2016-08-12T13:45:22-05:00 2015-09-30 930623286 AKT LLP 5665 SW MEADOWS RD SUITE 200 LAKE OSWEGO OR 97035 990 2014-10-01 431960221 WEST VALLEY HOSPITAL WEST 5038141938 525 SOUTHEAST WASHINGTON ST DALLAS OR 97338 JAMES PARR CHIEF FINANCIAL OFFICER 5038141938 2016-08-08 1 JOYLYN M ANKENEY CPA P00366587 5036204489 2016-08-08 2014 2016-09-27 15:27:22Z JAMES PARR 525 SOUTHEAST WASHINGTON ST DALLAS OR 97338 28529578 0 X WWW.WESTVALLEYHOSPITAL.ORG X 2002 OR WE STRIVE TO IMPROVE THE HEALTH AND WELL BEING OF THE PEOPLE AND COMMUNITY WE SERVE. 11 9 194 41 17693 10530 61774 111428 24445873 28411983 -3907 6167 0 0 24503740 28529578 15557 15000 0 0 12583050 13258679 0 0 0 9928633 10904361 22527240 24178040 1976500 4351538 16501146 16580625 9347237 4952451 7153909 11628174 TO IMPROVE THE HEALTH AND WELL BEING OF THE PEOPLE IN THE COMMUNITIES WE SERVE. 0 0 13308789 23893659 WEST VALLEY HOSPITAL IS A CRITICAL ACCESS HOSPITAL SERVING THE RURAL POLK COUNTY REGION WITH A POPULATION OF 98,000. SERVICES INCLUDE: DIAGNOSTIC IMAGING PROCEDURES 20,942, EMERGENCY DEPARTMENT VISITS 13,780, INPATIENT ADMISSIONS 186, LABORATORY TESTS/DRAWS 122,016, SURGERIES 571. 5941684 3979291 WEST VALLEY HOSPITAL PROVIDES HEALTHCARE TO PEOPLE IN OUR COMMUNITY REGARDLESS OF THEIR ABILITY TO PAY. IN FY 2015, THE COST OF SERVICES PROVIDED AS A COMMUNITY BENEFIT TOTALED $1,962,393. THIS FIGURE CONSISTED OF $412,367 IN COSTS TO PROVIDE CHARITY CARE TO INDIVIDUALS WHO CANNOT AFFORD TO PAY AND $1,550,026 IN UNDERPAYMENT BY MEDICAID AS THE AMOUNT PAID UNDER THE PROGRAM WAS LESS THAN THE COST TO PROVIDE THE SERVICES. WEST VALLEY 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. 1310410 15000 521340 WEST VALLEY HOSPITAL ACTIVELY PARTICIPATES IN COMMUNITY HEALTH IMPROVEMENT SERVICES. IN FY 2015, WEST VALLEY HOSPITAL GAVE $106,000 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. WEST VALLEY HOSPITAL SUBSIDIZES THE COST OF PROVIDING SERVICES TO THE COMMUNITY AT A FINANCIAL LOSS IN THE AMOUNT OF OVER $650,000. WEST VALLEY HOSPITAL PROVIDES CASH AND IN-KIND DONATIONS TO COMMUNITY PROGRAMS, THE LARGEST OF WHICH IS THE CONNECTIONS VAN WHICH PROVIDES TRANSPORTATION SERVICES TO PATIENTS NEEDING MEDICAL SERVICES. 20560883 1 1 0 0 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 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 31 0 1 194 1 1 1 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OR X X SALEM HOSPITAL 5038141938 890 OAK STREET SE SALEM OR 97301 ROBERT WELLS CHAIRPERSON 20.00 X X 0 0 0 ALAN K WYNN SECRETARY/TREASURER 3.00 X X 0 0 0 KATHERINE KEENE TRUSTEE 10.50 X 0 0 0 KENNETH SHERMAN JR TRUSTEE 4.00 X 0 0 0 BONNIE DRIGGERS RN TRUSTEE 6.30 X 0 0 0 LANE SHETTERLY TRUSTEE 9.00 X 0 0 0 THERESA HASKINS TRUSTEE 5.00 X 0 0 0 PAM VUKOVICH TRUSTEE 8.10 X 0 0 0 ROB KELLY MD TRUSTEE 8.10 X 0 0 0 NANCY REYES-MOLYNEUX MD TRUSTEE 7.00 X 0 0 0 NORMAN GRUBER PRESIDENT 6.00 34.00 X 0 854799 359824 AARON CRANE THRU 103114 CHIEF FINANCE & STRATEGY OFFICER 6.00 34.00 X 0 481746 45607 JAMES PARR AS OF 11114 CHIEF FINANCIAL OFFICER 6.00 34.00 X 0 267519 52372 PAMELA CORTEZ DIR. OF CLINICAL OPERATION 40.00 X 225248 0 43713 ROBERT BRANNIGAN CHIEF ADMIN OFFICER WVH/VP 30.00 10.00 X 0 350914 61875 ALISON SMITH MD GENERAL SURGEON 40.00 X 393110 0 65538 CHARLES ESSEX MD PHYSICIAN 40.00 X 266289 0 60139 JOHN HADLEY MD PHYSICIAN 40.00 X 236576 0 51158 REBECCA LUCAS MD ER PHYSICIAN 40.00 X 332030 0 53816 CELIA WALLIS RN STAFF NURSE 36.00 X 152923 0 35595 1606176 1954978 829637 14 0 1 0 SALEM RADIOLOGY CONSULTANTS PC PO BOX 12989 SALEM OR 97309 CONSULTING SERVICES 648404 EMCARE INC 7032 COLLECTION CTR DR CHICAGO IL 60693 CONTRACT LABOR 267970 CTM MANAGEMENT 476 NW HILLCREST LOOP MCMINNVILLE OR 97128 CONTRACT LABOR 244330 3 109381 2047 111428 NET PATIENT REVENUE 621110 14635224 14635224 LABORATORY 621500 10246577 10228884 17693 PHARMACY 621300 3006592 3006592 OTHER HOSPITAL SERVICES 900099 444988 444988 NUTRITION SERVICES 900099 78602 78602 28411983 2965 2965 3202 0 3202 3202 3202 28529578 28394290 17693 6167 15000 15000 278886 278886 10217288 9094545 1122743 586952 508572 78380 1466428 1270605 195823 709125 614431 94694 26930 26930 1832803 1807870 24933 10915 10915 1938748 365335 1573413 10737 972 9765 597219 584893 12326 37819 22077 15742 21540 18768 2772 1217169 1217169 97131 97131 UBI TAXES 1910 1910 PATIENT SUPPLIES 2765679 2719203 46476 0 BAD DEBT 1868795 1868795 0 0 OTHER PURCHASED SERVICE 388902 334396 54506 0 88064 21121 66943 24178040 20560883 3617157 0 299 301 350110 257427 2750145 2847584 370066 368856 157939 109427 21766722 9283516 12336240 12483206 275900 275900 260447 237924 16501146 16580625 3049941 2231442 6297296 2721009 9347237 4952451 X 7106273 11583101 47636 45073 7153909 11628174 16501146 16580625 X 4351538 122727 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 47636 13814 -9077 7300 45073 40908 3808 2920 47636 122681 4345 3956 90074 40908 65975 53985 5864 3143 122681 62724 3251 65975 1.00000 0 1 1 379197 379197 14478995 5196614 9282381 6751397 4059975 2691422 157133 26927 130206 12483206 DUE TO MEDICARE/MEDICAID 894875 OTHER LONG-TERM ACCRUALS 2214 LIABILITY FOR MALPRACTICE INSURANCE 144959 POST-RETIREMENT BENEFITS 288061 DUE TO SALEM HOSPITAL 1390900 2721009 X 28654868 125290 125290 28529578 0 28529578 24180603 2563 2563 24178040 0 24178040 PART V, LINE 4: ENDOWMENT FUNDS ARE HELD BY WEST VALLEY HOSPITAL FOUNDATION FOR WEST VALLEY 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. U.S. GENERALLY ACCEPTED ACCOUNTING PRINCIPLES 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: CHANGE IN POST RETIREMENT BENEFIT OBLIGATION 125,290. PART XII, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN BENEFICIAL INTEREST IN FOUNDATION 2,563. 1 1 X 1 X 1 X 1 1 1 0 1 1 3321 412367 412367 0.01850 12651 5529317 3979291 1550026 0.06950 15972 5941684 3979291 1962393 0.08800 4836 30064 4516 25548 0.00110 69 80689 80689 0.00360 1171190 516824 654366 0.02930 1214 28467 28467 0.00130 6119 1310410 521340 789070 0.03530 22091 7252094 4500631 2751463 0.12330 30 30344 30344 0.00140 30 30344 30344 0.00140 0 1868795 1667365 3742935 3667962 74973 X 1 1 1 1 WEST VALLEY HOSPITAL 525 SOUTHEAST WASHINGTON ST DALLAS OR 97338 X X X WEST VALLEY HOSPITAL 1 0 0 1 X X X X X X X X X 12 1 0 1 1 X WWW.WESTVALLEYHOSPITAL.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 WEST VALLEY 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 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.PARTNERING AGENCIES ARE LISTED IN POLK COUNTY COMMUNITY HEALTH NEEDS REPORT AND CHIP PUBLICATION AND INCLUDE:-THE CONFEDERATED TRIBES OF GRAND RONDE-DEPARTMENT OF HEALTH AND HUMAN SERVICES, STATE OF OREGON-EVANGELICAL BIBLE CHURCH-I LOVE ME DIABETES TASK FORCE-MARION COUNTY CHILD DEVELOPMENT BOARD-MARION AND POLK COUNTY PUBLIC HEALTH SERVICES-MARION-POLK MEDICAL SOCIETY-POLK COUNTY MENTAL HEALTH-OREGON CHILD DEVELOPMENT COALITION-OREGON HEALTH AND SCIENCES UNIVERSITY-OREGON HEALTH AUTHORITY-OREGON STATE UNIVERSITY EXTENSION SERVICE-PERFORMANCE MANAGEMENT PROGRAM-POLK COUNTY HEALTH ADVISORY BOARD-RED CROSS OF THE MID-WILLAMETTE VALLEY-RURAL METRO AMBULANCE-UNITED WAY OF THE MID-WILLAMETTE VALLEY-WESTERN OREGON UNIVERSITY-WESTERN OREGON UNIVERSITYS HEALTH AND WELLNESS CENTER-WILLAMETTE VALLEY HOSPICE-WVP HEALTH AUTHORITY-YMCAIN ADDITION, AS THE HOSPITAL BOARD OF TRUSTEES REVIEWED THE RICH SOURCES OF SECONDARY DATA, THE COLLABORATIVE HEALTH REPORT AND WORK OF THE CHIP, IT BECAME APPARENT THAT LIMITED PRIMARY DATA WAS AVAILABLE. LIKEWISE, THERE WAS LITTLE UNDERSTANDING OF PERCEIVED NEED FROM HEALTH SYSTEM PROVIDERS. IN 2012, THE BOARD ORGANIZED A SERIES OF FIVE FOCUS GROUPS TO HELP FURTHER UNDERSTAND THE NEEDS OF THE COMMUNITY. THE FOCUS GROUP PARTICIPANTS INCLUDED EMERGENCY DEPARTMENT AND URGENT CARE PROVIDERS, SAFETY NET PROVIDERS, PRIMARY CARE PROVIDERS, MENTAL AND BEHAVIORAL HEALTH PROVIDERS AND SENIOR SERVICES AGENCY REPRESENTATIVES. THE GOAL WAS TO GAIN FIRST-HAND KNOWLEDGE OF THE CHALLENGES WITHIN THE CURRENT HEALTH SYSTEM IN PROVIDING SERVICES FOR VULNERABLE POPULATIONS. WEST VALLEY HOSPITAL PART V, SECTION B, LINE 6A: THERE ARE NO OTHER HOSPITALS IN POLK COUNTY. WEST VALLEY 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. WEST VALLEY HOSPITAL PART V, SECTION B, LINE 11: 2014 IS THE LAST REPORTING YEAR FOR THE 2012- 2014 COMMUNITY BENEFIT IMPLEMENTATION PLAN. IN POLK COUNTY, COMMUNITY MEMBERS AND REPRESENTATIVES FROM PARTNERING AGENCIES ARE WORKING COLLABORATIVELY WITH WEST VALLEY HOSPITALS TO DECREASE THE PREVALENCE OF OBESITY ACROSS ALL AGE RANGES.OBESITY RATES IN POLK COUNTIES REMAIN ABOVE STATE AND NATIONAL AVERAGES AND ABOVE THE HP2020 GOAL OF 30.5% FOR ADULTS. WEST VALLEY HOSPITAL CONTINUES 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. WEST VALLEY HOSPITAL PART V, SECTION B, LINE 22D: WEST VALLEY 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 WEST VALLEY HOSPITAL PART V, SECTION B, LINE 16A WEBSITE: HTTPS://WWW.SALEMHOSPITALBILL.COM/FINANCIAL_ASSISTANCE.ASPX WEST VALLEY HOSPITAL PART V, SECTION B, LINE 16B WEBSITE: HTTPS://WWW.SALEMHOSPITALBILL.COM/FINANCIAL_ASSISTANCE.ASPX WEST VALLEY HOSPITAL PART V, SECTION B, LINE 16C WEBSITE: HTTPS://WWW.SALEMHOSPITALBILL.COM/FINANCIAL_ASSISTANCE.ASPX 1 MONMOUTH MEDICAL CENTER 512 E MAIN ST 300 MONMOUTH OR 97361 CLINIC PART I, LINE 3C: IT IS THE POLICY OF WEST VALLEY HOSPITAL TO PROVIDE FINANCIAL COUNSELING TO PATIENTS REGARDING THEIR FINANCIAL OBLIGATION AT THE EARLIEST OPPORTUNITY POSSIBLE. WEST VALLEY 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 EXPENSES.1. 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, LINE 7G: MARION AND POLK COUNTY MUA/HPSA DESIGNATION, HEALTH ASSESSMENT DATA SETS AND MARION POLK RESIDENT (2008) SURVEY RESULTS DEMONSTRATE HEALTHCARE ACCESS PROBLEMS, SPECIFICALLY LACK OF PHYSICIANS WILLING TO TAKE MEDICARE AND OREGON HEALTH INSURANCE (MEDICAID). LIKEWISE, ACCESS TO HEALTHCARE WAS ALSO ONE OF THE TOP THREE COMMUNITY HEALTH CONCERNS CITED BY PROVIDERS SURVEY RESPONDENTS. WHILE REGION 3, WHICH INCLUDES MARION, BENTON, LANE, LINN AND POLK COUNTIES, HAS 94 (OR 111) PRIMARY CARE PROVIDERS PER 100,000 POPULATION, ONLY 86 (OR 98) OF THOSE ACCEPT MEDICARE, AND OF THOSE 86, ONLY A PORTION ARE ACTUALLY ACCEPTING NEW PATIENTS. A SIMILAR SITUATION EXISTS FOR OREGON HEALTH PLAN; EVEN WHEN PEOPLE HAVE COVERAGE, THEY MAY NOT HAVE ACCESS TO ESTABLISHING CARE WITH A LOCAL MEDICAL PROVIDER. TO EASE THIS ACCESS BURDEN, WEST VALLEY HOSPITAL HAS SUBSIDIZED PHYSICIAN PRACTICES AND REPORTS THESE SUBSIDIES IN PART 1, LINE 7, COLUMN (F). 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 $1,868,795. 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 FALLS AT OR BELOW 200% OF FEDERAL POVERTY GUIDELINES ARE INCLUDED ON THIS LINE. 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: WEST VALLEY HOSPITAL("WVH"), AS PART OF SALEM HEALTH, THE POLK COUNTIES, PUBLIC HEALTH MANAGER WORKED WITH THE SALEM HOSPITAL COMMUNITY BENEFIT DIRECTOR TO GATHER COMMUNITY PARTNERS FOR REVIEW OF HEALTH INDICATORS AND TO PRIORITIZE NEEDS. A PRIORITIZED DESCRIPTION OF THE COMMUNITY HEALTH NEEDS IDENTIFIED IN THE POLK COUNTY COMMUNITY HEALTH REPORT AND THE SALEM HEALTH WEB-BASED, POLK COUNTY INDICATOR TOOLS ARE INCLUDED IN THE COMMUNITY HEALTH IMPROVEMENT PLAN (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 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 FACILITATORS 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.IN ADDITION, THE HOSPITAL WILL FOCUS RESOURCES AND ALIGN COMMUNITY BENEFIT WORK TO IMPACT SOCIAL DETERMINANTS OF HEALTH IDENTIFIED IN THE CHNA. 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. PART VI, LINE 3: IT IS THE POLICY OF WEST VALLEY HOSPITAL TO PROVIDE FINANCIAL COUNSELING TO PATIENTS REGARDING THEIR FINANCIAL OBLIGATION AT THE EARLIEST OPPORTUNITY POSSIBLE. WEST VALLEY 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.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.WEST VALLEY 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 WEST VALLEY 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: WEST VALLEY HOSPITAL SERVES POLK COUNTY; 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. PART VI, LINE 5: WEST VALLEY HOSPITAL, AS A PART OF SALEM HEALTH, IS GOVERNED BY AN ALL-VOLUNTEER COMMUNITY-BASED BOARD OF TRUSTEES (BOARD). WEST VALLEY HOSPITAL LEADERSHIP AND HEALTH SYSTEM 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. WEST VALLEY HOSPITAL PROVIDES FINANCIAL SUPPORT AND SPONSORSHIP TO NONPROFIT ORGANIZATIONS. BY LEVERAGING HOSPITAL RESOURCES AND WORKING IN COLLABORATIVE PARTNERSHIPS, THE HOSPITAL IS ABLE TO PROVIDE BENEFITS THAT REACH BEYOND HEALTHCARE DELIVERY AND POSITIVELY IMPACT THE SOCIAL DETERMINANTS OF HEALTH. PART VI, LINE 6: SALEM HEALTH 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 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.WEST VALLEY HOSPITAL IS ALSO AN OREGON NON-PROFIT CORPORATION. WEST VALLEY HOSPITAL, FORMERLY NAMED VALLEY COMMUNITY HOSPITAL, IS LOCATED IN DALLAS, OREGON, AND BECAME A CONTROLLED SUBSIDIARY OF SALEM HEALTH IN 2002. THE CORPORATION ALSO DOES BUSINESS UNDER THE NAME "WEST VALLEY HOSPITAL, A PART OF SALEM HEALTH." IT IS DESIGNATED AS A CRITICAL ACCESS HEALTH CENTER WITH 25 LICENSED BEDS. WEST VALLEY 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 WEST VALLEY HOSPITAL'S COMMUNITY BENEFIT COMMITMENTS AND CONNECTIONS WITH COMMUNITY NEEDS AND PRIMARY CONSTITUENCIES. THE COMMUNITY BENEFIT PLAN ASSURES MEASUREMENT AND COMPARISON OF WEST VALLEY 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 0 POLK COUNTY SERVICE INTEGRATION TEAMS 182 SW ACADEMY STREET 220 DALLAS OR 97338 936000869 GOVERNMENTAL 15000 IMPROVE SOCIAL DETERMINATES OF HEALTH X X X X X 0 1 0 0 0 1 1 1 0 NORMAN GRUBER PRESIDENT 0 735929 0 96303 0 22567 0 319500 0 40324 0 1214623 0 0 AARON CRANE THRU 103114 CHIEF FINANCE & STRATEGY OFFICER 0 425850 0 52703 0 3193 0 19500 0 26107 0 527353 0 0 JAMES PARR AS OF 11114 CHIEF FINANCIAL OFFICER 0 230816 0 36414 0 289 0 20305 0 32067 0 319891 0 0 PAMELA CORTEZ DIR. OF CLINICAL OPERATION 197376 0 27498 0 374 0 19434 0 24279 0 268961 0 0 0 ROBERT BRANNIGAN CHIEF ADMIN OFFICER WVH/VP 0 295652 0 47921 0 7341 0 34984 0 26891 0 412789 0 0 ALISON SMITH MD GENERAL SURGEON 363103 0 25482 0 4525 0 38554 0 26984 0 458648 0 0 0 CHARLES ESSEX MD PHYSICIAN 250979 0 11201 0 4109 0 28985 0 31154 0 326428 0 0 0 JOHN HADLEY MD PHYSICIAN 216674 0 17139 0 2763 0 27006 0 24152 0 287734 0 0 0 REBECCA LUCAS MD ER PHYSICIAN 315779 0 15284 0 967 0 27243 0 26573 0 385846 0 0 0 CELIA WALLIS RN STAFF NURSE 152504 0 0 0 419 0 13180 0 22415 0 188518 0 0 0 PART I, LINE 4B SOME OF THE HOSPITAL'S OFFICERS AND 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 OTHER REPORTABLE COMPENSATION AND $300,000 INCLUDED IN DEFERRED COMPENSATION) ROBERT BRANNIGAN 37,579 ($16,895 INCLUDED IN OTHER REPORTABLE COMPENSATION AND $20,684 INCLUDED IN DEFERRED COMPENSATION) ALISON SMITH 47,136 ($25,482 INCLUDED IN OTHER REPORTABLE COMPENSATION AND $21,654 INCLUDED IN DEFERRED COMPENSATION) CHARLES ESSEX 23,597 ($11,201 INCLUDED IN OTHER REPORTABLE COMPENSATION AND $12,396 INCLUDED IN DEFERRED COMPENSATION) JOHN HADLEY 29,895 ($17,139 INCLUDED IN OTHER REPORTABLE COMPENSATION AND $12,756 INCLUDED IN DEFERRED COMPENSATION) REBECCA LUCAS 27,923 ($15,284 INCLUDED IN OTHER REPORTABLE COMPENSATION AND $12,639 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. 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. 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 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 COMPENSATION FOR THE CEO IS REVIEWED ON AN ANNUAL BASIS. THE GOVERNANCE COMMITTEE ENGAGES AN OUTSIDE CONSULTANT TO DO A MARKET REVIEW AND COMPARISON. THE CONSULTANT WORKS DIRECTLY WITH THE GOVERNANCE COMMITTEE CHAIR AS WELL AS HUMAN RESOURCES TO COMPLETE THE ASSESSMENT AND MAKE A RECOMMENDATION. THE FINAL RECOMMENDATION IS BROUGHT BEFORE THE BOARD IN EXECUTIVE SESSION FOR FINAL APPROVAL. 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 BENEFICIAL INTEREST (FAS 136) -2,563. CHANGE IN POST RETIREMENT BENEFIT 125,290. SALEM HOSPITAL 890 OAK STREET SE SALEM OR 97301 930579722 HOSPITAL OR 501(C)(3) LINE 3 SALEM HEALTH 0 SALEM HOSPITAL FOUNDATION 890 OAK STREET SE SALEM OR 97301 237002687 SUPPORTS SALEM HOSPITAL OR 501(C)(3) LINE 11A, I SALEM HEALTH 0 SALEM HOSPITAL AUXILIARY 890 OAK STREET SE SALEM OR 97301 931081113 SUPPORTS SALEM HOSPITAL OR 501(C)(3) LINE 9 N/A 0 SALEM HEALTH 890 OAK STREET SE SALEM OR 97301 930823471 LEASES LAND TO SALEM HOSPITAL OR 501(C)(3) LINE 11A, I N/A 0 WEST VALLEY HOSPITAL FOUNDATION 525 SOUTHEAST WASHINGTON STREET DALLAS OR 97338 931298564 SUPPORTS WEST VALLEY HOSPITAL OR 501(C)(3) LINE 11A, I SALEM HEALTH 0 WILLAMETTE VALLEY INSURANCE COMPANY 745 FORT STREET HONOLULU HI 96813 201836190 CAPTIVE INSURANCE HI 501(C)(3) LINE 11A, I SALEM HEALTH 0 WILLAMETTE VALLEY PROFESSIONAL SERVICES 890 OAK STREET SE SALEM OR 97301 753175249 BILLING SERVICE FOR PROFESSIONAL SERVICES OR 501(C)(3) LINE 3 SALEM HEALTH 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 0 0