Get documents about "YE108-2010
Shared by: ajizai
-
Stats
- views:
- 0
- posted:
- 9/21/2012
- language:
- English
- pages:
- 246
Document Sample
The square footage statistic is provided for all cost centers including the plant and this way
square footage identified by cost center will total the gross square footage stated as the statistic in the plant cost center.
The operating expenses, the units of measure and the operating expenses per unit of measure are stated on line 484 thru line 568 in columns
B thru G. Increases or decreases in operating expenses per unit of measure exceeding 25% are stated in column H. Please submit an
attachment with the report that addresses why those changes took place. Also please provide any corrections that might be in order.
Your hospital license number and fiscal year end have already been entered. These items need to be in alpha format rather
than numeric format in order to pick up correctly for upload to the year end report database.
If you want to review what you reported for the prior year you can click on the tab titled prior year.
If you have any questions or concerns please call Randy Huyck at 360-236-4210 or send an e-mail to
randall.huyck@doh.wa.gov.
To submit your report by electronic mail, please send to: randall.huyck@doh.wa.gov.
Please remember to send a signed certification page and an audited financial statement by regular mail when they are available.
It is only necessary to enter data on this page. Items will automatically transfer from this page to the report pages.
Employee Benefits
The employee benefits can be entered directly, assigned to the cost centers based on a percentage of salaries, or a combination of the two.
1) Enter the amount of employee benefits directly recorded in cell B47.
2) Enter the employee benefits directly recorded by cost center in cells C47..CC47.
3) Enter the total unassigned employee benefits that will be assigned based on salaries in cell B48.
Depreciation
The Depreciation can be entered directly, assigned by square footage, or a combination of the two.
1) Enter the total amount of depreciation directly assigned in cell B51.
2) Enter the amount of depreciation directly recorded by cost center in cells C51..CC51.
3) Enter the amount of depreciation that will be assigned by square footage in cell B52.
After the salaries and the departmental square footage statistics are entered, the departmental employee benefits and depreciation will be
calculated on lines 48 and 52, respectively.
6010 6030 6070 6100 6120
See Instructions Intensive Semi-Intensive Acute Alternative Physical
Employee Benefits Above Care Care Care Birth Ctr Rehab
directly recorded
assigned based on salaries 4,027,959 226,112 0 494,382 0 0
total 4,027,959
Depreciation
depreciation directly recorded
depreciation based on sq. ft. 3,208,805 66,182 0 215,182 0 0
total 3,208,805
Account Number 6010 6030 6070 6100 6120
Account Intensive Semi-Intensive Acute Alternative Physical
Name Care Care Care Birth Ctr Rehab
Unit of Measure Description Patient Days Patient Days Patient Days Patient Days Patient Days
Units of Measure 1,487 4,527
Full Time Equivalents 15.82 41.28
Salaries & Wages 950,329 2,077,850
Employee Benefits 226,112 0 494,382 0 0
Professional Fees 11,025
Supplies 60,879 186,673
Purch. Serv. - Utilities 531
Purch. Serv. - Other 166 8,381
Depreciation 66,182 0 215,182 0 0
Lease/Rental 174 9,964
Bad Debt Expense xxxxxxxxxxxxxxxxx xxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Other Direct Expenses 7,890 25,383
Recoveries
Total Adj Exp 1,311,732 0 3,029,371 0 0
Tax Revenue xxxxxxxxxxxxxxxxx xxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
IP Revenue 2,411,708 4,772,290
OP Revenue (2,693) 178,187
Gross Revenue 2,409,015 0 4,950,477 0 0
Sq FT 2,168 7,049
Patient Meals Served 2,757 21,946
Housekeeping Hours of Service 1,257 3,770
Dry Pounds of Laundry 488 1,465
Nursing FTE's 11.18 26.21
YE-A HOSPITAL INFORMATION Page 1 of 2
Fiscal Year Ended 12/31/2010
License Number : 108
Hospital Name : Tri-State Memorial Hospital
Street Address
Mailing Address : PO Box 189
City, State, Zip : Clarkston, WA 99403
County : Asotin
Chief Executive Officer : Donald Wee
Chief Financial Officer : Alex Town
Chair of Governing Board : Dr. Donald Greggain
Telephone Number : 509-758-5511
Facsimile Number : 509-758-3566
TYPE OF ORGANIZATION (If applies enter 1)
Governmental
State :
County :
District :
Not For Profit
Church Operated :
Other : 1
For Profit
Individual :
Partnership :
Corporation :
YE-A HOSPITAL INFORMATION Page 2 of 2
ACTUAL UTILIZATION Admissions Patient Days
ICU, SICU, ACUTE, PSYCH : 1,561 6,014
Skilled Nursing/Swing : 52 356
Chemical Dependency/ATC :
Number of Births :
NUMBER OF BEDS AVAILABLE Beds
Intensive Care : 4
Semi-Intensive Care :
Acute Care - Med/Surg : 21
Acute Care - Pediatrics :
Acute Care - Obstetrics :
Acute Care - Rehab :
Psychiatric :
Skilled Nursing :
Swing Beds
Chemical Dependency/ATC :
Other (Exclude Nursery) :
Total Beds Available 25
Total Beds Licensed : 61
Nursery - Bassinets :
SNF/SWING Ancillary Revenue : 647,297
PAYER UNITS OF SERVICE AND REVENUE
HOSPITAL Medicare Medicaid Other Total
Admissions 1,089 54 418 1,561
Patient Days 4,478 277 1,259 6,014
OP Visits 48,777 6,397 24,788 79,962
IP Revenue 20,936,660 1,846,473 9,553,510 32,336,643
OP Revenue 34,183,403 4,603,059 17,971,763 56,758,225
SNF/SWING Medicare Medicaid Other Total
Admissions 45 1 6 52
Patient Days 308 13 35 356
OP Visits 0 0 0 0
IP Revenue 564,547 44,314 38,436 647,297
OP Revenue 0 0 0 0
ATC Medicare Medicaid Other Total
Admissions 0
Patient Days 0
OP Visits 0
IP Revenue 0
OP Revenue 0
HBP Component Revenue Expense
HBP Component
SUPPORTING SCHEDULES
SS-2 EMPLOYEE BENEFITS
FICA Taxes : 1,250,121
Unemployment Compensation :
Workers Compensation : 376,728
Group Health Insurance : 1,714,603
Group Life Insurance : 73,330
Pension & Retirement : 613,177
Other Employee Benefits :
Other Employee Benefits :
Total 4,027,959
SS-3 RENTAL AND LEASE EXPENSE
Rental & Lease Exp - Bldgs : 198,064
Rental & Lease Exp - Equip : 421,854
Total 619,918
SS-5 INSURANCE EXPENSE
Hospital & Prof Malpractice : 357,551
Other Insurance :
Total 357,551
LICENSE AND TAXES
License Fees : 44,964
Taxes (other than income) : 402,306
Other :
Total 447,270
SS-6 INTEREST EXPENSE
Interest Expense - WC : 593,930
Interest Expense - Other :
Total 593,930
SS-4 DEPRECIATION EXPENSE
FIXED ASSETS
Beg. Balance Additions Retirement Ending Balance
Land 647,866 0 0 647,866
Land Improvements 190,024 (1) 0 190,023
Buildings 25,627,737 124,962 0 25,752,699
Fixed Equipment - Bldg Srv 608,311 0 0 608,311
Fixed Equipment - Other 61,518 2,346,233 0 2,407,751
Equip - Major Moveable 12,901,005 1,649,144 0 14,550,149
Equip - Minor 0 0 0 0
Leasehold Improvements 248,300 0 0 248,300
Construction In Progress 0 25,500 25,500
Total 40,284,761 4,145,838 0 44,430,599
ACCUMULATED DEPRECIATION
Beg. Balance Additions Retirement Ending Balance
Land
Land Improvements 108,454 16,496 0 124,950
Buildings 7,711,169 934,664 0 8,645,833
Fixed Equipment - Bldg Srv 0 0 0 0
Fixed Equipment - Other 0 0 0 0
Equip - Major Moveable 9,583,648 2,257,645 0 11,841,293
Equip - Minor 0 0 0 0
Leasehold Improvements 0 0 0 0
Construction In Progress 0 0 0 0
Total 17,403,271 3,208,805 0 20,612,076
SS-8 DEDUCTIONS FROM REVENUE
Contractuals
Medicare : 26,814,766
Medicaid : 3,515,395
Workers Comp : 545,775
Other Government Programs : 889,420
Negotiated Rate :
Other : 5,083,915
Total Contractuals 36,849,271
Charity Care
Number of Charity Care Patients : : 1,620
Inpatient Charity Care Provided : 399,381
Outpatient Charity Care Provided : 844,452
Total Charity Care Provided 1,243,833
Other Deductions
Administrative Adjustments : 215,641
Other Deductions :
Total Other Deductions 215,641
Total Deductions From Revenue 38,308,745
FS - 1 BALANCE SHEET (Assets)
CURRENT ASSETS:
Cash : 7,212,199
Marketable Securities : 6,380,888
Accounts Receivable : 12,299,163
Less-Est. Uncoll. & Allow. : 6,051,906
Rec. From 3rd Party Payers : 71,730
Pledges & Other Receivables : 159,856
Due From Restricted Funds : 0
Inventory : 1,769,676
Prepaid Expenses : 396,724
Current Portion of FHT : 0
Total Current Assets 22,238,330
BOARD DESIGNATED ASSETS
Cash : 74,539
Marketable Securities :
Other Assets :
Total BDA 74,539
PROP, PLANT, & EQUIP
Land : 647,866
Land Improvements : 190,023
Buildings : 25,752,699
Fixed Equip - Bldg Srv : 608,311
Fixed Equip - Other : 2,407,751
Equipment : 14,550,149
Leasehold Improvements : 248,300
Construction In Progress : 25,500
Total P P & E 44,430,599
Less Accum. Depreciation : 20,612,076
Net P P & E 23,818,523
INVESTMENTS & OTHER ASSETS
Investments In P P & E : 516,049
Less - Accum Depre :
Other Investments :
Other Assets : 994,795
Total Invest. & Other Assets 1,510,844
INTANGIBLE ASSETS
Goodwill :
Unamortized Loan Costs :
Preopening & Other Org Costs :
Other Intangible Assets :
Total Intangible Assets 0
Total Assets 47,642,236
FS - 1 BALANCE SHEET ( Liabilities)
CURRENT LIABILITIES
Notes and Loans Payable : 0
Accounts Payable : 1,879,311
Accrued Compensation : 885,097
Other Accrued Expenses : 824,958
Advances From 3rd Parties : 0
Payables to 3rd Party Payers : 34,774
Due to Restricted Funds : 0
Income Taxes Payable : 0
Other Current Liabilities : 83,137
Current Maturities of LTD : 1,308,537
Total Current Liabilities 5,015,814
DEFERRED CREDITS
Deferred Income Taxes : 0
Deferred 3rd Party Revenue : 0
Other Deferred Credits : 0
Total Deferred Credits 0
LONG TERM DEBT
Mortgage Payable : 10,680,979
Construction Loans - Interim : 0
Notes Payable : 0
Capitalized Lease Obligations : 0
Bonds Payable : 0
Notes and Loans Payable to Parent : 0
Noncurrent Liabilities : 0
Total 10,680,979
Less Current Maturities LTD 1,308,537
Total Long Term Debt 9,372,442
Unrestricted Fund Balance : 33,064,086
Preferred Stock : 0
Common Stock : 0
Additional Paid In Capital : 0
Retained Earnings : 189,894
Less: Treasury Stock : 0
Total Liab & Fund Bal or Equity 47,642,236
Check Figure Total Assets 47,642,236
FS - 3 STATEMENT OF REVENUE & EXPENSE
OPERATING REVENUE
Inpatient Revenue : 32,983,940
Outpatient Revenue : 56,758,225
Total Patient Services Revenue 89,742,165
DEDUCTIONS FROM REVENUE
Contractual Adjustments : 37,064,913
Charity & Uncompensated Care : 1,243,832
Other Adj. & Allowances :
Total Deductions From Revenue 38,308,745
Net Patient Service Revenue 51,433,420
OTHER OPERATING REVENUE
Other Operating Revenue : 1,208,147
Tax Revenues :
Total Other Operating Rev 1,208,147
Total Operating Revenue 52,641,567
FS - 3 STATEMENT OF REVENUE & EXPENSE
Salaries and Wages : 16,929,192
Employee Benefits : 4,027,959
Professional Fees : 4,325,622
Supplies : 13,393,812
Purch Srv - Utilities : 1,184,338
Purch Srv - Other : 4,286,094
Depreciation : 3,208,805
Rentals/Leases : 619,918
Insurance : 357,551
License & Taxes : 447,270
Interest : 593,930
Provision for Bad Debts 1,425,100
Other Direct Expense : 1,487,415
Total Operating Expenses 52,287,006
Net Operating Revenue 354,561
Non Operating Rev Net of Exp : 1,111,508
Net Rev. Before Items Listed Below 1,466,069
Extraordinary Items :
Federal Income Taxes :
Net Revenue or (Expense) 1,466,069
EDIT
Tri-State Memorial Hospital H-0 FYE 12/31/2010
VOLUME: Info Page Payer CC Detail
Hospital Admissions 1,561 1,561
Hospital Patient Days 6,014 6,014 6,014
SNF/Swing Admissions 52 52
SNF/Swing Patient Days 356 356 0
ATC Admissions 0 0
ATC Patient Days 0 0 0
Newborn Admissions 0
Newborn Patient Days 0 0
OPERATING EXPENSES: FS-3 CC Detail Support Sched.
Salaries 16,929,192 16,929,192
Employee Benefits 4,027,959 4,027,959 4,027,959
Professional Fees 4,325,622 4,325,622
Supplies 13,393,812 13,393,812
Purch Srv - Utilities 1,184,338 1,184,338
Purch Srv - Other 4,286,094 4,286,094
Depreciation 3,208,805 3,208,805 3,208,805
Leases/Rentals 619,918 619,918 619,918
Insurance 357,551 357,551
Licenses & Taxes 447,270 447,270
Interest 593,930 593,930
Ins, Lic. & Taxes, and Interest 1,398,751 1,398,751 1,398,751
Bad Debt Expense 1,425,100 1,425,100
Other Direct Expense 1,487,415 1,487,415
Total Other Direct Expense 2,886,166 2,886,166
Total Expenses 52,287,006 52,287,006
DEDUCTIONS: SS-8 FS-3
Contractuals 36,849,271 37,064,913
Charity Care 1,243,833 1,243,832
Other Deductions 215,641 0
Total Other Deductions 38,308,745 38,308,745
CHARITY CARE Deductions
From Revenue
Support Sched.
# Of Patients 1,620
Inpatient 399,381
Outpatient 844,452
OTHER REVENUES: FS-3 CC-DETAIL
Other Revenue 1,208,147 1,208,147
Tax Revenue 0 0
PATIENT SERVICE REVENUE: PAYER
FS-3 CC-DETAIL INFO
IP Revenue 32,983,940 32,983,940 32,983,940
OP Revenue 56,758,225 56,758,225 56,758,225
Gross Revenue 89,742,165 89,742,165 89,742,165
FIXED ASSET ENDING BALANCES: FS-1 SS-4
Land 647,866 647,866
Land Improvements 190,023 190,023
Buildings 25,752,699 25,752,699
Fixed Equip - Bldg Serv 608,311 608,311
Fixed Equip - Other 2,407,751 2,407,751
Equipment (Moveable) 14,550,149 14,550,149
Leasehold Improvements 248,300 248,300
Construction In Progress 25,500 25,500
Total 44,430,599 44,430,599
Accum Depre Ending Balance 20,612,076 20,612,076
Balance Sheet
FS-1 Assets 47,642,236
FS-1 Liabilities & Fund Balance 47,642,236
The actual operating expenses and units of measure are presented for the past two years in columns B-E.
The operating expenses per unit of measure are presented in columns F and G.
If the percentage change in operating expenses varies by more or less than 25 %, the variance appears in column H.
If the percentage change is more or less than 25%., please provide an explanation that is provided as an attachment with your
year end report submittal. Also please provide any corrections required to the prior years information.
Tri-State Memorial Hospital 2007 2010 2007 2010 2007 2010
Operating Operating Units of Units of Op Exp / Op Exp /
Expense Expense Measure Measure UOM UOM
6010 Intensive Care 1,101,399 1,311,732 1,740 1,487 632.99 882.13
6030 Semi-Intensive Care 0 0 0 0
6070 Acute Care 3,207,129 3,029,371 5,266 4,527 609.03 669.18
6100 Alternative Birthing Center 0 0 0 0
6120 Physical Rehabilitation 0 0 0 0
6140 Psychiatric Care 0 0 0 0
6150 Chemical Dependency 0 0 0 0
6170 Nursery 0 0 0 0
6200 Skilled Nursing 0 0 0 0
6210 Swing Beds 0 0 0 0
6330 Hospice Inpatient 0 0 0 0
6400 Other Daily Services 0 0 0 0
7010 Labor Delivery 0 0 0 0
7020 Surgical Services 2,223,889 2,623,762 433,961 186,163 5.12 14.09
7030 Recovery Room 298,835 349,480 153,840 106,365 1.94 3.29
7040 Anesthesiology 788,814 608,504 433,961 0 1.82
7050 Central Services 6,283,660 7,369,121 N/A N/A
7060 Intravenous Therapy 0 0 N/A N/A
7070 Laboratory 1,670,504 2,323,272 79,247 125,598 21.08 18.50
7110 Electrodiagnosis 0 0 0 0
7120 Magnetic Resonance Imaging 0 0 0 0
7130 Ct Scanning 0 0 0 0
7140 Radiology - Diagnostic 2,699,734 2,819,148 202,392 182,958 13.34 15.41
7150 Radiology - Therapeutic 0 0 0 0
7160 Nuclear Medicine 0 0 0 0
7170 Pharmacy 2,807,823 3,266,886 N/A N/A
7180 Respiratory Therapy 519,300 873,160 27,040 26,059 19.20 33.51
7190 Dialysis 1,496,758 3,837,481 39,684 0 37.72
7200 Physical Therapy 143,816 162,506 3,022 3,346 47.59 48.57
7220 Psychiatric Day Care 0 0 0 0
7230 Emergency Room 2,683,576 4,023,010 15,104 16,082 177.67 250.16
7240 Ambulance 7,653 0 0 0
7250 Short Stay 100,921 331,064 687 388 146.90 853.26
7260 Clinics 2,992,863 3,783,193 10,661 11,522 280.73 328.35
7310 Occupational Therapy 0 0 0 0
7320 Speech Therapy 13,786 22,189 132 360 104.44 61.64
7330 Recreational Therapy 0 0 0 0
7340 Electromyography 0 0 0 0
7350 Observation Unit 0 0 4,961 2,193
7380 Free-Standing Clinics 0 0 0 0
7390 Air Transportation 0 17,877 0 34 525.79
7400 Home Care Services 1,097,548 1,315,045 12,596 9,152 87.13 143.69
7410 Lithotripsy 0 0 0 0
7420 Organ Transplants 0 0 0 0
7430 Outpatient Chem. Dep. 0 0 0 0
7490 Other Ancillary 233,897 358,798 N/A N/A
8200 Research / Education 0 0 N/A N/A
8310 Printing & Duplication 0 0 N/A N/A
8320 Dietary 942,431 1,112,623 26,236 24,703 35.92 45.04
8330 Cafeteria 0 0 124,073 160,650
8350 Laundry & Linen 204,355 197,747 0 0
8360 Social Services 21,366 14,428 N/A N/A
8370 Central Transportation 0 0 N/A N/A
8420 Purchasing 297,826 412,666 N/A N/A
8430 Plant 1,314,574 1,245,820 106,138 105,115 12.39 11.85
8460 Housekeeping 510,716 654,039 N/A N/A
8470 Communication 0 142,032 N/A N/A
8480 Data Processing 466,006 698,590 N/A N/A
8490 Other General Services 0 49,717 N/A N/A
8510 Accounting 288,641 536,869 N/A N/A
8530 Patient Accounts 777,306 89,044 N/A N/A
8560 Admitting 148,216 453,111 N/A N/A
8590 Other Fiscal Services 0 742,305 N/A N/A
8610 Hospital Administration 884,318 1,031,063 N/A N/A
8620 Employee Health 0 14,973 N/A N/A
8630 Public Relations 363,547 402,156 N/A N/A
8640 Management Engineering 0 0 N/A N/A
8650 Personnel 160,048 310,173 N/A N/A
8660 Auxiliary Groups 0 0 N/A N/A
8670 Chaplaincy Services 0 0 N/A N/A
8680 Medical Library 0 0 N/A N/A
8690 Medical Records 688,972 847,465 N/A N/A
8700 Medical Staff 0 29,936 N/A N/A
8710 Utilization Management 30,956 186,391 N/A N/A
8720 Nursing Administration 219,299 367,271 N/A N/A
8730 Nursing Float Personnel 0 0 N/A N/A
8740 Inservice Education 55,982 63,631 N/A N/A
8770 Comm. Health Education 85,666 62,610 N/A N/A
8790 Other Admin. Services 555,714 1,226,999 N/A N/A
8830-8900 Unassigned Other Direct 532,485 1,615,704 N/A N/A
DIRECT 100,106 46,753,751 13,245,642 24,703
OP EXP SQ FT ACCUM COST SUPPLIES MEALS SRV
8430 Plant 1,245,820
Unassigned Expenses 1,615,704 2,861,524
8310 Printing & Duplication 0 0
8510 Accounting 536,869 0
8470 Communications 142,032 0
8610 Hospital Administration 1,031,063 167,851
8790 Other Administrative Services 1,226,999 513,614
8630 Public Relations 402,156 96,017
8770 Community Health Education 62,610 0
8640 Management Engineering 0 0 4,179,211
8420 Purchasing 412,666 93,873 45,278 551,817
8320 Dietary 1,112,623 96,245 108,058 14,201 1,331,127
8650 Personnel 310,173 0 27,726 360 0
8620 Employee Health Services 14,973 0 1,338 374 0
8330 Cafeteria 0 0 0 0 0
8460 Housekeeping 654,039 41,477 62,171 3,036 0
8350 Laundry & Linen 197,747 0 17,676 0 0
8200 Research & Education 0 0 0 0 0
8360 Social Services 14,428 11,891 2,353 11 0
8370 Central Transportation 0 0 0 0 0
8490 Other General Services 49,717 0 4,444 60 0
8530 Patient Accounts 89,044 77,837 14,917 0 0
8480 Data Processing 698,590 0 62,445 272 0
8560 Admitting 453,111 15,464 41,885 693 0
8590 Other Fiscal Services 742,305 0 66,353 2,851 0
8660 Auxiliary Groups 0 0 0 0 0
8670 Chaplaincy Services 0 0 0 0 0
8680 Medical Library 0 0 0 0 0
8690 Medical Records 847,465 37,875 79,139 431 0
8700 Medical Staff 29,936 0 2,676 5 0
8710 Medical Care Evaluation 186,391 0 16,661 257 0
8720 Nursing Administration 367,271 0 32,830 264 0
8730 Nursing Float Personnel 0 0 0 0 0
8740 Inservice Education 63,631 0 5,688 734 0
12,507,363
DIRECT
OP EXP SQ FT ACCUM COST SUPPLIES MEALS SRV
6010 Intensive Care 1,311,732 61,972 122,792 2,536 148,562
6030 Semi-Intensive Care 0 0 0 0 0
6070 Acute Care 3,029,371 201,495 288,800 7,777 1,182,566
6100 Alternative Birthing Center 0 0 0 0 0
6120 Physical Rehabilitation 0 0 0 0 0
6140 Psychiatric Care 0 0 0 0 0
6150 Alcoholism Treatment 0 0 0 0 0
6170 Nursery 0 0 0 0 0
6200 Skilled Nursing 0 0 0 0 0
6210 Swing Beds 0 0 0 0 0
6330 Hospice Care 0 0 0 0 0
6400 Other Daily Services 0 0 0 0 0
7010 Labor and Delivery 0 0 0 0 0
7020 Surgical Services 2,623,762 243,344 256,284 23,738 0
7030 Recovery Room 349,480 30,414 33,958 640 0
7040 Anesthesiology 608,504 0 54,393 5,829 0
7050 Central Services 7,369,121 24,612 660,909 296,651 0
7060 Intravenous Therapy 0 0 0 0 0
7070 Laboratory 2,323,272 17,723 209,256 10 0
7110 Electrodiagnosis 0 0 0 0 0
7120 Magnetic Resonance 0 0 0 0 0
7130 CT Scanning 0 0 0 0 0
7140 Radiology - Diagnostic 2,819,148 301,171 278,918 6,302 0
7150 Radiology - Therapeutic 0 0 0 0 0
7160 Nuclear Medicine 0 0 0 0 0
7170 Pharmacy 3,266,886 23,840 294,150 109,191 0
7180 Respiratory Therapy 873,160 21,667 79,987 3,193 0
7190 Dialysis 3,837,481 327,412 372,290 29,336 0
7200 Physical Therapy 162,506 0 14,526 0 0
7220 Psychiatric Day Care 0 0 0 0 0
7230 Emergency Room 4,023,010 185,202 376,162 5,023 0
7240 Ambulance 0 0 0 0 0
7250 Short Stay 331,064 142,925 42,369 2,944 0
7260 Clinics 3,783,193 0 338,171 29,064 0
7310 Occupational Therapy 0 0 0 0 0
7320 Speech Therapy 22,189 0 1,983 0 0
7330 Recreational Therapy 0 0 0 0 0
7340 Electromyography 0 0 0 0 0
7350 Observation Unit 0 0 0 0 0
7380 Free Standing Clinics 0 0 0 0 0
7390 Air Transportation 17,877 0 1,598 0 0
7400 Home Care Services 1,315,045 127,603 128,955 3,717 0
7410 Lithotripsy 0 0 0 0 0
7420 Organ Acquisitions 0 0 0 0 0
7430 Outpatient Chemical Dependency 0 0 0 0 0
7490 Other Ancillary 358,798 0 32,072 2,320 0
50,932,962 2,861,524 4,179,211 551,817 1,331,127
51,078,859 2,861,524 4,179,211 551,817 1,331,127
The square footage statistic is provided for all cost centers including the plant and this way
square footage identified by cost center will total the gross square footage stated as the statistic in the plant cost center.
The operating expenses, the units of measure and the operating expenses per unit of measure are stated on line 484 thru line 568 in columns
B thru G. Increases or decreases in operating expenses per unit of measure exceeding 25% are stated in column H. Please submit an
attachment with the report that addresses why those changes took place. Also please provide any corrections that might be in order.
Your hospital license number and fiscal year end have already been entered. These items need to be in alpha format rather
than numeric format in order to pick up correctly for upload to the year end report database.
If you want to review what you reported for the prior year you can click on the tab titled prior year.
If you have any questions or concerns please call Randy Huyck at 360-236-4210 or send an e-mail to
To submit your report by electronic mail, please send to:
Please remember to send a signed certification page and an audited financial statement by regular mail when they are available.
It is only necessary to enter data on this page. Items will automatically transfer from this page to the report pages.
Employee Benefits
The employee benefits can be entered directly, assigned to the cost centers based on a percentage of salaries, or a combination of the two.
1) Enter the amount of employee benefits directly recorded in cell B47.
2) Enter the employee benefits directly recorded by cost center in cells C47..CC47.
3) Enter the total unassigned employee benefits that will be assigned based on salaries in cell B48.
Depreciation
The Depreciation can be entered directly, assigned by square footage, or a combination of the two.
1) Enter the total amount of depreciation directly assigned in cell B51.
2) Enter the amount of depreciation directly recorded by cost center in cells C51..CC51.
3) Enter the amount of depreciation that will be assigned by square footage in cell B52.
After the salaries and the departmental square footage statistics are entered, the departmental employee benefits and depreciation will be
calculated on lines 48 and 52, respectively.
6140 6150 6170 6200 6210 6330 6400
Psychiatric Chemical Nursery Skilled Swing Hospice Other Daily
Employee Benefits Care Dependency Nursing Beds Inpatient Services
directly recorded
assigned based on salaries 0 0 0 0 0 0 0
total
Depreciation
depreciation directly recorded
depreciation based on sq. ft. 0 0 0 0 0 0 0
total
Account Number 6140 6150 6170 6200 6210 6330 6400
Account Psychiatric Chemical Nursery Skilled Swing Hospice Other Daily
Name Care Dependency Nursing Beds Inpatient Services
Unit of Measure Description Patient Days Patient Days Newborn Days Patient Days Patient Days Patient Days Patient Days
Units of Measure
Full Time Equivalents
Salaries & Wages
Employee Benefits 0 0 0 0 0 0 0
Professional Fees
Supplies
Purch. Serv. - Utilities
Purch. Serv. - Other
Depreciation 0 0 0 0 0 0 0
Lease/Rental
Bad Debt Expense xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Other Direct Expenses
Recoveries
Total Adj Exp 0 0 0 0 0 0 0
Tax Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
IP Revenue
OP Revenue
Gross Revenue 0 0 0 0 0 0 0
Sq FT
Patient Meals Served
Housekeeping Hours of Service
Dry Pounds of Laundry
Nursing FTE's
YE-A HOSPITAL INFORMATION Page 1 of 2
Fiscal Year Ended
License Number
Hospital Name
Street Address
Mailing Address
City, State, Zip
County
Chief Executive Officer
Chief Financial Officer
Chair of Governing Board
Telephone Number
Facsimile Number
TYPE OF ORGANIZATION (If applies enter 1)
Governmental
State
County
District
Not For Profit
Church Operated
Other
For Profit
Individual
Partnership
Corporation
YE-A HOSPITAL INFORMATION Page 2 of 2
ACTUAL UTILIZATION
ICU, SICU, ACUTE, PSYCH
Skilled Nursing/Swing
Chemical Dependency/ATC
Number of Births
NUMBER OF BEDS AVAILABLE
Intensive Care
Semi-Intensive Care
Acute Care - Med/Surg
Acute Care - Pediatrics
Acute Care - Obstetrics
Acute Care - Rehab
Psychiatric
Skilled Nursing
Swing Beds
Chemical Dependency/ATC
Other (Exclude Nursery)
Total Beds Available
Total Beds Licensed
Nursery - Bassinets
SNF/SWING Ancillary Revenue
PAYER UNITS OF SERVICE AND REVENUE
HOSPITAL
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
SNF/SWING
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
ATC
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
HBP Component
HBP Component
SUPPORTING SCHEDULES
SS-2 EMPLOYEE BENEFITS
FICA Taxes
Unemployment Compensation
Workers Compensation
Group Health Insurance
Group Life Insurance
Pension & Retirement
Other Employee Benefits
Other Employee Benefits
Total
SS-3 RENTAL AND LEASE EXPENSE
Rental & Lease Exp - Bldgs
Rental & Lease Exp - Equip
Total
SS-5 INSURANCE EXPENSE
Hospital & Prof Malpractice
Other Insurance
Total
LICENSE AND TAXES
License Fees
Taxes (other than income)
Other
Total
SS-6 INTEREST EXPENSE
Interest Expense - WC
Interest Expense - Other
Total
SS-4 DEPRECIATION EXPENSE
FIXED ASSETS
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
ACCUMULATED DEPRECIATION
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
SS-8 DEDUCTIONS FROM REVENUE
Contractuals
Medicare
Medicaid
Workers Comp
Other Government Programs
Negotiated Rate
Other
Total Contractuals
Charity Care
Number of Charity Care Patients :
Inpatient Charity Care Provided
Outpatient Charity Care Provided
Total Charity Care Provided
Other Deductions
Administrative Adjustments
Other Deductions
Total Other Deductions
Total Deductions From Revenue
FS - 1 BALANCE SHEET (Assets)
CURRENT ASSETS:
Cash
Marketable Securities
Accounts Receivable
Less-Est. Uncoll. & Allow.
Rec. From 3rd Party Payers
Pledges & Other Receivables
Due From Restricted Funds
Inventory
Prepaid Expenses
Current Portion of FHT
Total Current Assets
BOARD DESIGNATED ASSETS
Cash
Marketable Securities
Other Assets
Total BDA
PROP, PLANT, & EQUIP
Land
Land Improvements
Buildings
Fixed Equip - Bldg Srv
Fixed Equip - Other
Equipment
Leasehold Improvements
Construction In Progress
Total P P & E
Less Accum. Depreciation
Net P P & E
INVESTMENTS & OTHER ASSETS
Investments In P P & E
Less - Accum Depre
Other Investments
Other Assets
Total Invest. & Other Assets
INTANGIBLE ASSETS
Goodwill
Unamortized Loan Costs
Preopening & Other Org Costs
Other Intangible Assets
Total Intangible Assets
Total Assets
FS - 1 BALANCE SHEET ( Liabilities)
CURRENT LIABILITIES
Notes and Loans Payable
Accounts Payable
Accrued Compensation
Other Accrued Expenses
Advances From 3rd Parties
Payables to 3rd Party Payers
Due to Restricted Funds
Income Taxes Payable
Other Current Liabilities
Current Maturities of LTD
Total Current Liabilities
DEFERRED CREDITS
Deferred Income Taxes
Deferred 3rd Party Revenue
Other Deferred Credits
Total Deferred Credits
LONG TERM DEBT
Mortgage Payable
Construction Loans - Interim
Notes Payable
Capitalized Lease Obligations
Bonds Payable
Notes and Loans Payable to Parent
Noncurrent Liabilities
Total
Less Current Maturities LTD
Total Long Term Debt
Unrestricted Fund Balance
Preferred Stock
Common Stock
Additional Paid In Capital
Retained Earnings
Less: Treasury Stock
Total Liab & Fund Bal or Equity
Check Figure Total Assets
FS - 3 STATEMENT OF REVENUE & EXPENSE
OPERATING REVENUE
Inpatient Revenue
Outpatient Revenue
Total Patient Services Revenue
DEDUCTIONS FROM REVENUE
Contractual Adjustments
Charity & Uncompensated Care
Other Adj. & Allowances
Total Deductions From Revenue
Net Patient Service Revenue
OTHER OPERATING REVENUE
Other Operating Revenue
Tax Revenues
Total Other Operating Rev
Total Operating Revenue
FS - 3 STATEMENT OF REVENUE & EXPENSE
Salaries and Wages
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Rentals/Leases
Insurance
License & Taxes
Interest
Provision for Bad Debts
Other Direct Expense
Total Operating Expenses
Net Operating Revenue
Non Operating Rev Net of Exp
Net Rev. Before Items Listed Below
Extraordinary Items
Federal Income Taxes
Net Revenue or (Expense)
Tri-State Memorial Hospital H-0 FYE 12/31/2010
VOLUME:
Hospital Admissions
Hospital Patient Days
SNF/Swing Admissions
SNF/Swing Patient Days
ATC Admissions
ATC Patient Days
Newborn Admissions
Newborn Patient Days
OPERATING EXPENSES:
Salaries
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Leases/Rentals
Insurance
Licenses & Taxes
Interest
Ins, Lic. & Taxes, and Interest
Bad Debt Expense
Other Direct Expense
Total Other Direct Expense
Total Expenses
DEDUCTIONS:
Contractuals
Charity Care
Other Deductions
Total Other Deductions
CHARITY CARE
# Of Patients
Inpatient
Outpatient
OTHER REVENUES:
Other Revenue
Tax Revenue
PATIENT SERVICE REVENUE:
IP Revenue
OP Revenue
Gross Revenue
FIXED ASSET ENDING BALANCES:
Land
Land Improvements
Buildings
Fixed Equip - Bldg Serv
Fixed Equip - Other
Equipment (Moveable)
Leasehold Improvements
Construction In Progress
Total
Accum Depre Ending Balance
Balance Sheet
FS-1 Assets
FS-1 Liabilities & Fund Balance
The actual operating expenses and units of measure are presented for the past two years in columns B-E.
The operating expenses per unit of measure are presented in columns F and G.
If the percentage change in operating expenses varies by more or less than 25 %, the variance appears in column H.
If the percentage change is more or less than 25%., please provide an explanation that is provided as an attachment with your
year end report submittal. Also please provide any corrections required to the prior years information.
Tri-State Memorial Hospital
% chg
<> 25%
6010 Intensive Care 39.36%
6030 Semi-Intensive Care
6070 Acute Care
6100 Alternative Birthing Center
6120 Physical Rehabilitation
6140 Psychiatric Care
6150 Chemical Dependency
6170 Nursery
6200 Skilled Nursing
6210 Swing Beds
6330 Hospice Inpatient
6400 Other Daily Services
7010 Labor Delivery
7020 Surgical Services 175.02%
7030 Recovery Room 69.15%
7040 Anesthesiology
7050 Central Services
7060 Intravenous Therapy
7070 Laboratory
7110 Electrodiagnosis
7120 Magnetic Resonance Imaging
7130 Ct Scanning
7140 Radiology - Diagnostic
7150 Radiology - Therapeutic
7160 Nuclear Medicine
7170 Pharmacy
7180 Respiratory Therapy 74.47%
7190 Dialysis
7200 Physical Therapy
7220 Psychiatric Day Care
7230 Emergency Room 40.80%
7240 Ambulance
7250 Short Stay 480.84%
7260 Clinics
7310 Occupational Therapy
7320 Speech Therapy -40.98%
7330 Recreational Therapy
7340 Electromyography
7350 Observation Unit
7380 Free-Standing Clinics
7390 Air Transportation
7400 Home Care Services 64.90%
7410 Lithotripsy
7420 Organ Transplants
7430 Outpatient Chem. Dep.
7490 Other Ancillary
8200 Research / Education
8310 Printing & Duplication
8320 Dietary 25.39%
8330 Cafeteria
8350 Laundry & Linen
8360 Social Services
8370 Central Transportation
8420 Purchasing
8430 Plant
8460 Housekeeping
8470 Communication
8480 Data Processing
8490 Other General Services
8510 Accounting
8530 Patient Accounts
8560 Admitting
8590 Other Fiscal Services
8610 Hospital Administration
8620 Employee Health
8630 Public Relations
8640 Management Engineering
8650 Personnel
8660 Auxiliary Groups
8670 Chaplaincy Services
8680 Medical Library
8690 Medical Records
8700 Medical Staff
8710 Utilization Management
8720 Nursing Administration
8730 Nursing Float Personnel
8740 Inservice Education
8770 Comm. Health Education
8790 Other Admin. Services
8830-8900 Unassigned Other Direct
290.13 24,685 6,161 89,736,777 99.49
F T E'S HRS OF SRV DRY LBS GROSS REV NRS F T E'S
8430 +BE
+CD
8310 +AX
8510 +BJ
8470 +BG
8610 +BN
8790 +CC
8630 +BP
8770 +CB
8640 +BQ
8420 +BD
8320 +AY
8650 +BR
8620 +BO
8330 354,944 +AZ
8460 18,021 778,743 +BF
8350 73 0 215,497 +BA
8200 0 0 0 +AW
8360 0 0 0 +BB
8370 0 0 0 +BC
8490 0 36,532 0 +BI
8530 14,681 0 0 +BK
8480 0 0 0 +BH
8560 13,115 0 0 +BL
8590 0 0 0 +BM
8660 0 0 0 +BS
8670 0 0 0 +BT
8680 0 0 0 +BU
8690 20,443 0 0 +BV
8700 416 0 0 +BW
8710 0 0 0 3,634,692 +BX
8720 4,955 0 0 0 +BY
8730 0 0 0 0 +BZ
8740 1,309 0 0 0 476,681 +CA
TOTAL
F T E'S HRS OF SRV DRY LBS GROSS REV NRS F T E'S ALLOCATION
6010 19,354 39,655 17,069 97,575 53,566 563,081 +C
6030 0 0 0 0 0 0 +D
6070 50,502 118,933 51,242 200,514 125,579 2,227,407 +E
6100 0 0 0 0 0 0 +F
6120 0 0 0 0 0 0 +G
6140 0 0 0 0 0 0 +H
6150 0 0 0 0 0 0 +I
6170 0 0 0 0 0 0 +J
6200 0 0 0 0 0 0 +K
6210 0 0 0 0 0 0 +L
6330 0 0 0 0 0 0 +M
6400 0 0 0 0 0 0 +N
7010 0 0 0 0 0 0 +O
7020 19,244 171,396 10,353 212,475 50,356 987,190 +P
7030 4,796 0 10,703 30,664 12,697 123,871 +Q
7040 0 0 0 89,008 0 149,230 +R
7050 4,722 38,204 0 690,072 0 1,715,169 +S
7060 0 0 0 0 0 0 +T
7070 0 0 0 281,243 0 508,232 +U
7110 0 0 0 0 0 0 +V
7120 0 0 0 0 0 0 +W
7130 0 0 0 0 0 0 +X
7140 26,144 60,066 28,297 480,675 1,246 1,182,818 +Y
7150 0 0 0 0 0 0 +Z
7160 0 0 0 0 0 0 +AA
7170 6,875 0 0 366,069 0 800,125 +AB
7180 7,671 0 0 88,670 0 201,188 +AC
7190 35,307 95,904 28,577 375,708 46,331 1,310,865 +AD
7200 0 0 0 15,997 0 30,523 +AE
7220 0 0 0 0 0 0 +AF
7230 35,809 111,740 44,771 273,190 69,904 1,101,801 +AG
7240 0 0 0 0 0 0 +AH
7250 13,152 1,514 0 57,613 36,078 296,594 +AI
7260 42,966 104,800 9,479 255,026 46,379 825,885 +AJ
7310 0 0 0 0 0 0 +AK
7320 0 0 0 2,446 0 4,430 +AL
7330 0 0 0 0 0 0 +AM
7340 0 0 0 0 0 0 +AN
7350 0 0 0 5,002 0 5,002 +AO
7380 0 0 0 0 0 0 +AP
7390 0 0 0 596 0 2,194 +AQ
7400 15,390 0 0 55,586 34,545 365,797 +AR
7410 0 0 0 0 0 0 +AS
7420 0 0 0 0 0 0 +AT
7430 0 0 0 0 0 0 +AU
7490 0 0 15,005 56,566 0 105,963 +AV
354,944 778,743 215,497 3,634,692 476,681 12,507,365 Total Allocations Ma
354,944 778,743 215,497 3,634,692 476,681 12,507,363 Total Costs To Be A
The square footage statistic is provided for all cost centers including the plant and this way
square footage identified by cost center will total the gross square footage stated as the statistic in the plant cost center.
The operating expenses, the units of measure and the operating expenses per unit of measure are stated on line 484 thru line 568 in columns
B thru G. Increases or decreases in operating expenses per unit of measure exceeding 25% are stated in column H. Please submit an
attachment with the report that addresses why those changes took place. Also please provide any corrections that might be in order.
Your hospital license number and fiscal year end have already been entered. These items need to be in alpha format rather
than numeric format in order to pick up correctly for upload to the year end report database.
If you want to review what you reported for the prior year you can click on the tab titled prior year.
If you have any questions or concerns please call Randy Huyck at 360-236-4210 or send an e-mail to
To submit your report by electronic mail, please send to:
Please remember to send a signed certification page and an audited financial statement by regular mail when they are available.
It is only necessary to enter data on this page. Items will automatically transfer from this page to the report pages.
Employee Benefits
The employee benefits can be entered directly, assigned to the cost centers based on a percentage of salaries, or a combination of the two.
1) Enter the amount of employee benefits directly recorded in cell B47.
2) Enter the employee benefits directly recorded by cost center in cells C47..CC47.
3) Enter the total unassigned employee benefits that will be assigned based on salaries in cell B48.
Depreciation
The Depreciation can be entered directly, assigned by square footage, or a combination of the two.
1) Enter the total amount of depreciation directly assigned in cell B51.
2) Enter the amount of depreciation directly recorded by cost center in cells C51..CC51.
3) Enter the amount of depreciation that will be assigned by square footage in cell B52.
After the salaries and the departmental square footage statistics are entered, the departmental employee benefits and depreciation will be
calculated on lines 48 and 52, respectively.
7010 7020 7030 7040 7050 7060
Labor & Surgical Recovery Anesthesiology Central Intravenous
Employee Benefits Delivery Services Room Services Therapy
directly recorded
assigned based on salaries 0 314,209 57,644 0 27,729 0
total
Depreciation
depreciation directly recorded
depreciation based on sq. ft. 0 259,873 32,480 0 26,283 0
total
Account Number 7010 7020 7030 7040 7050 7060
Account Labor & Surgical Recovery Anesthesiology Central Intravenous
Name Delivery Services Room Services Therapy
Unit of Measure Description Procedures Operating Min. Recovery Min. Anesthesia Min. xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Units of Measure 186,163 106,365
Full Time Equivalents 15.73 3.92 3.86
Salaries & Wages 1,320,596 242,272 116,541
Employee Benefits 0 314,209 57,644 0 27,729 0
Professional Fees 64,417 469,020
Supplies 569,799 15,353 139,928 7,120,707
Purch. Serv. - Utilities
Purch. Serv. - Other 33,428 (444) 63,678
Depreciation 0 259,873 32,480 0 26,283 0
Lease/Rental 1,323 7,807
Bad Debt Expense xxxxxxxxxxxxxx xxxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Other Direct Expenses 60,117 1,731 0 6,376
Recoveries
Total Adj Exp 0 2,623,762 349,480 608,504 7,369,121 0
Tax Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
IP Revenue 2,696,045 318,811 985,140 12,304,743
OP Revenue 2,549,740 438,245 1,212,363 4,732,418
Gross Revenue 0 5,245,785 757,056 2,197,503 17,037,161 0
Sq FT 8,513 1,064 861
Patient Meals Served
Housekeeping Hours of Service 5,433 1,211
Dry Pounds of Laundry 296 306
Nursing FTE's 10.51 2.65
YE-A HOSPITAL INFORMATION Page 1 of 2
Fiscal Year Ended
License Number
Hospital Name
Street Address
Mailing Address
City, State, Zip
County
Chief Executive Officer
Chief Financial Officer
Chair of Governing Board
Telephone Number
Facsimile Number
TYPE OF ORGANIZATION (If applies enter 1)
Governmental
State
County
District
Not For Profit
Church Operated
Other
For Profit
Individual
Partnership
Corporation
YE-A HOSPITAL INFORMATION Page 2 of 2
ACTUAL UTILIZATION
ICU, SICU, ACUTE, PSYCH
Skilled Nursing/Swing
Chemical Dependency/ATC
Number of Births
NUMBER OF BEDS AVAILABLE
Intensive Care
Semi-Intensive Care
Acute Care - Med/Surg
Acute Care - Pediatrics
Acute Care - Obstetrics
Acute Care - Rehab
Psychiatric
Skilled Nursing
Swing Beds
Chemical Dependency/ATC
Other (Exclude Nursery)
Total Beds Available
Total Beds Licensed
Nursery - Bassinets
SNF/SWING Ancillary Revenue
PAYER UNITS OF SERVICE AND REVENUE
HOSPITAL
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
SNF/SWING
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
ATC
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
HBP Component
HBP Component
SUPPORTING SCHEDULES
SS-2 EMPLOYEE BENEFITS
FICA Taxes
Unemployment Compensation
Workers Compensation
Group Health Insurance
Group Life Insurance
Pension & Retirement
Other Employee Benefits
Other Employee Benefits
Total
SS-3 RENTAL AND LEASE EXPENSE
Rental & Lease Exp - Bldgs
Rental & Lease Exp - Equip
Total
SS-5 INSURANCE EXPENSE
Hospital & Prof Malpractice
Other Insurance
Total
LICENSE AND TAXES
License Fees
Taxes (other than income)
Other
Total
SS-6 INTEREST EXPENSE
Interest Expense - WC
Interest Expense - Other
Total
SS-4 DEPRECIATION EXPENSE
FIXED ASSETS
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
ACCUMULATED DEPRECIATION
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
SS-8 DEDUCTIONS FROM REVENUE
Contractuals
Medicare
Medicaid
Workers Comp
Other Government Programs
Negotiated Rate
Other
Total Contractuals
Charity Care
Number of Charity Care Patients :
Inpatient Charity Care Provided
Outpatient Charity Care Provided
Total Charity Care Provided
Other Deductions
Administrative Adjustments
Other Deductions
Total Other Deductions
Total Deductions From Revenue
FS - 1 BALANCE SHEET (Assets)
CURRENT ASSETS:
Cash
Marketable Securities
Accounts Receivable
Less-Est. Uncoll. & Allow.
Rec. From 3rd Party Payers
Pledges & Other Receivables
Due From Restricted Funds
Inventory
Prepaid Expenses
Current Portion of FHT
Total Current Assets
BOARD DESIGNATED ASSETS
Cash
Marketable Securities
Other Assets
Total BDA
PROP, PLANT, & EQUIP
Land
Land Improvements
Buildings
Fixed Equip - Bldg Srv
Fixed Equip - Other
Equipment
Leasehold Improvements
Construction In Progress
Total P P & E
Less Accum. Depreciation
Net P P & E
INVESTMENTS & OTHER ASSETS
Investments In P P & E
Less - Accum Depre
Other Investments
Other Assets
Total Invest. & Other Assets
INTANGIBLE ASSETS
Goodwill
Unamortized Loan Costs
Preopening & Other Org Costs
Other Intangible Assets
Total Intangible Assets
Total Assets
FS - 1 BALANCE SHEET ( Liabilities)
CURRENT LIABILITIES
Notes and Loans Payable
Accounts Payable
Accrued Compensation
Other Accrued Expenses
Advances From 3rd Parties
Payables to 3rd Party Payers
Due to Restricted Funds
Income Taxes Payable
Other Current Liabilities
Current Maturities of LTD
Total Current Liabilities
DEFERRED CREDITS
Deferred Income Taxes
Deferred 3rd Party Revenue
Other Deferred Credits
Total Deferred Credits
LONG TERM DEBT
Mortgage Payable
Construction Loans - Interim
Notes Payable
Capitalized Lease Obligations
Bonds Payable
Notes and Loans Payable to Parent
Noncurrent Liabilities
Total
Less Current Maturities LTD
Total Long Term Debt
Unrestricted Fund Balance
Preferred Stock
Common Stock
Additional Paid In Capital
Retained Earnings
Less: Treasury Stock
Total Liab & Fund Bal or Equity
Check Figure Total Assets
FS - 3 STATEMENT OF REVENUE & EXPENSE
OPERATING REVENUE
Inpatient Revenue
Outpatient Revenue
Total Patient Services Revenue
DEDUCTIONS FROM REVENUE
Contractual Adjustments
Charity & Uncompensated Care
Other Adj. & Allowances
Total Deductions From Revenue
Net Patient Service Revenue
OTHER OPERATING REVENUE
Other Operating Revenue
Tax Revenues
Total Other Operating Rev
Total Operating Revenue
FS - 3 STATEMENT OF REVENUE & EXPENSE
Salaries and Wages
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Rentals/Leases
Insurance
License & Taxes
Interest
Provision for Bad Debts
Other Direct Expense
Total Operating Expenses
Net Operating Revenue
Non Operating Rev Net of Exp
Net Rev. Before Items Listed Below
Extraordinary Items
Federal Income Taxes
Net Revenue or (Expense)
Tri-State Memorial Hospital H-0 FYE 12/31/2010
VOLUME:
Hospital Admissions
Hospital Patient Days
SNF/Swing Admissions
SNF/Swing Patient Days
ATC Admissions
ATC Patient Days
Newborn Admissions
Newborn Patient Days
OPERATING EXPENSES:
Salaries
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Leases/Rentals
Insurance
Licenses & Taxes
Interest
Ins, Lic. & Taxes, and Interest
Bad Debt Expense
Other Direct Expense
Total Other Direct Expense
Total Expenses
DEDUCTIONS:
Contractuals
Charity Care
Other Deductions
Total Other Deductions
CHARITY CARE
# Of Patients
Inpatient
Outpatient
OTHER REVENUES:
Other Revenue
Tax Revenue
PATIENT SERVICE REVENUE:
IP Revenue
OP Revenue
Gross Revenue
FIXED ASSET ENDING BALANCES:
Land
Land Improvements
Buildings
Fixed Equip - Bldg Serv
Fixed Equip - Other
Equipment (Moveable)
Leasehold Improvements
Construction In Progress
Total
Accum Depre Ending Balance
Balance Sheet
FS-1 Assets
FS-1 Liabilities & Fund Balance
The actual operating expenses and units of measure are presented for the past two years in columns B-E.
The operating expenses per unit of measure are presented in columns F and G.
If the percentage change in operating expenses varies by more or less than 25 %, the variance appears in column H.
If the percentage change is more or less than 25%., please provide an explanation that is provided as an attachment with your
year end report submittal. Also please provide any corrections required to the prior years information.
Tri-State Memorial Hospital
6010 Intensive Care
6030 Semi-Intensive Care
6070 Acute Care
6100 Alternative Birthing Center
6120 Physical Rehabilitation
6140 Psychiatric Care
6150 Chemical Dependency
6170 Nursery
6200 Skilled Nursing
6210 Swing Beds
6330 Hospice Inpatient
6400 Other Daily Services
7010 Labor Delivery
7020 Surgical Services
7030 Recovery Room
7040 Anesthesiology
7050 Central Services
7060 Intravenous Therapy
7070 Laboratory
7110 Electrodiagnosis
7120 Magnetic Resonance Imaging
7130 Ct Scanning
7140 Radiology - Diagnostic
7150 Radiology - Therapeutic
7160 Nuclear Medicine
7170 Pharmacy
7180 Respiratory Therapy
7190 Dialysis
7200 Physical Therapy
7220 Psychiatric Day Care
7230 Emergency Room
7240 Ambulance
7250 Short Stay
7260 Clinics
7310 Occupational Therapy
7320 Speech Therapy
7330 Recreational Therapy
7340 Electromyography
7350 Observation Unit
7380 Free-Standing Clinics
7390 Air Transportation
7400 Home Care Services
7410 Lithotripsy
7420 Organ Transplants
7430 Outpatient Chem. Dep.
7490 Other Ancillary
8200 Research / Education
8310 Printing & Duplication
8320 Dietary
8330 Cafeteria
8350 Laundry & Linen
8360 Social Services
8370 Central Transportation
8420 Purchasing
8430 Plant
8460 Housekeeping
8470 Communication
8480 Data Processing
8490 Other General Services
8510 Accounting
8530 Patient Accounts
8560 Admitting
8590 Other Fiscal Services
8610 Hospital Administration
8620 Employee Health
8630 Public Relations
8640 Management Engineering
8650 Personnel
8660 Auxiliary Groups
8670 Chaplaincy Services
8680 Medical Library
8690 Medical Records
8700 Medical Staff
8710 Utilization Management
8720 Nursing Administration
8730 Nursing Float Personnel
8740 Inservice Education
8770 Comm. Health Education
8790 Other Admin. Services
8830-8900 Unassigned Other Direct
8430
8310
8510
8470
8610
8790
8630
8770
8640
8420
8320
8650
8620
8330
8460
8350
8200
8360
8370
8490
8530
8480
8560
8590
8660
8670
8680
8690
8700
8710
8720
8730
8740
6010
6030
6070
6100
6120
6140
6150
6170
6200
6210
6330
6400
7010
7020
7030
7040
7050
7060
7070
7110
7120
7130
7140
7150
7160
7170
7180
7190
7200
7220
7230
7240
7250
7260
7310
7320
7330
7340
7350
7380
7390
7400
7410
7420
7430
7490
Total Allocations Made
Total Costs To Be Allocated
The square footage statistic is provided for all cost centers including the plant and this way
square footage identified by cost center will total the gross square footage stated as the statistic in the plant cost center.
The operating expenses, the units of measure and the operating expenses per unit of measure are stated on line 484 thru line 568 in columns
B thru G. Increases or decreases in operating expenses per unit of measure exceeding 25% are stated in column H. Please submit an
attachment with the report that addresses why those changes took place. Also please provide any corrections that might be in order.
Your hospital license number and fiscal year end have already been entered. These items need to be in alpha format rather
than numeric format in order to pick up correctly for upload to the year end report database.
If you want to review what you reported for the prior year you can click on the tab titled prior year.
If you have any questions or concerns please call Randy Huyck at 360-236-4210 or send an e-mail to
To submit your report by electronic mail, please send to:
Please remember to send a signed certification page and an audited financial statement by regular mail when they are available.
It is only necessary to enter data on this page. Items will automatically transfer from this page to the report pages.
Employee Benefits
The employee benefits can be entered directly, assigned to the cost centers based on a percentage of salaries, or a combination of the two.
1) Enter the amount of employee benefits directly recorded in cell B47.
2) Enter the employee benefits directly recorded by cost center in cells C47..CC47.
3) Enter the total unassigned employee benefits that will be assigned based on salaries in cell B48.
Depreciation
The Depreciation can be entered directly, assigned by square footage, or a combination of the two.
1) Enter the total amount of depreciation directly assigned in cell B51.
2) Enter the amount of depreciation directly recorded by cost center in cells C51..CC51.
3) Enter the amount of depreciation that will be assigned by square footage in cell B52.
After the salaries and the departmental square footage statistics are entered, the departmental employee benefits and depreciation will be
calculated on lines 48 and 52, respectively.
7070 7110 7120 7130 7140 7150 7160
Laboratory Electro- Magnetic Res CT Radiology - Radiology - Nuclear
Employee Benefits diagnosis Imaging Scanning Diagnostic Therapeutic Medicine
directly recorded
assigned based on salaries 0 0 0 0 300,532 0 0
total
Depreciation
depreciation directly recorded
depreciation based on sq. ft. 18,927 0 0 0 321,628 0 0
total
Account Number 7070 7110 7120 7130 7140 7150 7160
Account Laboratory Electro- Magnetic Res CT Radiology - Radiology - Nuclear
Name diagnosis Imaging Scanning Diagnostic Therapeutic Medicine
Unit of Measure Description Billable Tests Billable Tests MRI RVU HECT Unit RVU RVU RVU
Units of Measure 125,598 182,958
Full Time Equivalents 21.37
Salaries & Wages 1,263,112
Employee Benefits 0 0 0 0 300,532 0 0
Professional Fees 39,000
Supplies 232 151,269
Purch. Serv. - Utilities 407
Purch. Serv. - Other 2,304,113 721,685
Depreciation 18,927 0 0 0 321,628 0 0
Lease/Rental 4,603
Bad Debt Expense xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Other Direct Expenses 0 16,912
Recoveries
Total Adj Exp 2,323,272 0 0 0 2,819,148 0 0
Tax Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
IP Revenue 2,543,626 1,268,625
OP Revenue 4,399,976 10,598,732
Gross Revenue 6,943,602 0 0 0 11,867,357 0 0
Sq FT 620 10,536
Patient Meals Served
Housekeeping Hours of Service 1,904
Dry Pounds of Laundry 809
Nursing FTE's 0.26
YE-A HOSPITAL INFORMATION Page 1 of 2
Fiscal Year Ended
License Number
Hospital Name
Street Address
Mailing Address
City, State, Zip
County
Chief Executive Officer
Chief Financial Officer
Chair of Governing Board
Telephone Number
Facsimile Number
TYPE OF ORGANIZATION (If applies enter 1)
Governmental
State
County
District
Not For Profit
Church Operated
Other
For Profit
Individual
Partnership
Corporation
YE-A HOSPITAL INFORMATION Page 2 of 2
ACTUAL UTILIZATION
ICU, SICU, ACUTE, PSYCH
Skilled Nursing/Swing
Chemical Dependency/ATC
Number of Births
NUMBER OF BEDS AVAILABLE
Intensive Care
Semi-Intensive Care
Acute Care - Med/Surg
Acute Care - Pediatrics
Acute Care - Obstetrics
Acute Care - Rehab
Psychiatric
Skilled Nursing
Swing Beds
Chemical Dependency/ATC
Other (Exclude Nursery)
Total Beds Available
Total Beds Licensed
Nursery - Bassinets
SNF/SWING Ancillary Revenue
PAYER UNITS OF SERVICE AND REVENUE
HOSPITAL
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
SNF/SWING
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
ATC
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
HBP Component
HBP Component
SUPPORTING SCHEDULES
SS-2 EMPLOYEE BENEFITS
FICA Taxes
Unemployment Compensation
Workers Compensation
Group Health Insurance
Group Life Insurance
Pension & Retirement
Other Employee Benefits
Other Employee Benefits
Total
SS-3 RENTAL AND LEASE EXPENSE
Rental & Lease Exp - Bldgs
Rental & Lease Exp - Equip
Total
SS-5 INSURANCE EXPENSE
Hospital & Prof Malpractice
Other Insurance
Total
LICENSE AND TAXES
License Fees
Taxes (other than income)
Other
Total
SS-6 INTEREST EXPENSE
Interest Expense - WC
Interest Expense - Other
Total
SS-4 DEPRECIATION EXPENSE
FIXED ASSETS
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
ACCUMULATED DEPRECIATION
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
SS-8 DEDUCTIONS FROM REVENUE
Contractuals
Medicare
Medicaid
Workers Comp
Other Government Programs
Negotiated Rate
Other
Total Contractuals
Charity Care
Number of Charity Care Patients :
Inpatient Charity Care Provided
Outpatient Charity Care Provided
Total Charity Care Provided
Other Deductions
Administrative Adjustments
Other Deductions
Total Other Deductions
Total Deductions From Revenue
FS - 1 BALANCE SHEET (Assets)
CURRENT ASSETS:
Cash
Marketable Securities
Accounts Receivable
Less-Est. Uncoll. & Allow.
Rec. From 3rd Party Payers
Pledges & Other Receivables
Due From Restricted Funds
Inventory
Prepaid Expenses
Current Portion of FHT
Total Current Assets
BOARD DESIGNATED ASSETS
Cash
Marketable Securities
Other Assets
Total BDA
PROP, PLANT, & EQUIP
Land
Land Improvements
Buildings
Fixed Equip - Bldg Srv
Fixed Equip - Other
Equipment
Leasehold Improvements
Construction In Progress
Total P P & E
Less Accum. Depreciation
Net P P & E
INVESTMENTS & OTHER ASSETS
Investments In P P & E
Less - Accum Depre
Other Investments
Other Assets
Total Invest. & Other Assets
INTANGIBLE ASSETS
Goodwill
Unamortized Loan Costs
Preopening & Other Org Costs
Other Intangible Assets
Total Intangible Assets
Total Assets
FS - 1 BALANCE SHEET ( Liabilities)
CURRENT LIABILITIES
Notes and Loans Payable
Accounts Payable
Accrued Compensation
Other Accrued Expenses
Advances From 3rd Parties
Payables to 3rd Party Payers
Due to Restricted Funds
Income Taxes Payable
Other Current Liabilities
Current Maturities of LTD
Total Current Liabilities
DEFERRED CREDITS
Deferred Income Taxes
Deferred 3rd Party Revenue
Other Deferred Credits
Total Deferred Credits
LONG TERM DEBT
Mortgage Payable
Construction Loans - Interim
Notes Payable
Capitalized Lease Obligations
Bonds Payable
Notes and Loans Payable to Parent
Noncurrent Liabilities
Total
Less Current Maturities LTD
Total Long Term Debt
Unrestricted Fund Balance
Preferred Stock
Common Stock
Additional Paid In Capital
Retained Earnings
Less: Treasury Stock
Total Liab & Fund Bal or Equity
Check Figure Total Assets
FS - 3 STATEMENT OF REVENUE & EXPENSE
OPERATING REVENUE
Inpatient Revenue
Outpatient Revenue
Total Patient Services Revenue
DEDUCTIONS FROM REVENUE
Contractual Adjustments
Charity & Uncompensated Care
Other Adj. & Allowances
Total Deductions From Revenue
Net Patient Service Revenue
OTHER OPERATING REVENUE
Other Operating Revenue
Tax Revenues
Total Other Operating Rev
Total Operating Revenue
FS - 3 STATEMENT OF REVENUE & EXPENSE
Salaries and Wages
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Rentals/Leases
Insurance
License & Taxes
Interest
Provision for Bad Debts
Other Direct Expense
Total Operating Expenses
Net Operating Revenue
Non Operating Rev Net of Exp
Net Rev. Before Items Listed Below
Extraordinary Items
Federal Income Taxes
Net Revenue or (Expense)
Tri-State Memorial Hospital H-0 FYE 12/31/2010
VOLUME:
Hospital Admissions
Hospital Patient Days
SNF/Swing Admissions
SNF/Swing Patient Days
ATC Admissions
ATC Patient Days
Newborn Admissions
Newborn Patient Days
OPERATING EXPENSES:
Salaries
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Leases/Rentals
Insurance
Licenses & Taxes
Interest
Ins, Lic. & Taxes, and Interest
Bad Debt Expense
Other Direct Expense
Total Other Direct Expense
Total Expenses
DEDUCTIONS:
Contractuals
Charity Care
Other Deductions
Total Other Deductions
CHARITY CARE
# Of Patients
Inpatient
Outpatient
OTHER REVENUES:
Other Revenue
Tax Revenue
PATIENT SERVICE REVENUE:
IP Revenue
OP Revenue
Gross Revenue
FIXED ASSET ENDING BALANCES:
Land
Land Improvements
Buildings
Fixed Equip - Bldg Serv
Fixed Equip - Other
Equipment (Moveable)
Leasehold Improvements
Construction In Progress
Total
Accum Depre Ending Balance
Balance Sheet
FS-1 Assets
FS-1 Liabilities & Fund Balance
The actual operating expenses and units of measure are presented for the past two years in columns B-E.
The operating expenses per unit of measure are presented in columns F and G.
If the percentage change in operating expenses varies by more or less than 25 %, the variance appears in column H.
If the percentage change is more or less than 25%., please provide an explanation that is provided as an attachment with your
year end report submittal. Also please provide any corrections required to the prior years information.
Tri-State Memorial Hospital
6010 Intensive Care
6030 Semi-Intensive Care
6070 Acute Care
6100 Alternative Birthing Center
6120 Physical Rehabilitation
6140 Psychiatric Care
6150 Chemical Dependency
6170 Nursery
6200 Skilled Nursing
6210 Swing Beds
6330 Hospice Inpatient
6400 Other Daily Services
7010 Labor Delivery
7020 Surgical Services
7030 Recovery Room
7040 Anesthesiology
7050 Central Services
7060 Intravenous Therapy
7070 Laboratory
7110 Electrodiagnosis
7120 Magnetic Resonance Imaging
7130 Ct Scanning
7140 Radiology - Diagnostic
7150 Radiology - Therapeutic
7160 Nuclear Medicine
7170 Pharmacy
7180 Respiratory Therapy
7190 Dialysis
7200 Physical Therapy
7220 Psychiatric Day Care
7230 Emergency Room
7240 Ambulance
7250 Short Stay
7260 Clinics
7310 Occupational Therapy
7320 Speech Therapy
7330 Recreational Therapy
7340 Electromyography
7350 Observation Unit
7380 Free-Standing Clinics
7390 Air Transportation
7400 Home Care Services
7410 Lithotripsy
7420 Organ Transplants
7430 Outpatient Chem. Dep.
7490 Other Ancillary
8200 Research / Education
8310 Printing & Duplication
8320 Dietary
8330 Cafeteria
8350 Laundry & Linen
8360 Social Services
8370 Central Transportation
8420 Purchasing
8430 Plant
8460 Housekeeping
8470 Communication
8480 Data Processing
8490 Other General Services
8510 Accounting
8530 Patient Accounts
8560 Admitting
8590 Other Fiscal Services
8610 Hospital Administration
8620 Employee Health
8630 Public Relations
8640 Management Engineering
8650 Personnel
8660 Auxiliary Groups
8670 Chaplaincy Services
8680 Medical Library
8690 Medical Records
8700 Medical Staff
8710 Utilization Management
8720 Nursing Administration
8730 Nursing Float Personnel
8740 Inservice Education
8770 Comm. Health Education
8790 Other Admin. Services
8830-8900 Unassigned Other Direct
8430
8310
8510
8470
8610
8790
8630
8770
8640
8420
8320
8650
8620
8330
8460
8350
8200
8360
8370
8490
8530
8480
8560
8590
8660
8670
8680
8690
8700
8710
8720
8730
8740
6010
6030
6070
6100
6120
6140
6150
6170
6200
6210
6330
6400
7010
7020
7030
7040
7050
7060
7070
7110
7120
7130
7140
7150
7160
7170
7180
7190
7200
7220
7230
7240
7250
7260
7310
7320
7330
7340
7350
7380
7390
7400
7410
7420
7430
7490
The square footage statistic is provided for all cost centers including the plant and this way
square footage identified by cost center will total the gross square footage stated as the statistic in the plant cost center.
The operating expenses, the units of measure and the operating expenses per unit of measure are stated on line 484 thru line 568 in columns
B thru G. Increases or decreases in operating expenses per unit of measure exceeding 25% are stated in column H. Please submit an
attachment with the report that addresses why those changes took place. Also please provide any corrections that might be in order.
Your hospital license number and fiscal year end have already been entered. These items need to be in alpha format rather
than numeric format in order to pick up correctly for upload to the year end report database.
If you want to review what you reported for the prior year you can click on the tab titled prior year.
If you have any questions or concerns please call Randy Huyck at 360-236-4210 or send an e-mail to
To submit your report by electronic mail, please send to:
Please remember to send a signed certification page and an audited financial statement by regular mail when they are available.
It is only necessary to enter data on this page. Items will automatically transfer from this page to the report pages.
Employee Benefits
The employee benefits can be entered directly, assigned to the cost centers based on a percentage of salaries, or a combination of the two.
1) Enter the amount of employee benefits directly recorded in cell B47.
2) Enter the employee benefits directly recorded by cost center in cells C47..CC47.
3) Enter the total unassigned employee benefits that will be assigned based on salaries in cell B48.
Depreciation
The Depreciation can be entered directly, assigned by square footage, or a combination of the two.
1) Enter the total amount of depreciation directly assigned in cell B51.
2) Enter the amount of depreciation directly recorded by cost center in cells C51..CC51.
3) Enter the amount of depreciation that will be assigned by square footage in cell B52.
After the salaries and the departmental square footage statistics are entered, the departmental employee benefits and depreciation will be
calculated on lines 48 and 52, respectively.
7170 7180 7190 7200 7220 7230
Pharmacy Respiratory Dialysis Physical Psychiatric Emergency
Employee Benefits Therapy Therapy Day Care Room
directly recorded
assigned based on salaries 109,117 126,798 439,682 0 0 398,267
total
Depreciation
depreciation directly recorded
depreciation based on sq. ft. 25,459 23,139 349,652 0 0 197,782
total
Account Number 7170 7180 7190 7200 7220 7230
Account Pharmacy Respiratory Dialysis Physical Psychiatric Emergency
Name Therapy Therapy Day Care Room
Unit of Measure Description xxxxxxxxxxxxxx Treatments Hours Treatments Visits Visits
Units of Measure 26,059 3,346 16,082
Full Time Equivalents 5.62 6.27 28.86 29.27
Salaries & Wages 458,610 532,922 1,847,947 1,673,886
Employee Benefits 109,117 126,798 439,682 0 0 398,267
Professional Fees 72,970 115,385 162,506 1,517,366
Supplies 2,620,975 76,647 704,164 120,573
Purch. Serv. - Utilities 39,035 2,096
Purch. Serv. - Other 13,939 15,926 113,864 87,909
Depreciation 25,459 23,139 349,652 0 0 197,782
Lease/Rental 37,821 21,501 207,035 5,284
Bad Debt Expense xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxxx
Other Direct Expenses 965 3,257 20,717 19,847
Recoveries
Total Adj Exp 3,266,886 873,160 3,837,481 162,506 0 4,023,010
Tax Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxxx
IP Revenue 2,179,356 1,157,009 251,447 390,414 201,301
OP Revenue 6,858,502 1,032,156 9,024,399 4,526 6,543,466
Gross Revenue 9,037,858 2,189,165 9,275,846 394,940 0 6,744,767
Sq FT 834 758 11,454 6,479
Patient Meals Served
Housekeeping Hours of Service 3,040 3,542
Dry Pounds of Laundry 817 1,280
Nursing FTE's 9.67 14.59
YE-A HOSPITAL INFORMATION Page 1 of 2
Fiscal Year Ended
License Number
Hospital Name
Street Address
Mailing Address
City, State, Zip
County
Chief Executive Officer
Chief Financial Officer
Chair of Governing Board
Telephone Number
Facsimile Number
TYPE OF ORGANIZATION (If applies enter 1)
Governmental
State
County
District
Not For Profit
Church Operated
Other
For Profit
Individual
Partnership
Corporation
YE-A HOSPITAL INFORMATION Page 2 of 2
ACTUAL UTILIZATION
ICU, SICU, ACUTE, PSYCH
Skilled Nursing/Swing
Chemical Dependency/ATC
Number of Births
NUMBER OF BEDS AVAILABLE
Intensive Care
Semi-Intensive Care
Acute Care - Med/Surg
Acute Care - Pediatrics
Acute Care - Obstetrics
Acute Care - Rehab
Psychiatric
Skilled Nursing
Swing Beds
Chemical Dependency/ATC
Other (Exclude Nursery)
Total Beds Available
Total Beds Licensed
Nursery - Bassinets
SNF/SWING Ancillary Revenue
PAYER UNITS OF SERVICE AND REVENUE
HOSPITAL
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
SNF/SWING
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
ATC
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
HBP Component
HBP Component
SUPPORTING SCHEDULES
SS-2 EMPLOYEE BENEFITS
FICA Taxes
Unemployment Compensation
Workers Compensation
Group Health Insurance
Group Life Insurance
Pension & Retirement
Other Employee Benefits
Other Employee Benefits
Total
SS-3 RENTAL AND LEASE EXPENSE
Rental & Lease Exp - Bldgs
Rental & Lease Exp - Equip
Total
SS-5 INSURANCE EXPENSE
Hospital & Prof Malpractice
Other Insurance
Total
LICENSE AND TAXES
License Fees
Taxes (other than income)
Other
Total
SS-6 INTEREST EXPENSE
Interest Expense - WC
Interest Expense - Other
Total
SS-4 DEPRECIATION EXPENSE
FIXED ASSETS
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
ACCUMULATED DEPRECIATION
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
SS-8 DEDUCTIONS FROM REVENUE
Contractuals
Medicare
Medicaid
Workers Comp
Other Government Programs
Negotiated Rate
Other
Total Contractuals
Charity Care
Number of Charity Care Patients :
Inpatient Charity Care Provided
Outpatient Charity Care Provided
Total Charity Care Provided
Other Deductions
Administrative Adjustments
Other Deductions
Total Other Deductions
Total Deductions From Revenue
FS - 1 BALANCE SHEET (Assets)
CURRENT ASSETS:
Cash
Marketable Securities
Accounts Receivable
Less-Est. Uncoll. & Allow.
Rec. From 3rd Party Payers
Pledges & Other Receivables
Due From Restricted Funds
Inventory
Prepaid Expenses
Current Portion of FHT
Total Current Assets
BOARD DESIGNATED ASSETS
Cash
Marketable Securities
Other Assets
Total BDA
PROP, PLANT, & EQUIP
Land
Land Improvements
Buildings
Fixed Equip - Bldg Srv
Fixed Equip - Other
Equipment
Leasehold Improvements
Construction In Progress
Total P P & E
Less Accum. Depreciation
Net P P & E
INVESTMENTS & OTHER ASSETS
Investments In P P & E
Less - Accum Depre
Other Investments
Other Assets
Total Invest. & Other Assets
INTANGIBLE ASSETS
Goodwill
Unamortized Loan Costs
Preopening & Other Org Costs
Other Intangible Assets
Total Intangible Assets
Total Assets
FS - 1 BALANCE SHEET ( Liabilities)
CURRENT LIABILITIES
Notes and Loans Payable
Accounts Payable
Accrued Compensation
Other Accrued Expenses
Advances From 3rd Parties
Payables to 3rd Party Payers
Due to Restricted Funds
Income Taxes Payable
Other Current Liabilities
Current Maturities of LTD
Total Current Liabilities
DEFERRED CREDITS
Deferred Income Taxes
Deferred 3rd Party Revenue
Other Deferred Credits
Total Deferred Credits
LONG TERM DEBT
Mortgage Payable
Construction Loans - Interim
Notes Payable
Capitalized Lease Obligations
Bonds Payable
Notes and Loans Payable to Parent
Noncurrent Liabilities
Total
Less Current Maturities LTD
Total Long Term Debt
Unrestricted Fund Balance
Preferred Stock
Common Stock
Additional Paid In Capital
Retained Earnings
Less: Treasury Stock
Total Liab & Fund Bal or Equity
Check Figure Total Assets
FS - 3 STATEMENT OF REVENUE & EXPENSE
OPERATING REVENUE
Inpatient Revenue
Outpatient Revenue
Total Patient Services Revenue
DEDUCTIONS FROM REVENUE
Contractual Adjustments
Charity & Uncompensated Care
Other Adj. & Allowances
Total Deductions From Revenue
Net Patient Service Revenue
OTHER OPERATING REVENUE
Other Operating Revenue
Tax Revenues
Total Other Operating Rev
Total Operating Revenue
FS - 3 STATEMENT OF REVENUE & EXPENSE
Salaries and Wages
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Rentals/Leases
Insurance
License & Taxes
Interest
Provision for Bad Debts
Other Direct Expense
Total Operating Expenses
Net Operating Revenue
Non Operating Rev Net of Exp
Net Rev. Before Items Listed Below
Extraordinary Items
Federal Income Taxes
Net Revenue or (Expense)
Tri-State Memorial Hospital H-0 FYE 12/31/2010
VOLUME:
Hospital Admissions
Hospital Patient Days
SNF/Swing Admissions
SNF/Swing Patient Days
ATC Admissions
ATC Patient Days
Newborn Admissions
Newborn Patient Days
OPERATING EXPENSES:
Salaries
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Leases/Rentals
Insurance
Licenses & Taxes
Interest
Ins, Lic. & Taxes, and Interest
Bad Debt Expense
Other Direct Expense
Total Other Direct Expense
Total Expenses
DEDUCTIONS:
Contractuals
Charity Care
Other Deductions
Total Other Deductions
CHARITY CARE
# Of Patients
Inpatient
Outpatient
OTHER REVENUES:
Other Revenue
Tax Revenue
PATIENT SERVICE REVENUE:
IP Revenue
OP Revenue
Gross Revenue
FIXED ASSET ENDING BALANCES:
Land
Land Improvements
Buildings
Fixed Equip - Bldg Serv
Fixed Equip - Other
Equipment (Moveable)
Leasehold Improvements
Construction In Progress
Total
Accum Depre Ending Balance
Balance Sheet
FS-1 Assets
FS-1 Liabilities & Fund Balance
The actual operating expenses and units of measure are presented for the past two years in columns B-E.
The operating expenses per unit of measure are presented in columns F and G.
If the percentage change in operating expenses varies by more or less than 25 %, the variance appears in column H.
If the percentage change is more or less than 25%., please provide an explanation that is provided as an attachment with your
year end report submittal. Also please provide any corrections required to the prior years information.
Tri-State Memorial Hospital
6010 Intensive Care
6030 Semi-Intensive Care
6070 Acute Care
6100 Alternative Birthing Center
6120 Physical Rehabilitation
6140 Psychiatric Care
6150 Chemical Dependency
6170 Nursery
6200 Skilled Nursing
6210 Swing Beds
6330 Hospice Inpatient
6400 Other Daily Services
7010 Labor Delivery
7020 Surgical Services
7030 Recovery Room
7040 Anesthesiology
7050 Central Services
7060 Intravenous Therapy
7070 Laboratory
7110 Electrodiagnosis
7120 Magnetic Resonance Imaging
7130 Ct Scanning
7140 Radiology - Diagnostic
7150 Radiology - Therapeutic
7160 Nuclear Medicine
7170 Pharmacy
7180 Respiratory Therapy
7190 Dialysis
7200 Physical Therapy
7220 Psychiatric Day Care
7230 Emergency Room
7240 Ambulance
7250 Short Stay
7260 Clinics
7310 Occupational Therapy
7320 Speech Therapy
7330 Recreational Therapy
7340 Electromyography
7350 Observation Unit
7380 Free-Standing Clinics
7390 Air Transportation
7400 Home Care Services
7410 Lithotripsy
7420 Organ Transplants
7430 Outpatient Chem. Dep.
7490 Other Ancillary
8200 Research / Education
8310 Printing & Duplication
8320 Dietary
8330 Cafeteria
8350 Laundry & Linen
8360 Social Services
8370 Central Transportation
8420 Purchasing
8430 Plant
8460 Housekeeping
8470 Communication
8480 Data Processing
8490 Other General Services
8510 Accounting
8530 Patient Accounts
8560 Admitting
8590 Other Fiscal Services
8610 Hospital Administration
8620 Employee Health
8630 Public Relations
8640 Management Engineering
8650 Personnel
8660 Auxiliary Groups
8670 Chaplaincy Services
8680 Medical Library
8690 Medical Records
8700 Medical Staff
8710 Utilization Management
8720 Nursing Administration
8730 Nursing Float Personnel
8740 Inservice Education
8770 Comm. Health Education
8790 Other Admin. Services
8830-8900 Unassigned Other Direct
8430
8310
8510
8470
8610
8790
8630
8770
8640
8420
8320
8650
8620
8330
8460
8350
8200
8360
8370
8490
8530
8480
8560
8590
8660
8670
8680
8690
8700
8710
8720
8730
8740
6010
6030
6070
6100
6120
6140
6150
6170
6200
6210
6330
6400
7010
7020
7030
7040
7050
7060
7070
7110
7120
7130
7140
7150
7160
7170
7180
7190
7200
7220
7230
7240
7250
7260
7310
7320
7330
7340
7350
7380
7390
7400
7410
7420
7430
7490
The square footage statistic is provided for all cost centers including the plant and this way
square footage identified by cost center will total the gross square footage stated as the statistic in the plant cost center.
The operating expenses, the units of measure and the operating expenses per unit of measure are stated on line 484 thru line 568 in columns
B thru G. Increases or decreases in operating expenses per unit of measure exceeding 25% are stated in column H. Please submit an
attachment with the report that addresses why those changes took place. Also please provide any corrections that might be in order.
Your hospital license number and fiscal year end have already been entered. These items need to be in alpha format rather
than numeric format in order to pick up correctly for upload to the year end report database.
If you want to review what you reported for the prior year you can click on the tab titled prior year.
If you have any questions or concerns please call Randy Huyck at 360-236-4210 or send an e-mail to
To submit your report by electronic mail, please send to:
Please remember to send a signed certification page and an audited financial statement by regular mail when they are available.
It is only necessary to enter data on this page. Items will automatically transfer from this page to the report pages.
Employee Benefits
The employee benefits can be entered directly, assigned to the cost centers based on a percentage of salaries, or a combination of the two.
1) Enter the amount of employee benefits directly recorded in cell B47.
2) Enter the employee benefits directly recorded by cost center in cells C47..CC47.
3) Enter the total unassigned employee benefits that will be assigned based on salaries in cell B48.
Depreciation
The Depreciation can be entered directly, assigned by square footage, or a combination of the two.
1) Enter the total amount of depreciation directly assigned in cell B51.
2) Enter the amount of depreciation directly recorded by cost center in cells C51..CC51.
3) Enter the amount of depreciation that will be assigned by square footage in cell B52.
After the salaries and the departmental square footage statistics are entered, the departmental employee benefits and depreciation will be
calculated on lines 48 and 52, respectively.
7240 7250 7260 7310 7320 7330 7340
Ambulance Short Clinics Occupational Speech Recreational Electro-
Employee Benefits Stay Therapy Therapy Therapy myogray
directly recorded
assigned based on salaries 0 15,086 301,631 0 0 0 0
total
Depreciation
depreciation directly recorded
depreciation based on sq. ft. 0 152,633 0 0 0 0 0
total
Account Number 7240 7250 7260 7310 7320 7330 7340
Account Ambulance Short Clinics Occupational Speech Recreational Electro-
Name Stay Therapy Therapy Therapy myogray
Unit of Measure Description Occasions Patients Visits Treatments Treatments Treatments Procedures
Units of Measure 388 11,522 360
Full Time Equivalents 10.75 35.12
Salaries & Wages 63,406 1,267,729
Employee Benefits 0 15,086 301,631 0 0 0 0
Professional Fees 22,046 1,436,774 22,189
Supplies 70,661 697,640
Purch. Serv. - Utilities 2,687
Purch. Serv. - Other 11,268
Depreciation 0 152,633 0 0 0 0 0
Lease/Rental 8,259
Bad Debt Expense xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Other Direct Expenses 7,232 57,205
Recoveries
Total Adj Exp 0 331,064 3,783,193 0 22,189 0 0
Tax Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
IP Revenue 1,304,175 60,401
OP Revenue 1,422,399 4,992,158
Gross Revenue 0 1,422,399 6,296,333 0 60,401 0 0
Sq FT 5,000
Patient Meals Served
Housekeeping Hours of Service 48 3,322
Dry Pounds of Laundry 271
Nursing FTE's 7.53 9.68
YE-A HOSPITAL INFORMATION Page 1 of 2
Fiscal Year Ended
License Number
Hospital Name
Street Address
Mailing Address
City, State, Zip
County
Chief Executive Officer
Chief Financial Officer
Chair of Governing Board
Telephone Number
Facsimile Number
TYPE OF ORGANIZATION (If applies enter 1)
Governmental
State
County
District
Not For Profit
Church Operated
Other
For Profit
Individual
Partnership
Corporation
YE-A HOSPITAL INFORMATION Page 2 of 2
ACTUAL UTILIZATION
ICU, SICU, ACUTE, PSYCH
Skilled Nursing/Swing
Chemical Dependency/ATC
Number of Births
NUMBER OF BEDS AVAILABLE
Intensive Care
Semi-Intensive Care
Acute Care - Med/Surg
Acute Care - Pediatrics
Acute Care - Obstetrics
Acute Care - Rehab
Psychiatric
Skilled Nursing
Swing Beds
Chemical Dependency/ATC
Other (Exclude Nursery)
Total Beds Available
Total Beds Licensed
Nursery - Bassinets
SNF/SWING Ancillary Revenue
PAYER UNITS OF SERVICE AND REVENUE
HOSPITAL
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
SNF/SWING
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
ATC
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
HBP Component
HBP Component
SUPPORTING SCHEDULES
SS-2 EMPLOYEE BENEFITS
FICA Taxes
Unemployment Compensation
Workers Compensation
Group Health Insurance
Group Life Insurance
Pension & Retirement
Other Employee Benefits
Other Employee Benefits
Total
SS-3 RENTAL AND LEASE EXPENSE
Rental & Lease Exp - Bldgs
Rental & Lease Exp - Equip
Total
SS-5 INSURANCE EXPENSE
Hospital & Prof Malpractice
Other Insurance
Total
LICENSE AND TAXES
License Fees
Taxes (other than income)
Other
Total
SS-6 INTEREST EXPENSE
Interest Expense - WC
Interest Expense - Other
Total
SS-4 DEPRECIATION EXPENSE
FIXED ASSETS
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
ACCUMULATED DEPRECIATION
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
SS-8 DEDUCTIONS FROM REVENUE
Contractuals
Medicare
Medicaid
Workers Comp
Other Government Programs
Negotiated Rate
Other
Total Contractuals
Charity Care
Number of Charity Care Patients :
Inpatient Charity Care Provided
Outpatient Charity Care Provided
Total Charity Care Provided
Other Deductions
Administrative Adjustments
Other Deductions
Total Other Deductions
Total Deductions From Revenue
FS - 1 BALANCE SHEET (Assets)
CURRENT ASSETS:
Cash
Marketable Securities
Accounts Receivable
Less-Est. Uncoll. & Allow.
Rec. From 3rd Party Payers
Pledges & Other Receivables
Due From Restricted Funds
Inventory
Prepaid Expenses
Current Portion of FHT
Total Current Assets
BOARD DESIGNATED ASSETS
Cash
Marketable Securities
Other Assets
Total BDA
PROP, PLANT, & EQUIP
Land
Land Improvements
Buildings
Fixed Equip - Bldg Srv
Fixed Equip - Other
Equipment
Leasehold Improvements
Construction In Progress
Total P P & E
Less Accum. Depreciation
Net P P & E
INVESTMENTS & OTHER ASSETS
Investments In P P & E
Less - Accum Depre
Other Investments
Other Assets
Total Invest. & Other Assets
INTANGIBLE ASSETS
Goodwill
Unamortized Loan Costs
Preopening & Other Org Costs
Other Intangible Assets
Total Intangible Assets
Total Assets
FS - 1 BALANCE SHEET ( Liabilities)
CURRENT LIABILITIES
Notes and Loans Payable
Accounts Payable
Accrued Compensation
Other Accrued Expenses
Advances From 3rd Parties
Payables to 3rd Party Payers
Due to Restricted Funds
Income Taxes Payable
Other Current Liabilities
Current Maturities of LTD
Total Current Liabilities
DEFERRED CREDITS
Deferred Income Taxes
Deferred 3rd Party Revenue
Other Deferred Credits
Total Deferred Credits
LONG TERM DEBT
Mortgage Payable
Construction Loans - Interim
Notes Payable
Capitalized Lease Obligations
Bonds Payable
Notes and Loans Payable to Parent
Noncurrent Liabilities
Total
Less Current Maturities LTD
Total Long Term Debt
Unrestricted Fund Balance
Preferred Stock
Common Stock
Additional Paid In Capital
Retained Earnings
Less: Treasury Stock
Total Liab & Fund Bal or Equity
Check Figure Total Assets
FS - 3 STATEMENT OF REVENUE & EXPENSE
OPERATING REVENUE
Inpatient Revenue
Outpatient Revenue
Total Patient Services Revenue
DEDUCTIONS FROM REVENUE
Contractual Adjustments
Charity & Uncompensated Care
Other Adj. & Allowances
Total Deductions From Revenue
Net Patient Service Revenue
OTHER OPERATING REVENUE
Other Operating Revenue
Tax Revenues
Total Other Operating Rev
Total Operating Revenue
FS - 3 STATEMENT OF REVENUE & EXPENSE
Salaries and Wages
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Rentals/Leases
Insurance
License & Taxes
Interest
Provision for Bad Debts
Other Direct Expense
Total Operating Expenses
Net Operating Revenue
Non Operating Rev Net of Exp
Net Rev. Before Items Listed Below
Extraordinary Items
Federal Income Taxes
Net Revenue or (Expense)
Tri-State Memorial Hospital H-0 FYE 12/31/2010
VOLUME:
Hospital Admissions
Hospital Patient Days
SNF/Swing Admissions
SNF/Swing Patient Days
ATC Admissions
ATC Patient Days
Newborn Admissions
Newborn Patient Days
OPERATING EXPENSES:
Salaries
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Leases/Rentals
Insurance
Licenses & Taxes
Interest
Ins, Lic. & Taxes, and Interest
Bad Debt Expense
Other Direct Expense
Total Other Direct Expense
Total Expenses
DEDUCTIONS:
Contractuals
Charity Care
Other Deductions
Total Other Deductions
CHARITY CARE
# Of Patients
Inpatient
Outpatient
OTHER REVENUES:
Other Revenue
Tax Revenue
PATIENT SERVICE REVENUE:
IP Revenue
OP Revenue
Gross Revenue
FIXED ASSET ENDING BALANCES:
Land
Land Improvements
Buildings
Fixed Equip - Bldg Serv
Fixed Equip - Other
Equipment (Moveable)
Leasehold Improvements
Construction In Progress
Total
Accum Depre Ending Balance
Balance Sheet
FS-1 Assets
FS-1 Liabilities & Fund Balance
The actual operating expenses and units of measure are presented for the past two years in columns B-E.
The operating expenses per unit of measure are presented in columns F and G.
If the percentage change in operating expenses varies by more or less than 25 %, the variance appears in column H.
If the percentage change is more or less than 25%., please provide an explanation that is provided as an attachment with your
year end report submittal. Also please provide any corrections required to the prior years information.
Tri-State Memorial Hospital
6010 Intensive Care
6030 Semi-Intensive Care
6070 Acute Care
6100 Alternative Birthing Center
6120 Physical Rehabilitation
6140 Psychiatric Care
6150 Chemical Dependency
6170 Nursery
6200 Skilled Nursing
6210 Swing Beds
6330 Hospice Inpatient
6400 Other Daily Services
7010 Labor Delivery
7020 Surgical Services
7030 Recovery Room
7040 Anesthesiology
7050 Central Services
7060 Intravenous Therapy
7070 Laboratory
7110 Electrodiagnosis
7120 Magnetic Resonance Imaging
7130 Ct Scanning
7140 Radiology - Diagnostic
7150 Radiology - Therapeutic
7160 Nuclear Medicine
7170 Pharmacy
7180 Respiratory Therapy
7190 Dialysis
7200 Physical Therapy
7220 Psychiatric Day Care
7230 Emergency Room
7240 Ambulance
7250 Short Stay
7260 Clinics
7310 Occupational Therapy
7320 Speech Therapy
7330 Recreational Therapy
7340 Electromyography
7350 Observation Unit
7380 Free-Standing Clinics
7390 Air Transportation
7400 Home Care Services
7410 Lithotripsy
7420 Organ Transplants
7430 Outpatient Chem. Dep.
7490 Other Ancillary
8200 Research / Education
8310 Printing & Duplication
8320 Dietary
8330 Cafeteria
8350 Laundry & Linen
8360 Social Services
8370 Central Transportation
8420 Purchasing
8430 Plant
8460 Housekeeping
8470 Communication
8480 Data Processing
8490 Other General Services
8510 Accounting
8530 Patient Accounts
8560 Admitting
8590 Other Fiscal Services
8610 Hospital Administration
8620 Employee Health
8630 Public Relations
8640 Management Engineering
8650 Personnel
8660 Auxiliary Groups
8670 Chaplaincy Services
8680 Medical Library
8690 Medical Records
8700 Medical Staff
8710 Utilization Management
8720 Nursing Administration
8730 Nursing Float Personnel
8740 Inservice Education
8770 Comm. Health Education
8790 Other Admin. Services
8830-8900 Unassigned Other Direct
8430
8310
8510
8470
8610
8790
8630
8770
8640
8420
8320
8650
8620
8330
8460
8350
8200
8360
8370
8490
8530
8480
8560
8590
8660
8670
8680
8690
8700
8710
8720
8730
8740
6010
6030
6070
6100
6120
6140
6150
6170
6200
6210
6330
6400
7010
7020
7030
7040
7050
7060
7070
7110
7120
7130
7140
7150
7160
7170
7180
7190
7200
7220
7230
7240
7250
7260
7310
7320
7330
7340
7350
7380
7390
7400
7410
7420
7430
7490
The square footage statistic is provided for all cost centers including the plant and this way
square footage identified by cost center will total the gross square footage stated as the statistic in the plant cost center.
The operating expenses, the units of measure and the operating expenses per unit of measure are stated on line 484 thru line 568 in columns
B thru G. Increases or decreases in operating expenses per unit of measure exceeding 25% are stated in column H. Please submit an
attachment with the report that addresses why those changes took place. Also please provide any corrections that might be in order.
Your hospital license number and fiscal year end have already been entered. These items need to be in alpha format rather
than numeric format in order to pick up correctly for upload to the year end report database.
If you want to review what you reported for the prior year you can click on the tab titled prior year.
If you have any questions or concerns please call Randy Huyck at 360-236-4210 or send an e-mail to
To submit your report by electronic mail, please send to:
Please remember to send a signed certification page and an audited financial statement by regular mail when they are available.
It is only necessary to enter data on this page. Items will automatically transfer from this page to the report pages.
Employee Benefits
The employee benefits can be entered directly, assigned to the cost centers based on a percentage of salaries, or a combination of the two.
1) Enter the amount of employee benefits directly recorded in cell B47.
2) Enter the employee benefits directly recorded by cost center in cells C47..CC47.
3) Enter the total unassigned employee benefits that will be assigned based on salaries in cell B48.
Depreciation
The Depreciation can be entered directly, assigned by square footage, or a combination of the two.
1) Enter the total amount of depreciation directly assigned in cell B51.
2) Enter the amount of depreciation directly recorded by cost center in cells C51..CC51.
3) Enter the amount of depreciation that will be assigned by square footage in cell B52.
After the salaries and the departmental square footage statistics are entered, the departmental employee benefits and depreciation will be
calculated on lines 48 and 52, respectively.
7350 7380 7390 7400 7410 7420 7430
Observation Free-Standing Air Home Care Lithotripsy Organ Outpatient
Employee Benefits Unit Clinics Transportation Services Transplants Chem. Dep.
directly recorded
assigned based on salaries 0 0 0 144,330 0 0 0
total
Depreciation
depreciation directly recorded
depreciation based on sq. ft. 0 0 0 136,271 0 0 0
total
Account Number 7350 7380 7390 7400 7410 7420 7430
Account Observation Free-Standing Air Home Care Lithotripsy Organ Outpatient
Name Unit Clinics Transportation Services Transplants Chem. Dep.
Unit of Measure Description Hours Visits Occasions Visits Treatments Acquisitions Visits
Units of Measure 2,193 34 9,152
Full Time Equivalents 12.58
Salaries & Wages 606,609
Employee Benefits 0 0 0 144,330 0 0 0
Professional Fees 0
Supplies 89,231
Purch. Serv. - Utilities 12,097
Purch. Serv. - Other 17,877 227,535
Depreciation 0 0 0 136,271 0 0 0
Lease/Rental 41,470
Bad Debt Expense xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Other Direct Expenses 57,502
Recoveries
Total Adj Exp 0 0 17,877 1,315,045 0 0 0
Tax Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
IP Revenue 12,056 14,716
OP Revenue 111,432 1,372,360
Gross Revenue 123,488 0 14,716 1,372,360 0 0 0
Sq FT 4,464
Patient Meals Served
Housekeeping Hours of Service
Dry Pounds of Laundry
Nursing FTE's 7.21
YE-A HOSPITAL INFORMATION Page 1 of 2
Fiscal Year Ended
License Number
Hospital Name
Street Address
Mailing Address
City, State, Zip
County
Chief Executive Officer
Chief Financial Officer
Chair of Governing Board
Telephone Number
Facsimile Number
TYPE OF ORGANIZATION (If applies enter 1)
Governmental
State
County
District
Not For Profit
Church Operated
Other
For Profit
Individual
Partnership
Corporation
YE-A HOSPITAL INFORMATION Page 2 of 2
ACTUAL UTILIZATION
ICU, SICU, ACUTE, PSYCH
Skilled Nursing/Swing
Chemical Dependency/ATC
Number of Births
NUMBER OF BEDS AVAILABLE
Intensive Care
Semi-Intensive Care
Acute Care - Med/Surg
Acute Care - Pediatrics
Acute Care - Obstetrics
Acute Care - Rehab
Psychiatric
Skilled Nursing
Swing Beds
Chemical Dependency/ATC
Other (Exclude Nursery)
Total Beds Available
Total Beds Licensed
Nursery - Bassinets
SNF/SWING Ancillary Revenue
PAYER UNITS OF SERVICE AND REVENUE
HOSPITAL
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
SNF/SWING
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
ATC
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
HBP Component
HBP Component
SUPPORTING SCHEDULES
SS-2 EMPLOYEE BENEFITS
FICA Taxes
Unemployment Compensation
Workers Compensation
Group Health Insurance
Group Life Insurance
Pension & Retirement
Other Employee Benefits
Other Employee Benefits
Total
SS-3 RENTAL AND LEASE EXPENSE
Rental & Lease Exp - Bldgs
Rental & Lease Exp - Equip
Total
SS-5 INSURANCE EXPENSE
Hospital & Prof Malpractice
Other Insurance
Total
LICENSE AND TAXES
License Fees
Taxes (other than income)
Other
Total
SS-6 INTEREST EXPENSE
Interest Expense - WC
Interest Expense - Other
Total
SS-4 DEPRECIATION EXPENSE
FIXED ASSETS
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
ACCUMULATED DEPRECIATION
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
SS-8 DEDUCTIONS FROM REVENUE
Contractuals
Medicare
Medicaid
Workers Comp
Other Government Programs
Negotiated Rate
Other
Total Contractuals
Charity Care
Number of Charity Care Patients :
Inpatient Charity Care Provided
Outpatient Charity Care Provided
Total Charity Care Provided
Other Deductions
Administrative Adjustments
Other Deductions
Total Other Deductions
Total Deductions From Revenue
FS - 1 BALANCE SHEET (Assets)
CURRENT ASSETS:
Cash
Marketable Securities
Accounts Receivable
Less-Est. Uncoll. & Allow.
Rec. From 3rd Party Payers
Pledges & Other Receivables
Due From Restricted Funds
Inventory
Prepaid Expenses
Current Portion of FHT
Total Current Assets
BOARD DESIGNATED ASSETS
Cash
Marketable Securities
Other Assets
Total BDA
PROP, PLANT, & EQUIP
Land
Land Improvements
Buildings
Fixed Equip - Bldg Srv
Fixed Equip - Other
Equipment
Leasehold Improvements
Construction In Progress
Total P P & E
Less Accum. Depreciation
Net P P & E
INVESTMENTS & OTHER ASSETS
Investments In P P & E
Less - Accum Depre
Other Investments
Other Assets
Total Invest. & Other Assets
INTANGIBLE ASSETS
Goodwill
Unamortized Loan Costs
Preopening & Other Org Costs
Other Intangible Assets
Total Intangible Assets
Total Assets
FS - 1 BALANCE SHEET ( Liabilities)
CURRENT LIABILITIES
Notes and Loans Payable
Accounts Payable
Accrued Compensation
Other Accrued Expenses
Advances From 3rd Parties
Payables to 3rd Party Payers
Due to Restricted Funds
Income Taxes Payable
Other Current Liabilities
Current Maturities of LTD
Total Current Liabilities
DEFERRED CREDITS
Deferred Income Taxes
Deferred 3rd Party Revenue
Other Deferred Credits
Total Deferred Credits
LONG TERM DEBT
Mortgage Payable
Construction Loans - Interim
Notes Payable
Capitalized Lease Obligations
Bonds Payable
Notes and Loans Payable to Parent
Noncurrent Liabilities
Total
Less Current Maturities LTD
Total Long Term Debt
Unrestricted Fund Balance
Preferred Stock
Common Stock
Additional Paid In Capital
Retained Earnings
Less: Treasury Stock
Total Liab & Fund Bal or Equity
Check Figure Total Assets
FS - 3 STATEMENT OF REVENUE & EXPENSE
OPERATING REVENUE
Inpatient Revenue
Outpatient Revenue
Total Patient Services Revenue
DEDUCTIONS FROM REVENUE
Contractual Adjustments
Charity & Uncompensated Care
Other Adj. & Allowances
Total Deductions From Revenue
Net Patient Service Revenue
OTHER OPERATING REVENUE
Other Operating Revenue
Tax Revenues
Total Other Operating Rev
Total Operating Revenue
FS - 3 STATEMENT OF REVENUE & EXPENSE
Salaries and Wages
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Rentals/Leases
Insurance
License & Taxes
Interest
Provision for Bad Debts
Other Direct Expense
Total Operating Expenses
Net Operating Revenue
Non Operating Rev Net of Exp
Net Rev. Before Items Listed Below
Extraordinary Items
Federal Income Taxes
Net Revenue or (Expense)
Tri-State Memorial Hospital H-0 FYE 12/31/2010
VOLUME:
Hospital Admissions
Hospital Patient Days
SNF/Swing Admissions
SNF/Swing Patient Days
ATC Admissions
ATC Patient Days
Newborn Admissions
Newborn Patient Days
OPERATING EXPENSES:
Salaries
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Leases/Rentals
Insurance
Licenses & Taxes
Interest
Ins, Lic. & Taxes, and Interest
Bad Debt Expense
Other Direct Expense
Total Other Direct Expense
Total Expenses
DEDUCTIONS:
Contractuals
Charity Care
Other Deductions
Total Other Deductions
CHARITY CARE
# Of Patients
Inpatient
Outpatient
OTHER REVENUES:
Other Revenue
Tax Revenue
PATIENT SERVICE REVENUE:
IP Revenue
OP Revenue
Gross Revenue
FIXED ASSET ENDING BALANCES:
Land
Land Improvements
Buildings
Fixed Equip - Bldg Serv
Fixed Equip - Other
Equipment (Moveable)
Leasehold Improvements
Construction In Progress
Total
Accum Depre Ending Balance
Balance Sheet
FS-1 Assets
FS-1 Liabilities & Fund Balance
The actual operating expenses and units of measure are presented for the past two years in columns B-E.
The operating expenses per unit of measure are presented in columns F and G.
If the percentage change in operating expenses varies by more or less than 25 %, the variance appears in column H.
If the percentage change is more or less than 25%., please provide an explanation that is provided as an attachment with your
year end report submittal. Also please provide any corrections required to the prior years information.
Tri-State Memorial Hospital
6010 Intensive Care
6030 Semi-Intensive Care
6070 Acute Care
6100 Alternative Birthing Center
6120 Physical Rehabilitation
6140 Psychiatric Care
6150 Chemical Dependency
6170 Nursery
6200 Skilled Nursing
6210 Swing Beds
6330 Hospice Inpatient
6400 Other Daily Services
7010 Labor Delivery
7020 Surgical Services
7030 Recovery Room
7040 Anesthesiology
7050 Central Services
7060 Intravenous Therapy
7070 Laboratory
7110 Electrodiagnosis
7120 Magnetic Resonance Imaging
7130 Ct Scanning
7140 Radiology - Diagnostic
7150 Radiology - Therapeutic
7160 Nuclear Medicine
7170 Pharmacy
7180 Respiratory Therapy
7190 Dialysis
7200 Physical Therapy
7220 Psychiatric Day Care
7230 Emergency Room
7240 Ambulance
7250 Short Stay
7260 Clinics
7310 Occupational Therapy
7320 Speech Therapy
7330 Recreational Therapy
7340 Electromyography
7350 Observation Unit
7380 Free-Standing Clinics
7390 Air Transportation
7400 Home Care Services
7410 Lithotripsy
7420 Organ Transplants
7430 Outpatient Chem. Dep.
7490 Other Ancillary
8200 Research / Education
8310 Printing & Duplication
8320 Dietary
8330 Cafeteria
8350 Laundry & Linen
8360 Social Services
8370 Central Transportation
8420 Purchasing
8430 Plant
8460 Housekeeping
8470 Communication
8480 Data Processing
8490 Other General Services
8510 Accounting
8530 Patient Accounts
8560 Admitting
8590 Other Fiscal Services
8610 Hospital Administration
8620 Employee Health
8630 Public Relations
8640 Management Engineering
8650 Personnel
8660 Auxiliary Groups
8670 Chaplaincy Services
8680 Medical Library
8690 Medical Records
8700 Medical Staff
8710 Utilization Management
8720 Nursing Administration
8730 Nursing Float Personnel
8740 Inservice Education
8770 Comm. Health Education
8790 Other Admin. Services
8830-8900 Unassigned Other Direct
8430
8310
8510
8470
8610
8790
8630
8770
8640
8420
8320
8650
8620
8330
8460
8350
8200
8360
8370
8490
8530
8480
8560
8590
8660
8670
8680
8690
8700
8710
8720
8730
8740
6010
6030
6070
6100
6120
6140
6150
6170
6200
6210
6330
6400
7010
7020
7030
7040
7050
7060
7070
7110
7120
7130
7140
7150
7160
7170
7180
7190
7200
7220
7230
7240
7250
7260
7310
7320
7330
7340
7350
7380
7390
7400
7410
7420
7430
7490
The square footage statistic is provided for all cost centers including the plant and this way
square footage identified by cost center will total the gross square footage stated as the statistic in the plant cost center.
The operating expenses, the units of measure and the operating expenses per unit of measure are stated on line 484 thru line 568 in columns
B thru G. Increases or decreases in operating expenses per unit of measure exceeding 25% are stated in column H. Please submit an
attachment with the report that addresses why those changes took place. Also please provide any corrections that might be in order.
Your hospital license number and fiscal year end have already been entered. These items need to be in alpha format rather
than numeric format in order to pick up correctly for upload to the year end report database.
If you want to review what you reported for the prior year you can click on the tab titled prior year.
If you have any questions or concerns please call Randy Huyck at 360-236-4210 or send an e-mail to
To submit your report by electronic mail, please send to:
Please remember to send a signed certification page and an audited financial statement by regular mail when they are available.
It is only necessary to enter data on this page. Items will automatically transfer from this page to the report pages.
Employee Benefits
The employee benefits can be entered directly, assigned to the cost centers based on a percentage of salaries, or a combination of the two.
1) Enter the amount of employee benefits directly recorded in cell B47.
2) Enter the employee benefits directly recorded by cost center in cells C47..CC47.
3) Enter the total unassigned employee benefits that will be assigned based on salaries in cell B48.
Depreciation
The Depreciation can be entered directly, assigned by square footage, or a combination of the two.
1) Enter the total amount of depreciation directly assigned in cell B51.
2) Enter the amount of depreciation directly recorded by cost center in cells C51..CC51.
3) Enter the amount of depreciation that will be assigned by square footage in cell B52.
After the salaries and the departmental square footage statistics are entered, the departmental employee benefits and depreciation will be
calculated on lines 48 and 52, respectively.
7490 8200 8310 8320 8330 8350 8360
Other Research/Education Printing & Dietary Cafeteria Laundry & Social
Employee Benefits Ancillary Costs Duplication Linen Services
directly recorded
assigned based on salaries 52,081 0 0 124,810 0 376 0
total
Depreciation
depreciation directly recorded
depreciation based on sq. ft. 0 0 0 102,783 0 0 12,699
total
Account Number 7490 8200 8310 8320 8330 8350 8360
Account Other Research/Education Printing & Dietary Cafeteria Laundry & Social
Name Ancillary Costs Duplication Linen Services
Unit of Measure Description xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx Patient Meals Patient Meals xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Units of Measure 24,703 160,650
Full Time Equivalents 16.08 0.06
Salaries & Wages 218,892 524,566 1,580
Employee Benefits 52,081 0 0 124,810 0 376 0
Professional Fees 12,000
Supplies 55,683 340,872 260
Purch. Serv. - Utilities 1,444
Purch. Serv. - Other 1,462 4,352 195,791
Depreciation 0 0 0 102,783 0 0 12,699
Lease/Rental 18,680
Bad Debt Expense xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Other Direct Expenses 15,240 25
Recoveries
Total Adj Exp 358,798 0 0 1,112,623 0 197,747 14,428
Tax Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
IP Revenue 112,077 xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
OP Revenue 1,284,471 xxxxxxxxxxxxxx xxxxxxxxxxxxxx 5,388 xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Gross Revenue 1,396,548 xxxxxxxxxxxxxx xxxxxxxxxxxxxx 5,388 xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Sq FT 3,367 416
Patient Meals Served xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Housekeeping Hours of Service xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Dry Pounds of Laundry 429 xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Nursing FTE's xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
YE-A HOSPITAL INFORMATION Page 1 of 2
Fiscal Year Ended
License Number
Hospital Name
Street Address
Mailing Address
City, State, Zip
County
Chief Executive Officer
Chief Financial Officer
Chair of Governing Board
Telephone Number
Facsimile Number
TYPE OF ORGANIZATION (If applies enter 1)
Governmental
State
County
District
Not For Profit
Church Operated
Other
For Profit
Individual
Partnership
Corporation
YE-A HOSPITAL INFORMATION Page 2 of 2
ACTUAL UTILIZATION
ICU, SICU, ACUTE, PSYCH
Skilled Nursing/Swing
Chemical Dependency/ATC
Number of Births
NUMBER OF BEDS AVAILABLE
Intensive Care
Semi-Intensive Care
Acute Care - Med/Surg
Acute Care - Pediatrics
Acute Care - Obstetrics
Acute Care - Rehab
Psychiatric
Skilled Nursing
Swing Beds
Chemical Dependency/ATC
Other (Exclude Nursery)
Total Beds Available
Total Beds Licensed
Nursery - Bassinets
SNF/SWING Ancillary Revenue
PAYER UNITS OF SERVICE AND REVENUE
HOSPITAL
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
SNF/SWING
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
ATC
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
HBP Component
HBP Component
SUPPORTING SCHEDULES
SS-2 EMPLOYEE BENEFITS
FICA Taxes
Unemployment Compensation
Workers Compensation
Group Health Insurance
Group Life Insurance
Pension & Retirement
Other Employee Benefits
Other Employee Benefits
Total
SS-3 RENTAL AND LEASE EXPENSE
Rental & Lease Exp - Bldgs
Rental & Lease Exp - Equip
Total
SS-5 INSURANCE EXPENSE
Hospital & Prof Malpractice
Other Insurance
Total
LICENSE AND TAXES
License Fees
Taxes (other than income)
Other
Total
SS-6 INTEREST EXPENSE
Interest Expense - WC
Interest Expense - Other
Total
SS-4 DEPRECIATION EXPENSE
FIXED ASSETS
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
ACCUMULATED DEPRECIATION
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
SS-8 DEDUCTIONS FROM REVENUE
Contractuals
Medicare
Medicaid
Workers Comp
Other Government Programs
Negotiated Rate
Other
Total Contractuals
Charity Care
Number of Charity Care Patients :
Inpatient Charity Care Provided
Outpatient Charity Care Provided
Total Charity Care Provided
Other Deductions
Administrative Adjustments
Other Deductions
Total Other Deductions
Total Deductions From Revenue
FS - 1 BALANCE SHEET (Assets)
CURRENT ASSETS:
Cash
Marketable Securities
Accounts Receivable
Less-Est. Uncoll. & Allow.
Rec. From 3rd Party Payers
Pledges & Other Receivables
Due From Restricted Funds
Inventory
Prepaid Expenses
Current Portion of FHT
Total Current Assets
BOARD DESIGNATED ASSETS
Cash
Marketable Securities
Other Assets
Total BDA
PROP, PLANT, & EQUIP
Land
Land Improvements
Buildings
Fixed Equip - Bldg Srv
Fixed Equip - Other
Equipment
Leasehold Improvements
Construction In Progress
Total P P & E
Less Accum. Depreciation
Net P P & E
INVESTMENTS & OTHER ASSETS
Investments In P P & E
Less - Accum Depre
Other Investments
Other Assets
Total Invest. & Other Assets
INTANGIBLE ASSETS
Goodwill
Unamortized Loan Costs
Preopening & Other Org Costs
Other Intangible Assets
Total Intangible Assets
Total Assets
FS - 1 BALANCE SHEET ( Liabilities)
CURRENT LIABILITIES
Notes and Loans Payable
Accounts Payable
Accrued Compensation
Other Accrued Expenses
Advances From 3rd Parties
Payables to 3rd Party Payers
Due to Restricted Funds
Income Taxes Payable
Other Current Liabilities
Current Maturities of LTD
Total Current Liabilities
DEFERRED CREDITS
Deferred Income Taxes
Deferred 3rd Party Revenue
Other Deferred Credits
Total Deferred Credits
LONG TERM DEBT
Mortgage Payable
Construction Loans - Interim
Notes Payable
Capitalized Lease Obligations
Bonds Payable
Notes and Loans Payable to Parent
Noncurrent Liabilities
Total
Less Current Maturities LTD
Total Long Term Debt
Unrestricted Fund Balance
Preferred Stock
Common Stock
Additional Paid In Capital
Retained Earnings
Less: Treasury Stock
Total Liab & Fund Bal or Equity
Check Figure Total Assets
FS - 3 STATEMENT OF REVENUE & EXPENSE
OPERATING REVENUE
Inpatient Revenue
Outpatient Revenue
Total Patient Services Revenue
DEDUCTIONS FROM REVENUE
Contractual Adjustments
Charity & Uncompensated Care
Other Adj. & Allowances
Total Deductions From Revenue
Net Patient Service Revenue
OTHER OPERATING REVENUE
Other Operating Revenue
Tax Revenues
Total Other Operating Rev
Total Operating Revenue
FS - 3 STATEMENT OF REVENUE & EXPENSE
Salaries and Wages
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Rentals/Leases
Insurance
License & Taxes
Interest
Provision for Bad Debts
Other Direct Expense
Total Operating Expenses
Net Operating Revenue
Non Operating Rev Net of Exp
Net Rev. Before Items Listed Below
Extraordinary Items
Federal Income Taxes
Net Revenue or (Expense)
Tri-State Memorial Hospital H-0 FYE 12/31/2010
VOLUME:
Hospital Admissions
Hospital Patient Days
SNF/Swing Admissions
SNF/Swing Patient Days
ATC Admissions
ATC Patient Days
Newborn Admissions
Newborn Patient Days
OPERATING EXPENSES:
Salaries
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Leases/Rentals
Insurance
Licenses & Taxes
Interest
Ins, Lic. & Taxes, and Interest
Bad Debt Expense
Other Direct Expense
Total Other Direct Expense
Total Expenses
DEDUCTIONS:
Contractuals
Charity Care
Other Deductions
Total Other Deductions
CHARITY CARE
# Of Patients
Inpatient
Outpatient
OTHER REVENUES:
Other Revenue
Tax Revenue
PATIENT SERVICE REVENUE:
IP Revenue
OP Revenue
Gross Revenue
FIXED ASSET ENDING BALANCES:
Land
Land Improvements
Buildings
Fixed Equip - Bldg Serv
Fixed Equip - Other
Equipment (Moveable)
Leasehold Improvements
Construction In Progress
Total
Accum Depre Ending Balance
Balance Sheet
FS-1 Assets
FS-1 Liabilities & Fund Balance
The actual operating expenses and units of measure are presented for the past two years in columns B-E.
The operating expenses per unit of measure are presented in columns F and G.
If the percentage change in operating expenses varies by more or less than 25 %, the variance appears in column H.
If the percentage change is more or less than 25%., please provide an explanation that is provided as an attachment with your
year end report submittal. Also please provide any corrections required to the prior years information.
Tri-State Memorial Hospital
6010 Intensive Care
6030 Semi-Intensive Care
6070 Acute Care
6100 Alternative Birthing Center
6120 Physical Rehabilitation
6140 Psychiatric Care
6150 Chemical Dependency
6170 Nursery
6200 Skilled Nursing
6210 Swing Beds
6330 Hospice Inpatient
6400 Other Daily Services
7010 Labor Delivery
7020 Surgical Services
7030 Recovery Room
7040 Anesthesiology
7050 Central Services
7060 Intravenous Therapy
7070 Laboratory
7110 Electrodiagnosis
7120 Magnetic Resonance Imaging
7130 Ct Scanning
7140 Radiology - Diagnostic
7150 Radiology - Therapeutic
7160 Nuclear Medicine
7170 Pharmacy
7180 Respiratory Therapy
7190 Dialysis
7200 Physical Therapy
7220 Psychiatric Day Care
7230 Emergency Room
7240 Ambulance
7250 Short Stay
7260 Clinics
7310 Occupational Therapy
7320 Speech Therapy
7330 Recreational Therapy
7340 Electromyography
7350 Observation Unit
7380 Free-Standing Clinics
7390 Air Transportation
7400 Home Care Services
7410 Lithotripsy
7420 Organ Transplants
7430 Outpatient Chem. Dep.
7490 Other Ancillary
8200 Research / Education
8310 Printing & Duplication
8320 Dietary
8330 Cafeteria
8350 Laundry & Linen
8360 Social Services
8370 Central Transportation
8420 Purchasing
8430 Plant
8460 Housekeeping
8470 Communication
8480 Data Processing
8490 Other General Services
8510 Accounting
8530 Patient Accounts
8560 Admitting
8590 Other Fiscal Services
8610 Hospital Administration
8620 Employee Health
8630 Public Relations
8640 Management Engineering
8650 Personnel
8660 Auxiliary Groups
8670 Chaplaincy Services
8680 Medical Library
8690 Medical Records
8700 Medical Staff
8710 Utilization Management
8720 Nursing Administration
8730 Nursing Float Personnel
8740 Inservice Education
8770 Comm. Health Education
8790 Other Admin. Services
8830-8900 Unassigned Other Direct
8430
8310
8510
8470
8610
8790
8630
8770
8640
8420
8320
8650
8620
8330
8460
8350
8200
8360
8370
8490
8530
8480
8560
8590
8660
8670
8680
8690
8700
8710
8720
8730
8740
6010
6030
6070
6100
6120
6140
6150
6170
6200
6210
6330
6400
7010
7020
7030
7040
7050
7060
7070
7110
7120
7130
7140
7150
7160
7170
7180
7190
7200
7220
7230
7240
7250
7260
7310
7320
7330
7340
7350
7380
7390
7400
7410
7420
7430
7490
The square footage statistic is provided for all cost centers including the plant and this way
square footage identified by cost center will total the gross square footage stated as the statistic in the plant cost center.
The operating expenses, the units of measure and the operating expenses per unit of measure are stated on line 484 thru line 568 in columns
B thru G. Increases or decreases in operating expenses per unit of measure exceeding 25% are stated in column H. Please submit an
attachment with the report that addresses why those changes took place. Also please provide any corrections that might be in order.
Your hospital license number and fiscal year end have already been entered. These items need to be in alpha format rather
than numeric format in order to pick up correctly for upload to the year end report database.
If you want to review what you reported for the prior year you can click on the tab titled prior year.
If you have any questions or concerns please call Randy Huyck at 360-236-4210 or send an e-mail to
To submit your report by electronic mail, please send to:
Please remember to send a signed certification page and an audited financial statement by regular mail when they are available.
It is only necessary to enter data on this page. Items will automatically transfer from this page to the report pages.
Employee Benefits
The employee benefits can be entered directly, assigned to the cost centers based on a percentage of salaries, or a combination of the two.
1) Enter the amount of employee benefits directly recorded in cell B47.
2) Enter the employee benefits directly recorded by cost center in cells C47..CC47.
3) Enter the total unassigned employee benefits that will be assigned based on salaries in cell B48.
Depreciation
The Depreciation can be entered directly, assigned by square footage, or a combination of the two.
1) Enter the total amount of depreciation directly assigned in cell B51.
2) Enter the amount of depreciation directly recorded by cost center in cells C51..CC51.
3) Enter the amount of depreciation that will be assigned by square footage in cell B52.
After the salaries and the departmental square footage statistics are entered, the departmental employee benefits and depreciation will be
calculated on lines 48 and 52, respectively.
8370 8420 8430 8460 8470 8480 8490
Central Purchasing Plant Housekeeping Communication Data Other General
Employee Benefits Transportation Processing Services
directly recorded
assigned based on salaries 0 58,389 68,973 97,227 0 24,251 7,727
total
Depreciation
depreciation directly recorded
depreciation based on sq. ft. 0 100,249 152,908 44,294 0 0 0
total
Account Number 8370 8420 8430 8460 8470 8480 8490
Account Central Purchasing Plant Housekeeping Communication Data Other General
Name Transportation Processing Services
Unit of Measure Description xxxxxxxxxxxxxx xxxxxxxxxxxxxx Gross Sq Ft xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Units of Measure 105,115
Full Time Equivalents 7.05 5.65 14.73 2.14
Salaries & Wages 245,403 289,889 408,636 101,927 32,474
Employee Benefits 0 58,389 68,973 97,227 0 24,251 7,727
Professional Fees
Supplies 5,188 112,513 72,871 6,529 1,432
Purch. Serv. - Utilities 460,831 2,132 95,042 561,804
Purch. Serv. - Other 153,061 28,119 650
Depreciation 0 100,249 152,908 44,294 0 0 0
Lease/Rental 359 4,655
Bad Debt Expense xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxx
Other Direct Expenses 3,078 7,645 760 46,990 3,429 3,429
Recoveries
Total Adj Exp 0 412,666 1,245,820 654,039 142,032 698,590 49,717
Tax Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
IP Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
OP Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Gross Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Sq FT 3,284 5,009 1,451
Patient Meals Served xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Housekeeping Hours of Service xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx 1,158
Dry Pounds of Laundry xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Nursing FTE's xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
YE-A HOSPITAL INFORMATION Page 1 of 2
Fiscal Year Ended
License Number
Hospital Name
Street Address
Mailing Address
City, State, Zip
County
Chief Executive Officer
Chief Financial Officer
Chair of Governing Board
Telephone Number
Facsimile Number
TYPE OF ORGANIZATION (If applies enter 1)
Governmental
State
County
District
Not For Profit
Church Operated
Other
For Profit
Individual
Partnership
Corporation
YE-A HOSPITAL INFORMATION Page 2 of 2
ACTUAL UTILIZATION
ICU, SICU, ACUTE, PSYCH
Skilled Nursing/Swing
Chemical Dependency/ATC
Number of Births
NUMBER OF BEDS AVAILABLE
Intensive Care
Semi-Intensive Care
Acute Care - Med/Surg
Acute Care - Pediatrics
Acute Care - Obstetrics
Acute Care - Rehab
Psychiatric
Skilled Nursing
Swing Beds
Chemical Dependency/ATC
Other (Exclude Nursery)
Total Beds Available
Total Beds Licensed
Nursery - Bassinets
SNF/SWING Ancillary Revenue
PAYER UNITS OF SERVICE AND REVENUE
HOSPITAL
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
SNF/SWING
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
ATC
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
HBP Component
HBP Component
SUPPORTING SCHEDULES
SS-2 EMPLOYEE BENEFITS
FICA Taxes
Unemployment Compensation
Workers Compensation
Group Health Insurance
Group Life Insurance
Pension & Retirement
Other Employee Benefits
Other Employee Benefits
Total
SS-3 RENTAL AND LEASE EXPENSE
Rental & Lease Exp - Bldgs
Rental & Lease Exp - Equip
Total
SS-5 INSURANCE EXPENSE
Hospital & Prof Malpractice
Other Insurance
Total
LICENSE AND TAXES
License Fees
Taxes (other than income)
Other
Total
SS-6 INTEREST EXPENSE
Interest Expense - WC
Interest Expense - Other
Total
SS-4 DEPRECIATION EXPENSE
FIXED ASSETS
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
ACCUMULATED DEPRECIATION
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
SS-8 DEDUCTIONS FROM REVENUE
Contractuals
Medicare
Medicaid
Workers Comp
Other Government Programs
Negotiated Rate
Other
Total Contractuals
Charity Care
Number of Charity Care Patients :
Inpatient Charity Care Provided
Outpatient Charity Care Provided
Total Charity Care Provided
Other Deductions
Administrative Adjustments
Other Deductions
Total Other Deductions
Total Deductions From Revenue
FS - 1 BALANCE SHEET (Assets)
CURRENT ASSETS:
Cash
Marketable Securities
Accounts Receivable
Less-Est. Uncoll. & Allow.
Rec. From 3rd Party Payers
Pledges & Other Receivables
Due From Restricted Funds
Inventory
Prepaid Expenses
Current Portion of FHT
Total Current Assets
BOARD DESIGNATED ASSETS
Cash
Marketable Securities
Other Assets
Total BDA
PROP, PLANT, & EQUIP
Land
Land Improvements
Buildings
Fixed Equip - Bldg Srv
Fixed Equip - Other
Equipment
Leasehold Improvements
Construction In Progress
Total P P & E
Less Accum. Depreciation
Net P P & E
INVESTMENTS & OTHER ASSETS
Investments In P P & E
Less - Accum Depre
Other Investments
Other Assets
Total Invest. & Other Assets
INTANGIBLE ASSETS
Goodwill
Unamortized Loan Costs
Preopening & Other Org Costs
Other Intangible Assets
Total Intangible Assets
Total Assets
FS - 1 BALANCE SHEET ( Liabilities)
CURRENT LIABILITIES
Notes and Loans Payable
Accounts Payable
Accrued Compensation
Other Accrued Expenses
Advances From 3rd Parties
Payables to 3rd Party Payers
Due to Restricted Funds
Income Taxes Payable
Other Current Liabilities
Current Maturities of LTD
Total Current Liabilities
DEFERRED CREDITS
Deferred Income Taxes
Deferred 3rd Party Revenue
Other Deferred Credits
Total Deferred Credits
LONG TERM DEBT
Mortgage Payable
Construction Loans - Interim
Notes Payable
Capitalized Lease Obligations
Bonds Payable
Notes and Loans Payable to Parent
Noncurrent Liabilities
Total
Less Current Maturities LTD
Total Long Term Debt
Unrestricted Fund Balance
Preferred Stock
Common Stock
Additional Paid In Capital
Retained Earnings
Less: Treasury Stock
Total Liab & Fund Bal or Equity
Check Figure Total Assets
FS - 3 STATEMENT OF REVENUE & EXPENSE
OPERATING REVENUE
Inpatient Revenue
Outpatient Revenue
Total Patient Services Revenue
DEDUCTIONS FROM REVENUE
Contractual Adjustments
Charity & Uncompensated Care
Other Adj. & Allowances
Total Deductions From Revenue
Net Patient Service Revenue
OTHER OPERATING REVENUE
Other Operating Revenue
Tax Revenues
Total Other Operating Rev
Total Operating Revenue
FS - 3 STATEMENT OF REVENUE & EXPENSE
Salaries and Wages
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Rentals/Leases
Insurance
License & Taxes
Interest
Provision for Bad Debts
Other Direct Expense
Total Operating Expenses
Net Operating Revenue
Non Operating Rev Net of Exp
Net Rev. Before Items Listed Below
Extraordinary Items
Federal Income Taxes
Net Revenue or (Expense)
Tri-State Memorial Hospital H-0 FYE 12/31/2010
VOLUME:
Hospital Admissions
Hospital Patient Days
SNF/Swing Admissions
SNF/Swing Patient Days
ATC Admissions
ATC Patient Days
Newborn Admissions
Newborn Patient Days
OPERATING EXPENSES:
Salaries
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Leases/Rentals
Insurance
Licenses & Taxes
Interest
Ins, Lic. & Taxes, and Interest
Bad Debt Expense
Other Direct Expense
Total Other Direct Expense
Total Expenses
DEDUCTIONS:
Contractuals
Charity Care
Other Deductions
Total Other Deductions
CHARITY CARE
# Of Patients
Inpatient
Outpatient
OTHER REVENUES:
Other Revenue
Tax Revenue
PATIENT SERVICE REVENUE:
IP Revenue
OP Revenue
Gross Revenue
FIXED ASSET ENDING BALANCES:
Land
Land Improvements
Buildings
Fixed Equip - Bldg Serv
Fixed Equip - Other
Equipment (Moveable)
Leasehold Improvements
Construction In Progress
Total
Accum Depre Ending Balance
Balance Sheet
FS-1 Assets
FS-1 Liabilities & Fund Balance
The actual operating expenses and units of measure are presented for the past two years in columns B-E.
The operating expenses per unit of measure are presented in columns F and G.
If the percentage change in operating expenses varies by more or less than 25 %, the variance appears in column H.
If the percentage change is more or less than 25%., please provide an explanation that is provided as an attachment with your
year end report submittal. Also please provide any corrections required to the prior years information.
Tri-State Memorial Hospital
6010 Intensive Care
6030 Semi-Intensive Care
6070 Acute Care
6100 Alternative Birthing Center
6120 Physical Rehabilitation
6140 Psychiatric Care
6150 Chemical Dependency
6170 Nursery
6200 Skilled Nursing
6210 Swing Beds
6330 Hospice Inpatient
6400 Other Daily Services
7010 Labor Delivery
7020 Surgical Services
7030 Recovery Room
7040 Anesthesiology
7050 Central Services
7060 Intravenous Therapy
7070 Laboratory
7110 Electrodiagnosis
7120 Magnetic Resonance Imaging
7130 Ct Scanning
7140 Radiology - Diagnostic
7150 Radiology - Therapeutic
7160 Nuclear Medicine
7170 Pharmacy
7180 Respiratory Therapy
7190 Dialysis
7200 Physical Therapy
7220 Psychiatric Day Care
7230 Emergency Room
7240 Ambulance
7250 Short Stay
7260 Clinics
7310 Occupational Therapy
7320 Speech Therapy
7330 Recreational Therapy
7340 Electromyography
7350 Observation Unit
7380 Free-Standing Clinics
7390 Air Transportation
7400 Home Care Services
7410 Lithotripsy
7420 Organ Transplants
7430 Outpatient Chem. Dep.
7490 Other Ancillary
8200 Research / Education
8310 Printing & Duplication
8320 Dietary
8330 Cafeteria
8350 Laundry & Linen
8360 Social Services
8370 Central Transportation
8420 Purchasing
8430 Plant
8460 Housekeeping
8470 Communication
8480 Data Processing
8490 Other General Services
8510 Accounting
8530 Patient Accounts
8560 Admitting
8590 Other Fiscal Services
8610 Hospital Administration
8620 Employee Health
8630 Public Relations
8640 Management Engineering
8650 Personnel
8660 Auxiliary Groups
8670 Chaplaincy Services
8680 Medical Library
8690 Medical Records
8700 Medical Staff
8710 Utilization Management
8720 Nursing Administration
8730 Nursing Float Personnel
8740 Inservice Education
8770 Comm. Health Education
8790 Other Admin. Services
8830-8900 Unassigned Other Direct
8430
8310
8510
8470
8610
8790
8630
8770
8640
8420
8320
8650
8620
8330
8460
8350
8200
8360
8370
8490
8530
8480
8560
8590
8660
8670
8680
8690
8700
8710
8720
8730
8740
6010
6030
6070
6100
6120
6140
6150
6170
6200
6210
6330
6400
7010
7020
7030
7040
7050
7060
7070
7110
7120
7130
7140
7150
7160
7170
7180
7190
7200
7220
7230
7240
7250
7260
7310
7320
7330
7340
7350
7380
7390
7400
7410
7420
7430
7490
The square footage statistic is provided for all cost centers including the plant and this way
square footage identified by cost center will total the gross square footage stated as the statistic in the plant cost center.
The operating expenses, the units of measure and the operating expenses per unit of measure are stated on line 484 thru line 568 in columns
B thru G. Increases or decreases in operating expenses per unit of measure exceeding 25% are stated in column H. Please submit an
attachment with the report that addresses why those changes took place. Also please provide any corrections that might be in order.
Your hospital license number and fiscal year end have already been entered. These items need to be in alpha format rather
than numeric format in order to pick up correctly for upload to the year end report database.
If you want to review what you reported for the prior year you can click on the tab titled prior year.
If you have any questions or concerns please call Randy Huyck at 360-236-4210 or send an e-mail to
To submit your report by electronic mail, please send to:
Please remember to send a signed certification page and an audited financial statement by regular mail when they are available.
It is only necessary to enter data on this page. Items will automatically transfer from this page to the report pages.
Employee Benefits
The employee benefits can be entered directly, assigned to the cost centers based on a percentage of salaries, or a combination of the two.
1) Enter the amount of employee benefits directly recorded in cell B47.
2) Enter the employee benefits directly recorded by cost center in cells C47..CC47.
3) Enter the total unassigned employee benefits that will be assigned based on salaries in cell B48.
Depreciation
The Depreciation can be entered directly, assigned by square footage, or a combination of the two.
1) Enter the total amount of depreciation directly assigned in cell B51.
2) Enter the amount of depreciation directly recorded by cost center in cells C51..CC51.
3) Enter the amount of depreciation that will be assigned by square footage in cell B52.
After the salaries and the departmental square footage statistics are entered, the departmental employee benefits and depreciation will be
calculated on lines 48 and 52, respectively.
8510 8530 8560 8590 8610 8620 8630
Accounting Patient Admitting Other Hospital Employee Public
Employee Benefits Accounts Fiscal Svcs Administration Health Relations
directly recorded
assigned based on salaries 68,122 0 78,949 96,810 67,610 0 17,233
total
Depreciation
depreciation directly recorded
depreciation based on sq. ft. 0 83,124 16,515 0 179,252 0 102,539
total
Account Number 8510 8530 8560 8590 8610 8620 8630
Account Accounting Patient Admitting Other Hospital Employee Public
Name Accounts Fiscal Svcs Administration Health Relations
Unit of Measure Description xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Units of Measure
Full Time Equivalents 4.72 12.00 10.72 3.00 3.17
Salaries & Wages 286,313 331,818 406,886 284,161 72,430
Employee Benefits 68,122 0 78,949 96,810 67,610 0 17,233
Professional Fees 116,971 108,301 155,652
Supplies 10,373 16,633 68,428 18,902 8,986 1,410
Purch. Serv. - Utilities 5,518
Purch. Serv. - Other 47,172 3,294 3,813 974 5,987 144,847
Depreciation 0 83,124 16,515 0 179,252 0 102,539
Lease/Rental 2,576 415 58,067 7,171
Bad Debt Expense xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Other Direct Expenses 5,342 5,920 5,487 311,823 63,697
Recoveries
Total Adj Exp 536,869 89,044 453,111 742,305 1,031,063 14,973 402,156
Tax Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
IP Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
OP Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Gross Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Sq FT 2,723 541 5,872 3,359
Patient Meals Served xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Housekeeping Hours of Service xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Dry Pounds of Laundry xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Nursing FTE's xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
YE-A HOSPITAL INFORMATION Page 1 of 2
Fiscal Year Ended
License Number
Hospital Name
Street Address
Mailing Address
City, State, Zip
County
Chief Executive Officer
Chief Financial Officer
Chair of Governing Board
Telephone Number
Facsimile Number
TYPE OF ORGANIZATION (If applies enter 1)
Governmental
State
County
District
Not For Profit
Church Operated
Other
For Profit
Individual
Partnership
Corporation
YE-A HOSPITAL INFORMATION Page 2 of 2
ACTUAL UTILIZATION
ICU, SICU, ACUTE, PSYCH
Skilled Nursing/Swing
Chemical Dependency/ATC
Number of Births
NUMBER OF BEDS AVAILABLE
Intensive Care
Semi-Intensive Care
Acute Care - Med/Surg
Acute Care - Pediatrics
Acute Care - Obstetrics
Acute Care - Rehab
Psychiatric
Skilled Nursing
Swing Beds
Chemical Dependency/ATC
Other (Exclude Nursery)
Total Beds Available
Total Beds Licensed
Nursery - Bassinets
SNF/SWING Ancillary Revenue
PAYER UNITS OF SERVICE AND REVENUE
HOSPITAL
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
SNF/SWING
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
ATC
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
HBP Component
HBP Component
SUPPORTING SCHEDULES
SS-2 EMPLOYEE BENEFITS
FICA Taxes
Unemployment Compensation
Workers Compensation
Group Health Insurance
Group Life Insurance
Pension & Retirement
Other Employee Benefits
Other Employee Benefits
Total
SS-3 RENTAL AND LEASE EXPENSE
Rental & Lease Exp - Bldgs
Rental & Lease Exp - Equip
Total
SS-5 INSURANCE EXPENSE
Hospital & Prof Malpractice
Other Insurance
Total
LICENSE AND TAXES
License Fees
Taxes (other than income)
Other
Total
SS-6 INTEREST EXPENSE
Interest Expense - WC
Interest Expense - Other
Total
SS-4 DEPRECIATION EXPENSE
FIXED ASSETS
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
ACCUMULATED DEPRECIATION
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
SS-8 DEDUCTIONS FROM REVENUE
Contractuals
Medicare
Medicaid
Workers Comp
Other Government Programs
Negotiated Rate
Other
Total Contractuals
Charity Care
Number of Charity Care Patients :
Inpatient Charity Care Provided
Outpatient Charity Care Provided
Total Charity Care Provided
Other Deductions
Administrative Adjustments
Other Deductions
Total Other Deductions
Total Deductions From Revenue
FS - 1 BALANCE SHEET (Assets)
CURRENT ASSETS:
Cash
Marketable Securities
Accounts Receivable
Less-Est. Uncoll. & Allow.
Rec. From 3rd Party Payers
Pledges & Other Receivables
Due From Restricted Funds
Inventory
Prepaid Expenses
Current Portion of FHT
Total Current Assets
BOARD DESIGNATED ASSETS
Cash
Marketable Securities
Other Assets
Total BDA
PROP, PLANT, & EQUIP
Land
Land Improvements
Buildings
Fixed Equip - Bldg Srv
Fixed Equip - Other
Equipment
Leasehold Improvements
Construction In Progress
Total P P & E
Less Accum. Depreciation
Net P P & E
INVESTMENTS & OTHER ASSETS
Investments In P P & E
Less - Accum Depre
Other Investments
Other Assets
Total Invest. & Other Assets
INTANGIBLE ASSETS
Goodwill
Unamortized Loan Costs
Preopening & Other Org Costs
Other Intangible Assets
Total Intangible Assets
Total Assets
FS - 1 BALANCE SHEET ( Liabilities)
CURRENT LIABILITIES
Notes and Loans Payable
Accounts Payable
Accrued Compensation
Other Accrued Expenses
Advances From 3rd Parties
Payables to 3rd Party Payers
Due to Restricted Funds
Income Taxes Payable
Other Current Liabilities
Current Maturities of LTD
Total Current Liabilities
DEFERRED CREDITS
Deferred Income Taxes
Deferred 3rd Party Revenue
Other Deferred Credits
Total Deferred Credits
LONG TERM DEBT
Mortgage Payable
Construction Loans - Interim
Notes Payable
Capitalized Lease Obligations
Bonds Payable
Notes and Loans Payable to Parent
Noncurrent Liabilities
Total
Less Current Maturities LTD
Total Long Term Debt
Unrestricted Fund Balance
Preferred Stock
Common Stock
Additional Paid In Capital
Retained Earnings
Less: Treasury Stock
Total Liab & Fund Bal or Equity
Check Figure Total Assets
FS - 3 STATEMENT OF REVENUE & EXPENSE
OPERATING REVENUE
Inpatient Revenue
Outpatient Revenue
Total Patient Services Revenue
DEDUCTIONS FROM REVENUE
Contractual Adjustments
Charity & Uncompensated Care
Other Adj. & Allowances
Total Deductions From Revenue
Net Patient Service Revenue
OTHER OPERATING REVENUE
Other Operating Revenue
Tax Revenues
Total Other Operating Rev
Total Operating Revenue
FS - 3 STATEMENT OF REVENUE & EXPENSE
Salaries and Wages
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Rentals/Leases
Insurance
License & Taxes
Interest
Provision for Bad Debts
Other Direct Expense
Total Operating Expenses
Net Operating Revenue
Non Operating Rev Net of Exp
Net Rev. Before Items Listed Below
Extraordinary Items
Federal Income Taxes
Net Revenue or (Expense)
Tri-State Memorial Hospital H-0 FYE 12/31/2010
VOLUME:
Hospital Admissions
Hospital Patient Days
SNF/Swing Admissions
SNF/Swing Patient Days
ATC Admissions
ATC Patient Days
Newborn Admissions
Newborn Patient Days
OPERATING EXPENSES:
Salaries
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Leases/Rentals
Insurance
Licenses & Taxes
Interest
Ins, Lic. & Taxes, and Interest
Bad Debt Expense
Other Direct Expense
Total Other Direct Expense
Total Expenses
DEDUCTIONS:
Contractuals
Charity Care
Other Deductions
Total Other Deductions
CHARITY CARE
# Of Patients
Inpatient
Outpatient
OTHER REVENUES:
Other Revenue
Tax Revenue
PATIENT SERVICE REVENUE:
IP Revenue
OP Revenue
Gross Revenue
FIXED ASSET ENDING BALANCES:
Land
Land Improvements
Buildings
Fixed Equip - Bldg Serv
Fixed Equip - Other
Equipment (Moveable)
Leasehold Improvements
Construction In Progress
Total
Accum Depre Ending Balance
Balance Sheet
FS-1 Assets
FS-1 Liabilities & Fund Balance
The actual operating expenses and units of measure are presented for the past two years in columns B-E.
The operating expenses per unit of measure are presented in columns F and G.
If the percentage change in operating expenses varies by more or less than 25 %, the variance appears in column H.
If the percentage change is more or less than 25%., please provide an explanation that is provided as an attachment with your
year end report submittal. Also please provide any corrections required to the prior years information.
Tri-State Memorial Hospital
6010 Intensive Care
6030 Semi-Intensive Care
6070 Acute Care
6100 Alternative Birthing Center
6120 Physical Rehabilitation
6140 Psychiatric Care
6150 Chemical Dependency
6170 Nursery
6200 Skilled Nursing
6210 Swing Beds
6330 Hospice Inpatient
6400 Other Daily Services
7010 Labor Delivery
7020 Surgical Services
7030 Recovery Room
7040 Anesthesiology
7050 Central Services
7060 Intravenous Therapy
7070 Laboratory
7110 Electrodiagnosis
7120 Magnetic Resonance Imaging
7130 Ct Scanning
7140 Radiology - Diagnostic
7150 Radiology - Therapeutic
7160 Nuclear Medicine
7170 Pharmacy
7180 Respiratory Therapy
7190 Dialysis
7200 Physical Therapy
7220 Psychiatric Day Care
7230 Emergency Room
7240 Ambulance
7250 Short Stay
7260 Clinics
7310 Occupational Therapy
7320 Speech Therapy
7330 Recreational Therapy
7340 Electromyography
7350 Observation Unit
7380 Free-Standing Clinics
7390 Air Transportation
7400 Home Care Services
7410 Lithotripsy
7420 Organ Transplants
7430 Outpatient Chem. Dep.
7490 Other Ancillary
8200 Research / Education
8310 Printing & Duplication
8320 Dietary
8330 Cafeteria
8350 Laundry & Linen
8360 Social Services
8370 Central Transportation
8420 Purchasing
8430 Plant
8460 Housekeeping
8470 Communication
8480 Data Processing
8490 Other General Services
8510 Accounting
8530 Patient Accounts
8560 Admitting
8590 Other Fiscal Services
8610 Hospital Administration
8620 Employee Health
8630 Public Relations
8640 Management Engineering
8650 Personnel
8660 Auxiliary Groups
8670 Chaplaincy Services
8680 Medical Library
8690 Medical Records
8700 Medical Staff
8710 Utilization Management
8720 Nursing Administration
8730 Nursing Float Personnel
8740 Inservice Education
8770 Comm. Health Education
8790 Other Admin. Services
8830-8900 Unassigned Other Direct
8430
8310
8510
8470
8610
8790
8630
8770
8640
8420
8320
8650
8620
8330
8460
8350
8200
8360
8370
8490
8530
8480
8560
8590
8660
8670
8680
8690
8700
8710
8720
8730
8740
6010
6030
6070
6100
6120
6140
6150
6170
6200
6210
6330
6400
7010
7020
7030
7040
7050
7060
7070
7110
7120
7130
7140
7150
7160
7170
7180
7190
7200
7220
7230
7240
7250
7260
7310
7320
7330
7340
7350
7380
7390
7400
7410
7420
7430
7490
The square footage statistic is provided for all cost centers including the plant and this way
square footage identified by cost center will total the gross square footage stated as the statistic in the plant cost center.
The operating expenses, the units of measure and the operating expenses per unit of measure are stated on line 484 thru line 568 in columns
B thru G. Increases or decreases in operating expenses per unit of measure exceeding 25% are stated in column H. Please submit an
attachment with the report that addresses why those changes took place. Also please provide any corrections that might be in order.
Your hospital license number and fiscal year end have already been entered. These items need to be in alpha format rather
than numeric format in order to pick up correctly for upload to the year end report database.
If you want to review what you reported for the prior year you can click on the tab titled prior year.
If you have any questions or concerns please call Randy Huyck at 360-236-4210 or send an e-mail to
To submit your report by electronic mail, please send to:
Please remember to send a signed certification page and an audited financial statement by regular mail when they are available.
It is only necessary to enter data on this page. Items will automatically transfer from this page to the report pages.
Employee Benefits
The employee benefits can be entered directly, assigned to the cost centers based on a percentage of salaries, or a combination of the two.
1) Enter the amount of employee benefits directly recorded in cell B47.
2) Enter the employee benefits directly recorded by cost center in cells C47..CC47.
3) Enter the total unassigned employee benefits that will be assigned based on salaries in cell B48.
Depreciation
The Depreciation can be entered directly, assigned by square footage, or a combination of the two.
1) Enter the total amount of depreciation directly assigned in cell B51.
2) Enter the amount of depreciation directly recorded by cost center in cells C51..CC51.
3) Enter the amount of depreciation that will be assigned by square footage in cell B52.
After the salaries and the departmental square footage statistics are entered, the departmental employee benefits and depreciation will be
calculated on lines 48 and 52, respectively.
8640 8650 8660 8670 8680 8690 8700
Management Personnel Auxiliary Chaplaincy Medical Medical Medical
Employee Benefits Engineering Groups Services Library Records Staff
directly recorded
assigned based on salaries 0 42,534 0 0 0 143,690 4,177
total
Depreciation
depreciation directly recorded
depreciation based on sq. ft. 0 0 0 0 0 40,448 0
total
Account Number 8640 8650 8660 8670 8680 8690 8700
Account Management Personnel Auxiliary Chaplaincy Medical Medical Medical
Name Engineering Groups Services Library Records Staff
Unit of Measure Description xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Units of Measure
Full Time Equivalents 2.73 16.71 0.34
Salaries & Wages 178,765 603,919 17,556
Employee Benefits 0 42,534 0 0 0 143,690 4,177
Professional Fees
Supplies 8,639 10,338 109
Purch. Serv. - Utilities
Purch. Serv. - Other 70,763 2,696 3,077
Depreciation 0 0 0 0 40,448
0 0
Lease/Rental 36,396
Bad Debt Expense xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Other Direct Expenses 9,472 9,978 5,017
Recoveries
Total Adj Exp 0 310,173 0 0 0 847,465 29,936
Tax Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
IP Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
OP Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Gross Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Sq FT 1,325
Patient Meals Served xxxxxxxxxxxxxx
Housekeeping Hours of Service xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Dry Pounds of Laundry xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Nursing FTE's xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
YE-A HOSPITAL INFORMATION Page 1 of 2
Fiscal Year Ended
License Number
Hospital Name
Street Address
Mailing Address
City, State, Zip
County
Chief Executive Officer
Chief Financial Officer
Chair of Governing Board
Telephone Number
Facsimile Number
TYPE OF ORGANIZATION (If applies enter 1)
Governmental
State
County
District
Not For Profit
Church Operated
Other
For Profit
Individual
Partnership
Corporation
YE-A HOSPITAL INFORMATION Page 2 of 2
ACTUAL UTILIZATION
ICU, SICU, ACUTE, PSYCH
Skilled Nursing/Swing
Chemical Dependency/ATC
Number of Births
NUMBER OF BEDS AVAILABLE
Intensive Care
Semi-Intensive Care
Acute Care - Med/Surg
Acute Care - Pediatrics
Acute Care - Obstetrics
Acute Care - Rehab
Psychiatric
Skilled Nursing
Swing Beds
Chemical Dependency/ATC
Other (Exclude Nursery)
Total Beds Available
Total Beds Licensed
Nursery - Bassinets
SNF/SWING Ancillary Revenue
PAYER UNITS OF SERVICE AND REVENUE
HOSPITAL
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
SNF/SWING
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
ATC
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
HBP Component
HBP Component
SUPPORTING SCHEDULES
SS-2 EMPLOYEE BENEFITS
FICA Taxes
Unemployment Compensation
Workers Compensation
Group Health Insurance
Group Life Insurance
Pension & Retirement
Other Employee Benefits
Other Employee Benefits
Total
SS-3 RENTAL AND LEASE EXPENSE
Rental & Lease Exp - Bldgs
Rental & Lease Exp - Equip
Total
SS-5 INSURANCE EXPENSE
Hospital & Prof Malpractice
Other Insurance
Total
LICENSE AND TAXES
License Fees
Taxes (other than income)
Other
Total
SS-6 INTEREST EXPENSE
Interest Expense - WC
Interest Expense - Other
Total
SS-4 DEPRECIATION EXPENSE
FIXED ASSETS
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
ACCUMULATED DEPRECIATION
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
SS-8 DEDUCTIONS FROM REVENUE
Contractuals
Medicare
Medicaid
Workers Comp
Other Government Programs
Negotiated Rate
Other
Total Contractuals
Charity Care
Number of Charity Care Patients :
Inpatient Charity Care Provided
Outpatient Charity Care Provided
Total Charity Care Provided
Other Deductions
Administrative Adjustments
Other Deductions
Total Other Deductions
Total Deductions From Revenue
FS - 1 BALANCE SHEET (Assets)
CURRENT ASSETS:
Cash
Marketable Securities
Accounts Receivable
Less-Est. Uncoll. & Allow.
Rec. From 3rd Party Payers
Pledges & Other Receivables
Due From Restricted Funds
Inventory
Prepaid Expenses
Current Portion of FHT
Total Current Assets
BOARD DESIGNATED ASSETS
Cash
Marketable Securities
Other Assets
Total BDA
PROP, PLANT, & EQUIP
Land
Land Improvements
Buildings
Fixed Equip - Bldg Srv
Fixed Equip - Other
Equipment
Leasehold Improvements
Construction In Progress
Total P P & E
Less Accum. Depreciation
Net P P & E
INVESTMENTS & OTHER ASSETS
Investments In P P & E
Less - Accum Depre
Other Investments
Other Assets
Total Invest. & Other Assets
INTANGIBLE ASSETS
Goodwill
Unamortized Loan Costs
Preopening & Other Org Costs
Other Intangible Assets
Total Intangible Assets
Total Assets
FS - 1 BALANCE SHEET ( Liabilities)
CURRENT LIABILITIES
Notes and Loans Payable
Accounts Payable
Accrued Compensation
Other Accrued Expenses
Advances From 3rd Parties
Payables to 3rd Party Payers
Due to Restricted Funds
Income Taxes Payable
Other Current Liabilities
Current Maturities of LTD
Total Current Liabilities
DEFERRED CREDITS
Deferred Income Taxes
Deferred 3rd Party Revenue
Other Deferred Credits
Total Deferred Credits
LONG TERM DEBT
Mortgage Payable
Construction Loans - Interim
Notes Payable
Capitalized Lease Obligations
Bonds Payable
Notes and Loans Payable to Parent
Noncurrent Liabilities
Total
Less Current Maturities LTD
Total Long Term Debt
Unrestricted Fund Balance
Preferred Stock
Common Stock
Additional Paid In Capital
Retained Earnings
Less: Treasury Stock
Total Liab & Fund Bal or Equity
Check Figure Total Assets
FS - 3 STATEMENT OF REVENUE & EXPENSE
OPERATING REVENUE
Inpatient Revenue
Outpatient Revenue
Total Patient Services Revenue
DEDUCTIONS FROM REVENUE
Contractual Adjustments
Charity & Uncompensated Care
Other Adj. & Allowances
Total Deductions From Revenue
Net Patient Service Revenue
OTHER OPERATING REVENUE
Other Operating Revenue
Tax Revenues
Total Other Operating Rev
Total Operating Revenue
FS - 3 STATEMENT OF REVENUE & EXPENSE
Salaries and Wages
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Rentals/Leases
Insurance
License & Taxes
Interest
Provision for Bad Debts
Other Direct Expense
Total Operating Expenses
Net Operating Revenue
Non Operating Rev Net of Exp
Net Rev. Before Items Listed Below
Extraordinary Items
Federal Income Taxes
Net Revenue or (Expense)
Tri-State Memorial Hospital H-0 FYE 12/31/2010
VOLUME:
Hospital Admissions
Hospital Patient Days
SNF/Swing Admissions
SNF/Swing Patient Days
ATC Admissions
ATC Patient Days
Newborn Admissions
Newborn Patient Days
OPERATING EXPENSES:
Salaries
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Leases/Rentals
Insurance
Licenses & Taxes
Interest
Ins, Lic. & Taxes, and Interest
Bad Debt Expense
Other Direct Expense
Total Other Direct Expense
Total Expenses
DEDUCTIONS:
Contractuals
Charity Care
Other Deductions
Total Other Deductions
CHARITY CARE
# Of Patients
Inpatient
Outpatient
OTHER REVENUES:
Other Revenue
Tax Revenue
PATIENT SERVICE REVENUE:
IP Revenue
OP Revenue
Gross Revenue
FIXED ASSET ENDING BALANCES:
Land
Land Improvements
Buildings
Fixed Equip - Bldg Serv
Fixed Equip - Other
Equipment (Moveable)
Leasehold Improvements
Construction In Progress
Total
Accum Depre Ending Balance
Balance Sheet
FS-1 Assets
FS-1 Liabilities & Fund Balance
The actual operating expenses and units of measure are presented for the past two years in columns B-E.
The operating expenses per unit of measure are presented in columns F and G.
If the percentage change in operating expenses varies by more or less than 25 %, the variance appears in column H.
If the percentage change is more or less than 25%., please provide an explanation that is provided as an attachment with your
year end report submittal. Also please provide any corrections required to the prior years information.
Tri-State Memorial Hospital
6010 Intensive Care
6030 Semi-Intensive Care
6070 Acute Care
6100 Alternative Birthing Center
6120 Physical Rehabilitation
6140 Psychiatric Care
6150 Chemical Dependency
6170 Nursery
6200 Skilled Nursing
6210 Swing Beds
6330 Hospice Inpatient
6400 Other Daily Services
7010 Labor Delivery
7020 Surgical Services
7030 Recovery Room
7040 Anesthesiology
7050 Central Services
7060 Intravenous Therapy
7070 Laboratory
7110 Electrodiagnosis
7120 Magnetic Resonance Imaging
7130 Ct Scanning
7140 Radiology - Diagnostic
7150 Radiology - Therapeutic
7160 Nuclear Medicine
7170 Pharmacy
7180 Respiratory Therapy
7190 Dialysis
7200 Physical Therapy
7220 Psychiatric Day Care
7230 Emergency Room
7240 Ambulance
7250 Short Stay
7260 Clinics
7310 Occupational Therapy
7320 Speech Therapy
7330 Recreational Therapy
7340 Electromyography
7350 Observation Unit
7380 Free-Standing Clinics
7390 Air Transportation
7400 Home Care Services
7410 Lithotripsy
7420 Organ Transplants
7430 Outpatient Chem. Dep.
7490 Other Ancillary
8200 Research / Education
8310 Printing & Duplication
8320 Dietary
8330 Cafeteria
8350 Laundry & Linen
8360 Social Services
8370 Central Transportation
8420 Purchasing
8430 Plant
8460 Housekeeping
8470 Communication
8480 Data Processing
8490 Other General Services
8510 Accounting
8530 Patient Accounts
8560 Admitting
8590 Other Fiscal Services
8610 Hospital Administration
8620 Employee Health
8630 Public Relations
8640 Management Engineering
8650 Personnel
8660 Auxiliary Groups
8670 Chaplaincy Services
8680 Medical Library
8690 Medical Records
8700 Medical Staff
8710 Utilization Management
8720 Nursing Administration
8730 Nursing Float Personnel
8740 Inservice Education
8770 Comm. Health Education
8790 Other Admin. Services
8830-8900 Unassigned Other Direct
8430
8310
8510
8470
8610
8790
8630
8770
8640
8420
8320
8650
8620
8330
8460
8350
8200
8360
8370
8490
8530
8480
8560
8590
8660
8670
8680
8690
8700
8710
8720
8730
8740
6010
6030
6070
6100
6120
6140
6150
6170
6200
6210
6330
6400
7010
7020
7030
7040
7050
7060
7070
7110
7120
7130
7140
7150
7160
7170
7180
7190
7200
7220
7230
7240
7250
7260
7310
7320
7330
7340
7350
7380
7390
7400
7410
7420
7430
7490
The square footage statistic is provided for all cost centers including the plant and this way
square footage identified by cost center will total the gross square footage stated as the statistic in the plant cost center.
The operating expenses, the units of measure and the operating expenses per unit of measure are stated on line 484 thru line 568 in columns
B thru G. Increases or decreases in operating expenses per unit of measure exceeding 25% are stated in column H. Please submit an
attachment with the report that addresses why those changes took place. Also please provide any corrections that might be in order.
Your hospital license number and fiscal year end have already been entered. These items need to be in alpha format rather
than numeric format in order to pick up correctly for upload to the year end report database.
If you want to review what you reported for the prior year you can click on the tab titled prior year.
If you have any questions or concerns please call Randy Huyck at 360-236-4210 or send an e-mail to
To submit your report by electronic mail, please send to:
Please remember to send a signed certification page and an audited financial statement by regular mail when they are available.
It is only necessary to enter data on this page. Items will automatically transfer from this page to the report pages.
Employee Benefits
The employee benefits can be entered directly, assigned to the cost centers based on a percentage of salaries, or a combination of the two.
1) Enter the amount of employee benefits directly recorded in cell B47.
2) Enter the employee benefits directly recorded by cost center in cells C47..CC47.
3) Enter the total unassigned employee benefits that will be assigned based on salaries in cell B48.
Depreciation
The Depreciation can be entered directly, assigned by square footage, or a combination of the two.
1) Enter the total amount of depreciation directly assigned in cell B51.
2) Enter the amount of depreciation directly recorded by cost center in cells C51..CC51.
3) Enter the amount of depreciation that will be assigned by square footage in cell B52.
After the salaries and the departmental square footage statistics are entered, the departmental employee benefits and depreciation will be
calculated on lines 48 and 52, respectively.
8710 8720 8730 8740 8770 8790 8830-8900
Utilization Nursing Nursing Float Inservice Comm. Health Other
Employee Benefits Management Administration Personnel Education Education Admin Services
directly recorded
assigned based on salaries 34,489 64,737 0 8,221 12,034 0
total
Depreciation
depreciation directly recorded
depreciation based on sq. ft. 0 0 0 0 0 548,503
total
Account Number 8710 8720 8730 8740 8770 8790 8830-8900
Account Utilization Nursing Nursing Float Inservice Comm. Health Other Unassigned
Name Management Administration Personnel Education Education Admin Services Other Direct
Unit of Measure Description xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Units of Measure
Full Time Equivalents 4.05 1.07 xxxxxxxxxxxxxx
Salaries & Wages 144,953 272,086 34,553 50,576 xxxxxxxxxxxxxx
Employee Benefits 34,489 64,737 0 8,221 12,034 0 xxxxxxxxxxxxxx
Professional Fees xxxxxxxxxxxxxx
Supplies 6,175 6,329 17,627 (216)
Purch. Serv. - Utilities 63 651 xxxxxxxxxxxxxx
Purch. Serv. - Other 711 xxxxxxxxxxxxxx
Depreciation 0 0 0 0 0 548,503 xxxxxxxxxxxxxx
Lease/Rental 245 146,113
Bad Debt Expense xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx 1,425,100
Other Direct Expenses 23,223 3,230 678,496 1,398,751
Recoveries 1,208,147
Total Adj Exp 186,391 367,271 0 63,631 62,610 1,226,999 1,615,704
Tax Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
IP Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
OP Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Gross Revenue xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Sq FT 17,968 xxxxxxxxxxxxxx
Patient Meals Served xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Housekeeping Hours of Service xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Dry Pounds of Laundry xxxxxxxxxxxxxx xxxxxxxxxxxxxx
Nursing FTE's xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxx
YE-A HOSPITAL INFORMATION Page 1 of 2
Fiscal Year Ended
License Number
Hospital Name
Street Address
Mailing Address
City, State, Zip
County
Chief Executive Officer
Chief Financial Officer
Chair of Governing Board
Telephone Number
Facsimile Number
TYPE OF ORGANIZATION (If applies enter 1)
Governmental
State
County
District
Not For Profit
Church Operated
Other
For Profit
Individual
Partnership
Corporation
YE-A HOSPITAL INFORMATION Page 2 of 2
ACTUAL UTILIZATION
ICU, SICU, ACUTE, PSYCH
Skilled Nursing/Swing
Chemical Dependency/ATC
Number of Births
NUMBER OF BEDS AVAILABLE
Intensive Care
Semi-Intensive Care
Acute Care - Med/Surg
Acute Care - Pediatrics
Acute Care - Obstetrics
Acute Care - Rehab
Psychiatric
Skilled Nursing
Swing Beds
Chemical Dependency/ATC
Other (Exclude Nursery)
Total Beds Available
Total Beds Licensed
Nursery - Bassinets
SNF/SWING Ancillary Revenue
PAYER UNITS OF SERVICE AND REVENUE
HOSPITAL
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
SNF/SWING
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
ATC
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
HBP Component
HBP Component
SUPPORTING SCHEDULES
SS-2 EMPLOYEE BENEFITS
FICA Taxes
Unemployment Compensation
Workers Compensation
Group Health Insurance
Group Life Insurance
Pension & Retirement
Other Employee Benefits
Other Employee Benefits
Total
SS-3 RENTAL AND LEASE EXPENSE
Rental & Lease Exp - Bldgs
Rental & Lease Exp - Equip
Total
SS-5 INSURANCE EXPENSE
Hospital & Prof Malpractice
Other Insurance
Total
LICENSE AND TAXES
License Fees
Taxes (other than income)
Other
Total
SS-6 INTEREST EXPENSE
Interest Expense - WC
Interest Expense - Other
Total
SS-4 DEPRECIATION EXPENSE
FIXED ASSETS
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
ACCUMULATED DEPRECIATION
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
SS-8 DEDUCTIONS FROM REVENUE
Contractuals
Medicare
Medicaid
Workers Comp
Other Government Programs
Negotiated Rate
Other
Total Contractuals
Charity Care
Number of Charity Care Patients :
Inpatient Charity Care Provided
Outpatient Charity Care Provided
Total Charity Care Provided
Other Deductions
Administrative Adjustments
Other Deductions
Total Other Deductions
Total Deductions From Revenue
FS - 1 BALANCE SHEET (Assets)
CURRENT ASSETS:
Cash
Marketable Securities
Accounts Receivable
Less-Est. Uncoll. & Allow.
Rec. From 3rd Party Payers
Pledges & Other Receivables
Due From Restricted Funds
Inventory
Prepaid Expenses
Current Portion of FHT
Total Current Assets
BOARD DESIGNATED ASSETS
Cash
Marketable Securities
Other Assets
Total BDA
PROP, PLANT, & EQUIP
Land
Land Improvements
Buildings
Fixed Equip - Bldg Srv
Fixed Equip - Other
Equipment
Leasehold Improvements
Construction In Progress
Total P P & E
Less Accum. Depreciation
Net P P & E
INVESTMENTS & OTHER ASSETS
Investments In P P & E
Less - Accum Depre
Other Investments
Other Assets
Total Invest. & Other Assets
INTANGIBLE ASSETS
Goodwill
Unamortized Loan Costs
Preopening & Other Org Costs
Other Intangible Assets
Total Intangible Assets
Total Assets
FS - 1 BALANCE SHEET ( Liabilities)
CURRENT LIABILITIES
Notes and Loans Payable
Accounts Payable
Accrued Compensation
Other Accrued Expenses
Advances From 3rd Parties
Payables to 3rd Party Payers
Due to Restricted Funds
Income Taxes Payable
Other Current Liabilities
Current Maturities of LTD
Total Current Liabilities
DEFERRED CREDITS
Deferred Income Taxes
Deferred 3rd Party Revenue
Other Deferred Credits
Total Deferred Credits
LONG TERM DEBT
Mortgage Payable
Construction Loans - Interim
Notes Payable
Capitalized Lease Obligations
Bonds Payable
Notes and Loans Payable to Parent
Noncurrent Liabilities
Total
Less Current Maturities LTD
Total Long Term Debt
Unrestricted Fund Balance
Preferred Stock
Common Stock
Additional Paid In Capital
Retained Earnings
Less: Treasury Stock
Total Liab & Fund Bal or Equity
Check Figure Total Assets
FS - 3 STATEMENT OF REVENUE & EXPENSE
OPERATING REVENUE
Inpatient Revenue
Outpatient Revenue
Total Patient Services Revenue
DEDUCTIONS FROM REVENUE
Contractual Adjustments
Charity & Uncompensated Care
Other Adj. & Allowances
Total Deductions From Revenue
Net Patient Service Revenue
OTHER OPERATING REVENUE
Other Operating Revenue
Tax Revenues
Total Other Operating Rev
Total Operating Revenue
FS - 3 STATEMENT OF REVENUE & EXPENSE
Salaries and Wages
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Rentals/Leases
Insurance
License & Taxes
Interest
Provision for Bad Debts
Other Direct Expense
Total Operating Expenses
Net Operating Revenue
Non Operating Rev Net of Exp
Net Rev. Before Items Listed Below
Extraordinary Items
Federal Income Taxes
Net Revenue or (Expense)
Tri-State Memorial Hospital H-0 FYE 12/31/2010
VOLUME:
Hospital Admissions
Hospital Patient Days
SNF/Swing Admissions
SNF/Swing Patient Days
ATC Admissions
ATC Patient Days
Newborn Admissions
Newborn Patient Days
OPERATING EXPENSES:
Salaries
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Leases/Rentals
Insurance
Licenses & Taxes
Interest
Ins, Lic. & Taxes, and Interest
Bad Debt Expense
Other Direct Expense
Total Other Direct Expense
Total Expenses
DEDUCTIONS:
Contractuals
Charity Care
Other Deductions
Total Other Deductions
CHARITY CARE
# Of Patients
Inpatient
Outpatient
OTHER REVENUES:
Other Revenue
Tax Revenue
PATIENT SERVICE REVENUE:
IP Revenue
OP Revenue
Gross Revenue
FIXED ASSET ENDING BALANCES:
Land
Land Improvements
Buildings
Fixed Equip - Bldg Serv
Fixed Equip - Other
Equipment (Moveable)
Leasehold Improvements
Construction In Progress
Total
Accum Depre Ending Balance
Balance Sheet
FS-1 Assets
FS-1 Liabilities & Fund Balance
The actual operating expenses and units of measure are presented for the past two years in columns B-E.
The operating expenses per unit of measure are presented in columns F and G.
If the percentage change in operating expenses varies by more or less than 25 %, the variance appears in column H.
If the percentage change is more or less than 25%., please provide an explanation that is provided as an attachment with your
year end report submittal. Also please provide any corrections required to the prior years information.
Tri-State Memorial Hospital
6010 Intensive Care
6030 Semi-Intensive Care
6070 Acute Care
6100 Alternative Birthing Center
6120 Physical Rehabilitation
6140 Psychiatric Care
6150 Chemical Dependency
6170 Nursery
6200 Skilled Nursing
6210 Swing Beds
6330 Hospice Inpatient
6400 Other Daily Services
7010 Labor Delivery
7020 Surgical Services
7030 Recovery Room
7040 Anesthesiology
7050 Central Services
7060 Intravenous Therapy
7070 Laboratory
7110 Electrodiagnosis
7120 Magnetic Resonance Imaging
7130 Ct Scanning
7140 Radiology - Diagnostic
7150 Radiology - Therapeutic
7160 Nuclear Medicine
7170 Pharmacy
7180 Respiratory Therapy
7190 Dialysis
7200 Physical Therapy
7220 Psychiatric Day Care
7230 Emergency Room
7240 Ambulance
7250 Short Stay
7260 Clinics
7310 Occupational Therapy
7320 Speech Therapy
7330 Recreational Therapy
7340 Electromyography
7350 Observation Unit
7380 Free-Standing Clinics
7390 Air Transportation
7400 Home Care Services
7410 Lithotripsy
7420 Organ Transplants
7430 Outpatient Chem. Dep.
7490 Other Ancillary
8200 Research / Education
8310 Printing & Duplication
8320 Dietary
8330 Cafeteria
8350 Laundry & Linen
8360 Social Services
8370 Central Transportation
8420 Purchasing
8430 Plant
8460 Housekeeping
8470 Communication
8480 Data Processing
8490 Other General Services
8510 Accounting
8530 Patient Accounts
8560 Admitting
8590 Other Fiscal Services
8610 Hospital Administration
8620 Employee Health
8630 Public Relations
8640 Management Engineering
8650 Personnel
8660 Auxiliary Groups
8670 Chaplaincy Services
8680 Medical Library
8690 Medical Records
8700 Medical Staff
8710 Utilization Management
8720 Nursing Administration
8730 Nursing Float Personnel
8740 Inservice Education
8770 Comm. Health Education
8790 Other Admin. Services
8830-8900 Unassigned Other Direct
8430
8310
8510
8470
8610
8790
8630
8770
8640
8420
8320
8650
8620
8330
8460
8350
8200
8360
8370
8490
8530
8480
8560
8590
8660
8670
8680
8690
8700
8710
8720
8730
8740
6010
6030
6070
6100
6120
6140
6150
6170
6200
6210
6330
6400
7010
7020
7030
7040
7050
7060
7070
7110
7120
7130
7140
7150
7160
7170
7180
7190
7200
7220
7230
7240
7250
7260
7310
7320
7330
7340
7350
7380
7390
7400
7410
7420
7430
7490
The square footage statistic is provided for all cost centers including the plant and this way
square footage identified by cost center will total the gross square footage stated as the statistic in the plant cost cente
The operating expenses, the units of measure and the operating expenses per unit of measure are stated on line 484
B thru G. Increases or decreases in operating expenses per unit of measure exceeding 25% are stated in column H.
attachment with the report that addresses why those changes took place. Also please provide any corrections that mi
Your hospital license number and fiscal year end have already been entered. These items need to be in alpha format
than numeric format in order to pick up correctly for upload to the year end report database.
If you want to review what you reported for the prior year you can click on the tab titled prior year.
If you have any questions or concerns please call Randy Huyck at 360-236-4210 or send an e-mail to
To submit your report by electronic mail, please send to:
Please remember to send a signed certification page and an audited financial statement by regular mail when they are
It is only necessary to enter data on this page. Items will automatically transfer from this page to the report pages.
Employee Benefits
The employee benefits can be entered directly, assigned to the cost centers based on a percentage of salaries, or a c
1) Enter the amount of employee benefits directly recorded in cell B47.
2) Enter the employee benefits directly recorded by cost center in cells C47..CC47.
3) Enter the total unassigned employee benefits that will be assigned based on salaries in cell B48.
Depreciation
The Depreciation can be entered directly, assigned by square footage, or a combination of the two.
1) Enter the total amount of depreciation directly assigned in cell B51.
2) Enter the amount of depreciation directly recorded by cost center in cells C51..CC51.
3) Enter the amount of depreciation that will be assigned by square footage in cell B52.
After the salaries and the departmental square footage statistics are entered, the departmental employee benefits and
calculated on lines 48 and 52, respectively.
9999
Grand
Employee Benefits Total
directly recorded 0
assigned based on salaries 4,027,959
total
Depreciation
depreciation directly recorded 0
depreciation based on sq. ft. 3,208,805
total
Account Number 9999
Account Grand
Name Total
Unit of Measure Description xxxxxxxxxxxxxx
Units of Measure
Full Time Equivalents 334.67
Salaries & Wages 16,929,192
Employee Benefits 4,027,959
Professional Fees 4,325,622
Supplies 13,393,812
Purch. Serv. - Utilities 1,184,338
Purch. Serv. - Other 4,286,094
Depreciation 3,208,805
Lease/Rental 619,918
Bad Debt Expense 1,425,100
Other Direct Expenses 2,886,166
Recoveries 1,208,147
Total Adj Exp 51,078,859
Tax Revenue
IP Revenue 32,983,940
OP Revenue 56,758,225
Gross Revenue 89,742,165
Sq FT 105,115 (0)
Patient Meals Served 24,703 0
Housekeeping Hours of Service 24,685
Dry Pounds of Laundry 6,161 0
Nursing FTE's 99.49
YE-A HOSPITAL INFORMATION Page 1 of 2
Fiscal Year Ended
License Number
Hospital Name
Street Address
Mailing Address
City, State, Zip
County
Chief Executive Officer
Chief Financial Officer
Chair of Governing Board
Telephone Number
Facsimile Number
TYPE OF ORGANIZATION (If applies enter 1)
Governmental
State
County
District
Not For Profit
Church Operated
Other
For Profit
Individual
Partnership
Corporation
YE-A HOSPITAL INFORMATION Page 2 of 2
ACTUAL UTILIZATION
ICU, SICU, ACUTE, PSYCH
Skilled Nursing/Swing
Chemical Dependency/ATC
Number of Births
NUMBER OF BEDS AVAILABLE
Intensive Care
Semi-Intensive Care
Acute Care - Med/Surg
Acute Care - Pediatrics
Acute Care - Obstetrics
Acute Care - Rehab
Psychiatric
Skilled Nursing
Swing Beds
Chemical Dependency/ATC
Other (Exclude Nursery)
Total Beds Available
Total Beds Licensed
Nursery - Bassinets
SNF/SWING Ancillary Revenue
PAYER UNITS OF SERVICE AND REVENUE
HOSPITAL
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
SNF/SWING
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
ATC
Admissions
Patient Days
OP Visits
IP Revenue
OP Revenue
HBP Component
HBP Component
SUPPORTING SCHEDULES
SS-2 EMPLOYEE BENEFITS
FICA Taxes
Unemployment Compensation
Workers Compensation
Group Health Insurance
Group Life Insurance
Pension & Retirement
Other Employee Benefits
Other Employee Benefits
Total
SS-3 RENTAL AND LEASE EXPENSE
Rental & Lease Exp - Bldgs
Rental & Lease Exp - Equip
Total
SS-5 INSURANCE EXPENSE
Hospital & Prof Malpractice
Other Insurance
Total
LICENSE AND TAXES
License Fees
Taxes (other than income)
Other
Total
SS-6 INTEREST EXPENSE
Interest Expense - WC
Interest Expense - Other
Total
SS-4 DEPRECIATION EXPENSE
FIXED ASSETS
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
ACCUMULATED DEPRECIATION
Land
Land Improvements
Buildings
Fixed Equipment - Bldg Srv
Fixed Equipment - Other
Equip - Major Moveable
Equip - Minor
Leasehold Improvements
Construction In Progress
Total
SS-8 DEDUCTIONS FROM REVENUE
Contractuals
Medicare
Medicaid
Workers Comp
Other Government Programs
Negotiated Rate
Other
Total Contractuals
Charity Care
Number of Charity Care Patients :
Inpatient Charity Care Provided
Outpatient Charity Care Provided
Total Charity Care Provided
Other Deductions
Administrative Adjustments
Other Deductions
Total Other Deductions
Total Deductions From Revenue
FS - 1 BALANCE SHEET (Assets)
CURRENT ASSETS:
Cash
Marketable Securities
Accounts Receivable
Less-Est. Uncoll. & Allow.
Rec. From 3rd Party Payers
Pledges & Other Receivables
Due From Restricted Funds
Inventory
Prepaid Expenses
Current Portion of FHT
Total Current Assets
BOARD DESIGNATED ASSETS
Cash
Marketable Securities
Other Assets
Total BDA
PROP, PLANT, & EQUIP
Land
Land Improvements
Buildings
Fixed Equip - Bldg Srv
Fixed Equip - Other
Equipment
Leasehold Improvements
Construction In Progress
Total P P & E
Less Accum. Depreciation
Net P P & E
INVESTMENTS & OTHER ASSETS
Investments In P P & E
Less - Accum Depre
Other Investments
Other Assets
Total Invest. & Other Assets
INTANGIBLE ASSETS
Goodwill
Unamortized Loan Costs
Preopening & Other Org Costs
Other Intangible Assets
Total Intangible Assets
Total Assets
FS - 1 BALANCE SHEET ( Liabilities)
CURRENT LIABILITIES
Notes and Loans Payable
Accounts Payable
Accrued Compensation
Other Accrued Expenses
Advances From 3rd Parties
Payables to 3rd Party Payers
Due to Restricted Funds
Income Taxes Payable
Other Current Liabilities
Current Maturities of LTD
Total Current Liabilities
DEFERRED CREDITS
Deferred Income Taxes
Deferred 3rd Party Revenue
Other Deferred Credits
Total Deferred Credits
LONG TERM DEBT
Mortgage Payable
Construction Loans - Interim
Notes Payable
Capitalized Lease Obligations
Bonds Payable
Notes and Loans Payable to Parent
Noncurrent Liabilities
Total
Less Current Maturities LTD
Total Long Term Debt
Unrestricted Fund Balance
Preferred Stock
Common Stock
Additional Paid In Capital
Retained Earnings
Less: Treasury Stock
Total Liab & Fund Bal or Equity
Check Figure Total Assets
FS - 3 STATEMENT OF REVENUE & EXPENSE
OPERATING REVENUE
Inpatient Revenue
Outpatient Revenue
Total Patient Services Revenue
DEDUCTIONS FROM REVENUE
Contractual Adjustments
Charity & Uncompensated Care
Other Adj. & Allowances
Total Deductions From Revenue
Net Patient Service Revenue
OTHER OPERATING REVENUE
Other Operating Revenue
Tax Revenues
Total Other Operating Rev
Total Operating Revenue
FS - 3 STATEMENT OF REVENUE & EXPENSE
Salaries and Wages
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Rentals/Leases
Insurance
License & Taxes
Interest
Provision for Bad Debts
Other Direct Expense
Total Operating Expenses
Net Operating Revenue
Non Operating Rev Net of Exp
Net Rev. Before Items Listed Below
Extraordinary Items
Federal Income Taxes
Net Revenue or (Expense)
Tri-State Memorial Hospital H-0 FYE 12/31/2010
VOLUME:
Hospital Admissions
Hospital Patient Days
SNF/Swing Admissions
SNF/Swing Patient Days
ATC Admissions
ATC Patient Days
Newborn Admissions
Newborn Patient Days
OPERATING EXPENSES:
Salaries
Employee Benefits
Professional Fees
Supplies
Purch Srv - Utilities
Purch Srv - Other
Depreciation
Leases/Rentals
Insurance
Licenses & Taxes
Interest
Ins, Lic. & Taxes, and Interest
Bad Debt Expense
Other Direct Expense
Total Other Direct Expense
Total Expenses
DEDUCTIONS:
Contractuals
Charity Care
Other Deductions
Total Other Deductions
CHARITY CARE
# Of Patients
Inpatient
Outpatient
OTHER REVENUES:
Other Revenue
Tax Revenue
PATIENT SERVICE REVENUE:
IP Revenue
OP Revenue
Gross Revenue
FIXED ASSET ENDING BALANCES:
Land
Land Improvements
Buildings
Fixed Equip - Bldg Serv
Fixed Equip - Other
Equipment (Moveable)
Leasehold Improvements
Construction In Progress
Total
Accum Depre Ending Balance
Balance Sheet
FS-1 Assets
FS-1 Liabilities & Fund Balance
The actual operating expenses and units of measure are presented for the past two years in columns B-E.
The operating expenses per unit of measure are presented in columns F and G.
If the percentage change in operating expenses varies by more or less than 25 %, the variance appears in column H.
If the percentage change is more or less than 25%., please provide an explanation that is provided as an attachment w
year end report submittal. Also please provide any corrections required to the prior years information.
Tri-State Memorial Hospital
6010 Intensive Care
6030 Semi-Intensive Care
6070 Acute Care
6100 Alternative Birthing Center
6120 Physical Rehabilitation
6140 Psychiatric Care
6150 Chemical Dependency
6170 Nursery
6200 Skilled Nursing
6210 Swing Beds
6330 Hospice Inpatient
6400 Other Daily Services
7010 Labor Delivery
7020 Surgical Services
7030 Recovery Room
7040 Anesthesiology
7050 Central Services
7060 Intravenous Therapy
7070 Laboratory
7110 Electrodiagnosis
7120 Magnetic Resonance Imaging
7130 Ct Scanning
7140 Radiology - Diagnostic
7150 Radiology - Therapeutic
7160 Nuclear Medicine
7170 Pharmacy
7180 Respiratory Therapy
7190 Dialysis
7200 Physical Therapy
7220 Psychiatric Day Care
7230 Emergency Room
7240 Ambulance
7250 Short Stay
7260 Clinics
7310 Occupational Therapy
7320 Speech Therapy
7330 Recreational Therapy
7340 Electromyography
7350 Observation Unit
7380 Free-Standing Clinics
7390 Air Transportation
7400 Home Care Services
7410 Lithotripsy
7420 Organ Transplants
7430 Outpatient Chem. Dep.
7490 Other Ancillary
8200 Research / Education
8310 Printing & Duplication
8320 Dietary
8330 Cafeteria
8350 Laundry & Linen
8360 Social Services
8370 Central Transportation
8420 Purchasing
8430 Plant
8460 Housekeeping
8470 Communication
8480 Data Processing
8490 Other General Services
8510 Accounting
8530 Patient Accounts
8560 Admitting
8590 Other Fiscal Services
8610 Hospital Administration
8620 Employee Health
8630 Public Relations
8640 Management Engineering
8650 Personnel
8660 Auxiliary Groups
8670 Chaplaincy Services
8680 Medical Library
8690 Medical Records
8700 Medical Staff
8710 Utilization Management
8720 Nursing Administration
8730 Nursing Float Personnel
8740 Inservice Education
8770 Comm. Health Education
8790 Other Admin. Services
8830-8900 Unassigned Other Direct
8430
8310
8510
8470
8610
8790
8630
8770
8640
8420
8320
8650
8620
8330
8460
8350
8200
8360
8370
8490
8530
8480
8560
8590
8660
8670
8680
8690
8700
8710
8720
8730
8740
6010
6030
6070
6100
6120
6140
6150
6170
6200
6210
6330
6400
7010
7020
7030
7040
7050
7060
7070
7110
7120
7130
7140
7150
7160
7170
7180
7190
7200
7220
7230
7240
7250
7260
7310
7320
7330
7340
7350
7380
7390
7400
7410
7420
7430
7490
Page 1 of 21
TRANSMITTAL AND CERTIFICATION
HOSPITAL'S YEAR END REPORT
TO
The Department of Health
Office of Hospital and Patient Data
P.O. Box 47814
Olympia, Washington 98504-7814
FROM
Name of Hospital: Tri-State Memorial Hospital
License Number: H-108
Street Address: 0
Mailing Address: PO Box 189
City and Zip Code: Clarkston, WA 99403
CERTIFICATION OF OFFICER OF HOSPITAL
I HEREBY CERTIFY that I have examined the accompanying Hospital Year End Report as specified
by the Department of Health for the fiscal year ended 12/31/2010.
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:
Date:
x
Signature of Chair of Governing Board
Name/Title:
Date:
Page 2 of 21
HOSPITAL INFORMATION
1 Fiscal Year Ended: 12/31/2010 License Number: H-108
2 Hospital Name Tri-State Memorial Hospital
3 County Asotin
4 Executive Officer Donald Wee
5 Financial Officer Alex Town
6 Chair of Gov Brd Dr. Donald Greggain
7 Telephone # 509-758-5511
8 Facsimile # 509-758-3566
9 TYPE OF ORGANIZATION HAVING CONTROL (check one only)
Governmental Not For Profit For Profit
State Church Op. Individual
County X Other Partnership
City/County Corporation
Hosp. Dist.
10 ACTUAL UTILIZATION Admissions Patient Days
Intensive, Semi-Intensive, Acute & Psych 1,561 6,014
Skilled Nursing Facility / Swing 52 356
Chemical Dependency / ATC 0 0
11 Number of Births 0 0
12 # of Beds Available Beds # of Beds Available Beds
Intensive Care 4 Skilled Nursing 0
Semi -Intensive Care 0 Swing Beds 0
Acute - Medical / Surg 21 Chemical Dependency 0
Acute - Pediatrics 0 Other (Excl Nursery) 0
Acute - Obstetrical 0 Total Beds Available 25
Acute - Rehabilitation 0 (Excluding Nursery)
Psychiatric 0 Total Beds Licensed 61
Nursery - Bassinets 0
13 Skilled Nursing
Ancillary Revenue : 647,297
15. PAYOR UNITS OF SERVICE AND REVENUE Page 3 of 21
Hospital Name: Tri-State Memorial Hospital YE-A
FYE: 12/31/2010
HOSPITAL ONLY
Units of Service Revenue
PAYOR Admissions Pat. Days OP Visits Inpatient Outpatient Total
Medicare 1,089 4,478 48,777 20,936,660 34,183,403 55,120,063
Medicaid 54 277 6,397 1,846,473 4,603,059 6,449,532
All Other 418 1,259 24,788 9,553,510 17,971,763 27,525,273
Total 1,561 6,014 79,962 32,336,643 56,758,225 89,094,868
SNF / SWING ONLY
Units of Service Revenue
PAYOR Admissions Pat. Days OP Visits Inpatient Outpatient Total
Medicare 45 308 0 564,547 0 564,547
Medicaid 1 13 0 44,314 0 44,314
All Other 6 35 0 38,436 0 38,436
Total 52 356 0 647,297 0 647,297
CHEMICAL DEPENDENCY/ATC ONLY
Units of Service Revenue
PAYOR Admissions Pat. Days OP Visits Inpatient Outpatient Total
Medicare 0 0 0 0 0 0
Medicaid 0 0 0 0 0 0
All Other 0 0 0 0 0 0
Total 0 0 0 0 0 0
16. Hospital Based Physicians - Professional Component
Revenue : 0
Expense : 0
SUPPORTING SCHEDULES Page 4 of 21
Hospital: Tri-State Memorial Hospital FYE: 12/31/2010
1 SS-2 EMPLOYEE BENEFITS
2 Fica Taxes 1,250,121
3 Unemployment Compensation 0
4 Workers Compensation 376,728
5 Group Health Insurance 1,714,603
6 Group Life Insurance 73,330
7 Pension & Retirement 613,177
8 Other Employee Benefits 0
9 Other Employee Benefits 0
10 TOTAL EMPLOYEE BENEFITS 4,027,959
11 SS-3 RENTAL AND LEASE EXPENSE
12 Rental & Lease Expense - Buildings 198,064
13 Rental & Lease Expense - Equipment 421,854
14 TOTAL RENTAL & LEASE EXPENSE 619,918
15 SS-5 INSURANCE EXPENSE
16 INSURANCE
17 Hospital & Professional Malpractice Insurance 357,551
18 Other Insurance 0
19 TOTAL INSURANCE 357,551
20 LICENSE AND TAXES
21 License Fees 44,964
22 Taxes (other than Income) 402,306
23 Other 0
24 TOTAL LICENSE AND TAXES 447,270
25 SS-6 INTEREST EXPENSE
26 Interest Expense - Working Capital 593,930
27 Interest Expense - Other 0
28 TOTAL INTEREST EXPENSE 593,930
SS-4 DEPRECIATION EXPENSE Page 5 of 21
Hospital: Tri-State Memorial Hospital FYE: 12/31/2010
FIXED ASSETS
Beginning Ending
Balance Additions Retirements Balance
1 Land 647,866 0 0 647,866
2 Land Improvements 190,024 (1) 0 190,023
3 Buildings 25,627,737 124,962 0 25,752,699
4 Fixed Equipment-Bldg Serv 608,311 0 0 608,311
5 Fixed Equipment-Other 61,518 2,346,233 0 2,407,751
6 Equip-Major Moveable 12,901,005 1,649,144 0 14,550,149
7 Equipment-Minor 0 0 0 0
8 Leasehold Improvements 248,300 0 0 248,300
9 Construction-in-process 0 25,500 0 25,500
10 TOTAL 40,284,761 4,145,838 0 44,430,599
ACCUMULATED DEPRECIATION
Beginning Total Ending
Balance Provision Retirements Balance
11 Land
12 Land Improvements 108,454 16,496 0 124,950
13 Buildings 7,711,169 934,664 0 8,645,833
14 Fixed Equipment-Bldg Serv 0 0 0 0
15 Fixed Equipment-Other 0 0 0 0
16 Equip-Major Moveable 9,583,648 2,257,645 0 11,841,293
17 Equipment-Minor 0 0 0 0
18 Leasehold Improvements 0 0 0 0
19 Construction-in-process 0 0 0 0
20 TOTAL 17,403,271 3,208,805 0 20,612,076
S-8 DEDUCTIONS FROM REVENUE Page 6 of 21
Hospital: Tri-State Memorial Hospital FYE: 12/31/2010
ACCT: Item:
1 Contractual Adjustments
2 5810 Medicare 26,814,766
3 5820 Medicaid 3,515,395
4 5830 Workers Compensation 545,775
5 5840 Other Government Programs 889,420
6 5850 Negotiated Rates 0
7 5860 Other 5,083,915
8 Total Contractual Adjustments 36,849,271
9
10 Charity Care
11 Number of Charity Care Patients 1,620
12
13 5900 Inpatient Charity Care Provided 399,381
14 5910 Outpatient Charity Care Provided 844,452
15
16
17 Total Charity Care 1,243,833
18
19 5970 Administrative Adjustments 215,641
20
21 5980 Other Deductions (specify) 0
22 TOTAL DEDUCTIONS FROM REVENUE 38,308,745
23 Explanations
FS-1 BALANCE SHEET (Pg 1)
Page 7 of 21
HOSPITAL: Tri-State Memorial Hospital FYE: 12/31/2010
ASSETS
1 CURRENT ASSETS:
2 Cash 7,212,199
3 Marketable Securities 6,380,888
4 Accounts Receivable 12,299,163
5 Less-Estimated Uncollectable & Allowances 6,051,906
6 Receivables From Third Party Payors 71,730
7 Pledges And Other Receivables 159,856
8 Due From Restricted Funds 0
9 Inventory 1,769,676
10 Prepaid Expenses 396,724
11 Current Portion Of Funds Held In Trust 0
12 TOTAL CURRENT ASSETS 22,238,330
13
14 BOARD DESIGNATED ASSETS:
15 Cash 74,539
16 Marketable Securities 0
17 Other Assets 0
18 TOTAL BOARD DESIGNATED ASSETS: 74,539
19
20 PROPERTY, PLANT AND EQUIPMENT:
21 Land 647,866
22 Land Improvements 190,023
23 Buildings 25,752,699
24 Fixed Equipment - Building Service 608,311
25 Fixed Equipment - Other 2,407,751
26 Equipment 14,550,149
27 Leasehold Improvements 248,300
28 Construction In Progress 25,500
29 TOTAL 44,430,599
30 Less Accumulated Depreciation 20,612,076
31 NET PROPERTY, PLANT & EQUIPMENT 23,818,523
32
33 INVESTMENTS AND OTHER ASSETS:
34 Investments In Property, Plant & Equipment 516,049
35 Less - Accumulated Depreciation 0
36 Other Investments 0
37 Other Assets 994,795
38 TOTAL INVESTMENTS & OTHER ASSETS 1,510,844
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 47,642,236
FS-1 BALANCE SHEET (Pg 2)
Page 8 of 21
HOSPITAL: Tri-State Memorial Hospital FYE: 12/31/2010
LIABILITIES AND FUND BALANCES-UNRESTRICTED
1 CURRENT LIABILITIES
2 Notes and Loans Payable 0
3 Accounts Payable 1,879,311
4 Accrued Compensation and Related Liabilities 885,097
5 Other Accrued Expenses 824,958
6 Advances from Third Party Payors 0
7 Payables to Third Party Payors 34,774
8 Due to Restricted Funds 0
9 Income Taxes Payable 0
10 Other Current Liabilities 83,137
11 Current Maturities of Long Term Debt 1,308,537
12 TOTAL CURRENT LIABILITIES 5,015,814
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 10,680,979
22 Construction Loans-Interim Financing 0
23 Notes Payable 0
24 Capitalized Lease Obligations 0
25 Bonds Payable 0
26 Notes and Loans Payable to Parent 0
27 Noncurrent Liabilities 0
28 TOTAL 10,680,979
29 Less Current Maturities of Long Term Debt 1,308,537
30 TOTAL LONG TERM DEBT 9,372,442
31
32 TOTAL FUND BALANCE 33,064,086
33
34 EQUITY (INVESTOR OWNED)
35 Preferred Stock 0
36
37 Common Stock 0
38
39 Additional Paid In Stock 0
40
41 Retained Earnings (Capital Account for Partnership 189,894
42 (or Sole Proprietorship)
43
44 Less Treasury Stock 0
45 TOTAL EQUITY 33,253,980
46 TOTAL LIABILITIES AND FUND BALANCE OR EQUITY 47,642,236
INCOME STATEMENT - UNRESTRICTED FUND
Page 9 of 21
HOSPITAL: Tri-State Memorial Hospital FYE: 12/31/2010
1 OPERATING REVENUE:
2 Inpatient Revenue 32,983,940
3 Outpatient Revenue 56,758,225
4 TOTAL PATIENT SERVICES REVENUE 89,742,165
5
6 DEDUCTIONS FROM REVENUE:
7 Contractual Adjustments 37,064,913
8 Charity and Uncompensated Care 1,243,832
9 Other Adjustments and Allowances 0
10 TOTAL DEDUCTIONS FROM REVENUE 38,308,745
11 NET PATIENT SERVICE REVENUE 51,433,420
12
13 OTHER OPERATING REVENUE
14 Other Operating Revenue 1,208,147
15 Tax Revenues 0
16 TOTAL OTHER OPERATING REVENUE 1,208,147
17 TOTAL OPERATING REVENUE 52,641,567
18
19 OPERATING EXPENSES
20 Salaries and Wages 16,929,192
21 Employee Benefits 4,027,959
22 Professional Fees 4,325,622
23 Supplies 13,393,812
24 Purchased Services - Utilities 1,184,338
25 Purchased Services - Other 4,286,094
26 Depreciation 3,208,805
27 Rentals and Leases 619,918
28 Insurance 357,551
29 License and Taxes 447,270
30 Interest 593,930
31 Provision for Bad Debts 1,425,100
32 Other Direct Expenses 1,487,415
34 TOTAL OPERATING EXPENSES 52,287,006
35 NET OPERATING REVENUE 354,561
36
37 NON-OPERATING REVENUE-NET OF EXPENSES 1,111,508
38
39 NET REVENUE BEFORE ITEMS LISTED BELOW 1,466,069
40
41 EXTRAORDINARY ITEM 0
42 FEDERAL INCOME TAX 0
43
44 NET REVENUE OR (EXPENSE) 1,466,069
45 EXPLANATION:
YEAR END REPORT COST CENTER SUMMARY
PAGE 10 OF 21
HOSPITAL NAME: Tri-State Memorial Hospital FYE: 12/31/2010
1 Account Number 6010 6030 6070 6100 6120 6140 6150
2 Account Name Intensive Semi Acute Alternative Physical Psychiatric Chemical
Care ICU Care Birthing Ctr Rehab Care Dependency
3 Unit Description Patient Days Patient Days Patient Days Patient Days Patient Days Patient Days Patient Days
4 Units of Measure 1,487 0 4,527 0 0 0 0
5 Full Time Equivalents 15.82 0.00 41.28 0.00 0.00 0.00 0.00
6 Salaries & Wages 950,329 0 2,077,850 0 0 0 0
7 Employee Benefits 226,112 0 494,382 0 0 0 0
8 Professional Fees 0 0 11,025 0 0 0 0
9 Supplies 60,879 0 186,673 0 0 0 0
10 Purch Srv - Utilities 0 0 531 0 0 0 0
11 Purch Srv - Other 166 0 8,381 0 0 0 0
12 Depreciation 66,182 0 215,182 0 0 0 0
13 Leases/Rentals 174 0 9,964 0 0 0 0
14 Other Direct Expenses 7,890 0 25,383 0 0 0 0
15 Recoveries 0 0 0 0 0 0 0
16 Adjusted Direct Expenses 1,311,732 0 3,029,371 0 0 0 0
17 Tax Revenue
18 Cost Allocations 563,081 0 2,227,407 0 0 0 0
19 Inpatient Revenue 2,411,708 0 4,772,290 0 0 0 0
20 Outpatient Revenue (2,693) 0 178,187 0 0 0 0
21 Total Patient Revenue 2,409,015 0 4,950,477 0 0 0 0
Cost Allocation Statistics
22 Plant Square Feet 2,168 0 7,049 0 0 0 0
23 Dietary Meals 2,757 0 21,946 0 0 0 0
24 Housekeeping Hours 1,257 0 3,770 0 0 0 0
25 Laundry Dry Pounds 488 0 1,465 0 0 0 0
26 Nursing FTE's 11.18 0.00 26.21 0.00 0.00 0.00 0.00
YEAR END REPORT COST CENTER SUMMARY
PAGE 11 OF 21
HOSPITAL NAME: Tri-State Memorial Hospital FYE: 12/31/2010
1 Account Number 6170 6200 6210 6330 6400 7010 7020
2 Account Name Skilled Swing Hospice - Other Daily Labor And Surgical
Nursery Nursing Beds Inpatient Services Delivery Services
3 Unit Description Newborn Days Patient Days Patient Days Patient Days Patient Days Procedures Operating Min.
4 Units of Measure 0 0 0 0 0 0 186,163
5 Full Time Equivalents 0.00 0.00 0.00 0.00 0.00 0.00 15.73
6 Salaries & Wages 0 0 0 0 0 0 1,320,596
7 Employee Benefits 0 0 0 0 0 0 314,209
8 Professional Fees 0 0 0 0 0 0 64,417
9 Supplies 0 0 0 0 0 0 569,799
10 Purch Srv - Utilities 0 0 0 0 0 0 0
11 Purch Srv - Other 0 0 0 0 0 0 33,428
12 Depreciation 0 0 0 0 0 0 259,873
13 Leases/Rentals 0 0 0 0 0 0 1,323
14 Other Direct Expenses 0 0 0 0 0 0 60,117
15 Recoveries 0 0 0 0 0 0 0
16 Adjusted Direct Expenses 0 0 0 0 0 0 2,623,762
17 Tax Revenue
18 Cost Allocations 0 0 0 0 0 0 987,190
19 Inpatient Revenue 0 0 0 0 0 0 2,696,045
20 Outpatient Revenue 0 0 0 0 0 0 2,549,740
21 Total Patient Revenue 0 0 0 0 0 0 5,245,785
Cost Allocation Statistics
22 Plant Square Feet 0 0 0 0 0 0 8,513
23 Dietary Meals 0 0 0 0 0 0 0
24 Housekeeping Hours 0 0 0 0 0 0 5,433
25 Laundry Dry Pounds 0 0 0 0 0 0 296
26 Nursing FTE's 0.00 0.00 0.00 0.00 0.00 0.00 10.51
YEAR END REPORT COST CENTER SUMMARY
PAGE 12 OF 21
HOSPITAL NAME: Tri-State Memorial Hospital FYE: 12/31/2010
1 Account Number 7030 7040 7050 7060 7070 7110 7120
2 Account Name Recovery Central Intravenous Electro- Magnetic Res
Room Anesthesia Services Therapy Laboratory diagnosis Imaging
3 Unit Description Recovery Min Anesthia Min Bill. Tests Bill. Tests MRI RVU
4 Units of Measure 106,365 0 125,598 0 0
5 Full Time Equivalents 3.92 0.00 3.86 0.00 0.00 0.00 0.00
6 Salaries & Wages 242,272 0 116,541 0 0 0 0
7 Employee Benefits 57,644 0 27,729 0 0 0 0
8 Professional Fees 0 469,020 0 0 0 0 0
9 Supplies 15,353 139,928 7,120,707 0 232 0 0
10 Purch Srv - Utilities 0 0 0 0 0 0 0
11 Purch Srv - Other 0 (444) 63,678 0 2,304,113 0 0
12 Depreciation 32,480 0 26,283 0 18,927 0 0
13 Leases/Rentals 0 0 7,807 0 0 0 0
14 Other Direct Expenses 1,731 0 6,376 0 0 0 0
15 Recoveries 0 0 0 0 0 0 0
16 Adjusted Direct Expenses 349,480 608,504 7,369,121 0 2,323,272 0 0
17 Tax Revenue
18 Cost Allocations 123,871 149,230 1,715,169 0 508,232 0 0
19 Inpatient Revenue 318,811 985,140 12,304,743 0 2,543,626 0 0
20 Outpatient Revenue 438,245 1,212,363 4,732,418 0 4,399,976 0 0
21 Total Patient Revenue 757,056 2,197,503 17,037,161 0 6,943,602 0 0
Cost Allocation Statistics
22 Plant Square Feet 1,064 0 861 0 620 0 0
23 Dietary Meals 0 0 0 0 0 0 0
24 Housekeeping Hours 0 0 1,211 0 0 0 0
25 Laundry Dry Pounds 306 0 0 0 0 0 0
26 Nursing FTE's 2.65 0.00 0.00 0.00 0.00 0.00 0.00
YEAR END REPORT COST CENTER SUMMARY
PAGE 13 OF 21
HOSPITAL NAME: Tri-State Memorial Hospital FYE: 12/31/2010
1 Account Number 7130 7140 7150 7160 7170 7180 7190
2 Account Name CT Radiology- Radiology- Nuclear Respiratory
Scanning Diagnostic Therapeutic Medicine Pharmacy Therapy Dialysis
3 Unit Description HECT Unit RVU RVU RVU Treatments Hours
4 Units of Measure 0 182,958 0 0 26,059 0
5 Full Time Equivalents 0.00 21.37 0.00 0.00 5.62 6.27 28.86
6 Salaries & Wages 0 1,263,112 0 0 458,610 532,922 1,847,947
7 Employee Benefits 0 300,532 0 0 109,117 126,798 439,682
8 Professional Fees 0 39,000 0 0 0 72,970 115,385
9 Supplies 0 151,269 0 0 2,620,975 76,647 704,164
10 Purch Srv - Utilities 0 407 0 0 0 0 39,035
11 Purch Srv - Other 0 721,685 0 0 13,939 15,926 113,864
12 Depreciation 0 321,628 0 0 25,459 23,139 349,652
13 Leases/Rentals 0 4,603 0 0 37,821 21,501 207,035
14 Other Direct Expenses 0 16,912 0 0 965 3,257 20,717
15 Recoveries 0 0 0 0 0 0 0
16 Adjusted Direct Expenses 0 2,819,148 0 0 3,266,886 873,160 3,837,481
17 Tax Revenue
18 Cost Allocations 0 1,182,818 0 0 800,125 201,188 1,310,865
19 Inpatient Revenue 0 1,268,625 0 0 2,179,356 1,157,009 251,447
20 Outpatient Revenue 0 10,598,732 0 0 6,858,502 1,032,156 9,024,399
21 Total Patient Revenue 0 11,867,357 0 0 9,037,858 2,189,165 9,275,846
Cost Allocation Statistics
22 Plant Square Feet 0 10,536 0 0 834 758 11,454
23 Dietary Meals 0 0 0 0 0 0 0
24 Housekeeping Hours 0 1,904 0 0 0 0 3,040
25 Laundry Dry Pounds 0 809 0 0 0 0 817
26 Nursing FTE's 0.00 0.26 0.00 0.00 0.00 0.00 9.67
YEAR END REPORT COST CENTER SUMMARY
PAGE 14 OF 21
HOSPITAL NAME: Tri-State Memorial Hospital FYE: 12/31/2010
1 Account Number 7200 7220 7230 7240 7250 7260 7310
2 Account Name Physical Psychiatric Emergency Short Occupational
Therapy Day Care Room Ambulance Stay Clinics Therapy
3 Unit Description Treatments Visits Visits Occasions Outpatients Visits Treatments
4 Units of Measure 3,346 0 16,082 0 388 11,522 0
5 Full Time Equivalents 0.00 0.00 29.27 0.00 10.75 35.12 0.00
6 Salaries & Wages 0 0 1,673,886 0 63,406 1,267,729 0
7 Employee Benefits 0 0 398,267 0 15,086 301,631 0
8 Professional Fees 162,506 0 1,517,366 0 22,046 1,436,774 0
9 Supplies 0 0 120,573 0 70,661 697,640 0
10 Purch Srv - Utilities 0 0 2,096 0 0 2,687 0
11 Purch Srv - Other 0 0 87,909 0 0 11,268 0
12 Depreciation 0 0 197,782 0 152,633 0 0
13 Leases/Rentals 0 0 5,284 0 0 8,259 0
14 Other Direct Expenses 0 0 19,847 0 7,232 57,205 0
15 Recoveries 0 0 0 0 0 0 0
16 Adjusted Direct Expenses 162,506 0 4,023,010 0 331,064 3,783,193 0
17 Tax Revenue
18 Cost Allocations 30,523 0 1,101,801 0 296,594 825,885 0
19 Inpatient Revenue 390,414 0 201,301 0 0 1,304,175 0
20 Outpatient Revenue 4,526 0 6,543,466 0 1,422,399 4,992,158 0
21 Total Patient Revenue 394,940 0 6,744,767 0 1,422,399 6,296,333 0
Cost Allocation Statistics
22 Plant Square Feet 0 0 6,479 0 5,000 0 0
23 Dietary Meals 0 0 0 0 0 0 0
24 Housekeeping Hours 0 0 3,542 0 48 3,322 0
25 Laundry Dry Pounds 0 0 1,280 0 0 271 0
26 Nursing FTE's 0.00 0.00 14.59 0.00 7.53 9.68 0.00
YEAR END REPORT COST CENTER SUMMARY
PAGE 15 OF 21
HOSPITAL NAME: Tri-State Memorial Hospital FYE: 12/31/2010
1 Account Number 7320 7330 7340 7350 7380 7390 7400
2 Account Name Speech Recreational Electro- Observation Free Standing Air Home Care
Therapy Therapy myography Unit Clinics Transport Services
3 Unit Description Treatments Treatments Procedures Hours Visits Occasions Visits
4 Units of Measure 360 0 0 2,193 0 34 9,152
5 Full Time Equivalents 0.00 0.00 0.00 0.00 0.00 0.00 12.58
6 Salaries & Wages 0 0 0 0 0 0 606,609
7 Employee Benefits 0 0 0 0 0 0 144,330
8 Professional Fees 22,189 0 0 0 0 0 0
9 Supplies 0 0 0 0 0 0 89,231
10 Purch Srv - Utilities 0 0 0 0 0 0 12,097
11 Purch Srv - Other 0 0 0 0 0 17,877 227,535
12 Depreciation 0 0 0 0 0 0 136,271
13 Leases/Rentals 0 0 0 0 0 0 41,470
14 Other Direct Expenses 0 0 0 0 0 0 57,502
15 Recoveries 0 0 0 0 0 0 0
16 Adjusted Direct Expenses 22,189 0 0 0 0 17,877 1,315,045
17 Tax Revenue
18 Cost Allocations 4,430 0 0 5,002 0 2,194 365,797
19 Inpatient Revenue 60,401 0 0 12,056 0 14,716 0
20 Outpatient Revenue 0 0 0 111,432 0 0 1,372,360
21 Total Patient Revenue 60,401 0 0 123,488 0 14,716 1,372,360
Cost Allocation Statistics
22 Plant Square Feet 0 0 0 0 0 0 4,464
23 Dietary Meals 0 0 0 0 0 0 0
24 Housekeeping Hours 0 0 0 0 0 0 0
25 Laundry Dry Pounds 0 0 0 0 0 0 0
26 Nursing FTE's 0.00 0.00 0.00 0.00 0.00 0.00 7.21
YEAR END REPORT COST CENTER SUMMARY
PAGE 16 OF 21
HOSPITAL NAME: Tri-State Memorial Hospital FYE: 12/31/2010
1 Account Number 7410 7420 7430 7490 8200 8310 8320
2 Account Name Organ Outpatient Other Research/ Printing &
Lithotripsy Acquisitions Chemical Dep. Ancillary Education Duplication Dietary
3 Unit Description Treatments Acquisitions Visits Patient Meals
4 Units of Measure 0 0 0 24,703
5 Full Time Equivalents 0.00 0.00 0.00 0.00 0.00 0.00 16.08
6 Salaries & Wages 0 0 0 218,892 0 0 524,566
7 Employee Benefits 0 0 0 52,081 0 0 124,810
8 Professional Fees 0 0 0 12,000 0 0 0
9 Supplies 0 0 0 55,683 0 0 340,872
10 Purch Srv - Utilities 0 0 0 0 0 0 0
11 Purch Srv - Other 0 0 0 1,462 0 0 4,352
12 Depreciation 0 0 0 0 0 0 102,783
13 Leases/Rentals 0 0 0 18,680 0 0 0
14 Other Direct Expenses 0 0 0 0 0 0 15,240
15 Recoveries 0 0 0 0 0 0 0
16 Adjusted Direct Expenses 0 0 0 358,798 0 0 1,112,623
17 Tax Revenue
18 Cost Allocations 0 0 0 105,963
19 Inpatient Revenue 0 0 0 112,077 x x x
20 Outpatient Revenue 0 0 0 1,284,471 x x 5,388
21 Total Patient Revenue 0 0 0 1,396,548 x x 5,388
Cost Allocation Statistics
22 Plant Square Feet 0 0 0 0 0 0 3,367
23 Dietary Meals 0 0 0 0 0 x x
24 Housekeeping Hours 0 0 0 0 0 x x
25 Laundry Dry Pounds 0 0 0 429 0 x x
26 Nursing FTE's 0.00 0.00 0.00 0.00 x x x
YEAR END REPORT COST CENTER SUMMARY
PAGE 17 OF 21
HOSPITAL NAME: Tri-State Memorial Hospital FYE: 12/31/2010
1 Account Number 8330 8350 8360 8370 8420 8430 8460
2 Account Name Laundry & Social Central
Cafeteria Linen Service Transport. Purchasing Plant Housekeeping
3 Unit Description Equiv. Meals Pds. Proc. Gross Sq Ft
4 Units of Measure 160,650 0 105,115
5 Full Time Equivalents 0.00 0.06 0.00 0.00 7.05 5.65 14.73
6 Salaries & Wages 0 1,580 0 0 245,403 289,889 408,636
7 Employee Benefits 0 376 0 0 58,389 68,973 97,227
8 Professional Fees 0 0 0 0 0 0 0
9 Supplies 0 0 260 0 5,188 112,513 72,871
10 Purch Srv - Utilities 0 0 1,444 0 0 460,831 2,132
11 Purch Srv - Other 0 195,791 0 0 0 153,061 28,119
12 Depreciation 0 0 12,699 0 100,249 152,908 44,294
13 Leases/Rentals 0 0 0 0 359 0 0
14 Other Direct Expenses 0 0 25 0 3,078 7,645 760
15 Recoveries 0 0 0 0 0 0 0
16 Adjusted Direct Expenses 0 197,747 14,428 0 412,666 1,245,820 654,039
17 Tax Revenue
18 Cost Allocations
19 Inpatient Revenue x x x x x x x
20 Outpatient Revenue x x x x x x x
21 Total Patient Revenue x x x x x x x
Cost Allocation Statistics
22 Plant Square Feet 0 0 416 0 3,284 5,009 1,451
23 Dietary Meals 0 0 0 0 x x 0
24 Housekeeping Hours x 0 0 0 x x x
25 Laundry Dry Pounds x x 0 0 x x x
26 Nursing FTE's x x x x x x x
YEAR END REPORT COST CENTER SUMMARY
PAGE 18 OF 21
HOSPITAL NAME: Tri-State Memorial Hospital FYE: 12/31/2010
1 Account Number 8470 8480 8490 8510 8530 8560 8590
2 Account Name Communica- Data Other General Patient Other
tion Processing Services Accounting Accounts Admitting Fiscal Services
3 Unit Description
4 Units of Measure
5 Full Time Equivalents 2.14 0.00 0.00 4.72 12.00 10.72 0.00
6 Salaries & Wages 0 101,927 32,474 286,313 0 331,818 406,886
7 Employee Benefits 0 24,251 7,727 68,122 0 78,949 96,810
8 Professional Fees 0 0 0 116,971 0 0 108,301
9 Supplies 0 6,529 1,432 10,373 0 16,633 68,428
10 Purch Srv - Utilities 95,042 561,804 0 0 0 0 0
11 Purch Srv - Other 0 650 0 47,172 0 3,294 3,813
12 Depreciation 0 0 0 0 83,124 16,515 0
13 Leases/Rentals 0 0 4,655 2,576 0 415 58,067
14 Other Direct Expenses 46,990 3,429 3,429 5,342 5,920 5,487 0
15 Recoveries 0 0 0 0 0 0 0
16 Adjusted Direct Expenses 142,032 698,590 49,717 536,869 89,044 453,111 742,305
17 Tax Revenue
18 Cost Allocations
19 Inpatient Revenue x x x x x x x
20 Outpatient Revenue x x x x x x x
21 Total Patient Revenue x x x x x x x
Cost Allocation Statistics
22 Plant Square Feet 0 0 0 0 2,723 541 0
23 Dietary Meals x 0 0 x 0 0 0
24 Housekeeping Hours x 0 1,158 x 0 0 0
25 Laundry Dry Pounds x 0 0 x 0 0 0
26 Nursing FTE's x x x x x x x
YEAR END REPORT COST CENTER SUMMARY
PAGE 19 OF 21
HOSPITAL NAME: Tri-State Memorial Hospital FYE: 12/31/2010
1 Account Number 8610 8620 8630 8640 8650 8660 8670
2 Account Name Hospital Employee Public Management Auxiliary Chaplaincy
Admin Health Relations Engineering Personnel Groups Services
3 Unit Description
4 Units of Measure
5 Full Time Equivalents 3.00 0.00 3.17 0.00 2.73 0.00 0.00
6 Salaries & Wages 284,161 0 72,430 0 178,765 0 0
7 Employee Benefits 67,610 0 17,233 0 42,534 0 0
8 Professional Fees 155,652 0 0 0 0 0 0
9 Supplies 18,902 8,986 1,410 0 8,639 0 0
10 Purch Srv - Utilities 5,518 0 0 0 0 0 0
11 Purch Srv - Other 974 5,987 144,847 0 70,763 0 0
12 Depreciation 179,252 0 102,539 0 0 0 0
13 Leases/Rentals 7,171 0 0 0 0 0 0
14 Other Direct Expenses 311,823 0 63,697 0 9,472 0 0
15 Recoveries 0 0 0 0 0 0 0
16 Adjusted Direct Expenses 1,031,063 14,973 402,156 0 310,173 0 0
17 Tax Revenue
18 Cost Allocations
19 Inpatient Revenue x x x x x x x
20 Outpatient Revenue x x x x x x x
21 Total Patient Revenue x x x x x x x
Cost Allocation Statistics
22 Plant Square Feet 5,872 0 3,359 0 0 0 0
23 Dietary Meals x x x x 0 0 0
24 Housekeeping Hours x x x x x 0 0
25 Laundry Dry Pounds x x x x x 0 0
26 Nursing FTE's x x x x x x x
YEAR END REPORT COST CENTER SUMMARY
PAGE 20 OF 21
HOSPITAL NAME: Tri-State Memorial Hospital FYE: 12/31/2010
1 Account Number 8680 8690 8700 8710 8720 8730 8740
2 Account Name Medical Medical Medical Utilization Nursing Nursing Float Inservice
Library Records Staff Management Admin Personnel Education
3 Unit Description
4 Units of Measure
5 Full Time Equivalents 0.00 16.71 0.34 0.00 4.05 0.00 1.07
6 Salaries & Wages 0 603,919 17,556 144,953 272,086 0 34,553
7 Employee Benefits 0 143,690 4,177 34,489 64,737 0 8,221
8 Professional Fees 0 0 0 0 0 0 0
9 Supplies 0 10,338 109 6,175 6,329 0 17,627
10 Purch Srv - Utilities 0 0 0 63 651 0 0
11 Purch Srv - Other 0 2,696 3,077 711 0 0 0
12 Depreciation 0 40,448 0 0 0 0 0
13 Leases/Rentals 0 36,396 0 0 245 0 0
14 Other Direct Expenses 0 9,978 5,017 0 23,223 0 3,230
15 Recoveries 0 0 0 0 0 0 0
16 Adjusted Direct Expenses 0 847,465 29,936 186,391 367,271 0 63,631
17 Tax Revenue
18 Cost Allocations
19 Inpatient Revenue x x x x x x x
20 Outpatient Revenue x x x x x x x
21 Total Patient Revenue x x x x x x x
Cost Allocation Statistics
22 Plant Square Feet 0 1,325 0 0 0 0 0
23 Dietary Meals 0 0 0 0 0 0 0
24 Housekeeping Hours 0 0 0 0 0 0 0
25 Laundry Dry Pounds 0 0 0 0 0 0 0
26 Nursing FTE's
YEAR END REPORT COST CENTER SUMMARY
PAGE 21 OF 21
HOSPITAL NAME: Tri-State Memorial Hospital FYE: 12/31/2010
1 Account Number 8770 8790 8830-8900
2 Account Name Comm. Health Other Unassigned Grand
Education Admin Srvcs Other Direct Total
3 Unit Description
4 Units of Measure
5 Full Time Equivalents 0.00 0.00 334.67
6 Salaries & Wages 50,576 0 16,929,192
7 Employee Benefits 12,034 0 4,027,959
8 Professional Fees 0 0 4,325,622
9 Supplies 0 0 13,393,812
10 Purch Srv - Utilities 0 0 1,184,338
11 Purch Srv - Other 0 0 4,286,094
12 Depreciation 0 548,503 3,208,805
13 Leases/Rentals 0 0 619,918
14 Provision for Bad Debts 1,425,100 1,425,100
15 Other Direct Expenses 0 678,496 1,398,751 2,886,166
16 Recoveries 0 0 1,208,147 (1,208,147)
17 Adjusted Direct Expenses 62,610 1,226,999 1,615,704 51,078,859
18 Tax Revenue 0
19 Cost Allocations
20 Inpatient Revenue x x 32,983,940
21 Outpatient Revenue x x 56,758,225
22 Total Patient Revenue x x 89,742,165
Cost Allocation Statistics
23 Plant Square Feet 0 17,968 105,115
24 Dietary Meals x 24,703
25 Housekeeping Hours x 24,685
26 Laundry Dry Pounds x 6,161
27 Nursing FTE's x 99.49
The square f ootage statistic is prov ided f or all cost centers including the plant and this way
square f ootage identif ied by cost center will total the gross square f ootage stated as the statistic in the plant cost center.
The operating expenses, the units of measure and the operating expenses per unit of measure are stated on line 484 thru line 568 in columns
B thru G. Increases or decreases in operating expenses per unit of measure exceeding 25% are stated in column H. Please submit an
attachment with the report that addresses why those changes took place. Also please prov ide any corrections that might be in order.
Y our hospital license number and f iscal y ear end hav e already been entered. These items need to be in alpha f ormat rather
than numeric f ormat in order to pick up correctly f or upload to the y ear end report database.
If y ou want to rev iew what y ou reported f or the prior y ear y ou can click on the tab titled prior y ear.
If y ou hav e any questions or concerns please call Randy Huy ck at 360-236-4210 or send an e-mail to
To submit y our report by electronic mail, please send to:
doh. a.
randal l . huyck@ w gov.
doh. a.
randal l . huyck@ w gov.
Please remember to send a signed certif ication page and an audited f inancial statement by regular mail when they are av ailable.
It is only necessary to enter data on this page. Items will automatically transf er f rom this page to the report pages.
Employ ee Benef its
The employ ee benef its can be entered directly , assigned to the cost centers based on a percentage of salaries, or a combination of the two.
1) Enter the amount of employ ee benef its directly recorded in cell B47.
2) Enter the employ ee benef its directly recorded by cost center in cells C47..CC47.
3) Enter the total unassigned employ ee benef its that will be assigned based on salaries in cell B48.
Depreciation
The Depreciation can be entered directly , assigned by square f ootage, or a combination of the two.
1) Enter the total amount of depreciation directly assigned in cell B51.
2) Enter the amount of depreciation directly recorded by cost center in cells C51..CC51.
3) Enter the amount of depreciation that will be assigned by square f ootage in cell B52.
Af ter the salaries and the departmental square f ootage statistics are entered, the departmental employ ee benef its and depreciation will be
calculated on lines 48 and 52, respectiv ely .
6010 6030 6070 6100 6120 6140 6150 6170 6200 6210 6330 6400 7010 7020 7030 7040 7050 7060 7070 7110 7120 7130 7140 7150 7160 7170 7180 7190 7200 7220 7230 7240 7250 7260 7310 7320 7330 7340 7350 7380 7390 7400 7410 7420 7430 7490 8200 8310 8320 8330 8350 8360 8370 8420 8430 8460 8470 8480 8490 8510 8530 8560 8590 8610 8620 8630 8640 8650
See Instructions Intensiv e Semi-Intensiv e Acute Alternativ e Phy sical Psy chiatric Chemical Nursery Skilled Swing Hospice Other Daily Labor & Surgical Recov ery Anesthesiology Central Intrav enous Laboratory Electro- Magnetic Res CT Radiology - Radiology - Nuclear Pharmacy Respiratory Dialy sis Phy sical Psy chiatric Emergency Ambulance Short Clinics Occupational Speech Recreational Electro- Observ ation Free-Standing Air Home Care Lithotripsy Organ Outpatient Other Research/Education Printing & Dietary Caf eteria Laundry & Social Central Purchasing Plant Housekeeping Communication Data Other General Accounting Patient Admitting Other Hospital Employ ee Public Management Personnel
Employ ee Benef its Abov e Care Care Care Birth Ctr Rehab Care Dependency Nursing Beds Inpatient Serv ices Deliv ery Serv ices Room Serv ices Therapy diagnosis Imaging Scanning Diagnostic Therapeutic Medicine Therapy Therapy Day Care Room Stay Therapy Therapy Therapy my ogray Unit Clinics Transportation Serv ices Transplants Chem. Dep. Ancillary Costs Duplication Linen Serv ices Transportation Processing Serv ices Accounts Fiscal Sv cs Administration Health Relations Engineering
directly recorded
assigned based on salaries 3,446,920 198,934 0 489,382 0 0 0 0 0 0 0 0 0 0 335,817 55,272 83,921 24,925 0 0 0 0 0 330,282 0 0 87,970 86,102 181,612 0 0 254,137 0 16,831 312,701 0 0 0 0 0 0 0 126,763 0 0 0 0 0 0 110,402 0 3,042 1,983 0 42,681 70,365 85,819 0 29,232 0 39,479 104,300 23,279 0 89,541 0 18,989 0 30,057
total 3,446,920
Depreciation
depreciation directly recorded
depreciation based on sq. f t. 2,761,005 56,397 0 183,368 0 0 0 0 0 0 0 0 0 0 344,027 27,678 0 22,397 0 16,128 0 0 0 291,818 0 0 21,695 19,718 113,262 0 0 168,540 0 7,492 222,232 0 0 0 0 0 0 0 116,124 0 0 0 0 0 0 87,587 0 0 10,822 0 85,428 130,301 37,745 0 0 0 0 70,834 14,073 0 152,750 0 87,379 0 0
total 2,761,005
Account Number 6010 6030 6070 6100 6120 6140 6150 6170 6200 6210 6330 6400 7010 7020 7030 7040 7050 7060 7070 7110 7120 7130 7140 7150 7160 7170 7180 7190 7200 7220 7230 7240 7250 7260 7310 7320 7330 7340 7350 7380 7390 7400 7410 7420 7430 7490 8200 8310 8320 8330 8350 8360 8370 8420 8430 8460 8470 8480 8490 8510 8530 8560 8590 8610 8620 8630 8640 8650
Account Intensiv e Semi-Intensiv e Acute Alternativ e Phy sical Psy chiatric Chemical Nursery Skilled Swing Hospice Other Daily Labor & Surgical Recov ery Anesthesiology Central Intrav enous Laboratory Electro- Magnetic Res CT Radiology - Radiology - Nuclear Pharmacy Respiratory Dialy sis Phy sical Psy chiatric Emergency Ambulance Short Clinics Occupational Speech Recreational Electro- Observ ation Free-Standing Air Home Care Lithotripsy Organ Outpatient Other Research/Education Printing & Dietary Caf eteria Laundry & Social Central Purchasing Plant Housekeeping Communication Data Other General Accounting Patient Admitting Other Hospital Employ ee Public Management Personnel
Name Care Care Care Birth Ctr Rehab Care Dependency Nursing Beds Inpatient Serv ices Deliv ery Serv ices Room Serv ices Therapy diagnosis Imaging Scanning Diagnostic Therapeutic Medicine Therapy Therapy Day Care Room Stay Therapy Therapy Therapy my ogray Unit Clinics Transportation Serv ices Transplants Chem. Dep. Ancillary Costs Duplication Linen Serv ices Transportation Processing Serv ices Accounts Fiscal Sv cs Administration Health Relations Engineering
Unit of Measure Description Patient Day s Patient Day s Patient Day s Patient Day s Patient Day s Patient Day s Patient Day s Newborn Day s Patient Day s Patient Day s Patient Day s Patient Day s Procedures Operating Min. Recov ery Min. Anesthesia Min. xxxxxxxxxxx xxxxxxxxxxx Billable Tests Billable Tests MRI RVU HECT Unit RVU RVU RVU xxxxxxxxxxx Treatments Hours Treatments Visits Visits Occasions Patients Visits Treatments Treatments Treatments Procedures Hours Visits Occasions Visits Treatments Acquisitions Visits xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx Patient Meals Patient Meals xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx Gross Sq Ft xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx
Units of Measure 1,740 5,266 433,961 153,840 433,961 79,247 202,392 27,040 39,684 3,022 15,104 687 10,661 132 4,961 12,596 26,236 124,073 106,138
Full Time Equiv alents 13.78 40.02 23.16 3.95 1.00 3.20 26.84 4.44 5.87 16.96 20.85 1.38 22.95 9.25 14.05 0.48 0.19 5.31 6.03 13.52 2.56 2.00 12.49 3.52 3.37 3.01 2.00
Salaries & Wages 750,748 0 1,846,855 0 0 0 0 0 0 0 0 0 0 1,267,322 208,590 316,707 94,064 0 0 0 0 0 1,246,436 0 0 331,985 324,935 685,377 959,073 63,516 1,180,088 0 478,383 416,639 11,481 7,482 161,073 265,548 323,867 110,318 148,988 393,611 87,850 337,915 71,661 0 113,431
Employ ee Benef its 198,934 0 489,382 0 0 0 0 0 0 0 0 0 0 335,817 55,272 83,921 24,925 0 0 0 0 0 330,282 0 0 87,970 86,102 181,612 0 0 254,137 0 16,831 312,701 0 0 0 0 0 0 0 126,763 0 0 0 0 0 0 110,402 0 3,042 1,983 0 42,681 70,365 85,819 0 29,232 0 39,479 104,300 23,279 0 89,541 0 18,989 0 30,057
Prof essional Fees 332,534 314,878 40 60,585 143,816 1,202,832 543,913 13,786 6,000 77,814 101,385 115,543
Supplies 35,616 133,472 191,510 6,422 44,405 5,989,268 1,487 164,059 2,245,760 72,513 438,837 67,768 12,883 658,717 58,985 1,030 319,043 508 5,512 176,913 58,127 14,763 3,701 50,607 16,050 5,912 14,747 6,978
Purch. Serv . - Utilities 600 3,123 10,544 444,076 247,562 2,717 1,549
Purch. Serv . - Other 8,075 11,722 16,872 1,488,617 624,540 9,980 11,150 32,374 3,567 7,653 21,550 267,735 229,945 2,454 189,832 57,202 2,348 14,727 2,418 100,455
Depreciation 56,397 0 183,368 0 0 0 0 0 0 0 0 0 0 344,027 27,678 0 22,397 0 16,128 0 0 0 291,818 0 0 21,695 19,718 113,262 0 0 168,540 0 7,492 222,232 0 0 0 0 0 0 0 83,557 0 0 0 0 0 0 87,587 0 0 10,822 0 85,428 130,301 37,745 0 0 0 0 70,834 14,073 0 152,750 0 87,379 0 0
Lease/Rental 355 7,957 1,006 26,923 5,070 22,535 471 18,190 3,736 16,363 137 137,151 181 37,682 742 2,301 4,918
Bad Debt Expense xxxxxxxxxxxxxx xxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx
Other Direct Expenses 59,349 205,486 72,485 873 11,431 126,083 164,272 37,489 27,313 4,411 27,106 27,659 199 46,803 49,218 2,922 6,306 571 2,995 33,018 5,158 61,783 3,751 18,887 3,804 177,639 63,849 9,582
Recov eries
Total Adj Exp 1,101,399 0 3,207,129 0 0 0 0 0 0 0 0 0 0 2,223,889 298,835 788,814 6,283,660 0 1,670,504 0 0 0 2,699,734 0 0 2,807,823 519,300 1,496,758 143,816 0 2,683,576 7,653 100,921 2,992,863 0 13,786 0 0 0 0 0 1,097,548 0 0 0 233,897 0 0 942,431 0 204,355 21,366 0 297,826 1,314,574 510,716 0 466,006 0 288,641 777,306 148,216 0 884,318 0 363,547 0 160,048
Tax Rev enue xxxxxxxxxxxxxx xxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx
IP Rev enue 1,503,398 4,107,158 31,680 1,731,668 298,405 307,450 10,737,493 2,544,058 1,102,487 2,397,377 1,126,149 133,003 313,746 144,506 6,739 8,624 488,271 2,896 xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx
OP Rev enue 6,647 73,889 2,745,024 396,704 498,183 5,570,323 2,979,146 9,227,828 6,151,861 211,810 4,784,022 2,376 4,890,049 579,423 5,786,615 221,555 1,076,661 6,524 xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx
Gross Rev enue 1,510,045 0 4,181,047 0 31,680 0 0 0 0 0 0 0 0 4,476,692 695,109 805,633 16,307,816 0 5,523,204 0 0 0 10,330,315 0 0 8,549,238 1,337,959 4,917,025 316,122 0 5,034,555 6,739 588,047 6,274,886 0 0 0 0 224,451 0 0 1,076,661 0 0 0 6,524 xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx
Sq FT 2,168 7,049 13,225 1,064 861 620 11,218 834 758 4,354 6,479 288 8,543 4,464 3,367 416 3,284 5,009 1,451 2,723 541 5,872 3,359
Patient Meals Serv ed 2,640 23,596 xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx
Housekeeping Hours of Serv ice 1,257 3,770 5,433 1,211 1,904 3,040 3,542 48 3,322 xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx 1,158 xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx
Dry Pounds of Laundry 16,187 48,559 69,972 15,594 24,521 39,156 45,627 616 42,785 xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx 14,931 xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx
Nursing FTE's 9.39 26.59 17.11 2.77 6.04 11.08 0.70 5.39 5.00 xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx
Y E-A HOSPITAL INFORMATION Page 1 of 2
Fiscal Y ear Ended 12/31/2007
License Number : 108
Hospital Name : Tri-State Memorial Hopsital
Street Address
Mailing Address : PO box 189
City , State, Zip : Clarkston, Washington 99403
County : Asotin
Chief Executiv e Of f icer : Christopher Noland
Chief Financial Of f icer : Alex Town
Chair of Gov erning Board : Dr. Donald Greggain
Telephone Number : (509) 758-5511
Facsimile Number : (509) 758-3566
TY PE OF ORGANIZATION (If applies enter 1)
Gov ernmental
State :
County :
District :
Not For Prof it
Church Operated :
Other : 1
For Prof it
Indiv idual :
Partnership :
Corporation :
Y E-A HOSPITAL INFORMATION Page 2 of 2
ACTUAL UTILIZATION Admissions Patient Day s
ICU, SICU, ACUTE, PSY CH : 1,592 6,369
Skilled Nursing/Swing : 84 637
Chemical Dependency /ATC :
Number of Births :
NUMBER OF BEDS AVAILABLE Beds
Intensiv e Care : 4
Semi-Intensiv e Care :
Acute Care - Med/Surg : 21
Acute Care - Pediatrics :
Acute Care - Obstetrics :
Acute Care - Rehab :
Psy chiatric :
Skilled Nursing :
Swing Beds
Chemical Dependency /ATC :
Other (Exclude Nursery ) :
Total Beds Av ailable 25
Total Beds Licensed : 61
Nursery - Bassinets :
SNF/SWING Ancillary Rev enue : 912,580
PAY ER UNITS OF SERVICE AND REVENUE
HOSPITAL Medicare Medicaid Other Total
Admissions 1,116 93 383 1,592
Patient Day s 4,570 399 1,400 6,369
OP Visits 43,338 6,229 23,888 73,455
IP Rev enue 17,912,802 1,625,325 6,534,401 26,072,528
OP Rev enue 27,027,911 3,874,256 14,306,473 45,208,640
SNF/SWING Medicare Medicaid Other Total
Admissions 82 1 1 84
Patient Day s 613 21 3 637
OP Visits 0 0 0 0
IP Rev enue 891,758 18,181 2,641 912,580
OP Rev enue 0 0 0 0
ATC Medicare Medicaid Other Total
Admissions 0
Patient Day s 0
OP Visits 0
IP Rev enue 0
OP Rev enue 0
HBP Component Rev enue Expense
HBP Component 0 0
SUPPORTING SCHEDULES
SS-2 EMPLOY EE BENEFITS
FICA Taxes : 949,243
Unemploy ment Compensation : 68,771
Workers Compensation : 417,806
Group Health Insurance : 1,526,539
Group Lif e Insurance : 0
Pension & Retirement : 484,561
Other Employ ee Benef its : 0
Other Employ ee Benef its : 0
Total 3,446,920
SS-3 RENTAL AND LEASE EXPENSE
Rental & Lease Exp - Bldgs : 0
Rental & Lease Exp - Equip : 317,694
Total 317,694
SS-5 INSURANCE EXPENSE
Hospital & Prof Malpractice : 344,398
Other Insurance : 68,259
Total 412,657
LICENSE AND TAXES
License Fees : 399,800
Taxes (other than income) : 19,287
Other : 0
Total 419,087
SS-6 INTEREST EXPENSE
Interest Expense - WC : 373,380
Interest Expense - Other : 145,103
Total 518,483
SS-4 DEPRECIATION EXPENSE
FIXED ASSETS
Beg. Balance Additions Retirement Ending Balance
Land 647,866 0 0 647,866
Land Improv ements 110,507 0 0 110,507
Buildings 24,688,338 886,561 0 25,574,899
Fixed Equipment - Bldg Srv 608,311 0 0 608,311
Fixed Equipment - Other 61,518 0 0 61,518
Equip - Major Mov eable 8,440,412 1,308,871 0 9,749,283
Equip - Minor 1,152,439 0 0 1,152,439
Leasehold Improv ements 0 0 0 0
Construction In Progress 341,574 0 328,103 13,471
Total 36,050,965 2,195,432 328,103 37,918,294
ACCUMULATED DEPRECIATION
Beg. Balance Additions Retirement Ending Balance
Land
Land Improv ements 61,716 11,128 0 72,844
Buildings 4,911,441 938,401 0 5,849,842
Fixed Equipment - Bldg Srv 428,571 31,625 0 460,196
Fixed Equipment - Other 41,915 3,052 0 44,967
Equip - Major Mov eable 2,161,736 1,605,102 0 3,766,838
Equip - Minor 991,658 129,669 0 1,121,327
Leasehold Improv ements 0 0 0 0
Construction In Progress 0 0 0 0
Total 8,597,037 2,718,977 0 11,316,014
SS-8 DEDUCTIONS FROM REVENUE
Contractuals
Medicare : 22,864,594
Medicaid : 2,978,089
Workers Comp : 0
Other Gov ernment Programs : 475
Negotiated Rate : 0
Other : 3,974,409
Total Contractuals 29,817,567
Charity Care
Number of Charity Care Patients : 792
Inpatient Charity Care Prov ided : 335,923
Outpatient Charity Care Prov ided : 604,793
Total Charity Care Prov ided 940,716
Other Deductions
Administrativ e Adjustments : 173,067
Other Deductions : 2,692
Total Other Deductions 175,759
Total Deductions From Rev enue 30,934,042
FS - 1 BALANCE SHEET (Assets)
CURRENT ASSETS:
Cash : 5,812,870
Marketable Securities : 7,500,851
Accounts Receiv able : 10,797,840
Less-Est. Uncoll. & Allow. : 4,723,000
Rec. From 3rd Party Pay ers : 594,473
Pledges & Other Receiv ables : 136,125
Due From Restricted Funds : 0
Inv entory : 1,508,362
Prepaid Expenses : 171,602
Current Portion of FHT : 0
Total Current Assets 21,799,123
BOARD DESIGNATED ASSETS
Cash : 71,939
Marketable Securities : 0
Other Assets : 0
Total BDA 71,939
PROP, PLANT, & EQUIP
Land : 647,866
Land Improv ements : 110,507
Buildings : 25,574,899
Fixed Equip - Bldg Srv : 608,311
Fixed Equip - Other : 61,518
Equipment : 10,901,722
Leasehold Improv ements : 0
Construction In Progress : 13,470
Total P P & E 37,918,293
Less Accum. Depreciation : 11,316,014
Net P P & E 26,602,279
INVESTMENTS & OTHER ASSETS
Inv estments In P P & E : 107,283
Less - Accum Depre :
Other Inv estments : 431,374
Other Assets : 334,647
Total Inv est. & Other Assets 873,304
INTANGIBLE ASSETS
Goodwill : 0
Unamortized Loan Costs : 0
Preopening & Other Org Costs : 0
Other Intangible Assets : 0
Total Intangible Assets 0
Total Assets 49,346,645
FS - 1 BALANCE SHEET ( Liabilities)
CURRENT LIABILITIES
Notes and Loans Pay able : 60,017
Accounts Pay able : 1,779,441
Accrued Compensation : 415,618
Other Accrued Expenses : 636,326
Adv ances From 3rd Parties : 0
Pay ables to 3rd Party Pay ers : 1,694,078
Due to Restricted Funds : 0
Income Taxes Pay able : 0
Other Current Liabilities : 902,174
Current Maturities of LTD : 0
Total Current Liabilities 5,487,654
DEFERRED CREDITS
Def erred Income Taxes : 0
Def erred 3rd Party Rev enue : 0
Other Def erred Credits : 0
Total Def erred Credits 0
LONG TERM DEBT
Mortgage Pay able : 14,157,031
Construction Loans - Interim : 0
Notes Pay able : 0
Capitalized Lease Obligations : 0
Bonds Pay able : 0
Notes and Loans Pay able to Parent : 0
Noncurrent Liabilities : 0
Total 14,157,031
Less Current Maturities LTD 0
Total Long Term Debt 14,157,031
Unrestricted Fund Balance : 29,590,833
Pref erred Stock : 0
Common Stock : 0
Additional Paid In Capital : 111,127
Retained Earnings : 0
Less: Treasury Stock : 0
Total Liab & Fund Bal or Equity 49,346,645
Check Figure Total Assets 49,346,645
FS - 3 STATEMENT OF REVENUE & EXPENSE
OPERATING REVENUE
Inpatient Rev enue : 26,985,108
Outpatient Rev enue : 45,208,640
Total Patient Serv ices Rev enue 72,193,748
DEDUCTIONS FROM REVENUE
Contractual Adjustments : 29,817,567
Charity & Uncompensated Care : 940,716
Other Adj. & Allowances : 175,759
Total Deductions From Rev enue 30,934,042
Net Patient Serv ice Rev enue 41,259,706
OTHER OPERATING REVENUE
Other Operating Rev enue : 1,784,561
Tax Rev enues : 0
Total Other Operating Rev 1,784,561
Total Operating Rev enue 43,044,267
FS - 3 STATEMENT OF REVENUE & EXPENSE
Salaries and Wages : 13,008,155
Employ ee Benef its : 3,446,920
Prof essional Fees : 2,913,126
Supplies : 10,835,899
Purch Srv - Utilities : 710,171
Purch Srv - Other : 3,107,483
Depreciation : 2,761,005
Rentals/Leases : 317,694
Insurance : 412,658
License & Taxes : 419,086
Interest : 518,483
Prov ision f or Bad Debts 966,819
Other Direct Expense : 1,287,390
Total Operating Expenses 40,704,889
Net Operating Rev enue 2,339,378
Non Operating Rev Net of Exp : 661,118
Net Rev . Bef ore Items Listed Below 3,000,496
Extraordinary Items : 0
Federal Income Taxes : 0
Net Rev enue or (Expense) 3,000,496
EDIT
Tri-State Memorial Hopsital H-0 FY E 12/31/2007
VOLUME: Inf o Page Pay er CC Detail
Hospital Admissions 1,592 1,592
Hospital Patient Day s 6,369 6,369 7,006
SNF/Swing Admissions 84 84
SNF/Swing Patient Day s 637 637 0
ATC Admissions 0 0
ATC Patient Day s 0 0 0
Newborn Admissions 0
Newborn Patient Day s 0 0
OPERATING EXPENSES: FS-3 CC Detail Support Sched.
Salaries 13,008,155 13,008,155
Employ ee Benef its 3,446,920 3,446,920 3,446,920
Prof essional Fees 2,913,126 2,913,126
Supplies 10,835,899 10,835,899
Purch Srv - Utilities 710,171 710,171
Purch Srv - Other 3,107,483 3,107,483
Depreciation 2,761,005 2,761,006 2,718,977
Leases/Rentals 317,694 317,694 317,694
Insurance 412,658 412,657
Licenses & Taxes 419,086 419,087
Interest 518,483 518,483
Ins, Lic. & Taxes, and Interest 1,350,227 1,350,227 1,350,227
Bad Debt Expense 966,819 966,819
Other Direct Expense 1,287,390 1,287,390
Total Other Direct Expense 2,637,617 2,637,617
Total Expenses 40,704,889 40,704,890
DEDUCTIONS: SS-8 FS-3
Contractuals 29,817,567 29,817,567
Charity Care 940,716 940,716
Other Deductions 175,759 175,759
Total Other Deductions 30,934,042 30,934,042
CHARITY CARE Deductions
From Rev enue
Support Sched.
# Of Patients 792
Inpatient 335,923
Outpatient 604,793
OTHER REVENUES: FS-3 CC-DETAIL
Other Rev enue 1,784,561 1,784,561
Tax Rev enue 0 0
PATIENT SERVICE REVENUE: PAY ER
FS-3 CC-DETAIL INFO
IP Rev enue 26,985,108 26,985,108 26,985,108
OP Rev enue 45,208,640 45,208,640 45,208,640
Gross Rev enue 72,193,748 72,193,748 72,193,748
FIXED ASSET ENDING BALANCES: FS-1 SS-4
Land 647,866 647,866
Land Improv ements 110,507 110,507
Buildings 25,574,899 25,574,899
Fixed Equip - Bldg Serv 608,311 608,311
Fixed Equip - Other 61,518 61,518
Equipment (Mov eable) 10,901,722 10,901,722
Leasehold Improv ements 0 0
Construction In Progress 13,470 13,471
Total 37,918,293 37,918,294
Accum Depre Ending Balance 11,316,014 11,316,014
Balance Sheet
FS-1 Assets 49,346,645
FS-1 Liabilities & Fund Balance 49,346,645
The actual operating expenses and units of measure are presented f or the past two y ears in columns B-E.
The operating expenses per unit of measure are presented in columns F and G.
If the percentage change in operating expenses v aries by more or less than 25 %, the v ariance appears in column H.
If the percentage change is more or less than 25%., please prov ide an explanation that is prov ided as an attachment with y our
y ear end report submittal. Also please prov ide any corrections required to the prior y ears inf ormation.
Tri-State Memorial Hopsital 2006 2007 2006 2007 2006 2007
Operating Operating Units of Units of Op Exp / Op Exp / % chg
Expense Expense Measure Measure UOM UOM <> 25%
6010 Intensiv e Care 1,092,722 1,101,399 1,688 1,740 647.35 632.99
6030 Semi-Intensiv e Care 0 0 0 0
6070 Acute Care 2,676,016 3,207,129 5,065 5,266 528.33 609.03
6100 Alternativ e Birthing Center 0 0 0 0
6120 Phy sical Rehabilitation 0 0 0 0
6140 Psy chiatric Care 0 0 0 0
6150 Chemical Dependency 0 0 0 0
6170 Nursery 0 0 0 0
6200 Skilled Nursing 0 0 0 0
6210 Swing Beds 0 0 749 0
6330 Hospice Inpatient 0 0 0 0
6400 Other Daily Serv ices 0 0 0 0
7010 Labor Deliv ery 0 0 0 0
7020 Surgical Serv ices 1,697,313 2,223,889 389,149 433,961 4.36 5.12
7030 Recov ery Room 252,500 298,835 124,740 153,840 2.02 1.94
7040 Anesthesiology 523,816 788,814 389,149 433,961 1.35 1.82 35.04% Hired a MD Anesthesiologist @ TSMH as an employ ee.
7050 Central Serv ices 3,927,694 6,283,660 N/A N/A
7060 Intrav enous Therapy 0 0 N/A N/A
7070 Laboratory 1,436,456 1,670,504 69,846 79,247 20.57 21.08
7110 Electrodiagnosis 0 0 0 0
7120 Magnetic Resonance Imaging 0 0 0 0
7130 Ct Scanning 0 0 0 0
7140 Radiology - Diagnostic 2,383,689 2,699,734 191,197 202,392 12.47 13.34
7150 Radiology - Therapeutic 0 0 0 0
7160 Nuclear Medicine 0 0 0 0
7170 Pharmacy 2,399,576 2,807,823 N/A N/A
7180 Respiratory Therapy 544,415 519,300 26,765 27,040 20.34 19.20
7190 Dialy sis 1,349,914 1,496,758 32,308 39,684 41.78 37.72
7200 Phy sical Therapy 123,505 143,816 2,443 3,022 50.55 47.59
7220 Psy chiatric Day Care 0 0 0 0
7230 Emergency Room 2,385,089 2,683,576 14,980 15,104 159.22 177.67
7240 Ambulance 0 7,653 0 0
7250 Short Stay 0 100,921 0 687 146.90
7260 Clinics 2,776,202 2,992,863 9,390 10,661 295.66 280.73
7310 Occupational Therapy 0 0 189 0
7320 Speech Therapy 19,702 13,786 209 132 94.27 104.44
7330 Recreational Therapy 0 0 0 0
7340 Electromy ography 0 0 0 0
7350 Observ ation Unit 0 0 0 4,961
7380 Free-Standing Clinics 0 0 0 0
7390 Air Transportation 0 0 0 0
7400 Home Care Serv ices 1,197,393 1,097,548 6,840 12,596 175.06 87.13 -50.23% Experienced a signif icant drop in patient census.
7410 Lithotripsy 0 0 0 0
7420 Organ Transplants 0 0 0 0
7430 Outpatient Chem. Dep. 0 0 0 0
7490 Other Ancillary 0 233,897 N/A N/A
8200 Research / Education 0 0 N/A N/A
8310 Printing & Duplication 0 0 N/A N/A
8320 Dietary 851,300 942,431 23,899 26,236 35.62 35.92
8330 Caf eteria 0 0 120,508 124,073
8350 Laundry & Linen 183,770 204,355 0 0
8360 Social Serv ices 64,090 21,366 N/A N/A
8370 Central Transportation 0 0 N/A N/A
8420 Purchasing 239,212 297,826 N/A N/A
8430 Plant 2,150,991 1,314,574 106,138 106,138 20.27 12.39 -38.89% Completed construction on new Imaging / Emergency Department
8460 Housekeeping 488,319 510,716 N/A N/A
8470 Communication 0 0 N/A N/A
8480 Data Processing 0 466,006 N/A N/A
8490 Other General Serv ices 0 0 N/A N/A
8510 Accounting 291,879 288,641 N/A N/A
8530 Patient Accounts 686,945 777,306 N/A N/A
8560 Admitting 131,167 148,216 N/A N/A
8590 Other Fiscal Serv ices 0 0 N/A N/A
8610 Hospital Administration 865,796 884,318 N/A N/A
8620 Employ ee Health 0 0 N/A N/A
8630 Public Relations 355,801 363,547 N/A N/A
8640 Management Engineering 0 0 N/A N/A
8650 Personnel 147,037 160,048 N/A N/A
8660 Auxiliary Groups 8,851 0 N/A N/A
8670 Chaplaincy Serv ices 0 0 N/A N/A
8680 Medical Library 0 0 N/A N/A
8690 Medical Records 611,987 688,972 N/A N/A
8700 Medical Staf f 0 0 N/A N/A
8710 Utilization Management 0 30,956 N/A N/A
8720 Nursing Administration 334,496 219,299 N/A N/A
8730 Nursing Float Personnel 0 0 N/A N/A
8740 Inserv ice Education 53,136 55,982 N/A N/A
8770 Comm. Health Education 78,460 85,666 N/A N/A
8790 Other Admin. Serv ices 0 555,714 N/A N/A
8830-8900 Unassigned Other Direct 787,463 532,485 N/A N/A
DIRECT 102,381 36,249,039 10,621,161 26,236 244.81 24,685 317,948 72,193,748 84.07
OP EXP SQ FT ACCUM COST SUPPLIES MEALS SRV F T E'S HRS OF SRV DRY LBS GROSS REV NRS F T E'S
8430 Plant 1,314,574 +BE
Unassigned Expenses 532,485 1,847,059 +CD
8310 Printing & Duplication 0 0 +AX
8510 Accounting 288,641 0 +BJ
8470 Communications 0 0 +BG
8610 Hospital Administration 884,318 105,937 +BN
8790 Other Administrativ e Serv ices555,714 326,867 +CC
8630 Public Relations 363,547 60,600 +BP
8770 Community Health Education 85,666 0 +CB
8640 Management Engineering 0 0 2,671,290 +BQ
8420 Purchasing 297,826 59,247 26,314 383,386 +BD
8320 Dietary 942,431 60,744 73,927 11,516 1,088,618 +AY
8650 Personnel 160,048 0 11,794 252 0 +BR
8620 Employ ee Health Serv ices 0 0 0 0 0 +BO
8330 Caf eteria 0 0 0 0 0 172,094 +AZ
8460 Housekeeping 510,716 26,178 39,565 2,098 0 9,504 588,061 +BF
8350 Laundry & Linen 204,355 0 15,059 0 0 337 0 219,752 +BA
8200 Research & Education 0 0 0 0 0 0 0 0 +AW
8360 Social Serv ices 21,366 7,505 2,128 18 0 134 0 0 +BB
8370 Central Transportation 0 0 0 0 0 0 0 0 +BC
8490 Other General Serv ices 0 0 0 0 0 0 27,587 10,320 +BI
8530 Patient Accounts 777,306 49,126 60,902 1,827 0 8,780 0 0 +BK
8480 Data Processing 466,006 0 34,341 533 0 1,800 0 0 +BH
8560 Admitting 148,216 9,760 11,642 579 0 2,474 0 0 +BL
8590 Other Fiscal Serv ices 0 0 0 0 0 0 0 0 +BM
8660 Auxiliary Groups 0 0 0 0 0 0 0 0 +BS
8670 Chaplaincy Serv ices 0 0 0 0 0 0 0 0 +BT
8680 Medical Library 0 0 0 0 0 0 0 0 +BU
8690 Medical Records 688,972 23,904 52,534 505 0 10,249 0 0 +BV
8700 Medical Staf f 0 0 0 0 0 0 0 0 +BW
8710 Medical Care Ev aluation 30,956 0 2,281 4 0 337 0 0 2,452,092 +BX
8720 Nursing Administration 219,299 0 16,161 129 0 1,645 0 0 0 +BY
8730 Nursing Float Personnel 0 0 0 0 0 0 0 0 0 +BZ
8740 Inserv ice Education 55,982 0 4,125 530 0 703 0 0 0 298,574 +CA
8,548,424
DIRECT TOTAL
OP EXP SQ FT ACCUM COST SUPPLIES MEALS SRV F T E'S HRS OF SRV DRY LBS GROSS REV NRS F T E'S ALLOCATION
6010 Intensiv e Care 1,101,399 39,113 84,047 1,286 109,542 9,687 29,945 11,187 51,289 33,349 369,446 +C
6030 Semi-Intensiv e Care 0 0 0 0 0 0 0 0 0 0 0 +D
6070 Acute Care 3,207,129 127,171 245,714 4,818 979,076 28,133 89,811 33,562 142,011 94,434 1,744,730 +E
6100 Alternativ e Birthing Center 0 0 0 0 0 0 0 0 0 0 0 +F
6120 Phy sical Rehabilitation 0 0 0 0 0 0 0 0 1,076 0 1,076 +G
6140 Psy chiatric Care 0 0 0 0 0 0 0 0 0 0 0 +H
6150 Alcoholism Treatment 0 0 0 0 0 0 0 0 0 0 0 +I
6170 Nursery 0 0 0 0 0 0 0 0 0 0 0 +J
6200 Skilled Nursing 0 0 0 0 0 0 0 0 0 0 0 +K
6210 Swing Beds 0 0 0 0 0 0 0 0 0 0 0 +L
6330 Hospice Care 0 0 0 0 0 0 0 0 0 0 0 +M
6400 Other Daily Serv ices 0 0 0 0 0 0 0 0 0 0 0 +N
7010 Labor and Deliv ery 0 0 0 0 0 0 0 0 0 0 0 +O
7020 Surgical Serv ices 2,223,889 238,593 181,467 6,913 0 16,281 129,428 48,362 152,053 60,766 833,862 +P
7030 Recov ery Room 298,835 19,196 23,437 232 0 2,777 0 0 23,610 9,838 79,088 +Q
7040 Anesthesiology 788,814 0 58,130 1,603 0 703 0 0 27,364 0 87,799 +R
7050 Central Serv ices 6,283,660 15,533 464,205 216,191 0 2,250 28,849 10,778 553,902 0 1,291,708 +S
7060 Intrav enous Therapy 0 0 0 0 0 0 0 0 0 0 0 +T
7070 Laboratory 1,670,504 11,185 123,928 54 0 0 0 0 187,598 0 322,765 +U
7110 Electrodiagnosis 0 0 0 0 0 0 0 0 0 0 0 +V
7120 Magnetic Resonance 0 0 0 0 0 0 0 0 0 0 0 +W
7130 CT Scanning 0 0 0 0 0 0 0 0 0 0 0 +X
7140 Radiology - Diagnostic 2,699,734 202,384 213,865 5,922 0 18,868 45,358 16,948 350,874 0 854,219 +Y
7150 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 +Z
7160 Nuclear Medicine 0 0 0 0 0 0 0 0 0 0 0 +AA
7170 Pharmacy 2,807,823 15,046 208,025 81,064 0 3,121 0 0 290,379 0 597,635 +AB
7180 Respiratory Therapy 519,300 13,675 39,276 2,617 0 4,126 0 0 45,444 0 105,140 +AC
7190 Dialy sis 1,496,758 78,551 116,089 15,840 0 11,922 72,421 27,063 167,009 21,451 510,346 +AD
7200 Phy sical Therapy 143,816 0 10,598 0 0 0 0 0 10,737 0 21,335 +AE
7220 Psy chiatric Day Care 0 0 0 0 0 0 0 0 0 0 0 +AF
7230 Emergency Room 2,683,576 116,888 206,374 2,446 0 14,657 84,380 31,535 171,001 39,351 666,631 +AG
7240 Ambulance 7,653 0 564 0 0 0 0 0 229 0 793 +AH
7250 Short Stay 100,921 5,196 7,820 465 0 970 1,143 426 19,973 2,486 38,480 +AI
7260 Clinics 2,992,863 154,125 231,910 23,777 0 16,133 79,139 29,571 213,129 19,143 766,927 +AJ
7310 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 +AK
7320 Speech Therapy 13,786 0 1,016 0 0 0 0 0 0 0 1,016 +AL
7330 Recreational Therapy 0 0 0 0 0 0 0 0 0 0 0 +AM
7340 Electromy ography 0 0 0 0 0 0 0 0 0 0 0 +AN
7350 Observ ation Unit 0 0 0 0 0 0 0 0 7,624 0 7,624 +AO
7380 Free Standing Clinics 0 0 0 0 0 0 0 0 0 0 0 +AP
7390 Air Transportation 0 0 0 0 0 0 0 0 0 0 0 +AQ
7400 Home Care Serv ices 1,097,548 80,535 86,816 2,129 0 6,502 0 0 36,569 17,757 230,310 +AR
7410 Lithotripsy 0 0 0 0 0 0 0 0 0 0 0 +AS
7420 Organ Acquisitions 0 0 0 0 0 0 0 0 0 0 0 +AT
7430 Outpatient Chemical Dependency 0 0 0 0 0 0 0 0 0 0 0 +AU
7490 Other Ancillary 233,897 0 17,237 37 0 0 0 0 222 0 17,495 +AV
38,920,329 1,847,059 2,671,290 383,386 1,088,618 172,094 588,061 219,752 2,452,092 298,574 8,548,425 Total Allocations Made
38,920,329 1,847,059 2,671,290 383,386 1,088,618 172,094 588,061 219,752 2,452,092 298,574 8,548,424 Total Costs To Be Allocated
Support
@ID Y EBSFIC Y EBSSUC Y EBSUTC Y EBSGHI Y EBSGLI Y EBSPRO Y EBSOTH Y BLDRL Y EQRL Y INSMAL Y INSOTR Y LIFE Y TXOTI Y OTHLT Y INTEWC Y INTOTH FABBLAN FAALAN FARETLAN FABBLIM FAALIM FARETLIM FABBBLD FAABLD FARETBLD FABBFE FAAFE FARETFE FABBFEO FAAFEO FARETFEO FABBMME FAAMME FARETMME FABBME FAAME FARETME FABBLHI FAALHI FARETLHI FABBCIP FAACIP FARETCIP ADBBLAN ADTPLAN ADRETLAN ADBBLIM ADTPLIM ADRETLIM ADBBBLD ADTPBLD ADRETBLD ADBBFE ADTPFE ADRETFE ADBBFEO ADTPFEO ADRETFEO ADBBMME ADTPMME ADRETMME ADBBME ADTPME ADRETME ADBBLHI ADTPLHI ADRETLHI ADBBCIP ADTPCIP
108*2007*A 949,243 68,771 417,806 1,526,539 0 484,561 0 0 317,694 344,398 68,259 399,800 19,287 0 373,380 145,103 647,866 0 0 110,507 0 0 24,688,338 886,561 0 608,311 0 0 61,518 0 0 8,440,412 1,308,871 0 1,152,439 0 0 0 0 0 341,574 0 328,103 0 0 0 61,716 11,128 0 4,911,441 938,401 0 428,571 31,625 0 41,915 3,052 0 2,161,736 1,605,102 0 991,658 129,669 0 0 0 0 0 0
Hospital
@ID Y ADMISAP Y ADMSNF Y ADMATC Y BIRTHS Y HPDY S Y SPDY S Y APDY S Y NBDY S Y IC Y SIC Y ACMS Y ACPED Y ACOB Y ACREH Y PSY Y SNF Y SWI Y ATC Y ICF Y OTH Y TBL Y BAS PUSAMAR PUSPMAR PUSOMAR PRVIMAR PRVOMAR PUSAMAI PUSPMAI PUSOMAI PRVIMAI PRVOMAI PUSAOTH PUSPOTH PUSOOTH PRVIOTH PRVOOTH PUSAMARS PUSPMARS PUSOMARS PRVIMARS PRVOMARS PUSAMAIS PUSPMAIS PUSOMAIS PRVIMAIS PRVOMAIS PUSAOTHS PUSPOTHS PUSOOTHS PRVIOTHS PRVOOTHS PUSAMARA PUSPMARA PUSOMARA PRVIMARA PRVOMARA PUSAMAIA PUSPMAIA PUSOMAIA PRVIMAIA PRVOMAIA PUSAOTHA PUSPOTHA PUSOOTHA PRVIOTHA PRVOOTHA PHBPREV PHBPEXP
108*2007*A 1,592 84 0 0 6,369 637 0 0 4 0 21 0 0 0 0 0 0 0 0 0 61 0 1,116 4,570 43,338 17,912,802 27,027,911 93 399 6,229 1,625,325 3,874,256 383 1,400 23,888 6,534,401 14,306,473 82 613 0 891,758 0 1 21 0 18,181 0 1 3 0 2,641 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Funds
@ID Y BSCASH Y BSMS Y BSAR Y BSUNC Y BSOREC Y BSPOR Y BSDFR Y BSINV Y BSPRE Y BSCPFHT Y BSBDAC Y BSBDAM Y BSBDAO Y BSPPEL Y BSPPELI Y BSPPEB Y BSPPEFB Y BSPPEFO Y BSPPEEQ Y BSPPELH Y BSPPECP Y BSPPEOP Y BSPPELAD Y BSIOIPPE Y BSIOLAD Y BSIOOI Y BSIOOA Y BSIAG Y BSIAULC Y BSIAPOOC Y BSIAOIA Y BSNLP Y BSAP Y BSACRL Y BSOAE Y BSAPP Y BSPPP Y BSDRF Y BSITP Y BSOCL Y BSCMLT Y BSDIT Y BSDPR Y BSODC Y BSLTMP Y BSLTCLI Y BSLTNP Y BSLTCLO Y BSLTBP Y BSLTPP Y BSLTNL Y BSLTOLTD Y BSUFB Y BSEPS Y BSECS Y BSEAPC Y BSERE Y BSETS Y BSEOE Y CSFTE Y CSIPR Y CSOPR Y CSCA Y CSCUC Y CSOAA Y CSOOR Y CSTR Y CSSLS Y CSEBS
108*2007*A 5,812,870 7,500,851 10,797,840 4,723,000 594,473 136,125 0 1,508,362 171,602 0 71,939 0 0 647,866 110,507 25,574,899 608,311 61,518 10,901,722 0 13,470 0 11,316,014 107,283 0 431,374 334,647 0 0 0 0 60,017 1,779,441 415,618 636,326 0 1,694,078 0 0 902,174 0 0 0 0 14,157,031 0 0 0 0 0 0 0 29,590,833 0 0 0 111,127 0 0 284.14 26,985,108 45,208,640 29,817,567 940,716 175,759 1,784,561 0 13,008,155 3,446,920
Costcenter
@ID Y UTS Y FTE Y SLS Y EBS Y PFS Y SUP Y PSU Y PSO Y DRL Y RL Y ODE Y REC Y REV Y IRV SPSF SDMS SHHS SLDP SHNF Y UNAS Y UNABD Y UNAREC Y TAX SNAR Y CAS
108*2007*6010*A 1,740 13.78 750,748 198,934 0 35,616 0 0 56,397 355 59,349 0 1,510,045 1,503,398 2,168 2,640 1,257 16,187 9.39 369,446
108*2007*6030*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*6070*A 5,266 40.02 1,846,855 489,382 332,534 133,472 0 8,075 183,368 7,957 205,486 0 4,181,047 4,107,158 7,049 23,596 3,770 48,559 26.59 1,744,730
108*2007*6100*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*6120*A 0 0.00 0 0 0 0 0 0 0 0 0 0 31,680 31,680 0 0 0 0 0.00 1,076
108*2007*6140*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*6150*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*6170*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*6200*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*6210*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*6330*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*6400*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*7010*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*7020*A 433,961 23.16 1,267,322 335,817 0 191,510 0 11,722 344,027 1,006 72,485 0 4,476,692 1,731,668 13,225 0 5,433 69,972 17.11 833,862
108*2007*7030*A 153,840 3.95 208,590 55,272 0 6,422 0 0 27,678 0 873 0 695,109 298,405 1,064 0 0 0 2.77 79,088
108*2007*7040*A 433,961 1.00 316,707 83,921 314,878 44,405 600 16,872 0 0 11,431 0 805,633 307,450 0 0 0 0 0.00 87,799
108*2007*7050*A 3.20 94,064 24,925 0 5,989,268 0 0 22,397 26,923 126,083 0 16,307,816 10,737,493 861 0 1,211 15,594 0.00 1,291,708
108*2007*7060*A 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*7070*A 79,247 0.00 0 0 0 1,487 0 1,488,617 16,128 0 164,272 0 5,523,204 2,544,058 620 0 0 0 0.00 322,765
108*2007*7110*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*7120*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*7130*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*7140*A 202,392 26.84 1,246,436 330,282 40 164,059 0 624,540 291,818 5,070 37,489 0 10,330,315 1,102,487 11,218 0 1,904 24,521 0.00 854,219
108*2007*7150*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*7160*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*7170*A 4.44 331,985 87,970 60,585 2,245,760 0 9,980 21,695 22,535 27,313 0 8,549,238 2,397,377 834 0 0 0 0.00 597,635
108*2007*7180*A 27,040 5.87 324,935 86,102 0 72,513 0 11,150 19,718 471 4,411 0 1,337,959 1,126,149 758 0 0 0 0.00 105,140
108*2007*7190*A 39,684 16.96 685,377 181,612 0 438,837 0 32,374 113,262 18,190 27,106 0 4,917,025 133,003 4,354 0 3,040 39,156 6.04 510,346
108*2007*7200*A 3,022 0.00 0 0 143,816 0 0 0 0 0 0 0 316,122 313,746 0 0 0 0 0.00 21,335
108*2007*7220*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*7230*A 15,104 20.85 959,073 254,137 1,202,832 67,768 0 3,567 168,540 0 27,659 0 5,034,555 144,506 6,479 0 3,542 45,627 11.08 666,631
108*2007*7240*A 0 0.00 0 0 0 0 0 7,653 0 0 0 0 6,739 6,739 0 0 0 0 0.00 793
108*2007*7250*A 687 1.38 63,516 16,831 0 12,883 0 0 7,492 0 199 0 588,047 8,624 288 0 48 616 0.70 38,480
108*2007*7260*A 10,661 22.95 1,180,088 312,701 543,913 658,717 3,123 21,550 222,232 3,736 46,803 0 6,274,886 488,271 8,543 0 3,322 42,785 5.39 766,927
108*2007*7310*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*7320*A 132 0.00 0 0 13,786 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 1,016
108*2007*7330*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*7340*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*7350*A 4,961 0.00 0 0 0 0 0 0 0 0 0 0 224,451 2,896 0 0 0 0 0.00 7,624
108*2007*7380*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*7390*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*7400*A 12,596 9.25 478,383 126,763 6,000 58,985 10,544 267,735 83,557 16,363 49,218 0 1,076,661 0 4,464 0 0 0 5.00 230,310
108*2007*7410*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*7420*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*7430*A 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00 0
108*2007*7490*A 0.00 0 0 0 1,030 0 229,945 0 0 2,922 0 6,524 0 0 0 0 0 0.00 17,495
108*2007*8200*A 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00
108*2007*8310*A 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00
108*2007*8320*A 26,236 14.05 416,639 110,402 0 319,043 0 2,454 87,587 0 6,306 0 3,367 0 0 0 0.00
108*2007*8330*A 124,073 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00
108*2007*8350*A 0 0.48 11,481 3,042 0 0 0 189,832 0 0 0 0 0 0 0 0 0.00
108*2007*8360*A 0.19 7,482 1,983 0 508 0 0 10,822 0 571 0 416 0 0 0 0.00
108*2007*8370*A 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00
108*2007*8420*A 5.31 161,073 42,681 0 5,512 0 0 85,428 137 2,995 0 3,284 0 0 0 0.00
108*2007*8430*A 106,138 6.03 265,548 70,365 0 176,913 444,076 57,202 130,301 137,151 33,018 0 5,009 0 0 0 0.00
108*2007*8460*A 13.52 323,867 85,819 0 58,127 0 0 37,745 0 5,158 0 1,451 0 0 0 0.00
108*2007*8470*A 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00
108*2007*8480*A 2.56 110,318 29,232 0 14,763 247,562 2,348 0 0 61,783 0 0 0 0 0 0.00
108*2007*8490*A 0.00 0 0 0 0 0 0 0 0 0 0 0 0 1,158 14,931 0.00
108*2007*8510*A 2.00 148,988 39,479 77,814 3,701 0 14,727 0 181 3,751 0 0 0 0 0 0.00
108*2007*8530*A 12.49 393,611 104,300 101,385 50,607 0 0 70,834 37,682 18,887 0 2,723 0 0 0 0.00
108*2007*8560*A 3.52 87,850 23,279 0 16,050 0 2,418 14,073 742 3,804 0 541 0 0 0 0.00
108*2007*8590*A 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00
108*2007*8610*A 3.37 337,915 89,541 115,543 5,912 2,717 0 152,750 2,301 177,639 0 5,872 0 0 0 0.00
108*2007*8620*A 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00
108*2007*8630*A 3.01 71,661 18,989 0 14,747 1,549 100,455 87,379 4,918 63,849 0 3,359 0 0 0 0.00
108*2007*8640*A 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00
108*2007*8650*A 2.00 113,431 30,057 0 6,978 0 0 0 0 9,582 0 0 0 0 0 0.00
108*2007*8660*A 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00
108*2007*8670*A 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00
108*2007*8680*A 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00
108*2007*8690*A 14.58 476,573 126,283 0 13,978 0 0 34,468 31,469 6,201 0 1,325 0 0 0 0.00
108*2007*8700*A 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00
108*2007*8710*A 0.48 20,083 5,322 0 112 0 0 0 0 5,439 0 0 0 0 0 0.00
108*2007*8720*A 2.34 159,690 42,315 0 3,582 0 0 0 507 13,205 0 0 0 0 0 0.00
108*2007*8730*A 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00
108*2007*8740*A 1.00 31,860 8,442 0 14,681 0 0 0 0 999 0 0 0 0 0 0.00
108*2007*8770*A 1.00 57,724 15,296 0 3,357 0 4,267 0 0 5,022 0 0 0 0 0 0.00
108*2007*8790*A 2.56 58,282 15,444 0 4,596 0 0 471,310 0 6,082 0 18,118 0 0 0 0.00
108*2007*9000*A 1,350,227 966,819 1,784,561 0 912,580
Upload Costcenter 284.14 13,008,155 3,446,920 2,913,126 10,835,899 710,171 3,107,483 2,761,006 317,694 2,637,617 1,784,561 72,193,748 26,985,108 107,390 26,236 24,685 317,948 84.07 1,350,227 966,819 1,784,561 0 912,580 8,548,425
CC's 284.14 13,008,155 3,446,920 2,913,126 10,835,899 710,171 3,107,483 2,761,006 317,694 2,637,617 1,784,561 72,193,748 26,985,108 107,390 26,236 24,685 317,948 84.07 NA NA NA NA NA 8,548,424
FS-3 ---------------- 13,008,155 3,446,920 2,913,126 10,835,899 710,171 3,107,483 2,761,005 317,694 2,637,617 1,784,561 72,193,748 26,985,108
8660 8670 8680 8690 8700 8710 8720 8730 8740 8770 8790 8830-8900 9999
Auxiliary Chaplaincy Medical Medical Medical Utilization Nursing Nursing Float Inserv ice Comm. Health Other Grand
Groups Serv ices Library Records Staf f Management Administration Personnel Education Education Admin Serv ices Total
0
0 0 0 126,283 0 5,322 42,315 0 8,442 15,296 15,444 3,446,920
0
0 0 0 34,468 0 0 0 0 0 0 471,310 2,793,573
8660 8670 8680 8690 8700 8710 8720 8730 8740 8770 8790 8830-8900 9999
Auxiliary Chaplaincy Medical Medical Medical Utilization Nursing Nursing Float Inserv ice Comm. Health Other Unassigned Grand
Groups Serv ices Library Records Staf f Management Administration Personnel Education Education Admin Serv ices Other Direct Total
xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx
14.58 0.48 2.34 1.00 1.00 2.56 xxxxxxxxxxx 284.14
476,573 20,083 159,690 31,860 57,724 58,282 xxxxxxxxxxx 13,008,155
0 0 0 126,283 0 5,322 42,315 0 8,442 15,296 15,444 xxxxxxxxxxx 3,446,920
xxxxxxxxxxx 2,913,126
13,978 112 3,582 14,681 3,357 4,596 xxxxxxxxxxx 10,835,899
xxxxxxxxxxx 710,171
4,267 xxxxxxxxxxx 3,107,483
0 0 0 34,468 0 0 0 0 0 0 471,310 xxxxxxxxxxx 2,761,006
31,469 507 xxxxxxxxxxx 317,694
xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx 966,819 966,819
6,201 5,439 13,205 999 5,022 6,082 1,350,227 2,637,617
1,784,561 1,784,561
0 0 0 688,972 0 30,956 219,299 0 55,982 85,666 555,714 532,485 38,920,329
xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx
xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx 26,985,108
xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx 45,208,640
xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx 72,193,748
1,325 18,118 xxxxxxxxxxx 107,390 (1,252)
xxxxxxxxxxx xxxxxxxxxxx 26,236 0
xxxxxxxxxxx xxxxxxxxxxx 24,685
xxxxxxxxxxx xxxxxxxxxxx 317,948 0
xxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxx 84.07
ADRETCIP Y DRMAR Y DRMAI Y DRWC Y DROGP Y DRNR Y DROCA Y DRNCCP Y DRIPC Y DROPC Y DROD
0 22,864,594 2,978,089 0 475 0 3,974,409 792 335,923 604,793 175,759
Y CSPFS Y CSSUP Y CSPSU Y CSPSO Y CSDRL Y CSRL Y CSINS Y CSLT Y CSINT Y CSPBD Y CSODE Y CSNORNE Y CSEI Y CSFIT
2,913,126 10,835,899 710,171 3,107,483 2,761,005 317,694 412,658 419,086 518,483 966,819 1,287,390 661,118 0 0
