODES WHOSE MEDIAN HOUSEHOLD INCOME FOR A FAMILY OF FOUR FALLS AT OR BELOW 200% OF FEDERAL POVERTY GUIDELINES ARE INCLUDED ON THIS LINE. PART III, LINE 8: MEDICARE PAYORS PAY A SIGNIFICANTLY REDUCED AMOUNT FOR MEDICAL SERVICES RENDERED TO THEIR ENROLLEES SUCH THAT THE NET REIMBURSEMENT DOES NOT EVEN COVER THE EXPENSES INCURRED TO PROVIDE THE SERVICE. SALEM HOSPITAL CONSIDERS THE DIFFERENCE BETWEEN THE COSTS TO PROVIDE CARE FOR MEDICARE ENROLLEES AND THE NET REIMBURSEMENT AS A BENEFIT TO THE COMMUNITY. MEDICARE FEE-FOR-SERVICE COSTS ARE DETERMINED FROM SALEM HOSPITALS FILED MEDICARE COST REPORT. THE CALCULATION OF NET BENEFIT IS EQUAL TO TOTAL MEDICARE PAYMENTS LESS MEDICARE COSTS. IN ADDITION TO TRADITIONAL MEDICARE FEE-FOR-SERVICE, SALEM HOSPITAL PROVIDES SUBSTANTIAL SERVICES TO OTHER MEDICARE POPULATIONS PARTICIPATING IN MEDICARE ADVANTAGE PLANS AT SIGNIFICANTLY REDUCED REIMBURSEMENT. THE NET REVENUES FOR THESE PLANS ARE LESS THAN THE COST TO PROVIDE CARE AND ARE NOT DISCLOSED IN PART III, LINE 8. SALEM HOSPITAL ALSO CONSIDERS THE DIFFERENCE BETWEEN THE NET COST TO PROVIDE CARE FOR MEDICARE ADVANTAGE ENROLLEES AND THE NET REIMBURSEMENT AS A BENEFIT TO THE COMMUNITY. THESE NET COSTS HAVE BEEN DETERMINED BY APPLYING THE RATIO OF COSTS TO CHARGES AS DETERMINED IN WORKSHEET 2 TO THE FULL BILLED CHARGES. THE CALCULATION OF NET BENEFIT IS EQUAL TO TOTAL MEDICARE ADVANTAGE PAYMENTS OF $133,433,588 LESS MEDICARE ADVANTAGE COSTS OF $158,698,109 FOR A TOTAL ADDITIONAL COMMUNITY BENEFIT IN THE AMOUNT OF $25,264,521. PART III, LINE 9B: IF THERE IS AN INDICATION THAT A PATIENT MAY BE UNABLE TO PAY THEIR BILL, A FINANCIAL QUESTIONNAIRE IS GIVEN OR SENT TO THE PATIENT. UPON RECEIPT OF THE COMPLETED QUESTIONNAIRE, THE PATIENT FINANCIAL COUNSELOR WILL DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE AND NOTIFY THE PATIENT REGARDING THEIR ELIGIBILITY FOR DISCOUNTS UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. ELIGIBILITY IS DETERMINED BASED ON THE QUESTIONNAIRE AND SUPPORTING DOCUMENTATION IN ACCORDANCE TO THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. PART VI, LINE 2: SALEM HOSPITAL COLLABORATED WITH THE MARION COUNTY AND POLK COUNTY HEALTH DEPARTMENTS IN PUBLICATION OF THEIR 2011 AND 2012 COMMUNITY HEALTH REPORTS. IN ADDITION, SALEM HOSPITAL HAS A CONTRACTUAL ARRANGEMENT WITH HEALTHY COMMUNITIES INSTITUTE (CHI) TO PROVIDE COMMUNITY MEMBERS, PARTNERING AGENCIES AND THE COUNTY HEALTH DEPARTMENT STAFF ACCESS TO WEB-BASED HEALTH INDICATOR DATA ON AN ONGOING BASIS. THE CHI WEB-BASED DATA DASHBOARD, MARION AND POLK COUNTY HEALTH ASSESSMENTS; MARION AND POLK COMMUNITY HEALTH IMPLEMENTATION PLANS ARE PUBLISHED ON THE SALEM HOSPITAL WEBSITE. THESE DOCUMENTS SERVE TO INFORM THE SALEM HOSPITAL BENEFIT STRATEGY.A PRIORITIZED DESCRIPTION OF THE COMMUNITY HEALTH NEEDS IDENTIFIED IN THE COMMUNITY HEALTH REPORTS AND THE SALEM HOSPITAL WEB-BASED, MARION AND POLK COUNTY INDICATOR TOOLS ARE INCLUDED IN THE COMMUNITY HEALTH IMPROVEMENT PLANS (CHIP). THE CHIP REPORTS ALSO DESCRIBE THE PROCESS AND CRITERIA USED IN PRIORITIZING HEALTH NEEDS. THE CHIP PLANNING COMMITTEES CHOSE KEY HEALTH INDICATORS THAT MOST ADVERSELY AFFECTED THE COMMUNITY AT LARGE FROM THE HEALTH REPORT AND DASHBOARD FINDINGS.IN MARION COUNTY 10 INDICATORS WERE CHOSEN FOR CONSIDERATION: ADULTS WHO ARE OBESE, ADULTS ENGAGING IN PHYSICAL ACTIVITY, ADULTS WITH ASTHMA, AGE-ADJUSTED DEATH RATE DUE TO COLORECTAL CANCER, MOTHERS WHO RECEIVED EARLY PRENATAL CARE, PNEUMONIA VACCINATION RATE FOR AGES 65+, TEEN FRUIT AND VEGETABLE CONSUMPTION, TEEN PREGNANCY RATE, TEENS WHO ENGAGE IN REGULAR PHYSICAL ACTIVITY, AND TEENS WHO USE MARIJUANA.COMMUNITY INPUT WAS SOLICITED IN THREE REGIONAL FORUMS ACROSS MARION COUNTY, AS DESCRIBED IN THE MARION COUNTY CHIP REPORT. PRIORITY AREAS BY REGION WERE SELECTED. SALEM HOSPITAL IS WORKING WITH COMMUNITY AGENCIES AND STAKEHOLDERS THAT HAVE CHOSEN TO PLACE PRIORITY ON DECREASING THE RATE OF TEEN PREGNANCY, INCREASING THE RATE OF MOTHERS WHO RECEIVE EARLY PRENATAL CARE AND DECREASING THE PERCENTAGE OF ADULT OBESITY IN MARION COUNTY. IN POLK COUNTY, THE CHIP PLANNING COMMITTEE CHOSE NINE KEY HEALTH INDICATORS THAT MOST ADVERSELY AFFECTED THE COMMUNITY AT LARGE FROM THE HEALTH REPORT AND DASHBOARD FINDINGS. THE REVIEW RESULTED IN THE FOLLOWING RANKINGS, LISTED IN ORDER OF RECEIVING THE MOST EXPRESSED CONCERN TO LEAST THE EXPRESSED CONCERN: TEENS WHO ARE OBESE; POOR MENTAL HEALTH DAYS; ADULTS WHO ARE OBESE; MOTHERS WHO RECEIVE EARLY PRENATAL CARE; TEEN PREGNANCY RATES; LOW-INCOME PRESCHOOL OBESITY; MALE ADULTS WHO BINGE DRINK; CANCER SCREENINGS AND PREVALENCE; AND TEEN MARIJUANA USE.THE NINE INDICATORS WERE PRESENTED TO REPRESENTATIVES FROM COMMUNITY PARTNERING AGENCIES AT THE POLK COMMUNITY HEALTH ASSESSMENT LAUNCH IN LATE 2011. THE GROUP WAS INSTRUCTED TO SELECT THREE TO FOUR FOCUS AREAS. INDICATORS SELECTED INCLUDED TEENS WHO ARE OBESE, ADULTS WHO ARE OBESE, AND LOW-INCOME PRESCHOOL OBESITY. ALL THREE INDICATORS FOCUSED ON THE ISSUE OF OBESITY. DESPITE THE FACILITATOR'S ENCOURAGEMENT TO THINK BROADLY, THE COMMUNITY STRONGLY SUPPORTED THE SINGLE ISSUE OF OBESITY, DUE, AMONG OTHER THINGS, TO THE IMPACT ON OTHER HEALTH ISSUES. THE COMMUNITY HEALTH IMPROVEMENT PLAN WORKGROUP AGREED THAT TARGETING THE HIGH RATE OF OBESITY IN POLK COUNTY WOULD HAVE A TREMENDOUS POSITIVE IMPACT DUE TO THE VARIETY OF HEALTH ISSUES DIRECTLY RELATED TO OBESITY INCLUDING: MOBILITY, CHRONIC CONDITIONS, WORKABILITY, SELF-ESTEEM, STRESS, AND PHYSICALITY. ALTHOUGH THE POLK COUNTY CHIP IDENTIFIED NINE HEALTH INDICATORS AND CHOSE TO FOCUS ON THOSE RELATED TO OBESITY, THE HOSPITAL DATA DASHBOARD INCLUDES SOCIAL DETERMINANTS OF HEALTH AS WELL. IN POLK COUNTY, EDUCATIONAL (3RD GRADE READING, AND 8TH GRADE MATH PROFICIENCY), GROCERY STORE DENSITY, AND VIOLENT CRIME RATE NEGATIVELY INFLUENCE HEALTH. THEREFORE, THESE FOUR INDICATORS WERE ALSO IDENTIFIED AS AREAS OF NEED.THE PUBLIC HEALTH DEPARTMENT AND HOSPITAL RECOGNIZE THE IMPORTANCE OF EACH OF THE HEALTH INDICATORS AND ARE COMMITTED TO IMPACT AS MANY HEALTH MEASURES AS POSSIBLE THROUGH DIRECT CONTRIBUTION, COMMUNITY COLLABORATION, AND PARTNERSHIP. SALEM HOSPITAL'S COMMUNITY BENEFIT ACTIVITIES WILL FOCUS PRIMARILY ON IMPROVING HEALTH IN MARION AND POLK COUNTIES, WHILE ASSISTING WEST VALLEY HOSPITAL, ALSO A PART OF SALEM HEALTH, WITH ITS WORK TO IMPACT HEALTH ISSUES IN POLK COUNTY. PART VI, LINE 3: IT IS THE POLICY OF SALEM HOSPITAL TO PROVIDE FINANCIAL COUNSELING TO PATIENTS REGARDING THEIR FINANCIAL OBLIGATION AT THE EARLIEST OPPORTUNITY POSSIBLE. SALEM HOSPITAL PROVIDES A VARIETY OF OPTIONS TO ASSIST PATIENTS IN RESOLVING THEIR ACCOUNTS, INCLUDING: OREGON HEALTH PLAN (OHP) SCREENING, CHARITY ASSISTANCE, LOANS, AND EXTENDED PAYMENT PLANS. DISCOUNTS MAY BE AVAILABLE ON THE NET BALANCE FOR PATIENTS AT OR BELOW 400% OF THE FEDERAL POVERTY LEVEL. PATIENTS AT OR BELOW 200% OF THE POVERTY LEVEL ARE ELIGIBLE FOR 100% CHARITY ASSISTANCE.ALL UNINSURED PATIENTS WITH BALANCES OVER $500 ARE SCREENED FOR ELIGIBILITY THROUGH THE OREGON HEALTH PLAN (OHP), CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA) ELIGIBILITY, AND/OR ELIGIBILITY INTO THE FAMILY HEALTH INSURANCE ASSISTANCE PLAN (FHIAP) PROGRAM.SALEM HOSPITAL OR ITS REPRESENTATIVE WILL REVIEW THE PATIENT'S CURRENT RESOURCES AND WORK WITH HIM/HER TO GAIN ELIGIBILITY FOR ANY OF THESE PROGRAMS AS APPROPRIATE.PATIENTS THAT ARE NOT ELIGIBLE FOR OHP OR THE OTHER PROGRAMS LISTED ABOVE, AND HAVE FINANCIAL CONSTRAINTS THAT INHIBIT THEIR ABILITY TO PAY, WILL BE ASSESSED FOR EITHER CHARITY CARE OR A FINANCIAL DISCOUNT.INFORMATION ON THE HOSPITAL'S CHARITY CARE & FINANCIAL POLICY SHALL BE MADE PUBLICLY AVAILABLE IN THE FOLLOWING MANNER:- NOTICES ARE POSTED IN KEY AREAS OF THE HOSPITAL, INCLUDING ADMITTING, THE EMERGENCY DEPARTMENT, OUTPATIENT DEPARTMENT REGISTRATION AREAS, AND THE BUSINESS OFFICE. - THE CONDITIONS OF ADMISSION FORM INFORMS THE PATIENT OF THEIR RIGHT TO APPLY FOR CHARITY CARE. - WRITTEN INFORMATION SHALL BE AVAILABLE IN ENGLISH AND SPANISH. THE HOSPITAL WILL PROVIDE THE APPROPRIATE INTERPRETATION SERVICES FOR ALL PATIENTS WHO DO NOT SPEAK ENGLISH. - FRONT-LINE STAFF IS TRAINED TO ANSWER CHARITY CARE QUESTIONS EFFECTIVELY AND WILL DIRECT ANY QUESTIONS THAT CANNOT BE ANSWERED TO BUSINESS OFFICE STAFF IN A TIMELY MANNER. - THIS POLICY IS POSTED ON SALEM HOSPITAL'S WEBSITE. WRITTEN INFORMATION ABOUT THIS POLICY IS MADE AVAILABLE TO ANY PERSON WHO REQUESTS THE INFORMATION. - THE FIRST PATIENT STATEMENT WILL INCLUDE A NOTICE THAT CHARITY CARE AND/OR FINANCIAL ASSISTANCE IS AVAILABLE. PART VI, LINE 4: SALEM HOSPITAL SERVES MARION AND POLK COUNTIES; THERE ARE 77,916 PEOPLE AND 28,239 HOUSEHOLDS RESIDING IN THE POLK COUNTY. THE POPULATION DENSITY WAS 101.8 INHABITANTS PER SQUARE MILE (39.3/KM2). THERE WERE 30,391 HOUSING UNITS. THE RACIAL MAKEUP OF THE COUNTY WAS 79.6% WHITE, 2.5% AMERICAN INDIAN, 2.0% ASIAN, 0.8% BLACK OR AFRICAN AMERICAN, 0.3% PACIFIC ISLANDER AND 3.4% FROM TWO OR MORE RACES. THOSE OF HISPANIC OR LATINO ORIGIN MADE UP 13% OF THE POPULATION. 7.3% OF THE POPULATION IS FOREIGN BORN.THE AVERAGE HOUSEHOLD SIZE WAS 2.62. 5.9% OF THE POPULATION ARE UNDER THE AGE OF 5 YEARS, 23.5% ARE UNDER THE AGE OF 18 AND 16.4% ARE OVER THE AGE OF 65 YEARS.THE MEDIAN INCOME FOR A HOUSEHOLD IN POLK COUNTY IS $52,808. THE PER CAPITA INCOME FOR THE COUNTY WAS $24,426. ABOUT 16.5% OF THE POPULATION LIVE BELOW THE POVERTY LINE.THE DEMOGRAPHIC OF MARION COUNTY IS VERY DIFFERENT FROM POLK. THERE ARE 326,110 PEOPLE AND 113,285 HOUSEHOLDS RESIDING IN THE MARION COUNTY. THE POPULATION DENSITY WAS 266.7 INHABITANTS PER SQUARE MILE (39.3/KM2). THERE WERE 121,628 HOUSING UNITS. THE RACIAL MAKEUP OF THE COUNTY IS 67.5% WHITE, 2.5% AMERICAN INDIAN, 2.2% ASIAN, 1.4% BLACK OR AFRICAN AMERICAN, 0.9% PACIFIC ISLANDER AND 3.2% FROM TWO OR MORE RACES. THOSE OF HISPANIC OR LATINO ORIGIN MADE UP 25.3 OF THE POPULATION. 13.7% OF THE POPULATION IS FOREIGN BORN.THE AVERAGE HOUSEHOLD SIZE WAS 2.72. SEVEN PERCENT OF THE POPULATION ARE UNDER THE AGE OF 5 YEARS, 25.6% ARE UNDER THE AGE OF 18 AND 13.9% ARE OVER THE AGE OF 65 YEARS.THE MEDIAN INCOME FOR A HOUSEHOLD IN MARION COUNTY IS $46,885. THE PER CAPITA INCOME FOR THE COUNTY WAS $22,001. ABOUT 18.6% OF THE POPULATION LIVE BELOW THE POVERTY LINE. PART VI, LINE 5: SALEM HOSPITAL IS GOVERNED BY AN ALL-VOLUNTEER COMMUNITY-BASED BOARD OF TRUSTEES (BOARD). HOSPITAL LEADERSHIP AND EXECUTIVE STAFF SERVE ON COMMUNITY NON-PROFIT ADVISORY BOARDS AND PROFESSIONAL ASSOCIATIONS. THE ORGANIZATION EXTENDS MEDICAL STAFF PRIVILEGES TO QUALIFIED PHYSICIANS IN ITS COMMUNITY AND PROVIDES FREE OFFICE SPACE AND OTHER IN-KIND SUPPORT SERVICES TO NON-PROFIT ORGANIZATIONS.SALEM HOSPITAL FUNDS A COMMUNITY HEALTH EDUCATION AND OUTREACH PROGRAM. THE CENTER IS STAFFED BY HEALTH EDUCATORS AND REGISTERED NURSES THAT PROVIDE EDUCATION SERVICES TO COMMUNITY MEMBERS ON A DROP IN BASIS. A MEDICAL PROFESSIONAL AND HEALTH CONSUMER LIBRARY ALLOWS PATRONS TO CHECK OUT HEALTH MATERIALS FREE OF CHARGE. MORE THAN 1500 CLASSES AND EVENTS ARE HELD AT THE CENTER AND IN THE COMMUNITY EACH YEAR TO PROMOTE HEALTH AND PREVENT CHRONIC CONDITIONS. THESE RANGE FROM PREVENTION AND EARLY DETECTION/SCREENING SERVICES TO CHRONIC DISEASE MANAGEMENT AND END OF LIFE DECISION SUPPORT. THE OUTREACH PRIORITIES SUPPORT THE CHNA AND STAFF WORK IN COLLABORATION WITH COMMUNITY PARTNERING AGENCIES TO IMPROVE THE HEALTH AND WELL-BEING OF THE COMMUNITIES AND INDIVIDUALS WITHIN MARION AND POLK COUNTIES. SALEM HOSPITAL PROVIDES FINANCIAL SUPPORT AND SPONSORSHIP TO NONPROFIT ORGANIZATIONS. BY LEVERAGING HOSPITAL RESOURCES AND WORKING IN COLLABORATIVE PARTNERSHIPS, SALEM HOSPITAL IS ABLE TO PROVIDE BENEFITS THAT REACH BEYOND HEALTHCARE DELIVERY AND POSITIVELY IMPACT THE SOCIAL DETERMINANTS OF HEALTH. PART VI, LINE 6: SALEM HOSPITAL IS AN OREGON NONPROFIT CORPORATION AND A TAX-EXEMPT ORGANIZATION DESCRIBED IN SECTION 501(C)(3) OF THE CODE. SALEM HEALTH IS THE "PARENT" CORPORATION AND SOLE CORPORATE MEMBER OF THE CORPORATION, SALEM HOSPITAL, SALEM HOSPITAL FOUNDATION, WEST VALLEY HOSPITAL, WEST VALLEY HOSPITAL FOUNDATION, WILLAMETTE VALLEY INSURANCE CORPORATION, AND WILLAMETTE VALLEY PROFESSIONAL SERVICES. ALL ENTITIES WITHIN THE PARENT CORPORATION ARE SEPARATE NONPROFIT CORPORATIONS.SALEM HOSPITAL IS AN OREGON NONPROFIT CORPORATION AND A TAX-EXEMPT ORGANIZATION. THE CORPORATION ALSO DOES BUSINESS UNDER THE NAME "SALEM HOSPITAL, A PART OF SALEM HEALTH." SALEM HOSPITAL IS ONE OF THE LARGEST ACUTE CARE HOSPITALS IN OREGON. LICENSED FOR 454 BEDS, SALEM HOSPITAL OFFERS A BROAD RANGE OF INPATIENT AND OUTPATIENT SERVICES AN AREA OF OVER 500,000 PEOPLE, INCLUDING ALL OF MARION AND POLK AND PORTIONS OF LINN AND YAMHILL COUNTIES INCLUDING THE RESIDENTS OF THE CITY OF SALEM, THE STATE CAPITAL OF OREGON.SALEM HOSPITAL IS THE LARGEST PRIVATE EMPLOYER IN SALEM, OREGON, WITH APPROXIMATELY 4,189 FULL AND PART-TIME EMPLOYEES (AS OF SEPTEMBER 30, 2015). THE MEDICAL STAFF IS COMPRISED OF APPROXIMATELY 482 PHYSICIANS REPRESENTING MORE THAN 50 SPECIALTIES AND SUBSPECIALTIES, AND MORE THAN 300 VOLUNTEERS PROVIDE NON-MEDICAL SUPPORT FOR SALEM HOSPITAL.SALEM HOSPITAL, AS PART OF SALEM HEALTH IS GOVERNED BY AN ALL-VOLUNTEER COMMUNITY-BASED BOARD OF TRUSTEES (BOARD). THE BOARD HAS THE RESPONSIBILITY FOR THE DEVELOPMENT AND OVERSIGHT OF SALEM HEALTH VALUES, VISION, PURPOSE AND LONG-TERM STRATEGY. THROUGH THESE DOCUMENTS, THE COMMUNITY BENEFIT STEERING COMMITTEE ASSESSES AND REAFFIRMS SALEM HOSPITAL'S COMMUNITY BENEFIT COMMITMENTS AND CONNECTIONS WITH COMMUNITY NEEDS AND PRIMARY CONSTITUENCIES. THE COMMUNITY BENEFIT PLAN ASSURES MEASUREMENT AND COMPARISON OF SALEM HOSPITAL'S COMMUNITY ACTIVITIES TO EVOLVING NORMS AND OVERSEES THE CLEAR AND ACCURATE COMMUNICATION OF THESE ACTIVITIES TO KEY CONSTITUENCIES. PART VI, LINE 7, REPORTS FILED WITH STATES OR 1 MEDICAL FOUNDATION OF MARION & POLK COUNTIES 2995 RYAN DRIVE STE 100 SALEM OR 97301 931261633 501(C)(3) 18000 SPONSORSHIP OF ANNUAL BENEFIT FUNDRAISER/SPONSOR PINK WALK/IMPROVE ACCESS TO HEALTHCARE AMERICAN CANCER SOCIETY 2120 1ST AV N SEATTLE WA 98121 841316555 501(C)(3) 5000 RELAY FOR LIFE SPONSORSHIP/IMPROVE SOCIAL DETERMINATE OF HEALTH MARCH OF DIMES 1220 SW MORRISON SUITE 510 PORTLAND OR 97205 131846366 501(C)(3) 11000 NURSE OF THE YEAR AWARDS/SPONSOR FOR SALEM MARCH FOR BABIES/IMPROVE SOCIAL DETERMINATE OF HEALTH SALEM HOSPITAL FOUNDATION PO BOX 14001 SALEM OR 97309 237002687 501(C)(3) 5000 CHARITABLE CONTRIBUTION GOLF TOURNAMENT SALEM KEIZER EDUCATION FOUNDATION 233 COMMERCIAL STREET NE SALEM OR 97301 930831467 501(C)(3) 5000 AWESOME 3000 SPONSORSHIP/DISEASE PREVENTION LINDA L VLADYKA BREAST WELLNESS FOUNDATION 4742 LIBERTY RD S PMB 270 SALEM OR 97302 931328274 501(C)(3) 5500 SPONSOR SOFTBALL TOURNAMENT/IMPROVE SOCIAL DETERMINATE OF HEALTH SALEM MULTICULTURAL INST PO BOX 4611 SALEM OR 97302 911780361 501(C)(3) 5000 SPONSOR WORLD BEAT FESTIVAL/IMPROVE SOCIAL DETERMINATE OF HEALTH BOYS & GIRLS CLUB 1395 SUMMER ST NE SALEM OR 97301 930581470 501(C)(3) 27000 COMMUNITY PARTNER GRANT/IMPROVE SOCIAL DETERMINATE OF HEALTH COMMUNITY ACTION AGENCY HOME YOUTH & RESOURCE CENTER 625 UNION ST NE SALEM OR 97301 237056987 501(C)(3) 41537 COMMUNITY PARTNER GRANT FACES OF AMERICA 1687 SUMMER ST NE SALEM OR 97301 264271875 501(C)(3) 5000 SPONSOR FAMILY LEARNING AND RESOURCE CENTER LIBERTY HOUSE 2685 4TH ST NE SALEM OR 97301 931236936 501(C)(3) 10000 BUSINESS & CORPORATE SUSTAINER GROUP MEMBERSHIP/DISEASE PREVENTION OHSU FOUNDATION 3181 SW SAM JACKSON PARK RD PORTLAND OR 97239 237083114 501(C)(3) 5000 GOLF TOURNAMENT & BENEFIT DINNER OREGON STATE UNIVERSITY 218 KERR ADMINISTRATION BUILDING CORVALLIS OR 97331 933001786 170(C)(1) 49940 EXPANSION OF "JUST WALK SALEM" PROGRAM SALVATION ARMY 1901 FRONT ST SALEM OR 97301 941156347 501(C)(3) 50000 COMMUNITY PARTNER GRANT UNITED WAY OF MID WILLAMETTE VALLEY 455 BLILER AVE NE SALEM OR 97303 930395586 501(C)(3) 5000 PRESIDENT'S LEADERSHIP CIRCLE/IMPROVE SOCIAL DETERMINATE OF HEALTH FESTIVAL OF LIGHTS 4742 LIBERTY RD S 211 SALEM OR 97302 931323330 501(C)(3) 5000 SPONSOR HOLIDAY PARADE/DISEASE PREVENTION POLK CO SERVICE INTEGRATION 182 SW ACADEMY STREET 220 DALLAS OR 97338 936000869 GOVERNMENTAL 15000 MATCHING CONTRIBUTION FOR 2015-2016 FY 15 4 CASH ASSISTANCE TO PATIENTS IN NEED FOR PRESCRIPTIONS, LIFELINE SUPPORT, REHABILITATION AND OTHER URGENT NEEDS. 221 54358 SCHOLARSHIPS FOR HEALTH PROFESSIONS EDUCATION 88 170224 PART I, LINE 2: GRANTS ARE ONLY MADE TO QUALIFIED EXEMPT ORGANIZATIONS. NO MONITORING IS REQUIRED. X X X X X 1 1 0 0 0 1 1 1 0 NORMAN GRUBER CHIEF EXECUTIVE OFFICER 735929 0 96303 0 22567 0 319500 0 40324 0 1214623 0 0 0 JAMES PARR AS OF 11114 CHIEF FINANCIAL OFFICER 230816 0 36414 0 288 0 20305 0 32067 0 319890 0 0 0 AARON CRANE THRU 103114 CHIEF FINANCE AND STRATEGY OFFICER 425850 0 52703 0 3193 0 19500 0 26107 0 527353 0 0 0 ROBERT BRANNIGAN CHIEF ADMIN OFFICER WVH 295652 0 47921 0 7341 0 34984 0 26891 0 412789 0 0 0 LAURIE BARR VP HUMAN RESOURCES 276221 0 53575 0 1646 0 35680 0 25884 0 393006 0 0 0 BRENDA BUBLITZ VP SURGICAL SERVICES 171281 0 11872 0 5396 0 17871 0 28996 0 235416 0 0 0 MARTIN MORRIS THRU 2615 VP/CHIEF DEVELOPMENT OFFICER 256644 0 38847 0 7332 0 37027 0 20895 0 360745 0 0 0 CHERYL NESTER WOLFE CHIEF OPERATING OFFICER 464829 0 114587 0 7341 0 0 0 7254 0 594011 0 0 0 CORT GARRISON CHIEF INFORMATION OFFICER 397720 0 63157 0 2558 0 45083 0 34552 0 543070 0 0 0 SARAH HORN CHIEF NURSING OFFICER 152293 0 11063 0 85 0 11717 0 29863 0 205021 0 0 0 LEAH MITCHELL VP KAIZEN QUALITY & SAFETY 225041 0 37195 0 968 0 32367 0 14825 0 310396 0 0 0 LORI JAMES-NIELSEN VP CHIEF STRATEGY OFFICER 212461 0 36100 0 1368 0 34761 0 32412 0 317102 0 0 0 JAYAPRAKASH REDDY MD PHYSICIAN 383373 0 20619 0 697 0 25011 0 33652 0 463352 0 0 0 NICOLE VANDERHEYDEN MD PHYSICIAN 476639 0 31660 0 3197 0 42977 0 36227 0 590700 0 0 0 THYE SCHUYLER MD PHYSICIAN 456819 0 0 0 838 0 30317 0 28505 0 516479 0 0 0 PREETHI PRAKASH MD PHYSICIAN 388295 0 23758 0 595 0 14300 0 22027 0 448975 0 0 0 SHERIF AL-HAWAREY MD PHYSICIAN 459158 0 20000 0 879 0 11200 0 28014 0 519251 0 0 0 MARTHA ENRIQUEZ FORMER CHIEF NURSING OFFICER 323239 0 22280 0 7341 0 36605 0 31748 0 421213 0 0 0 WILLIAM HOLLOWAY MD FORMER CHIEF MEDICAL OFFICER 362856 0 204314 0 214782 0 35765 0 29515 0 847232 0 0 0 ANNE KOLLER FORMER CHIEF MARKETING OFFICER 0 0 0 0 144055 0 0 0 9343 0 153398 0 0 0 PART I, LINES 4A-B WILLIAM HOLLOWAY M.D. RECEIVED SEVERANCE PAY UPON TERMINATION OF HIS EMPLOYMENT. THE TOTAL OF HIS SEVERANCE PAY WAS $212,390. THIS AMOUNT IS INCLUDED IN 'OTHER REPORTABLE COMPENSATION' IN COLUMN (B)(III). SOME OF THE HOSPITAL'S EMPLOYEES RECEIVE DEFERRED COMPENSATION UNDER A 457(F) NONQUALIFIED PLAN. THIS COMPENSATION IS INCLUDED IN COMPENSATION REPORTED IN PART II. THE TOTAL NONQUALIFIED PORTION OF EACH PERSONS DEFERRED COMPENSATION IS: NORMAN GRUBER $396,303 ($96,303 INCLUDED IN BONUS & INCENTIVE COMPENSATION AND $300,000 INCLUDED IN DEFERRED COMPENSATION) JAMES PARR $3,405 (INCLUDED IN DEFERRED COMPENSATION) ROBERT BRANNIGAN $37,579 ($16,895 INCLUDED IN BONUS & INCENTIVE COMPENSATION AND $20,684 INCLUDED IN DEFERRED COMPENSATION) LAURIE BARR $26,917 ($8,137 INCLUDED IN BONUS & INCENTIVE COMPENSATION AND $18,780 INCLUDED IN DEFERRED COMPENSATION) MARTHA ENRIQUEZ $22,305 (INCLUDED IN DEFERRED COMPENSATION) MARTIN MORRIS $38,847 ($21,320 INCLUDED IN BONUS & INCENTIVE COMPENSATION AND $17,527 INCLUDED IN DEFERRED COMPENSATION) CHERYL NESTER WOLFE $37,749 (INCLUDED IN BONUS & INCENTIVE COMPENSATION) CORT GARRISON $28,183 (INCLUDED IN DEFERRED COMPENSATION) WILLIAM HOLLOWAY $18,865 (INCLUDED IN DEFERRED COMPENSATION) SHERIF AL-HAWAREY $11,200 (INCLUDED IN DEFERRED COMPENSATION) NICOLE VANDERHEYDEN $57,737 ($31,660 INCLUDED IN BONUS & INCENTIVE COMPENSATION AND $26,077 INCLUDED IN DEFERRED COMPENSATION) THYE SCHUYLER $16,017 (INCLUDED IN DEFERRED COMPENSATION) LEAH MITCHELL $15,467 (INCLUDED IN DEFERRED COMPENSATION) LORI JAMES-NEILSEN $15,169 (INCLUDED IN DEFERRED COMPENSATION) JAYAPRAKASH REDDY $10,711 (INCLUDED IN DEFERRED COMPENSATION) BRENDA BUBLITZ $15,560 (INCLUDED IN DEFERRED COMPENSATION) PART I, LINE 6 CERTAIN PHYSICIANS RECEIVE INCENTIVE COMPENSATION IN ACCORDANCE WITH THEIR EMPLOYMENT AGREEMENTS WITH SALEM HOSPITAL. AMOUNTS NOTED ON SCHEDULE J PART II COLUMN (II) REFLECT PAYMENTS EARNED BY THESE PHYSICIAN EMPLOYEES IN SUCH AGREEMENTS. ADDITIONALLY, FOR KEY EMPLOYEES AND MANAGEMENT OF SALEM HOSPITAL THE BOARD OF TRUSTEES HAS APPROVED AN ANNUAL LEADERSHIP INCENTIVE PROGRAM THAT PROVIDES FOR INCENTIVE PAYMENTS BASED ON OBJECTIVE CRITERIA RELATED TO QUALITY AND SAFETY, ENGAGEMENT, PATIENT SATISFACTION AND FINANCIAL PERFORMANCE. ROBERT BRANNIGAN'S INCENTIVE PAYMENTS ARE BASED ON WEST VALLEY HOSPITAL'S BOARD APPROVED LEADERSHIP INCENTIVE PLAN. AMOUNTS NOTED ON SCHEDULE J PART II COLUMN (II) REFLECT PAYMENTS EARNED UNDER THE LEADERSHIP INCENTIVE PLAN. PART I, LINE 7 THE GOVERNANCE COMMITTEE OF THE BOARD OF TRUSTEES, IN CONSULTATION WITH INDEPENDENT COMPENSATION CONSULTANTS, REVIEWS CEO TOTAL COMPENSATION AND PERFORMANCE ANNUALLY. AS PART OF THE COMMITTEE'S ACTIONS, A NON-FIXED BONUS MAY BE AWARDED TO THE CEO. IN THIS YEAR THE NON-FIXED PAYMENT WAS PAID UNDER THE 457(F) NONQUALIFIED PLAN AND IS INCLUDED IN DEFERRED COMPENSATION REPORTED IN PART II. A THE HOSPITAL FACILITY AUTHORITY OF THE CITY OF SALEM OREGON REVENUE BONDS 521542796 794458CL1 2006-11-15 123122698 CONSTRUCTION AND RENOVATION OF VARIOUS CAMPUS FACILITIES 0 0 0 B THE HOSPITAL FACILITY AUTHORITY OF THE CITY OF SALEM OREGON REVENUE BONDS 521542796 794458CY3 2008-11-13 125000000 REFUND SERIES 2004AB AND 2006B. PATIENT TOWER CONSTRUCTION AND OTHER IMP. 0 0 0 C THE HOSPITAL FACILITY AUTHORITY OF THE CITY OF SALEM OREGON REVENUE BONDS 521542796 794458CX5 2008-10-08 60487711 REFUND SERIES 2004A; CONSTRUCTION AND RENOVATION OF VARIOUS BUILDINGS. 0 0 0 D THE HOSPITAL FACILITY AUTHORITY OF THE CITY OF SALEM OREGON REVENUE BONDS 521542796 NONEAVAIL 2013-06-27 69965000 CURRENT REFUNDING; FINANCE VARIOUS IMPROVEMENTS TO HEALTH CARE FACILITIES. 0 0 0 A 8070000 128355347 1105000 127250347 2009 0 0 1 1 B 50000000 125021764 633004 1153492 9260268 113975000 2009 1 0 1 1 C 20525000 60600453 6143987 837965 6160859 47630629 2009 1 0 1 1 D 1685000 70376249 290834 19697016 50003336 1 0 0 1 A 0 1 1 1 1 1 0.01200 0.00200 0.01400 0 0 1 B 0 1 1 1 1 1 0.00400 0.00100 0.00500 0 0 1 C 0 1 1 1 1 1 0.00500 0.00100 0.00600 0 0 1 D 0 1 1 1 1 1 0.00200 0.00000 0.00200 0 0 1 A 0 0 1 0 0 0 1 WELLS FARGO BANK NA 2.000000000000 1 0 1 B 0 0 1 0 1 1 UBS AG 25.800000000000 0 0 0 0 1 C 0 0 1 1 0 0 0 0 1 D 0 1 1 1 0 0 0 0 1 A 1 B 1 C 1 D 1 SUPPLEMENTAL INFORMATION: COLUMN A: DIFFERENCE BETWEEN PART I(E) AND PART II, LINE 3 IS DUE TO INTEREST EARNED FROM THE CONSTRUCTION FUND. PART III, LINE 7: AS PROVIDED IN TREASURY REGULATION SECTION 1.141-4(C)(2)(I)(B), THE AMOUNT OF PRIVATE PAYMENTS TAKEN INTO ACCOUNT UNDER THE PRIVATE PAYMENT TEST MAY NOT EXCEED THE AMOUNT OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS USE. ACCORDINGLY, THE AMOUNT OF PRIVATE PAYMENTS FOR THE REPORTING PERIOD DOES NOT EXCEED THE AMOUNT STATED IN PART III, LINE 6. THE ORGANIZATION HAS NOT UNDERTAKEN AN ANALYSIS OF THE PRIVATE SECURITY TEST WITH RESPECT TO THE BONDS, AS THE LEVEL OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS REPORTED IN PART III, LINE 6, IS NOT IN EXCESS OF AMOUNTS PERMITTED UNDER SECTION 145 OF THE CODE. PART IV, LINE 2(B): THE PORTION OF THE BONDS THAT WAS DEPOSITED TO THE CONSTRUCTION FUND HAS MET THE 2-YEAR EXPENDITURE EXCEPTION TO REBATE. PART IV, LINE 2(C): PROCEEDS OF THE BONDS HAVE MET A SPENDING EXCEPTION AND, THEREFORE, NO PAYMENT WILL EVER BE DUE ON THE BONDS. COLUMN B: DIFFERENCE BETWEEN PART I(E) AND PART II, LINE 3 IS DUE TO INTEREST EARNED FROM THE PROJECT, COSTS OF ISSUANCE, AND DEBT SERVICE RESERVE FUNDS. PART I(F): BONDS REFUNDED BY SERIES 2008A: SERIES 2004A (ISSUED NOVEMBER 23, 2004). PART III, LINE 7: AS PROVIDED IN TREASURY REGULATION SECTION 1.141-4(C)(2)(I)(B), THE AMOUNT OF PRIVATE PAYMENTS TAKEN INTO ACCOUNT UNDER THE PRIVATE PAYMENT TEST MAY NOT EXCEED THE AMOUNT OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS USE. ACCORDINGLY, THE AMOUNT OF PRIVATE PAYMENTS FOR THE REPORTING PERIOD DOES NOT EXCEED THE AMOUNT STATED IN PART III, LINE 6. THE ORGANIZATION HAS NOT UNDERTAKEN AN ANALYSIS OF THE PRIVATE SECURITY TEST WITH RESPECT TO THE BONDS, AS THE LEVEL OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS REPORTED IN PART III, LINE 6, IS NOT IN EXCESS OF AMOUNTS PERMITTED UNDER SECTION 145 OF THE CODE. PART IV, LINE 2(B): THE PORTION OF THE BONDS THAT WAS EXPENDED TO FINANCE A CURRENT REFUNDING HAS MET THE 6-MONTH EXPENDITURE EXCEPTION TO REBATE. PART IV, LINE 2(C): THE 5TH YEAR ANNIVERSARY REBATE COMPUTATION WAS PERFORMED AS OF OCTOBER 1, 2013, ON OCTOBER 18,2013. COLUMN C: DIFFERENCE BETWEEN PART I(E) AND PART II, LINE 3 IS DUE TO INTEREST EARNED FROM THE PROJECT FUND. PART I(F): BONDS REFUNDED BY SERIES 2008B: SERIES 2004AB (ISSUED NOVEMBER 23, 2004) AND SERIES 2006B (ISSUED NOVEMBER 15, 2006). PART II, LINE 1: BONDS REFUNDING SERIES 2008C: SERIES 2013AB (ISSUED JUNE 27, 2013). PART III, LINE 7: AS PROVIDED IN TREASURY REGULATION SECTION 1.141-4(C)(2)(I)(B), THE AMOUNT OF PRIVATE PAYMENTS TAKEN INTO ACCOUNT UNDER THE PRIVATE PAYMENT TEST MAY NOT EXCEED THE AMOUNT OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS USE. ACCORDINGLY, THE AMOUNT OF PRIVATE PAYMENTS FOR THE REPORTING PERIOD DOES NOT EXCEED THE AMOUNT STATED IN PART II, LINE 6. THE ORGANIZATION HAS NOT UNDERTAKEN AN ANALYSIS OF THE PRIVATE SECURITY TEST WITH RESPECT TO THE BONDS, AS THE LEVEL OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS REPORTED IN PART III, LINE 6, IS NOT IN EXCESS OF AMOUNTS PERMITTED UNDER SECTION 145 OF THE CODE. PART IV, LINE 2(B): THE PORTION OF THE BONDS THAT WAS EXPENDED TO FINANCE A CURRENT REFUNDING AND THE PORTION OF THE BONDS THAT WAS DEPOSITED TO THE PROJECT AND COSTS OF ISSUANCE FUNDS, COLLECTIVELY, HAVE MET THE 6-MONTH EXPENDITURE EXCEPTION TO REBATE. COLUMN D: DIFFERENCE BETWEEN PART I(E) AND PART II, LINE 3 IS DUE TO INTEREST EARNED FROM THE PROJECT FUND AND COSTS OF ISSUANCE. PART I(F): BONDS REFUNDED BY SERIES 2013AB: SERIES 2008C (ISSUED NOVEMBER 13, 2008). PART III, LINE 7: AS PROVIDED IN TREASURY REGULATION SECTION 1.141-4(C)(2)(I)(B), THE AMOUNT OF PRIVATE PAYMENTS TAKEN INTO ACCOUNT UNDER THE PRIVATE PAYMENT TEST MAY NOT EXCEED THE AMOUNT OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS USE. ACCORDINGLY, THE AMOUNT OF PRIVATE PAYMENTS FOR THE REPORTING PERIOD DOES NOT EXCEED THE AMOUNT STATED IN PART III, LINE 6. THE ORGANIZATION HAS NOT UNDERTAKEN AN ANALYSIS OF THE PRIVATE SECURITY TEST WITH RESPECT TO THE BONDS, AS THE LEVEL OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS REPORTED IN PART III, LINE 6, IS NOT IN EXCESS OF AMOUNTS PERMITTED UNDER SECTION 145 OF THE CODE. PART IV, LINE 2(B): THE REFUNDING AND NEW MONEY PORTIONS OF THE BONDS HAVE MET THE 6-MONTH AND 2-YEAR EXPENDITURE EXCEPTIONS TO REBATE, RESPECTIVELY. PART IV, LINE 2(C): PROCEEDS OF THE BONDS HAVE MET SPENDING EXCEPTIONS AND, THEREFORE, NO PAYMENT WILL EVER BE DUE ON THE BONDS. FORM 990, PART VI, SECTION B, LINE 11 THE GOVERNANCE COMMITTEE OF THE BOARD OF TRUSTEES REVIEWS THE 990. IT IS THEN FORWARDED TO THE ENTIRE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION B, LINE 12C ON AN ANNUAL BASIS THE SECRETARY OF THE HOSPITAL SHALL SEND TO EACH PERSON WHO IS A TRUSTEE, OFFICER, OR MEMBER OF A COMMITTEE, AND TO THOSE EMPLOYEES OF THE HOSPITAL AS THE BOARD MAY DETERMINE, A COPY OF THE POLICY REGARDING CONFLICTS OF INTEREST, TOGETHER WITH A QUESTIONNAIRE INQUIRING AS TO CONFLICTS, TO BE COMPLETED A AND RETURNED TO THE SECRETARY BY THE TRUSTEE, OFFICER, COMMITTEE MEMBER OR EMPLOYEE PRIOR TO THE BEGINNING OF EACH CALENDAR YEAR. FORM 990, PART VI, SECTION B, LINE 15 EXECUTIVE COMPENSATION AT SALEM HOSPITAL IS DESIGNED TO ALLOW THE ORGANIZATION TO RECRUIT AND RETAIN QUALIFIED SENIOR LEADERS. THE GOVERNANCE COMMITTEE OF THE SALEM HOSPITAL BOARD OF TRUSTEES, NONE OF WHOM IS A SALEM HOSPITAL EMPLOYEE, ENGAGES ONE OR MORE INDEPENDENT CONSULTANTS TO PROVIDE A MARKET DATA ON EXECUTIVE COMPENSATION, INCLUDING BENEFITS, FOR THE CEO AND OTHER EXECUTIVES IN SIMILAR ROLES AT COMPARABLE ORGANIZATIONS. THIS INFORMATION IS USED BY THE GOVERNANCE COMMITTEE IN ITS DISCUSSIONS AND DECISIONS ON CEO COMPENSATION. THE CEO, IN CONJUNCTION WITH OTHER SALARY SURVEY OR PUBLIC INFORMATION AND THE INDEPENDENT CONSULTANT, ENSURES THAT EACH EXECUTIVE'S COMPENSATION IS COMPETITIVE IN THE MARKET FOR SIMILAR POSITIONS AT COMPARABLE ORGANIZATIONS. FORM 990, PART VI, SECTION C, LINE 19 THE CONFLICT OF INTEREST POLICY AND GOVERNING DOCUMENTS ARE AVAILABLE ON THE HOSPITAL WEBSITE. FORM 990, PART XI, LINE 9: CHANGE IN FAIR VALUE OF INTEREST RATE SWAP AGREEMENT -3,170,737. CHANGE IN NET BENEFIT COST 292,668. CHANGE IN BENEFICIAL INTEREST IN FOUNDATION 59,127. EQUITY TRANSFER BETWEEN RELATED ENTITIES -4,694,227. FORM 990, PART XII, LINE 2C THERE HAVE NOT BEEN ANY CHANGES FROM THE PREVIOUS YEAR. MWVP INC 570 LIBERTY ST SE STE 200 SALEM OR 97301 123456789 HOLDS LAND OR SALEM HEALTH SALEM HOSPITAL FOUNDATION 890 OAK STREET SE SALEM OR 97301 237002687 SUPPORTS SALEM HOSPITAL OR 501(C)(3) 7 SALEM HEALTH 0 SALEM HOSPITAL AUXILIARY 890 OAK STREET SE SALEM OR 97301 931081113 SUPPORTS SALEM HOSPITAL OR 501(C)(3) 9 N/A 0 SALEM HEALTH 890 OAK STREET SE SALEM OR 97301 930823471 LEASES LAND TO SALEM HOSPITAL OR 501(C)(3) 11 TYPE 1 N/A 0 WEST VALLEY HOSPITAL 525 SOUTHEAST WASHINGTON STREET DALLAS OR 97338 431960221 HOSPITAL OR 501(C)(3) 3 SALEM HEALTH 0 WEST VALLEY HOSPITAL FOUNDATION 525 SOUTHEAST WASHINGTON STREET DALLAS OR 97338 931298564 SUPPORTS WEST VALLEY HOSPITAL OR 501(C)(3) 11 TYPE 1 SALEM HEALTH 0 WILLAMETTE VALLEY INSURANCE COMPANY 745 FORT STREET HONOLULU HI 96813 201836190 CAPTIVE INSURANCE HI 501(C)(3) 11 TYPE 1 SALEM HEALTH 0 WILLAMETTE VALLEY PROFESSIONAL SERVICES 890 OAK STREET SE SALEM OR 97301 753175249 BILLING SERVICE FOR PROFESSIONAL FEES OR 501(C)(3) 3 SALEM HEALTH 0 OREGON COMMUNITY IMAGING LLC 2925 RYAN DR SE SALEM OR 97301 202683062 MEDICAL IMAGING COOPERATIVE OR N/A 1 1 1 1 0 0 0 0 0 0 1 0 0 1 1 1 1 1 1