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Below is the input format for the budget year projections. If you have any questions please call Randy Huyck @ (360) 236-4210 or email
randall.huyck@doh.wa.gov
The budget projections should be supplied 30 days prior to the beginning of the hospital's fiscal year or as soon thereafter as practical.
The input begins in column B on line 24.
Hospital Information
Fiscal Year Ending 12/31/2010
License Number 152
Hospital Name Mason General Hospital
Street Address 901 Mt. View Dr., Bldg #1
Mailing Address PO Box 1668
City, State, Zip Shelton, WA, 98584
County Mason
Chief Executive Officer G. Robert Appel
Chief Financial Officer Merle Brandt
Chair of Governing Board Nancy Trucksess
Telephone Number 360 426 1611
Facsimile Number 360 427 1921
TYPE OF ORGANIZATION (If applies enter 1)
Governmental
State
County
District X
Not For Profit
Church Operated
Other
For Profit
Individual
Partnership
Corporation
ACTUAL UTILIZATION Admissions Patient Days
ICU, SICU, ACUTE, PSYCH 1,832 5,580
Skilled Nursing/Swing
Chemical Dependency/ATC
Number of Births 308
NUMBER OF BEDS AVAILABLE Beds
Intensive Care 10
Semi-Intensive Care 0
Acute Care - Med/Srg 15
Acute Care - Pediatrics 0
Acute Care - Obstetrics 0
Acute Care - Rehab 0
Psychiatric 0
Skilled Nursing 0
Chemical Dependency/ATC 0
Other (Exclude Nursery) 0
Total Beds Available 25
Total Beds Licensed 68
Nursery - Bassinets 6
Budgeted Hospital FTE's 371.20
Skilled Nursing / Swing Bed Revenue 0
Skilled Nursing Ancillary Revenue 0
Chemical Dependency / ATC Inpatient Revenue 0
Codes
1 Separately organized, staffed and equipped unit of hospital.
2 Service maintained in hospital.
3 Service Contracted but Hospsital based.
4 Service not maintained in hospital but available for outside contractor or other hospital.
5 Service not provided in hospital but shared with another hospital under contract.
6 Service not available.
7 Clinic services are commonly provided in the emergency suite to non-emergency outpatients by hospital based
physicians or residents.
8 Service available at but not billed by the hospital.
9 Service available, but not used during reporting cycle.
Intensive Care Services
003 Burn 6
002 Coronary 6
001 Medical /Surgical 2
005 Neonatal 6
185 Neurosurgical 6
004 Pediatric 2
006 Pulmonary 6
008 Semi-Intensive Care 6
Acute Care Services
186 Alternative Birthing Center (Licensed Beds) 6
013 Geriatric 2
009 Medical 2
021 Neonatal 6
187 Oncology 6
188 Orthopedic 2
011 Pediatric 2
030 Physical Rehabilitation 3
012 Post Partum 2
010 Surgical 2
Newborn Care Services
023 Developmentally Disabled Nursery Care 6
022 Newborn Nursery Care 2
024 Premature Nursery Care 6
189 Hospice Care 2
014 Inpatient Care Under Custody (Jail) 2
Long-Term Care
190 Behavior Disorder Care 6
033 Developmentally Disabled Care 6
031 Intermediate Care 6
032 Residential / Custodial Care 6
034 Self Care 6
028 Skilled Nursing Care 6
180 Sub-Acute Care 6
Chemical Dependency - Detoxification
191 Alcohol 6
192 Drug 6
Chemical Dependency - Rehabilitation
193 Alcohol 6
194 Drug 6
Psychiatric Services
195 Acute - Adult 6
196 Acute - Adolescent and Child 6
025 Intensive (Isolation) Care 6
027 Long - Term Care 6
Obstetric Services
058 Alternative Birthing Room 2
057 Labor and Delivery Room Services 2
197 Infertility Services 6
Surgery Services
061 Dental 2
198 General 2
066 Gynecologic 2
199 Heart 6
200 Kidney 6
071 Neurosurgical 6
068 Open Heart 6
072 Ophthalmologic 2
201 Organ Transplant - Heart 6
067 Organ Transplant - Kidney 6
202 Organ Transplant - Liver 6
203 Organ Transplant - Lung 6
204 Organ Transplant - Pancreas 6
073 Orthopedic 2
064 Otolaryngolic 2
205 Pediatric 2
065 Plastic 2
062 Podiatry 2
206 Thoracic 2
063 Urologic 2
075 Anesthesia Services 3
Laboratory Services
077 Anatomical Pathology 4
083 Autopsy Services 4
079 Chemistry 2
207 Clinical Pathology 2
208 Cytology 2
078 Hematology 2
209 Histocompatibility 6
210 Immunology 6
082 Microbiology 2
080 Serology 2
211 Surgical Pathology 2
081 Urinalysis 2
Diagnostic Imaging Services
094 Computed Tomography 2
070 Cystoscopy 2
212 Magnetic Resonance Imaging 2
213 Positive Emission Tomography 6
214 Ultrasonography 2
090 X-ray Examination 2
Diagnostic / Therapeutic Services
181 Audiology 6
215 Biofeedback Therapy 6
069 Cardiac Catheterization 6
092 Cobalt Therapy 6
095 Diagnostic Radioisotope 2
216 Echocardiology 2
088 Electrocardiography 2
087 Electroencephalography 6
089 Electromyography 6
217 Endoscopy 2
218 Gastro-Intestinal Laboratory 6
116 Hyperbaric Chamber Services 6
219 Lithotripsy 6
220 Nuclear Medicine 2
109 Occupational Therapy 3
108 Physical Therapy 3
221 Peripheral Vascular Laboratory 6
084 Pulmonary Function Services 2
222 Radiation Therapy 6
093 Radium Therapy 6
223 Radioactive Implants 6
111 Recreational Therapy 6
112 Rehabilitation Therapy 6
105 Respiratory Therapy 2
110 Speech - Language Pathology 3
224 Sports Care Medicine 6
225 Stress Testing 8
096 Therapeutic Radioisotope 6
091 X-ray Radiology Therapy 6
Psychiatric Services
114 Clinic Psychologist Services 6
226 Child Care Services 6
104 Electroconvulsive Therapy (Shock) 6
035 Night Care 6
113 Psychiatric Therapy 6
100 Psychopharmacological Therapy 6
156 Sheltered Workshop 6
115 Social Therapy 6
Renal Dialysis
227 Home Dialysis Support Services 6
106 Inpatient Renal Dialysis 6
107 Outpatient Renal Dialysis 6
228 Self Dialysis Training 6
085 Organ Acquisition 6
117 Blood Collection and Processing 6
229 Extra Corporeal Membrane Oxygenation 6
230 Pharmacy 6
Emergency Services
045 Emergency Communications System 2
047 Emergency Helicopter Service 4
043 Emergency Observation Service 2
038 Emergency Room Service 2
231 Heliport 2
039 Land Ambulance Transportation 4
040 Mobile Cardiac Care Service 6
232 Orthopedic Emergency Service 2
042 Psychiatric Emergency Services 2
046 Radioactive Decontamination Room 6
044 Trauma Treatment Service 2
048 24-Hour Coverage by Paid Physician 2
Clinic Services
233 Aids 6
139 Alcoholism 6
123 Allergy 6
118 Cardiology 6
119 Chest Medical 6
140 Child Diagnosis 6
141 Child Treatment 6
120 Communicable Disease 6
138 Dental 6
121 Dematology 6
122 Diabetes 2
142 Drug Abuse 6
143 Family Therapy 6
144 Group Therapy 6
130 Hypertension 6
124 Metabolic 6
125 Neurology 6
127 Neonatal 6
234 Obesity 6
129 Obstetrics 2
135 Opthamology 6
133 Orthopedic 2
136 Otolaryngology 6
126 Pediatric 2
137 Podiatry 2
183 Physical Medicine 6
128 Psychiatric 6
132 Renal 6
131 Rheumatic 6
235 Rural Health 6
182 Urology 9
Home Care Services
050 Home Health Aide Services 6
049 Home Nursing Care (Visiting Nurse) 6
051 Home Physical Medicine Care 6
052 Home Social Service Care 6
053 Home Dialysis Training 6
056 Home Hospice Care 6
236 Home I.V. Therapy Services 6
054 Jail Care 6
055 Psychiatric Foster Home Care 6
Ambulatory Services
037 Adult Day Health Care Center 6
074 Ambulatory Surgery Services 6
237 Comprehensive Outpatient Rehabilitation Srv. 6
238 Observation (Short Stay) Care 6
239 Satellite Ambulatory Surgery Center 6
184 Satellite Clinic Services 6
Other Services
147 Cancer / Tumor Registry 4
159 Chapel Maintained 6
158 Chaplaincy Services 8
152 Diabetic Training Class 2
150 Dietetic Counseling 2
146 Drug Reaction Information 6
148 Family Planning 6
160 Full Time Chief of Staff 6
149 Genetic Counseling 6
157 Hospital Auxilary 2
154 Medical Research 6
151 Parent Training Class 6
240 Patient Representative 6
153 Public Health Class 6
115 Social Work Services 2
145 Toxicology / Antidote Information 6
155 Vocational Services 6
A If the Hospital provides a Clinical Setting for College/University based programs,
enter an "X".
B If the Hospital has a Educational Program, as defined by Medicare,
enter the number of Participants.
C If the Hospital's Program is an accredited program, enter an "X".
A B C
161 Approved Residency
241 Approved Fellowship
242 Non-Approved Residency
243 Associate Records Technician
174 Diagnostic Radiologic Technologist
175 Dietetic Intern Program
163 Emergency Medical Technician
176 Hospital Administration Program
167 Licensed Practical Nurse
169 Medical Technologist Program
244 Medical Records Administrator
177 Medical records Technologies
168 Nurse Anesthetist
245 Nurse Practitioneer
246 Nurse Midwife
171 Occupational Therapist
172 Pharmacy Intern
164 Physicians Assistant
173 Physical Therapist
165 Registered Nurse (Baccalaureate)
166 Registered Nurse (Other)
170 Respiratory Therapist
178 Social Worker Program
Deductions From Revenue
Medicare 31,360,543 0
Medicaid 17,029,761
Workers Comp 1,084,794
Other Government Programs
Negotiated Rate 8,769,237
Other
Total Contractuals 58,244,335
Charity Care
Inpatient Charity Care Provided 4,263,880
Outpatient Charity Care Provided
Total Charity Care Provided 4,263,880
Other Deductions
Administrative Adjustments 71,824
Other Deductions
Total Other Deductions 71,824
Total Deductions From Revenue 62,580,039
FS - 1 BALANCE SHEET (Assets)
CURRENT ASSETS:
Cash 283,999
Marketable Securities
Accounts Receivable 19,557,282
Less-Est. Uncoll. & Allow. 11,722,494
Rec. From 3rd Party Payors
Pledges & Other Receivables 9,331,844
Due From Restricted Funds
Inventory 915,456
Prepaid Expenses 227,816
Current Portion of FHT
Total Current Assets 18,593,903
BOARD DESIGNATED ASSETS
Cash 34,461,862
Marketable Securities
Other Assets
Total BDA 34,461,862
FS - 1 BALANCE SHEET (Assets Continued)
PROP, PLANT, & EQUIP
Land 941,126
Land Improvements
Buildings 13,101,622
Fixed Equip - Bldg Srv 2,634,552
Fixed Equip - Other
Equipment 14,245,421
Leasehold Improvements
Construction In Progress 837,872
Total P P & E 31,760,593
Less Accum. Depreciation 16,532,885
Net P P & E 15,227,708
INVESTMENTS & OTHER ASSETS
Investments In P P & E
Less - Accum Depre
Other Investments
Other Assets
Total Invest. & Other Assets 0
INTANGIBLE ASSETS
Goodwill
Unamortized Loan Costs
Preopening & Other Org Costs
Other Intangible Assets
Total Intangible Assets 0
Total Assets 68,283,473
FS - 1 BALANCE SHEET ( Liabilities)
CURRENT LIABILITIES
Notes and Loans Payable
Accounts Payable 1,393,753
Accrued Compensation 3,946,866
Other Accrued Expenses 2,564,398
Advances From 3rd Parties
Payables to 3rd Party Payors 5,111,213
Due to Restricted Funds
Income Taxes Payable
Other Current Liabilities 71,449
Current Maturities of LTD
Total Current Liabilities 13,087,679
DEFERRED CREDITS
Deferred Income Taxes
Deferred 3rd Party Revenue
Other Deferred Credits
Total Deferred Credits 0
LONG TERM DEBT
Mortgage Payable
Construction Loans - Interim
Notes Payable
Capitalized Lease Obligations 106,123
Bonds Payable 2,456,715
Notes and Loans Payable to Parent
Noncurrent Liabilities
Total 2,562,838
Less Current Maturities LTD 0
Total Long Term Debt 2,562,838
EQUITY
Unrestricted Fund Balance 52,632,956
Preferred Stock
Common Stock
Retained Earnings
Additional Paid In Capital
Less: Treasury Stock
Total Liab & Fund Bal or Equity 68,283,473
Check Figure Total Assets 68,283,473
FS - 3 STATEMENT OF REVENUE & EXPENSE
OPERATING REVENUE
Inpatient Revenue 39,536,973
Outpatient Revenue 84,297,825
Total Patient Services Revenue 123,834,798
DEDUCTIONS FROM REVENUE
Contractual Adjustments 58,244,335
Charity & Uncompensated Care 4,263,880
Other Adj. & Allowances 71,824
Total Deductions From Revenue 62,580,039
Net Patient Service Revenue 61,254,759
OTHER OPERATING REVENUE
Other Operating Revenue 2,420,366
Tax Revenues 1,922,414
Total Other Operating Rev 4,342,780
Total Operating Revenue 65,597,539
OPERATING EXPENSES
Salaries and Wages 24,394,079
Employee Benefits 8,253,724
Professional Fees 2,691,720
Supplies 6,353,444
Purch Srv - Utilities 704,033
Purch Srv - Other 5,915,758
Depreciation 2,776,494
Rentals/Leases 352,241
Insurance 609,000
License & Taxes
Interest 72,057
Provision For Bad Debts 7,640,731
Other Direct Expense 2,051,317
Total Operating Expenses 61,814,598
Net Operating Revenue 3,782,941
Non Operating Rev Net of Exp 520,000
Net Rev. Before Items Listed Below 4,302,941
Extraordinary Items
0
Net Revenue or (Expense) 4,302,941
TRANSMITTAL AND CERTIFICATION
HOSPITAL'S ANNUAL REPORT
TO:
The Department of Health
Office of Hospital and Patient Data
P.O. Box 47814
Olympia, Washington 98504-7814
FROM:
Name of Hospital : Mason General Hospital
License Number : H-152
Street Address : 901 Mt. View Dr., Bldg #1
Mailing Address : PO Box 1668
City and Zip Code : Shelton, WA, 98584
CERTIFICATION OF OFFICER OF HOSPITAL
I HEREBY CERTIFY that I have examined the accompanying Hospital Annual Budget
12/31/2010
as specified by the Department of Health for the fiscal year ending
To the best of my knowledge and belief, they are true and correct statements
prepared from the books and records of the Hospital in accordance with applicable
instructions.
X
Signature of Chief Executive Officer
Name/Title:G. Robert Appel, CEO
Date :12/03/09
X
Signature of Chair of Governing Board
Name/Title:Nancy Trucksess, Chair of Governing Board
Date :12/03/09
DOH - OHPD November 1, 2003 Page 1 of 9
HOSPITAL INFORMATION
1 Fiscal Year Ending: 12/31/2010 License Number: H-152
2 Hospital Name Mason General Hospital
3 County Mason
4 Executive Officer G. Robert Appel
5 Financial Officer Merle Brandt
6 Chair of Gov Brd Nancy Trucksess
7 Telephone # 360 426 1611
8 Facsimile # 360 427 1921
9 TYPE OF ORGANIZATION HAVING CONTROL (check one only)
Governmental Not For Profit For Profit
State Church Op. Individual
County Other Partnership
City/County Corporation
X Hosp. Dist.
10 ACTUAL UTILIZATION Admissions Patient Days
Intensive, Semi-Intensive, Acute & Psychiatric 1,832 5,580
Skilled Nursing Facility / Swing 0 0
Chemical Dependency / ATC 0 0
11 Number of Births and Newborn Days 308 0
12 # of Beds Available Beds # of Beds Available Beds
Intensive Care 10 Skilled Nursing 0
Semi -Intensive Care 0 Chemical Dependency 0
Acute - Medical / Surg 15 Other (Excl Nursery) 0
Acute - Pediatrics 0 Total Beds Available 25
Acute - Obstetrical 0 (Excluding Nursery)
Acute - Rehabilitation 0 Total Beds Licensed 68
Psychiatric 0 Nursery - Bassinets 6
13 Budget Hospital F T E's 371
14 Skilled Nursing / Swing Bed Revenue 0
15 Skilled Nursing Ancillary Revenue 0
16 Chemical Dependency / Alcoholic Treatment Inpatient Revenue 0
DOH - OHPD November 1, 2003 Page 2 of 9
Services Inventory
Hospital: Mason General Hospital Budget Period Ending 12/31/2010
License Number: H-152
Daily Hospital Services Obstetric Services
Intensive Care Services 058 Alternative Birthing Room 2
003 Burn 6 057 Labor and Delivery Room Services 2
002 Coronary 6 197 Infertility Services 6
001 Medical /Surgical 2 Surgery Services
005 Neonatal 6 061 Dental 2
185 Neurosurgical 6 198 General 2
004 Pediatric 2 066 Gynecologic 2
006 Pulmonary 6 199 Heart 6
008 Semi-Intensive Care 6 200 Kidney 6
Acute Care Services 071 Neurosurgical 6
186 6
Alternative Birthing Center (Licensed Beds) 068 Open Heart 6
013 Geriatric 2 072 Ophthalmologic 2
009 Medical 2 201 Organ Transplant - Heart 6
021 Neonatal 6 067 Organ Transplant - Kidney 6
187 Oncology 6 202 Organ Transplant - Liver 6
188 Orthopedic 2 203 Organ Transplant - Lung 6
011 Pediatric 2 204 Organ Transplant - Pancreas 6
030 Physical Rehabilitation 3 073 Orthopedic 2
012 Post Partum 2 064 Otolaryngolic 2
010 Surgical 2 205 Pediatric 2
Newborn Care Services 065 Plastic 2
023 Developmentally Disabled Nursery Care 6 062 Podiatry 2
022 Newborn Nursery Care 2 206 Thoracic 2
024 Premature Nursery Care 6 063 Urologic 2
189 Hospice Care 2 075 Anesthesia Services 3
014 Inpatient Care Under Custody (Jail) 2 Laboratory Services
Long-Term Care 077 Anatomical Pathology 4
190 Behavior Disorder Care 6 083 Autopsy Services 4
033 Developmentally Disabled Care 6 079 Chemistry 2
031 Intermediate Care 6 207 Clinical Pathology 2
032 Residential / Custodial Care 6 208 Cytology 2
034 Self Care 6 078 Hematology 2
028 Skilled Nursing Care 6 209 Histocompatibility 6
180 Sub-Acute Care 6 210 Immunology 6
Chemical Dependency - Detoxification 082 Microbiology 2
191 Alcohol 6 080 Serology 2
192 Drug 6 211 Surgical Pathology 2
Chemical Dependency - Rehabilitation 081 Urinalysis 2
193 Alcohol 6 Diagnostic Imaging Services
194 Drug 6 094 Computed Tomography 2
Psychiatric Services 070 Cystoscopy 2
195 Acute - Adult 6 212 Magnetic Resonance Imaging 2
196 Acute - Adolescent and Child 6 213 Positive Emission Tomography 6
025 Intensive (Isolation) Care 6 214 Ultrasonography 2
027 Long - Term Care 6 090 X-ray Examination 2
DOH - OHPD November 1,2003 Page 3 of 9
Codes
1 Separately organized, staffed and equipped unit of hospital.
2 Service maintained in hospital.
3 Service Contracted but Hospital based.
4 Service not maintained in hospital but available for outside contractor or other hospital.
5 Service not provided in hospital but shared with another hospital under contract.
6 Service not available.
7 Clinic services are commonly provided in the emergency suite to non-emergency outpatients by hospital based
physicians or residents.
8 Service available at but not billed by the hospital.
9 Service available, but not used during reporting cycle.
Services Inventory
Hospital: Mason General Hospital Budget Period Ending: 12/31/2010
License Number: H-152
Diagnostic / Therapeutic Services 229 Extra Corporeal Membrane Oxygenation 6
181 Audiology 6 230 Pharmacy 6
215 Biofeedback Therapy 6 Emergency Services
069 Cardiac Catheterization 6 045 Emergency Communications System 2
092 Cobalt Therapy 6 047 Emergency Helicopter Service 4
095 Diagnostic Radioisotope 2 043 Emergency Observation Service 2
216 Echocardiology 2 038 Emergency Room Service 2
088 Electrocardiography 2 231 Heliport 2
087 Electroencephalography 6 039 Land Ambulance Transportation 4
089 Electromyography 6 040 Mobile Cardiac Care Service 6
217 Endoscopy 2 232 Orthopedic Emergency Service 2
218 Gastro-Intestinal Laboratory 6 042 Psychiatric Emergency Services 2
116 Hyperbaric Chamber Services 6 046 Radioactive Decontamination Room 6
219 Lithotripsy 6 044 Trauma Treatment Service 2
220 Nuclear Medicine 2 048 24-Hour Coverage by Paid Physician 2
109 Occupational Therapy 3 Clinic Services
108 Physical Therapy 3 233 Aids 6
221 Peripheral Vascular Laboratory 6 139 Alcoholism 6
084 Pulmonary Function Services 2 123 Allergy 6
222 Radiation Therapy 6 118 Cardiology 6
093 Radium Therapy 6 119 Chest Medical 6
223 Radioactive Implants 6 140 Child Diagnosis 6
111 Recreational Therapy 6 141 Child Treatment 6
112 Rehabilitation Therapy 6 120 Communicable Disease 6
105 Respiratory Therapy 2 138 Dental 6
110 Speech - Language Pathology 3 121 Dermatology 6
224 Sports Care Medicine 6 122 Diabetes 2
225 Stress Testing 8 142 Drug Abuse 6
096 Therapeutic Radioisotope 6 143 Family Therapy 6
091 X-ray Radiology Therapy 6 144 Group Therapy 6
Psychiatric Services 130 Hypertension 6
114 Clinic Psychologist Services 6 124 Metabolic 6
226 Child Care Services 6 125 Neurology 6
104 Electroconvulsive Therapy (Shock) 6 127 Neonatal 6
035 Night Care 6 234 Obesity 6
113 Psychiatric Therapy 6 129 Obstetrics 2
100 Psychopharmacological Therapy 6 135 Opthamology 6
156 Sheltered Workshop 6 133 Orthopedic 2
115 Social Therapy 6 136 Otolaryngology 6
Renal Dialysis 126 Pediatric 2
227 Home Dialysis Support Services 6 137 Podiatry 2
106 Inpatient Renal Dialysis 6 183 Physical Medicine 6
107 Outpatient Renal Dialysis 6 128 Psychiatric 6
228 Self Dialysis Training 6 132 Renal 6
085 Organ Acquisition 6 131 Rheumatic 6
117 Blood Collection and Processing 6 235 Rural Health 6
182 Urology 9
DOH - OHPD November 1,2003 Page 4 of 9
Codes
1 Separately organized, staffed and equipped unit of hospital.
2 Service maintained in hospital.
3 Service Contracted but Hospital based.
4 Service not maintained in hospital but available for outside contractor or other hospital.
5 Service not provided in hospital but shared with another hospital under contract.
6 Service not available.
7 Clinic services are commonly provided in the emergency suite to non-emergency outpatients by hospital based
physicians or residents.
8 Service available at but not billed by the hospital.
9 Service available, but not used during reporting cycle.
Services Inventory
Hospital: Mason General Hospital Budget Period Ending: 12/31/2010
License Number: H-152
Home Care Services Medical Education Programs
050 Home Health Aide Services 6 Code Category as Description Indicates
049 Home Nursing Care (Visiting Nurse) 6 A If the Hospital provides a Clinical Setting for College/University based programs,
051 Home Physical Medicine Care 6 enter an "X".
052 Home Social Service Care 6 B If the Hospital has a Educational Program, as defined by Medicare,
053 Home Dialysis Training 6 enter the number of Participants.
056 Home Hospice Care 6 C If the Hospital's Program is an accredited program, enter an "X".
236 Home I.V. Therapy Services 6 Program Title A B C
054 Jail Care 6 161 Approved Residency
055 Psychiatric Foster Home Care 6 241 Approved Fellowship
Ambulatory Services 242 Non-Approved Residency
037 Adult Day Health Care Center 6 243 Associate Records Technician
074 Ambulatory Surgery Services 6 174 Diagnostic Radiologic Technologist
237 Comprehensive Outpatient Rehabilitation Services 6 175 Dietetic Intern Program
238 Observation (Short Stay) Care 6 163 Emergency Medical Technician
239 Satellite Ambulatory Surgery Center 6 176 Hospital Administration Program
184 Satellite Clinic Services 6 167 Licensed Practical Nurse
Other Services 169 Medical Technologist Program
147 Cancer / Tumor Registry 4 244 Medical Records Administrator
159 Chapel Maintained 6 177 Medical Records Technologist
158 Chaplaincy Services 8 168 Nurse Anesthetist
152 Diabetic Training Class 2 245 Nurse Practitioner
150 Dietetic Counseling 2 246 Nurse Midwife
146 Drug Reaction Information 6 171 Occupational Therapist
148 Family Planning 6 172 Pharmacy Intern
160 Full Time Chief of Staff 6 164 Physicians Assistant
149 Genetic Counseling 6 173 Physical Therapist
157 Hospital Auxiliary 2 165 Registered Nurse (Baccalaureate)
154 Medical Research 6 166 Registered Nurse (Other)
151 Parent Training Class 6 170 Respiratory Therapist
240 Patient Representative 6 178 Social Worker Program
153 Public Health Class 6
115 Social Work Services 2
145 Toxicology / Antidote Information 6
155 Vocational Services 6
DOH - OHPD November 1, 2003 Page 5 of 9
Codes
1 Separately organized, staffed and equipped unit of hospital.
2 Service maintained in hospital.
3 Service Contracted but Hospital based.
4 Service not maintained in hospital but available for outside contractor or other hospital.
5 Service not provided in hospital but shared with another hospital under contract.
6 Service not available.
7 Clinic services are commonly provided in the emergency suite to non-emergency outpatients by hospital based
physicians or residents.
8 Service available at but not billed by the hospital.
9 Service available, but not used during reporting cycle.
DEDUCTIONS FROM REVENUE FYE: 12/31/2010
Hospital: Mason General Hospital Lic.#.: H-152
ACCT: Item: Budget Year
1 Contractual Adjustments
2 5810 Medicare 31,360,543
3 5820 Medicaid 17,029,761
4 5830 Workers Compensation 1,084,794
5 5840 Other Government Programs 0
6 5850 Negotiated Rates 8,769,237
7 5860 Other 0
8 Total Contractual Adjustments 58,244,335
9
10 Charity Care
11 5900 Inpatient Charity Care Provided 4,263,880
12 5910 Outpatient Charity Care Provided 0
13
14
15 Total Charity Care 4,263,880
16
17 5970 Administrative Adjustments 71,824
18
19 5980 Other Deductions (specify) 0
20 TOTAL DEDUCTIONS FROM REVENUE 62,580,039
21 Explanations
DOH - OHPD November 1,2003 Page 6 of 9
FS-1 BALANCE SHEET - UNRESTRICTED FUND
HOSPITAL: Mason General Hospital FYE: 12/31/2010
ASSETS Lic.#: H-152
1 CURRENT ASSETS:
2 Cash 283,999
3 Marketable Securities 0
4 Accounts Receivable 19,557,282
5 Less-Estimated Uncollectable & Allowances 11,722,494
6 Receivables From Third Party Payors 0
7 Pledges And Other Receivables 9,331,844
8 Due From Restricted Funds 0
9 Inventory 915,456
10 Prepaid Expenses 227,816
11 Current Portion Of Funds Held In Trust 0
12 TOTAL CURRENT ASSETS 18,593,903
13
14 BOARD DESIGNATED ASSETS:
15 Cash 34,461,862
16 Marketable Securities 0
17 Other Assets 0
18 TOTAL BOARD DESIGNATED ASSETS: 34,461,862
19
20 PROPERTY, PLANT AND EQUIPMENT:
21 Land 941,126
22 Land Improvements 0
23 Buildings 13,101,622
24 Fixed Equipment - Building Service 2,634,552
25 Fixed Equipment - Other 0
26 Equipment 14,245,421
27 Leasehold Improvements 0
28 Construction In Progress 837,872
29 TOTAL 31,760,593
30 Less Accumulated Depreciation 16,532,885
31 NET PROPERTY, PLANT & EQUIPMENT 15,227,708
32
33 INVESTMENTS AND OTHER ASSETS:
34 Investments In Property, Plant & Equipment 0
35 Less - Accumulated Depreciation 0
36 Other Investments 0
37 Other Assets 0
38 TOTAL INVESTMENTS & OTHER ASSETS 0
39
40 INTANGIBLE ASSETS:
41 Goodwill 0
42 Unamortized Loan Costs 0
43 Preopening And Other Organization Costs 0
44 Other Intangible Assets 0
45 TOTAL INTANGIBLE ASSETS 0
46 TOTAL ASSETS 68,283,473
DOH - OHPD November 1,2003 Page 7 of 9
BALANCE SHEET - UNRESTRICTED FUND
HOSPITAL: Mason General Hospital FYE: 12/31/2010
LIABILITIES AND FUND BALANCES-UNRESTRICTED Lic.#: H-152
1 CURRENT LIABILITIES
2 Notes and Loans Payable 0
3 Accounts Payable 1,393,753
4 Accrued Compensation and Related Liabilities 3,946,866
5 Other Accrued Expenses 2,564,398
6 Advances from Third Party Payors 0
7 Payables to Third Party Payors 5,111,213
8 Due to Restricted Funds 0
9 Income Taxes Payable 0
10 Other Current Liabilities 71,449
11 Current Maturities of Long Term Debt 0
12 TOTAL CURRENT LIABILITIES 13,087,679
13
14 DEFERRED CREDITS:
15 Deferred Income Taxes 0
16 Deferred Third Party Revenue 0
17 Other Deferred Credits 0
18 TOTAL DEFERRED CREDITS 0
19
20 LONG TERM DEBT
21 Mortgage Payable 0
22 Construction Loans-Interim Financing 0
23 Notes Payable 0
24 Capitalized Lease Obligations 106,123
25 Bonds Payable 2,456,715
26 Notes and Loans Payable to Parent 0
27 Noncurrent Liabilities 0
28 TOTAL 2,562,838
29 Less Current Maturities of Long Term Debt 0
30 TOTAL LONG TERM DEBT 2,562,838
31
32 UNRESTRICTED FUND BALANCE 52,632,956
33
34 EQUITY (INVESTOR OWNED)
35 Preferred Stock
36
37 Common Stock
38
39 Additional Paid In Stock 0
40
41 Retained Earnings (Capital Account for Partnership 0
42 (or Sole Proprietorship)
43
44 Less Treasury Stock
45 TOTAL EQUITY 52,632,956
46 TOTAL LIABILITIES AND FUND BALANCE OR EQUITY 68,283,473
DOH - OHPD November 1,2003 Page 8 of 9
COMPARISON STATEMENT OF REVENUE & EXPENSE - UNRESTRICTED FUNDS
HOSPITAL: Mason General Hospital FYE: 12/31/2010
Lic.#: H-152
1 OPERATING REVENUE:
2 Inpatient Revenue 39,536,973
3 Outpatient Revenue 84,297,825
4 TOTAL PATIENT SERVICES REVENUE 123,834,798
5
6 DEDUCTIONS FROM REVENUE:
7 Contractual Adjustments 58,244,335
8 Charity and Uncompensated Care 4,263,880
9 Other Adjustments and Allowances 71,824
10 TOTAL DEDUCTIONS FROM REVENUE 62,580,039
11 NET PATIENT SERVICE REVENUE 61,254,759
12
13 OTHER OPERATING REVENUE
14 Other Operating Revenue 2,420,366
15 Tax Revenues 1,922,414
16 TOTAL OTHER OPERATING REVENUE 4,342,780
17 TOTAL OPERATING REVENUE 65,597,539
18
19 OPERATING EXPENSES
20 Salaries and Wages 24,394,079
21 Employee Benefits 8,253,724
22 Professional Fees 2,691,720
23 Supplies 6,353,444
24 Purchased Services - Utilities 704,033
25 Purchased Services - Other 5,915,758
26 Depreciation 2,776,494
27 Rentals and Leases 352,241
28 Insurance 609,000
29 License and Taxes 0
30 Interest 72,057
31 Provision For Bad Debts 7,640,731
32 Other Direct Expenses 2,051,317
33 TOTAL OPERATING EXPENSES 61,814,598
34 NET OPERATING REVENUE 3,782,941
35
36 NON-OPERATING REVENUE-NET OF EXPENSES 520,000
37
38 NET REVENUE BEFORE ITEMS LISTED BELOW 4,302,941
39
40 EXTRAORDINARY ITEM 0
41 FEDERAL INCOME TAX 0
42
43 NET REVENUE OR (EXPENSE) 4,302,941
44 EXPLANATION:
45
DOH - OHPD November 1,2003 Page 9 of 9
