2015-05-12T12:31:23-05:00 2014-06-30 990 2013-07-01 271789847 SAINT ALPHONSUS MEDICAL CENTER - ONTARIO INC SAIN 5418817295 351 SW 9TH STREET ONTARIO OR 979142639 BLAINE PETERSEN CFO SAINT ALPHONSUS HEALTH SYS 5418817295 2015-05-12 2013 2016-03-07 17:11:31Z SEE SCHEDULE O KARL KEELER 351 SW 9TH STREET ONTARIO OR 979142639 64940427 0 0928 X WWW.SAINTALPHONSUS.ORG/ONTARIO X 2010 OR HEALTHCARE SERVICES 13 11 678 62 82121 0 138848 99494 60562772 60796575 868301 757274 2100243 3241988 63670164 64895331 167324 160485 0 0 32628952 30384298 0 0 180869 33072707 35259318 65868983 65804101 -2198819 -908770 59901421 59024174 33180308 32463927 26721113 26560247 HEALTHCARE SERVICES - SEE LINE 4 AND SCHEDULE H FOR ADDITIONAL INFORMATION 0 0 55102266 160485 63144692 SAINT ALPHONSUS MEDICAL CENTER - ONTARIO IS A 48-BED, ACUTE CARE HOSPITAL SERVING ONTARIO AND THE SURROUNDING COMMUNITIES IN EASTERN OREGON AND SOUTHWESTERN IDAHO. THE MISSION STATEMENT OF SAINT ALPHONSUS MEDICAL CENTER - ONTARIO IS AS FOLLOWS:WE, SAINT ALPHONSUS MEDICAL CENTER - ONTARIO, AND TRINITY HEALTH, SERVE TOGETHER IN THE SPIRIT OF THE GOSPEL AS A COMPASSIONATE AND TRANSFORMING HEALING PRESENCE WITHIN OUR COMMUNITIES. 55102266 1 1 0 1 0 0 0 0 0 0 1 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 1 0 0 1 0 0 0 0 0 1 1 1 1 0 0 1 168 0 1 678 1 1 1 0 0 0 0 0 0 0 0 0 X 13 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 OR X BRENT CHERNE CONTROLLER 2083677192 6301 EMERALD ST BOISE ID 83706 SALLY JEFFCOAT TRUSTEE; PRES & CEO IDAHO OREGON REG 1.00 54.00 X X 0 1050502 98506 RONALD GRAVES TRUSTEE; CHAIR 1.00 4.00 X X 0 0 0 MIKE REULING TRUSTEE; VICE CHAIR 1.00 4.00 X X 0 0 0 GEORGE JUETTEN TRUSTEE 1.00 4.00 X 0 0 0 J RICHARD O'CONNELL TRUSTEE; EVP & PRES WEST/MIDWEST GRP 1.00 54.00 X 0 1673574 145485 KAYE O'RIORDAN TRUSTEE 1.00 4.00 X 0 0 0 SR SHARLET WAGNER CSC TRUSTEE 1.00 4.00 X 0 0 0 SR SHARON FORD RSM TRUSTEE 1.00 4.00 X 0 0 0 VICTOR YAMAMOTO TRUSTEE 1.00 4.00 X 0 0 0 JON WAGNILD MD TRUSTEE 1.00 4.00 X 0 0 0 MATTHEW SHIRTCLIFF TRUSTEE 1.00 4.00 X 0 0 0 DARREL ANDERSON TRUSTEE 1.00 4.00 X 0 0 0 ANDREW BENTZ TRUSTEE THROUGH 12/13 1.00 4.00 X 0 0 0 DON ROUMAGOUX TRUSTEE AS OF 1/14 1.00 4.00 X 0 0 0 STEPHANIE WESTERMEIER SECRETARY; VP & GENERAL COUNSEL 1.00 49.00 X 0 286845 33328 BLAINE PETERSEN TREASURER AND SYSTEM CFO 1.00 49.00 X 0 473321 35641 KARL KEELER SAMC NAMPA & ONTARIO CEO 24.00 26.00 X 0 532654 46366 B LANNIE CHECKETTS SAMC NAMPA & ONTARIO CFO AT 9/13 24.00 26.00 X 0 262359 44305 JEAN BASOM REGIONAL DIRECTOR SUPPLY CHAIN 1.00 49.00 X 0 171192 61870 RODNEY REIDER SARMC PRESIDENT AND CEO 1.00 49.00 X 0 599714 73507 JAMES POLK SAHS, CHIEF QUALITY OFFICER 1.00 49.00 X 0 487941 44778 PAUL VACHEK CFO THROUGH 9/13 48.00 2.00 X 185409 0 29936 RICHARD PALAGI CEO THROUGH 1/14 48.00 2.00 X 0 506373 35700 GUILLERMO GUZMAN TREVINO MD PHYSICIAN 50.00 0.00 X 447300 0 27411 PAMELA BRUCE MD SURGEON 50.00 0.00 X 360716 0 35740 FRANK SPOKAS MD SURGEON 50.00 0.00 X 323299 0 31820 MARK CHRISTENSON MD PHYSICIAN 50.00 0.00 X 244439 0 28042 JOHN HANSILL MD SURGEON 50.00 0.00 X 224770 0 4828 KEDRICK ADKINS FORMER KEY EMPLOYEE 0.00 0.00 X 0 1808589 1739236 JOSEPH SWEDISH FORMER KEY EMPLOYEE 0.00 0.00 X 0 1463995 28888 MICHAEL SLUBOWSKI FORMER KEY EMPLOYEE 0.00 0.00 X 0 231799 0 1785933 9548858 2545387 26 1 1 0 ONTARIO EMERGENCY SPECIALISTS 351 SW 9TH ONTARIO OR 97914 EMERGENCY ROOM PHYSICIAN STAFFING 1918216 STRATEGIC STAFFING SOLUTIONS 645 GRISWOLD STE 2900 DETROIT MI 78226 STAFFING SERVICES 800757 REHABILITATION MGMT ASSO 901 N CURTIS 204 BOISE ID 83706 REHAB STAFFING 546840 APOGEE MEDICAL MANAGEMENT 2525 E CAMELBACK RD STE 1100 PHOENIX AZ 85016 PHYSICIAN SERVICES 315344 COMMERCIAL CONSTRUCTION 5030 FREEMONT RD NEW PLYMOUTH ID 83655 CONSTRUCTION SERVICES 269966 14 5082 94412 99494 NET PATIENT SVC REV 622110 60796575 60796575 60796575 226339 226339 328210 31786 296424 296424 296424 380732 163513 0 13310 380732 150203 530935 530935 GOV'T SUBSIDY-EHR 622110 1795767 1795767 CAFETERIA REVENUE 722514 289395 289395 PHARMACY REVENUE 446110 225931 225931 634471 552350 82121 2945564 64895331 63144692 82121 1569024 160485 160485 757419 757419 55832 55832 23890470 22819259 938490 132721 1012665 959986 47107 5572 2747724 2591562 141071 15091 1920188 1599357 311339 9492 974 974 4449 4449 22423 22423 5998646 5451903 542640 4103 190800 3317 181851 5632 1260032 1152073 103380 4579 2476613 49732 2426881 1760848 1534091 226757 132754 117529 13083 2142 19072 12554 6222 296 888531 888531 3463758 3010022 453736 413714 115191 298523 MEDICAL SUPPLIES 7340696 7340696 0 0 INTERCO. PURCHASED SVCS 4659975 1325104 3334871 0 BAD DEBT 3964388 3964388 0 0 UBI TAXES 59542 0 59542 0 2602103 1950654 650208 1241 65804101 55102266 10520966 180869 134622 1184063 100228 9707905 10543987 49726 110769 186555 139893 1449912 1226159 171497 154232 36644376 7862404 30167686 28781972 8835966 8102503 8489456 7185238 607868 1595358 59901421 59024174 9399604 8742558 22336 305508 738775 23452860 22982594 33180308 32463927 X 26620885 26560247 100228 0 26721113 26560247 59901421 59024174 X -908770 749872 -1968 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 9777 0 0 0 9777 0 PART II-B, LINE 1: SAINT ALPHONSUS MEDICAL CENTER-ONTARIO, INC. (SAMC-ONTARIO) HAS MADE GRANTS TO OTHER ORGANIZATIONS FOR LOBBYING PURPOSES. THESE GRANTS HAVE BEEN IN THE FORM OF MEMBERSHIP DUES PAID TO REGIONAL AND NATIONAL HEALTH CARE ORGANIZATIONS, WHERE THE ORGANIZATIONS HAVE PROVIDED SAMC-ONTARIO WITH AN ESTIMATED PERCENTAGE OF DUES PAYMENTS WHICH ARE USED FOR LOBBYING ACTIVITIES. SAMC-ONTARIO MADE NO CONTRIBUTIONS TO ANY LEGISLATORS OR CANDIDATES. 1158775 1158775 22537923 3662212 18875711 12069601 4200192 7869409 878077 878077 28781972 COMMINGLED FUNDS DIRECTLY HOLDING SECURITIES 1528774 F EQUITY METHOD INVESTMENTS 3363303 C HEDGE FUNDS 2293161 F 7185238 INTERCOMPANY NOTES PAYABLE 21916488 INTERCOMPANY ACCOUNTS PAYABLE 692552 ASSET RETIREMENT OBLIGATION(FIN 47) 373554 22982594 1 1 X 1 X 1 X 1 1 0 1 1 1648 2348672 2348672 0.03800 16 9735 12858078 10589323 2268755 0.03670 16 11383 15206750 10589323 4617427 0.07470 4 10487 81564 81564 0.00130 1 8 3526 3526 0.00010 1 110 73330 73330 0.00120 6 1853 131994 3531 128463 0.00210 12 12458 290414 3531 286883 0.00470 28 23841 15497164 10592854 4904310 0.07940 2 381 6610 6610 0.00010 1 630 13943 13943 0.00020 3 1011 20553 20553 0.00030 0 1694900 15220569 17832372 -2611803 X 1 1 1 1 ST ALPHONSUS MEDICAL CENTER - ONTARIO 351 SW 9TH ST ONTARIO OR 97914 HTTP://WWW.SAINTALPHONSUS.ORG/ONTARIO LICENSE 14- X X X ST ALPHONSUS MEDICAL CENTER - ONTARIO 1 1 X X X X X X X X X 13 1 0 1 X SEE SCHEDULE H, PART V, SECTION C X X X X X X X X X 0 0 1 1 200.000000000000 1 300.000000000000 1 X X X X X X X 1 1 X X X 1 0 X X X X 1 X 0 0 ST. ALPHONSUS MEDICAL CENTER - ONTARIO PART V, SECTION B, LINE 3: IN 2014, SAINT ALPHONSUS MEDICAL CENTER - ONTARIO CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSMENT TO DETERMINE THE STATE OF THE COMMUNITY IT SERVES. THIS SURVEY WAS CONDUCTED DURING THE PERIOD FROM FEBRUARY OF 2014 THROUGH MAY OF 2014 AND USED A WIDE VARIETY OF PRIMARY AND SECONDARY SOURCES TO OBTAIN A BROAD OVERVIEW OF INFORMATION. PRIMARY SOURCES: DATA WAS OBTAINED THROUGH COMMUNITY SURVEYS IN OREGON AND IDAHO. IN ORDER TO PROVIDE CONTINUITY OF INFORMATION THROUGHOUT THE SAINT ALPHONSUS HEALTH SYSTEM, ONE COMMUNITY SURVEY WAS UTILIZED FOR THE COMMUNITY HEALTH NEEDS ASSESSMENTS (CHNA) CONDUCTED IN ADA, CANYON AND GEM COUNTIES BY UNITED WAY OF TREASURE VALLEY AND THE UTAH FOUNDATION, AS WELL AS THE NEEDS ASSESSMENT CONDUCTED IN MALHEUR, PAYETTE AND WASHINGTON COUNTIES FOR SAINT ALPHONSUS MEDICAL CENTER - ONTARIO. THE SURVEY WAS DEVELOPED BY THE UNITED WAY OF TREASURE VALLEY WITH COMMUNITY ADVICE ON A NUMBER OF INDICATORS TO BEST DESCRIBE THE OVERALL HEALTH OF THE COMMUNITIES BEING SURVEYED. THE INDICATORS ARE GROUPED INTO FOUR CATEGORIES: FINANCIAL STABILITY AND INDEPENDENCE, SUCCESS IN EDUCATION, LIVING HEALTHY LIVES, AND ACCESS TO BASIC SERVICES.WHILE THE INDICATORS ARE GROUPED INTO CATEGORIES, MANY OF THE INDICATORS AND BARRIERS IDENTIFIED HAVE IMPLICATIONS IN OTHER CATEGORIES. THESE OVER-ARCHING BARRIERS TEND TO BE SOCIAL DETERMINANTS OF POPULATION HEALTH SUCH AS WAGE AND JOB OPPORTUNITIES, POVERTY, EDUCATIONAL ATTAINMENT, AVAILABILITY OF HEALTHY FOODS AND EXERCISE OPPORTUNITIES, AND ACCESS TO BASIC SERVICES. PAYING INCREASED ATTENTION TO THESE SOCIAL DETERMINANTS OF HEALTH REPRESENTS A FUNDAMENTAL SHIFT IN APPROACHING IMPROVEMENTS IN THE OVERALL HEALTH OF COMMUNITIES. ADMINISTERING THE SURVEY WAS ACCOMPLISHED THROUGH A VARIETY OF METHODS AIMED AT GETTING THE MOST DIVERSE CROSS-SECTION OF RESPONDENTS WITH RESPECT TO THOSE TYPICALLY AT RISK IN OUR COMMUNITIES INCLUDING PEOPLE WHO ARE POOR, SINGLE PARENTS, THE ELDERLY, LIMITED ENGLISH PROFICIENT PEOPLE, PEOPLE WITH LOW LEVELS OF LITERACY AND EDUCATION, RACIAL MINORITIES AND PEOPLE WITH UNDOCUMENTED RESIDENCY STATUS. SURVEYS WERE ADMINISTERED THROUGH PARTNERSHIPS WITH SERVICE AGENCIES AND COMMUNITY EXPERTS SUCH AS WICAP (WESTERN IDAHO COMMUNITY ACTION PARTNERSHIP, INC.), SENIOR CENTERS, SCHOOL DISTRICTS, FOOD PANTRIES, AND HEALTH CARE PROVIDERS. THE SURVEY WAS ADMINISTERED IN ENGLISH AND SPANISH, AS WELL AS ORALLY. THE SURVEY WAS ADMINISTERED IN A VARIETY OF SETTINGS, INCLUDING HEALTH CARE WAITING ROOMS, COMMUNITY EVENTS, SCHOOL FAIRS, CLIENT-BASED SERVICE SETTINGS, AND AREAS WHERE PEOPLE FROM UNDER-SERVED POPULATIONS TEND TO VISIT SUCH AS LAUNDROMATS, SENIOR CENTERS, SERVICE AGENCIES, LIBRARIES AND FOOD KITCHENS. COMMUNITY EXPERTS AND SERVICE AGENCIES PROVIDED MUCH INPUT THROUGH SURVEY WORK, DISCUSSIONS AND REVIEW OF THE NEEDS ASSESSMENT AND FINDINGS. THIS WORK OCCURRED DURING THE TIME PERIOD OF MARCH THROUGH MAY DURING THE SURVEY PERIOD AS WELL AS IN JUNE DURING DEVELOPMENT OF THE FINAL COMMUNITY HEALTH NEEDS ASSESSMENT. ST. ALPHONSUS MEDICAL CENTER - ONTARIO PART V, SECTION B, LINE 5D: LINE 5A: HTTP://WWW.SAINTALPHONSUS.ORG/COMMUNITY-NEEDS-ASSESSMENT ST. ALPHONSUS MEDICAL CENTER - ONTARIO PART V, SECTION B, LINE 7: SAINT ALPHONSUS MEDICAL CENTER - ONTARIO (SAMC - ONTARIO) DETERMINED THAT IT COULD EFFECTIVELY FOCUS ON ONLY THOSE HEALTH NEEDS WHICH IT DEEMED MOST PRESSING, UNDER-ADDRESSED, AND WITHIN ITS ABILITY TO INFLUENCE. SAMC - ONTARIO WILL NOT TAKE ACTION ON INJURY AND VIOLENCE PREVENTION, DUE TO LIMITED RESOURCES AND LOWER PRIORITY. FURTHERMORE, THE COUNTY HEALTH DEPARTMENT AND OTHER COMMUNITY ORGANIZATIONS ARE ADDRESSING THIS SPECIFIC NEED.SAMC - ONTARIO WILL ALSO NOT TAKE ACTION ON FINANCIAL STABILITY BECAUSE SAMC - ONTARIO BELIEVES THAT WHILE WE CANNOT DIRECTLY IMPACT THE FINANCIAL STABILITY OF THE COMMUNITY, WE CAN FOCUS EFFORTS ON ASSISTING THE COMMUNITY WITH ACCESS TO AFFORDABLE HEALTH CARE, ASSISTANCE WITH OBTAINING INSURANCE, DEVELOPMENT OF CAREER ADVANCEMENT PROGRAMS AND TUITION ASSISTANCE. ST. ALPHONSUS MEDICAL CENTER - ONTARIO PART V, SECTION B, LINE 12I: THE HOSPITAL RECOGNIZES THAT NOT ALL PATIENTS ARE ABLE TO PROVIDE COMPLETE FINANCIAL AND/OR SOCIAL INFORMATION. THEREFORE, APPROVAL FOR FINANCIAL SUPPORT MAY BE DETERMINED BASED ON AVAILABLE INFORMATION. EXAMPLES OF PRESUMPTIVE CASES INCLUDE: DECEASED PATIENTS WITH NO KNOWN ESTATE, THE HOMELESS, UNEMPLOYED PATIENTS, NON-COVERED MEDICALLY NECESSARY SERVICES PROVIDED TO PATIENTS QUALIFYING FOR PUBLIC ASSISTANCE PROGRAMS, PATIENT BANKRUPTCIES, AND MEMBERS OF RELIGIOUS ORGANIZATIONS WHO HAVE TAKEN A VOW OF POVERTY AND HAVE NO RESOURCES INDIVIDUALLY OR THROUGH THE RELIGIOUS ORDER.FOR THE PURPOSE OF HELPING FINANCIALLY NEEDY PATIENTS, A THIRD PARTY IS UTILIZED TO CONDUCT A REVIEW OF PATIENT INFORMATION TO ASSESS FINANCIAL NEED. THIS REVIEW UTILIZES A HEALTHCARE INDUSTRY-RECOGNIZED, PREDICTIVE MODEL THAT IS BASED ON PUBLIC RECORD DATABASES. THESE PUBLIC RECORDS ENABLE THE HOSPITAL TO ASSESS WHETHER THE PATIENT IS CHARACTERISTIC OF OTHER PATIENTS WHO HAVE HISTORICALLY QUALIFIED FOR FINANCIAL ASSISTANCE UNDER THE TRADITIONAL APPLICATION PROCESS. IN CASES WHERE THERE IS AN ABSENCE OF INFORMATION PROVIDED DIRECTLY BY THE PATIENT, AND AFTER EFFORTS TO CONFIRM COVERAGE AVAILABILITY, THE PREDICTIVE MODEL PROVIDES A SYSTEMATIC METHOD TO GRANT PRESUMPTIVE ELIGIBILITY TO FINANCIALLY NEEDY PATIENTS. ST. ALPHONSUS MEDICAL CENTER - ONTARIO PART V, SECTION B, LINE 14G: DUE TO THE COMPLEXITY OF THE POLICY, COPIES OF THE FULL POLICY ARE ONLY PROVIDED ON REQUEST AND ON ADMISSION. BROCHURES ARE AVAILABLE AT ALL REGISTRATION AREAS, WAITING ROOMS, CUSTOMER SERVICE AND FINANCIAL COUNSELING. POLICY AND FORMS ARE AVAILABLE FROM FINANCIAL ADVOCATE OFFICE, ALL REGISTRATION AREAS, AND THE REGIONAL SHARED SERVICES CENTER. INFORMATION ABOUT FINANCIAL ASSISTANCE IS PROVIDED DURING ENCOUNTERS WITH FINANCIAL ADVOCATES AND UPON REQUEST TO REGISTRARS, CUSTOMER SERVICE REPRESENTATIVES AT THE REGIONAL SHARED SERVICES CENTER AND THE BILLING COMPANY. BILLING STATEMENTS REFERENCE THE AVAILABILITY OF THE POLICY FOR THOSE UNABLE TO PAY. SUMMARY INFORMATION AND APPLICATION AVAILABLE ON WEBSITE: HTTP://WWW.SAINTALPHONSUS.ORG/FINANCIAL-SERVICES-2133 ST. ALPHONSUS MEDICAL CENTER - ONTARIO PART V, SECTION B, LINE 20D: PATIENTS WITH INCOME AT OR BELOW 200% OF THE FEDERAL POVERTY GUIDELINES (FPG) ARE ELIGIBLE FOR 100% CHARITY CARE WRITE OFF OF THE CHARGES FOR MEDICALLY NECESSARY SERVICES. PATIENTS WITH INCOME BETWEEN 201% AND 300% OF THE FPG RECEIVE A WRITE OFF OF HOSPITAL CHARGES FOR MEDICALLY NECESSARY SERVICES EQUAL TO THE HOSPITAL'S AVERAGE COMMERCIAL CONTRACTUAL ADJUSTMENT FOR ALL COMMERCIAL PAYERS. 2 FRUITLAND HEALTH PLAZA 910 NW 16TH STREET FRUITLAND ID 83619 FAMILY MEDICINE NEW PLYMOUTH CLINIC 213 N PLYMOUTH AVE NEW PLYMOUTH ID 83655 FAMILY MEDICINE PART I, LINE 3C: IN ADDITION TO LOOKING AT A MULTIPLE OF THE FEDERAL POVERTY GUIDELINES, OTHER FACTORS ARE CONSIDERED SUCH AS THE PATIENT'S FINANCIAL STATUS AND/OR ABILITY TO PAY AS DETERMINED THROUGH THE ASSESSMENT PROCESS. PART I, LINE 6A: SAINT ALPHONSUS MEDICAL CENTER - ONTARIO PREPARES AN ANNUAL COMMUNITY BENEFIT REPORT, WHICH IT SUBMITS TO THE STATE OF OREGON. IN ADDITION, SAINT ALPHONSUS MEDICAL CENTER - ONTARIO REPORTS ITS COMMUNITY BENEFIT INFORMATION AS PART OF THE CONSOLIDATED COMMUNITY BENEFIT INFORMATION REPORTED BY TRINITY HEALTH (EIN 35-1443425) IN ITS AUDTIED FINANCIAL STATEMENTS, AVAILABLE AT WWW.TRINITY-HEALTH.ORG.IN ADDITION, SAINT ALPHONSUS MEDICAL CENTER - ONTARIO INCLUDES A COPY OF ITS MOST RECENTLY FILED SCHEDULE H ON BOTH ITS OWN WEBSITE AND TRINITY HEALTH'S WEBSITE. PART I, LINE 7: THE BEST AVAILABLE DATA WAS USED TO CALCULATE THE COST AMOUNTS REPORTED IN ITEM 7. FOR CERTAIN CATEGORIES, PRIMARILY TOTAL CHARITY CARE AND MEANS-TESTED GOVERNMENT PROGRAMS, SPECIFIC COST-TO-CHARGE RATIOS WERE CALCULATED AND APPLIED TO THOSE CATEGORIES. THE COST-TO-CHARGE RATIO WAS DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES. IN OTHER CATEGORIES, THE BEST AVAILABLE DATA WAS DERIVED FROM THE HOSPITAL'S COST ACCOUNTING SYSTEM. PART I, LN 7 COL(F): THE FOLLOWING NUMBER, $3,964,388, REPRESENTS THE AMOUNT OF BAD DEBT EXPENSE INCLUDED IN TOTAL FUNCTIONAL EXPENSES IN FORM 990, PART IX, LINE 25. PER IRS INSTRUCTIONS, THIS AMOUNT WAS EXCLUDED FROM THE DENOMINATOR WHEN CALCULATING THE PERCENT OF TOTAL EXPENSE FOR SCHEDULE H, PART I, LINE 7, COLUMN (F). PART II, COMMUNITY BUILDING ACTIVITIES: COMMUNITY BUILDING ACTIVITIES AS AN AREA OF DECREASED EDUCATIONAL OPPORTUNITIES, SAINT ALPHONSUS MEDICAL CENTER - ONTARIO HAS BEEN WORKING WITH OTHER EDUCATIONAL INSTITUTIONS TO INCREASE COMMUNITY HEALTH EDUCATION, SUCCESS IN EDUCATION, AND CONTINUE WITH PHYSICIAN RECRUITING IN OUR AREA. PART III, LINE 2: METHODOLOGY USED FOR LINE 2 - BAD DEBT EXPENSE REPORTED ON LINE 2 IS SHOWN AT COST AND WAS CALCULATED USING A COST TO CHARGE RATIO METHODOLOGY.ANY DISCOUNTS PROVIDED OR PAYMENTS MADE TO A PARTICULAR PATIENT ACCOUNT ARE APPLIED TO THAT PATIENT ACCOUNT PRIOR TO ANY BAD DEBT WRITE-OFF AND ARE THUS NOT INCLUDED IN BAD DEBT EXPENSE. AS A RESULT OF THE PAYMENT AND ADJUSTMENT ACTIVITY BEING POSTED TO BAD DEBT ACCOUNTS, WE ARE ABLE TO REPORT BAD DEBT EXPENSE NET OF THESE TRANSACTIONS. PART III, LINE 3: SAINT ALPHONSUS MEDICAL CENTER - ONTARIO USES A PREDICTIVE MODEL THAT INCORPORATES THREE DISTINCT VARIABLES IN COMBINATION TO PREDICT WHETHER A PATIENT QUALIFIES FOR CHARITY: (1) SOCIO-ECONOMIC SCORE, (2) ESTIMATED FEDERAL POVERTY LEVEL (FPL), AND (3) HOMEOWNERSHIP. BASED ON THE MODEL, CHARITY CARE CAN STILL BE EXTENDED TO PATIENTS EVEN IF THEY HAVE NOT RESPONDED TO FINANCIAL COUNSELING EFFORTS AND ALL OTHER FUNDING SOURCES HAVE BEEN EXHAUSTED. FY13 WAS THE FIRST YEAR SAINT ALPHONSUS MEDICAL CENTER - ONTARIO UTILIZED THE PREDICTIVE MODEL WITH RESULTS USED FOR ANALYSIS ONLY. STARTING IN FY14, SAINT ALPHONSUS MEDICAL CENTER - ONTARIO IS RECORDING AMOUNTS AS CHARITY CARE (INSTEAD OF BAD DEBT EXPENSE) BASED ON THE RESULTS OF THE PREDICTIVE MODEL. THEREFORE, SAINT ALPHONSUS MEDICAL CENTER - ONTARIO IS REPORTING ZERO ON LINE 3, SINCE THEORETICALLY ANY POTENTIAL CHARITY CARE SHOULD HAVE BEEN IDENTIFIED THROUGH THE PREDICTIVE MODEL. PART III, LINE 4: SAINT ALPHONSUS MEDICAL CENTER - ONTARIO IS INCLUDED IN THE CONSOLIDATED FINANCIAL STATEMENTS OF TRINITY HEALTH. THE FOLLOWING IS THE TEXT OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS FOOTNOTE FROM PAGE 14 OF THOSE STATEMENTS: "THE CORPORATION RECOGNIZES A SIGNIFICANT AMOUNT OF PATIENT SERVICE REVENUE AT THE TIME THE SERVICES ARE RENDERED EVEN THOUGH THE CORPORATION DOES NOT ASSESS THE PATIENT'S ABILITY TO PAY AT THAT TIME. AS A RESULT, THE PROVISION FOR BAD DEBTS IS PRESENTED AS A DEDUCTION FROM PATIENT SERVICE REVENUE (NET OF CONTRACTUAL PROVISIONS AND DISCOUNTS). FOR UNINSURED AND UNDERINSURED PATIENTS THAT DO NOT QUALIFY FOR CHARITY CARE, THE CORPORATION ESTABLISHES AN ALLOWANCE TO REDUCE THE CARRYING VALUE OF SUCH RECEIVABLES TO THEIR ESTIMATED NET REALIZABLE VALUE. THIS ALLOWANCE IS ESTABLISHED BASED ON THE AGING OF ACCOUNTS RECEIVABLE AND THE HISTORICAL COLLECTION EXPERIENCE BY REGIONAL HEALTH MINISTRY AND FOR EACH TYPE OF PAYOR. A SIGNIFICANT PORTION OF THE CORPORATION'S PROVISION FOR DOUBTFUL ACCOUNTS RELATES TO SELF-PAY PATIENTS, AS WELL AS CO-PAYMENTS AND DEDUCTIBLES OWED TO THE CORPORATION BY PATIENTS WITH INSURANCE." PART III, LINE 8: SAINT ALPHONSUS MEDICAL CENTER - ONTARIO DOES NOT BELIEVE ANY MEDICARE SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT. THIS IS SIMILAR TO CHA RECOMMENDATIONS, WHICH STATE THAT SERVING MEDICARE PATIENTS IS NOT A DIFFERENTIATING FEATURE OF TAX-EXEMPT HEALTHCARE ORGANIZATIONS AND THAT THE EXISTING COMMUNITY BENEFIT FRAMEWORK ALLOWS COMMUNITY BENEFIT PROGRAMS THAT SERVE THE MEDICARE POPULATION TO BE COUNTED IN OTHER COMMUNITY BENEFIT CATEGORIES.PART III, LINE 8: COSTING METHODOLOGY FOR LINE 6 - MEDICARE COSTS WERE OBTAINED FROM THE FILED MEDICARE COST REPORT. THE COSTS ARE BASED ON MEDICARE ALLOWABLE COSTS AS REPORTED ON WORKSHEET B, COLUMN 27, WHICH EXCLUDE DIRECT MEDICAL EDUCATION COSTS. INPATIENT MEDICARE COSTS ARE CALCULATED BASED ON A COMBINATION OF ALLOWABLE COST PER DAY TIMES MEDICARE DAYS FOR ROUTINE SERVICES AND COST TO CHARGE RATIO TIMES MEDICARE CHARGES FOR ANCILLARY SERVICES. OUTPATIENT MEDICARE COSTS ARE CALCULATED BASED ON COST TO CHARGE RATIO TIMES MEDICARE CHARGES BY ANCILLARY DEPARTMENT. PART III, LINE 9B: THE HOSPITAL'S COLLECTION POLICY CONTAINS PROVISIONS ON THE COLLECTION PRACTICES TO BE FOLLOWED FOR PATIENTS WHO ARE KNOWN TO QUALIFY FOR FINANCIAL ASSISTANCE. CHARITY DISCOUNTS ARE APPLIED TO THE AMOUNTS THAT QUALIFY FOR FINANCIAL ASSISTANCE. COLLECTION PRACTICES FOR THE REMAINING BALANCES ARE CLEARLY OUTLINED IN THE ORGANIZATION'S COLLECTION POLICY. THE HOSPITAL HAS IMPLEMENTED BILLING AND COLLECTION PRACTICES FOR PATIENT PAYMENT OBLIGATIONS THAT ARE FAIR, CONSISTENT AND COMPLIANT WITH STATE AND FEDERAL REGULATIONS. PART VI, LINE 2: SAMC - ONTARIO ASSESSES THE HEALTH STATUS OF ITS COMMUNITY IN THE NORMAL COURSE OF OPERATIONS AND IN THE CONTINUOUS EFFORTS TO IMPROVE PATIENT CARE AND THE HEALTH OF THE OVERALL COMMUNITY. THE HOSPITAL MAY USE PATIENT DATA, PUBLIC HEALTH DATA, ANNUAL COUNTY HEALTH RANKINGS, MARKET STUDIES AND GEOGRAPHICAL MAPS SHOWING AREAS OF HIGH UTILIZATION FOR EMERGENCY SERVICES AND INPATIENT CARE, WHICH MAY INDICATE POPULATIONS OF INDIVIDUALS WHO DO NOT HAVE ACCESS TO PREVENTATIVE SERVICES OR ARE UNINSURED, IN THE ASSESSMENT OF THE COMMUNITY. WE ALSO UTILIZE THE EXPERTISE OF OUR PUBLIC HEALTH PARTNERS AND THEIR ANALYSIS OF COMMUNITY NEEDS. SAMC ONTARIO EXAMINED SEVERAL OTHER LOCAL NEEDS ASSESSMENTS AND OBTAINED INPUT FROM ORGANIZATIONS INVOLVED IN THOSE ASSESSMENTS, INCLUDING OUR EXTERNAL REVIEW COMMITTEE (FOUR RIVERS HEALTHY COMMUNITIES OREGON), THE MALHEUR COUNTY HEALTH DEPARTMENT AND THE EASTERN OREGON COORDINATED CARE ORGANIZATION TO IDENTIFY NEEDS BEING ADDRESSED BY OTHER AGENCIES. PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE - SAINT ALPHONSUS MEDICAL CENTER - ONTARIO IS COMMITTED TO:- PROVIDING ACCESS TO QUALITY HEALTHCARE SERVICES WITH COMPASSION, DIGNITY AND RESPECT FOR THOSE WE SERVE, PARTICULARLY THE POOR AND THE UNDERSERVED IN OUR COMMUNITIES- CARING FOR ALL PERSONS, REGARDLESS OF THEIR ABILITY TO PAY FOR SERVICES- ASSISTING PATIENTS WHO CANNOT PAY FOR PART OR ALL OF THE CARE THEY RECEIVE - BALANCING NEEDED FINANCIAL ASSISTANCE FOR SOME PATIENTS WITH BROADER FISCAL RESPONSIBILITIES IN ORDER TO SUSTAIN VIABILITY AND PROVIDE THE QUALITY AND QUANTITY OF SERVICES FOR ALL WHO MAY NEED CARE IN A COMMUNITYIN ACCORDANCE WITH AHA RECOMMENDATIONS, SAINT ALPHONSUS MEDICAL CENTER - ONTARIO HAS ADOPTED THE FOLLOWING GUIDING PRINCIPLES WHEN HANDLING THE BILLING, COLLECTION AND FINANCIAL SUPPORT FUNCTIONS FOR OUR PATIENTS:- PROVIDE EFFECTIVE COMMUNICATIONS WITH PATIENTS REGARDING HOSPITAL BILLS- MAKE AFFIRMATIVE EFFORTS TO HELP PATIENTS APPLY FOR PUBLIC AND PRIVATE FINANCIAL SUPPORT PROGRAMS- OFFER FINANCIAL SUPPORT TO PATIENTS WITH LIMITED MEANS- IMPLEMENT POLICIES FOR ASSISTING LOW-INCOME PATIENTS IN A CONSISTENT MANNER- IMPLEMENT FAIR AND CONSISTENT BILLING AND COLLECTION PRACTICES FOR ALL PATIENTS WITH PATIENT PAYMENT OBLIGATIONSSAINT ALPHONSUS MEDICAL CENTER - ONTARIO COMMUNICATES EFFECTIVELY WITH PATIENTS REGARDING PATIENT PAYMENT OBLIGATIONS. FINANCIAL COUNSELING IS PROVIDED TO PATIENTS ABOUT THEIR PAYMENT OBLIGATIONS AND HOSPITAL BILLS. INFORMATION ON HOSPITAL-BASED FINANCIAL SUPPORT POLICIES AND EXTERNAL PROGRAMS THAT PROVIDE COVERAGE FOR SERVICES ARE MADE AVAILABLE TO PATIENTS DURING THE PRE-REGISTRATION AND REGISTRATION PROCESSES AND/OR THROUGH COMMUNICATIONS WITH PATIENTS SEEKING FINANCIAL ASSISTANCE. ALL SELF-PAY PATIENTS ARE OFFERED FINANCIAL ASSISTANCE FORMS. EACH PATIENT RECEIVES INFORMATION ABOUT PAYMENT OPTIONS AND HOW TO APPLY FOR CHARITY CARE. PATIENTS ALSO ARE SCREENED FOR MEDICAID ELIGIBILITY, UTILIZING FINANCIAL ASSISTANCE FORMS. FINANCIAL COUNSELORS MAKE AFFIRMATIVE EFFORTS TO HELP PATIENTS APPLY FOR PUBLIC AND PRIVATE PROGRAMS FOR WHICH THEY MAY QUALIFY AND THAT MAY HELP THEM OBTAIN AND PAY FOR HEALTHCARE SERVICES. EVERY EFFORT IS MADE TO DETERMINE A PATIENT'S ELIGIBILITY PRIOR TO OR AT THE TIME OF ADMISSION OR SERVICE. HOWEVER, DETERMINATION FOR FINANCIAL SUPPORT CAN BE MADE DURING ANY STAGE OF THE PATIENT'S STAY AFTER STABILIZATION OR COLLECTION CYCLE.SAINT ALPHONSUS MEDICAL CENTER-ONTARIO OFFERS FINANCIAL SUPPORT TO PATIENTS WITH LIMITED MEANS. THIS SUPPORT IS AVAILABLE TO UNINSURED AND UNDERINSURED PATIENTS WHO DO NOT QUALIFY FOR PUBLIC PROGRAMS OR OTHER ASSISTANCE. NOTIFICATION ABOUT FINANCIAL ASSISTANCE, INCLUDING CONTACT INFORMATION, IS AVAILABLE. SELF-PAY INPATIENTS AND SURGERY PATIENTS ARE VISITED BY AN ASSOCIATE FROM PATIENT FINANCIAL SERVICES WHO ASSISTS THEM IN COMPLETING FINANCIAL ASSISTANCE FORMS FOR COUNTY INDIGENT ASSISTANCE, MEDICAID, SOCIAL SECURITY AND HOSPITAL CHARITY CARE. SAINT ALPHONSUS MEDICAL CENTER - ONTARIO HAS ESTABLISHED A WRITTEN POLICY FOR THE BILLING, COLLECTION AND SUPPORT FOR PATIENTS WITH PAYMENT OBLIGATIONS. SAINT ALPHONSUS MEDICAL CENTER - ONTARIO MAKES EVERY EFFORT TO ADHERE TO THE POLICY AND IS COMMITTED TO IMPLEMENTING AND APPLYING THE POLICY FOR ASSISTING PATIENTS WITH LIMITED MEANS IN A PROFESSIONAL, CONSISTENT MANNER. THE MEDICAL CENTER EDUCATES STAFF MEMBERS WHO WORK CLOSELY WITH PATIENTS (INCLUDING THOSE WORKING IN PATIENT REGISTRATION AND ADMITTING, FINANCIAL ASSISTANCE, CUSTOMER SERVICE, BILLING AND COLLECTIONS) ABOUT THESE POLICIES WITH AN EMPHASIS ON TREATING ALL PATIENTS WITH DIGNITY AND RESPECT REGARDLESS OF THEIR INSURANCE STATUS OR THEIR ABILITY TO PAY FOR SERVICES. PART VI, LINE 4: COMMUNITY INFORMATION - SAINT ALPHONSUS MEDICAL CENTER ONTARIO IS SITUATED IN MALHEUR COUNTY, OREGON, THE SECOND LARGEST COUNTY IN THE STATE; 9,926 SQUARE MILES IN THE SOUTHEASTERN-MOST CORNER OF THE STATE. BY DEFINITION, MALHEUR COUNTY IS CONSIDERED "FRONTIER" WITH A MERE 3.2 PERSONS PER SQUARE MILE ALTHOUGH THE POPULATION IS FAIRLY CLUSTERED TOGETHER IN SMALL COMMUNITIES. GEOGRAPHIC ISOLATION RESULTS IN CHALLENGES ACCESSING OREGON SERVICES. WHILE IDAHO IS IN CLOSE PROXIMITY, RESIDENTS OF MALHEUR COUNTY ARE OFTEN UNABLE TO UTILIZE GOVERNMENT SERVICES ACROSS STATE LINES. THE COUNTY HAS A TOTAL OF 31,313 RESIDENTS, OVER HALF OF WHICH LIVE IN THE CITY OF ONTARIO. THE LOCAL ECONOMY IS LARGELY BASED ON AGRICULTURE AND FARMING, AND THE COUNTY IS 94% RANGELAND.MALHEUR COUNTY IS NOTABLE FOR A HIGHER THAN AVERAGE HISPANIC/LATINO POPULATION, MANY OF WHOM ARE SEASONAL, OR MIGRANT, AGRICULTURE WORKERS. THIS IS ALSO EVIDENCED BY A HIGHER THAN AVERAGE PERCENTAGE OF LANGUAGES OTHER THAN ENGLISH SPOKEN AT HOME. MALHEUR COUNTY IS ALSO NOTABLE FOR A POPULATION DENSITY OF 3.2 PERSONS PER SQUARE MILE, WHERE RESIDENTS MUST TRAVEL LONG DISTANCES FOR SERVICES. MALHEUR COUNTY HAS THE LOWEST MEDIAN HOUSEHOLD INCOME AT $35,788, COMPARED TO $50,036 AT A STATE LEVEL AND $53,046 AT THE U.S. LEVEL. THE POVERTY LEVEL, AT 22.7%, IS THE HIGHEST OF THE THREE COUNTIES, AND IS SIGNIFICANTLY ABOVE STATE AND U.S. LEVELS.THE ABILITY TO EARN A LIVABLE WAGE WAS THE HIGHEST RATED BARRIER TO FINANCIAL STABILITY WITH ALMOST EVERY SURVEY RESPONDENT LISTING THIS AS THEIR PRIMARY NEED FOR ACHIEVING FINANCIAL STABILITY. LOW WAGES ALSO CONTRIBUTE TO THE OTHER MOST FREQUENTLY IDENTIFIED BARRIERS AS WELL, WITH INABILITY TO AFFORD TRAINING AND EDUCATION, INCLUDING COLLEGE AND TECHNICAL EDUCATION, AS A KEY THEME. HIGH HOUSING COST BURDENS FURTHER EXACERBATE THE DIFFICULTIES OF THOSE WITH LOW INCOME LEVELS. PART VI, LINE 5: OTHER INFORMATION - SAINT ALPHONSUS MEDICAL CENTER-ONTARIO STRONGLY SUPPORTS HEALTHCARE WORKFORCE DEVELOPMENT EFFORTS, INCLUDING ANNUAL FINANCIAL SUPPORT TO THE TREASURE VALLEY COMMUNITY COLLEGE NURSING PROGRAM. IN ADDITION, SAINT ALPHONSUS MEDICAL CENTER - ONTARIO SERVES AS A KEY CLINICAL TRAINING SITE FOR NURSES AND OTHER ALLIED HEALTH PROFESSIONALS.WE PROVIDE THE MAJORITY OF THE FUNDING, SPACE AND SUPPLIES TO STAFF A MATERNITY CARE CLINIC TO SERVE LOW-INCOME WOMEN WHO OTHERWISE COULD NOT AFFORD PRE-NATAL CARE.WE OFFER A VARIETY OF HEALTH EDUCATION AND SCREENING OPPORTUNITIES FREE OF CHARGE INCLUDING CARDIAC & STROKE SCREENINGS, FREE LIPID PROFILES, MAMMOGRAMS, AND MORE. WE USE THESE SCREENINGS AS AN OPPORTUNITY TO CONNECT PARTICIPANTS WITH A PRIMARY CARE PROVIDER FOR FURTHER HEALTH GUIDANCE. PART VI, LINE 6: SAINT ALPHONSUS MEDICAL CENTER - ONTARIO IS A MEMBER OF TRINITY HEALTH, ONE OF THE LARGEST CATHOLIC HEALTH CARE DELIVERY SYSTEMS IN THE COUNTRY. TRINITY HEALTH ANNUALLY REQUIRES THAT ALL MEMBER ORGANIZATIONS DEFINE - AND ACHIEVE - COMMUNITY BENEFIT GOALS THAT INCLUDE IMPLEMENTING NEEDED SERVICES OR EXPANDING ACCESS TO SERVICES FOR LOW-INCOME INDIVIDUALS. AS A NOT-FOR-PROFIT HEALTH SYSTEM, TRINITY HEALTH REINVESTS ITS PROFITS BACK INTO THE COMMUNITY THROUGH PROGRAMS SERVING THOSE WHO ARE POOR AND UNINSURED, HELPING MANAGE CHRONIC CONDITIONS LIKE DIABETES, PROVIDING HEALTH EDUCATION, PROMOTING WELLNESS AND REACHING OUT TO UNDERSERVED POPULATIONS. OVERALL, THE ORGANIZATION INVESTS MORE THAN $800 MILLION IN SUCH COMMUNITY BENEFITS AND WORKS TO ENSURE THAT ITS MEMBER HOSPITALS AND OTHER ENTITIES/AFFILIATES ENHANCE THE OVERALL HEALTH OF THE COMMUNITIES THEY SERVE BY ADDRESSING EACH COMMUNITY'S SPECIFIC NEEDS. FOR MORE INFORMATION ABOUT TRINITY HEALTH, VISIT WWW.TRINITY-HEALTH.ORG. PART VI, LINE 7, REPORTS FILED WITH STATES OR 1 TREASURE VALLEY COMMUNITY COLLEGE FOUNDATION 650 COLLEGE BLVD ONTARIO OR 97914 237052989 501(C)3 50000 243 FMV KINDLE SCIENCE CENTER FUND TREASURE VALLEY WOMENS CLINIC 1219 SW 4TH AVE STE 2 ONTARIO OR 97914 931161658 80000 MATERNAL CARE FOR THOSE UNABLE TO PAY 1 1 PART I, LINE 2: DONATIONS MADE BY SAINT ALPHONSUS MEDICAL CENTER- ONTARIO TO CHARITABLE ORGANIZATIONS ARE MADE IN FURTHERANCE OF THE RECIPIENT ORGANIZATION'S EXEMPT PURPOSE. DONATIONS ARE INCLUDED IN COMMUNITY BENEFITS IN SCHEDULE H IF THE CONTRIBUTION HAS BEEN FORMALLY RESTRICTED TO A COMMUNITY BENEFIT ACTIVITY THAT MEETS THE CRITERIA TO BE REPORTED ON SCHEDULE H. 1 1 0 0 0 0 0 0 0 SALLY JEFFCOAT TRUSTEE; PRES & CEO IDAHO OREGON REG 0 509104 0 449308 0 92090 0 74144 0 24362 0 1149008 0 0 J RICHARD O'CONNELL TRUSTEE; EVP & PRES WEST/MIDWEST GRP 0 731422 0 769386 0 172766 0 111806 0 33679 0 1819059 0 0 STEPHANIE WESTERMEIER SECRETARY; VP & GENERAL COUNSEL 0 285893 0 0 0 952 0 14046 0 19282 0 320173 0 0 BLAINE PETERSEN TREASURER AND SYSTEM CFO 0 364830 0 104896 0 3595 0 12866 0 22775 0 508962 0 0 KARL KEELER SAMC NAMPA & ONTARIO CEO 0 284082 0 208162 0 40410 0 24279 0 22087 0 579020 0 0 B LANNIE CHECKETTS SAMC NAMPA & ONTARIO CFO AT 9/13 0 222400 0 30054 0 9905 0 20336 0 23969 0 306664 0 0 JEAN BASOM REGIONAL DIRECTOR SUPPLY CHAIN 0 141258 0 26218 0 3716 0 46999 0 14871 0 233062 0 0 RODNEY REIDER SARMC PRESIDENT AND CEO 0 349521 0 200521 0 49672 0 48852 0 24655 0 673221 0 0 JAMES POLK SAHS, CHIEF QUALITY OFFICER 0 322843 0 160311 0 4787 0 28596 0 16182 0 532719 0 0 PAUL VACHEK CFO THROUGH 9/13 93985 0 30294 0 61130 0 6564 0 23372 0 215345 0 0 0 RICHARD PALAGI CEO THROUGH 1/14 0 249870 0 214405 0 42098 0 14771 0 20929 0 542073 0 0 GUILLERMO GUZMAN TREVINO MD PHYSICIAN 424200 0 0 0 23100 0 7650 0 19761 0 474711 0 0 0 PAMELA BRUCE MD SURGEON 337232 0 0 0 23484 0 13673 0 22067 0 396456 0 0 0 FRANK SPOKAS MD SURGEON 305505 0 15000 0 2794 0 28719 0 3101 0 355119 0 0 0 MARK CHRISTENSON MD PHYSICIAN 211905 0 30000 0 2534 0 8200 0 19842 0 272481 0 0 0 JOHN HANSILL MD SURGEON 182041 0 0 0 42729 0 0 0 4828 0 229598 0 0 0 KEDRICK ADKINS FORMER KEY EMPLOYEE 0 504488 0 873685 0 430416 0 1730702 0 8534 0 3547825 0 45090 JOSEPH SWEDISH FORMER KEY EMPLOYEE 0 344758 0 0 0 1119237 0 21706 0 7182 0 1492883 0 0 MICHAEL SLUBOWSKI FORMER KEY EMPLOYEE 0 0 0 0 0 231799 0 0 0 0 0 231799 0 231799 PART I, LINE 3 SAINT ALPHONSUS MEDICAL CENTER - ONTARIO IS A SUBSIDIARY IN THE TRINITY HEALTH SYSTEM. SAINT ALPHONSUS MEDICAL CENTER - ONTARIO'S CEO IS PAID DIRECTLY BY THE SYSTEM'S PARENT ENTITY, TRINITY HEALTH CORPORATION. TRINITY HEALTH CORPORATION USED THE FOLLOWING METHODS TO ESTABLISH THE COMPENSATION FOR SAINT ALPHONSUS MEDICAL CENTER - ONTARIO'S CEO: - COMPENSATION COMMITTEE - INDEPENDENT COMPENSATION CONSULTANT - FORM 990 OF OTHER ORGANIZATIONS - COMPENSATION SURVEY OR STUDY - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE, AND - WRITTEN EMPLOYMENT CONTRACT PART I, LINES 4A-B THE FOLLOWING INDIVIDUALS RECEIVED SEVERANCE PAYMENTS IN CALENDAR 2013. THESE AMOUNTS ARE INCLUDED IN COLUMN B(III): KEDRICK ADKINS - $310,298 PAUL VACHEK - $33,660 IN ADDITION, COLUMN C OF SCHEDULE J, PART II INCLUDES THE FOLLOWING SEVERANCE AMOUNT, WHICH WAS UNPAID AS OF 12/31/13: KEDRICK ADKINS - $1,347,759 ($814,924 PAID IN 2014 AND $532,835 TO BE PAID IN 2015) THE FOLLOWING IS A PARTICIPANT IN A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). THE FOLLOWING SERP ACCRUAL FOR 2013 IS INCLUDED IN COLUMN C OF SCHEDULE J, PART II: KEDRICK ADKINS - $258,812 THE FOLLOWING ARE PARTICIPANTS IN THE TRINITY HEALTH CASH BALANCE RESTORATION AND RETENTION PLAN, A NONQUALIFIED PLAN, WHICH PROVIDES RETENTION BENEFITS PLUS RETIREMENT BENEFITS FOR CERTAIN ASSOCIATES WITH EARNINGS ABOVE THE IRS PAY CAP FOR QUALIFIED PLANS ($255,000 FOR 2013). THE FOLLOWING ACCRUALS FOR 2013 FOR THIS PLAN ARE INCLUDED IN COLUMN C OF SCHEDULE J, PART II: KEDRICK ADKINS - $106,281 SALLY JEFFCOAT - $61,394 KARL KEELER - $15,079 J. RICHARD O'CONNELL - $99,056 RODNEY REIDER - $35,704 THE FOLLOWING INDIVIDUAL IS A PARTICIPANT IN A NON-QUALIFIED DEFERRED COMPENSATION PLAN UNDER SECTION 457(F). THE FOLLOWING DEFERRAL FOR CALENDAR YEAR 2013 IS INCLUDED IN COLUMN C OF SCHEDULE J, PART II: FRANK SPOKAS - $10,000 PART II: THE FOLLOWING INDIVIDUALS WERE VESTED IN A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). THE FOLLOWING VESTED SERP AMOUNTS ARE INCLUDED IN COLUMN B(III) OF SCHEDULE J, PART II: JOSEPH SWEDISH - $543,977 MICHAEL SLUBOWSKI - $231,799 COLUMN F OF SCHEDULE J INCLUDES THE PORTION OF THESE AMOUNTS THAT WERE REPORTED AS DEFERRED COMPENSATION IN PRIOR YEARS. PART II, COLUMN B (II): THE FOLLOWING INDIVIDUALS RECEIVED AMOUNTS IN 2013 FROM A LONG-TERM INCENTIVE PLAN (LTIP). PARTICIPANTS IN THE LTIP (CEO'S AND CERTAIN TRINITY EXECUTIVES) WERE ELIGIBLE TO RECEIVE A PAYMENT UNDER THE PLAN ONLY IF CERTAIN CULTURE OF SAFETY SURVEY SCORE TARGETS WERE ACHIEVED AT THE END OF A THREE-YEAR PERIOD (FY11 THROUGH FY13). THE FOLLOWING LTIP AMOUNTS ARE INCLUDED IN SCHEDULE J, PART II, COLUMN B(II): KEDRICK ADKINS - 372,833 SALLY JEFFCOAT - $236,045 KARL KEELER - $117,253 J. RICHARD O'CONNELL - $294,870 RICHARD PALAGI - $103,434 JAMES POLK - $68,349 RODNEY REIDER - $56,041 FRANK SPOKAS EMPLOYEE PHYSICIAN LOAN X 90000 32063 0 0 1 DAVID HANSILL EMPLOYEE PHYSICIAN LOAN X 122050 78706 0 0 1 110769 LEANNA BENTZ FAMILY MEMBER OF ANDREW BENTZ, TRUSTEE 55832 EMPLOYMENT ARRANGEMENT 0 FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF SAINT ALPHONSUS MEDICAL CENTER - ONTARIO, INC. IS SAINT ALPHONSUS HEALTH SYSTEM, INC. SEE LINE 7 FOR ADDITIONAL INFORMATION. FORM 990, PART VI, SECTION A, LINE 7A SAINT ALPHONSUS HEALTH SYSTEM, INC. IS THE SOLE MEMBER OF SAINT ALPHONSUS MEDICAL CENTER - ONTARIO, INC. SAINT ALPHONSUS HEALTH SYSTEM, INC. HAS THE RIGHT TO APPOINT ALL PERSONS TO THE BOARD OF TRUSTEES OF SAINT ALPHONSUS MEDICAL CENTER - ONTARIO, INC. FORM 990, PART VI, SECTION A, LINE 7B AS SOLE MEMBER, SAINT ALPHONSUS HEALTH SYSTEM, INC. MUST APPROVE CERTAIN DECISIONS OF THE GOVERNING BODY, INCLUDING THE STRATEGIC PLAN, ANNUAL CAPITAL PLAN, AND ANNUAL OPERATING BUDGET. SAINT ALPHONSUS HEALTH SYSTEM, INC. MUST ALSO APPROVE SIGNIFICANT CHANGES SUCH AS A MERGER, DISSOLUTION, SALE OF ASSETS IN EXCESS OF CERTAIN LIMITS, A MATERIAL CHANGE IN MISSION, AND MODIFICATIONS TO GOVERNING DOCUMENTS. FORM 990, PART VI, SECTION B, LINE 11 PRIOR TO FILING, THE FORM 990 FOR SAINT ALPHONSUS MEDICAL CENTER - ONTARIO, INC. IS REVIEWED BY SENIOR MANAGEMENT. IN ADDITION, CERTAIN KEY SECTIONS OF THE FORM ARE REVIEWED BY THE FINANCE COMMITTEE OF SAINT ALPHONSUS HEALTH SYSTEM. (SAINT ALPHONSUS HEALTH SYSTEM IS THE SOLE MEMBER OF THE CORPORATION.) THE BOARD RECEIVES A COPY OF THE RETURN IN ITS FINAL FORM BEFORE IT IS FILED WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C SAINT ALPHONSUS MEDICAL CENTER - ONTARIO, INC. HAS ADOPTED A CONFLICT OF INTEREST POLICY WHICH CONTAINS THE ELEMENTS IN THE MODEL CONFLICT OF INTEREST POLICY ISSUED BY THE IRS. IT APPLIES TO ALL "INTERESTED PERSONS" OF SAINT ALPHONSUS MEDICAL CENTER - ONTARIO, INC., WHICH INCLUDES TRUSTEES, PRINCIPAL OFFICERS AND EXECUTIVES, AND MEMBERS OF COMMITTEES WITH BOARD DESIGNATED POWERS. INTERESTED PERSONS ARE REQUIRED TO ACT AT ALL TIMES IN A MANNER CONSISTENT WITH SAINT ALPHONSUS MEDICAL CENTER - ONTARIO, INC.'S CHARITABLE PURPOSE AND SERVICE TO THE COMMUNITY AND TO AVOID CONFLICTS OF INTEREST. INTERESTED PERSONS ARE REQUIRED TO MAKE FULL DISCLOSURE TO SAINT ALPHONSUS MEDICAL CENTER - ONTARIO, INC. OF ANY FINANCIAL OR BUSINESS INTERESTS THAT MIGHT RESULT IN OR HAVE THE APPEARANCE OF A CONFLICT OF INTEREST. INTERESTED PERSONS ARE REQUIRED TO RECUSE THEMSELVES FROM DISCUSSION AND VOTING ON MATTERS INVOLVING A CONFLICT OF INTEREST. THE BOARD OF TRUSTEES OF SAINT ALPHONSUS MEDICAL CENTER - ONTARIO, INC. IS RESPONSIBLE FOR THE REVIEW AND APPROVAL OF TRANSACTIONS WITH INTERESTED PERSONS, INCLUDING DETERMINING THAT SUCH TRANSACTIONS ARE FAIR AND REASONABLE TO SAINT ALPHONSUS MEDICAL CENTER - ONTARIO, INC. ON AN ANNUAL BASIS, INTERESTED PERSONS ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST DISCLOSURE STATEMENT AND TO AFFIRM THEIR RECEIPT OF THE CONFLICT OF INTEREST POLICY, COMPLIANCE WITH ITS REQUIREMENTS, AND AGREE TO NOTIFY THE ORGANIZATION OF CHANGES IMPACTING THEIR ANNUAL DISCLOSURE IN ACCORDANCE WITH THE POLICY. THE ANNUAL DISCLOSURES ARE REVIEWED WITH THE BOARD OF TRUSTEES OF SAINT ALPHONSUS MEDICAL CENTER - ONTARIO, INC. ON A YEARLY BASIS. FORM 990, PART VI, SECTION B, LINE 15 QUESTIONS 15A AND 15B ARE ANSWERED "NO" BECAUSE THE COMPENSATION FOR SAINT ALPHONSUS MEDICAL CENTER - ONTARIO, INC.'S CEO, OFFICERS, AND KEY MANAGEMENT OFFICIALS IS ESTABLISHED AND PAID BY TRINITY HEALTH, A RELATED ORGANIZATION. TRINITY HEALTH FOLLOWS A PROCESS AND POLICY THAT IS INTENDED TO MIRROR THE IRC SECTION 4958 GUIDELINES FOR OBTAINING A "REBUTTABLE PRESUMPTION OF REASONABLENESS" WITH REGARD TO COMPENSATION AND BENEFITS. AS PART OF THAT PROCESS, THE COMPENSATION AND BENEFITS OF CERTAIN OFFICERS AND KEY MANAGEMENT OFFICIALS OF SAINT ALPHONSUS MEDICAL CENTER - ONTARIO, INC. ARE REVIEWED AT LEAST ANNUALLY BY THE TRINITY HEALTH BOARD OR THE TRINITY HEALTH HUMAN RESOURCES AND COMPENSATION COMMITTEE (HRCC) OF THE BOARD, AUTHORIZED TO ACT ON BEHALF OF THE BOARD WITH RESPECT TO CERTAIN COMPENSATION MATTERS. AS PART OF ITS REVIEW PROCESS, THE HRCC RETAINS AN INDEPENDENT FIRM EXPERIENCED IN COMPENSATION AND BENEFIT MATTERS FOR NOT-FOR-PROFIT HEALTHCARE ORGANIZATIONS TO ADVISE IT IN THE DETERMINATIONS IT MAKES ON THE REASONABLENESS OF PROPOSED COMPENSATION AND BENEFITS ARRANGEMENTS. FORM 990, PART VI, SECTION C, LINE 19 SAINT ALPHONSUS MEDICAL CENTER - ONTARIO, INC. IS A SUBSIDIARY ORGANIZATION IN THE TRINITY HEALTH SYSTEM. TRINITY HEALTH MAKES CERTAIN OF ITS KEY DOCUMENTS AVAILABLE TO THE PUBLIC ON ITS WEBSITE, WWW.TRINITY-HEALTH.ORG, IN THE "ABOUT US" SECTION. IN THIS SECTION, THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS ARE PUBLICLY AVAILABLE. IN ADDITION, SAINT ALPHONSUS MEDICAL CENTER - ONTARIO, INC. INCLUDES A COPY OF ITS MOST RECENTLY FILED SCHEDULE H ON BOTH ITS OWN WEBSITE AND TRINITY HEALTH'S WEBSITE. SAINT ALPHONSUS MEDICAL CENTER - ONTARIO, INC.'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST. FORM 990, PART XI, LINE 9: OTHER TRANSACTIONS: -1,968. FORM 990, PART XII, LINE 2: SAINT ALPHONSUS MEDICAL CENTER - ONTARIO, INC'S FINANCIAL STATEMENTS WERE INCLUDED IN THE FY14 CONSOLIDATED FINANCIAL STATEMENTS OF TRINITY HEALTH, WHICH WERE AUDITED BY AN INDEPENDENT PUBLIC ACCOUNTING FIRM. FORM 990, PAGE I, DOING BUSINESS AS NAMES: HOLY ROSARY, TRINITY HOLY ROSARY, SAINT ALPHONSUS, SAINT ALPHONSUS - ONTARIO, SAMG-ONTARIO PATHWAY HOSPICE LLC 1050 SW 3RD AVE SUITE 1600 ONTARIO OR 97914 931310235 HOSPICE CARE OR 0 0 SAINT ALPHONSUS MEDICAL CENTER-ONTARIO ADVANTAGE HEALTHSAINT MARY'S MEDICAL GROUP 245 STATE ST SE GRAND RAPIDS MI 49503 272491974 HEALTHCARE SERVICES MI 501(C)(3) LINE 9 TRINITY HEALTH-MICHIGAN 1 ALLEGANY FRANCISCAN MINISTRIES INC 33920 US HIGHWAY 19 NORTH SUITE 269 PALM HARBOR FL 34684 581492325 MANAGEMENT & SUPPORT SERVICES FL 501(C)(3) LINE 11A, I CATHOLIC HEALTH EAST 1 AMICARE HOSPICE SERVICES INC 20555 VICTOR PARKWAY LIVONIA MI 48152 382949053 PROVIDE HOSPICE SERVICES MI 501(C)(3) LINE 9 TRINITY HOME HEALTH SERVICES INC 1 AUXILIARY OF HOLY ROSARY HOSPITAL 351 SW 9TH STREET ONTARIO OR 97914 943059469 SUPPORTS SERVICES OF RELATED HOSPITAL OR 501(C)(3) LINE 9 SAINT ALPHONSUS MEDICAL CENTER-ONTARIO 1 BAUM HARMON MERCY HOSPITAL 255 NORTH WELCH AVENUE PRIMGHAR IA 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