2015-08-14T16:23:56-05:00 2014-09-30 910189318 MOSS ADAMS LLP 805 SW BROADWAY STE 1200 PORTLAND OR 97205 990 2013-10-01 930281321 SILVERTON HEALTH SILV 5038731500 342 FAIRVIEW STREET SILVERTON OR 97381 DAN JESSUP CFO 5038731500 2015-08-05 1 WENDY CAMPOS P00448102 5032421447 2013 2016-03-07 17:11:31Z RICHARD CAGEN 342 FAIRVIEW STREET SILVERTON OR 97381 125005171 0 X SILVERTONHEALTH.ORG X 1918 OR THROUGH SILVERTON HEALTH WE COME TOGETHER TO IMPROVE THE HEALTH OF OUR COMMUNITIES. RECOGNIZING OUR RESPONSIBILITY FOR CAREFUL USE OF RESOURCES, IT IS OUR MISSION TO ENCOURAGE WELLNESS AND DELIVER QUALITY HEALTH CARE, TO ORGANIZE OURSELVES AS A COLLABORATIVE TEAM FOSTERING INTEGRITY, ACCOUNTABILITY AND INNOVATION, AND TO CREATE AN ENVIRONMENT THAT PROMOTES COMPASSION AND RECOGNIZES THE DIGNITY OF ALL, WITH SENSITIVITY TO THE VALUES AND CULTURES OF THOSE WHO ENTRUST US WITH THEIR CARE. 13 12 959 206 396849 0 823174 409838 106948982 116976911 104438 -81620 3146163 7501465 111022757 124806594 211254 200809 0 0 63697974 64107123 0 0 0 49969274 60788346 113878502 125096278 -2855745 -289684 66076664 79417430 25674617 40636696 40402047 38780734 X THROUGH SILVERTON HEALTH WE COME TOGETHER TO IMPROVE THE HEALTH OF OUR COMMUNITIES. RECOGNIZING OUR RESPONSIBILITY FOR CAREFUL USE OF RESOURCES, IT IS OUR MISSON TO ENCOURAGE WELLNESS AND DELIVER QUALITY HEALTH CARE, TO ORGANIZE OURSELVES AS A COLLABORATIVE TEAM FOSTERING INTEGRITY, ACCOUNTABILITY AND INNOVATION, AND TO CREATE AN ENVIRONMENT THAT PROMOTES COMPASSION AND RECOGNIZES THE DIGNITY OF ALL, WITH SENSITIVITY TO THE VALUES AND CULTURES OF THOSE WHO ENTRUST US WITH THEIR CARE. 0 0 99364492 200809 124081527 GENERAL HOSPITAL INPATIENT AND OUTPATIENT CARE AND EDUCATION FOR PATIENTS IN THE LOCAL COMMUNITY, INCLUDING MEDICARE AND MEDICAID PATIENTS AND CHARITY CARE. CHARGES WRITTEN OFF DUE TO INADEQUATE REIMBURSEMENT - $63.9 MILLION. CHARGES FORGONE FOR CHARITY CARE - $7.2 MILLION. 99364492 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 1 117 0 1 959 1 1 1 0 0 0 0 0 0 0 0 0 X 13 12 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 0 OR X DAN JESSUP 5038731548 342 FAIRVIEW STREET SILVERTON OR 97381 GAYLE GOSCHIE CHAIRMAN 2.00 X X 0 0 0 DAVE BUCK VICE-CHAIR 2.00 X X 0 0 0 DARCY RUEF TREASURER 2.00 X X 0 0 0 BETH DAVISSON SECRETARY 2.00 X X 0 0 0 JOHN WEBSTER SECRETARY 2.00 X X 0 0 0 ELIZABETH BLOUNT BOARD MEMBER 2.00 2.00 X 0 0 0 MIKE DICKMAN BOARD MEMBER 2.00 X 0 0 0 ROBERT ENGLE BOARD MEMBER 2.00 2.00 X 0 0 0 ROBERTO FRANCO BOARD MEMBER 2.00 X 0 0 0 FRANK GOLDEN BOARD MEMBER 2.00 X 0 0 0 JANE JONES BOARD MEMBER 2.00 2.00 X 0 0 0 GARY SIMON BOARD MEMBER 2.00 X 0 0 0 JOHN ZIELINSKI BOARD MEMBER 2.00 X 0 0 0 BROOKE RENARD BOARD MEMBER 2.00 X 0 0 0 RICHARD CAGEN PRESIDENT 40.00 X 475569 0 19908 DAN JESSUP CFO 40.00 X 0 0 0 CHRISTINE DENNING COO 40.00 X 167120 0 25016 LINDA DAMIANO COO CLINICS 40.00 X 158528 0 29776 ROB JOHNSON EXECUTIVE VP 40.00 X 232265 0 28750 KAREN BRADY CIO 40.00 X 130660 0 10454 TERRI MERRITT-WORDEN VP HEALTH & WELLNESS 40.00 X 160089 0 32790 DAVID THORSETT DOCTOR 40.00 X 646175 0 33673 BRIAN PUSKAS DOCTOR 40.00 X 568287 0 23751 HARRIS WATERS DOCTOR 40.00 X 505737 0 10818 RICHARD BLOCK DOCTOR 40.00 X 446252 0 30296 MARC HOUSTON ASST MEDICAL DIRECTOR 36.00 X 408673 0 30316 3899355 0 275548 94 0 1 0 PROVIDENCE HEALTH SYSTEM-OREGON 1235 NE 47TH AVE SUITE 260 PORTLAND OR 97213 BILLING SERVICES 976592 PT NORTHWEST LLC 685 36TH AVE NE SALEM OR 97301 PATIENT SERVICES 914424 LEOPOLD KETEL LLC 112 SW FIRST AVE PORTLAND OR 97204 ADVERTISING 418908 RELAYHEALTH PO BOX 98347 CHICAGO IL 60693 BILLING SERVICES 315305 DELL MARKETING LP ONE DELL WAY ROUND ROCK TX 78682 COMPUTER/SOFTWARE MAINTENANCE 298949 24 314811 31301 63726 10090 409838 PATIENT SERVICES 621990 116976911 116976911 116976911 116957 116957 198577 -198577 -198577 -198577 OTHER OPERATING REVENUES 900099 6753064 6753064 PASSTHROUGH INCOME 900099 748401 351552 396849 7501465 124806594 124081527 396849 -81620 200809 200809 1448268 950860 497408 49809764 37357323 12452441 2021892 1516419 505473 7496412 5622309 1874103 3330787 2498090 832697 210136 210136 88620 88620 10238524 7678893 2559631 255399 255399 1147653 860740 286913 1105483 829112 276371 4465841 3349381 1116460 82203 61652 20551 150275 112706 37569 481482 481482 4120321 3090241 1030080 759823 759823 CAPITATED EXPENSE 15750483 15750483 SUPPLIES 11704829 8778622 2926207 CHARITY CARE 7245123 7245123 BAD DEBT EXPENSE 828899 828899 2153252 1895949 257303 125096278 99364492 25731786 0 5171615 10059656 15017008 14866578 108751 100000 1533228 1665612 1371871 1252281 80443690 45713903 36294846 34729787 100000 100000 6479345 16643516 66076664 79417430 12092528 20053871 6264423 5605989 7317666 14976836 25674617 40636696 X 40402047 38780734 40402047 38780734 66076664 79417430 X -289684 -2040 -1329589 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 197792 11400 15699 30641 194250 232087 1124 18362 53781 197792 263361 21602 52876 232087 171238 99785 -2104 5558 263361 107739 57837 11226 5564 171238 0.87090 0.12910 0.00000 1 1 1 2768949 2768949 36500954 17256055 19244899 812889 688155 124734 39713968 27769693 11944275 646930 646930 34729787 OTHER RECEIVABLES 2308536 OTHER ASSETS 11168047 ASSETS LIMITED AS TO USE 3166933 16643516 ESTIMATED MEDICAL MALPRACTICE LIABILITY 11456119 CAPITAL LEASE OBLIGATIONS 3520717 14976836 X PART V, LINE 4: ENDOWMENTS ARE HELD BY A RELATED ORGANIZATION, SILVERTON HEALTH FOUNDATION, FOR THE BENEFIT OF SILVERTON HEALTH. THE EARNINGS OF THE ENDOWMENT FUNDS ARE USED TO SUPPORT THE MISSION OF SILVERTON HEALTH. PART X, LINE 2: FIN 48 (ASC 740) FOOTNOTE - THE ORGANIZATION HAD NO UNRECOGNIZED TAX LIABILITIES AT SEPTEMBER 30, 2014 AND SEPTEMBER 30, 2013. THE ORGANIZATION RECOGNIZES INTEREST ACCRUED AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AS AN ADMINISTRATIVE EXPENSE. DURING THE YEARS ENDED SEPTEMBER 30, 2014 AND 2013, THE ORGANIZATION RECOGNIZED NO INTEREST AND PENALTIES. THE ORGANIZATION FILES AN EXEMPT ORGANIZATION INCOME TAX RETURN IN THE U.S. FEDERAL JURISDICTION AND UNRELATED BUSINESS INCOME TAX RETURNS IN THE U.S. FEDERAL JURISDICTION AND WITH THE OREGON DEPARTMENT OF REVENUE. 1 1 X 1 X 1 X 1 1 0 1 1 1400 3031411 58889 2972522 0.02390 30707 22855991 21578557 1277434 0.01030 0 32107 25887402 21637446 4249956 0.03420 18 18307 522288 171174 351114 0.00280 14 106 216454 216454 0.00170 18 10641 185314 185314 0.00150 50 29054 924056 171174 752882 0.00600 50 61161 26811458 21808620 5002838 0.04020 1 0 69 69 0.00000 4 652 14250 14250 0.00010 3 1272 11782 11782 0.00010 2 850 2760 2760 0.00000 4 583 53865 28879 24986 0.00020 14 3357 82726 28879 53847 0.00040 1 828899 18793849 24972220 -6178371 X 1 1 1 1 SILVERTON HOSPITAL 342 FAIRVIEW STREET SILVERTON OR 97381 X X X SILVERTON HOSPITAL 1 1 X X X X X X X X X 13 1 1 1 X HTTP://SILVERTONHEALTH.ORG/ X X X X X X X X 1 0 1 1 200.000000000000 1 300.000000000000 1 X X X X X 1 1 X X 1 X X X 1 X X X X X 1 X 0 0 SILVERTON HOSPITAL PART V, SECTION B, LINE 1J: SILVERTON HEALTH ACCOUNTABLE CARE PRIORITIES SILVERTON HOSPITAL PART V, SECTION B, LINE 3: COMMUNITY MEMBERS AND PARTNERS WERE INVITED TO CHIP MEETINGS, WITH OVER 60 PARTICIPANTS IN ATTENDANCE. SILVERTON HOSPITAL PART V, SECTION B, LINE 4: SALEM HEALTHSANTIAM HOSPITALMEMORIAL HOSPITAL SILVERTON HOSPITAL PART V, SECTION B, LINE 5D: PLACED AT CLINIC AND HOSPITAL RECEPTION DESKS. SILVERTON HOSPITAL PART V, SECTION B, LINE 12I: PATIENTS MUST LIVE IN THE SERVICE ARE OR BE PATIENTS OF SILVERTON HEALTH PCP. SILVERTON HOSPITAL PART V, SECTION B, LINE 20D: INITIALLY BILL BASED ON FULL CHARGES AND THEN PROVIDE A DISCOUNT BASED ON THE CHARITY CARE POLICY. 16 WOODBURN FAMILY MEDICINE 1475 MT HOOD AVE WOODBURN OR 97071 PRIMARY CARE CLINIC WOODBURN DIAGNOSTIC IMAGING 693 RAY J GLATT CIR WOODBURN OR 97071 OUTPATIENT CLINIC SH SPECIALISTS CLINIC 452 WELCH ST SILVERTON OR 97381 SPECIALISTS CLINIC MT ANGEL FAMILY MEDICINE 250 W MARQUAM ST MT ANGEL OR 97362 PRIMARY CARE CLINIC SILVERTON REHAB SERVICES 240 PHELPS ST SILVERTON OR 97381 OUTPATIENT CLINIC WOODBURN IMMEDIATE CARE 1475 MT HOOD AVE WOODBURN OR 97071 URGENT CARE CLINIC WOODBURN REHAB SERVICES 1475 MT HOOD AVE WOODBURN OR 97071 OUTPATIENT CLINIC WOODBURN GENERAL SURGERY 1475 MT HOOD AVE WOODBURN OR 97071 SPECIALISTS CLINIC MIDWIFERY & WOMENS WELLNESS 409 WELCH ST SILVERTON OR 97381 PRIMARY CARE CLINIC KEIZER HEALTH CENTER 5685 INLAND SHORES WAY N KEIZER OR 97303 PRIMARY CARE CLINIC SILVERTON FAMILY PHYSICIANS 347 FAIRVIEW ST SILVERTON OR 97381 PRIMARY CARE CLINIC SILVERTON INTERNAL MEDICINE 347 FAIRVIEW ST SILVERTON OR 97381 PRIMARY CARE CLINIC WOODBURN SURGERY CENTER 1475 MT HOOD AVE WOODBURN OR 97071 OUTPATIENT CLINIC WOODBURN STEPS 693 RAY J GLATT CIR WOODBURN OR 97071 OUTPATIENT CLINIC MCCLAINE STREET CLINIC 442 MCCLAINE ST SILVERTON OR 97381 PRIMARY CARE CLINIC TUKWILA MENTAL HEALTH 693 RAY J GLATT CIR WOODBURN OR 97071 OUTPATIENT CLINIC PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 828,899. PART II, COMMUNITY BUILDING ACTIVITIES: SILVERTON HEALTH'S COMMUNITY BUILDING ACTIVITIES PROMOTE COMMUNITY HEALTH IN MULTIPLE WAYS. OUR PARTICIPATION IN LOCAL CHAMBERS OF COMMERCE AND ECONOMIC DEVELOPMENT GROUPS HELPS SUPPORT THE GROWTH OF JOBS IN OUR COMMUNITY, ENABLING THE UNEMPLOYED TO FIND WORK, AND FROM THAT, THE ABILITY TO AFFORD HEALTHCARE AND FOOD/SHELTER FOR THEIR FAMILIES. IN ADDITION, SILVERTON HEALTH STAFF AND EMPLOYEES OFTEN PARTICIPATE IN HIGH SCHOOL CAREER FAIRS, ALLOW STUDENTS TO JOB SHADOW THEM, AND OFFER TOURS OF THE HOSPITAL TO YOUNG CHILDREN. THROUGH THIS PARTICIPATION, SILVERTON HEALTH HOPES TO ENCOURAGE STUDENTS TO GO TO COLLEGE AND POSSIBLY CONSIDER A CAREER IN THE HEALTHCARE FIELD, AS OUR STATE HAS A LARGE SHORTAGE IN THIS AREA. SILVERTON HEALTH ALSO SUPPORTS LOCAL SCHOOLS BY DONATING ROOM SPACE FOR MEETINGS AND TRAININGS, BY DONATING GIFT BASKETS TO HELP THE SCHOOLS RAISE MONEY, AND BY BEING RESPONSIVE WHEN NEEDS ARISE. BY SUPPORTING OUR LOCAL SCHOOLS, WE REDUCE THE GOVERNMENT BURDEN AND ALLOW THE SCHOOLS TO BETTER PROVIDE FOR THE YOUTH IN OUR COMMUNITY, INCLUDING OFFERING STUDENTS FOOD, SHELTER, EDUCATION, AND ASSISTANCE THEY MAY NOT RECEIVE AT HOME. SILVERTON HEALTH ALSO PLAYS A CRITICAL ROLE IN EMERGENCY MANAGEMENT FOR OUR RURAL AREA. SILVERTON HEALTH AND ITS STAFF ROUTINELY WORK WITH STATE, COUNTY, AND LOCAL ORGANIZATION STAFF TO TRAIN AND PREPARE FOR NATURAL DISASTERS, DISEASE OUTBREAKS, AND CASUALTIES OF MASS QUANTITIES. IN PREPARING OUR LOCAL ORGANIZATIONS AND CITIZENS FOR SUCH EVENTS BEFORE THEY HAPPEN, WE ENSURE ACCESS TO CARE IN CRITICAL TIMES AND GREATER EFFICIENCY IN TIMES OF TRAUMA. ADDITIONALLY, SILVERTON HEALTH MAKES DONATIONS TO HELP FUND PHYSICAL IMPROVEMENTS LIKE THE CONSTRUCTION OF A SENIOR CENTER IN SILVERTON AND THE CONSTRUCTION OF A WOODBURN BOYS AND GIRLS CLUB. THESE FACILITIES PROVIDE COMMUNITY MEMBERS SAFE SHELTER, PHYSICAL ACTIVITY, SOCIAL INTERACTION, SENSE OF COMMUNITY, AND SOMETIMES CLASSES OR MENTORING TO IMPROVE THEIR HEALTH. FINALLY, SILVERTON HEALTH PROVIDES MEETING SPACE AND DONATIONS TO GROUPS WHICH HELP KEEP DRIVERS SAFE (AARP DRIVER'S SAFETY CLASS) AND PROMOTE LITERACY (WOODBURN SCHOOL DISTRICT LITERACY PROGRAM) THEREBY PROVIDING LOCAL CITIZENS AND THEIR FAMILIES BETTER ACCESS TO CARE AND OVERALL HEALTH. PART III, LINE 4: THE ORGANIZATION UTILIZES A COST ACCOUNTING SYSTEM FOR DETERMINING THE ASSOCIATED COST OF PROVIDING SERVICES TO PATIENTS WITHOUT INSURANCE THAT ARE SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS. THAT PERCENTAGE IS THEN APPLIED TO THE TOTAL BAD DEBT EXPENSE PER THE GENERAL LEDGER (BASED ON CHARGES) TO DETERMINE THE ASSOCIATED COST. COLLECTIONS FROM THE PATIENT/GUARANTOR ARE NETTED AGAINST THAT COST TO DETERMINE A NET COST.ANY COLLECTIONS RECEIVED ON ACCOUNTS THAT WERE WRITTEN OFF TO BAD DEBT (EITHER PARTIALLY OR IN FULL) WERE NETTED AGAINST THE COST OF PROVIDING THE SERVICES TO THE PATIENT IN ORDER TO DETERMINE A NET COST.THE ORGANIZATION CURRENTLY DOES NOT HAVE THE SYSTEMS NECESSARY TO REASONABLY ESTIMATE THE AMOUNT OF BAD DEBT EXPENSE THAT COULD BE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY.THE HOSPITAL REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYORS, PATIENTS AND OTHERS. THE HOSPITAL PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS. AS A SERVICE TO THE PATIENT, THE HOSPITAL BILLS THIRD-PARTY PAYORS DIRECTLY AND BILLS THE PATIENT WHEN THE PATIENT'S LIABILITY IS DETERMINED. PATIENT ACCOUNTS RECEIVABLE ARE DUE IN FULL WHEN BILLED. ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT.THE FOOTNOTE THAT DISCUSSES BAD DEBT EXPENSE IS CONTAINED ON PAGE 10 OF THE ATTACHED FINANCIAL STATEMENTS, ENTITLED "PATIENT ACCOUNTS RECEIVABLE." PART III, LINE 8: SILVERTON HEALTH'S MISSION IS TO PROVIDE QUALITY HEALTHCARE SERVICES AND LEADERSHIP IN PROMOTING HEALTH IMPROVEMENT TO ALL PERSONS IN ITS SERVICE AREA ON A NON-DISCRIMINATORY BASIS AND WITHOUT REGARD TO ABILITY TO PAY. IN KEEPING WITH ITS COMMITMENT TO SERVE ALL MEMBERS OF THE COMMUNITY, THE HOSPITAL PROVIDES CARE TO INDIVIDUALS COVERED BY THE MEDICARE PROGRAM IN SPITE OF THE FACT THAT THE COST OF PROVIDING THOSE SERVICES EXCEEDS THE REVENUE RECEIVED. THE HOSPITAL ABSORBS THE SHORTFALL EACH YEAR, AND THIS CONTINUED COMMITMENT SHOULD BE TREATED AS A COMPONENT OF THE HOSPITAL'S COMMUNITY BENEFIT.THE ORGANIZATION UTILIZES A COST ACCOUNTING SYSTEM FOR DETERMINING THE ASSOCIATED COST OF PROVIDING SERVICES TO PATIENTS BY INDIVIDUAL PATIENT ACCOUNT. THE ACCOUNTS ARE THEN AGGREGATED FOR ALL PATIENT SEGMENTS BOTH BY TYPE OF SERVICE (INPATIENT, OUTPATIENT, EMERGENCY, ETC) AS WELL AS BY PAYOR (PRIVATE INSURANCE, MEDICARE, MEDICAID, SELF PAY, ETC) IN ORDER TO DETERMINE THE COST OF PROVIDING SERVICES TO ALL PATIENTS.THE COSTING METHODOLOGY USED FOR DETERMINING MEDICARE ALLOWABLE COSTS IS THAT REQUIRED BY CMS IN PREPARATION OF FORM CMS-2552. PART III, LINE 9B: SILVERTON HEALTH STRIVES TO PROVIDE ACCURATE AND TIMELY SERVICE WHEN BILLING AN INSURANCE COMPANY OR PATIENT DIRECTLY. EVERY BILL AND STATEMENT INCLUDES INFORMATION ABOUT HOW TO CONTACT FINANCIAL REPRESENTATIVES AND ARRANGE PAYMENT PLANS. WE ARE COMMITTED TO FINDING WAYS TO HELP EVERY PATIENT PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE RESPONSIBLE WITHOUT EXPERIENCING AN OVERWHELMING FINANCIAL BURDEN. IN ADDITION TO MAKING OUR BILLING PROCESS EASY TO UNDERSTAND AND ENSURING READY ACCESS TO CHARITY CARE AND FINANCIAL ASSISTANCE, WE ARE ABLE TO PROVIDE PATIENT COST INFORMATION IN ADVANCE OF SERVICES OR TREATMENT. PART VI, LINE 2: NEEDS ASSESSMENT - WE PURCHASED A PRODUCT FROM HEALTHY COMMUNITIES INSTITUTE WHICH PROVIDES HIGH-QUALITY COMMUNITY HEALTH ASSESSMENT DATA, IMPROVED HEALTH INDICATOR TRACKING, BEST PRACTICE SHARING AND COMMUNITY DEVELOPMENT TOOLS THAT FUNCTION TOGETHER TO HELP IMPROVE THE HEALTH AND ENVIRONMENTAL SUSTAINABILITY OF THE COMMUNITY. WE USED THE PRODUCT (WHICH HIGHLIGHTS BY COUNTY AND ZIPCODE) IN CONJUNCTION WITH COMMUNITY HEALTH WORK GROUPS WHICH WERE ASSEMBLED IN THREE AREAS OF OUR PSA: SALEM, SILVERTON AND WOODBURN. WE ALSO WORK WITH LOCAL NOT-FOR-PROFIT COMMUNITY ORGANIZATIONS AND LOCAL SCHOOLS TO IDENTIFY ADDITIONAL SMALLER NEEDS. FINALLY, WE RECEIVE DIRECT REQUESTS (VIA EMAIL, CALL, LETTER) FROM STATE, LOCAL, AND NOT-FOR-PROFIT GROUPS/ORGANIZATIONS ASKING US TO ASSIST THEM IN MEETING OTHER HEALTH AND COMMUNITY BUILDING NEEDS. PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE - ALL PATIENTS INQUIRING ABOUT FINANCIAL ASSISTANCE AND/OR CHARITY CARE ARE REFERRED TO THE FINANCIAL COUNSELORS WHERE THE PATIENT IS THEN PROVIDED WITH DETAILED INFORMATION ON THE APPLICATION AND REQUIREMENTS NEEDED TO SUPPORT CHARITY CARE ELIGIBILITY AND DETERMINATION. POLICIES EXIST BOTH IN WRITTEN AND ONLINE FORMATS. THE POLICY IS CURRENTLY AVAILABLE IN ENGLISH AND SPANISH. PART VI, LINE 4: COMMUNITY INFORMATION - SILVERTON HEALTH DEFINES ITS PRIMARY SERVICE AREA BY THE FOLLOWING ZIPCODES: 97381, 97362, 97071, 97038, 97375, 97026, 97032, 97301, 97302, 97303, 97305, 97373 AND 97317. THIS INCLUDES THE CITIES OF SILVERTON, MT. ANGEL, WOODBURN, GERVAIS, HUBBARD, SCOTTS MILLS, ST. BENEDICT, MOLALLA, KEIZER AND PARTS OF SALEM. THESE CITIES MAKE UP THE TOP 85% OF OUR TOTAL BUSINESS. OUR COVERAGE IS PRIMARILY IN MARION COUNTY BUT ALSO CLACKAMAS COUNTY (FOR MOLALLA). RESIDENTS OF OUR COMMUNITY ARE PRIMARILY CAUCASIAN AND HISPANIC. THERE IS A LARGE MIGRANT WORKER POPULATION IN THIS AREA AND SOME OF OUR SERVICE AREA INCLUDES MEDICALLY UNDERSERVED AREAS AS WELL AS HEALTH PROFESSIONAL SHORTAGE AREAS. IN ADDITION, WE HAVE AN UNCHARACTERISTICALLY LARGE POPULATION OF SENIORS IN SOME PORTIONS OF OUR SERVICE AREA, SPECIFICALLY IN WOODBURN AND THE SURROUNDING AREAS. PART VI, LINE 7, REPORTS FILED WITH STATES OR 1 KEIZER AREA CHAMBER OF COMMERCE 6075 ULALI DR NE SUITE 102 KEIZER OR 97303 936030759 501(C)(6) 12000 SPONSORSHIP OF COMMUNITY ACTIVITIES AND FESTIVALS AMERICAN CANCER SOCIETY - RELAY FOR LIFE PO BOX 22538 OKLAHOMA CITY OK 73123 841316555 501(C)(3) 9121 SPONSORSHIP OF A TEAM SALEM HOSPITAL FOUNDATION PO BOX 14001 SALEM OR 97309 237002687 501(C)(3) 9000 TO SUPPORT COMMUNITY NEEDS ASSESSMENT FOR OUR AREAS SALUD MEDICAL CENTER (YAKIMA VALLEY FARM WORKS CLINIC) 3896 BEVERLY AVE NE SALEM OR 97305 911019392 501(C)(3) 42432 COMMUNITY MEDICAL CARE BOYS & GIRLS CLUB-WOODBURN EXTENSION 1395 SUMMER ST NE SALEM OR 97303 930581470 501(C)(3) 5500 1075 FMV ROOM RENTALS PROVIDE MEETING SPACE TO PLAN COMMUNITY ACTIVITIES OREGON CHILD DEVELOPMENT COALITION PO BOX 2780 WILSONVILLE OR 97070 930591240 501(C)(3) 5675 FMV ROOM RENTALS PROVIDE MEETING SPACE TO PLAN COMMUNITY ACTIVITIES ROTARY INTERNATIONAL PO BOX 132 SILVERTON OR 97381 936032688 501(C)(4) 11000 FMV ROOM RENTALS PROVIDE MEETING SPACE TO PLAN COMMUNITY ACTIVITIES WOODBURN AREA CHAMBER OF COMMERCE PO BOX 194 WOODBURN OR 97071 936027273 501(C)(6) 7398 FMV ROOM RENTALS PROVIDE MEETING SPACE TO PLAN COMMUNITY ACTIVITIES KIWANIS INTERNATIONAL PO BOX 1046 WOODBURN OR 97071 936037102 501(C)(4) 15000 FMV ROOM RENTALS PROVIDE MEETING SPACE TO PLAN COMMUNITY ACTIVITIES ROTARY INTERNATIONAL PO BOX 247 WOODBURN OR 97071 936032666 501(C)(4) 15405 FMV ROOM RENTALS PROVIDE MEETING SPACE TO PLAN COMMUNITY ACTIVITIES 5 5 PART I, LINE 2: THE GRANTS AND ASSISTANCE PROVIDED TO LOCAL ORGANIZATIONS ARE CONSIDERED TO BE DONATION-TYPE CONTRIBUTIONS. SUCH CONTRIBUTIONS ARE GENERALLY MADE TO SECTION 501(C)(3) OR OTHER TAX-EXEMPT ORGANIZATIONS. X X X 1 0 0 0 0 0 0 0 0 RICHARD CAGEN PRESIDENT 296985 0 0 0 178584 0 4400 0 15508 0 495477 0 0 0 CHRISTINE DENNING COO 162120 0 5000 0 0 0 10909 0 14107 0 192136 0 0 0 LINDA DAMIANO COO CLINICS 135876 0 20989 0 1663 0 9717 0 20059 0 188304 0 0 0 ROB JOHNSON EXECUTIVE VP 211194 0 11398 0 9673 0 13200 0 15550 0 261015 0 0 0 TERRI MERRITT-WORDEN VP HEALTH & WELLNESS 141368 0 0 0 18721 0 8643 0 24147 0 192879 0 0 0 DAVID THORSETT DOCTOR 602306 0 43869 0 0 0 13200 0 20473 0 679848 0 0 0 BRIAN PUSKAS DOCTOR 411544 0 156743 0 0 0 3929 0 19822 0 592038 0 0 0 HARRIS WATERS DOCTOR 350637 0 155100 0 0 0 0 0 10818 0 516555 0 0 0 RICHARD BLOCK DOCTOR 446252 0 0 0 0 0 13200 0 17096 0 476548 0 0 0 MARC HOUSTON ASST MEDICAL DIRECTOR 408673 0 0 0 0 0 9843 0 20473 0 438989 0 0 0 PART I, LINE 4A TERRI MERRITT-WORDEN - A SEVERANCE AGREEMENT WAS ENTERED INTO FOR THE PERIOD OF NOVEMBER 2013 THROUGH SEPTEMBER 2014 AFTER EMPLOYEE WAS TERMINATED. A HOSPITAL FACILITY AUTHORITY - SILVERTONOR 931074291 2006-10-26 10097600 CAPITAL IMPROVEMENTS AND EQUIPMENT ACQUISITIONS 0 0 0 A 4491611 10097600 97600 6033330 3966670 2008 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 1 0 0 0 0 0 0 A 0 DAN JESSUP HOSPITAL CFO/EMPLOYEE OF MANAGEMENT COMPANY PROVIDING SERVICES TO HOSPITAL 274692 DAN JESSUP IS THE CFO OF THE HOSPITAL BY CONTRACT WITH A THIRD-PARTY MANAGEMENT COMPANY AND IS AN EMPLOYEE OF THAT MANAGEMENT COMPANY; THE MANAGEMENT COMPANY PROVIDES VARIOUS SERVICES TO THE HOSPITAL, WHICH INCLUDE THE CFO POSITION. THE TRANSACTION AMOUNT IS THE AMOUNT THE HOSPITAL PAID THE MANAGEMENT COMPANY FOR FINANCIAL SERVICES. 0 ROBERT ENGLE HOSPITAL BOARD MEMBER/OWNER OF PARTNERSHIPS LEASING PROPERTY TO HOSPITAL 2440158 ROBERT ENGLE IS A GREATER THAN 5% OWNER OF 3 PARTNERSHIPS, WHICH EACH LEASE PROPERTY TO THE HOSPITAL. THE TRANSACTION AMOUNT IS TOTAL LEASE PAYMENTS PAID TO THE 3 PARTNERSHIPS DURING THE FISCAL YEAR. 0 FORM 990, PART VI, SECTION A, LINE 3 THE HOSPITAL CONTRACTS WITH A THIRD-PARTY NONPROFIT CORPORATION TO PROVIDE VARIOUS MANAGEMENT SERVICES, INCLUDING FINANCIAL SERVICES (INCLUDING THE CFO POSITION), GROUP PURCHASING AND PATIENT ACCOUNTING SERVICES. FORM 990, PART VI, SECTION B, LINE 11 FORM 990 IS REVIEWED IN DETAIL BY THE CONTROLLER AND CFO AND APPROVED BY THE CEO. FORM 990 IS E-MAILED TO THE GOVERNING BOARD PRIOR TO FILING FOR REVIEW AND APPROVAL. IT IS THEN PRESENTED BY THE CFO TO THE FULL GOVERNING BOARD DURING AN EXECUTIVE SESSION OF THE REGULAR BOARD MEETING AT A LATER TIME. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY IS SENT OUT ANNUALLY FOR OFFICERS, DIRECTORS, TRUSTEES AND KEY EMPLOYEES TO REVIEW THE POLICY AND COMPLETE THE CONFLICT OF INTEREST STATEMENT. ANY CONFLICTS ARE DISCLOSED TO THE BOARD AND THE BOARD VOTES ON WHETHER OR NOT A CONFLICT EXISTS. IF A CONFLICT DOES EXIST, A DIFFERENT ALTERNATIVE WILL BE LOOKED AT WITH POSSIBLY AN EXTERNAL PARTY TO AVOID A CONFLICT. IF NONE EXISTS, THE BOARD SHALL DETERMINE BY MAJORITY VOTE WHETHER THE TRANSACTION IS IN THE ORGANIZATION'S BEST INTEREST AND FAIR AND REASONABLE AND WILL MAKE A DETERMINATION AS TO WHETHER TO ENTER INTO THE TRANSACTION. FORM 990, PART VI, SECTION B, LINE 15 LEGAL COUNSEL DEVELOPED A PROCESS TO DETERMINE COMPENSATION OF THE CEO, WHICH INCLUDES COMPARABILITY DATA AND DEVELOPMENT OF A COMPENSATION GRID. COMPARABILITY DATA WAS USED FROM NORTHWEST EXECUTIVE COMPENSATION SURVEY AND A STANDARD PROCESS WAS FOLLOWED IN DETERMINING COMPENSATION FOR KEY EMPLOYEES, WHEREIN JOBS ARE EVALUATED BY THE HUMAN RESOURCES DEPARTMENT USING SURVEY DATA AND INTERNAL EQUITY TO DETERMINE THE SLOTTING OF JOBS INTO ESTABLISHED PAY GRADES. WHEN EVALUATING A PAY GRADE THE 50TH PERCENTILE ON A SALARY SURVEY IS USED AS A STARTING PLACE FOR MIDPOINT TO DETERMINE IF THE RANGE IS APPROPRIATE. WITHIN A PAY GRADE WE THEN USE ESTABLISHED PAY GUIDELINES TO HELP US DETERMINE AT WHICH POINT IN THE PAY GRADE WE PLACE AN EMPLOYEE. THE GUIDELINES PROVIDE RECOMMENDED PERCENTAGE POINTS ABOVE MINIMUM - BASED ON EDUCATION, TRAINING, CERTIFICATION AND SKILL SETS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: BOOK/TAX DIFFERENCE FROM PASSTHROUGH INVESTMENT INCOME -1,329,589. SILVERTON HEALTH FOUNDATION 342 FAIRVIEW STREET SILVERTON OR 97381 930913392 TO PROVIDE SUPPORT FOR SILVERTON HEALTH'S CHARITABLE ACTIVITIES OR 501(C)(3) 170(B)(1) (A)(VI) SILVERTON HEALTH 0 MID-VALLEY MEDICAL MANAGEMENT COMPANY LLC 342 FAIRVIEW STREET SILVERTON OR 97381 800612509 MANAGEMENT OF CATH LAB AT SILVERTON HEALTH OR SILVERTON HEALTH RELATED 439955 0 0 0.51000 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 MID-VALLEY MEDICAL MANAGEMENT COMPANY LLC S 467012 CASH TRANSFERRED