2012-11-13T17:05:09-07:00 2011-12-31 990 2011-01-01 951183919 SAN ANTONIO COMMUNITY HOSPITAL INC SANA 9099204711 999 San Bernardino Road Upland CA 91786 Wah-chung Hsu 9099206103 2012-11-13 2011 2016-02-24 21:20:13Z Harris Koenig 999 San Bernardino Road Upland CA 91786 555265586 0 X sach.org X 1920 CA The mission of San Antonio Community Hospital is to improve the overall health of our regional community by offering healthcare services that both comfort and cure in settings that inspire confidence and in a manner that earns the trust of our patients our physicians and our employees. 15 12 2183 300 1506688 807829 1596162 0 292127584 265809104 12335342 9240346 924251 4368214 306983339 279417664 94000 126470 0 0 141396674 144665971 0 0 0 139723439 113032068 281214113 257824509 25769226 21593155 409421008 551683168 105120113 237789264 304300895 313893904 X The mission of San Antonio Community Hospital is to improve the overall health of our regional community by offering healthcare services that both comfort and cure in settings that inspire confidence and in a manner that earns the trust of our patients, our physicians, and our employees. 0 0 240546491 126470 268461952 See Schedule O for detailed description 0 0 0 240546491 1 0 0 1 0 0 0 0 0 1 1 0 0 1 1 0 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 1 1 0 1 394 0 1 2183 1 1 1 0 0 0 0 0 0 0 0 0 X 15 12 0 0 0 0 0 0 0 1 1 0 1 1 1 1 1 1 1 1 0 0 1 1 CA X Wah-chung Hsu 9099206103 999 San Bernardino Road Upland CA 917864920 X Donald Alpiner DO 4 X 2210 0 0 Dora Barilla 4 X 0 0 0 Mark Bertone 4 X X 0 0 0 Dann Bowman 4 X 0 0 0 Andrea Dutton 4 X 0 0 0 Thomas Easter MD 4 X 7517 0 0 Richard Gilbert 4 X 0 0 0 Stanley Kim MD 4 X 42000 0 0 Harris Koenig 40 X X 304597 0 9036 James Milhiser 4 X X 0 0 0 Thomas Ritchie 4 X 0 0 0 Al Ronco 4 X X 0 0 0 Tejinder Singh MD 4 X 1594 0 0 Carl Schultz MD 4 X 0 0 0 Steven Spears 4 X 0 0 0 Roger Parsons 40 X 344222 0 232907 Vincent Leist 40 X 268730 0 26692 Liz Aragon 40 X 251768 0 140196 Jaynie Boren 40 X 248102 0 36200 Lynn Kelly 40 X 243769 0 92333 Kenneth Saltgaver 40 X 165605 0 115583 Carola Drascich 40 X 155824 0 45935 Khoa Phan 40 X 160976 0 9136 Stanley Kwan 40 X 160114 0 85413 Dylan Dang 40 X 154891 0 4410 2511919 0 797841 175 0 1 0 Comforce 17682 Mitchell No Ste 100 Irvine CA 92614 Temporary Labor 1311648 Cerner Corporation 2800 Rockcreek Pkwy Kansas City MO 64117 Computer Remote Hosting 1240805 Softscript 2444 Wilshire Blvd Ste 280 Santa Monica CA 90403 Transcription 825304 Synergy Cardiothoracic Surgery Medical 901 San Bernardino Rd Upland CA 91786 Cardiology prof services 761021 Crothall Laundry Services 5410 East Frances Street Ontario CA 91761 Laundry Services 504239 38 0 Net Patient Revenue 622000 261410253 261410253 0 0 Rental Income MOB 531120 2984190 2984190 0 0 Lab Revenue UBI 621500 854540 0 854540 0 Capitation Revenue 622000 560121 560121 0 0 0 0 0 0 265809104 8312872 0 0 8312872 0 0 0 0 0 0 0 0 0 0 275471905 1173678 273832787 1885322 1639118 -711644 927474 0 0 927474 199960 129813 70147 0 0 70147 Cafeteria Revenue 722100 993070 0 0 993070 Surgery Center UBI Revenue 621990 652148 0 652148 0 Electronic Health Record Meaningful Use Revenue 622000 2036346 2036346 0 0 616503 616503 0 0 4298067 279417664 267607413 1506688 10303563 126470 126470 0 0 0 0 0 0 2533061 215870 2317191 0 0 0 0 0 106924796 101341623 5583173 0 10104406 9580341 524065 0 17171269 16280681 890588 0 7932439 7521023 411416 0 322091 0 322091 0 771865 0 771865 0 192913 0 192913 0 49539 49539 0 0 0 0 575094 0 575094 0 18661912 17693686 968226 0 1962017 1860256 101761 0 10181314 9650046 531268 0 8986136 8520070 466066 0 0 0 0 0 5427604 5146101 281503 0 209900 199014 10886 0 0 0 0 0 354787 336386 18401 0 1498342 1407638 90704 0 0 0 0 0 11482967 10787834 695133 0 3288789 3118216 170573 0 Medical Supplies 43635415 41372265 2263150 0 Medi-Cal Fee Program 3658486 3658486 0 0 Collection Expense 527240 499895 27345 0 Amort Def Financing Costs 475839 451160 24679 0 769818 729891 39927 0 257824509 240546491 17278018 0 9425 9425 26914450 7638883 0 0 43973060 51672022 0 0 0 0 423903 0 3194558 4255401 5228419 5917207 328299701 203454196 97388237 124845505 197621889 315894241 0 0 4202134 4647890 0 0 30464933 36802594 409421008 551683168 30178917 43650135 19320000 122369162 55621196 71769967 105120113 237789264 X 288466441 297475145 11816763 12391568 4017691 4027191 304300895 313893904 409421008 551683168 X 21593155 -12000146 X 0 1 1 X 0 X 0 0 0 0 0 0 0 0 1 49539 49539 0 SchC_P2B_S00_L01 Schedule C, Part II-B, Line 1 San Antonio Community Hospital is a member of the California Association of the American Hospital Association and the American Hospital Association which conducts lobbying activities in support of member hospitals and general healthcare issues. Both associations provide the percentage of dues that relate to lobbying activities. 4017691 9500 32936 0 -5194 38130 4027191 4017691 0 764343 0 743754 20589 4017691 4017691 0 614286 0 601219 13067 4017691 4002691 15000 -766842 0 -780189 13347 4017691 0 1 0 0 1 1 0 10687528 10687528 0 131198375 98978984 32219391 0 2257115 1081371 1175744 0 135503425 103393841 32109584 0 48653258 0 48653258 124845505 Beneficial Interest in SAHF 29293794 Malpractice LT Claims Receivable 4980745 Def Financing Costs 1753521 Def Comp Plan 440886 Due from Affiliates 215457 Physician Recruitment Receivable 118191 36802594 0 Pension Plan Liability 58534722 Self Insurance Liabilities 10303160 Def Gain Constr for other 2023663 Construction Contract Retention 878422 Physician Guarantee Liability 30000 71769967 SchD_P05_S00_L04 Schedule D, Part V, Line 4 San Antonio Community Hospital is the sole corporate owner of San Antonio Hospital Foundation Inc., SAHF, and is required to consolidate SAHF assets and liabilities onto its balance sheet. Proceeds from the endowment funds are intended for the purchase of property and equipment for the benefit of San Antonio Community Hospital. 1 1 X 1 X 3 1 X 1 1 0 1 1 2799029 2799029 0.0108 17439482 15488765 1950717 0.0075 0 0 20238511 15488765 4749746 0.0183 41 72228 739045 91954 647091 0.0025 4 5 220046 8415 211631 0.0008 2 0 494964 0 494964 0.0019 2 9843 61967 26615 35352 0.0001 49 82076 1516022 126984 1389038 0.0053 49 82076 21754533 15615749 6138784 0.0236 6250 0 6250 0 3638 0 3638 0 0 0 9888 0 9888 0 0 27661032 2760000 52213710 52945913 -732203 X 1 1 San Antonio Ambulatory Surgery Center Outpatient surgical center 0.29 0 0.67 1 1 San Antonio Community Hospital

999 San Bernardino Road Upland CA 91786

X X X San Antonio Community Hospital 1 1 1 300 1 350 1 X X X 1 1 X X X X 1 0 1 X 0 0 4 SACH 685 Building Diagnostic Center

685 N 13th Ave Upland CA 91786

Lab and Radiology services in a freestanding medical office building SACH 901 Building Diagnostic Center

999 San Bernardino Road Upland CA 91786

Radiology services in a freestanding medical office building SACH RSA Building Diagnostic Center

7777 Milliken Ave Rancho Cucamonga CA 91730

Lab and Radiology services in a freestanding medical office building SACH Sierra San Antonio diagnostic Center

16465 Sierra Lakes Pkwy Fontana CA 92336

Lab and Radiology services in a freestanding medical office building SchH_P01_S00_L06a Schedule H, Part I, Line 6a San Antonio Community Hospital prepared a Community Benefit Report as required by the State of California. The report was published and made available to the public online at www.SACH.org. Members of the public may request a copy of the Community Benefit Report by contacting the hospital's Community Health Specialist at (909) 920.6153. SchH_P01_S00_L06b Schedule H, Part I, Line 6b Members of the public may request a copy of the Community Benefit Report by contacting the hospital's Community Outreach Department. SchH_P01_S00_L07 Schedule H, Part I, Line 7 The costing methodology used on 7a: Calculated using Worksheets 1 & 2 in the instructions; the cost to charge option. The costing methodology used on 7b: Calculated using Worksheet 3 in the instructions; the cost to charge option. The costing methodology used on 7e to 7i: Calculated using actual costs from SACH's general ledger. SchH_P01_S00_L07b Schedule H, Part I, Line 7b The California Hospital fee program resulted in a net benefit to SACH of $791,997 that reduced SACH's medical shortfall. SchH_P01_S00_L07g Schedule H, Part I, Line 7g None of the costs on this line were attributable to a physician clinic. SchH_P02_S00_L00 Schedule H, Part II San Antonio Community Hospital provided support to four local community organizations. The organizations serve the communities surrounding the hospital. The hospital aided these organizations through financial contributions to enhance the health of the community. These organizations included Fist of Gold Youth Center, Lefty's 5K Run, Reach Out West End Community Health Fair, and the Friends of the Pacific Electric Trail Cucamonga Challenge. These organizations provided the community with the opportunity to participate in a health-related event or activity and promoted healthy eating and active living. The Coalition Building activity represents time spent by the SACH Community Health Specialist who worked directly with community groups to provide health education and technical assistance to support efforts that compliment the objectives identified in the community health needs assessment. Through these partnerships, San Antonio is able to work collaboratively to improve the health status of the communities they serve. In 2011, the hospital worked with one of its partners and the City of Upland to craft a city ordinance that would increase access to healthy food by expanding zoning for community gardens and certified farmers markets. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 Management estimates that approximately 10% of patient bad debts would have been eligible for financial assistance if appropriate information had been made available by applicable patients. From a different perspective, SACH estimates that approximately 80% of all patients eligible for financial assistance were identified. The majority of SACH's bad debts result from medically indigent patients in the Emergency Department. SACH provides this emergency care and related inpatient care without compensation improving the overall health and well being of the community. The following note appears in the audited financial statements: Allowances for Uncollectible Accounts In July 2011, the FASB issued 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 (ASU 2011-07). ASU 2011- 07 is effective for fiscal years and interim periods beginning after December 31, 2011, with early adoption permitted. Changes to the presentation of the provision for bad debts related to patient service revenue in the accompanying consolidated statements of operations should be applied retrospectively to all prior periods presented. ASU 2011-07 states that a health care entity that recognizes significant amounts of patient service revenue at the time the services are rendered even though it does not assess the patient's ability to pay must present the allowance for doubtful accounts as reduction of net patient revenue and not include it as a separate item in operating expenses. The Hospital early adopted this guidance effective January 1, 2011, and applied this presentation retrospectively to the Hospital's 2010 Statement of Operations. The change in presentation and additional disclosures, as required by ASU 2011-07, are reflected in the Hospital's consolidated financial statements. Patient service revenue is reduced by the provision for uncollectible accounts and accounts receivable are reduced by an allowance for uncollectible accounts. These amounts are based on management's assessment of historical and expected net collections for each major payor source, considering business and economic conditions, trends in healthcare coverage, and other collection indicators. Management regularly reviews data about these major payor sources of revenue in evaluating the sufficiency of the allowance for uncollectible accounts. On the basis of historical experience, a significant portion of the Hospital's uninsured patients will be unable or unwilling to pay for the services provided. Thus, the Hospital records a significant provision for uncollectible accounts in the period services are provided to self-pay patients, including both uninsured patients and patients with deductible and copayment balances due for which third-party coverage exists for a portion of their balance. For receivables associated with patients who have third-party coverage, the Hospital analyzes contractually due amounts and provides an allowance for uncollectible accounts and a provision for uncollectible accounts, if necessary. The Hospital increased its uninsured patient discount effective January 1, 2011, to 45% of billed charges from the 35% in place during 2010. Accounts receivable are written off after collection efforts have been followed in accordance with the Hospital's policies. A summary of the Hospital's allowance for uncollectible accounts activity is as follows: December 31 2011 2010 Allowance for uncollectible accounts - beginning balance $ 12,350,000 $ 11,550,000 Provision for uncollectible accounts 27,661,032 27,698,571 Bad debt write-offs, net of recoveries (25,361,032) (26,898,571) Allowance for uncollectible accounts - ending balance $ 14,650,000 $ 12,350,000 The Hospital serves certain patients whose medical care costs are not paid at established rates. These patients include those sponsored under government programs such as Medicare and Medi-Cal, those sponsored under private contractual agreements, charity patients, and other uninsured patients who have limited ability to pay. Patient service revenue is reported at estimated net realizable amounts for services rendered. The Hospital recognizes patient service revenue associated with patients who have third-party payor coverage on the basis of contractual rates for the services rendered. For uninsured patients that do not qualify for charity care, net revenue is recognized based on a range between the Hospital's uninsured patient discount rate and total charges further reduced by the Hospital's estimated bad debt and charity provision. Patient service revenues, net of contractual allowances and discounts and before the provision for uncollectible accounts, recognized from major payor sources are as follows: December 31 2011 % 2010 % Medicare $ 55,984,886 21.3% $ 57,349,527 22.0% Medi-Cal 19,878,611 7.6% 12,244,727 4.7% Managed care 177,987,640 67.9% 179,798,303 68.9% Self-pay and other 36,074,687 13.8% 39,208,664 15.0% Patient service revenues before Provision for uncollectible accounts 289,925,824 288,601,221 Provision for uncollectible accounts (27,661,032) (10.6%) (27,698,571) (10.6%) Net patient service revenues $ 262,264,792 100.0% $ 260,902,650 100.0% SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 SACH has not reported its Medicare shortfall as a community benefit. The cost and reimbursement data were taken directly from SACH's December 31, 2011 Medicare Cost Report. The Medicare Cost Report uses a stepdown cost allocation process and then apportions clinical department costs on a charge to charge basis. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b If a patient qualifies for charity care, or other financial assistance, the hospital does not make collection efforts. SchH_P05_S0B_L13 Schedule H, Part V, Section B, Line 13 Patients who may qualify for charity care under the hospital's Charity Care Policy are provided with information and an application form for Charity Care during the admitting or outpatient process. The hospital's charity care policy is posted in patient registration areas. The hospital's charity care policy provides relief to patients who have no means for making payment. Additionally, a letter is sent to uninsured patients to further promote our policy. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 Although California's Community Benefit Legislation (SB697) only requires a triennial community assessment, San Antonio Community Hospital (SACH) reviews and updates the secondary data each year and conducts primary research no less than every three years. In addition to the annual assessment of secondary data detailed below, the triennial assessment includes primary research that incorporates written surveys, telephone interviews and focus groups. The hospital has engaged independent consulting firms and university research centers to conduct the primary research. The annual assessment looks at the hospital's community from a wide perspective in terms of population, demographics and key health indicators. Most of the data is focused on the hospital's primary service area, since this is where over 80% of the hospital's patients reside, and is also the area most often targeted for its community outreach efforts. During the assessment, primary service area population and demographics are evaluated based on the following statistics: current year population estimates, five-year population segments (children, seniors, women of childbearing age), median age, marital status, households/families, ethnicity, language, education, employment, income, hospitalization rates and number of primary/specialty physicians. Although the assessment focuses on demographic and health information for SACH's service area, there are benefits in examining county data, since many health indicators are only available at the county level. In addition, given the transient nature of the population in San Bernardino County, it makes sense for hospitals to work together and with other healthcare agencies to address issues that affect all county residents. With this in mind, population and demographic data are updated and reviewed for San Bernardino County, while general health indicators are compared to other California counties, state averages and national goals. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 Patients who may qualify for charity care under the hospital's Charity Care Policy are provided with information and an application form for Charity Care during the admitting or outpatient process. The hospital's charity care policy is posted in patient registration areas. The hospital's charity care policy provides relief to families who have no means for making payment. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 SACH defines its community terms of its "service area", which is the geographic area from which it receives the majority of its hospital admissions. For purposes of analysis, the service area is divided into "primary" and "secondary" areas, with the primary service area accounting for approximately 80% of the admissions and the majority of SACH's planning efforts. SACH's primary service area is compromised of the cities of Chino, Claremont, Fontana, Montclair, Ontario, Rancho Cucamonga, and Upland with a total estimated population of 802,730, a median age of 31.8, and a median household income of $65,281. In the population 25 years of age and older, 24.4% have not graduated high school, 23.4% have a high school diploma, 23.4% have some education beyond high school, and 13.3% have a bachelor's degree or higher. The population is predominately Hispanic at 56.7%, followed by Caucasians at 26.6%, African-Americans at 7.6%, Asian-Americans at 6.2%, and all others at 2.9%. The secondary service area, which represents approximately 10% of SACH's admissions, includes Pomona on the west, Rialto to the east, Norco, and Eastvale to the southeast with an estimated total population of 442,905, a median age of 31.5, and a median household income of $58,555. In the population 25 years of age and older, 13% have not graduated high school, 24.2% have a high school diploma, 21.6% have some education beyond high school, and 13.9% have a bachelor's degree or higher. The population is predominately Hispanic at 57.7%, followed by Caucasians at 22.1%, Asian-Americans at 8.9%, African-Americans at 8.5%, and all others at 2.8%. SchH_P06_S00_L05 Schedule H, Part VI, Line 5 SACH has a community board and open medical staff privileges. As in most communities, health and service needs are great, but the resources limited. SACH understands the power of collaboration and seeks alliances with other health and social services providers to develop community based programs with defined goals and measurable outcomes. These partnerships help to leverage the community's scarce resources and achieve the maximum benefit for its residents, which results in demonstrated improvement in their health. The hospital has been proactive in responding to the specific health needs of special populations within our community this includes non-English speakers, persons who live in poverty, have mental or physical disabilities, or in other ways are disenfranchised. SACH is an integral part of San Bernardino County's Healthy Communities initiative which promotes physical, social, and economic environments that support the wellbeing of its members and embraces the belief that health is more than merely the absence of disease. Healthy Communities contain elements that enable people to maintain a high quality of life and productivity. Finally, healthy communities offer access to healthcare services that focus on both treatment prevention and treatment of disease for all members of the community. SACH has provided leadership and professional expertise to support the Healthy Cities in its service area including Healthy Chino, Healthy Fontana, Healthy Ontario, Healthy Rancho Cucamonga, and Healthy Upland. In addition, SACH has been involved in the Montclair Community Collaborative and is participating in the General Plan update for the City of Upland. SACH serves on executive committees, planning committees, and various workgroups in these Healthy cities, providing insight and advice to support strategic planning, implementation and evaluation of health and wellness initiatives. SACH has served on planning and task forces, such as Ontario's Planning, Health Access, and Prevention and Wellness Initiatives, Fontana's Steps Along the Way committee, and Rancho Cucamonga Executive, Steering, Farmers Market, Community Garden, and Nutrition Standards committees. These efforts have reaped substantial rewards, not only in community building, but also in improved health and wellness. For example Healthy RC Kids is addressing a growing concern regarding childhood obesity in our region, and Healthy Ontario is ensuring that low income, uninsured children are not falling through the growing gaps in the local healthcare safety net. The value of the aforementioned Coalition Building activities are reported in Part II Line 6. In addition to these collaborative efforts, SACH continues to provide monetary and in-kind support to health-related nonprofit community organizations such as the American Cancer Society, which provides educational outreach and support programs for cancer patients and their families, and the Children's Fund which helps to prevent child abuse in our community and to ensure that at risk children who are abused, neglected, or abandoned receive adequate food, clothing, shelter, medical care, and education. SchH_P06_S00_L06 Schedule H, Part VI, Line 6 Not applicable. SchH_P06_S00_L07 Schedule H, Part VI, Line 7 San Antonio Community Hospital files a Community Benefit Report with the State of California. 1 San Antonio Hospital Foundation 999 San Bernardino Road Upland CA 91786 330042666 501(c)(3) 55007 0 Meals on Wheels 4792 Falconview Court Fontana CA 92336 952799275 501(c)(3) 0 61967 Cost of goods Meals are provided Donate meals to Meals on Wheels to deliver to seniors 2 0 SchI_P01_S00_L02 Schedule I, Part I, Line 2 The Volunteers and Medical Staff of San Antonio Community Hospital raise funds to support the hospital. Those funds are donated annually to San Antonio Hospital Foundation, a related 501(c)(3) organization. The Hospital's CFO is also CFO for the Foundation. The Hospital CFO is resposible for monitoring all Foundation disbursements, including disbursements related to grant funding. X X 1 1 X X X X X 0 1 0 0 0 0 0 0 0 Harris Koenig 302845 0 0 0 1752 0 0 0 9036 0 313633 0 0 0 Roger Parsons 264512 0 66699 0 13011 0 224061 0 8846 0 577129 0 0 0 Vincent Leist 167910 0 69299 0 31521 0 19902 0 6790 0 295422 0 0 0 Liz Aragon 208361 0 37296 0 6111 0 126616 0 13580 0 391964 0 0 0 Jaynie Boren 149781 0 39091 0 59230 0 21794 0 14406 0 284302 0 0 0 Lynn Kelly 198963 0 38994 0 5812 0 81579 0 10754 0 336102 0 0 0 Kenneth Saltgaver 164995 0 0 0 610 0 104057 0 11526 0 281188 0 0 0 Khoa Phan 158865 0 2000 0 111 0 8635 0 501 0 170112 0 0 0 Stanley Kwan 155294 0 2870 0 1950 0 78683 0 6730 0 245527 0 0 0 Carola Drascich 142894 0 12232 0 698 0 34649 0 11286 0 201759 0 0 0 Dylan Dang 139835 0 0 0 15056 0 0 0 4410 0 159301 0 0 0 SchJ_P01_S00_L01a Schedule J, Part I, Line 1a The hospital requests board members to attend various educational sessions during their term. In recognition that board members serve without compensation and that attending educational sessions takes most board members away from their jobs or businesses, the hospital provides reimbursement for spousal travel. The hospital also grosses up the spousal travel reimbursement and reports the grossed up amount on a 1099 given to the board member. SchJ_P01_S00_L04 Schedule J, Part I, Line 4 San Antonio Community Hospital provides a 457(f) supplemental non-qualified plan for seven members of its executive management team. The plan provides an accrued (but not paid) benefit up to a maximum of 10% of each of the executive's base pay. The plan accrues earnings at the 10-year Treasury note rate on the last banking day of each year. The plan participants are not eligible to receive the funds in this plan until retirement or termination. City of Upland 956000805 915346FH8 2011-01-27 122414361 See attached statement 0 0 0 0 0 126537058 0 0 14667046 1865015 0 0 0 0 110004997 1 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 X SchK_P01_S00_L00a Schedule K, Part I, Column a The Certificates of Participation were issued by the City of Upland, California evidencing individual ownership interests of the holders there of in installment payments to be made by the City of Upland from purchase payments to be received from San Antonio Community Hospital SchK_P01_S00_L00c Schedule K, Part I, Column c CUSIP numbers are 915346EW6, 915346EX4, 915346EY2, 915346EZ9, 915346FA3, 915346FB1, 915346FC9, 915346FD7, 915346FE5, 915346FF2, 915346FG0, 915346FJ4 and 915346FH8. SchK_P01_S00_L00f Schedule K, Part I, Column f Borrowing proceeds to be used for the construction of a four story patient care tower, an energy plant, and related site utilities for $110,004,997 and to refund existing long term debt dated September 1, 1993 of $14,667,046. SchK_P03_S00_L07 Schedule K, Part III, Line 7 San Antonio Community Hospital is in the process of developing post-issuance procedures to be in place prior to debt financed addition being placed into service. San Antonio Radiological Group Trustee, Carl L Schultz 313276 Compensation for services 0 F990_P03_S00_L04a Form 990, Part III, Line 4a "Overview" -San Antonio Community Hospital (SACH) was founded by Dr. William Howard Craig in 1907, just a year after the City of Upland was incorporated. As the community surrounding the hospital grew, it became apparent that larger, more modern facilities were needed. Frances Mary Paul, the widow of a local banker, spearheaded the effort to raise funds to build a new hospital by personally donating $75,000. The community rallied and sufficient funds were raised. The hospital moved on July 30, 1924, from its original location on the corner of San Antonio Avenue and Arrow Highway, to its present location on San Bernardino Road. SACH has grown from its modest beginning as an eighteen-bed hospital with five physicians and limited staff to a 279-bed regional medical facility with 1,641 full time equivalent employees and a medical staff of nearly 500 physicians. In 2011, the Hospital had approximately 15,375 inpatient admissions, 137,000 outpatient visits, and 73,600 emergency room visits. SACH is currently constructing the largest expansion in its 100-year history to replace its emergency department and add a patient tower to meet the needs of the growing population in the west end of California's Inland Empire. "Leadership"-SACH is governed by a 15-member Board of Trustees. The hospital's President and Chief Executive Officer, and the medical staff's President-Elect, President, and Immediate Past President are members of the board by virtue of their offices. Two additional physicians are elected from the medical staff, and the remaining members are elected from the community at-large. The Board of Trustees, with physician leaders comprising 33 percent of its membership, sets the direction for the hospital and its Community Benefits Program. The Executive Management Group directs the hospital's strategic planning process and allocates resources for community benefit activities. The Executive Management Group is comprised of the Chief Executive Officer, Chief Financial Officer, Chief Nursing Officer, Vice President of Human Resources, Vice President of Administrative Services, Director of Business Development and Community Outreach and President of the Hospital Foundation. Department directors are responsible for the operation and management of the individual departments. The directors encourage employee participation in community benefit activities, and it is this support that ensures the ultimate success of the SACH's community outreach program. "Our commitment" -The leadership at SACH has an unwavering commitment to the hospital's mission, vision, values, and strategic plan, which focus on improving the region's overall health by providing quality patient care in a compassionate and caring environment. Our mission is to improve the overall health of our regional community by offering healthcare services that both comfort and cure, in settings that inspire confidence, and in a manner that earns the trust of our patients, our physicians, and our employees. Our vision is to use our strengths to enhance our reputation for excellence in quality care, patient experience, and an exceptional working and practice environment. Our values articulate the principles that help us to fulfill our mission and vision, and our strategic plan specifically addresses the development of programs and services in response to regional community needs. SACH's commitment to providing quality care for all members of our community has received national recognition. In its 2009 National Benchmarks study, Thomson Reuters recognized SACH as a "Top 100 Hospital" in the United States. SACH was the only large community hospital in California and the first California hospital in four years to receive an award. This recognition is based on performance achievements in nine areas: mortality, medical complications, patient safety, average length of stay, expenses, profitability, cash-to-debt ratio, patient satisfaction, and adherence to clinical standards of care. In addition to the Top 100 Hospital award, Thomas Reuters selected SACH as one of 23 hospitals nationally to receive its inaugural "Everest" award for sustained operational performance and rapid increase in performance improvement rates over the previous five years. In addition, HealthGrades has recognized SACH for quality excellence in Emergency Medicine, Stroke Care, and Maternity Care. In 2008, SACH became the 65th hospital in the United States to receive the Baby Friendly designation which measures infant health, breast feeding, and infant-parent attachment based on global criteria developed by the World Health organization and UNICEF. SACH has also been honored by the California Hospital Assessment Reporting Task Force (CHART) for excellence in clinical and safety measures. "Caring for our Community" - Community benefits are more than just numbers. They represent people-moms and dads, children and grandparents, and the homeless, helpless, and hopeless. San Antonio Community Hospital goes above and beyond the delivery of essential patient care services to ensure healthier children, early detection of disease, and enhanced access to basic healthcare services. It captures the essence of our purpose: to improve health and make the community a better place to work, grow, and play. As a regional healthcare provider, SACH is committed to maintaining the highest quality of care for those we serve. As a nonprofit hospital, all of our resources are devoted to providing healthcare services. Any surpluses generated from hospital operations are used to purchase new or upgraded equipment, expand services, and provide care for vulnerable populations. While the Inland Empire is a maturing economic market, as a whole, many individuals and families are at significant risk during a medical crisis due to their inability to access health insurance or as the result of inadequate insurance coverage. The hospital's charity care policy provides relief to these families who would otherwise face medical bankruptcy. During 2011, $2,799,029 (at cost) in charity care was provided for qualifying patients. In addition to this direct medical care, SACH reaches out to its community in a variety of ways that go well beyond the traditional care provided by an acute care hospital. "Planning"-SACH conducts a formal strategic planning process involving senior management, the board, the medical staff leadership every three years with annual reviews and updates. In 2008, the executive management team worked closely with SACH's Board of Trustees and Medical Staff to develop a three-year strategic plan for 2009 to 2011, which includes details of strategic, operational, quality and community benefit initiatives. In addition to programmatic and service enhancement projects, the strategic plan includes a Facilities Master Plan, which calls for the renovation and expansion of the hospital's main campus. " Facility Expansion" - The expansion, expected to open in late 2013, will include new medical/surgical and intensive care inpatient beds and a new Emergency Department, which are essential to accommodate the growing needs of SACH's service area and to offset the expected reduction in the number of medical/surgical beds as a result of current State seismic compliance requirements. The tremendous growth experienced in SACH's Emergency Department services is key driver of the planned expansion. The hospital's 29-bed Emergency Department, which was built in 1975, was designed to accommodate 30,000 patient visits per year. In fiscal year 2011, the SACH's Emergency Department had 73,600 visits. With the high unemployment in the hospital's service area, the number of uninsured patients treated in the Emergency Department continues to rise, adding additional stress to the already overburdened existing facilities. "Four-Story Patient Tower" - The primary structure in the planned addition to SACH's facilities will be a four-story patient care tower to be constructed on the east side of the hospital campus immediately adjacent to the existing patient tower and ancillary service departments. The four-story tower designed to include a 52-bed replacement Emergency Department, including computerized tomography ("CT") scanning and other radiology capabilities, 80 medical/surgical and telemetry rooms, 12 intensive care rooms, a new main lobby, 33,470 square feet of shelled space on the first floor, and site improvements including parking and landscaping. F990_P03_S00_L04b Form 990, Part III, Line 4b Continuation of explanation on line 4A: "Energy Plant and Site Utilities" - The addition of the new four-story patient care tower will require construction of a conventional energy plant to supplement existing co-generation capacity. The new energy plant will be built near the existing energy plant in a location consistent with appropriate environmental standards. The site utilities project will connect the new energy plant with the new four-story patient care tower. "Hospital Services" - SACH provides a full spectrum of preventive acute, primary, and specialty care to the communities it services. These services include inpatient medical and surgical service, emergency and intensive care services, palliative care and a community wellness and health promotion program. Areas of special expertise include cardiovascular services provided at SACH's Heart Center, specialized infant care provided at the Level II neonatal intensive care unit (NICU), and the diagnostic and treatment services available at its Cancer Center and Gamma Knife Center, "The Heart Center" - SACH's heart program coordinates the comprehensive cardiac service line, including non-invasive cardiology, diagnostic and interventional cardiac catheterization, cardiac nuclear scanning, cardiovascular surgery, and cardiac rehabilitation. SACH has been designated as "STEMI" (ST-elevation myocardial infarction)-receiving hospital by San Bernardino, Los Angeles and Riverside counties, meaning that the hospital has the equipment, expertise and facilities to administer percutaneous coronary intervention, the preferred method of treating severe heart attack patients. SACH is the only hospital in the Inland Empire with a three-county designation. "Cancer Center" - SACH's cancer program has been fully accredited by the American College of Surgeon's Commission on Cancer Since 1980. The hospital treats more than 800 new cancer cases per year. The cancer program treatment modalities include surgery, chemotherapy, hormone therapy, and immunotherapy. Outpatient radiation oncology services include 3D conformal, external beam, electron beam and intensity modulated therapy ("IMRT"). The Cancer Resource Center provides education and support services for cancer patients and their families. Nurse navigators are part of the cancer team and meet with every hospitalized patient with cancer. The navigators also work closely with the physicians on an outpatient basis to ensure that patients have a positive experience as they move between the inpatient and outpatient status during different stages of their treatment. "Gamma Knife Center" - SACH offers the only Gamma Knife radiosurgery system in its primary service area. The Gamma Knife enables the hospital's Radiation Oncology and Neurosurgery Department to conduct noninvasive, outpatient brain surgery, using low-dose radiation beams to target tumors and abnormal cells with precision. The less invasive method is performed on an outpatient basis, allowing patients to receive treatment and return home the same day. "Women's Breast and Imaging Center" - The Women's Breast and Imaging Center is located immediately adjacent to the main hospital facility and offers patients the latest advancements in screening and diagnostic procedures for early detection of breast cancer. The Center's technology includes digital mammography, ultrasound and stereotactic breast biopsy procedures. A dedicated nurse navigator coordinates the breast cancer patient's care throughout diagnosis, treatment, and recovery. Additional screening services for women's health offered at the Center include general ultrasound for diagnosing gynecological disorders and osteoporosis screening for assessing bone health. A focus of the Women's Center is assure that the patient's experience is as positive as their medical outcome. "Maternal Child Services" - coordinates care with obstetricians and pediatricians to provide comprehensive prenatal, delivery and postpartum care. The Maternal Child Department includes 32 maternity beds, four labor, delivery and recovery rooms, 10 labor, delivery, recovery and postpartum rooms, a cesarean section surgical suite and recovery room, and a 20-bed NICU. A postpartum follow-up center is located near the main hospital to provide screening and support services for infants and their parents. The services provided at the center are offered to all families regardless of where they delivered their baby, and the nominal fee is waived for any family that cannot afford to pay the services provided by SACH's Internationally Board Certified Lactation Consultant. SACH is designated a Baby Friendly hospital by the World Health Organization. This designation is an important part of SACH's Healthy Beginnings program, which reinforces the benefits of breastfeeding. "Surgical Services" - The Surgery Department operates nine surgical suites and two additional surgical suites dedicated to cardiovascular surgeries. The Surgery Department performs approximately 350 inpatient and 350 outpatient surgeries per month, including general surgery and surgeries in the specialties of orthopedics, cardiology, gynecology, urology, otolaryngology, and ophthalmology. "Imaging and Radiation Oncology Services" -The Radiology Department provides imaging services to support the SACH's Emergency, Surgery, and other departments. The imaging services offered to both inpatients and outpatients include diagnostic radiology and fluoroscopy, 64-slice CT scan, 3-T magnetic resonance imaging (MRI), interventional radiology, ultrasound, mammography, and special procedures. The Radiation Oncology Department provides external beam radiation for the treatment of various cancer conditions and brachytherapy for the treatment of prostate cancer. "Community Education"- SACH offers a broad array of education classes, support groups and community lectures to meet the health needs of its community. Some of the programs are offered on-site, but many are provided at locations throughout the community to reach those who may have special needs or lack transportation and would otherwise fail to access these important services. In addition to gaining knowledge about important health topics, participants may participate in free screenings to identify potential health concerns such as high blood pressure, high cholesterol, high glucose, skin cancer, and prostate cancer. "Community Benefit Initiatives" - As part of its mission to improve the health of the community it serves, SACH conducts an ongoing assessment process to identify community health needs. The hospital's Community Outreach Department supports a variety of services designed to meet these needs, including support groups, educational seminars and community health fairs, as well as several targeted health initiatives. A few if these programs are highlighted here. "Healthy Beginnings" - SACH's maternal/child services, collectively known as Healthy Beginnings, is committed to providing excellent service and care, which result in the best possible outcome for the newest members of its community and their families. In support of this goal, the hospital engaged in an extensive in an extensive process to become a "Baby Friendly Hospital," which is an international designation recognizing the institution's comprehensive program supporting breastfeeding and infant/parent bonding. As part of this program, parents are encouraged to take advantage of the many educational opportunities and support services offered before, during, and after delivery. Expectant parents attending the breastfeeding class receive encouragement and instruction to promote a successful breastfeeding experience. Internationally Board Certified Lactation Consultants, supported by lactation educators, are available to provide support during the family's hospital stay, and every family is encouraged to visit the Healthy Beginnings Newborn Feeding Center after they leave the hospital. In addition to providing breastfeeding evaluation and support, the Newborn Feeding Center assesses mother and newborn, providing referrals to community resources when needed. This thorough evaluation process has yielded significant outcomes including a reduction in newborn readmission rates, increased breastfeeding rates, early intervention for development delays and identification and treatment of postnatal illness, from baby blues to postpartum psychosis. While some families just need reassurance that their baby is thriving, others may require further education or support, and a few require intervention or treatment. The Center offers support to all new families in the community, regardless of where their babies are born. In fact, many local pediatricians include a visit to the Center as part of the discharge instructions for their patients. F990_P03_S00_L04c Form 990, Part III, Line 4c Continuation of explanation provided on line 4A. "Dental Center" - The San Antonio Community Hospital Dental Center has been operating for over 75 years with the mission to provide dental care to low-income, uninsured children in Western San Bernardino County. The Dental Center operates during the school year, with clinics held from October through May. In addition to direct patient care, the Dental Center provides in-school screening to identify children in need of dental care. The Dental Center's goal is to educate children about the importance of dental hygiene and to provide prophylactic and therapeutic dental and orthodontic services to this vulnerable population. Some of the children treated have been unable to eat properly or to function in school due to the pain being experienced. Once located on the hospital's campus, the Dental Center is now housed in a dedicated building in Rancho Cucamonga owned and operated by the Assistance League of the Foothill Communities. SACH paid the remodeling cost for the Dental Center building in 1985 and continues to provide financial assistance and other services to support the program. The Dental Center is a prime example of the benefits that can be provided to families in need through collaborative efforts. SACH, the Assistance League of the Foothill Communities, volunteer dentists, hygienists and other health and dental professionals, along with a variety of funding agencies are devoted to improving the health and well-being of elementary and junior high school children throughout the regional community. "Safe Surrender" -SACH's Safe Surrender program and DVD entitled "Safe Surrender. No Shame. No Blame. No Names." is a wonderful example of how the hospital and its employees recognize and take ownership in community health issues where they can make a difference. Officially called the "Safe Haven" law, the Safe Surrender program ensures that a baby can be surrendered anonymously to any hospital, fire department, or police department without criminal repercussions. While many healthcare workers were aware of the law, few junior high, high school and college students knew about this safe and secure option for both infant and parents. Produced in partnership with college film students, Safe Surrender. No Shame. No Blame. No Names. contains powerful imagery and interviews with teenage girls who relate to young women at their own level. The DVD is available free of charge to anyone willing to help raise awareness of the Safe Surrender alternative to infant abandonment. From the moment of its release, there has been an overwhelming response that has garnered statewide attention due to its poignant and highly effective portrayal of the unfortunate consequences of infant abandonment, as well as offering life-saving alternatives. To date more than 2,300 copies of the DVD have been distributed to over 750 different community organizations, school districts, nurse educators and teachers. The San Bernardino County Superintendent of Schools, through its School Linked Health Programs and Partnerships, has incorporated the hospital's Safe Surrender DVD into its Positive Prevention Plus sex education curriculum. San Bernardino County has rolled the program out to all 34 of its school districts, educating nurses and teachers and targeting thousands of middle school and high school students. After serving as a pilot project and seeing the program's impact on its students, San Bernardino County is printing the curriculum for distribution to school districts throughout California who request it. It is also available through the Department of Education's Healthy Kids Resource Center. With the additional exposure through the school curriculum, the number of young people touched by the DVD's message will continue to grow. "Sports Injury Clinic" - SACH launched the Sports Injury Screening Clinic at its Rancho San Antonio satellite facility in late 2009. The program was introduced to provide free screenings for community members who have sustained sports-related injuries. Through discussions with various school health advisory councils, SACH soon realized that in addition to the program for the general community, there was strong support for a free sports screening program targeted to local school districts, city community centers, youth league programs, senior citizen programs and adult intramural leagues. Using this targeted approach has enabled the clinic to help several uninsured high school athletes who were screened and educated about their injuries. The students not only learned how to manage their current injury to speed recovery, but also learned methods to avoid additional injuries in the future. These free services have allowed the students to get back to a healthy lifestyle and to return to their sport. One young athlete who suffered a head injury while playing soccer arrived at the clinic with an undiagnosed brain injury. The family had heard about the screenings and brought their athlete in to undergo a special test designed to diagnose patients with head injuries. When the serious nature of the injury was identified through the screening, the young woman was referred for an MRI and follow-up consultation with a neurologist. If this young athlete had failed to access treatment, this injury could have been debilitating, if not life-threatening, particularly if she were to sustain further injury. Through this program, SACH has been able to diagnose, educate, and immediately activate treatment plans for these athletes, and at no cost to the families. In these fragile economic times when many families have lost health insurance coverage, this community service takes on even greater importance. The walk-in screening clinic takes place every Monday from 4 pm to 6 pm at the Rancho San Antonio Rehabilitation Center in the City of Rancho Cucamonga. Each patient that comes into the clinic with a sports injury receives a free medical screening by a board-certified physician in addition to a free assessment by a physical therapist and/or athletic trainer. Plans for the program include increasing community awareness via local newspapers, school districts, and adult and youth sports leagues. Given the enthusiastic response of the people who have been served by the clinic, it is anticipated that demand will continue to grow which could lead to further expansion of the program. F990_P03_S00_L04d Form 990, Part III, Line 4d Continuation of explanation provided on line 4A. "HAPPY Children's Health Initiative" - SACH is an active participant in Healthy Ontario's prevention and wellness and healthcare access workgroups. These initiatives are closely aligned with the hospital's goal to improve the health status of the communities we serve and provide a tangible means for the hospital to respond to identified community needs. Healthcare access in the City of Ontario is particularly challenging given that 22% of the population is uninsured and 16% do not have a regular medical home. As a result, access for this particular population is primarily through the 911 system and hospital emergency departments. One of the key objectives established by the healthcare access workgroup was to encourage appropriate utilization of high-cost services and systems, and to properly channel resources to increase access to preventive and primary care. It is out of this objective that HAPPY (Health Access Partnership Project for Youth) was born. HAPPY's goals are to increase health plan enrollment for qualified children, conduct health screenings for children without access to healthcare through collaboration and coordination of care among public and private entities, and to demonstrate cost savings through new models of health care for children within targeted groups. Children are enrolled in the HAPPY Club through Kids Come First Community Clinic and are given an identification card. All services provided through the program are monitored and evaluated to measure health outcomes. Since the program is currently designed as a pilot project, it is limited to children who reside in the City of Ontario and are not currently covered in the health system. The HAPPY project is designed to increase access to children's preventative health services such as regular medical check-ups, preventative & wellness care, screening and assessment, immunizations, health education and specialty care referrals. The program began in the summer of 2009, but enrollment did not begin in earnest until school was in session. During its first year, the HAPPY Club enrolled 530 children, which put the program well on its way to achieving its goal to enroll 1,500 children over an 18-month period. Given its rapid growth in membership, it is likely that HAPPY will reach its enrollment goal during the 2011-2012 school year. Since its inception, the HAPPY Club has made a tremendous difference in the lives of many children and their families by filling the gap in the safety net. Each child enrolled in the Happy Club receives a medical screening, and in many cases these screenings lead to early intervention and referrals to critically needed medical care. This is where SACH steps in to help by facilitating referrals to physicians who can provide the specialized medical care needed. In addition to arranging for referrals to pediatric specialists on its medical staff, SACH provides laboratory, radiology, cardiology and various other diagnostic procedures for HAPPY children who need further medical follow-up. In addition to the expense incurred by the hospital, physician specialists including radiologists and cardiologists donate their time and resources to interpret the diagnostic exams and report their findings to the medical director at the Kids Come First clinic. Access to diagnostic testing has enabled the medical providers at the clinic to identify and treat health problems that had gone undiagnosed due to the family's inability to access medical care for their child. Without treatment, many of these children are at risk for more serious health problems that can develop into lifelong chronic diseases such as diabetes. Healthy Ontario's experience has demonstrated that new ways of thinking about health can lead to innovative models of care like the HAPPY Club, which is effectively filling some of the holes in the healthcare safety net. The hope for the future is that the success achieved by Healthy Ontario's pilot project will become a model that other cities can replicate to mirror the HAPPY Club's success in their own communities. F990_P06_S0B_L10a Form 990, Part VI, Section B, Line 10a The hospital has a Medical Staff organization whose activities are separate from the hospital's but the hospital's governing board has ultimate authority over certain medical staff actions. F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b The Form is prepared internally by the organization's Accounting Department and reviewed by the organization's CFO. The Form is then reviewed by the organization's external financial and tax audit firm. Following the external review, the CFO reviews the Form with the organization's CEO. The Form is then sent to members of the organization's Board Audit Committee for review and approval. The Form is then sent to the entire organization Board prior to final signatures and filing. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c The organization has a Compliance Officer who reviews the organization's compliance policies, including its conflict of interest statements, at least annually. The organization's Board has an organization meeting every January. At the annual organization meeting conflict of interest statements are distributed to all Board members and Officers and subsequently collected by the organization's Compliance Officer. The CFO, who attends all Board meetings, also reviews the Board conflict of interest statements. If a new potential conflict of interest arises during the year, a new conflict of interest statement is signed. If a potential conflict of interest exists during a Board discussion, the Board member is required to state the conflict and abstain from any related Board votes. Board minutes reflect these abstentions. At least semi-annually, the organization's Compliance Officer provides a verbal compliance update at a Board meeting and reminds Board members of their duty to disclose potential conflicts of interest. The organization follows a similar annual procedure for members of its executive management and department directors, including at least annual compliance education sessions. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 The organization has not made its governing documents or conflict of interest statements available to the public. The organization's financial statements are part of the Organization's annual report filed with the California Office of Statewide Health Planning and Development (OSHPD) and are available on the OSHPD Web site. The organization's financial statements are also included as part of its annual Medicare and Medicaid cost report filings which are publically available on the CMS (Medicare) Web site. The organization's financial statements are also provided to anyone upon a verbal or written request. The Audited Financial Statements are attached to the Form 990 in accordance with the IRS instructions. F990_P07_S0A_L01a Form 990, Part VII, Section A, Line 1a The average weekly hours worked by the officers of the hospital for related organizations are as follows: CEO, Foundation 2 hours and Health plan 1 hour and CFO, Foundation 2 hours and Health plan 3 hours and Chairman, Health Plan 1 hour and Trustee, Dann Bowman, Foundation 1 hour. F990_P11_S00_L05 Form 990, Part XI, Line 5 Unrealized gain on investments 3,811,288, Unfunded Pension liability ($16,893,091), increase of interest in subsidiary SAHF-temp restricted earnings of $574,805, interest in subsidiary SAHF - unrestricted earnings $431,143, interest in subsidiary SAHF - perm restricted earnings $9,500, book-tax difference in ASC income of $66,209. San Antonio Hospital Foundation Inc 999 San Bernardino Road Upland CA 91786 330042666 support SACH CA 501c(3) 7 SACH 1 San Antonio Community Health Care Plan 999 San Bernardino Road Upland CA 91786 237391094 Health Plan services CA 501c(9) SACH 1 Cucamonga Health Services 999 San Bernardino Road Upland CA 91786 330010073 holding company CA SACH C 148 345909 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 San Antonio Hospital Foundation Inc p 721685 Market Value San Antonio Community Health Care Plan q 11357579 Market Value San Antonio Hospital Foundation Inc b 55007 Market Value