2023-11-06T13:59:29-06:00 2022-12-31 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2022-01-01 910545036 TRI-STATE MEMORIAL HOSPITAL TRI- 5097585511 1221 HIGHLAND AVENUE CLARKSTON WA 99403 KYM CLIFT CEO 5097585511 2023-10-30 1 KYM CLIFT 999009999 1 TERRI REXRODE CPA MST P00096513 9206620016 2023-10-30 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z TRISTATE HEALTH KYM CLIFT 1221 HIGHLAND AVENUE CLARKSTON WA 99403 125959769 0 X WWW.TSH.ORG X 1955 WA TRI-STATE MEMORIAL HOSPITAL, A 62 BED LICENSED NOT-FOR-PROFIT COMMUNITY OWNED HOSPITAL, IS CURRENTLY OPERATING AS A 25 BED CRITICAL ACCESS HOSPITAL. THE HOSPITAL SERVES A 10 COUNTY REGION IN THREE STATES (WASHINGTON, OREGON, AND IDAHO). 13 11 778 35 -428031 0 8984083 5127973 113772198 122692475 1759582 393783 -2480743 -3539009 122035120 124675222 7800 6250 0 0 54802223 58477182 0 0 0 53776228 60925619 108586251 119409051 13448869 5266171 107847750 116790521 27866101 38139966 79981649 78650555 FROM OUR FIRST DAY OF OPERATION UNTIL TODAY, WE ARE PROUD TO SAY THAT OUR MISSION HAS ALWAYS REMAINED THE SAME: THE PATIENT IS OUR FIRST PRIORITY. 0 0 106402162 6250 118271425 THE HOSPITAL PROVIDED 4,570 DAYS OF CARE TO 1,108 PATIENTS IN 2022. IN ADDITION, THE HOSPITAL PROVIDED APPROXIMATELY 326,340 OUTPATIENT VISITS IN THE EMERGENCY ROOM, RENTAL DIALYSIS, SURGICAL, AND OTHER PATIENT SERVICE CENTERS. THE HOSPITAL PROVIDED APPROXIMATELY $2,523,316 IN CHARITABLE SERVICES TO PATIENTS UNABLE TO PAY FOR HEALTHCARE SERVICES. 106402162 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 0 1 0 1 62 0 778 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 13 11 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 0 0 X TERESA GALL 5097585511 1221 HIGHLAND AVENUE CLARKSTON WA 99403 KIMBERLY BLEWETT BOARD MEMBER 40.00 X 253018 0 31913 JOHN RUDOLPH MD BOARD MEMBER 40.00 X 392262 0 31355 DON MCQUARY PRESIDENT 1.00 X X 0 0 0 MIKE MARTIN VICE PRESIDENT 1.00 X X 0 0 0 DAN KLAVEANO SECRETARY/TREASURER 1.00 X X 0 0 0 SCOTT ARNONE BOARD MEMBER 1.00 X 0 0 0 DEBRA R AUSMAN BOARD MEMBER 1.00 X 0 0 0 STEVE CLAASSEN BOARD MEMBER 1.00 X 0 0 0 E WAYNE DAY MD BOARD MEMBER 1.00 X 0 0 0 DICK FLERCHINGER BOARD MEMBER 1.00 X 0 0 0 K DAVID HAGEN BOARD MEMBER 1.00 X 0 0 0 PAUL JELINEK BOARD MEMBER 1.00 X 0 0 0 RICK WASEM BOARD MEMBER 1.00 X 0 0 0 KYM CLIFT CEO 40.00 X 361634 0 23233 JIM HEILSBERG CFO 40.00 X 235693 0 14603 CRAIG FLINDERS PHYSICIAN 40.00 X 560538 0 38931 LEROY SMITH PHYSICIAN 40.00 X 485367 0 22086 ELINA CHERNYAK PHYSICIAN 40.00 X 607157 0 20558 TALMADGE CAVINESS PHYSICIAN 40.00 X 546801 0 31512 KENNETH BERGER PHYSICIAN 40.00 X 556878 0 22509 3999348 0 236700 84 0 1 0 PATHOLOGISTS REGIONAL LAB PO BOX 956 LEWISTON ID 83501 LAB SERVICES 4210118 MEDEFIS CONSOLIDATED PO BOX 5068 NEW YORK NY 10087 LOCUM STAFF & PHYSICIANS 3790391 SPRING RIVER EMERGENCY 4535 DRESSLER ROAD NW CANTON OH 44718 EMERGENCY ROOM PHYSICIANS 2633662 TWIN CITY RADIOLOGY PO BOX 136 CLARKSTON WA 99403 RADIOLOGY PHYSICIANS 1626389 RURAL PHYSICIANS GROUP 10023 BRYCE ROSE AVE LAS VEGAS NV 89148 HOSPITALISTS PHYSICIANS 560084 22 3829587 1298386 5127973 NET PATIENT SERVICE 621400 119336215 119336215 340B REVENUE 621400 1242821 1242821 MOB RENTAL INCOME 621400 37278 37278 2076161 2076161 122692475 821547 821547 428752 856783 -428031 -428031 -428031 190145 237619 -190145 -237619 -427764 -427764 INCOME ON INVESTMENT IN SUBSIDIAR 900099 -4421050 -4421050 1310072 1310072 -3110978 124675222 118271425 -428031 1703855 X 6250 6250 1343711 423617 920094 45086999 39229478 5857521 1229694 1014427 215267 7301047 6134479 1166568 3515731 2911077 604654 83836 83836 37656 896 36760 22404366 20395499 2008867 458130 290267 167863 2590550 2141123 449427 11711 11711 3405678 3405678 963237 963237 MEDICAL SUPPLIES 25221111 25221111 BAD DEBT 1318510 1318510 LICENSES AND TAXES 965476 965476 304B EXPENSES 895949 895949 2569409 1073377 1496032 119409051 106402162 13006889 0 12963524 7420226 2913964 6449073 14863061 14453426 277588 2785321 3024974 799779 802340 117845759 62995078 35243294 54850681 27292181 15461551 124585 114366 3384400 3384400 7477641 10551896 107847750 116790521 9545252 11155371 412402 13890447 17908447 13094148 27866101 38139966 X 72507734 72135794 7473915 6514761 79981649 78650555 107847750 116790521 X 5266171 -5050485 -1546780 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4073 4073 0 PART II-B, LINE 1: THE FACILITY PAYS DUES TO THE WASHINGTON STATE HOSPITAL ASSOCIATION, THE NATIONAL RURAL HEALTH ASSOCIATION AND THE IDAHO HOSPITAL ASSOCIATION. A PERCENTAGE OF THESE DUES WERE USED FOR LOBBYING ON BEHALF OF HEALTH CARE ORGANIZATIONS. 5798346 76531 -1152140 -113512 4836249 5704063 33538 1107194 1046449 5798346 4868807 124950 907885 197579 5704063 3489793 507510 871504 4868807 3682682 -192889 3489793 0.00000 0.11430 0.88570 0 1 1 2667156 2667156 42579759 24351112 18228647 1079344 269572 809772 46282154 38374394 7907760 25237346 25237346 54850681 INTEREST IN NET ASSETS OF THE FOUNDATION 6339325 LAND HELD FOR FUTURE EXPANSION 240710 RIGHT OF USE ASSET - FINANCE 3971861 10551896 THIRD PARTY PAYOR SETTLEMENTS PAYABLE 77729 INVESTMENT IN SUBSIDIARIES 8816405 FINANCE LEASE LIABILITIES 2543068 OPERATING LEASE LIABILITIES 1656946 13094148 X PART V, LINE 4: THE FOUNDATION'S ARTICLES OF INCORPORATION PROVIDE THAT ALL FUNDS RAISED, EXCEPT FOR FUNDS REQUIRED FOR OPERATION OF THE FOUNDATION, SHALL BE DISTRIBUTED TO OR HELD PRIMARILY FOR THE BENEFIT OF THE HOSPITAL OR THE HOSPITAL'S MISSION IN THE COMMUNITY. THE HOSPITAL ALSO HOLDS PERMANENTLY AND TEMPORARILY DONOR-RESTRICTED ENDOWMENT FUNDS. PART X, LINE 2: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE ORGANIZATION DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED ON EXAMINATION BY THE TAXING AUTHORITIES BASED ON THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THE TAX POSITION IS NOT RECOGNIZED IN THE CONSOLIDATED FINANCIAL STATEMENTS. 1 1 X 1 X 1 X 1 1 1 0 1 1 1170695 34016 1136679 0.00960 13973348 12685378 1287970 0.01090 15144043 12719394 2424649 0.02050 26115 26115 0.00020 26115 26115 0.00020 15170158 12719394 2450764 0.02070 28578 28578 0.00020 28578 28578 0.00020 1 606515 0 40310054 40242919 67135 X 1 1 1 1 TRI-STATE MEMORIAL HOSPITAL 1221 HIGHLAND AVENUE CLARKSTON WA 99403 WWW.TSH.ORG H-108 X X X X TRI-STATE MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 22 1 0 0 1 X HTTPS://WWW.TSH.ORG/COMMUNITY/ X 1 22 1 HTTPS://WWW.TSH.ORG/COMMUNITY/ 0 1 X 200.000000000000 350.000000000000 X X X X 1 1 X X X 1 X HTTPS://WWW.TSH.ORG/POLICIES-BILLING/ X HTTPS://WWW.TSH.ORG/POLICIES-BILLING/ X HTTPS://WWW.TSH.ORG/POLICIES-BILLING/ X X X X 1 X 0 X X X 1 X 0 0 TRI-STATE MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: IN THE FALL OF 2022, TSMH ENGAGED COMMUNITY LEADERS TO SECURE INPUT REGARDING UNMET HEALTH NEEDS AND PRIORITIES. TSMH DISTRIBUTED A SURVEY TO KEY COMMUNITY ORGANIZATIONS, INCLUDING REPRESENTATIVES FROM PUBLIC HEALTH, PHYSICAL AND MENTAL HEALTH, SCHOOLS, SOCIAL SERVICES, PHILANTHROPY, ELECTED OFFICIALS, THE GENERAL COMMUNITY, AND OTHERS THROUGHOUT THE LEWIS-CLARK VALLEY. TRI-STATE MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: BASED ON THE DATA, THE KEY INFORMANT SURVEYS, AND THE BOARD'S CONSIDERATION OF TSMH'S RESOURCES AND EXPERTISE, TSMH HAS ELECTED TO CONTINUE TO BUILD OFF THE 2020-2022 CHNA PRIORITIES AND HAS MODIFIED THE OVERALL PRIORITY TO ADD BEHAVIORAL HEALTH: SUPPORT INDIVIDUALS AND FAMILIES THROUGH COMPREHENSIVE AND PATIENT-CENTERED PRIMARY CARE, BEHAVIORAL HEALTH, AND WELLNESS PROGRAMMING.SPECIFIC FOCUS AREAS FOR 2023-2025 INCLUDE:RECRUIT AND DEVELOP SERVICES AND SUPPORTS TO RETAIN PRIMARY CARE PROVIDERS.OPTIMIZATION OF WORKFLOWS, PROCESSES, PEOPLE, AND TECHNOLOGY TO SUPPORT EFFICIENT AND EFFECTIVE DELIVERY OF PRIMARY CARE AND TO SUPPORT RETENTION OF PROVIDERS.CONTINUE GROWTH OF BEHAVIORAL HEALTH SERVICES, WITH A SPECIAL FOCUS ON YOUTH IN THE COMMUNITY AND INTEGRATING BEHAVIORAL HEALTH SERVICES WITH PRIMARY CARE.CONTINUE TO GROW TELEMEDICINE AND TELE-BEHAVIORAL HEALTH SERVICES.PARTNER WITH COMMUNITY ORGANIZATIONS TO EDUCATE, INFORM, AND SUPPORT YOUTH AND ADULTS AROUND HEALTHY LIVING.SUPPORT HEALTHY AGING AND MITIGATE IMPACTS OF CHRONIC HEALTH AND BEHAVIORAL HEALTH CONCERNS IN THE VALLEY'S ELDERLY. 13 1 - TSMH IPC 1119 HIGHLAND AVENUE SUITE 11 CLARKSTON WA 99403 PROVIDER BASED CLINIC 2 - TSMH CMC CLINIC 1534 17TH STREET LEWISTON ID 83501 NON-PROVIDER BASED CLINIC 3 - TSMH FAMILY PRACTICE CLARKSTON 1119 HIGHLAND AVENUE SUITE 10 CLARKSTON WA 99403 PROVIDER BASED CLINIC 4 - TSMH UROLOGY 1119 HIGHLAND AVENUE SUITE 1 CLARKSTON WA 99403 PROVIDER BASED CLINIC 5 - TSMH WOUND CARE & PODIATRY 1221 HIGHLAND AVENUE SUITE 7 CLARKSTON WA 99403 PROVIDER BASED CLINIC 6 - TSMH LEW FP CLINIC 2841 JUNIPER DRIVE 2 LEWISTON ID 83501 NON-PROVIDER BASED CLINIC 7 - TSMH MINOR CARE CLINIC 1267 BELMONT WAY CLARKSTON WA 99403 PROVIDER BASED CLINIC 8 - TSMH SLEEP LAB 1119 HIGHLAND AVENUE SUITE 8 CLARKSTON WA 99403 PROVIDER BASED CLINIC 9 - TSMH BEHAVIORAL HEALTH CLINIC 1119 HIGHLAND AVENUE SUITE 6 CLARKSTON WA 99403 PROVIDER BASED CLINIC 10 - TSMH GENERAL SURGERY 1119 HIGHLAND AVENUE SUITE 4 CLARKSTON WA 99403 PROVIDER BASED CLINIC 11 - TSMH FAMILY PULMONOLOGY CLINIC 1119 HIGHLAND AVENUE SUITE 2 CLARKSTON WA 99403 PROVIDER BASED CLINIC 12 - TSMH NEPHR CLINIC 1221 HIGHLAND AVENUE SUITE 5 CLARKSTON WA 99403 PROVIDER BASED CLINIC 13 - TSMH RHEUM CLINIC 1119 HIGHLAND AVENUE SUITE 3 CLARKSTON WA 99403 PROVIDER BASED CLINIC PART I, LINE 7: THE COST-TO-CHARGE RATIO USED WAS DERIVED BASED ON THE FILED 2022 MEDICARE COST REPORT. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 1,318,510. PART II, COMMUNITY BUILDING ACTIVITIES: TRI-STATE MEMORIAL HOSPITAL HELPS PROMOTE THE HEALTH OF THE COMMUNITIES IT SERVES BY PROVIDING SUPPORT AMONGST A NUMBER OF LOCAL CHARITIES, FOOD BANKS AND OTHER AGENCIES. IN 2022 TRI-STATE HOSPITAL CONTRIBUTED $6,250 TO THE BOYS AND GIRLS CLUBS OF THE LEWIS-CLARK VALLEY WHICH THEY USED FOR THE PARTNERSHIP FOR KIDS, THE ANNUAL CAMPAIGN, THE GRILLED CHEESE PROGRAM AND MEDICAL SUPPLIES/FIRST AID DONATIONS. THE WORLD SERIES OF NAIA BASEBALL IS PLAYED IN LEWISTON AND TRI-STATE MEMORIAL HOSPITAL SPONSORED THAT EVENT AND SPONSORED THE MEDICAL TENT AND REFRESHMENTS FOR ALL MEDICAL VOLUNTEERS FOR THIS EVENT. ADDITIONALLY, TRI-STATE MEMORIAL HOSPITAL GAVE DONATIONS TO THE WASHINGTON POISON CONTROL, VALLEY VISION, AND FIELD OF DREAMS. TRI-STATE MEMORIAL HOSPITAL CONTINUES TO FIND WAYS TO SUPPORT THE COMMUNITIES IT SERVES IN BROAD AND EXPANDING WAYS, TRYING TO REACH ALL PATIENTS FROM ADOLESCENCE TO ADULTHOOD. PART III, LINE 2: THE ORGANIZATION'S BAD DEBT EXPENSE AT COST WAS ESTIMATED BY MULTIPLYING THE BAD DEBT EXPENSE BY THE ORGANIZATION'S COST-TO-CHARGE RATIO. PART III, LINE 3: THE FACILITY REPORTS BAD DEBT EXPENSE IN ACCORDANCE WITH HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION STATEMENT NUMBER 15, SO NONE OF THE BAD DEBT EXPENSE REPORTED ON SCHEDULE H, PART III, LINE 2 IS ESTIMATED TO BE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE FACILITY'S FINANCIAL ASSISTANCE POLICY. PART III, LINE 4: WHILE THE FACILITY DOES NOT HAVE A NOTE REGARDING BAD DEBT EXPENSE IN ITS FINANCIAL STATEMENTS, THE AMOUNT OF BAD DEBT EXPENSE FOR EACH YEAR IS DISCLOSED ON THE FACILITY'S STATEMENTS OF REVENUE AND EXPENSES. THE AMOUNT OF BAD DEBT EXPENSE REPORTED WAS $1,318,510 FOR THE YEAR ENDED DECEMBER 31, 2022. THE COSTING METHODOLOGY USED TO DETERMINE THE COST OF BAD DEBT IS BASED ON THE FACILITY'S CALCULATED COST-TO-CHARGE RATIO. PART III, LINE 8: THE FACILITY IS DESIGNATED AS A CRITICAL ACCESS HOSPITAL AND IS REIMBURSED BY MEDICARE AT APPROXIMATELY 99% OF MEDICARE'S COSTS.THE TOTAL REVENUE RECEIVED FROM MEDICARE AND RELATED MEDICARE ALLOWABLE COSTS WERE DERIVED FROM THE FACILITY'S FILED 2022 MEDICARE COST REPORT. PART III, LINE 9B: THE FULL PATIENT BALANCE FOR THOSE KNOWN TO QUALIFY FOR CHARITY CARE WILL BE EVALUATED FOR FINANCIAL ASSISTANCE ELIGIBILITY AS FOLLOWS: THEY QUALIFY FOR A 100% DISCOUNT IF THE PATIENT'S GROSS FAMILY INCOME IS AT OR BELOW 200% OF THE CURRENT FEDERAL POVERTY GUIDELINES, THEY QUALIFY FOR A 75% DISCOUNT IF THE PATIENT'S GROSS FAMILY INCOME IS AT OR BETWEEN 201% TO 250% OF THE CURRENT FEDERAL POVERTY GUIDELINES, THEY QUALIFY FOR A 50% DISCOUNT IF THE PATIENT'S GROSS FAMILY INCOME IS AT OR BETWEEN 251% TO 300% OF THE CURRENT FEDERAL POVERTY GUIDELINES AND THEY QUALIFY FOR A 25% DISCOUNT IF THE PATIENT'S GROSS FAMILY INCOME IS AT OR BETWEEN 301%-350% OF THE CURRENT FEDERAL POVERTY GUIDELINES.THE HOSPITAL MAY CHOOSE TO GRANT FINANCIAL ASSISTANCE BASED SOLELY UPON THE INITIAL DETERMINATION OF THE PATIENT. ANY PATIENTS WHO ARE ON STATE ASSISTANCE, ARE UNEMPLOYED, DISABLED, TRANSIENT OR INCOMPETENT MAY BE VALID "PRIMA-FACIE" CANDIDATES. IN SUCH CASES, THE HOSPITAL MAY NOT COMPLETE FULL VERIFICATION OR DOCUMENTATION OF ANY REQUESTS.UNINSURED AND UNDERINSURED WASHINGTON AND IDAHO PATIENTS MAY QUALIFY FOR A DISCOUNT. DETERMINATION WILL BE MADE BY TSMH ADMINISTRATION UPON PATIENT'S COMPLETION OF THE SPECIAL CONSIDERATION FINANCIAL ASSISTANCE APPLICATION AND THE SPECIFIED SUPPORTING DOCUMENTATION AS PROOF OF SEVERE FINANCIAL HARDSHIP OF PERSONAL LOSS FROM TIME OF REQUEST BASED ON ECONOMIC SITUATION. THE COLLECTION PRACTICE FOR PATIENTS KNOWN TO QUALIFY FOR CHARITY CARE IS AS FOLLOWS: 75% OF THE PATIENT'S BILL IS ADJUSTED OFF IF THE PERSON IS BETWEEN 201-250% OF THE FPL TO CHARITY CARE AND THE REMAINING 25% IS THE PATIENT'S RESPONSIBILITY. IF THE PATIENT IS UP TO 200% OF THE FPL THEN 100% OF THE PATIENT'S BILL IS ADJUSTED OFF AS CHARITY CARE. THIS POLICY IS APPLIED TO ALL PATIENTS THAT HAVE COMPLETED A FINANCIAL ASSISTANCE APPLICATION AND WHOSE INCOMES LEVELS HAVE BEEN VERIFIED. PATIENTS ARE ALSO IDENTIFIED WHO MAY BE ELIGIBLE FOR ASSISTANCE BEYOND THE HOSPITAL THROUGH MEDICAID OR COUNTY AID. PART VI, LINE 2: IN THE FALL OF 2022, TSMH ENGAGED COMMUNITY LEADERS TO SECURE INPUT REGARDING UNMET HEALTH NEEDS AND PRIORITIES. TSMH DISTRIBUTED A SURVEY TO KEY COMMUNITY ORGANIZATIONS, INCLUDING REPRESENTATIVES FROM PUBLIC HEALTH, PHYSICAL AND MENTAL HEALTH, SCHOOLS, SOCIAL SERVICES, PHILANTHROPY, ELECTED OFFICIALS, THE GENERAL COMMUNITY, AND OTHERS THROUGHOUT THE LEWIS-CLARK VALLEY. PART VI, LINE 3: FINANCIAL BROCHURES ARE SENT WITH ITEMIZED STATEMENTS TO ALL UNINSURED PATIENTS. AT THE TIME PATIENT MAKES CONTACT, THE PATIENT FINANCIAL COUNSELOR WILL:1. DISCUSS THE HOSPITAL GUIDELINE FOR REIMBURSEMENT OF HOSPITAL SERVICES.2. THE 10% DISCOUNT IS OFFERED TO UNINSURED PATIENTS WHEN BALANCE IS PAID IN FULL. 3. ESTABLISH A PAYMENT CONTRACT IN ORDER TO RESOLVE THE ACCOUNT BALANCE WITHIN APPLICABLE GUIDELINES. THE MINIMUM ACCEPTABLE PAYMENT IS $50 OR 5% (WHICHEVER IS GREATER).4. IDENTIFY A PATIENT WHO MAY BE ELIGIBLE FOR ASSISTANCE TO INCLUDE BUT NOT LIMITED TO MEDICAID OR COUNTY AID FOR THE STATE THE PATIENT RESIDES.5. DETERMINE IF HOUSEHOLD INCOME MEETS OR FALLS BELOW THE CURRENT YEAR'S POVERTY GUIDELINES THEN EXPLAIN TSMH FINANCIAL ASSISTANCE PROGRAM. PART VI, LINE 4: TSMH IS LOCATED IN THE LEWIS-CLARK VALLEY (THE VALLEY), AT THE CONFLUENCE OF THE SNAKE AND CLEARWATER RIVERS IN THE SOUTHEASTERN MOST CORNER OF WASHINGTON STATE. THE CITY OF CLARKSTON IS CONTIGUOUS TO THE CITY OF LEWISTON IN NEIGHBORING NEZ PERCE COUNTY IN IDAHO. TSMH SERVES RESIDENTS OF BOTH ASOTIN COUNTY AND ADJOINING NEZ PERCE COUNTY. COLLECTIVELY, THESE TWO COUNTIES ARE CONSIDERED THE SERVICE AREA COMMUNITY. PART VI, LINE 5: THE HOSPITAL PERFORMS SURGERIES REQUIRING INPATIENT STAYS AND ALSO SAME DAY OPERATIONS, NOT REQUIRING A HOSPITAL STAY. OUTPATIENT SERVICES INCLUDE RENAL DIALYSIS CENTERS IN CLARKSTON, WA, WOUND HEALING & HYPERBARIC CENTER, SLEEP DIAGNOSTIC CENTER, AND A 24 HOUR PHYSICIAN STAFFED EMERGENCY DEPARTMENT. OTHER OUTPATIENT SERVICES INCLUDE A NEPHROLOGY CENTER, PRIMARY CARE CLINIC, INTERNAL MEDICINE CLINIC, GENERAL SURGERY CLINIC, UROLOGY CLINIC, RHEUMATOLOGY CLINIC, AND PAIN CLINIC. THE HOSPITAL OPERATES WITH OVER 690 FULL AND PART-TIME EMPLOYEES, 35 VOLUNTEERS AND 340 PHYSICIANS ON STAFF. TRI-STATE HOSPITAL FOUNDATION IS A NON-PROFIT ORGANIZATION WHICH BENEFITS THE HEALTH CARE NEEDS OF THE COMMUNITY SERVED BY THE HOSPITAL. GIFTS TO THE FOUNDATION ARE USED TO PURCHASE SPECIALIZED EQUIPMENT THAT HELP EXPAND SERVICES PROVIDED BY THE HOSPITAL TO THE COMMUNITY. 1 BOYS & GIRLS CLUBS OF THE LEWIS-CLARK VALLEY 1021 BURRELL AVE LEWISTON ID 83501 826001432 501(C)(3) 6250 0 PARTNERSHIP FOR KIDS, ANNUAL CAMPAIGN, SCHOLARSHIPS, GRILLED CHEESE PROGRAM 1 0 PART I, LINE 2: THE HOSPITAL RECEIVES AND REVIEWS DETAILED REPORTS PROVIDED BY THE CHARITABLE ORGANIZATIONS THAT RECEIVE GRANT FUNDS FROM THE HOSPITAL. THE HOSPITAL IS ABLE TO SUBSTANTIATE THE PROPER USE OF THE FUNDS THROUGH THE REPORTS PROVIDED BY THE CHARITABLE ORGANIZATIONS. X X X X X X 0 0 0 0 0 0 0 0 0 ELINA CHERNYAK PHYSICIAN 337006 0 270151 0 0 0 6899 0 13659 0 627715 0 0 0 CRAIG FLINDERS PHYSICIAN 560538 0 0 0 0 0 15250 0 23681 0 599469 0 0 0 KENNETH BERGER PHYSICIAN 511933 0 44945 0 0 0 423 0 22086 0 579387 0 0 0 TALMADGE CAVINESS PHYSICIAN 546801 0 0 0 0 0 6100 0 25412 0 578313 0 0 0 LEROY SMITH PHYSICIAN 485367 0 0 0 0 0 0 0 22086 0 507453 0 0 0 JOHN RUDOLPH MD BOARD MEMBER 382535 0 9727 0 0 0 12187 0 19168 0 423617 0 0 0 KYM CLIFT CEO 315134 0 40500 0 6000 0 2170 0 21063 0 384867 0 0 0 KIMBERLY BLEWETT BOARD MEMBER 253018 0 0 0 0 0 11662 0 20251 0 284931 0 0 0 JIM HEILSBERG CFO 235693 0 0 0 0 0 1566 0 13037 0 250296 0 0 0 MIKE MARTIN BOARD MEMBER 167158 INSURANCE BROKER - OWNER OF MARTIN INSURANCE 0 FORM 990, PART VI, SECTION B, LINE 11B A COPY IS PROVIDED TO THE CEO FOR REVIEW PRIOR TO FILING. THE BOARD AUTHORIZES THE CEO TO REVIEW AND APPROVE THE 990. THE FINAL 990 IS FILED AFTER CEO APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C IT IS THE ORGANIZATION'S POLICY TO REQUEST THE DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST SO THAT APPROPRIATE ACTION MAY BE TAKEN TO ENSURE THAT SUCH CONFLICT DOES NOT INAPPROPRIATELY INFLUENCE IMPORTANT DECISIONS. THE HOSPITAL REVIEWS ITS RELATIONSHIP AND ITS STAFF'S RELATIONSHIPS WITH OTHER CARE PROVIDERS, EDUCATIONAL INSTITUTIONS, AND PAYERS TO ENSURE THAT THOSE RELATIONSHIPS ARE WITHIN LAW AND REGULATION AND DETERMINE IF CONFLICTS OF INTEREST EXIST. BOARD MEMBERS ARE REQUIRED TO SUBMIT AN ANNUAL DISCLOSURE FORM. BOARD MEMBERS, ADMINISTRATION AND MEDICAL STAFF LEADERS ARE REQUIRED TO DISCLOSE POTENTIAL CONFLICTS RELATED TO DECISIONS THAT ARISE DURING THE COURSE OF THE YEAR ON A CASE-BY-CASE BASIS. THE GOVERNING BOARD, SENIOR MANAGEMENT, OR THE MEDICAL EXECUTIVE COMMITTEE WILL REVIEW POTENTIAL CONFLICTS AND TAKE APPROPRIATE ACTION. IN THE EVENT A POTENTIAL CONFLICT OF INTEREST HAS A DIRECT IMPLICATION FOR PATIENT CARE, THE INSTITUTION MAY CONVENE AN ETHICS COMMITTEE TO ASSIST IN THE RESOLUTION OF THE ISSUE. FORM 990, PART VI, SECTION B, LINE 15A COMPENSATION IS DETERMINED BASED ON FAIR MARKET VALUE. TSMH USES NATIONAL AND REGIONAL BENCHMARKS (MILLIMAN SURVEY & STATE OF IDAHO). BASED ON THESE COMPARISONS, THE BOARD OF DIRECTORS DETERMINES THE COMPENSATION FOR THE CEO AND THE CEO DETERMINES THE COMPENSATION FOR THE REMAINING EMPLOYEES OF THE FACILITY. THE BOARD HAS FULL DETERMINATION OF THE CEO'S COMPENSATION. DECISIONS ARE MADE BY THOSE WITHOUT CONFLICT AND THE DECISIONS ARE DOCUMENTED. FORM 990, PART VI, SECTION C, LINE 19 TRI-STATE MEMORIAL HOSPITAL'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G LAB PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 4,081,090. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,081,090. MAINTENANCE SERVICES: PROGRAM SERVICE EXPENSES 1,568,460. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,568,460. TRAVELING STAFF: PROGRAM SERVICE EXPENSES 4,015,448. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,015,448. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 10,730,501. MANAGEMENT AND GENERAL EXPENSES 2,008,867. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 12,739,368. FORM 990, PART XI, LINE 9: TEMPORARILY RESTRICTED - NET GRANT FUNDS RECEIVED 4,000. TEMPORARILY RESTRICTED - RELEASED FOR OPERATIONS -65,549. TEMPORARILY RESTRICTED - INTEREST INCOME 2. TEMPORARILY RESTRICTED - CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION -897,606. INTERCOMPANY TRANSFERS -587,627. AQUAVIA PO BOX 189 CLARKSON WA 99403 472643240 REAL ESTATE RENTAL WA -665649 4198880 TRI-STATE MEMORIAL HOSPITAL VANNVEI LLC PO BOX 341 LEWISTON ID 83501 832881716 HEALTH SERVICES WA -2932565 1918972 TRI-STATE MEMORIAL HOSPITAL TRI-STATE HOSPITAL FOUNDATION 1347 12TH STREET CLARKSTON WA 99403 911307818 FUNDRAISING FOR TRI-STATE MEMORIAL HOSPITAL WA 501(C)(3) LINE 7 TRI-STATE MEMORIAL HOSPITAL 1 TRI-STATE MEMORIAL HOSPITAL AUXILIARY PO BOX 189 CLARKSTON WA 99403 911357957 FUNDRAISING FOR TRI-STATE MEMORIAL HOSPITAL WA 501(C)(3) LINE 12B, II TRI-STATE MEMORIAL HOSPITAL 1 EVERGREEN ESTATES RETIREMENT AND ASSISTED LIVING COMMUNITY LLC 1215 EVERGREEN COURT CLARKSTON WA 99403 263462257 ASSISTED LIVING WA TRI-STATE MEMORIAL HOSPITAL C -1390291 16516985 1.00000 1 1 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 EVERGREEN ESTATES A 89539 CASH EVERGREEN ESTATES B 587625 CASH TRI-STATE HOSPITAL FOUNDATION C 3829587 CASH