2010 078

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2010 078 Powered By Docstoc
					Below is the input format for the budget year projections. If you have any questions please call Randy Huyck @ (360) 236-4210 or email
randall.huyck@doh.wa.gov

The budget projections should be supplied 30 days prior to the beginning of the hospital's fiscal year or as soon thereafter as practical.

The input begins in column B on line 24.




                                                Hospital Information
Fiscal Year Ending                              12/31/2010
License Number                                  078
Hospital Name                                   Samaritan Hospital
Street Address                                  801 East Wheeler Road
Mailing Address
City, State, Zip                                Moses Lake, WA 98837
County                                          Grant
Chief Executive Officer                         Andrew Bair
Chief Financial Officer                         Daniel Smith
Chair of Governing Board                        Mike Bolander
Telephone Number                                (506) 765-5606
Facsimile Number                                (509) 764-6507

TYPE OF ORGANIZATION (If applies enter 1)
                                                    Governmental
State
County
District                                        X
                                                    Not For Profit
Church Operated
Other
                                                      For Profit
Individual
Partnership
Corporation

ACTUAL UTILIZATION                                  Admissions        Patient Days
ICU, SICU, ACUTE, PSYCH                                     3,460              9,604
Skilled Nursing/Swing
Chemical Dependency/ATC
Number of Births                                              1,150           2,137
NUMBER OF BEDS AVAILABLE                               Beds
Intensive Care                                                           9
Semi-Intensive Care
Acute Care - Med/Srg                                                    24
Acute Care - Pediatrics
Acute Care - Obstetrics                                                 14
Acute Care - Rehab
Psychiatric
Skilled Nursing
Chemical Dependency/ATC
Other (Exclude Nursery)
Total Beds Available                                                                      47
Total Beds Licensed                                                     50
Nursery - Bassinets                                                     10

Budgeted Hospital FTE's                                            402.53

Skilled Nursing / Swing Bed Revenue

Skilled Nursing Ancillary Revenue

Chemical Dependency / ATC Inpatient Revenue


      Codes
1     Separately organized, staffed and equipped unit of hospital.
2     Service maintained in hospital.
3     Service Contracted but Hospsital based.
4     Service not maintained in hospital but available for outside contractor or other hospital.
5     Service not provided in hospital but shared with another hospital under contract.
6     Service not available.
7     Clinic services are commonly provided in the emergency suite to non-emergency outpatients by hospital based
       physicians or residents.
8     Service available at but not billed by the hospital.
9     Service available, but not used during reporting cycle.

                                                       Intensive Care Services
003      Burn                                                            6
002      Coronary                                                        6
001      Medical /Surgical                                               1
005      Neonatal                                                        6
185      Neurosurgical                                                   6
004      Pediatric                                                       2
006      Pulmonary                                                       2
008      Semi-Intensive Care                                             2
                                                         Acute Care Services
186      Alternative Birthing Center (Licensed Beds)                     2
013      Geriatric                                                       2
009      Medical                                                         2
021      Neonatal                                                        6
187      Oncology                                                        6
188      Orthopedic                                                      2
011      Pediatric                                                       2
030      Physical Rehabilitation                                         2
012      Post Partum                                                     1
010      Surgical                                                        2
                                                       Newborn Care Services
023      Developmentally Disabled Nursery Care                           6
022      Newborn Nursery Care                                            1
024      Premature Nursery Care                                          2
189      Hospice Care                                                    6
014   Inpatient Care Under Custody (Jail)                            6
                                                      Long-Term Care
190   Behavior Disorder Care                                         6
033   Developmentally Disabled Care                                  6
031   Intermediate Care                                              6
032   Residential / Custodial Care                                   6
034   Self Care                                                      6
028   Skilled Nursing Care                                           6
180   Sub-Acute Care                                                 6
                                            Chemical Dependency - Detoxification
191   Alcohol                                                        6
192   Drug                                                           6
                                            Chemical Dependency - Rehabilitation
193   Alcohol                                                        6
194   Drug                                                           6
                                                   Psychiatric Services
195   Acute - Adult                                                  6
196   Acute - Adolescent and Child                                   6
025   Intensive (Isolation) Care                                     6
027   Long - Term Care                                               6
                                                     Obstetric Services
059   Abortion Services                                              6
058   Alternative Birthing Room                                      1
057   Labor and Delivery Room Services                               1
197   Infertility Services                                           6
                                                     Surgery Services
061   Dental                                                         6
198   General                                                        1
066   Gynecologic                                                    2
199   Heart                                                          6
200   Kidney                                                         6
071   Neurosurgical                                                  6
068   Open Heart                                                     6
072   Ophthalmologic                                                 2
201   Organ Transplant - Heart                                       6
067   Organ Transplant - Kidney                                      6
202   Organ Transplant - Liver                                       6
203   Organ Transplant - Lung                                        6
204   Organ Transplant - Pancreas                                    6
073   Orthopedic                                                     2
064   Otolaryngolic                                                  2
205   Pediatric                                                      2
065   Plastic                                                        6
062   Podiatry                                                       2
206   Thoracic                                                       6
063   Urologic                                                       2
075   Anesthesia Services                                            1
                                                   Laboratory Services
077   Anatomical Pathology                                           4
083   Autopsy Services                                               8
079   Chemistry                                                      2
207   Clinical Pathology                                             4
208   Cytology                                                       2
078   Hematology                                                     2
209   Histocompatibility                                             2
210   Immunology                                                     2
082   Microbiology                                                   2
080   Serology                                                       2
211   Surgical Pathology                                           2
081   Urinalysis                                                   2
                                             Diagnostic Imaging Services
094   Computed Tomography                                          1
070   Cystoscopy                                                   2
212   Magnetic Resonance Imaging                                   1
213   Positive Emission Tomography                                 6
214   Ultrasonography                                              1
090   X-ray Examination                                            1
                                           Diagnostic / Therapeutic Services
181   Audiology                                                    6
215   Biofeedback Therapy                                          6
069   Cardiac Catheterization                                      6
092   Cobalt Therapy                                               6
095   Diagnostic Radioisotope                                      6
216   Echocardiology                                               2
088   Electrocardiography                                          2
087   Electroencephalography                                       6
089   Electromyography                                             6
217   Endoscopy                                                    2
218   Gastro-Intestinal Laboratory                                 6
116   Hyperbaric Chamber Services                                  6
219   Lithotripsy                                                  6
220   Nuclear Medicine                                             1
109   Occupational Therapy                                         4
108   Physical Therapy                                             1
221   Peripheral Vascular Laboratory                               6
084   Pulmonary Function Services                                  1
222   Radiation Therapy                                            6
093   Radium Therapy                                               6
223   Radioactive Implants                                         6
111   Recreational Therapy                                         6
112   Rehabilitation Therapy                                       6
105   Respiratory Therapy                                          1
110   Speech - Language Pathology                                  8
224   Sports Care Medicine                                         6
225   Stress Testing                                               1
096   Therapeutic Radioisotope                                     6
091   X-ray Radiology Therapy                                      6
                                                 Psychiatric Services
114   Clinic Psychologist Services                                 6
226   Child Care Services                                          6
104   Electroconvulsive Therapy (Shock)                            6
035   Night Care                                                   6
113   Psychiatric Therapy                                          6
100   Psychopharmacological Therapy                                6
156   Sheltered Workshop                                           6
115   Social Therapy                                               6
                                                    Renal Dialysis
227   Home Dialysis Support Services                               6
106   Inpatient Renal Dialysis                                     6
107   Outpatient Renal Dialysis                                    4
228   Self Dialysis Training                                       6
085   Organ Acquisition                                            6
117   Blood Collection and Processing                              6
229   Extra Corporeal Membrane Oxygenation                         6
230   Pharmacy                                                     1
                                                Emergency Services
045   Emergency Communications System                                 4
047   Emergency Helicopter Service                                    4
043   Emergency Observation Service                                   2
038   Emergency Room Service                                          1
231   Heliport                                                        2
039   Land Ambulance Transportation                                   4
040   Mobile Cardiac Care Service                                     6
232   Orthopedic Emergency Service                                    2
042   Psychiatric Emergency Services                                  6
046   Radioactive Decontamination Room                                6
044   Trauma Treatment Service                                        2
048   24-Hour Coverage by Paid Physician                              1
                                                       Clinic Services
233   Aids                                                            6
139   Alcoholism                                                      6
123   Allergy                                                         6
118   Cardiology                                                      4
119   Chest Medical                                                   6
140   Child Diagnosis                                                 6
141   Child Treatment                                                 6
120   Communicable Disease                                            6
138   Dental                                                          6
121   Dematology                                                      2
122   Diabetes                                                        6
142   Drug Abuse                                                      6
143   Family Therapy                                                  6
144   Group Therapy                                                   6
130   Hypertension                                                    6
124   Metabolic                                                       6
125   Neurology                                                       6
127   Neonatal                                                        6
234   Obesity                                                         6
129   Obstetrics                                                      2
135   Opthamology                                                     6
133   Orthopedic                                                      6
136   Otolaryngology                                                  6
126   Pediatric                                                       6
137   Podiatry                                                        2
183   Physical Medicine                                               6
128   Psychiatric                                                     6
132   Renal                                                           6
131   Rheumatic                                                       6
235   Rural Health                                                    1
182   Urology                                                         6
                                                     Home Care Services
050   Home Health Aide Services                                       6
049   Home Nursing Care (Visiting Nurse)                              6
051   Home Physical Medicine Care                                     6
052   Home Social Service Care                                        6
053   Home Dialysis Training                                          6
056   Home Hospice Care                                               6
236   Home I.V. Therapy Services                                      6
054   Jail Care                                                       6
055   Psychiatric Foster Home Care                                    6
                                                     Ambulatory Services
037   Adult Day Health Care Center                                    6
074   Ambulatory Surgery Services                                     1
237   Comprehensive Outpatient Rehabilitation Srv.                    6
238    Observation (Short Stay) Care                                     6
239    Satellite Ambulatory Surgery Center                               6
184    Satellite Clinic Services                                         6
                                                           Other Services
147    Cancer / Tumor Registry                                           1
159    Chapel Maintained                                                 1
158    Chaplaincy Services                                               6
152    Diabetic Training Class                                           2
150    Dietetic Counseling                                               2
146    Drug Reaction Information                                         6
148    Family Planning                                                   6
160    Full Time Chief of Staff                                          6
149    Genetic Counseling                                                6
157    Hospital Auxilary                                                 2
154    Medical Research                                                  6
151    Parent Training Class                                             6
240    Patient Representative                                            2
153    Public Health Class                                               6
115    Social Work Services                                              1
145    Toxicology / Antidote Information                                 6
155    Vocational Services                                               6



A If the Hospital provides a Clinical Setting for College/University based programs,
   enter an "X".

B If the Hospital has a Educational Program, as defined by Medicare,
   enter the number of Participants.

C If the Hospital's Program is an accredited program, enter an "X".


                                                                 A                     B   C
161    Approved Residency
241    Approved Fellowship
242    Non-Approved Residency
243    Associate Records Technician
174    Diagnostic Radiologic Technologist                        X
175    Dietetic Intern Program
163    Emergency Medical Technician
176    Hospital Administration Program
167    Licensed Practical Nurse
169    Medical Technologist Program                              X
244    Medical Records Administrator
177    Medical records Technologies
168    Nurse Anesthetist
245    Nurse Practitioneer
246    Nurse Midwife
171    Occupational Therapist
172    Pharmacy Intern                                           X
164    Physicians Assistant
173    Physical Therapist
165    Registered Nurse (Baccalaureate)                          X
166    Registered Nurse (Other)                                  X
170    Respiratory Therapist
178    Social Worker Program
                                           Deductions From Revenue
Medicare                                            23,578,189
Medicaid                                            10,475,987
Workers Comp                                          2,241,327
Other Government Programs                               407,551
Negotiated Rate                                     12,498,115
Other                                                 9,928,082
Total Contractuals                                                   59,129,251

                                                 Charity Care
Inpatient Charity Care Provided                      2,060,928
Outpatient Charity Care Provided                       144,794

Total Charity Care Provided                                            2,205,722

                                               Other Deductions
Administrative Adjustments                             336,520
Other Deductions
Total Other Deductions                                                  336,520

Total Deductions From Revenue                                        61,671,493


                                       FS - 1 BALANCE SHEET (Assets)
                                              CURRENT ASSETS:
Cash                                                2,233,564
Marketable Securities
Accounts Receivable                                 17,230,391
Less-Est. Uncoll. & Allow.                           9,490,499
Rec. From 3rd Party Payors
Pledges & Other Receivables                             65,700
Due From Restricted Funds
Inventory                                              354,900
Prepaid Expenses                                     1,180,785
Current Portion of FHT
Total Current Assets                                                 11,574,841
                                        BOARD DESIGNATED ASSETS
Cash                                             18,434,188
Marketable Securities
Other Assets
Total BDA                                                            18,434,188


                                   FS - 1 BALANCE SHEET (Assets Continued)
                                            PROP, PLANT, & EQUIP
Land                                                  829,861
Land Improvements                                     340,687
Buildings                                          46,619,052
Fixed Equip - Bldg Srv                              3,733,904
Fixed Equip - Other
Equipment                                           27,715,246
Leasehold Improvements
Construction In Progress
Total P P & E                                                        79,238,750
Less Accum. Depreciation                            40,715,411
Net P P & E                                                     38,523,339
                                       INVESTMENTS & OTHER ASSETS
Investments In P P & E
Less - Accum Depre
Other Investments
Other Assets                                             32,676
Total Invest. & Other Assets                                                 32,676

                                              INTANGIBLE ASSETS
Goodwill
Unamortized Loan Costs
Preopening & Other Org Costs
Other Intangible Assets
Total Intangible Assets                                                          0

Total Assets                                                           68,565,044

                                       FS - 1 BALANCE SHEET ( Liabilities)
                                              CURRENT LIABILITIES
Notes and Loans Payable
Accounts Payable                                      1,276,015
Accrued Compensation                                  4,086,889
Other Accrued Expenses                                1,769,642
Advances From 3rd Parties
Payables to 3rd Party Payors
Due to Restricted Funds
Income Taxes Payable
Other Current Liabilities
Current Maturities of LTD                             1,224,813
Total Current Liabilities                                               8,357,359
                                              DEFERRED CREDITS
Deferred Income Taxes
Deferred 3rd Party Revenue
Other Deferred Credits
Total Deferred Credits                                                           0

                                               LONG TERM DEBT
Mortgage Payable
Construction Loans - Interim
Notes Payable
Capitalized Lease Obligations
Bonds Payable                                        20,318,498
Notes and Loans Payable to Parent
Noncurrent Liabilities
Total                                                                  20,318,498
Less Current Maturities LTD                                             1,224,813
Total Long Term Debt                                                   19,093,685

                                                    EQUITY
Unrestricted Fund Balance                            41,114,000

Preferred Stock
Common Stock
Retained Earnings
Additional Paid In Capital
Less: Treasury Stock
Total Liab & Fund Bal or Equity                                        68,565,044

Check Figure Total Assets                                              68,565,044

                                    FS - 3 STATEMENT OF REVENUE & EXPENSE
                                        OPERATING REVENUE
Inpatient Revenue                             51,739,095
Outpatient Revenue                            74,042,760
Total Patient Services Revenue                             125,781,855
                                     DEDUCTIONS FROM REVENUE
Contractual Adjustments                       59,465,771
Charity & Uncompensated Care                   2,205,722
Other Adj. & Allowances
Total Deductions From Revenue                                  61,671,493
Net Patient Service Revenue                                    64,110,362
                                     OTHER OPERATING REVENUE
Other Operating Revenue                        1,624,090
Tax Revenues                                   1,609,634
Total Other Operating Rev                                       3,233,724
Total Operating Revenue                                        67,344,086

                                       OPERATING EXPENSES
Salaries and Wages                            27,846,239
Employee Benefits                              8,024,099
Professional Fees                              3,429,688
Supplies                                       9,853,176
Purch Srv - Utilities                            500,212
Purch Srv - Other                              1,982,039
Depreciation                                   4,245,000
Rentals/Leases                                   833,487
Insurance                                        970,900
License & Taxes
Interest                                       1,041,462
Provision For Bad Debts                        4,559,102
Other Direct Expense                           2,505,666
Total Operating Expenses                                       65,791,070
Net Operating Revenue                                           1,553,016
Non Operating Rev Net of Exp                     270,000
Net Rev. Before Items Listed Below                              1,823,016
Extraordinary Items
                                       0
Net Revenue or (Expense)                                        1,823,016
                            TRANSMITTAL AND CERTIFICATION
                              HOSPITAL'S ANNUAL REPORT


                                               TO:

                                     The Department of Health
                                Office of Hospital and Patient Data

                                        P.O. Box 47814
                                Olympia, Washington 98504-7814

                                            FROM:
Name of Hospital            :   Samaritan Hospital
License Number              :   H-078
Street Address              :   801 East Wheeler Road
Mailing Address             :          0
City and Zip Code           :   Moses Lake, WA 98837

                       CERTIFICATION OF OFFICER OF HOSPITAL
I HEREBY CERTIFY that I have examined the accompanying Hospital Annual Budget
                                                                12/31/2010
as specified by the Department of Health for the fiscal year ending

To the best of my knowledge and belief, they are true and correct statements
prepared from the books and records of the Hospital in accordance with applicable
instructions.

X
Signature of Chief Executive Officer
Name/Title: Andrew Bair
Date       :


X
Signature of Chair of Governing Board
Name/Title: Mike Bolander
Date       :
DOH - OHPD                                              November 1, 2003            Page 1 of 9
                                          HOSPITAL INFORMATION


   1 Fiscal Year Ending: 12/31/2010                                    License Number: H-078
   2 Hospital Name                       Samaritan Hospital
   3 County                              Grant
   4 Executive Officer                   Andrew Bair
   5 Financial Officer                   Daniel Smith
   6 Chair of Gov Brd                    Mike Bolander
   7 Telephone #                         (506) 765-5606
   8 Facsimile #                         (509) 764-6507


   9 TYPE OF ORGANIZATION HAVING CONTROL (check one only)
      Governmental                       Not For Profit                              For Profit
      State                          Church Op.                        Individual
      County                         Other                             Partnership
      City/County                                                      Corporation
  X   Hosp. Dist.


  10 ACTUAL UTILIZATION                                                    Admissions             Patient Days
      Intensive, Semi-Intensive, Acute & Psychiatric                                  3,460                 9,604
      Skilled Nursing Facility / Swing                                                     0                     0
      Chemical Dependency / ATC                                                            0                     0


  11 Number of Births and Newborn Days                                                1,150                 2,137


  12 # of Beds Available                         Beds           # of Beds Available                  Beds
      Intensive Care                                          9 Skilled Nursing                                  0
      Semi -Intensive Care                                    0 Chemical Dependency                              0
      Acute - Medical / Surg                              24 Other (Excl Nursery)                                0
      Acute - Pediatrics                                      0 Total Beds Available                             47
      Acute - Obstetrical                                 14 (Excluding Nursery)
      Acute - Rehabilitation                                  0 Total Beds Licensed                              50
      Psychiatric                                             0 Nursery - Bassinets                              10


  13 Budget Hospital F T E's                                                                                 403
  14 Skilled Nursing / Swing Bed Revenue                                                                       0
  15 Skilled Nursing Ancillary Revenue                                                                         0
  16 Chemical Dependency / Alcoholic Treatment Inpatient Revenue                                                 0
DOH - OHPD                                          November 1, 2003                              Page 2 of 9
                                        Services Inventory

Hospital: Samaritan Hospital                            Budget Period Ending 12/31/2010
                                                        License Number: H-078
             Daily Hospital Services                                      Obstetric Services
            Intensive Care Services                     059    Abortion Services                    6
003    Burn                                     6       058    Alternative Birthing Room            1
002   Coronary                                  6       057    Labor and Delivery Room Services     1
001   Medical /Surgical                         1       197    Infertility Services                 6
005   Neonatal                                  6                          Surgery Services
185   Neurosurgical                             6       061    Dental                               6
004   Pediatric                                 2       198    General                              1
006   Pulmonary                                 2       066    Gynecologic                          2
008   Semi-Intensive Care                       2       199    Heart                                6
              Acute Care Services                       200    Kidney                               6
186                                             2
      Alternative Birthing Center (Licensed Beds)       071    Neurosurgical                        6
013   Geriatric                                 2       068    Open Heart                           6
009   Medical                                   2       072    Ophthalmologic                       2
021   Neonatal                                  6       201    Organ Transplant - Heart             6
187   Oncology                                  6       067    Organ Transplant - Kidney            6
188   Orthopedic                                2       202    Organ Transplant - Liver             6
011   Pediatric                                 2       203    Organ Transplant - Lung              6
030   Physical Rehabilitation                   2       204    Organ Transplant - Pancreas          6
012   Post Partum                               1       073    Orthopedic                           2
010   Surgical                                  2       064    Otolaryngolic                        2
         Newborn Care Services                          205    Pediatric                            2
023   Developmentally Disabled Nursery Care 6           065    Plastic                              6
022   Newborn Nursery Care                      1       062    Podiatry                             2
024   Premature Nursery Care                    2       206    Thoracic                             6
189   Hospice Care                              6       063    Urologic                             2
014   Inpatient Care Under Custody (Jail)       6       075    Anesthesia Services                  1
                Long-Term Care                                           Laboratory Services
190   Behavior Disorder Care                    6       077    Anatomical Pathology                 4
033   Developmentally Disabled Care             6       083    Autopsy Services                     8
031   Intermediate Care                         6       079    Chemistry                            2
032   Residential / Custodial Care              6       207    Clinical Pathology                   4
034   Self Care                                 6       208    Cytology                             2
028   Skilled Nursing Care                      6       078    Hematology                           2
180   Sub-Acute Care                            6       209    Histocompatibility                   2
     Chemical Dependency - Detoxification               210    Immunology                           2
191   Alcohol                                   6       082    Microbiology                         2
192   Drug                                      6       080    Serology                             2
     Chemical Dependency - Rehabilitation               211    Surgical Pathology                   2
193   Alcohol                                   6       081    Urinalysis                           2
194   Drug                                      6                  Diagnostic Imaging Services
              Psychiatric Services                      094    Computed Tomography                  1
195   Acute - Adult                             6       070    Cystoscopy                           2
196   Acute - Adolescent and Child              6       212    Magnetic Resonance Imaging           1
025   Intensive (Isolation) Care                6       213    Positive Emission Tomography         6
027   Long - Term Care                          6       214    Ultrasonography                      1
                                                        090    X-ray Examination                    1
DOH - OHPD                                   November 1,2003                                    Page 3 of 9
   Codes
1 Separately organized, staffed and equipped unit of hospital.
2 Service maintained in hospital.
3 Service Contracted but Hospital based.
4 Service not maintained in hospital but available for outside contractor or other hospital.
5 Service not provided in hospital but shared with another hospital under contract.
6 Service not available.
7 Clinic services are commonly provided in the emergency suite to non-emergency outpatients by hospital based
    physicians or residents.
8 Service available at but not billed by the hospital.
9 Service available, but not used during reporting cycle.
                                               Services Inventory

Hospital: Samaritan Hospital                             Budget Period Ending: 12/31/2010
                                                         License Number: H-078
           Diagnostic / Therapeutic Services             229    Extra Corporeal Membrane Oxygenation         6
181    Audiology                                   6     230    Pharmacy                                     1
215    Biofeedback Therapy                         6                     Emergency Services
069    Cardiac Catheterization                     6     045    Emergency Communications System              4
092    Cobalt Therapy                              6     047    Emergency Helicopter Service                 4
095    Diagnostic Radioisotope                     6     043    Emergency Observation Service                2
216    Echocardiology                              2     038    Emergency Room Service                       1
088    Electrocardiography                         2     231    Heliport                                     2
087    Electroencephalography                      6     039    Land Ambulance Transportation                4
089    Electromyography                            6     040    Mobile Cardiac Care Service                  6
217    Endoscopy                                   2     232    Orthopedic Emergency Service                 2
218    Gastro-Intestinal Laboratory                6     042    Psychiatric Emergency Services               6
116    Hyperbaric Chamber Services                 6     046    Radioactive Decontamination Room             6
219    Lithotripsy                                 6     044    Trauma Treatment Service                     2
220    Nuclear Medicine                            1     048    24-Hour Coverage by Paid Physician           1
109    Occupational Therapy                        4                        Clinic Services
108    Physical Therapy                            1     233    Aids                                         6
221    Peripheral Vascular Laboratory              6     139    Alcoholism                                   6
084    Pulmonary Function Services                 1     123    Allergy                                      6
222    Radiation Therapy                           6     118    Cardiology                                   4
093    Radium Therapy                              6     119    Chest Medical                                6
223    Radioactive Implants                        6     140    Child Diagnosis                              6
111    Recreational Therapy                        6     141    Child Treatment                              6
112    Rehabilitation Therapy                      6     120    Communicable Disease                         6
105    Respiratory Therapy                         1     138    Dental                                       6
110    Speech - Language Pathology                 8     121    Dermatology                                  2
224    Sports Care Medicine                        6     122    Diabetes                                     6
225    Stress Testing                              1     142    Drug Abuse                                   6
096    Therapeutic Radioisotope                    6     143    Family Therapy                               6
091    X-ray Radiology Therapy                     6     144    Group Therapy                                6
                Psychiatric Services                     130    Hypertension                                 6
114    Clinic Psychologist Services                6     124    Metabolic                                    6
226    Child Care Services                         6     125    Neurology                                    6
104    Electroconvulsive Therapy (Shock)           6     127    Neonatal                                     6
035    Night Care                                  6     234    Obesity                                      6
113    Psychiatric Therapy                         6     129    Obstetrics                                   2
100    Psychopharmacological Therapy               6     135    Opthamology                                  6
156    Sheltered Workshop                          6     133    Orthopedic                                   6
115    Social Therapy                              6     136    Otolaryngology                               6
                   Renal Dialysis                        126    Pediatric                                    6
227    Home Dialysis Support Services              6     137    Podiatry                                     2
106    Inpatient Renal Dialysis                    6     183    Physical Medicine                            6
107    Outpatient Renal Dialysis                   4     128    Psychiatric                                  6
228    Self Dialysis Training                      6     132    Renal                                        6
085    Organ Acquisition                           6     131    Rheumatic                                    6
117    Blood Collection and Processing             6     235    Rural Health                                 1
                                                         182    Urology                                      6
DOH - OHPD                                      November 1,2003                                    Page 4 of 9
  Codes
1 Separately organized, staffed and equipped unit of hospital.
2 Service maintained in hospital.
3 Service Contracted but Hospital based.
4 Service not maintained in hospital but available for outside contractor or other hospital.
5 Service not provided in hospital but shared with another hospital under contract.
6 Service not available.
7 Clinic services are commonly provided in the emergency suite to non-emergency outpatients by hospital based
   physicians or residents.
8 Service available at but not billed by the hospital.
9 Service available, but not used during reporting cycle.
                                                         Services Inventory

Hospital: Samaritan Hospital                                    Budget Period Ending: 12/31/2010
                                                                License Number: H-078
                      Home Care Services                                                Medical Education Programs
050    Home Health Aide Services                            6   Code Category as Description Indicates
049    Home Nursing Care (Visiting Nurse)                   6   A If the Hospital provides a Clinical Setting for College/University based program
051    Home Physical Medicine Care                          6       enter an "X".
052    Home Social Service Care                             6   B If the Hospital has a Educational Program, as defined by Medicare,
053    Home Dialysis Training                               6       enter the number of Participants.
056    Home Hospice Care                                    6   C If the Hospital's Program is an accredited program, enter an "X".
236    Home I.V. Therapy Services                           6                  Program Title                     A          B           C
054    Jail Care                                            6   161    Approved Residency
055    Psychiatric Foster Home Care                         6   241    Approved Fellowship
                  Ambulatory Services                           242    Non-Approved Residency
037    Adult Day Health Care Center                         6   243    Associate Records Technician
074    Ambulatory Surgery Services                          1   174    Diagnostic Radiologic Technologist        X
237    Comprehensive Outpatient Rehabilitation Services 6       175    Dietetic Intern Program
238    Observation (Short Stay) Care                        6   163    Emergency Medical Technician
239    Satellite Ambulatory Surgery Center                  6   176    Hospital Administration Program
184    Satellite Clinic Services                            6   167    Licensed Practical Nurse
                      Other Services                            169    Medical Technologist Program              X
147    Cancer / Tumor Registry                              1   244    Medical Records Administrator
159    Chapel Maintained                                    1   177    Medical Records Technologist
158    Chaplaincy Services                                  6   168    Nurse Anesthetist
152    Diabetic Training Class                              2   245    Nurse Practitioner
150    Dietetic Counseling                                  2   246    Nurse Midwife
146    Drug Reaction Information                            6   171    Occupational Therapist
148    Family Planning                                      6   172    Pharmacy Intern                           X
160    Full Time Chief of Staff                             6   164    Physicians Assistant
149    Genetic Counseling                                   6   173    Physical Therapist
157    Hospital Auxiliary                                   2   165    Registered Nurse (Baccalaureate)          X
154    Medical Research                                     6   166    Registered Nurse (Other)                  X
151    Parent Training Class                                6   170    Respiratory Therapist
240    Patient Representative                               2   178    Social Worker Program
153    Public Health Class                                  6
115    Social Work Services                                 1
145    Toxicology / Antidote Information                    6
155    Vocational Services                                  6
DOH - OHPD                                              November 1, 2003                                                                 Page 5 o
    Codes
1 Separately organized, staffed and equipped unit of hospital.
2 Service maintained in hospital.
3 Service Contracted but Hospital based.
4 Service not maintained in hospital but available for outside contractor or other hospital.
5 Service not provided in hospital but shared with another hospital under contract.
6 Service not available.
7 Clinic services are commonly provided in the emergency suite to non-emergency outpatients by hospital based
     physicians or residents.
8 Service available at but not billed by the hospital.
9 Service available, but not used during reporting cycle.
                 DEDUCTIONS FROM REVENUE                 FYE: 12/31/2010
Hospital: Samaritan Hospital                             Lic.#.: H-078

        ACCT:                           Item:                  Budget Year
    1                          Contractual Adjustments
    2     5810 Medicare                                                  23,578,189
    3     5820 Medicaid                                                  10,475,987
    4     5830 Workers Compensation                                       2,241,327
    5     5840 Other Government Programs                                   407,551
    6     5850 Negotiated Rates                                          12,498,115
    7     5860 Other                                                      9,928,082
    8           Total Contractual Adjustments                            59,129,251
    9
   10                               Charity Care
   11     5900 Inpatient Charity Care Provided                            2,060,928
   12     5910 Outpatient Charity Care Provided                            144,794
   13
   14
   15                             Total Charity Care                      2,205,722
   16
   17     5970 Administrative Adjustments                                  336,520
   18
   19     5980 Other Deductions (specify)                                        0
   20 TOTAL DEDUCTIONS FROM REVENUE                                      61,671,493
   21 Explanations




DOH - OHPD                        November 1,2003               Page 6 of 9
                  FS-1 BALANCE SHEET - UNRESTRICTED FUND
HOSPITAL: Samaritan Hospital                               FYE: 12/31/2010
                                         ASSETS            Lic.#: H-078
          1                          CURRENT ASSETS:
          2 Cash                                                           2,233,564
          3 Marketable Securities                                                 0
          4 Accounts Receivable                                           17,230,391
          5 Less-Estimated Uncollectable & Allowances                      9,490,499
          6 Receivables From Third Party Payors                                   0
          7 Pledges And Other Receivables                                    65,700
          8 Due From Restricted Funds                                             0
          9 Inventory                                                       354,900
        10 Prepaid Expenses                                                1,180,785
        11 Current Portion Of Funds Held In Trust                                 0
        12 TOTAL CURRENT ASSETS                                           11,574,841
        13
        14                     BOARD DESIGNATED ASSETS:
        15 Cash                                                           18,434,188
        16 Marketable Securities                                                  0
        17 Other Assets                                                           0
        18 TOTAL BOARD DESIGNATED ASSETS:                                 18,434,188
        19
        20                PROPERTY, PLANT AND EQUIPMENT:
        21 Land                                                             829,861
        22 Land Improvements                                                340,687
        23 Buildings                                                      46,619,052
        24 Fixed Equipment - Building Service                              3,733,904
        25 Fixed Equipment - Other                                                0
        26 Equipment                                                      27,715,246
        27 Leasehold Improvements                                                 0
        28 Construction In Progress                                               0
        29 TOTAL                                                          79,238,750
        30 Less Accumulated Depreciation                                  40,715,411
        31 NET PROPERTY, PLANT & EQUIPMENT                                38,523,339
        32
        33                INVESTMENTS AND OTHER ASSETS:
        34 Investments In Property, Plant & Equipment                             0
        35 Less - Accumulated Depreciation                                        0
        36 Other Investments                                                      0
        37 Other Assets                                                      32,676
        38 TOTAL INVESTMENTS & OTHER ASSETS                                  32,676
        39
        40                          INTANGIBLE ASSETS:
        41 Goodwill                                                               0
        42 Unamortized Loan Costs                                                 0
        43 Preopening And Other Organization Costs                                0
        44 Other Intangible Assets                                                0
        45 TOTAL INTANGIBLE ASSETS                                                 0
        46 TOTAL ASSETS                                                   68,565,044
DOH - OHPD                            November 1,2003            Page 7 of 9
                          BALANCE SHEET - UNRESTRICTED FUND
HOSPITAL: Samaritan Hospital                                    FYE: 12/31/2010
                   LIABILITIES AND FUND BALANCES-UNRESTRICTED   Lic.#: H-078
          1                         CURRENT LIABILITIES
          2 Notes and Loans Payable                                                    0
          3 Accounts Payable                                                    1,276,015
          4 Accrued Compensation and Related Liabilities                        4,086,889
          5 Other Accrued Expenses                                              1,769,642
          6 Advances from Third Party Payors                                           0
          7 Payables to Third Party Payors                                             0
          8 Due to Restricted Funds                                                    0
          9 Income Taxes Payable                                                       0
        10 Other Current Liabilities                                                   0
        11 Current Maturities of Long Term Debt                                 1,224,813
        12 TOTAL CURRENT LIABILITIES                                            8,357,359
        13
        14                          DEFERRED CREDITS:
        15 Deferred Income Taxes                                                       0
        16 Deferred Third Party Revenue                                                0
        17 Other Deferred Credits                                                      0
        18 TOTAL DEFERRED CREDITS                                                      0
        19
        20                             LONG TERM DEBT
        21 Mortgage Payable                                                            0
        22 Construction Loans-Interim Financing                                        0
        23 Notes Payable                                                               0
        24 Capitalized Lease Obligations                                               0
        25 Bonds Payable                                                       20,318,498
        26 Notes and Loans Payable to Parent                                           0
        27 Noncurrent Liabilities                                                      0
        28 TOTAL                                                               20,318,498
        29 Less Current Maturities of Long Term Debt                            1,224,813
        30 TOTAL LONG TERM DEBT                                                19,093,685
        31
        32                   UNRESTRICTED FUND BALANCE                         41,114,000
        33
        34                     EQUITY (INVESTOR OWNED)
        35 Preferred Stock
        36
        37 Common Stock
        38
        39 Additional Paid In Stock                                                    0
        40
        41 Retained Earnings (Capital Account for Partnership                          0
        42             (or Sole Proprietorship)
        43
        44 Less Treasury Stock
        45 TOTAL EQUITY                                                        41,114,000
        46 TOTAL LIABILITIES AND FUND BALANCE OR EQUITY                        68,565,044
DOH - OHPD                             November 1,2003                Page 8 of 9
          COMPARISON STATEMENT OF REVENUE & EXPENSE - UNRESTRICTED FUNDS
HOSPITAL: Samaritan Hospital                                  FYE: 12/31/2010
                                                              Lic.#: H-078
          1                       OPERATING REVENUE:
          2 Inpatient Revenue                                                51,739,095
          3 Outpatient Revenue                                               74,042,760
          4 TOTAL PATIENT SERVICES REVENUE                               125,781,855
          5
          6                    DEDUCTIONS FROM REVENUE:
          7 Contractual Adjustments                                          59,465,771
          8 Charity and Uncompensated Care                                    2,205,722
          9 Other Adjustments and Allowances                                         0
        10 TOTAL DEDUCTIONS FROM REVENUE                                     61,671,493
        11 NET PATIENT SERVICE REVENUE                                       64,110,362
        12
        13                     OTHER OPERATING REVENUE
        14 Other Operating Revenue                                            1,624,090
        15 Tax Revenues                                                       1,609,634
        16 TOTAL OTHER OPERATING REVENUE                                      3,233,724
        17 TOTAL OPERATING REVENUE                                           67,344,086
        18
        19                       OPERATING EXPENSES
        20 Salaries and Wages                                                27,846,239
        21 Employee Benefits                                                  8,024,099
        22 Professional Fees                                                  3,429,688
        23 Supplies                                                           9,853,176
        24 Purchased Services - Utilities                                      500,212
        25 Purchased Services - Other                                         1,982,039
        26 Depreciation                                                       4,245,000
        27 Rentals and Leases                                                  833,487
        28 Insurance                                                           970,900
        29 License and Taxes                                                         0
        30 Interest                                                           1,041,462
        31 Provision For Bad Debts                                            4,559,102
        32 Other Direct Expenses                                              2,505,666
        33 TOTAL OPERATING EXPENSES                                          65,791,070
        34 NET OPERATING REVENUE                                              1,553,016
        35
        36 NON-OPERATING REVENUE-NET OF EXPENSES                               270,000
        37
        38 NET REVENUE BEFORE ITEMS LISTED BELOW                              1,823,016
        39
        40 EXTRAORDINARY ITEM                                                        0
        41 FEDERAL INCOME TAX                                                        0
        42
        43 NET REVENUE OR (EXPENSE)                                           1,823,016
        44 EXPLANATION:
        45
DOH - OHPD                            November 1,2003               Page 9 of 9

				
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