oshpd reports (3)

HOSPITAL SUMMARY INDIVIDUAL DISCLOSURE REPORTUSING DATA SUBMITTED BY FACILITYFACILITY NO:106434138ST LOUISE REGIONAL HOPSITAL

PAGE: 1 OF 5REPORT PERIOD: 07/01/2013 THRU 06/30/2014

DATE PREPARED: 6/24/2015

9400 NO NAME UNOGILROY CA 95020

PHONE NO: (408)848-8607OWNER: DAUGHTERS OF CHARITY HEALTH SYSTEM

TYPE OF CONTROL: ChurchTYPE OF CARE: General

INTENSIVE 8ACUTE 64LONG-TERMOTHER TOTAL 72OCCUPANCY RATE 40.10%*EXCLUDES BEDS IN SUSPENSE

LICENSED BEDS* INTENSIVE 8ACUTE 64LONG-TERMOTHER TOTAL 72OCCUPANCY RATE 40.10%NO. BASSINETS 18

AVAILABLE BEDS X EMERGENCY ROOM

TRAUMA CENTER DESIGNATIONX OBSERVATIONX ORTHOPEDICX PSYCHIATRICX HELICOPTER

EMERGENCY SERVICES

FINANCIAL AND UTILIZATION DATA BY PAYER TOTAL MEDICARETRADITIONAL

MEDICAREMANAGED CARE

MEDI-CALTRADITIONAL

Patient (Census) Days 10,551 4,776 591 1,503 Hospital Discharges (Excluding Nursery) 3,045 1,153 137 498 Average Length of Stay (Including L-T Care) 3.5 4.1 4.3 3 Average Length of Stay (Excluding L-T Care) 3.5 4.1 4.3 3 Outpatient Visits (Incl. ER Visits) 56,659 11,251 994 7,144 Outpatient Emergency Services Visits 24,813 2,796 452 2,894 Gross Inpatient Revenue $210,629,453 $96,303,850 $12,075,357 $29,521,866 Gross Outpatient Revenue $220,282,158 $60,167,102 $7,832,534 $18,307,768 Deductions From Revenue $350,675,329 $132,650,873 $17,213,731 $37,137,587 Net Inpatient Revenue $37,360,673 $14,899,587 $1,634,173 $6,599,448 Net Outpatient Revenue $42,875,609 $8,920,492 $1,059,987 $4,092,599 Net Inpatient Revenue Per Day $3,541 $3,120 $2,765 $4,391 Net Inpatient Revenue Per Discharge $12,270 $12,922 $11,928 $13,252 Net Outpatient Revenue Per Visit $757 $793 $1,066 $573

Adjusted Patient Days 21,586 Net Revenue Per Adj Patient Day $3,717 Purchased Inpatient Days

FINANCIAL AND UTILIZATION DATA BY PAYER THIRD PARTYMANAGED CARE

OTHERINDIGENT

OTHERPAYERS

Patient (Census) Days 2,338 256 Hospital Discharges (Excluding Nursery) 738 89 Average Length of Stay (Including L-T Care) 3.2 2.9 Average Length of Stay (Excluding L-T Care) 3.2 2.9 Outpatient Visits (Incl. ER Visits) 21,297 3,613 Outpatient Emergency Services Visits 6,120 2,750 Gross Inpatient Revenue $47,228,580 $4,369,987 Gross Outpatient Revenue $72,345,271 $16,127,171 Deductions From Revenue $95,778,606 $8,964,608 Net Inpatient Revenue $9,398,507 $2,411,532 Net Outpatient Revenue $14,396,738 $9,121,018 Net Inpatient Revenue Per Day $4,020 $9,420 Net Inpatient Revenue Per Discharge $12,735 $27,096 Net Outpatient Revenue Per Visit $676 $2,524

Adjusted Patient Days Net Revenue Per Adj Patient Day Purchased Inpatient Days

FINANCIAL AND UTILIZATION DATA BY PAYER MEDI-CALMANAGED CARE

CO. INDIGENTTRADITIONAL

CO. INDIGENTMANAGED CARE

THIRD PARTYTRADITIONAL

Patient (Census) Days 1,010 77 Hospital Discharges (Excluding Nursery) 412 18 Average Length of Stay (Including L-T Care) 2.5 4.3 Average Length of Stay (Excluding L-T Care) 2.5 4.3 Outpatient Visits (Incl. ER Visits) 11,453 907 Outpatient Emergency Services Visits 9,239 562 Gross Inpatient Revenue $19,640,971 $1,488,842 Gross Outpatient Revenue $41,393,750 $4,108,562 Deductions From Revenue $54,343,264 $4,586,660 Net Inpatient Revenue $2,153,311 $264,115 Net Outpatient Revenue $4,538,146 $746,629 Net Inpatient Revenue Per Day $2,132 $3,430 Net Inpatient Revenue Per Discharge $5,226 $14,673 Net Outpatient Revenue Per Visit $396 $823

Adjusted Patient Days Net Revenue Per Adj Patient Day Purchased Inpatient Days

COUNTY: Santa ClaraHSA NO: 07 HFPA NO: 0433

GENERAL INFORMATION

HOSPITAL SUMMARY INDIVIDUAL DISCLOSURE REPORT

GROSS PATIENT REVENUE BY REVENUE CENTER PERCENT OF TOTAL DAILY HOSPITAL SERVICES $85,917,358 19.9 AMBULATORY SERVICES $87,920,968 20.4 ANCILLARY SERVICES $257,073,285 59.7 TOTAL GROSS PATIENT REVENUE $430,911,611 100.0

LIVE BIRTH SUMMARY NATURAL BIRTHS 439 CESAREAN SECTIONS 127 TOTAL LIVE BIRTHS 566

SUMMARY STATEMENT OF INCOME GROSS PATIENT REVENUE $430,911,611 PROVISION FOR BAD DEBT $3,399,094 MEDICARE TRAD. CONTRACTUAL ADJ $132,473,801 MEDICARE MANAGED CONTRACTUAL ADJ $16,924,623 MEDI-CAL TRAD. CONTRACTUAL ADJ $36,714,212 MEDI-CAL MANAGED CONTRACTUAL ADJ $52,947,935 DISPROPORTIONATE SHARE FUNDS REC'D CO. INDIGENT TRAD. CONTRACTUAL ADJ CO. INDIGENT MANAGED CONTRACTUAL ADJ THIRD PARTY TRAD. CONTRACTUAL ADJ $4,507,051 THIRD PARTY MANAGED CONTRACTUAL ADJ $81,997,186 CHARITY OTHER $9,647,418 ALL OTHER DEDUCTIONS $12,064,009 TOTAL DEDUCTIONS FROM REVENUE $350,675,329 CAPITATION PREMIUM REVENUE NET PATIENT REVENUE $80,236,282

OTHER OPERATING REVENUE $2,030,636 TOTAL OPERATING EXPENSES $93,428,345 NET FROM OPERATIONS ($11,161,427)

NON-OPERATING REVENUE + $1,498,788 NON-OPERATING EXPENSES - $784,244 PROVISION FOR INCOME TAXES - EXTRAORDINARY ITEMS - NET INCOME ($10,446,883)

OPERATING EXPENSES BY CLASSIFICATION SALARIES AND WAGES $40,587,201 EMPLOYEE BENEFITS $13,988,300 PHYSICIANS PROFESSIONAL FEES $4,151,422 OTHER PROFESSIONAL FEES $2,418,143 SUPPLIES $7,963,640 PURCHASED SERVICES $9,783,246 DEPRECIATION $5,641,101 LEASES AND RENTALS $546,819 INTEREST $1,984,617 ALL OTHER EXPENSES $6,363,856 TOTAL OPERATING EXPENSES $93,428,345

ADJUSTED PATIENT REVENUE ADJUSTED INPATIENT REVENUE REVENUE PER DAY REVENUE PER DISCHARGE

ADJUSTED OUTPATIENT REVENUE REVENUE PER VISIT

ADJUSTED PATIENT EXPENSES ADJUSTED INPATIENT EXPENSES EXPENSES PER DAY EXPENSES PER DISCHARGE

ADJUSTED OUTPATIENT EXPENSES EXPENSES PER VISIT


DATE PREPARED: 6/24/2015USING DATA SUBMITTED BY FACILITYFACILITY NO:106434138ST LOUISE REGIONAL HOPSITAL

OPERATING EXPENSES BY COST CENTER GROUP DAILY HOSPITAL SERVICES $18,468,877 AMBULATORY SERVICES $7,649,597 ANCILLARY SERVICES $21,552,894 PURCHASED INPATIENT SERVICES PURCHASED OUTPATIENT SERVICES RESEARCH EDUCATION GENERAL SERVICES $13,910,476 FISCAL SERVICES $2,417,561 ADMINISTRATIVE SERVICES $20,295,222 UNASSIGNED COSTS $9,133,718 TOTAL OPERATING EXPENSES $93,428,345



TOTAL CURRENT ASSETS $22,788,522LIMITED USE ASSETS $277,970NET PROPERTY, PLANT, AND EQUIPMENT $23,887,070CONSTRUCTION-IN-PROGRESS $204,666OTHER ASSETSINTANGIBLE ASSETSTOTAL ASSETS $47,158,228

TOTAL CURRENT LIABILITIES $51,165,540DEFERRED INCOMENET LONG-TERM DEBT $30,596,239TOTAL LIABILITIES $81,761,779

EQUITY ($34,603,551)TOTAL LIABILITIES AND EQUITY $47,158,228

BALANCE SHEET SUMMARY

FINANCIAL RATIO FORMULAS

LIQUIDITY RATIOS FORMULAS

CURRENT RATIO .45 (TOTAL CURRENT ASSETS + BOARD DESIG. CASH + BOARD DESIG. INVESTMENTS) / TOTAL CURRENT LIABILITIES

ACID TEST RATIO .05 (CASH + MARKETABLE SECURITIES + BOARD DESIG. CASH + BOARD DESIG. INVESTMENTS) / TOTAL CURRENT LIABILITIES

DAYS IN ACCOUNTS RECEIVABLE 58.05 NET ACCOUNTS RECEIVABLE / (NET PATIENT REVENUE / DAYS IN REPORT PERIOD)

BAD DEBT RATE 0.79% (PROVISION FOR BAD DEBTS / TOTAL GROSS PATIENT REVENUE) X 100

DEBT, RISK, AND LEVERAGE RATIOS

LONG-TERM DEBT TO ASSETS RATE 64.88% (NET LONG-TERM DEBT / TOTAL ASSETS) X 100

DEBT SERVICE COVERAGE RATIO ( 1.42) (NET INCOME + INTEREST-WORKING CAPITAL + INTEREST-OTHER + DEPRECIATION EXPENSE) / PRINCIPAL PAYMENTS ON SHORT-TERM AND LONG-TERM DEBT, NOTES, AND LOANS + INTEREST-WORKING CAPITAL + INTEREST-OTHER)

INTEREST EXPENSE AS A PERCENTAGE OF OPERATING EXPENSE

2.12% ((INTEREST-WORKING CAPITAL + INTEREST-OTHER) / TOTAL OPERATING EXPENSE) X 100

PROFITABILITY RATIOS

NET RETURN ON OPERATING ASSETS ( 19.66%) ((NET FROM OPERATIONS + INTEREST-WORKING CAPITAL + INTEREST-OTHER) / (TOTAL CURRENT ASSETS + NET PROPERTY, PLANT AND EQUIPMENT)) X 100

NET RETURN ON EQUITY 30.19% (NET INCOME / EQUITY) X 100

OPERATING MARGIN ( 13.57%) (NET FROM OPERATIONS / TOTAL OPERATING REVENUE) X 100

TURNOVER ON OPERATING ASSETS 1.76 TOTAL OPERATING REVENUE / (TOTAL CURRENT ASSETS + NET PROPERTY, PLANT, AMD EQUIPMENT)

FIXED ASSET RATIOS

FIXED ASSET GROWTH RATE 7.23% ((CURRENT YEAR GROSS PROPERTY, PLANT AND EQUIPMENT + CONSTRUCTION-IN-PROGRESS) - (PRIOR YEAR GROSS PROPERTY, PLANT, AND EQUIPMENT + CONSTRUCTION-IN-PROGRESS)) / (PRIOR YEAR NET PROPERTY, PLANT, AND EQUIPMENT + CONSTRUCTION-IN-PROGRESS) X 100

AVERAGE AGE OF PLANT 10.61 ACCUMULATED DEPRECIATION / DEPRECIATION EXPENSE

NET PPE ASSETS PER BED 334,607 (NET PROPERTY, PLANT, AND EQUIPMENT + CONSTRUCTION-IN-PROGRESS) / LICENSED BEDS (END OF PERIOD)

REVENUE-PRODUCING COST CENTERS UNITS OFSERVICE

UNITCODE

GROSS REVPER UNIT

ADJ REVPER UNIT

ADJ DIRECTEXP PER UNIT

ADJ TOTALEXP PER UNIT

PROFIT/LOSSPER UNIT

DAILY HOSPITAL SERVICESMEDICAL/SURGICAL INTENSIVE CARE 1,780 1 $12,708.51 $2,925.93

CORONARY CARE 1

BURN CARE 1

DEFINITIVE OBSERVATION 1

MEDICAL/SURGICAL ACUTE 7,447 1 $7,019.30 $1,338.05

PEDIATRIC ACUTE 1

PSYCHIATRIC ACUTE - ADULT 1

OBSTETRICS ACUTE 1,324 1 $4,562.70 $2,489.62

ALTERNATE BIRTHING CENTER 1

CHEMICAL DEPENDENCY SERVICES 1

SKILLED NURSING CARE 1

TOTAL PATIENT CARE SERVICES 10,551 2 $7,670.83 $1,750.44

NURSERY ACUTE 1,093 3 $4,558.53 $0.00

AMBULATORY SERVICESEMERGENCY SERVICES 24,813 4 $3,130.64 $271.61

CLINICS 11,838 4 $865.05 $76.89

OBSERVATION CARE 5

HOME HEALTH CARE SERVICES 6

SUMMARY OF FINANCIAL AND UTILIZATION DATA FOR SELECTED COST CENTERS





REVENUE-PRODUCING COST CENTERS UNITS OFSERVICE

UNITCODE

GROSS REVPER UNIT

ADJ REVPER UNIT


ADJ TOTALEXP PER UNIT

PROFIT/LOSSPER UNIT

ANCILLARY SERVICESLABOR AND DELIVERY SERVICES 565 7 $7,868.43 $3,801.39SURGERY AND RECOVERY SERVICES 194,994 8 $213.45 $18.90MEDICAL SUPPLIES SOLD TO PATIENTS 21,123 9 $964.82 $139.99CLINICAL LABORATORY SERVICES 186,970 10 $336.72 $21.61CARDIAC CATHETERIZATION SERVICES 11RADIOLOGY - DIAGNOSTIC 35,219 11 $2,038.11 $119.31MAGNETIC RESONANCE IMAGING 11COMPUTED TOMOGRAPHIC SCANNER 11DRUGS SOLD TO PATIENTS 15,853 14 $1,437.08 $98.38RESPIRATORY THERAPY 13,949 12 $1,772.00 $143.24LITHOTRIPSY SERVICES 11PHYSICAL THERAPY 33,136 27 $213.32 $22.80

COST CENTER UNITS OFSERVICE

UNITCODE


DIETARY 36,112 16 $48.65 LAUNDRY AND LINEN 17 SOCIAL WORK SERVICES 2,129 18 $62.46 HOUSEKEEPING 105,453 19 $14.62 PLANT OPERATIONS & MAINTENANCE 120,619 20 $31.64 PATIENT ACCOUNTING 21 ADMITTING 2,893 22 $513.76

NON-REVENUE PRODUCING COST CENTERS

COST CENTER UNITS OFSERVICE

UNITCODE*


HOSPITAL ADMINISTRATION 372 23 $23,223.87 MEDICAL RECORDS 21,586 24 $66.74 NURSING ADMINISTRATION 111 25 $7,188.65 UTILIZATION MANAGEMENT 2,893 22 $643.38 COMMUNITY HEALTH EDUCATION 1,553 26 $422.27 INSURANCE - MALPRACTICE 430,912 21 $0.72 INTEREST - OTHER 120,619 20 $16.45

UNIT CODE DESCRIPTIONS

UNIT CODE 1 NUMBER OF PATIENT DAYS2 TOTAL PATIENT DAYS (EXCLUDING NEWBORN)3 NUMBER OF NEWBORN DAYS4 NUMBER OF VISITS5 NUMBER OF OBSERVATION HOURS6 NUMBER OF HOME HEALTH CARE VISITS7 NUMBER OF DELIVERIES8 NUMBER OF OPERATING MINUTES9 NUMBER OF CS & S ADJUSTED INPATIENT DAYS10 NUMBER OF TESTS11 NUMBER OF PROCEDURES12 NUMBER OF RESPIRATORY THERAPY ADJUSTED INPATIENT DAYS14 NUMBER OF PHARMACY ADJUSTED INPATIENT DAYS16 NUMBER OF PATIENT MEALS17 NUMBER OF DRY AND CLEAN POUNDS PROCESSED18 NUMBER OF PERSONAL CONTACTS19 NUMBER OF SQUARE FEET SERVICED20 NUMBER OF GROSS SQUARE FEET21 $ 1,000 OF GROSS PATIENT REVENUE22 NUMBER OF ADMISSIONS23 NUMBER OF HOSPITAL FULL-TIME EQUIVALENT (FTE) EMPLOYEES24 NUMBER OF ADJUSTED INPATIENT DAYS25 NUMBER OF NURSING SERVICE FULL-TIME EQUIVALENT PERSONNEL26 NUMBER OF PARTICIPANTS27 NUMBER OF SESSIONS




PERCENTAGE OF HOURS AND AVERAGE HOURLY RATE BY EMPLOYEE CLASSIFICATION

COST CENTER GROUP MANAGEMENT ANDSUPERVISION

TECHNICAL ANDSPECIALIST

REGISTERED NURSES

LICENSEDVOCATIONAL NURSES

AIDES ANDORDERLIES

DAILY HOSPITAL SERVICES 1.39% 1.24% 74.33% 6.08% 11.18% AMBULATORY SERVICES 4.59% 8.83% 62.57% % % ANCILLARY SERVICES 4.95% 48.60% 21.07% % 1.15% TOTAL PATIENT CARE SERVICES 3.41% 21.64% 50.79% 2.53% 5.10%

COST CENTER GROUP ENVIRON. AND FOOD SERV.

CLERICALAND OTHEREMPLOYEES

REGISTRY ANDTEMP HELP

TOTALPRODUCTIVE HOURS

TOTAL PAIDHOURS

DAILY HOSPITAL SERVICES % 5.34% 0.43% 161,841 208,401 AMBULATORY SERVICES % 23.39% 0.63% 71,330 86,422 ANCILLARY SERVICES % 18.10% 6.14% 156,434 186,816 TOTAL PATIENT CARE SERVICES % 13.77% 2.76% 389,605 481,639

RESEARCH % % % % % EDUCATION % % % % % GENERAL SERVICES 8.07% 20.70% % % % FISCAL SERVICES 3.72% 28.88% % % % ADMINISTRATIVE SERVICES 24.40% 30.58% % % %

RESEARCH % % % EDUCATION % % % GENERAL SERVICES 43.46% 27.76% 14.30% 108,967 142,576 FISCAL SERVICES % 67.41% % 35,169 41,440 ADMINISTRATIVE SERVICES 0.07% 44.96% 12.99% 116,894 149,189

TOTAL OPERATING COST CTRS 7.62% 22.42% 29.04% 1.44% 2.92% NON-OPERATING COST CENTERS % % % % %

AVERAGE HOURLY RATE $0.00 $0.00 $0.00 $0.00 $0.00

TOTAL OPERATING COST CTRS 6.96% 23.50% 6.09% 681,403 814,844 NON-OPERATING COST CENTERS % % 100.00% 2,883 2,883

AVERAGE HOURLY RATE $0.00 $0.00 $0.00

HOSPITAL PERSONNEL PROFILE

TOTAL NUMBER OF PRODUCTIVE HOSPITAL FTE'S* 308 NUMBER OF NURSING REGISTRY AND TEMP HELP FTE'S 5

TOTAL NUMBER OF NURSING FTE'S** 111NUMBER OF NURSING REGISTRY FTE'S 1

* EXCLUDES REGISTRY NURSES AND TEMPORARY HELP**INCLUDES NURSING REGISTRY

GENERAL INFORMATION AND CERTIFICATION

12. City: REDWOOD CITY

13. Zip Code: 94065

1.Health Care Institution(Legal Name): ST LOUISE REGIONAL HOSPITAL

2. OSHPD Facility Number: 106434138

3. D. B.A. (Doing Business As) Name: ST LOUISE REGIONAL HOPSITAL

4. Hospital Business Phone: (408) 848-8607

5.Medi-Cal Contract Provider Number:

6. Medi-Cal Non-Contract Provider Number: HSP30688G

7.Medicare Provider Number: 050688

8. Street Address: 9400 NO NAME UNO

9. City: GILROY

10.Zip Code: 95020

14. Chief Executive Officer: JIM DOVER

15. Title: CEO

16. Hospital Web Site Address: HTTP://WWW.SAINTLOUISEREGIONALHOSPITAL.ORG

17. Name of Owner: DAUGHTERS OF CHARITY HEALTH SYSTEM

18.Previous Name of Institution if Changed Since Previous Report:

23. Person Completing Report: GLENN S BUNTING

11. Mailing Address (if different) - Street or P.O. Box: 203 REDWOOD SHORES PKWY #800

24. Organization Name: MOSS ADAMS LLP

25. Phone Number: (916) 503-8195 Ext: -

26. FAX Phone Number: (916) 503-8101

28. Mailing Address - Street or P.O. Box: 3100 ZINFANDEL DRIVE

29. City: RANCHO CORDOVA

30. State : CA

31. Zip Code: 95670

36. Report Period: From: 07/01/2013

37. Through: 06/30/2014

38. Medi-Cal Contract Period: From: 07/01/2013

39. Through: 06/30/2014

40. Was this disclosure report completed after an independent financial audit ?

41. Are audit adjustments made by the independent auditor reflected in this report ?

__X__ Yes ____ No

__X__ Yes ____ No

( Page 0 Submitted Data )

Date Prepared: 6/24/2015 HOSPITAL DISCLOSURE REPORT FACSIMILE

Line No MISC INFORMATION (1)

5 Licensed Beds (End of Period) 7210 Available Beds 7215 Staffed Beds (Average) 3120 HSA No 725 If Designated Trauma Center30 Indicate Level (1,2 or 3)35 If CCS approved NICU, 40 indicate the standard below:45 Regional 50 Community 55 Intermediate

TYPE OF CONTROL (2)

Church XNon-Profit Corporation Non-Profit Other Investor - Individual Investor - Partnership Investor - Corporation State County City/County City District

TYPE OF CARE (3) Line NoShort-Term - General X 5Short-Term - Childrens 10Short-Term - Psychiatric 15Short-Term - Specialty 20Long-Term - General 25Long-Term - Childrens 30Long-Term - Psychiatric 35Long-Term - Specialty 40

455055

Line No GOVERNMENT PROGRAMS (1)

60 Medicare X65 Medi-Cal X70 Children's Medical Services 75 Short-Doyle 80 CHAMPUS X85 County Indigent 90 Other (Specify) 95 100 105

PREPAID PROGRAMS (2) No.of

Each TypeHospitalBasedParent Organization BasedState ContractsFederal ContractsMedical Foundation ContractsCommercial Plan ContractsOther (Specify)

24 HR. ON PREMISES COVERAGE (3)

Line No

Emergency Services X 60Psychiatric ER 65Physician X 70Pharmacist X 75Operating Room X 80Laboratory Services X 85Radiology Services X 90Anesthesiologist X 95

100105

Line No

CLINICAL SPECIALTY HOSPITAL BASED NON-HOSPITAL BASED RESIDENTS/FELLOWS(Enter FTEs)

Line No

Board Certified

(1) Board Eligible

(2) Other

(3)Board

Certified (4)

Board Eligible

(5) Other

(6) Residents

(7)Fellows

(8)110 Aerospace Medicine 110115 Allergy and Immunology 2 115120 Anesthesiology 10 120125 Cardiovascular Diseases 5 125130 Child Psychiatry 130135 Colon and Rectal Surgery 1 135140 Dental 2 140145 Dermatology 1 145150 Diagnostic Radiology 10 150155 Forensic Pathology 155160 Gastroenterology 2 160165 General/Family Practice 10 165170 General Preventive Medicine 170175 General Surgery 8 175180 Internal Medicine 7 180185 Neurological Surgery 1 185190 Neurology 1 190195 Nuclear Medicine 195200 Obstetrics and Gynecology 12 200205 Occupational Medicine 205210 Oncology 4 210215 Ophthalmology 4 215220 Oral Surgery 1 220

ACTIVE MEDICAL STAFF PROFILE - MD's, DO's, Podiatrists and Dentists (Enter No)

1. HOSPITAL DESCRIPTION

ST LOUISE REGIONAL HOPSITAL 06/30/2014Facility D.B.A. Name : Report Period End:

( Page 1 (1 of 2) Submitted Data )Date Prepared: 6/24/2015 HOSPITAL DISCLOSURE REPORT FACSIMILE

Line No

CLINICAL SPECIALTY HOSPITAL BASED NON-HOSPITAL BASED RESIDENTS/FELLOWS(Enter FTEs)

Line No

Board Certified

(1) Board Eligible

(2) Other

(3)Board

Certified (4)

Board Eligible

(5) Other

(6) Residents

(7)Fellows

(8)225 Orthopaedic Surgery 6 225230 Otolaryngology 2 230235 Pathology 3 235240 Pediatric-Allergy 240245 Pediatric-Cardiology 245250 Pediatric-Surgery 250255 Pediatrics 6 255260 Physical Medicine/Rehabilitation 2 260265 Plastic Surgery 1 265270 Podiatry 3 270275 Psychiatry 275280 Public Health 280285 Pulmonary Disease 2 285290 Radiology 290295 Therapeutic Radiology 295300 Thoracic Surgery 300305 Urology 4 305310 Vascular Surgery 1 310315 Other Specialties 22 53 315320 TOTAL 45 141 320

1. HOSPITAL DESCRIPTION



CODE

1- Service is available at the hospital. 3 - Service not available.

2- Service is available through arrangement at 4 - Clinic services are commonly provided in the emergency suite to another health care entity. non-emergency outpatients by hospital-based physicians or residents. *

* Code 4 used only for Clinic Services.

Line No

(1)Code

(2) Code

(3)Code

5 INTENSIVE CARE SERVICES Microbiology 1 Dental 310 Burn 3 Necropsy 3 Dermatology 315 Coronary 1 Serology 1 Diabetes 320 Medical 1 Surgical Pathology 1 Drug Abuse 325 Neonatal 3 DIAGNOSTIC IMAGING SERVICES Family Therapy 330 Neurosurgical 1 Computed Tomography 1 Group Therapy 335 Pediatric 3 Cystoscopy 1 Hypertension 340 Pulmonary 1 Magnetic Resonance Imaging 1 Metabolic 345 Surgical 1 Positron Emission Tomography 3 Neurology 350 Definitive Observation Care 1 Ultrasonography 1 Neonatal 355 ACUTE CARE SERVICES X-Ray - Radiology 1 Obesity 360 Alternate Birthing Center (Licensed Beds) 3 DIAGNOSTIC/THERAPEUTIC

SERVICES Obstetrics 1

65 Geriatric 1 Audiology 3 Ophthalmology 370 Medical 1 Biofeedback Therapy 3 Orthopedic 375 Neonatal 3 Cardiac Catheterization 3 Otolaryngology 380 Oncology 1 Cobalt Therapy 3 Pediatric 385 Orthopedic 1 Diagnostic Radioisotope 3 Pediatric Surgery 390 Pediatric 1 Echocardiology 1 Podiatry 395 Physical Rehabilitation 1 Electrocardiology 3 Psychiatric 3100 Post Partum 1 Electroencephalography 3 Renal 3105 Surgical 1 Electromyography 3 Rheumatic 3107 Transitional Inpatient Care (Acute Beds) 3 110 NEWBORN CARE SERVICES Endoscopy 1 Rural Health 3115 Developmentally Disabled Nursery Care 3 Gastro-Intestinal Laboratory 1 Surgery 3120 Newborn Nursery Care 1 Hyperbaric Chamber Services 1 125 Premature Nursery Care 1 Lithotripsy 1 HOME CARE SERVICES 130 Hospice Care 3 Nuclear Medicine 1 Home Health Aide Services 3135 Inpatient Care Under Custody (Jail) 3 Occupational Therapy 1 Home Nursing Care (Visiting Nurse) 3140 LONG-TERM CARE Physical Therapy 1 Home Physical Medicine Care 3145 Behavioral Disorder Care 3 Peripheral Vascular Laboratory 3 Home Social Service Care 3150 Developmentally Disabled Care 3 Pulmonary Function Services 1 Home Dialysis Training 3155 Intermediate Care 3 Radiation Therapy 3 Home Hospice Care 3160 Residential/Self Care 3 Radium Therapy 3 Home IV Therapy Services 3165 Self Care 3 Radioactive Implants 3 Jail Care 3170 Skilled Nursing Care 3 Recreational Therapy 3 Psychiatric Foster Home Care 3175 Sub-Acute Care 3 Respiratory Therapy Services 1 177 Sub-Acute Care-Pediatric 3 179 Transitional Inpatient Care (SNF Beds) 3 180 CHEMICAL DEPENDENCY - DETOX Speech-Language Pathology 3 AMBULATORY SERVICES 185 Alcohol 3 Spotcare Medicine 1 Adult Day Health Care Center 3190 Drug 3 Stress Testing 1 Ambulatory Surgery Services 1195 CHEMICAL DEPENDENCY - REHAB Therapeutic Radioisotope 3 Comprehensive Outpatient Rehab

Facility1

200 Alcohol 3 X-Ray Radiology Therapy 1 Observation (Short Stay) Care 1205 Drug 3 PSYCHIATRIC SERVICES Satellite Ambulatory Surgery Center 3

2. SERVICES INVENTORY



CODE

1- Service is available at the hospital. 3 - Service not available.

2- Service is available through arrangement at 4 - Clinic services are commonly provided in the emergency suite to another health care entity. non-emergency outpatients by hospital-based physicians or residents. *

* Code 4 used only for Clinic Services.

Line No

(1)Code

(2) Code

(3)Code

210 PSYCHIATRIC SERVICES Clinic Psychologist Services 3 Satellite Clinic Services 3215 Psychiatric Acute- Adult 3 Child Care Services 3 220 Psychiatric - Adolescent and Child 3 Electroconvulsive Therapy (Shock) 3 OTHER SERVICES 225 Psychiatric Intensive (Isolation) Care 3 Milieu Therapy 3 Diabetic Training class 1230 Psychiatric Long-Term Care 3 Night Care 3 Dietetic Counseling 1235 Psychiatric Therapy 3 Drug Reaction Information 1240 OBSTETRIC SERVICES Psychopharmacological Therapy 3 Family Planning 3245 Abortion Services 3 Sheltered Workshop 3 Genetic Counseling 3250 Combined Labor/Delivery Birthing Room 1 RENAL DIALYSIS Medical Research 3255 Delivery Room Services 1 Hemodialysis 1 Parent Training Class 1260 Infertility Services 3 Home Dialysis Support Services 3 Patient Representative 1265 Labor Room Services 1 Peritoneal 1 Public Health Class 3270 SURGERY SERVICES Self-Dialysis Training 3 Social Work Services 1275 Dental 1 Organ Acquisition 3 Toxicology/Antidote Information 1280 General 1 Blood Bank 1 Vocational Services 3285 Gynecological 1 Extracorporeal Membrane Oxygenation 3 290 Heart 1 Pharmacy 1 MEDICAL EDUCATION PROGRAMS 295 Kidney 1 Approved Residency 3300 Neurosurgical 3 EMERGENCY SERVICES Approved Fellowship 3305 Open Heart 3 Emergency Communications Systems 1 Non-Approved Residency 3310 Ophthalmologic 1 Emergency Helicopter Service 1 Associate Records Technician 3315 Organ Transplant 3 Emergency Observation Service 3 Diagnostic Radiologic Technologist 1320 Orthopedic 1 Emergency Room Service 1 Dietetic Intern Program 3325 Otolaryngologic 1 Heliport 1 Hospital Administration Program 1330 Pediatric 1 Medical Transportation 3 Hospital Administration Program 3335 Plastic 1 Mobile Cardiac Care Services 3 Licensed Vocational Nurse 3340 Podiatry 1 Orthopedic Emergency Services 1 Medical Technologist Program 3345 Thoracic 1 Psychiatric Emergency Services 3 Medical Records Administrator 3350 Urologic 1 Radioisotope Decontamination Room 3 Nurse Anesthetist 3355 Anesthesia Services 1 Trauma Treatment E. R. 3 Nurse Practitioner 3360 Nurse Midwife 3365 LABORATORY SERVICES CLINIC SERVICES Occupational Therapist 3370 Anatomical Pathology 1 AIDS 3 Pharmacy Intern 1375 Chemistry 1 Alcoholism 3 Physician's Assistant 3380 Clinical Pathology 1 Allergy 3 Physical Therapist 3385 Cytogenetics 3 Cardiology 3 Registered Nurse 1390 Cytology 1 Chest Medical 3 Respiratory Therapist 3395 Hematology 1 Child Diagnosis 3 Social Worker Program 3400 Histocompatibility 1 Child Treatment 3 405 Immunology 1 Communicable Disease 3

2. SERVICES INVENTORY



Codes

Use Codes A,B, and G to indicate the relationship of the hospital to related organizations and codes C,D,E,F and G to indicate relationship of hospital with organizations with related personnel.

A. Corporation, partnership or other organization has ownership interest in hospital. [Complete columns (4) through (11).] B. Hospital has ownership interest (stockholder, partner, etc.) in both related organization and hospital. [Complete columns (4) through (11).] C. Individual has ownership interest (stockholder, partner, etc.) in both related organization and hospital. (Complete all columns.) D. Director, officer, administrator or key person or relative of such person has ownership interest in related organization. [Complete columns(2),(4) through (11).] E. Individual is director, officer, administrator or key person of hospital and related organization. [Complete columns(2), (4) through (11).] F. Director, officer, administrator or key person or related organization or relative of such person has ownership interest in hospital. [Complete columns(2),(4) through (11).] G. Other (ownership or non-financial) interest, specify on lines 13-16. (complete columns as applicable.)

NOTE: Relatives are defined as: spouse, son, daughter, grandchild, great grandchild, stepchild, brother, sister, half-brother, half-sister, stepbrother, stepsister, parent, grandparent, great grandparent, stepmother, stepfather, niece, nephew, aunt, uncle, son-in-law, daughter-in-law, father-in-law, mother-in-law, brother-in-law, or sister-in-law.

A. Are any costs included which are a result of transactions with a related organizations as defined in 42 CFR 413.17?

1.

B. Are any costs included which are a result of transactions with a related organization of which a hospital employee, board member or member of the which medical staff, or relative of such person is an officer or owner ? (Ignore stock ownership less than 3%)

2.

Yes No (If "Yes", complete item C.)X

Yes No (If "Yes", complete item C.)X

Line No

Code(1)

Name of Individual - (Complete for Codes C- G)

(2) Percent Ownership of

Hospital (3)Related Organizations

Name (4) Percent Ownership(5)

Type of Business (6)

3 A DAUGHTERS OF CHARITY HEALTH SYSTEM

100 CORPORATE OFFICE / PARENT

456789101112

Line Nature of Service or Supply Amount Expense Included on

No (7) (8) Page (9) Column (10) Line (11)3 ADMIN, BUS OFFICE, ACCOUNTING $4,442,108 18 6 205456789101112

COMMENTS:

13141516

3.1 RELATED HOSPITAL INFORMATION

C. Complete the following to show the relationships of the hospital with related organizations and with organizations with related personnel from the hospital obtained services, facilities, or supplies during the reporting period.

ST LOUISE REGIONAL HOPSITAL 06/30/2014Facility D.B.A. Name : Report Period End: ( Page 3.1 Submitted Data )


Sole Pro-

prietorship

Partners Corporation Officers

Line No

Name (1)

Title and Function (2)

Percentage of

Customary Work Week Devoted to Business

(3)

Percent Share of

Operation Profit or

(Loss)(4)

Percentage of


(5)

Percent of Provider's

Stock Owned

(6)

Percentage of


(7)

Compensation Included in Costs for the Period

(8) *1718192021

E. Are any funds held in trust by an outside party which are not reflected on the Balance Sheet ?

22. Yes No If "Yes", what is the total amount ?X

Financial Arrangement

Line No

Hospital Cost Center (1)

Joint (2)

Contracted (3)

Rental (4)

Independent (5)

Agency (6)

Salaried (7)

Other (8)

23 Clinical and Pathological Laboratory Services X

24 Radiology - Diagnostic and Therapeutic X

25 Nuclear Medicine X

26 Cardiology Services X

27 Emergency Services X

28 Gastro-Intestinal Services X

29 Pulmonary Function Services X

30 Psychiatric Therapy

31 Anesthesiology X

32 Other (Specify)

F. Section 1191 of the Hospital Accounting and Reporting Manual references six general types of financial arrangements which exist between hospital and hospital-based physicians. Check the appropriate boxes below to indicate the type of financial arrangement which exists in your hospital for the various hospital cost centers having such arrangements. If none of the six types of financial arrangements described are appropriate, check the Other column and describe the arrangement in the comment section. For cost centers other than those listed below, please complete the Other line

COMMENTS:33

34

35

36


* Compensation as used in this schedule has the same definition as 42CFR 413.102

NOTE: Relatives are defined as: spouse, son, daughter, grandchild, great grandchild, stepchild, brother, sister, half-brother, half-sister, stepbrother, stepsister, parent, grandparent, great grandparent, stepmother, stepfather, niece, nephew, aunt, uncle, son-in-law, daughter-in-law, father-in-law, mother-in-law,brother-in-law, or sister-in-law.


D. STATEMENT OF COMPENSATION OF OWNERS AND THEIR RELATIVES

( Page 3.2 Submitted Data )Date Prepared: 6/24/2015 HOSPITAL DISCLOSURE REPORT FACSIMILE

* Compensation paid to the individual from all sources for services rendered personally to or on behalf of the hospital.

Line No Name (1)

Occupation (2)

Check if Owner

(3)

Percentage of Hospital

Ownership (4)

Check if Board Member

(5) Compensation*

(6) 37 SISTER ANN LEITAO, DC NUN X $038 SISTER MARION BILL, DC NUN X $039 SISTER ARTHUR GORDON, DC NUN X $040 SISTER FRAN CILUAGA NUN X $041 SISTER JUDITH SCHOMISCH, DC NUN X $042 ROBERT ISSAI DCHS PRESIDENT X $043 MARK AHN PHYSICIAN X $044 GEORGE CHIALA FARMER X $045 SCOTT BENNINGHOVEN PHYSICIAN X $046 GEORGE GREEN PHYSICIAN X $047 ALLEN HAYES INSURANCE BROKER X $048495051525354555657585960616263646566


G. HOSPITAL OWNERS AND GOVERNMENT BOARD MEMBERS


( Page 3.3 Submitted Data )


Facility D.B.A. Name :

Line No

(1) Physician Name

(2) Percent of Stock Owned

(3) Describe Contract, Lease and Other Arrangements

70717273747576777879

J. Is this facility operated by a management firm ? (This excludes related parties, e.g, management by a parent corporation.)

Yes X No. (If "Yes", complete lines 81 through 102.)

81. Name of the management firm:

82. Address:

83. City: 84. State: 85. ZIP Code:

86. Amount paid to the management firm for the reporting period:

K. Does the hospital administrator work for the management firm ?

87. Yes No

L. List the services provided by the management firm.

80.

8889909192

M. Are the amounts paid to the management firm functionally accounted and reported as required ?

Yes No. (If "No", complete lines 99 through 102.)98.

Please explain why amounts paid to the management firm are not functionally accounted and reported.

99100101102

I. To be completed by all closely held corporations. If a physician is an owner or an owner of the corporation which owns the hospital, identify all business relationships between the physician and the hospital. This would include percentage of stock owned by the physician, all contracts between the physician and the hospital, and all lease arrangements between the physician and the hospital. If more than ten owners, provide data for the ten with the largest percentage of stock owned.


ST LOUISE REGIONAL HOPSITAL 06/30/2014Report Period End:

9394959697


BEDS PATIENT (CENSUS) DAYS DISCHARGESLine No

DAILY HOSPITAL SERVICES (1) Licensed (End of Period)

(2) Available

(Average) (3) Staffed

(Average) (4)

Adult (5)

Pediatric (11)

Service (12)

TotalLine No

5 Medical/Surgical Intensive Care 8 8 5 1,780 216 510 Coronary Care 1015 Pediatric Intensive Care 1520 Neonatal Intensive Care 2025 Psychiatric Intensive ( Isolation ) Care 2530 Burn Care 3035 Other Intensive Care 3540 Definitive Observation 4045 Medical/Surgical Acute 48 48 22 7,447 2,138 4550 Pediatric Acute 5055 Psychiatric Acute - Adult 5560 Psychiatric Acute - Adolescent & Child 6065 Obstetrics Acute 16 16 4 1,324 691 6570 Alternate Birthing Center 7075 Chemical Dependency Services 7580 Physical Rehabilitation Care 8085 Hospice - Inpatient Care 8590 Other Acute Care 90100 Sub-Acute Care 100101 Sub-Acute Care - Pediatric 101105 Skilled Nursing Care 105110 Psychiatric Long-Term Care 110115 Intermediate Care 115120 Residential Care 120125 Other Long-Term Care Services 125145 Other Daily Hospital Services 145150 Total 72 72 31 10,551 3,045 150155 Nursery Acute 18 5 155

4 PATIENT UTILIZATION STATISTICS

Facility D.B.A. Name : ST LOUISE REGIONAL HOPSITAL 06/30/2014Report Period End:


Line No

ACCOUNT DESCRIPTION STANDARD UNIT OF MEASURE (1) Total Units of

Service [Sum of columns (7) and

(13)]

(7) Total Inpatient Units

of Service

(13) Total Outpatient Units of Service

Line No.

160AMBULATORY SERVICES Emergency Services Visits 24,813 24,813 160

165 Medical Transportation Services Occasions of Service 165170 Psychiatric Emergency Rooms Visits 170175 Clinics Visits 11,838 11,838 175180 Satellite Clinics Visits 180185 Satellite Ambulatory Surgery Center Operating Minutes 185190 Outpatient Chemical Dependency Svcs Visits 190195 Observation Care Observation Hours 195200 Partial Hospitalization - Psychiatric Day-Night Care Days 200205 Home Health Care Services Home Health Visits 205210 Hospice - Outpatient Visits 210215 Adult Day Health Care Visits 215

230ANCILLARY SERVICESLabor and Delivery Services Deliveries 565 565 230

235 Surgery and Recovery Services Operating Minutes 194,994 112,391 82,603 235240 Ambulatory Surgery Services Operating Minutes 240245 Anesthesiology Anesthesia Minutes 245250 Medical Supplies Sold to Patients CS & S Adj. Inpatient Days 21,123 250255 Durable Medical Equipment Adjusted Inpatient Days 255260 Clinical Laboratory Services Tests 186,970 90,519 96,451 260265 Pathological Laboratory Services Tests 265270 Blood Bank Units of Blood Issued 270275 Echocardiology Procedures 275280 Cardiac Catheterization Services Procedures 280285 Cardiology Services Procedures 285290 Electromyography Procedures 290295 Electroencephalography Procedures 295300 Radiology - Diagnostic Procedures 35,219 7,380 27,839 300305 Radiology - Therapeutic Procedures 305310 Nuclear Medicine Procedures 310315 Magnetic Resonance Imaging Procedures 315320 Ultrasonography Procedures 320325 Computed Tomographic Scanner Procedures 325330 Drugs Sold to Patients Pharmacy Adj. Inpatient Days 15,853 330335 Respiratory Therapy Respiratory Therapy Adj. Inpatient

Days13,949 335

340 Pulmonary Function Services Procedures 340345 Renal Dialysis Hours of Treatment 1,184 1,168 16 345350 Lithotripsy Procedures 350355 Gastro-Intestinal Services Procedures 355360 Physical Therapy Sessions 33,136 20,938 12,198 360365 Speech-Language Pathology Sessions 365370 Occupational Therapy Sessions 370380 Electroconvulsive Therapy Treatments 380385 Psychiatric/Psychological Testing Sessions 385390 Psychiatric Individual/Group Therapy Sessions 390395 Organ Acquisition Organs acquired 395




(a) Sum of column 13, lines 160,170,175,180,190,200,205,210,215,505,515,535,545,550, and 555.

OTHER STATISTICS (1) Total Units of

Service

(7) Inpatient Units of

Service

(13) Outpatient Units of

Service505 Satellite Ambulatory Surgery Center Surgeries 1,619 1,619 505510 Satellite Ambulatory Surgery Center Satellite Operating Rooms 510515 Surgery and Recovery Services Surgeries 515520 Surgery and Recovery Services Open Heart Surgery Minutes 520525 Surgery and Recovery Services Open Heart Surgeries 525530 Surgery and Recovery Services Inpatient Operating Rooms 530535 Ambulatory Surgery Services Surgeries 535540 Ambulatory Surgery Services Outpatient Operating Rooms 540545 Observation Care Days 545550 Renal Dialysis Care Visits 4 4 550555 Referred Visits 18,385 18,385 555560 Total Outpatient Visits(a) 56,659 56,659 560

LIVE BIRTH SUMMARY (1) Total Births [Sum of

columns (7) and (13)]

(7) Natural Births

(13) Cesarean Sections

600 Labor and Delivery Services 566 439 127 600605 Surgery and Recovery Services 605610 Alternate Birthing Services 610615 Obstetrics Acute 615620 Emergency Services and other areas within the hospital 620625 Total Births (Sum of Lines 600 through 620) 566 439 127 625




PATIENT (CENSUS ) DAYS

Line No

TYPE OF CARE (1) Medicare -Traditional

(2) Medicare -

Managed Care

(3) Medi-Cal -Traditional

(4) Medi-Cal-

Managed Care

(5) County Indigent

Programs - Traditional

(6) County Indigent

Programs -Managed Care

Line No

5 Acute Care 4,776 591 1,503 1,010 510 Psychiatric Care 1015 Chemical Dependency Care 1520 Rehabilitation Care 2025 Long-Term Care 2530 Other Care 3035 Total 4,776 591 1,503 1,010 3540 Nursery Acute 452 342 4045 Purchased Inpatient Services 45

DISCHARGES

Line No

TYPE OF CARE (12) Medicare - Traditional

(13) Medicare -

Managed Care


(15) Medi-Cal-

Managed Care

(16) County Indigent


(17) County Indigent


Line No

5 Acute Care 1,153 137 498 412 510 Psychiatric Care 1015 Chemical Dependency Care 1520 Rehabilitation Care 2025 Long-Term Care 2530 Other Care 3035 Total 1,153 137 498 412 3540 Nursery Acute 219 172 4045 Purchased Inpatient Services 45

4.1 PATIENT UTILIZATION STATISTICS BY PAYER

PATIENT (CENSUS ) DAYS

Line No

TYPE OF CARE (7) Other Third

Parties Traditional

(8) Other Third

Parties Managed Care

(9) Other Indigent

(10) Other Payors

(11) Total Patient

Days

Line No

5 Acute Care 77 2,338 256 10,551 510 Psychiatric Care 1015 Chemical Dependency Care 1520 Rehabilitation Care 2025 Long-Term Care 2530 Other Care 3035 Total 77 2,338 256 10,551 3540 Nursery Acute 299 1,093 4045 Purchased Inpatient Services 45

DISCHARGES

Line No

TYPE OF CARE (18) Other Third

Parties Traditional

(19) Other Third

Parties Managed Care

(20) Other Indigent

(21) Other Payors

(22) Total Discharges

Line No

5 Acute Care 18 738 89 3,045 510 Psychiatric Care 1015 Chemical Dependency Care 1520 Rehabilitation Care 2025 Long-Term Care 2530 Other Care 3035 Total 18 738 89 3,045 3540 Nursery Acute 140 531 4045 Purchased Inpatient Services 45

Facility D.B.A. Name : ST LOUISE REGIONAL HOPSITAL 06/30/2014Report Period End: ( Page 4.1 (1 of 2) Submitted Data )


OUTPATIENT VISITS

Line No

TYPE OF OUTPATIENT VISIT (1) Medicare - Traditional

(2) Medicare -

Managed Care


(4) Medi-Cal-

Managed Care

(5) County Indigent


(6) County Indigent


Line No

60 Emergency Svcs. (incl. Psych ER) 2,796 452 2,894 9,239 6065 Clinic (incl. Satellite Clinics) 1,815 59 3,201 279 6570 Observation Care Days 7075 Psychiatric Day-Night Care Days 7580 Home Health Care Services 8085 Hospice - Outpatient 8590 Outpatient Surgeries 706 88 18 68 9095 Private Referred 5,934 395 1,031 1,867 95100 Other * 100105 Total 11,251 994 7,144 11,453 105

4.1 PATIENT UTILIZATION STATISTICS BY PAYER


OUTPATIENT VISITS

Line No

TYPE OF OUTPATIENT VISIT (7) Other Third

Parties -Traditional

(8) Other Third

Parties -Managed Care

(9) Other Indigent

(10) Other Payors

(11) Total

OutPatient Visits

Line No

60 Emergency Svcs. (incl. Psych ER) 562 6,120 2,750 24,813 6065 Clinic (incl. Satellite Clinics) 115 5,946 423 11,838 6570 Observation Care Days 7075 Psychiatric Day-Night Care Days 7580 Home Health Care Services 8085 Hospice - Outpatient 8590 Outpatient Surgeries 36 698 5 1,619 9095 Private Referred 194 8,529 435 18,385 95100 Other * 4 4 100105 Total 907 21,297 3,613 56,659 105

Includes Chemical Dependency Services, Adult Day Health Care, & Renal Dialysis Visits

( Page 4.1 (2 of 2) Submitted Data )Date Prepared: 6/24/2015 HOSPITAL DISCLOSURE REPORT FACSIMILE

Line No

ASSETS Account No (1) Current Year (2) Prior Year Line No

CURRENT ASSETS5 Cash 1000 $2,758,564 $2,533,426 510 Marketable securities 1010 1015 Accounts and notes receivable 1020 $66,817,916 $60,861,264 1520 Less allowance for uncollectible receivables and thrid-party contractual withholds 1040 ($54,057,581) ($49,662,173) 2025 Receivables from third-party payors 1050 2530 Pledges and other receivables 1060 3035 Due from restricted funds 1070 3540 Inventory 1080 $1,229,308 $1,103,753 4045 Intercompany receivables 1090 $5,693,274 $6,991,137 4550 Prepaid expenses and other current assets 1100 $347,041 $3,701,420 5055 TOTAL CURRENT ASSETS (Sum of lines 5 through 50) $22,788,522 $25,528,827 55

ASSETS WHOSE USE IS LIMITED60 Limited use cash 1110 6065 Limited use investments 1120 $43,955 $13,436 6570 Limited use other assets 1130 $234,015 $235,115 7075 TOTAL ASSETS WHOSE USE IS LIMITED (Sum of lines 60 through 70) $277,970 $248,551 75

PROPERTY, PLANT AND EQUIPMENT - AT COST80 Land 1200 $6,512,933 $6,511,544 8085 Land improvements 1210 $4,547,286 $4,547,286 8590 Buildings and improvements 1220 $28,121,852 $28,121,852 9095 Leasehold improvements 1230 $12,627,768 $12,627,768 95100 Equipment 1240 $31,930,206 $29,796,927 100105 TOTAL PROPERTY, PLANT AND EQUIPMENT (Sum of lines 80 through 100) $83,740,045 $81,605,377 105195 Less accumulated depreciation and amortization 1260 ($59,852,975) ($53,965,746) 195200 NET TOTAL PROPERTY, PLANT AND EQUIPMENT (Sum of lines 105 & 195) $23,887,070 $27,639,631 200205 Construction in progress 1250 $204,666 $317,440 205

INVESTMENTS AND OTHER ASSETS210 Investments in property, plant and equipment 1310 210215 Less accumulated depreciation - investments in plant and equipment 1320 215220 Other Investments 1330 220225 Intercompany receivables 1340 225230 Other Assets 1350 230235 TOTAL INVESTMENTS IN OTHER ASSETS (Sum of lines 210 through 230) 235

INTANGIBLE ASSETS245 Goodwill 1360 245250 Unamortized loan costs 1370 250255 Preopening and other organization costs 1380 255260 Other Intangible assets 1390 260265 TOTAL INTANGIBLE ASSETS (Sum of lines 245 through 260) 265

TOTAL270 TOTAL ASSETS (Sum of lines 55, 75,200,205,235 , and 265) $47,158,228 $53,734,449 270

Line No

OTHER INFORMATION (1) Current Year (2) Prior Year Line No

405 Current market value - current assets marketable securities (Line 10) 405410 Current market value - limited use investments (Line 65) 410415 Current market value - other investments (Line 220) 415420 Total cost to complete construction in progress (Line 205) $204,666 $317,440 420

5 BALANCE SHEET - UNRESTRICTED FUND



5 BALANCE SHEET - UNRESTRICTED FUND

Line No

LIABILITIES AND EQUITY Account No (3) Current Year (4)Prior Year Line No

CURRENT LIABILITIES5 Notes and loans payable 2010 $365,003 $565,030 510 Accounts payable 2020 $2,537,451 $909,120 1015 Accrued compensation and related liabilities 2030 $3,830,969 $3,938,438 1520 Other accrued expenses 2040 $359,998 $390,500 2025 Advances from third-party payors 2050 2530 Payable to third-party payors 2060 $425,295 $3,890,299 3035 Due to restricted funds 2070 3540 Income Taxes payable 2080 $758,602 $787,258 4045 Intercompany payables 2090 $34,252,748 $25,703,223 4550 Current maturities of long-term debt (Must agree with line 125) 5055 Other current liabilities 2100 $8,635,474 $9,583,205 5560 TOTAL CURRENT LIABILITIES (Sum of lines 5 through 55) $51,165,540 $45,767,073 60

DEFERRED CREDITS65 Deferred income taxes 2110 6570 Deferred third-party income 2120 7075 Other deferred credits 2130 7580 TOTAL DEFERRED CREDITS (Sum of lines 65 through 75) 80

LONG-TERM DEBT Unpaid Principal(a)85 Mortgages payable 2210 8590 Construction loans 2220 9095 Notes under revolving credit 2230 95100 Capital lease obligations 2240 100105 Bonds payable 2250 $30,596,239 $46,465,430 105110 Intercompany payables 2260 110115 Other non-current liabilities 2270 115120 TOTAL LONG-TERM DEBT (Sum of lines 85 through 115) $30,596,239 $46,465,430 120125 Less amount shown as current maturities (Must agree with line 50) 125130 NET TOTAL LONG-TERM DEBT(Sum of lines 120 and 125) $30,596,239 $46,465,430 130135 TOTAL LIABILITIES (Sum of lines 60,80 and 130) $81,761,779 $92,232,503 135

EQUITY (Non Profit)140 Unrestricted Fund Balance 2310 ($34,603,551) ($38,498,054) 140

EQUITY (Investor-Owned - Corporation)145 Preferred stock 2310 145150 Common stock 2320 150155 Additional paid-in-capital 2330 155160 Retained earnings 2340 160165 Less Treasury stock 2350 165

EQUITY (Investor-Owned - Partnership)170 Capital - unrestricted 2310 170175 Less Partner's draw 2320 175

EQUITY (Investor-Owned - Division of a Corporation)180 Preferred Stock 2710 180185 Common Stock 2720 185190 Additional paid-in-capital 2730 190195 Division equity - unrestricted 2740 195200 Less Treasury stock 2750 200205 TOTAL EQUITY(Sum of lines 140 through 200) ($34,603,551) ($38,498,054) 205

TOTAL270 TOTAL LIABILITIES AND EQUITY (Sum of lines 135 and 205) $47,158,228 $53,734,449 270

(a) Complete Report Page 5.1 to provide detailed long-term debt information.


Line No

(5) Detail For Page 5, column(3), Line No

(6)Date Obligation Incurred (Year Only*)

(7) Due Date (Year Only*)

(8) Interest Rate (a)

(9) Unpaid Principal Balance at Year End

Line No

5 105 2006 2040 7.45 $30,596,239 510 1015 1520 2025 2530 3035 3540 4045 4550 5055 5560 6065 6570 7075 7580 8085 8590 9095 95100 100105 105110 110115 115120 120125 125130 130135 135140 140145 145150 150155 155160 160165 165170 170175 175180 180185 185190 190195 195200 200205 205210 210215 215220 220225 225230 230235 235240 240245 245250 250

5.1 SUPPLEMENTAL LONG - TERM DEBT INFORMATION Facility D.B.A. Name : ST LOUISE REGIONAL HOPSITAL 06/30/2014Report Period End:

*Do not report month and day. Report year only.(a) If more than one due date or interest rate, list each with related unpaid principal amount.


*Do not report month and day. Report year only.(a) If more than one due date or interest rate, list each with related unpaid principal amount.

Line No

(5) Detail For Page 5, column(3), Line No

(6)Date Obligation Incurred (Year Only*)

(7) Due Date (Year Only*)

(8) Interest Rate (a)

(9) Unpaid Principal Balance at Year End

Line No

255 255260 260265 265270 270275 275280 280285 285290 290295 295300 300305 305310 310315 315320 320

5.1 SUPPLEMENTAL LONG - TERM DEBT INFORMATION Facility D.B.A. Name : ST LOUISE REGIONAL HOPSITAL 06/30/2014Report Period End:


Line

(1) (2) (3)

Additions

(4) (5) (6)

LineNo Description Beginning

Balance(a)Purchase Donation Transfers Disposals and

Retirements Ending

Balance (b)No

5 Land $6,511,544 $1,389 $6,512,933 510 Land Improvements $4,547,286 $4,547,286 1015 Buildings and Improvements $28,121,852 $28,121,852 1520 Leasehold Improvements $12,627,768 $12,627,768 2025 Equipment $29,796,927 $2,133,279 $31,930,206 2530 Construction-in-progress $317,440 ($112,774) $204,666 3035 TOTAL $81,922,817 $2,134,668 ($112,774) $83,944,711 35

5.2 STATEMENT OF CHANGES IN PROPERTY, PLANT AND EQUIPMENT


(a) Column(1), line 35 must agree with page 5, column(2), sum of lines 105 and 205.(b) Column(6), line 35 must agree with page 5, column(1), sum of lines 105 and 205.


Line No

ASSETS Account No

(1) Current Year

(2) Prior Year

Line No

SPECIFIC PURPOSE FUNDS5 Cash 1510 510 Investments Marketable Securities 1521 1015 Other Investments 1529 1520 Receivables 1530 2025 Due from other funds 1540 2530 Other assets 1550 3075 TOTAL SPECIFIC PURPOSE FUND ASSETS (Sum of lines 5 through 30) 75

PLANT REPLACEMENT AND EXPANSION FUNDS 105 Cash 1410 105110 Investments Marketable Securities 1421 110115 Mortgages investments 1422 115120 Real property (net of accumulated depreciation) 1423

1424120

125 Other Investments 1429 125130 Receivables 1430 130135 Due from other funds 1440 135140 Other assets 1450 140170 TOTAL PLANT REPLACEMENT AND EXPANSION FUND ASSETS (Sum

of lines 105 through 140)170

ENDOWMENT FUNDS205 Cash 1610 205210 Investments Marketable Securities 1621 210215 Mortgages 1622 215220 Real property (net of accumulated depreciation) 1623

1624220

225 Other investments 1629 225230 Receivables 1630 230235 Due from other funds 1640 235240 Other assets 1650 240275 TOTAL ENDOWMENT FUND ASSETS (Sum of lines 205 through 240) 275

Line No

OTHER INFORMATION (1) Current Year

(2) Prior Year

Line No

405 Current market value - specific purpose funds marketable securities (Line 10) 405410 Current market value - Property Replacement & Exp. funds marketable securities (line

110)410

415 Current market value - endowment funds marketable securities (line 210) 415

6 BALANCE SHEET - RESTRICTED FUND



6 BALANCE SHEET - RESTRICTED FUND

Line No

LIABILITIES AND FUND BALANCES Account No

(3) Current Year

(4) Prior Year

Line No

SPECIFIC PURPOSE FUNDS5 Due to unrestricted fund 2510 510 Due to plant replacement and expansion fund 2520 1015 Due to endowment fund 2530 1570 Fund balance 2570 7075 TOTAL SPECIFIC PURPOSE FUND LIABILITIES AND FUND BALANCE

(Sum of lines 5 through 70) 75

PLANT REPLACEMENT AND EXPANSION FUNDS105 Due to unrestricted fund 2410 105110 Due to specific purpose fund 2420 110115 Due to endowment fund 2430 115165 Fund balance 2470 165170 TOTAL PLANT REPLACEMENT AND EXPANSION FUND LIABILITIES

AND FUND BALANCE (Sum of lines 105 through 165)170

ENDOWMENT FUNDS205 Mortgages 2610 205210 Other non-current liabilities 2620 210215 Due to unrestricted fund 2630 215220 Due to plant replacement and expansion fund 2640 220225 Due to specific purpose fund 2650 225270 Fund balance 2670 270275 TOTAL ENDOWMENT FUND LIABILITIES AND FUND BALANCE (Sum of

lines 205 through 270)275



(a) District Hospitals. Include bond interest and redemption.

RESTRICTED FUNDS

Line No

ASSETS (1) Funds Unrestricted

(2) Specific Purpose (a)

(3) Plant Replacement and Expansion

(4) Endowment Line No

5BALANCE AT BEGINNING OF YEAR, AS PREVIOUSLY REPORTED ($38,498,054) 5

10 Prior period audit adjustment 1015 Restatement (describe) 1520 2025 2530 3035 3540 4045 45

50BALANCE AT BEGINNING OF YEAR, AS RESTATED ($38,498,054) 50

55ADDITIONS (DEDUCTIONS):Net Income (Loss) ($10,446,883) 55

60 Acquisitions of pooled companies 6065 Proceeds from sale of stock 6570 Stock options exercised 7075 Restricted contributions and grants 7580 Restricted investment income 8085 Expenditures for specific purposes 8590 Dividends declared 9095 Donated property, plant and equipment 95100 Intercompany transfers 100105 Dispo. Share funds transferred to public entity 105110 Other (Describe) EQUITY TRANSFER $14,341,386 110115 115120 120125 TOTAL ADDITIONS (DEDUCTIONS) $3,894,503 125

130TRANSFERS:Property and equipment additions 130

135 Principal payments on long-term debt 135140 Other (Describe) 140145 145150 150155 155160 160165 165170 170

175TOTAL TRANSFERS (Sum of columns (1) through (4) must equal 0) 175

185BALANCE AT END OF YEAR (Sum of lines 50,125 and 175) ($34,603,551) 185

7 STATEMENT OF CHANGES IN EQUITY


( Page 7 Submitted Data )Date Prepared: 6/24/2015 HOSPITAL DISCLOSURE REPORT FACSIMILE

(a) Report Page 8, Section II must be completed to provide detailed deductions from revenue information.(b) Report Page 8, Section II must be completed to provide detailed capitation premium revenue information.(c) Report Page 8, Section III must be completed to provide detailed non-operating revenue and expense information.

Line No

SECTION I (1) Current Year

(2) Prior Year

Line No

5OPERATING REVENUES:Daily hospital services $85,917,358 $87,821,359 5

10 Ambulatory services $87,920,968 $90,256,444 1015 Ancillary services $257,073,285 $243,379,269 1530 GROSS PATIENT REVENUE (Sum of lines 5 through 15) $430,911,611 $421,457,072 30105 DEDUCTIONS FROM REVENUE (From line 395) (a) $350,675,329 $343,084,286 105107 CAPITATION PREMIUM REVENUE (From line 450) (b) 107110 NET PATIENT REVENUE (Line 30 minus line 105 plus line 107) $80,236,282 $78,372,786 110135 TOTAL OTHER OPERATING REVENUE $2,030,636 $307,498 135140 TOTAL OPERATING REVENUE (Sum of lines 110 and 135) $82,266,918 $78,680,284 140

146OPERATING EXPENSES:Daily Hospital Services $18,468,877 $19,661,383 146

151 Ambulatory Services $7,649,597 $7,761,065 151156 Ancillary Services $21,552,894 $21,805,957 156161 Research Costs 161166 Education Costs 166171 General Services $13,910,476 $13,548,272 171176 Fiscal Services $2,417,561 $2,943,978 176181 Administrative Services $20,295,222 $19,184,366 181186 Unassigned Costs $9,133,718 $4,360,876 186190 Purchased Inpatient Services 190195 Purchased Outpatient Services 195200 TOTAL OPERATING EXPENSES (Sum of Lines 146 through 195) $93,428,345 $89,265,897 200205 NET FROM OPERATIONS (Line 140 minus line 200) ($11,161,427) ($10,585,613) 205210 NET NON-OPERATING REVENUE AND EXPENSE (From Line 700) (c) $714,544 ($3,936,176) 210

215NET INCOME BEFORE TAXES AND EXTRAORDINARY ITEMS: (Sum of lines 205 and 210) ($10,446,883) ($14,521,789) 215

220PROVISION FOR INCOME TAXES:Current 220

225 Deferred 225

230NET INCOME BEFORE EXTRAORDINARY ITEMS: (Line 215 minus 220 and 225) ($10,446,883) ($14,521,789) 230

235EXTRAORDINARY ITEMS:(Specify)

235240 240245 NET INCOME (Line 230 minus lines 235 and 240) ($10,446,883) ($14,521,789) 245

8 STATEMENT OF INCOME- UNRESTRICTED FUND



8 STATEMENT OF INCOME- UNRESTRICTED FUND (DEDUCTIONS FROM REVENUE AND CAPITATION PREMIUM REVENUE)

Line No

SECTION II (1) Current Year

(2) Prior Year

Line No

300DEDUCTIONS FROM REVENUE:Provision for bad debt $3,399,094 $2,208,871 300

305 Contractual adjustments - Medicare - traditional $132,473,801 $136,303,298 305310 Contractual adjustments - Medicare - managed care $16,924,623 $16,363,834 310315 Contractual adjustments - Medi-Cal - traditional $36,714,212 $27,202,498 315320 Contractual adjustments - Medi-Cal - managed care $52,947,935 $45,854,723 320325 Disproportionate share payments for Medi-Cal patient days (SB 855) (credit bal)

(d)325

330 Contractual adjustments - County indigent programs - traditional 330335 Contractual adjustments - County indigent programs - managed care 335340 Contractual adjustments - Other third parties - traditional $4,507,051 $4,193,517 340345 Contractual adjustments - Other third parties - managed care $81,997,186 $82,182,888 345350 Charity discounts - Hill Burton 350355 Charity discounts - other $9,647,418 $28,774,657 355360 Restricted donations and subsidies for indigent care (credit balance) 360365 Teaching allowances (Teaching Hospitals only) 365370 Support for clinical teaching (credit balance (Teaching Hospitals only) 370375 Policy discounts 375380 Administrative adjustments 380385 Other deductions from revenue $12,064,009 385395 TOTAL DEDUCTIONS FROM REVENUE (Sum of lines 300 thru 385) $350,675,329 $343,084,286 395

430CAPITATION PREMIUM REVENUE:Capitation Premium Revenue - Medicare 430

435 Capitation Premium Revenue - Medi-Cal 435440 Capitation Premium Revenue - County indigent programs 440445 Capitation Premium Revenue - Other third parties 445450 TOTAL CAPITATION PREMIUM REVENUE (Sum of lines 430 thru 445) 450

Facility D.B.A. Name : ST LOUISE REGIONAL HOPSITAL Report Period End: 06/30/2014

(d) Disproportionate share funds transferred back to a related public entity must be reported on page 7, column(1), line 105.


Line No

SECTION III Account No

(1) Current Year

(2) Prior Year

Line No

500NON-OPERATING REVENUES:Gains on sale of hospital property 9010 500

505 Maintenance of restricted funds revenue 9030 505510 Unrestricted contributions 9040 $976,789 $883,246 510515 Donated services 9050 515520 Income, gains and losses from unrestricted investments 9060 $41,921 $62,370 520525 Unrestricted income from endowment funds 9070 525530 Unrestricted income from other restricted funds 9080 530535 Term endowment funds becoming unrestricted 9090 535540 Transfers from restricted funds for non-operating expenses 9100 540545 Assessment revenue (e) 9150 545550 County allocation of taxes revenue (e) 9160 550555 Special district augmentation revenue (e) 9170 555560 Debt service taxes revenue (e) 9180 560565 State homeowner's property tax relief (e) 9190 565570 State appropriation 9200 570575 County appropriation - Realignment funds 9210 575580 County appropriation - County general funds 9220 580585 County appropriation - Other county funds 9230 585590 Physician's offices and other rentals - revenue 9250 $425,360 $406,411 590595 Medical office building revenue 9260 595600 Child care services revenue (non-employee) 9270 600605 Family housing revenue 9280 605610 Retail operations revenue 9290 610615 Other non-operating revenue 9400 $54,718 $83,642 615625 TOTAL NON-OPERATING REVENUE (Sum of lines 500 thru 615) $1,498,788 $1,435,669 625

640NON-OPERATING EXPENSES:Loses on sale of hospital property 9020 640

645 Maintenance of restricted funds expense 9030 645650 Physician's offices and other rentals expense 9510 $915,378 650655 Medical office building expense 9520 655660 Child care services expense (non-employee) 9530 660665 Family housing expense 9540 665670 Retail operations expense 9550 670675 Other non-operating expense 9800 $784,244 $4,456,467 675685 TOTAL NON-OPERATING EXPENSE (Sum of lines 640 thru 675) $784,244 $5,371,845 685

700NET NON-OPERATING REVENUE AND EXPENSE (Line 625 minus line 685) $714,544 ($3,936,176) 700

705 Interest on long-term debt (e) 705

8 STATEMENT OF INCOME- UNRESTRICTED FUND (NON-OPERATING REVENUE AND EXPENSE)

06/30/2014Facility D.B.A. Name : ST LOUISE REGIONAL HOPSITAL Report Period End:

(e) District Hospital only.


Line No

(1) Current Year (2) Prior Year Line No

5CASH FLOW FROM OPERATING ACTIVITIES AND NON-OPERATING REVENUE:Net income (loss) ($10,446,883) ($14,521,789) 5

15

Adjustments to reconcile net income to net cash provided by (used for) operating activities and non-operating revenue :Depreciation and amortization $5,887,230 $4,308,777 15

17 Amortization of intangible assets 1720 Change in marketable securities 2030 Change in accounts and notes receivable, net of allowance for uncollectible receivables and

third-party contractual withholds ($1,561,244) $948,239 30

35 Change in receivables from third-party payors 3540 Change in pledges and other receivables 4045 Change in due from restricted funds 4550 Change in inventory ($125,555) ($176,142) 5055 Change in intercompany receivables $1,297,863 $164,107 5557 Change in Prepaid expenses and other current assets $3,354,379 $228,647 5760 Change in accounts payable $1,628,331 ($432,669) 6065 Change in accrued compensation and related liabilities ($107,469) $361,478 6570 Change in other accrued expenses ($30,502) ($237,800) 7075 Change in advances from third-party payors 7580 Change in payable to third-party payors ($3,465,004) $268,710 8085 Change in due to restricted funds 8587 Change in income taxes payable ($28,656) $92,517 8790 Change in intercompany payables $8,549,525 $16,555,565 9095 Change in other current liabilities ($947,731) ($1,215,035) 95100 Change in deferred credits 100102 Other (Describe): 102103 Other (Describe): 103104 Other (Describe): 104105 TOTAL ADJUSTMENTS (Sum of lines 15 through 104) $14,451,167 $20,866,394 105115 NET CASH PROVIDED BY (USED FOR) OPERATING ACTIVITIES (Sum of lines 5 and 105) $4,004,284 $6,344,605 115

130CASH FLOW FROM INVESTING ACTIVITIES: Change in assets whose use is limited ($29,419) ($22,203) 130

135 Purchase of plant, property and equipment and construction-in-progress ($2,134,668) ($10,094,041) 135140 Other (Describe): 140141 Other (Describe): 141142 Other (Describe): 142

145NET CASH PROVIDED BY (USED FOR) INVESTING ACTIVITIES (Sum of lines 130 through 142) ($2,164,087) ($10,116,244) 145

160CASH FLOW FROM FINANCING ACTIVITIES:Proceeds from issuance of long-term debt ($15,869,191) 160

165 Principal payments on long-term debt ($565,030) 165170 Proceeds from issuance of short-term notes and loans ($200,027) $565,030 170175 Principal payments on short-term notes and loans 175180 Dividends paid 180185 Proceeds from issuance of common stock 185190 Other (Describe): CY EQUITY TRANSFER; PY UNLOCAT $14,454,159 $2,889,824 190191 Other (Describe): 191192 Other (Describe): 192

195NET CASH PROVIDED BY (USED FOR) FINANCING ACTIVITIES (Sum of lines 160 through 192) ($1,615,059) $2,889,824 195

205 NET INCREASE (DECREASE) IN CASH (Sum of lines 115, 145 and 195) $225,138 ($881,815) 205215 CASH AT BEGINNING OF YEAR $2,533,426 $3,415,238 215225 CASH AT END OF YEAR (Sum of lines 205 and 215) $2,758,564 $2,533,423 225

9 STATEMENT OF CASH FLOWS - UNRESTRICTED FUND Facility D.B.A. Name : ST LOUISE REGIONAL HOPSITAL Report Period End: 06/30/2014

( Page 9 Submitted Data )Date Prepared: 6/24/2015 HOSPITAL DISCLOSURE REPORT FACSIMILE

Line No

REVENUE PRODUCING CENTERS (1)Units ofService

from Page 17,Column (13)

(2)AdjustedDirect Expenses


(3)AllocatedCosts

Column(4) minus (2)

(4)Total PatientCare Costs fromPage 20, Column

(16),Lines 505 - 915

(5)Average UnitPatient Care

Costs, Column (4) (1)

Line No

5DAILY HOSPITAL SERVICES:Medical/Surgical Intensive Care 5

10 Coronary Care 1015 Pediatric Intensive Care 1520 Neonatal Intensive Care 2025 Psychiatric Intensive (Isolation) Care 2530 Burn Care 3035 Other Intensive Care 3540 Definitive Observation 4045 Medical/Surgical Acute 4550 Pediatric Acute 5055 Psychiatric Acute - Adult 5560 Psychiatric Acute - Adol & Child 6065 Obstetrics Acute 6570 Alternate Birthing Center 7075 Chemical Dependency Services 7580 Physical Rehabilitation Care 8085 Hospice - Inpatient Care 8590 Other Acute Care 9095 Nursery Acute 95100 Sub-Acute Care 100101 Sub-Acute Care - Pediatric 101105 Skilled Nursing Care 105110 Psychiatric Long-Term Care 110115 Intermediate Care 115120 Residential Care 120125 Other Long-Term Care Services 125145 Other Daily Hospital Services 145150 TOTAL DAILY HOSPITAL SERVICES 150

160AMBULATORY SERVICES:Emergency Services 160

165 Medical Transportation Services 165170 Psychiatric Emergency Rooms 170175 Clinics 175180 Satellite Clinics 180185 Satellite Ambulatory Surgery Center 185190 Outpatient Chemical Dependency Svcs 190195 Observation Care 195200 Partial Hospitalization - Psychiatric 200205 Home Health Care Services 205210 Hospice - Outpatient Services 210215 Adult Day Health Care Services 215220 Other Ambulatory Services 220225 TOTAL AMBULATORY SERVICES 225

10 (OPTIONAL) SUMMARY OF REVENUES AND COSTS



Line No

REVENUE PRODUCING CENTERS (6) Reallocated Net Research Costs from

Page 20, Col.(17), Lines 505-

915

(7) Reallocated Net Education

Costs from Page 20, Cols.

(18) + (19) + (20) +(21), Lines 505

- 915

(8) Transfers for Operating Costs from

Page 20, Column (22),

Lines 505 - 915

(9) Net Costs as Reallocated Column

(4) + (6) +(7) - (8)(10) Average Unit Cost Column (9)

(1)Line No









Line No

REVENUE PRODUCING CENTERS (11) Gross Revenue from Page 12, Columns (21) + (22)

(12)Deductions from Revenue from Page 12,

Column 23 Line 455 - 457

(13)Adjustment for Professional

Component from Page 15, Columns (9) &

(13)

(14)Net Revenue Column (11) - (12) -

(13)(15)Average Unit

Net Revenue Column (14) (1)

Line No








Line No

REVENUE PRODUCING CENTERS (16) Net Revenue Minus

Net Costs Column (14)

minus (9)

(17) Average Unit Net

Column (16) (1)

Line No


10 Coronary Care 1015 Pediatric Intensive Care 1520 Neonatal Intensive Care 2025 Psychiatric Intensive (Isolation) Care 2530 Burn Care 3035 Other Intensive Care 3540 Definitive Observation 4045 Medical/Surgical Acute 4550 Pediatric Acute 5055 Psychiatric Acute - Adult 5560 Psychiatric Acute - Adol & Child 6065 Obstetrics Acute 6570 Alternate Birthing Center 7075 Chemical Dependency Services 7580 Physical Rehabilitation Care 8085 Hospice - Inpatient Care 8590 Other Acute Care 9095 Nursery Acute 95

100 Sub-Acute Care 100101 Sub-Acute Care - Pediatric 101105 Skilled Nursing Care 105110 Psychiatric Long-Term Care 110115 Intermediate Care 115120 Residential Care 120125 Other Long-Term Care Services 125145 Other Daily Hospital Services 145150 TOTAL DAILY HOSPITAL SERVICES 150





Line No

REVENUE PRODUCING CENTERS (1)Units ofService


(2)AdjustedDirect Expenses


(3)AllocatedCosts

Column(4) minus (2)

(4)Total PatientCare Costs fromPage 20, Column

(16),Lines 505 - 915

(5)Average UnitPatient Care

Costs, Column (4) (1)

Line No

230ANCILLARY SERVICES:Labor and Delivery Services 230

235 Surgery and Recovery Services 235240 Ambulatory Surgery Services 240245 Anesthesiology 245250 Medical Supplies Sold to Patients 250255 Durable Medical Equipment 255260 Clinical Laboratory Services 260265 Pathological Laboratory Services 265270 Blood Bank 270275 Echocardiology 275280 Cardiac Catheterization Services 280285 Cardiology Services 285290 Electromyography 290295 Electroencephalography 295300 Radiology - Diagnostic 300305 Radiology - Therapeutic 305310 Nuclear Medicine 310315 Magnetic Resonance Imaging 315320 Ultrasonography 320325 Computed Tomographic Scanner 325330 Drugs Sold to Patients 330335 Respiratory Therapy 335340 Pulmonary Function Services 340345 Renal Dialysis 345350 Lithotripsy 350355 Gastro-Intestinal Services 355360 Physical Therapy 360365 Speech-Language Pathology 365370 Occupational Therapy 370375 Other Physical Medicine 375380 Electroconvulsive Therapy 380385 Psychiatric/Psychological Testing 385390 Psychiatric Individual/Group Therapy 390395 Organ Acquisition 395400 Other Ancillary Services 400405 TOTAL ANCILLARY SERVICES 405410 Purchased Inpatient Services 410411 Purchased Outpatient Services 411415 TOTAL OPERATING REV. & EXP. (A) 415420 Non-Operating Cost Centers/Revenue 420425 Provision for Income Taxes 425430 Extraordinary Items 430435 TOTALS/NET PROFIT (LOSS) (B) 435



(A) Sum of lines 150, 225, 405, and 410. (B) Column (16), Line 435 must agree with Page 8, Column 1, Line 245.


Line No

REVENUE PRODUCING CENTERS (6) Reallocated Net Research Costs from

Page 20, Col.(17), Lines 505-

915

(7) Reallocated Net Education

Costs from Page 20, Cols.

(18) + (19) + (20) +(21), Lines 505

- 915

(8) Transfers for Operating Costs from

Page 20, Column (22),

Lines 505 - 915

(9) Net Costs as Reallocated Column

(4) + (6) +(7) - (8)(10) Average Unit Cost Column (9)

(1)Line No








Line No

REVENUE PRODUCING CENTERS (11) Gross Revenue from Page 12, Columns (21) + (22)

(12)Deductions from Revenue from Page 12,

Column 23 Line 455 - 457

(13)Adjustment for Professional

Component from Page 15, Columns (9) &

(13)

(14)Net Revenue Column (11) - (12) -

(13)(15)Average Unit Net Revenue Column (14) (1)

Line No







Line No

REVENUE PRODUCING CENTERS (16) Net Revenue Minus

Net Costs Column (14)

minus (9)

(17) Average Unit Net Column (16)

(1)Line No


235 Surgery and Recovery Services 235240 Ambulatory Surgery Services 240245 Anesthesiology 245250 Medical Supplies Sold to Patients 250255 Durable Medical Equipment 255260 Clinical Laboratory Services 260265 Pathological Laboratory Services 265270 Blood Bank 270275 Echocardiology 275280 Cardiac Catheterization Services 280285 Cardiology Services 285290 Electromyography 290295 Electroencephalography 295300 Radiology - Diagnostic 300305 Radiology - Therape

oshpd reports (3)

Documents

net inpatient revenue

net outpatient revenue

gross inpatient revenue

gross outpatient revenue

outpatient visits

inpatient daysfinancial

t care

er visits