2012-11-20T22:32:36-08:00 2011-12-31 990 2011-01-01 680395149 Adventist Health Clearlake Hospital Inc dba St Helena Hospital Clearlake ADVE 7079946486 15630 18th Ave Clearlake CA 95422 Carlton Jacobson 2012-11-20 2011 2016-02-24 21:20:13Z Newmyer Terrance 10 Woodland Rd St Helena CA 94574 66252396 false false X http://www.shhclearlake.org X 1996 CA To share God's love by providing physical, mental, and spiritual healing. 13 8 462 40 0 902072 156865 63182421 65880405 184740 160662 18332 13808 64287565 66211740 0 0 26639875 31121354 0 130017 30709908 32068919 57349783 63190273 6937782 3021467 36062491 42051593 58720045 61687680 -22657554 -19636087 To share God's love by providing physical, mental, and spiritual healing. false false 55837239 65906498 St. Helena Hospital Clearlake provides quality medical health care regardless of race, creed, sex, national origin, handicap, age, or ability to pay. Although reimbursement for services rendered is critical to the operation and stability of St. Helena Hospital Clearlake, the organization recognizes that not all individuals possess the ability to pay for essential medical services. Adventist Health's vision is to enhance the health of the communities where we live and serve, by engaging our communities and our patients in a new definition of a partnership for personal community health. In keeping with this committment to serve all members of the community, the following will be considered when individuals who need health care cannot pay:Providing free care and/or subsidized careProviding care to persons covered by governmental programs at below costProviding health/wellness activities and community education programsNot only does St. Helena Hospital Clearlake provide low-cost care to individuals covered by government programs and those unable to afford health care, but it also helps patients find and access private and governmental resources for health care benefits. St. Helena Hospital Clearlake recognizes below-cost reimbursement as charity and uncompensated care in meeting its mission to the entire community. The unreimbursed value of providing care to these patients in 2011 was $2,890,699. Inpatient services in 2011 were provided to 1,755 patients. These services included: 193 Babies delivered 340 Surgeries performed 42,592 Laboratory tests performedOutpatient services in 2011 were provided to 188,527 patients. These services included: 18,089 Emergency room visits 1,489 Outpatient surgeries performed 90,267 Medical clinic visits 218,698 Laboratory testsSt. Helena Hospital Clearlake recognizes it has an obligation to provide human services above and beyond its role as a healing facility. The following community benefits demonstrate the tangible ways in which the organization is fulfilling its mission:Child Immunization ClinicsHealth FairsBlood Pressure ClinicsStudent Nursing ProgramOperation Christmas Joy 55837239 true false false true false false false false false true true false false true true false false true false false false false false false false false true true false false true false false false false false false false false false false false false false false false false true false false false false true 59 0 true 462 true false false false false false false false false false false false 0 false false false false false false false false false false false X 13 8 false false false false true false true true true false false false true true true true true true true true false false X Carlton Jacobson 7079946486 15630 18th Ave Clearlake CA 95422 X Bradshaw Robert DDS 1.00 X 0 4652 0 Torkelson Max 1.00 X 0 2381 0 Rippey Wes 1.00 X 0 98503 0 Reimche Al 1.00 X 0 1637 0 Jones Helmuth 1.00 X 0 350 0 Jobe Meredith 1.00 X 0 54617 0 Innocent Larry 1.00 X 0 350 0 Herber Steven 1.00 X 0 219911 41678 Graham Ricardo 1.00 X 0 2652 0 Friestad Christine 1.00 X 0 2927 0 Fike Ruthita 1.00 X 0 635 0 Creitz Lynn 1.00 X 0 3123 0 Caviness Larry 1.00 X 0 2666 0 Reiner Scott 50.00 X X 0 907841 160287 Dodds Larry 50.00 X X 0 685344 96060 Carmen Robert 50.00 X X 0 1749297 39804 Santos David 50.00 X 0 237118 57598 McDonald Edward 50.00 X 0 315241 69417 Newmyer Terrance 50.00 X 0 686327 110783 Wing Bill 50.00 X 0 321581 89967 Wehtje Rodney 50.00 X 0 506336 95494 Rebok Douglas 50.00 X 0 857414 147299 Williams Patricia 0.00 X 0 0 0 Bockmann Rick 0.00 X 0 235463 29151 Simons Marjorie 50.00 X 0 202670 53508 Robinson Ken 55.00 X 0 0 0 Gumpert Norman 46.00 X 0 0 0 Myers Irvin 49.00 X 0 0 0 Coppernoll Belinda 45.00 X 0 0 0 McCurry William 48.00 X 0 0 0 Olson Joaline 0.00 X 0 537545 96637 7636581 1087683 0 true true false Adventist Health-California Medical Group PO Box 266 Deer Park CA 94576 Physician Services Alliance Healthcare Services PO Box 6600 Newport Beach CA 92658 Medical Imaging Svcs NPH Medical Services Inc 2639 Forest Ave Ste 110 Chico CA 95928 Staffing Services Quantum Healthcare Medical 5000 Hopyard Rd Ste 100 Pleasanton CA 94588 Hospitalist Services Helmer & Sons Inc 910 Howell Mtn Rd N Angwin CA 94508 Construction Svcs 0 156865 156865 Other Revenue 900099 33710 33710 Rental Income 531120 88727 88727 Dietary 722210 179592 179592 Patient Service Revenue 621990 65578376 65578376 65880405 160662 160662 0 0 0 0 0 0 54464 40656 13808 13808 0 66211740 65880405 174470 0 0 0 0 0 0 21862251 20264848 1531692 65711 660094 660094 6944705 6321757 595492 27456 1654304 1539776 109201 5327 0 527818 527818 199016 199016 0 0 0 10803173 10601476 201697 202177 9025 171727 21425 1253461 877897 373658 1906 1678349 1642866 35483 0 1752596 1594550 158046 68979 36555 30933 1491 0 78630 29514 48016 1100 983420 983420 0 1997907 1921087 76820 531887 531887 Rentals/Leases 353711 310954 39056 3701 All Other Expenses 877790 629381 246509 1900 Patient Care Supplies 4167478 4167478 Purchased Services 6592527 3714674 2877853 0 63190273 55837239 7223017 130017 359071 375928 7047246 3520777 760782 685782 4969667 5806357 0 0 0 501603 607391 317262 142685 42308482 20395382 20263439 21913100 0 0 0 0 1843421 8999573 36062491 42051593 5034953 4256545 16202951 16120615 37482141 41310520 58720045 61687680 X -23733225 -20806604 1075671 1170517 -22657554 -19636087 36062491 42051593 3021467 X false true true X false false X false false false false false false false false false false true 6299 6299 false false Part II-B, Line 1i Part II-B, Line 1i - Other Activities Description Portion of dues paid to membership organizations allocable to lobbying activities. 1075671 156865 62019 1170517 205167 902072 31568 1075671 163745 101725 60303 205167 false false false 1354985 1354985 629680 16771694 11387078 6014296 10291882 7987199 2304683 13260241 1021105 12239136 21913100 Other Receivables 207490 Other Investments - Funds in Trust 639567 Receivables from Related Organizations 8152516 8999573 Payables to 3rd Party Payors 2403136 Payables to Related Organizations 37436688 Workers' Comp Payable 1470696 41310520 Part V, Line 4 Part V, Line 4: Intended uses of the endowment fund. Board-designated, temporary and permanently restricted endowment funds are for specified operating and capital projects. The funds are released as project costs are expended. true true X true X true X true false false false false false 743736 743736 0.01180 19245464 24668872 -5423408 4258078 3184766 1073312 0.01700 24247278 27853638 -3606360 0.02880 3983 3983 0.00010 2500 2500 6483 6483 0.00010 24253761 27853638 -3599877 0.02890 5000 5000 0.00010 12500 12500 0.00020 17500 17500 0.00030 false 1739068 539111 23220231 22350737 869494 X true true 1 0 St Helena Hospital Clearlake

15630 18th Ave Clearlake CA 95422

X X X X St Helena Hospital Clearlake 1 false false false false false false false false true X false false 6 Family Health Ctr - Middletown

21337 Bush St Middletown CA 95461

Rural Health Clinic Family Health Ctr -Kelseyville

5290 State St Kelseyville CA 95451

Rural Health Clinic Family Health Ctr - Clearlake

15230 Lakeshore Drive Clearlake CA 95422

Rural Health Clinic St Helena General Surgery - Clearlake

15230 Lakeshore Dr Ste 102 Clearlake CA 95422

Outpatient Clinic St Helena Therapy Services - Clearlake

14880 Olympic Dr Clearlake CA 95422

Outpatient Clinic St Helena Cardiology - Lake Silverado

15250 Lakeshore Dr Ste C Clearlake CA 95422

Outpatient Clinic Part VI - Additional Information Schedule H, Part V, Section B, Lines 1 through 7 is optional for the reporting organization as the tax year began prior to March 23, 2012, according to the instructions for Schedule H. Lacerte software has not provided a tool for an organization to indicate that it is opting not to complete Part V, Section B. In addition, the software has been programmed so that it populates responses when the organization chooses to provide no data inputs. Part V, Section B should be blank as the reporting organization opts to not complete it. Part VI - States Where Community Benefit Report Filed CA Part VI - Affilated Health Care System Roles and Promotion The hospital is a member of Adventist Health, a health care system which provides healthcare services in diverse markets within the Western United States. A member hospital may share some services with other member hospitals in its geographic area, such as clinical, management and support services. Using today's technology, hospitals outside the geographic area are able to provide support through remote services such as telepharmacy and robotics surgery. The Corporate Office provides important shared administrative support for member hospitals' rural health clinics and home care agencies, quality of care, other clinical needs, financing and risk management, and shared clinical and financial information technology. As many experienced and new physicians search for alternatives to independent practice, there is also corporate administrative support for hospital affiliated medical groups that engage physicians through employment or other contracts. This provides stability and growth of qualified physicians across many specialties, which is very important to make healthcare services available and to maintain and improve health within the communites served Part VI - Explanation Of How Organization Furthers Its Exempt Purpose We do not wait until a community member needs our services through our clinics or our Emergency Department. We are active in the community we serve. By involving ourselves in various activities, groups, and outreaches, we communicate our willingness to serve our community and our commitment to our mission. Our community health needs assessment keeps us current with changes in the health of our community. By working with other groups and agencies we are better able to assess the needs of the community then if we relied only on our own resources. Part VI - Community Building Activities Our hospital is involved in numerous community building activities which promote the health of the communities it serves. Numerous community concerns are addressed, including health improvement, education, poverty, workforce development and access to care. We also encourage our employees to serve on community collaboration boards, health advocacy programs, and physical improvement projects to promote the health of the communities we serve. And, we work with neighborhood programs, including schools, work sites and safety net providers to promote health and wellness and prevent disease. These activities are not included elsewhere on Schedule H. Part VI - Community Information The hospital is in a rural setting, predominately agricultural based. The average income is at or below the FPG. The population is predominately Caucasian, high-school educated, with a large portion over age 65. Part VI - Patient Education of Eligibility for Assistance At the time of registration, patients who are uninsured and underinsured are provided information about government healthcare programs. Patients also are orally informed of their right to request charity assistance. Signs are displayed in the patient business office, patient registration areas and the emergency room in multiple languages informing patients of this right as well. The hospital also provides a brochure during the registration process that explains the hospital billing and collection procedures, and how to request financial assistance. In addition, every billing statement sent to patients contains information on how to request financial assistance. The hospital charity assistance policy is posted on the hospital website. Part VI - Needs Assessment The health system retains outside research firms every three years to assess changes in the market and community perception. Data is collected through a variety of sources, including phone surveys, paper surveys, and focus groups. Questions were added to the survey to help assess the impact of our community benefit activities and residents' barriers to access for health care services as well as unmet community needs. Number of Hospital Faciltiy - 0 Part V, Line 19d - Other Billing Determination of Individuals Without Insurance The hospital's financial assistance policy has three income ranges for patients who received emergency medical care, which provides a discount based on Medicare rates. There are also three income ranges for patients who received non-emergency medical care; the two lower income ranges provide a discount based on Medicare rates. The higher income range provides a discount from the balance due after the uninsured discount, that is available to all uninsured patients without regard to income. Only five of the six income ranges are discounted based on Medicare rates. Part III, Line 9b - Provisions On Collection Practices For Qualified Patients When a patient has requested screening for charity care, the hospital must immediately cease collection activity and place the account in a charity pending status. If 100% charity is approved, the entire account balance is written off to charity care. If the patient has a sliding scale liability based on the federal poverty guidelines, they are billed only for that liability. If the patient fails to pay their after-charity liability, they are assigned to a collection agency with an identifier that indicates to the agency that the patient is "low income" and the following criteria must be followed by the agency:1. They may not report the patient to a credit bureau2. They may not file a lawsuit to recover the outstanding liability3. They may not charge interest Part III, Line 8 - Explanation Of Shortfall As Community Benefit The Medicare cost report apportions the hospitals costs on the basis of inpatient days and ancillary and outpatient charges to establish the costing methodology.Healthcare delivery by hospitals is a complex, highly regulated business in the United States. Healthcare unit cost inflation is driven by compliance with ever-expanding regulatory requirements, shortages of highly skilled labor and evolving medical and information technology. The health care market basket is unrelated to that of the average individual consumer. Since the 1997 Balanced Budget Act, Medicare annual payment updates have fallen behind actual healthcare cost inflation to the point that Medicare payments to many U.S. hospitals are well below the cost of providing care. These unreimbursed costs are a community benefit for seniors and others in the community as these individuals are continuing to receive care without which many would become dependent on other governmental resources such as Medicaid. The benefit to the community for healthier Medicare recipients is no different than those benefits the community realizes for uninsured and underinsured patients who are eligible for partial and full charity care. Medicare is a safety net for seniors and others. Without Medicare coverage, many individuals would undoubtedly qualify for charity care.In addition to the mismatch between Medicare payment increases and healthcare cost inflation, the highly complex Medicare payment systems and formulas produce disparate payment levels from one hospital to another for the same service. These disparate payment levels create disparate results within groups of hospitals.Reconciliation of Medicare Revenue from the hospital's Medicare Cost Report to GL:*Medicare Cost Report Revenue 23,124,263Prior Year Settlements 1,123,192Cost Report Reimbursable Bad Debts 2,774,622Estimates and Accrual Variances (1,697,308)Other (2,104,538)Subtotal - Amount reported in Pt III, line 5 23,220,231Amounts include in Part 1, lines g and f -Total Medicare Revenue 23,220,231*Note: The Medicare Cost Report revenue does not include the bad debt reimbursement. The Cost Report revenue does include the patient co-pay and deductible amounts. Adding the bad debt reimbursement would have duplicated the revenue already accounted for in the co-pay and deductible amounts. Part III, Line 4 - Bad Debt Expense Uncollected patient accounts are analyzed using written patient financial services policies that apply standard procedures for all patient accounts. The result of the analysis is what is recognized as bad debt expense. For example, all self-pay patients receive a discount. If the discounted account is unpaid after collection efforts, the unpaid balance is classified as bad debt. The cost-to-charge ratio described for Part I, Line 7 is multiplied times the hospital's bad debt expense as reported in the system-wide audited combined financial statements. The resulting figure has been reported as bad debts at cost on Part III, Line 2.The portion of the bad debts attributed to charity care as reported on Part III, Line 3 was calculated by an independent third-party consulting firm. This is an estimate of additional charity care that would have been granted if patients had cooperated by furnishing family financial information. A statistically valid sampling of patient accounts written-off was evaluated. The evaluation used various factors to determine which patients would have been eligible for charity care. Had the hospital obtained sufficient information from all patients who qualified for financial assistance, these additional accounts would have been recorded as charity care instead of bad debt.The system-wide audited combined financial statements do not contain a footnote describing bad debt expense. X X X X false true false false false false false false false false Bockmann Rick 196097 30345 9021 11904 17247 264614 Simons Marjorie 144713 29825 28132 32136 21372 256178 15216 Santos David 180901 19500 36717 35628 21970 294716 McDonald Edward 235038 36501 43702 48010 21407 384658 28885 Newmyer Terrance 413446 98800 174081 91550 19233 797110 76183 Wing Bill 305801 15780 74419 15548 411548 Wehtje Rodney 340430 78784 87122 78557 16937 601830 52751 Rebok Douglas 533280 149092 175042 128096 19203 1004713 123894 Herber Steven 212461 7450 27400 14278 261589 Reiner Scott 577345 149092 181404 138780 21507 1068128 119583 Dodds Larry 303557 171094 210693 79089 16971 781404 120139 Carmen Robert 934340 267209 547748 18150 21654 1789101 424494 Olson Joaline 333500 81559 122486 75167 21470 634182 80814 Form 990, Part VII, Line 1a - Board Comp The directors serve on the Board without compensation. Amounts reported generally are for taxable benefits. Form 990, Part VI, Line 7a The hospital bylaws define its board of directors to be the same individuals who are members of the Adventist Health System/West board of directors. Adventist Health System/West, a California not-for-profit religious corporation, is the sole corporate member of the hospital. Form 990, Part VI, Line 19 Form 990, Part VI, Line 19: Other Organization Documents Publicly Available The hospital does not make its governing documents publicly available, beyond required filings of articles of incorporation with the secretary of state. The hospital does not make its conflict of interest policy available upon request, but does file monthly/quarterly summary financial reports with the state health-planning agency. Form 990, Part VI, Line 15b Form 990, Part VI, Line 15b: Compensation Review and Approval Process for Officers and Key Employees The hospital board of directors has established a Compensation Committee to oversee the executive compensation program. This committee is composed of independent directors with no conflicts of interest. The committee performs the following functions: recommends a total compensation philosophy to the board; assures compliance with the board-approved philosophy; meets annually to review comparability data from outside consultants; recommends any adjustments to current executive compensation, including salary ranges for hospital CEOs and CFOs, that would be indicated by the data; evaluates executive performance against annual goals; recommends appropriate incentive awards to the board for approval; follows a diligent process that meets regulatory requirements for a rebuttable presumption of reasonableness; records committee deliberations and decisions in timely minutes; selects, engages and supervises any consultant hired to advise and provide comparability data.The board-approved executive compensation philosophy specifies that salary ranges will be established for hospital CEOs and executives, with midpoints aligned with the 50th percentile of comparable system hospital data, and having a 24 percent spread from minimum to maximum (industry norm is approximately a 50 percent spread). A hospital CEO has a maximum potential incentive of 30 percent of base salary. (This incentive potential is less than the industry norm.) Other hospital executives have a maximum potential incentive of 20 percent of base salary. Form 990, Part VI, Line 12c Form 990, Part VI, Line 12c: Explanation of Monitoring and Enforcement of Conflicts During the first quarter of each year, the annual conflict of interest questionnaire is sent to board members, hospital officers, key employees and department directors for completion and signature. The questionnaire is accompanied by a letter of explanation, to illustrate examples of a conflict and to remind the recipient that if any perceived conflict should arise before the next annual questionnaire, he/she is to notify the CEO immediately. The corporate internal audit staff review these questionnaires and disclosures each year during the audit process. Form 990, Part VI, Line 11 Form 990, Part VI, Line 11: Form 990 Review Process The completed Form 990 is shared with members of the hospital's board of directors by electronic communication for their review prior to filing. A special board meeting is scheduled to answer questions and receive input from the board after their review but prior to filing. Form 990, Part VI, Line 7b Form 990, Part VI, Line 7b: Describe Decisions of Governing Body Approval by Members or Shareholders The sole corporate member, Adventist Health System/West, must approve all changes to the articles of incorporation and bylaws. Form 990, Part VI, Line 6 Form 990, Part VI, Line 6: Explanation of Classes of Members or Shareholder The hospital is organized as a not-for-profit religious corporation. The sole corporate member is Adventist Health System/West, a California not-for-profit religious corporation. The hospital operates as an affiliate of Adventist Health System/West. Reedley Community Hospital 372 W Cypress Ave Reedley CA 93654 453220509 Hospital CA 501(c)(3) 1 Adventist Health SystemWest false Adventist Health Physicians Network 2100 Douglas Blvd Roseville CA 95661 680357690 Medical Foundation CA 501(c)(3) 11b, II Adventist Health SystemWest false Willits Hospital Inc 1 Madrone St Willits CA 95490 680108919 Hospital CA 501(c)(3) 1 Adventist Health SystemWest false White Memorial Medical Center 1720 Cesar E Chavez Ave Los Angeles CA 90033 952282647 Hospital CA 501(c)(3) 1 Adventist Health SystemWest false Walla Walla General Hospital 1025 S Second Ave Walla Walla WA 99362 910617726 Hospital WA 501(c)(3) 1 Adventist Health SystemWest false Ukiah Adventist Hospital 275 Hospital Dr Ukiah CA 95482 941639901 Hospital CA 501(c)(3) 1 Adventist Health SystemWest false Sonora Community Hospital 1000 Greenley Rd Sonora CA 95370 941415069 Hospital CA 501(c)(3) 1 Adventist Health SystemWest false Simi Valley Hospital & Health Care Svcs 2975 N Sycamore Dr Simi Valley CA 93065 956064971 Hospital CA 501(c)(3) 1 Adventist Health SystemWest false San Joaquin Community Hospital 2615 Chester Ave Bakersfield CA 93301 952294234 Hospital CA 501(c)(3) 1 Adventist Health SystemWest false St Helena Hospital 10 Woodland Rd St Helena CA 94574 941279779 Hospital CA 501(c)(3) 1 Adventist Health SystemWest false Portland Adventist Medical Center 10123 SE Market St Portland OR 97216 930429015 Hospital OR 501(c)(3) 1 Adventist Health SystemWest false Paradise Valley Hospital 2100 Douglas Blvd Roseville CA 95661 951816034 Wind down after sale of hospital facilities CA 501(c)(3) 1 Adventist Health SystemWest false NW Medical Foundation of Tillamook 1000 Third St Tillamook OR 97141 930622075 Hospital OR 501(c)(3) 1 Adventist Health SystemWest false Hanford Community Hospital 450 Greenfield Ave Hanford CA 93230 940535360 Hospital CA 501(c)(3) 1 Adventist Health SystemWest false Glendale Adventist Medical Center 1509 Wilson Ter Glendale CA 91206 951816017 Hospital CA 501(c)(3) 1 Adventist Health SystemWest false Feather River Hospital 5974 Pentz Rd Paradise CA 95969 941101228 Hospital CA 501(c)(3) 1 Adventist Health SystemWest false Central Valley General Hospital 1025 N Douty St Hanford CA 93230 770324630 Hospital CA 501(c)(3) 1 Adventist Health SystemWest false Castle Medical Center 640 Ulukahiki St Kailua HI 96734 990107330 Hospital HI 501(c)(3) 1 Adventist Health SystemWest false Adventist Health SystemWest 2100 Douglas Blvd Roseville CA 956619002 953484589 Support and Manage System-wide Activities CA 501(c)(3) 1 NA false South Coast Medical Center 2100 Douglas Blvd Roseville CA 95661 952037297 Wind down after sale of hospital CA N/A C Corp false false false false false false false false false false false false false false false false false false