2021-04-14T15:53:33-05:00 2019-12-31 160765486 LUMSDEN & MCCORMICK LLP 369 FRANKLIN STREET BUFFALO NY 14202 990 2019-01-01 160743102 OLEAN GENERAL HOSPITAL OLEA 7163756104 515 MAIN ST OLEAN NY 14760 JEFFREY ZEWE PRESIDENT/CEO 7163756104 2021-04-13 1 JILL M JOHNSON CPA P01701478 7168563300 2021-04-13 2019 2022-09-23 18:48:47Z JEFFREY ZEWE 515 MAIN ST OLEAN NY 14760 194179389 0 X WWW.OGH.ORG X 1898 NY THE MISSION OF OLEAN GENERAL HOSPITAL TO PROVIDE EXCELLENT CARE IN RESPONSE TO THE HEALTH CARE NEEDS OF THE OLEAN, NY AND BRADFORD, PA COMMUNITIES. IN SUPPORT OF THIS MISSION, OLEAN GENERAL HOSPITAL IS COMMITTED TO THE FOLLOWING:- COMPASSION: OUR SYMPATHETIC AWARENESS OF EACH PERSON'S NEEDS- INTEGRITY: OUR DEDICATION TO HONESTY- INNOVATION: OUR PURSUIT OF CREATIVITY- RESPECT: OUR COMMITMENT TO TREAT EVERYONE WITH DIGNITY- COMMUNITY: OUR UNDERSTANDING THAT WE EXIST TO SERVE THOSE AMONG US- EDUCATION: OUR BELIEF THAT KNOWLEDGE FOSTERS EXCELLENCE 16 14 1817 200 0 0 2077426 7503134 177297495 179292695 305433 183311 8751781 5614917 188432135 192594057 0 0 0 0 95500020 93027632 0 0 0 94904999 97247214 190405019 190274846 -1972884 2319211 186881219 191808369 102043312 110641240 84837907 81167129 X THE MISSION OF OLEAN GENERAL HOSPITAL IS TO PROVIDE EXCELLENT CARE IN RESPONSE TO THE HEALTH CARE NEEDS OF THE OLEAN, NY AND BRADFORD, PA COMMUNITIES. IN SUPPORT OF THIS MISSION, OLEAN GENERAL HOSPITAL IS COMMITTED TO THE FOLLOWING:- COMPASSION: OUR SYMPATHETIC AWARENESS OF EACH PERSON'S NEEDS- INTEGRITY: OUR DEDICATION TO HONESTY- INNOVATION: OUR PURSUIT OF CREATIVITY- RESPECT: OUR COMMITMENT TO TREAT EVERYONE WITH DIGNITY- COMMUNITY: OUR UNDERSTANDING THAT WE EXIST TO SERVE THOSE AMONG US- EDUCATION: OUR BELIEF THAT KNOWLEDGE FOSTERS EXCELLENCE 0 0 123213128 179292695 IN 2019, OLEAN GENERAL HOSPITAL (OGH) DISCHARGED APPROXIMATELY 9,956 PATIENTS AND PROVIDED SERVICES TO APPROXIMATELY 186,000 OUTPATIENT VISITORS.THE OGH CAMPUS IN OLEAN, NY INCLUDES 186 PATIENT ROOMS, TOGETHER WITH COMPREHENSIVE PATIENT, ADMINISTRATIVE AND PHYSICIAN SERVICES AND ACCOMMODATIONS TO MEET THE DIAGNOSTIC, TREATMENT, ADMINISTRATIVE AND EDUCATIONAL NEEDS OF ITS PATIENTS AND MEDICAL STAFF. THE BRMC CAMPUS INCLUDES 89 PATIENT ROOMS AND 95 SKILLED NURSING BEDS. OGH OFFERS PATIENTS AND THEIR FAMILIES A FULL RANGE OF DIAGNOSTIC AND MEDICAL SERVICES, AS WELL AS MANY SPECIALTY SERVICES. A WIDE ARRAY OF MULTI-SPECIALTY PHYSICIANS AND CLINICIANS OFFER SERVICES RANGING FROM CANCER, CARDIAC AND VASCULAR CARE, OB/GYN, GENERAL SURGERY, UROLOGY, WOMEN'S HEALTH, INTERNAL MEDICINE, PEDIATRICS, SLEEP MEDICINE, AND PSYCHIATRIC CARE.HIGHLIGHTED BELOW ARE SOME OF THE INITIATIVES THAT WERE REALIZED IN 2019 AT OGH.PROGRAM SERVICE ACCOMPLISHMENTS -PROVIDER RECRUITMENT IS CRITICAL TO OFFER EXISTING AND CERTAINLY EXPANDED SERVICES AT A HEALTH SYSTEM. DURING 2019, OLEAN GENERAL HOSPITAL WAS SUCCESSFUL IN RECRUITING AND PROGRAM DEVELOPMENT IN THE FOLLOWING AREAS:PRIMARY CARE - 2 PROVIDERS HIRED IN 2019SURGERY - 3 PROVIDERS HIRED IN 2019CARDIOLOGY - 1 PROVIDER HIREDHOSPITALIST/INFECTIOUS DISEASE - 1 PROVIDER HIREDOTHER - 6 PROVIDERS HIRED - 1 PROVIDER IN EACH SUBSPECIALTY HIRED: UROLOGY, ENT, OCCUPATIONAL HEALTH, NEUROLOGY, WOUND CARE, PAIN MANAGEMENT2019 FINANCIAL PERFORMANCE -OLEAN GENERAL HOSPITAL (OGH) HAD AN OPERATING GAIN OF $2,319,000 IN 2019 WHICH WAS AN IMPROVEMENT FROM THE LOSS IN 2018 OF ($1,972,000). THE LOWER OPERATING LOSS WAS THE RESULTS OF SEVERAL FACTORS INCLUDING:- IMPROVED NET PATIENT REVENUE OVER THE PRIOR PERIOD OF $4,200,000, INCLUDING DSRIP FUNDS RECOGNIZED IN 2019.- EXPENSE DECLINE OF ($130,000) RESULTING FROM DILIGENT OVERSIGHT- FURTHER EFFICIENCIES GAINED FROM THE JANUARY 12, 2018 MERGER OF BRADFORD REGIONAL MEDICAL CENTER (BRMC) INTO OGH. ONCE FULLY IMPLEMENTED IN 2019, THE MERGER PLAN RESULTED IN ANNUAL FINANCIAL IMPROVEMENT TO THE SYSTEM OF IN EXCESS OF $2.5M.2019 QUALITY MATTERS -NUMEROUS QUALITY IMPROVEMENT INITIATIVES SHOWED POSITIVE RESULTS IN 2019 INCLUDING:- MAINTAINED C-DIFFICILE (CDI) RATES AT OR BELOW INDUSTRY STANDARD RATES- MAINTAINED LOWER CATHETER-ASSOCIATED URINARY TRACT INFECTIONS (CAUTIS) THAN INDUSTRY RATES- MAINTAINED HOSPITAL READMISSION RATES BELOW INDUSTRY AVERAGES- INCREASED PHYSICIAN USE OF COMPUTERIZED PHYSICIAN ORDERING FOR MEDICATIONS- CONTINUED TO MAKE PATIENT SATISFACTION A KEY PERFORMANCE INDICATOR AND WORK TO DRIVE UP PERFORMANCE2019 INFORMATION TECHNOLOGY MATTERS -- BRMC AND OGH UPGRADED ITS MEDITECH EHR SYSTEM TO THE LATEST VERSION. SOFTWARE ENHANCEMENTS INCLUDED IN THE UPGRADE INCLUDE: (A) ENHANCED AUDIT REPORTS (B) INCREASED SUPPORT PUBLIC HEALTH INTERFACES (C) IMPROVED CONTINUATION OF CARE DOCUMENT (CCD) INTERFACE (D) PATIENT PORTAL/PATIENT ENGAGEMENT ENHANCEMENTS (E) NEW CMS PROMOTING INTEROPERABILITY REPORTS- BRMC AND OGH UPGRADED THE ENTERPRISE RADIOLOGY PACS SYSTEM TO THE LATEST VERSION TO IMPROVE CLINICAL CAPABILITIES AND VENDOR SUPPORT.- BRMC AND OGH CONTINUED TO IMPROVE ITS CYBERSECURITY PROFILE. ENHANCED EMAIL FILTERING, NETWORK MONITORING AND USB DEVICE MANAGEMENT TOOLS WERE IMPLEMENTED.- BRMC AND OGH UPGRADED ITS END USER COMPUTER OPERATING SYSTEMS FROM WINDOWS 2007 TO WINDOWS 10.- BRMC AND OGH IMPLEMENTED CBORD HOSPITAL NUTRITION SOFTWARE SYSTEM. THE SYSTEM IMPROVES PATIENT MEAL SATISFACTION BY ALLOWING MENUS TO BE EASILY CUSTOMIZED WHILE ENSURING PATIENT SAFETY AND REGULATORY COMPLIANCE.- BRMC IMPLEMENTED LONG TERM CARE SOFTWARE FROM POINTCLICKCARE. THE SOFTWARE HELPS TO ACCURATELY RECORD AND STORE ADL AND MDS PATIENT DOCUMENTATION. 123213128 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 138 0 1 1817 0 0 0 0 0 0 0 0 0 0 0 X 16 14 0 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X X RICHARD G BRAUN JR CPA 7163756190 515 MAIN STREET OLEAN NY 14760 TIMOTHY J FINAN PRESIDENT AND CEO 40.00 5.50 X X 646873 0 38066 BRENDA MCGEE BOARD CHAIR 5.50 1.00 X X 0 0 0 MUHAMMED JAVED MD BOARD VICE CHAIR 5.50 1.00 X X 66967 0 0 JEFF BELT BOARD TREASURER 5.50 1.00 X X 0 0 0 JEANNINE SCHOENECKER BOARD SECRETARY 5.50 1.00 X X 0 0 0 THOMAS BUFFAMANTE DIRECTOR 5.50 1.00 X 0 0 0 DANIEL DEROSE DIRECTOR 5.50 1.00 X 0 0 0 MARTIN J DIGEL DIRECTOR 5.50 1.00 X 0 0 0 PIERRE DIONNE MD DIRECTOR 5.50 1.00 X 0 0 0 LISA FIORENTINO PHD RN DIRECTOR 5.50 1.00 X 0 0 0 LUIS GONZALEZ MD DIRECTOR 5.50 1.00 X 0 0 0 JULIE MARASCO DIRECTOR 5.50 1.00 X 0 0 0 DOUGLAS PISANO DIRECTOR 5.50 1.00 X 0 0 0 ANIL PRADHAN MD DIRECTOR 5.50 1.00 X 0 0 0 PAUL RIDLEY DIRECTOR 5.50 1.00 X 0 0 0 MELISSA SCHOLL OSP DIRECTOR 5.50 1.00 X 0 0 0 JEFFREY S ZEWE VP OPERATIONS 40.00 1.00 X 320037 0 57568 WILLIAM MILLS VP MEDICAL AFFAIRS 23.50 15.00 X 308854 0 32283 GAIL BAGAZZOLI VP QUALITY AND CNO 40.00 X 206761 0 34361 MELISSA SULLIVAN VP CLINICAL AND SUPPORT SERVICES 40.00 X 178281 0 30383 VI-ANNE ANTRUM VP PATIENT CARE SERVICES 40.00 X 66813 0 4458 TIMOTHY MCNAMARA VP HUMAN RESOURCES 40.00 1.00 X 8579 0 11983 DAVID GODFREY PHYSICIAN 40.00 X 440714 0 55825 MOHANED A AL-HUMADI PHYSICIAN 40.00 X 1337710 0 44788 JAVAID A MALIK PHYSICIAN 40.00 X 833568 0 41318 ASIM MAKHDOM PHYSICIAN 40.00 X 629946 0 17287 GARY CARL PHYSICIAN 40.00 X 454617 0 33629 5499720 0 401949 70 0 1 0 COMPLETERX LTD 3100 S GESSNER SUITE 640 HOUSTON TX 77063 PHARMACY MANAGEMENT SERVICES 12103909 PA MOUNTAIN HEALTHCARE 150 MCCRACKEN RUN ROAD DUBOIS PA 15081 HEALTH INSURANCE 11712952 QUEST DIAGNOSTIC INC 500 PLAZA DRIVE SECAUCUS NJ 07094 LABORATORY SERVICE 7068081 ASSOCIATED CLINICAL LABORATORY 1526 PEACH STREET ERIE PA 16501 LABORATORY SERVICE 4772480 KALEIDA HEALTH 726 EXCHANGE STREET BUFFALO NY 14210 SHARED SERVICES 4342500 28 498842 7004292 7503134 PATIENT SERVICE REVENUE 621990 179292695 179292695 179292695 338412 338412 615468 0 615468 615468 615468 1430231 1585332 -155101 -155101 -155101 OTHER 900099 3944596 3944596 CAFETERIA/VENDING 722210 703156 703156 PHARMACY 340B 900099 351697 351697 4999449 192594057 179292695 0 5798228 X 2012267 408104 1604163 71132415 37886043 33246372 4854108 2585570 2268538 10325801 5448469 4877332 4703041 2465151 2237890 479391 479391 84961 84961 44400507 30390275 14010232 392677 392677 3621109 2431114 1189995 3878199 3878199 358372 358372 1039358 1039358 7370388 5159272 2211116 3768084 3261724 506360 SUPPLIES 31753161 29198200 2554961 PROPERTY TAXES 98219 98219 PATIENT/RESIDENT ACTIVI 2788 2788 190274846 123213128 67061718 0 7801670 6634153 36264035 44366251 5161079 5353875 2062938 2068846 135429329 73850852 67039354 61578477 18607580 19725866 2758476 2971466 47186087 49109435 186881219 191808369 31205553 34981175 26445311 25418003 44392448 50242062 102043312 110641240 X 37956031 36734557 46881876 44432572 84837907 81167129 186881219 191808369 X 2319211 2761506 -8751495 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 16811783 1984251 18796034 18039649 -1227866 16811783 17858282 181367 18039649 17616950 241332 17858282 16679420 222204 715326 17616950 0.13400 0.86600 1 0 2364059 2364059 82992814 40610984 42381830 1723260 768978 954282 43780340 29521720 14258620 4568856 2949170 1619686 61578477 ASSETS LIMITED AS TO USE 42700851 OTHER ASSETS 4749475 DUE FROM AFFILIATES 1659109 49109435 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 13536447 ACCRUED PENSION LIABILITY 36705615 50242062 PART V, LINE 4: TO PROVIDE SUPPORT AND RENEW PLANT AND EQUIPMENT BASED ON HOSPITAL NEED. 1 1 X 1 X 400.000000000000 1 X 1 1 0 0 21 6722 94368 21707 72661 0.00040 3 143 915324 175000 740324 0.00390 1 100 1000 1000 0.00000 25 6965 1010692 196707 813985 0.00430 25 6965 1010692 196707 813985 0.00430 0 X 1 1 2 1 OLEAN GENERAL HOSPITAL 515 MAIN STREET OLEAN NY 14760 X X X X DENTAL CLINIC, RADIATION ONCOLOGY 2 OLEAN GENERAL HOSPITAL DBA BRADFORD REGIONAL MEDICAL CENTER 116 INTERSTATE PARKWAY BRADFORD PA 16701 X X X OLEAN GENERAL HOSPITAL 1 0 0 1 X X X X X X X X X X 19 1 0 1 1 X WWW.OGH.ORG AND WWW.BRMC.COM X 1 19 1 WWW.OGH.ORG AND WWW.BRMC.COM 0 1 X 400.000000000000 400.000000000000 X X X X X 1 1 X X X 1 X WWW.OGH.ORG X WWW.OGH.ORG X WWW.OGH.ORG X X X X X 1 X 0 X X X 1 X 0 0 OLEAN GENERAL HOSPITAL PART V, SECTION B, LINE 5: OLEAN GENERAL HOSPITAL AND BRADFORD REGIONAL MEDICAL CENTER ARE A MERGED ORGANIZATION. HOWEVER, THE TWO CAMPUSES HAVE BEEN CONDUCTING INDEPENDENT COMMUNITY HEALTH NEEDS ASSESSMENTS AND COMMUNITY HEALTH IMPROVEMENT PLANS OVER THEIR HISTORIES. BECAUSE THE TWO CAMPUSES ARE IN SEPARATE STATES AND THE SERVICE NEEDS BETWEEN THE TWO SERVICE AREAS ARE DIFFERENT, A DECISION WAS MADE TO CONTINUE TO CONDUCT SEPARATE CHNAS FOR THE TWO CAMPUSES.IN ADDITION, THE THREE-YEAR CYCLES OF THE TWO HOSPITAL ARE DIFFERENT. OLEAN GENERAL HOSPITAL APPROVED ITS MOST RECENT CHNA IN AUGUST, 2019. THE LATEST CHNA FOR THE BRADFORD REGIONAL MEDICAL CENTER CAMPUS WAS COMPLETED IN DECEMBER, 2018. CHNAS FOR BOTH HOSPITALS APPEAR ON THE RESPECTIVE WEBSITES FOR OLEAN GENERAL HOSPITAL (WWW.OGH.ORG) AND BRADFORD REGIONAL MEDICAL CENTER (WWW.BRMC.COM).OLEAN GENERAL HOSPITAL - THE 2019-2021 CATTARAUGUS COUNTY COMMUNITY SERVICE PLAN (CSP) AND COMMUNITY HEALTH ASSESSMENT AND COMMUNITY HEALTH IMPROVEMENT PLAN (CHA-CHIP) WERE DEVELOPED IN PARTNERSHIP BETWEEN OLEAN GENERAL HOSPITAL (OGH), WHICH IS PART OF UPPER ALLEGHENY HEALTH SYSTEM (UAHS) AND THE CATTARAUGUS COUNTY HEALTH DEPARTMENT (CCHD). STRATEGY SOLUTIONS, INC. (SSI) WAS ENGAGED BY CCHD AND OGH TO ASSIST WITH THE ASSESSMENT. REPRESENTATIVES FROM OGH AND CCHD WORKED COLLABORATIVELY TO GUIDE AND CONDUCT THE ASSESSMENT. A STEERING COMMITTEE MADE UP OF SENIOR LEADERS OF UAHS, OGH, CCHD, AND REPRESENTATIVES FROM THE CATTARAUGUS COUNTY HEALTHY LIVABLE COMMUNITIES CONSORTIUM, WHICH INCLUDES LEADING HEALTH AND SOCIAL SERVICE ORGANIZATIONS AND MUNICIPALITIES, PROVIDED ADDITIONAL INPUT. THE COMBINED EXPERTISE, INPUT AND KNOWLEDGE OF THE MEMBERS OF THE STEERING COMMITTEE WAS VITAL TO THE PROJECT. THIS GROUP DESERVES SPECIAL RECOGNITION FOR THEIR TIRELESS OVERSIGHT AND SUPPORT OF THE CSP/CHA-CHIP PROCESS. DURING THE CSP/CHA-CHIP PROJECT, TEN (10) STAKEHOLDERS WERE INTERVIEWED BY STRATEGY SOLUTIONS, INC. (SSI). SSI CONDUCTED A COMMUNITY HEALTH SURVEY WITH 669 SURVEYS COMPLETED, AND CCHD CONDUCTED A COMMUNITY HEALTH SURVEY WITH 227 SURVEYS COMPLETED. FINALLY, INFORMATION WAS GATHERED BY THE PROJECT TEAM THROUGH A SERIES OF TEN (10) FOCUS GROUPS WITH A TOTAL OF 56 PARTICIPANTS, INCLUDING A CROSS SECTOR OF COMMUNITY GROUPS. INFORMATION-GATHERING EFFORTS ALLOWED THE PROJECT TEAM AND STEERING COMMITTEE TO GAIN A BETTER UNDERSTANDING OF THE HEALTH STATUS, HEALTH CARE NEEDS, SERVICE GAPS, AND BARRIERS TO CARE FOR THOSE LIVING IN CATTARAUGUS COUNTY. FOLLOWING THE CONSOLIDATION OF DATA FOR THE COMMUNITY HEALTH ASSESSMENT (CHA), A PLANNING PROCESS WAS INITIATED TO CREATE A 2019-2021 COMMUNITY HEALTH IMPROVEMENT PLAN (CHIP). A TOTAL OF 28 PARTICIPANTS DESIGNATED AS THE CHIP PARTNERSHIP COMMITTEE FOCUSED ON THE TWO HEALTH PRIORITIES, WHICH WERE IDENTIFIED THROUGH A RIGOROUS COMMUNITY DATA ASSESSMENT STUDY AND DEVELOPED A GUIDE FOR IMPLEMENTING AN ACTION PLAN. A DISCUSSION OF EVIDENCED-BASED HEALTH RELATED PROGRAMS AND INITIATIVES THAT ARE CURRENTLY OFFERED OR ARE PLANNED FOR THE FUTURE WAS FACILITATED BY STRATEGY SOLUTIONS. BASED ON THIS DISCUSSION, A PLAN TO MEET THE COMMUNITY HEALTH NEEDS WAS DEVELOPED.THE 2019-2021 OLEAN GENERAL HOSPITAL COMMUNITY SERVICE PLAN (CSP) AND THE CATTARAUGUS COUNTY HEALTH DEPARTMENT'S COMMUNITY HEALTH ASSESSMENT AND COMMUNITY HEALTH IMPROVEMENT PLAN (CHA-CHIP) WERE CONDUCTED TO IDENTIFY SIGNIFICANT HEALTH NEEDS AS OUTLINED BY NEW YORK STATE DEPARTMENT OF HEALTH'S 2019-2024 PREVENTION AGENDA). IT ALSO PROVIDES CRITICAL INFORMATION TO OLEAN GENERAL HOSPITAL (OGH), CATTARAUGUS COUNTY HEALTH DEPARTMENT (CCHD), AND OTHERS IN A POSITION TO MAKE A POSITIVE IMPACT ON THE HEALTH OF THE REGION'S RESIDENTS. OGH, WHICH NOW INCLUDES BRADFORD REGIONAL MEDICAL CENTER IN BRADFORD, PA, IS A MEMBER HOSPITAL OF UPPER ALLEGHENY HEALTH SYSTEM AND AN AFFILIATE OF KALEIDA HEALTH, BUFFALO, NY. THE RESULTS ENABLE THE HEALTH DEPARTMENT, HOSPITAL AND OTHER COMMUNITY PARTNERS TO STRATEGICALLY ESTABLISH PRIORITIES, DEVELOP INTERVENTIONS AND DIRECT RESOURCES TO IMPROVE THE HEALTH OF RESIDENTS LIVING IN THE SERVICE AREA. TO CONDUCT THE COLLABORATIVE STUDY, OGH AND CCHD RETAINED STRATEGY SOLUTIONS, INC. (SSI), AN ERIE, PA PLANNING AND RESEARCH FIRM WHOSE MISSION IS TO CREATE HEALTHY COMMUNITIES. THE ASSESSMENT FOLLOWED BEST PRACTICES AS OUTLINED BY THE ASSOCIATION OF COMMUNITY HEALTH IMPROVEMENT (ACHI). THE ASSESSMENT WAS ALSO DESIGNED TO ENSURE OGH COMPLIANCE WITH CURRENT INTERNAL REVENUE SERVICE (IRS) GUIDELINES FOR CHARITABLE 501(C)(3) TAX-EXEMPT HOSPITALS THAT WAS PUBLISHED IN DECEMBER 2014. THE PREVENTION AGENDA IS A SIX-YEAR EFFORT TO MAKE NEW YORK THE HEALTHIEST STATE. DEVELOPED IN COLLABORATION WITH 140 ORGANIZATIONS, THE PLAN IDENTIFIES NEW YORK'S MOST URGENT HEALTH CONCERNS, AND SUGGESTS WAYS LOCAL HEALTH DEPARTMENTS, HOSPITALS, AND PARTNERS FROM HEALTH, BUSINESS, EDUCATION, AND COMMUNITY ORGANIZATIONS CAN WORK TOGETHER TO SOLVE THEM. THE CSP/CHA-CHIP INCLUDES A DETAILED EXAMINATION OF PRIORITY AREAS IDENTIFIED IN THE NYS PREVENTION AGENDA: (1) PREVENT CHRONIC DISEASES; (2) PROMOTE A HEALTHY AND SAFE ENVIRONMENT; (3) PROMOTE HEALTHY WOMEN, INFANTS AND CHILDREN; (4) PROMOTE WELL-BEING AND PREVENT MENTAL HEALTH AND SUBSTANCE USE DISORDERS; AND (5) PREVENT COMMUNICABLE DISEASES. OTHER AREAS INCLUDED IN THIS CSP/CHA-CHIP THAT MEET THE DECEMBER 2014 IRS REQUIREMENTS INCLUDE: EVALUATION OF THE 2016-2018(9) CSP/CHA-CHIP, DEMOGRAPHICS AND SOCIO-ECONOMIC INDICATORS, PRIORITIZATION OF NEEDS, AND CHIP/IMPLEMENTATION STRATEGY FOR NEXT THREE YEARS.A DETAILED PLAN OF IMPLEMENTATION IS DESCRIBED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT AND COMMUNITY HEALTH IMPLEMENTATION PLAN ON PAGES 149-171.HTTPS://WWW.OGH.ORG/IMAGES/UPLOADS/CHNA-CHIP%20FINAL%20REPORT%202019-2021.PDFBRADFORD REGIONAL MEDICAL CENTER - THIS REPORT SUMMARIZES A COMPREHENSIVE REVIEW AND ANALYSIS OF HEALTH STATUS INDICATORS, PUBLIC HEALTH, SOCIOECONOMIC, DEMOGRAPHIC AND OTHER QUALITATIVE AND QUANTITATIVE DATA FROM THE PRIMARY SERVICE AREA OF BRMC. THIS REPORT ALSO INCLUDES SECONDARY/ DISEASE INCIDENCE AND PREVALENCE DATA FROM MCKEAN COUNTY ,THE PRIMARY SERVICE AREA OF THE HOSPITAL. THE DATA WAS REVIEWED AND ANALYZED TO DETERMINE THE TOP PRIORITY NEEDS AND ISSUES FACING THE REGION OVERALL.THE PRIMARY PURPOSE OF THIS ASSESSMENT WAS TO IDENTIFY THE HEALTH NEEDS AND ISSUES OF THE MCKEAN COUNTY COMMUNITY DEFINED AS THE PRIMARY SERVICE AREA OF BRMC. IN ADDITION, THE CHNA PROVIDES USEFUL INFORMATION FOR PUBLIC HEALTH AND HEALTH CARE PROVIDERS, POLICY MAKERS, SOCIAL SERVICE AGENCIES, COMMUNITY GROUPS AND ORGANIZATIONS, RELIGIOUS INSTITUTIONS, BUSINESSES, AND CONSUMERS WHO ARE INTERESTED IN IMPROVING THE HEALTH STATUS OF THE COMMUNITY AND REGION. THE RESULTS ENABLE THE HOSPITAL, AS WELL AS OTHER COMMUNITY PROVIDERS, TO MORE STRATEGICALLY IDENTIFY COMMUNITY HEALTH PRIORITIES, DEVELOP INTERVENTIONS, AND COMMIT RESOURCES TO IMPROVE THE HEALTH STATUS OF THE REGION.IMPROVING THE HEALTH OF THE COMMUNITY IS THE FOUNDATION OF THE MISSION OF BRMC, AND AN IMPORTANT FOCUS FOR EVERYONE IN THE SERVICE REGION, INDIVIDUALLY AND COLLECTIVELY. IN ADDITION TO THE EDUCATION, PATIENT CARE, AND PROGRAM INTERVENTIONS PROVIDED THROUGH THE HOSPITAL, WE HOPE THAT THE INFORMATION IN THIS CHNA WILL ENCOURAGE ADDITIONAL ACTIVITIES AND COLLABORATIVE EFFORTS TO IMPROVE THE HEALTH STATUS OF THE COMMUNITY THAT BRMC SERVES.FACILITATED BY STRATEGY SOLUTIONS, INC., A PLANNING AND RESEARCH FIRM WITH ITS MISSION TO CREATE HEALTHY COMMUNITIES, THIS CHNA FOLLOWS BEST PRACTICES AS OUTLINED BY THE ASSOCIATION FOR COMMUNITY HEALTH IMPROVEMENT, A DIVISION OF THE AMERICAN HOSPITAL ASSOCIATION, AND ENSURES COMPLIANCE WITH INTERNAL REVENUE SERVICE (IRS) GUIDELINES (IRS NOTICE 2011-52) THE PROCESS HAS TAKEN INTO ACCOUNT INPUT FROM THOSE WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITIES SERVED BY BRADFORD REGIONAL MEDICAL CENTER (BRMC), INCLUDING THOSE WITH KNOWLEDGE OF PUBLIC HEALTH, THE MEDICALLY UNDERSERVED, AND POPULATIONS WITH CHRONIC DISEASE.THE 2018 BRMC CHNA WAS CONDUCTED TO IDENTIFY PRIMARY HEALTH ISSUES, CURRENT HEALTH STATUS, AND HEALTH NEEDS TO PROVIDE CRITICAL INFORMATION TO THOSE IN A POSITION TO MAKE A POSITIVE IMPACT ON THE HEALTH OF THE REGION'S RESIDENTS. THE RESULTS ENABLE COMMUNITY MEMBERS TO MORE STRATEGICALLY ESTABLISH PRIORITIES, DEVELOP INTERVENTIONS, AND DIRECT RESOURCES TO IMPROVE THE HEALTH OF PEOPLE LIVING IN THE COMMUNITY.TWENTY STEERING COMMITTEE MEMBERS FROM A ACROSS THE COMMUNITY PARTICIPATED IN THE PRIORITIZATION EXERCISE. AFTER PRIORITIZATION AND DISCUSSION THE BRMC STEERING COMMITTEE IDENTIFIED FOUR NEEDS AS PRIORITIES FOR INTERVENTION AND ACTION PLANNING: CHRONIC DISEASE, ACCESS TO HEALTHCARE, MENTAL HEALTH AND SUBSTANCE ABUSE DISORDERS. CONTINUED IN PART VI. OLEAN GENERAL HOSPITAL PART V, SECTION B, LINE 6B: IN DEVELOPING THE COMMUNITY HEALTH NEEDS ASSESSMENT FOR CATTARAUGUS COUNTY, OTHER MEMBERS CONSULTED INCLUDED ALLEGANY/W. STEUBEN RURAL HEALTH NETWORK, AMERICAN RED CROSS, CANCER SERVICES PROGRAM (ALLEGANY CO.), CATTARAUGUS COUNTY DEPARTMENT OF THE AGING, CATTARAUGUS COUNTY HEALTH DEPARTMENT, CATTARAUGUS COUNTY YOUTH BUREAU, CITY OF OLEAN YOUTH BUREAU, CORNELL COOPERATIVE EXTENSION, DIRECTIONS IN INDEPENDENT LIVING, EVERYWOMAN OPPORTUNITY CENTER, HEALTH CARE ACCESS COALITION, HEALTHY COMMUNITY ALLIANCE, HEALTHY SCHOOLS NY, P2 COLLABORATIVE OF WNY, SALAMANCA YOUTH BUREAU, SOUTHERN TIER HEALTHCARE SYSTEMS, SOUTHERN TIER WEST, STRAWW, TOBACCO-REALITY CHECK, TOTAL SENIOR CARE, TRICOUNTY TOBACCO COALITION, AND UNIVERA COMMUNITY HEALTH. OLEAN GENERAL HOSPITAL PART V, SECTION B, LINE 11: DBA BRADFORD REGIONAL MEDICAL CENTER: THE HOSPITAL'S EFFORTS IN ADDRESSING SIGNIFICANT NEEDS ARE DESCRIBED IN ITS 2016-2018 COMMUNITY HEALTH NEEDS EXECUTIVE SUMMARY, PAGE 5. FORM 990, SCHEDULE H, PART V, SECTION 5, LINE 5 CONTINUED SECONDARY DATA ON DISEASE INCIDENCE AND MORTALITY, AS WELL AS BEHAVIORAL RISK FACTORS WERE GATHERED FROM THE PENNSYLVANIA DEPARTMENT OF HEALTH AND THE CENTERS FOR DISEASE CONTROL, AS WELL AS HEALTHY PEOPLE 2020, COUNTY HEALTH RANKINGS, US CENSUS, AMERICAN COMMUNITY SURVEY, AND A NUMBER OF OTHER REPORTS AND PUBLICATIONS.AGGREGATE UTILIZATION DATA WAS INCLUDED FROM BRMC PATIENT RECORDS (NO PRIVATE PATIENT INFORMATION WAS EVER TRANSMITTED TO STRATEGY SOLUTIONS, INC.). DEMOGRAPHIC DATA WAS COLLECTED FROM CLARITAS-POP-FACTS PREMIER, 2018, ENVIRONICS ANALYTICS. PRIMARY DATA COLLECTED SPECIFICALLY FOR THIS STUDY WERE BASED ON THE PRIMARY SERVICE AREA OF MCKEAN COUNTY. BRMC COLLECTED A TOTAL OF 304 COMMUNITY SURVEYS AND 25 INTERCEPT SURVEYS, AND CONDUCTED FOUR (4) FOCUS GROUPS WITH 90 PARTICIPANTS AS WELL AS 12 STAKEHOLDER INTERVIEWS. IT SHOULD BE NOTED THAT AN ADDITIONAL FOCUS GROUP WAS CONDUCTED BY A THIRD PARTY MCKEAN COUNTY COLLABORATIVE BOARD AND THE RESULTS SHARED WITH BRMC FOR THIS REPORT. THIS FOCUS GROUP HAD 38 PARTICIPANTS.A FULL ACCOUNTING OF INPUT FROM COMMUNITY GROUPS, IDENTIFIED COMMUNITY HEALTH ISSUES AS TOP PRIORITIES TO BE UNDERTAKEN BY THE HOSPITAL APPEAR IN THE FULL CHNA.HTTPS://WWW.BRMC.COM/BRMC%20CHNA%202018%20WEB.PDF PART I, LINE 7G: SUBSIDIZED PROGRAMS ARE NOT RECORDED AT THIS LEVEL OF DETAIL. ALL COSTS ASSOCIATED WITH THESE PROGRAMS, INCLUDING IP PSYCHIATRIC DEPARTMENT, EMERGENCY DEPARTMENT AND SALAMANCA CLINIC ARE INCLUDED IN THE AMOUNTS PROVIDED. PART II, COMMUNITY BUILDING ACTIVITIES: OVER THE LAST 10 YEARS, THE OLEAN AND BRADFORD AREAS HAD SIGNIFICANT PRIMARY CARE AND SPECIALIST CARE SHORTFALLS. AFTER A FEW YEARS OF SUCCESSFUL RECRUITING, NUMEROUS MID-LEVEL PRIMARY CARE PROVIDERS HAVE BEEN RECRUITED, HOWEVER THERE ARE STILL PHYSICIAN SHORTAGES IN THE PRIMARY CARE SPACE. SPECIALIST PHYSICIANS ARE STILL IN GREAT DEMAND IN THE AREA. THE MOST PRESSING NEEDS CURRENTLY ARE IN: CARDIOLOGY, UROLOGY, DERMATOLOGY, PSYCHIATRY AND GASTROENTEROLOGY.THE HOSPITAL ALSO PROVIDES CLINICAL ROTATIONS FOR MEDICAL STUDENTS IN INTERNAL AND EMERGENCY MEDICINE THROUGH AN AFFILIATION AGREEMENT WITH LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE. IN ADDITION, ST BONAVENTURE UNIVERSITY PRE-MEDICAL STUDENTS PARTICIPATE IN A 14 WEEK ROTATION PROVIDING EXPOSURE TO VARIOUS CLINICAL SPECIALTIES AND DIAGNOSTIC MODALITIES, FOR AN IN-DEPTH EXPOSURE TO THE REALITIES OF A CAREER IN MEDICINE. THE UNIVERSITY OF PITTSBURGH AT BRADFORD NURSING STUDENTS PARTICIPATE IN CLINICAL ROTATIONS THROUGH THE BRADFORD CAMPUS. PART III, LINE 3: THE RATIONALE USED TO ESTIMATE THE AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE PLAN WAS DETERMINED BY USING THE PERCENTAGE OF INCOMPLETE FINANCIAL ASSISTANCE APPLICATIONS TO TOTAL FINANCIAL ASSISTANCE APPLICATIONS (4%). PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF PATIENT ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO HAVE FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE HOSPITAL'S 2017 RCC WAS APPLIED TO THE TOTAL BAD DEBT EXPENSE TO DETERMINE BAD DEBT EXPENSE AT COST. THE BAD DEBT AMOUNTS ABSORBED BY THE HOSPITAL ARE PART OF ITS COMMUNITY BENEFIT DUE TO ITS POLICY TO PROVIDE MEDICAL SERVICE TO THE COMMUNITY REGARDLESS OF THE PATIENT'S ABILITY TO PAY. PART III, LINE 8: THE ALLOWABLE COSTS REPORTED ON LINE 6 ARE DIRECTLY FROM THE HOSPITAL'S 2019 MEDICARE COST REPORT, WHICH IS PREPARED USING A RATIO OF COST TO CHARGES BASIS (RCC) AS REQUIRED BY MEDICARE. PART III, LINE 9B: COLLECTION PRACTICES:I) OGH WILL NOT CAUSE THE FORCED SALE OR FORECLOSURE ON A PATIENT'S PRIMARY RESIDENCE.II) OGH WILL NOT SEND ACCOUNT TO COLLECTION IF THE PATIENT HAS SUBMITTED A COMPLETED APPLICATION FOR FINANCIAL ASSISTANCE, INCLUDING THE REQUIRED DOCUMENTATION, WHILE AN APPLICATION IS PENDING.III) OGH WILL PROVIDE WRITTEN NOTIFICATION TO A PATIENT AT LEAST 30-DAYS BEFORE AN ACCOUNT IS SENT TO COLLECTION. THIS WRITTEN NOTICE MAY BE INCLUDED ON A BILL. IV) OGH REQUIRES THAT A COLLECTION AGENCY HAVE ITS WRITTEN CONSENT PRIOR TO STARTING LEGAL ACTION FOR COLLECTION.V) OGH WILL TRAIN ALL GENERAL HOSPITAL STAFF WHO INTERACT WITH PATIENTS OR HAVE RESPONSIBILITY FOR BILLING AND COLLECTION.VI) OGH WILL MEASURE OUR COMPLIANCE WITH THESE POLICES.VII) OGH REQUIRES ANY COLLECTION AGENCY UNDER CONTRACT TO FOLLOW OUR FINANCIAL ASSISTANCE POLICY AND PROVIDES INFORMATION TO PATIENT'S ON HOW TO APPLY, WHERE APPROPRIATE.VIII) OGH DOES NOT ALLOW COLLECTION ACTIVITY IF THE PATIENT IS DETERMINED ELIGIBLE FOR MEDICAID FOR THE SERVICES THAT WERE RENDERED AND OGH IS ABLE TO COLLECT MEDICAID PAYMENT. PART VI, LINE 2: THE STRATEGIC PLANNING COMMITTEE OF OLEAN GENERAL HOSPITAL IS CHARGED WITH DEVELOPING A STRATEGIC DIRECTION FOR THE HOSPITAL. OVER THE LAST FEW YEARS THAT COMMITTEE ASSISTED IN THE DEVELOPMENT OF SUSTAINABILITY STRATEGIES FOR THE HOSPITAL INCLUDING THE AFFILIATION WITH A TERTIARY CARE PROVIDER IN 2017 AND THE MERGER OF THE TWO PREVIOUS HOSPITALS (OLEAN GENERAL HOSPITAL AND BRADFORD REGIONAL MEDICAL CENTER INTO THE ONE SURVIVING HOSPITAL- OLEAN GENERAL HOSPITAL) IN 2018. IN 2019 THE COMMITTEE BEGAN DEVELOPING ADDITIONAL SUSTAINABILITY STRATEGIES FOR THE SYSTEM INCLUDING LOOKING AT TAKING ADVANTAGE OF THE HOSPITALS VARIOUS STRENGTHS IN DIFFERENT GEOGRAPHIC AREAS.NO CONCLUSIONS WERE REACHED IN 2019 HOWEVER THE COMMITTEE BEGAN TO DEVELOP INFORMATION NEEDS FOR REVIEW INCLUDING THE FOLLOWING: MARKET SHARE DATA (BOTH OLEAN, NY AND BRADFORD, PA); QUALITY DATA BY LOCATION; SPECIALTY CAPABILITIES BY LOCATION; CONTRIBUTION MARGIN ANALYSIS BY SERVICE; POPULATION TREND DATA; INPATIENT AND OUTPATIENT USE TRENDS AND FORECASTS FOR THE NEXT 10 YEARS.ESSENTIAL TO THE SUCCESS OF ANY STRATEGIC PLAN IS THE HOSPITAL'S ABILITY TO BOTH IMPLEMENT RECOMMENDATIONS MADE WITHIN THE PLAN AND TO RECOGNIZE THE DOCUMENT AS A DYNAMIC AND FLEXIBLE TOOL TO BE USED AS A GUIDE FOR THE FUTURE. SPECIFIC GOALS AND STRATEGIES MAY OR MAY NOT BE OBTAINED AND, UPON EVALUATION AND THE AVAILABILITY OF NEW INFORMATION AND DEVELOPMENTS, MAY NEED TO BE MODIFIED. A SUCCESSFUL STRATEGIC PLAN RECOGNIZES THIS POTENTIAL FOR CHANGE AND IS FLEXIBLE ENOUGH TO ACCOMMODATE NEW OR DIFFERENT OPPORTUNITIES AND CHALLENGES.CRITICAL HEALTH CARE ISSUESTHE HEALTH CARE INDUSTRY IS UNDER CONSTANT SCRUTINY TO PROVIDE AFFORDABLE HEALTH CARE SERVICES THAT ARE ALSO OF THE HIGHEST QUALITY. A HOSPITAL'S ABILITY TO ACCOMPLISH THIS GOAL IS INFLUENCED BY SEVERAL FACTORS. FOLLOWING IS A LISTING OF CRITICAL ISSUES THAT WILL CONTINUE TO AFFECT HOSPITALS' ABILITY TO PERFORM.1. QUALITY: HEALTH CARE QUALITY AND SAFETY HAVE BEEN STRATEGICALLY IMPORTANT FOR SEVERAL YEARS. WIDESPREAD PUBLIC REPORTING OF HOSPITAL QUALITY RESULTS AND VALUE BASED PAYMENT MODELS HAVE POSITIONED QUALITY AT THE FOREFRONT OF HEALTHCARE DELIVERY. RECRUITMENT AND RETENTION OF HIGHLY SKILLED DOCTORS AND NURSES, COMBINED WITH CAPABLE INFORMATION SYSTEMS ARE CRITICAL TO MEET THE HIGH STANDARDS SET TODAY IN HEALTHCARE. CONCEPTS SUCH AS: "RE-ADMISSIONS", HOSPITAL ACQUIRED INFECTIONS, FALL FREQUENCY AND PREVENTABLE MEDICATION ERRORS ARE HOUSEHOLD WORDS WHEN IT COMES TO EVALUATING A HOSPITAL'S QUALITY TODAY. HOSPITALS MUST MARSHAL THE NOTED RESOURCES AND PROVIDE HIGH-END CARE AS COMPARED TO OTHERS. THE VALUE BASED PAYMENT METHODOLOGIES ALSO HAVE SIGNIFICANT FINANCIAL IMPLICATIONS FOR HOSPITALS TODAY. CONSUMERS WILL CONTINUE TO SEEK OUT MORE AND MORE QUALITY DATA UPON WHICH TO BASE CARE DECISIONS ON.2. INFORMATION TECHNOLOGY: HEALTH INFORMATION TECHNOLOGY INCLUDES COMPUTER BASED TOOLS DEVELOPED SPECIFICALLY FOR HEALTH CARE DELIVERY. THESE TOOLS CAN PROVIDE CLINICIANS UP-TO-DATE INFORMATION ON THEIR PATIENTS, ACCESS TO THE LATEST MEDICAL KNOWLEDGE AND BEST PRACTICES THROUGH DECISION SUPPORT SYSTEMS. IT IS UNDERSTOOD THAT INVESTMENTS IN NEW CLINICAL AND INFORMATION TECHNOLOGY CAN SIGNIFICANTLY ENHANCE PATIENT SAFETY AND CLINICAL OUTCOMES. COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE), BAR CODING AND ITS POTENTIAL TO REDUCE MEDICATION ERRORS, AND ELECTRONIC MEDICAL RECORDS (EMRS) AND THEIR POSITIVE IMPACT ON MEDICAL ERRORS ARE ALL EXAMPLES OF HEALTH CARE'S USE OF IT SOLUTIONS TO IMPROVE QUALITY. THE FEDERAL GOVERNMENT HAS HIGHLIGHTED THE ROLE OF HEALTH INFORMATION TECHNOLOGY AS A MEANS TO IMPROVE HEALTH CARE QUALITY, SAFETY PROVIDED STIMULUS AND INCENTIVE PAYMENTS TO PROVIDERS TO FACILITATE AND HASTEN THEIR ADOPTION INTO THE CARE DELIVERY PROCESS. EMR'S HAVE BECOME A PREREQUISITE OF ANY DELIVERY SYSTEM THAT INTENDS TO PROVIDE COORDINATED COST EFFECTIVE CARE.3. PHYSICIANS: PHYSICIANS HAVE EMERGED AS CRITICAL OPERATIONAL AND STRATEGIC PARTNERS TO HOSPITALS. THOSE THAT ARE SUCCESSFUL IN ENGAGING AND COLLABORATING WITH THEIR MEDICAL STAFF WILL BE BEST ABLE TO DEMONSTRATE HIGH QUALITY CARE AND COMPLIANCE WITH HEALTH REFORM'S VALUE BASED PURCHASING AND OTHER QUALITY MANDATES. THE ABILITY TO SUCCESSFULLY RECRUIT PHYSICIANS WILL BE CRITICAL. AT A TIME WHEN HEALTHCARE EMPHASIZES THE ROLE OF PRIMARY CARE, THERE IS A SPECIAL NEED TO INTENSIFY EFFORTS TO RECRUIT, RETAIN AND AGGREGATE PRIMARY CARE PROVIDERS. BECAUSE THE VAST MAJORITY OF NEW PHYSICIANS PREFER EMPLOYMENT AS THEIR PRACTICE PREFERENCE, THE ABILITY OF HOSPITALS TO BE ABLE TO OFFER PHYSICIANS A CONTEMPORARY AND COMPETITIVE "EMPLOYMENT PLATFORM" IS ESSENTIAL.4. FINANCE AND CAPITAL: FINANCIAL PERFORMANCE AND ACCESS TO CAPITAL WILL CONTINUE TO BE AMONG THE MOST CRITICAL ISSUES CONFRONTING HOSPITALS. EVEN WITH HEALTHCARE REFORM EFFORTS, HEALTHCARE COSTS WILL CONTINUE TO OUTPACE INFLATION. INCREASING WAGE AND SALARY COSTS, AND RISING HEALTH CARE COSTS IN GENERAL WILL CONTINUE TO IMPACT OPERATING PERFORMANCE AND PRESS HOSPITALS TO CONTINUE A RELENTLESS FOCUS ON COST MANAGEMENT. ADDITIONALLY, REVENUE STRATEGIES WILL NEED TO BE DEVELOPED TO GENERATE PROFITABLE GROWTH IN PATIENT VOLUME, AS WILL THE NEED TO ENSURE OPTIMAL MANAGEMENT OF ALL REVENUE CYCLE ACTIVITIES. HOSPITALS ARE FACING SIGNIFICANT ANNUAL PAYMENT REDUCTIONS IN TERMS OF DECREASES IN MEDICARE UPDATES, DISPROPORTIONATE SHARE, SNF AND HOMECARE PAYMENTS, AND MEDICAID PAYMENT LEVELS. AS HOSPITALS CONTINUE TO POST LOW OR NO PROFIT MARGINS, INVESTMENT INCOME WILL BE MORE IMPORTANT THAN EVER. HOWEVER, GIVEN THE FACT THAT INVESTMENT INCOME IS A HIGHLY UNCERTAIN COMPONENT OF A HOSPITAL'S OVERALL FINANCIAL HEALTH, HOSPITALS WILL BE DRIVEN TO PURSUE MORE PHILANTHROPY. HOSPITAL CAPITAL SPENDING WILL BE DRIVEN BY GROWING DEMANDS FOR ADVANCED TECHNOLOGY NEEDED TO ENSURE PATIENT QUALITY AND SAFETY, THE NEED TO REPLACE AND UPDATE AGING FACILITIES, AND THE DESIRE AND NEED TO IMPROVE TECHNOLOGY BASED SERVICES.SEE CONTINUATION AT THE END OF PART VI. PART VI, LINE 3: INSURANCE INFORMATION IS GATHERED DURING THE SCHEDULING AND/OR REGISTRATION PROCESS. IF THE PATIENT INDICATES THAT THEY HAVE NO INSURANCE, REGISTRATION STAFF WILL ASK THE PATIENT FOR PERMISSION TO TRANSFER THEM TO SOUTHERN TIER HEALTHCARE SYSTEMS FOR ASSISTANCE WITH SCREENING FOR ELIGIBILITY FOR GOVERNMENT PROGRAMS (I.E. MEDICAID, CHILD HEALTH PLUS, FAMILY HEALTH PLUS). SOUTHERN TIER HEALTHCARE SYSTEMS' PERSONNEL WILL CONTACT THE PATIENT AND DISCUSS OPTIONS, INCLUDING THE HOSPITAL'S FINANCIAL ASSISTANCE PROGRAM. ALL REGISTRATION, CARE MANAGEMENT AND BILLING PERSONNEL ARE EDUCATED ABOUT THE HOSPITAL'S FINANCIAL ASSISTANCE PROGRAM AND CAN DISCUSS AND SHARE INFORMATION WITH PATIENTS AT ANY TIME BEFORE, DURING OR AFTER THE EPISODE OF CARE. BILLING STATEMENTS CONTAIN THE FOLLOWING MESSAGE: IF YOU HAVE ANY QUESTIONS OR WOULD LIKE TO APPLY FOR OUR FINANCIAL ASSISTANCE PROGRAM, PLEASE CALL OUR OFFICE AT ...". THE FINANCIAL ASSISTANCE POLICY IS POSTED ON THE HOSPITAL WEBSITE TO HELP EDUCATE THE PUBLIC. PART VI, LINE 4: OLEAN GENERAL HOSPITAL IS LOCATED IN OLEAN, NEW YORK, THE LARGEST CITY IN CATTARAUGUS COUNTY. THE HOSPITAL SERVES APPROXIMATELY 88,000 RESIDENTS OF CATTARAUGUS COUNTY AND THE SURROUNDING AREA. THE POPULATION OF THE AREA IS DISTRIBUTED AS FOLLOWS: 22% UNDER THE AGE OF 18, 60% AGE 18 TO 64 AND 18% 65 AND OLDER. THE ANNUAL HOUSEHOLD INCOME WAS DISTRIBUTED AS FOLLOWS: 27% EARNING LESS THAN $25K; 29% EARNING BETWEEN $25-$50K; AND 44% EARNING $50K OR HIGHER.THE BRADFORD CAMPUS IS LOCATED IN BRADFORD, PA. THE HOSPITAL SERVES APPROXIMATELY 55,000 RESIDENTS OF MCKEAN COUNTY AND THE SURROUNDING AREA. THE POPULATION OF THE AREA IS DISTRIBUTED AS FOLLOWS: 20% UNDER THE AGE OF 18, 60% AGE 18 TO 64 AND 20% 65 AND OLDER. THE ANNUAL HOUSEHOLD INCOME WAS DISTRIBUTED AS FOLLOWS: 28% EARNING LESS THAN $25,000; 30% EARNING BETWEEN $25-$50K; AND 42% EARNING $50K OR HIGHER. PART VI, LINE 6: OLEAN GENERAL HOSPITAL IS PART OF THE UPPER ALLEGHENY HEALTH SYSTEM (UAHS), ORIGINALLY AN INTEGRATION OF TWO REGIONAL HOSPITALS UNDER A COMMON PARENT ORGANIZATION. UAHS HAS A MISSION OF COLLABORATIVE HEALTH CARE IN THE TWO COMMUNITIES SERVED BY THE INTEGRATED HOSPITALS TO MEET THE HEALTH CARE NEEDS OF THE RESIDENTS AND SURROUNDING AREAS. TO FURTHER THIS INTEGRATION, BRMC WAS MERGED INTO OGH ON JANUARY 12, 2018 AND IS NOW PART OF A 2 CAMPUS HOSPITAL. PART VI, LINE 7, REPORTS FILED WITH STATES NY PART VI, LINE 2 5.RISK MANAGEMENT AND COMPLIANCE: HEALTHCARE'S TECHNOLOGY HAS NEVER BEEN MORE COMPLICATED, PATIENTS' DEMANDS HIGHER, AND THE BUSINESS CHALLENGES GREATER. ACCORDINGLY, COMPREHENSIVE RISK MANAGEMENT PROGRAM ARE ESSENTIAL IN ASSURING CARE DELIVERY SYSTEMS THAT ARE HIGHLY EFFECTIVE IN TERMS OF ASSURING APPROPRIATE LEVELS OF PATIENT SAFETY AND QUALITY. THE DEPARTMENT OF JUSTICE ESTIMATES THAT THE FEDERAL GOVERNMENT LOSES BILLIONS OF DOLLARS ANNUALLY IN HEALTH CARE FRAUD. CONSEQUENTLY, THE GOVERNMENT'S HEALTHCARE FRAUD ENFORCEMENT ACTIVITIES WITH RESPECT TO ALL HEALTHCARE PROVIDERS CONTINUE TO GROW AND EXPAND. WELL ESTABLISHED CORPORATE COMPLIANCE PROGRAMS ARE ESSENTIAL IN TERMS OF ALLOWING HOSPITALS TO IDENTIFY POTENTIAL AREAS OF LIABILITY AND TO CORRECT PROBLEMS.6.NURSING: NURSES AND NURSING CARE ARE CENTRAL TO THE DELIVERY OF SAFE AND EFFECTIVE PATIENT CARE. ACCORDINGLY, ENSURING AN ADEQUATE NURSING WORKFORCE AND CREATING A WORK ENVIRONMENT THAT SUPPORTS NURSING PRACTICE AND INTERDISCIPLINARY COLLABORATION ARE IMPORTANT PRIORITIES FOR HOSPITALS TODAY. X X X 1 1 X X X X X 0 1 0 0 0 0 0 0 0 TIMOTHY J FINAN PRESIDENT AND CEO 646873 0 0 0 0 0 30631 0 7435 0 684939 0 0 0 JEFFREY S ZEWE VP OPERATIONS 320037 0 0 0 0 0 29281 0 28287 0 377605 0 0 0 WILLIAM MILLS VP MEDICAL AFFAIRS 308854 0 0 0 0 0 11631 0 20652 0 341137 0 0 0 GAIL BAGAZZOLI VP QUALITY AND CNO 206761 0 0 0 0 0 13665 0 20696 0 241122 0 0 0 MELISSA SULLIVAN VP CLINICAL AND SUPPORT SERVICES 178281 0 0 0 0 0 5369 0 25014 0 208664 0 0 0 DAVID GODFREY PHYSICIAN 440714 0 0 0 0 0 38752 0 17073 0 496539 0 0 0 MOHANED A AL-HUMADI PHYSICIAN 1337710 0 0 0 0 0 29281 0 15507 0 1382498 0 0 0 JAVAID A MALIK PHYSICIAN 833568 0 0 0 0 0 19000 0 22318 0 874886 0 0 0 ASIM MAKHDOM PHYSICIAN 629946 0 0 0 0 0 10612 0 6675 0 647233 0 0 0 GARY CARL PHYSICIAN 454617 0 0 0 0 0 19000 0 14629 0 488246 0 0 0 A CATTARAUGUS COUNTY CAPITAL RESOURCES CORPORATION 273458026 2010-10-06 21585000 REFUNDING OF BONDS, FINANCE AND NEW AMBULATORY SURGERY CENTER & HIS 0 0 0 A 21585000 431700 2012 1 0 1 1 A 0 0 0 0 0 0 0 A 0 0 0 0 1 0 0 0 0 A 0 FORM 990, PART III, LINE 1, DESCRIPTION OF ORGANIZATION MISSION:(CONTINUED) THE HOSPITAL IS GOVERNED BY A 17 MEMBER BOARD OF DIRECTORS COMPRISED OF 16 VOLUNTARY INDIVIDUALS WHO RESIDE THROUGHOUT THE OLEAN GENERAL HOSPITAL AND BRADFORD REGIONAL MEDICAL CENTER SERVICE AREAS AND THE CEO OF UPPER ALLEGHENY HEALTH SYSTEM. WITH A LICENSED CAPACITY OF 186 BEDS ON THE OLEAN CAMPUS AND 89 BEDS AT THE BRADFORD CAMPUS, THE HOSPITAL PROVIDES THE COMMUNITY WITH VITAL HEALTH CARE SERVICES INCLUDING MEDICAL/SURGICAL, PEDIATRIC AND OBSTETRICAL CARE. THE HOSPITAL ALSO PROVIDES INTENSIVE AND CORONARY CARE, BEHAVIORAL HEALTH, CHRONIC DIALYSIS, AND 24 HOUR EMERGENCY SERVICES WITH ACCESS TO HELICOPTERS FOR EMERGENCY TRANSFER OF PATIENTS REQUIRING TERTIARY CARE. ADDITIONAL SERVICES INCLUDE DIAGNOSTIC IMAGING, LABORATORY, CARDIOPULMONARY, OCCUPATIONAL WELLNESS, DIABETES TEACHING, PATIENT EDUCATION, RADIATION ONCOLOGY SPECIFICALLY ON THE OGH CAMPUS, A SLEEP DISORDERS CENTER, OUTPATIENT PRIMARY CARE, AND A DENTAL CENTER. OLEAN GENERAL HOSPITAL, IN CONJUNCTION WITH THE STATE UNIVERSITY OF NEW YORK AT BUFFALO, SPONSORS NEW YORK STATE'S ONLY RURAL TRACK POST GRADUATE MEDICAL EDUCATION/RESIDENCY TRAINING PROGRAM. FORM 990, PART VI, SECTION A, LINE 6 UPPER ALLEGHENY HEALTH SYSTEM, INC. IS THE SOLE CORPORATE MEMBER OF THE HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7B GOVERNANCE DECISIONS ARE SUBMIT TO APPROVAL BY KALEIDA HEALTH. FORM 990, PART VI, SECTION B, LINE 11B A DRAFT COPY OF THE FORM 990 IS REVIEWED FOR ACCURACY AND COMPLETENESS BY THE HOSPITAL'S CHIEF FINANCIAL OFFICER AND SENIOR MANAGEMENT OF UPPER ALLEGHENY HEALTH SYSTEM. IN ADDITION, A FINAL DRAFT COPY OF THE FORM 990 IS PROVIDED TO MEMBERS OF THE BOARD OF DIRECTORS TO REVIEW AND COMMENT PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE HOSPITAL'S CONFLICT OF INTEREST POLICY IS PRESENTED AND REVIEWED ANNUALLY. EACH MEMBER OF THE BOARD COMPLETES A DISCLOSURE FORM. SEE THE FORMAL POLICY, AS OUTLINED IN THE ORGANIZATION'S BYLAWS, BELOW. CONFLICTS OF INTEREST: EACH DIRECTOR, PRIOR TO TAKING HIS POSITION ON THE BOARD, AND ALL PRESENT DIRECTORS AS SOON AS PRACTICABLE AFTER THE ADOPTION OF THESE BYLAWS, SHALL SUBMIT IN WRITING TO THE CHAIRMAN OF THE BOARD AND THE CHIEF EXECUTIVE OFFICER A LIST OF ALL BUSINESS OR OTHER ORGANIZATIONS OF WHICH HE IS AN OFFICER, DIRECTOR, TRUSTEE, MEMBER, OWNER (EITHER AS SOLE PROPRIETOR OR PARTNER), SHAREHOLDER WITH 5% OR GREATER INTEREST IN ALL OUTSTANDING VOTING SHARE, EMPLOYEE OR AGENT, WIHT WHICH THE CORPORATE HAS, OR MIGHT BE REASONABLY IN THE FUTURE ENTER INTO, A RELATIONSHIP OR A TRANSACTION IN WHICH THE DIRECTOR WOULD HAVE CONFLICTING INTERESTS. EACH WRITTEN STATEMENT WILL BE RESUBMITTED WITH ANY NECESSARY CHANGES EACH YEAR. THE CHAIRMAN OF THE BOARD SHALL BECOME FAMILIAR WITH THE STATEMENTS OF ALL DIRECTORS IN ORDER TO GUIDE HIS CONDUCT SHALL A CONFLICT ARISE. THE CHAIRMAN-ELECT OF THE BOARD SHALL BE FAMILIAR WITH THE STATEMENT FILED BY THE CHAIRMAN. SHOULD THE CHAIRMAN-ELECT POSITION BE VACANT, THE MOST SENIOR MEMBER OF THE EXECUTIVE COMMITTEE WILL ASSUME THIS RESPONSIBILITY. AT SUCH TIME AS ANY MATTER COMES BEFORE THE BOARD IN SUCH A WAY AS TO GIVE RISE TO A CONFLICT OF INTEREST, THE AFFECTED DIRECTOR SHALL MAKE KNOWN THE POTENTIAL CONFLICT WHETHER DISCLOSED BY HIS WRITTEN STATEMENT OR NOT, AND AFTER ANSWERING ANY QUESTIONS THAT MIGHT BE ASKED OF HIM, SHALL WITHDRAW FROM THE MEETING FOR SO LONG AS THE MATTER SHALL CONTINUE UNDER DISCUSSION. SHOULD THE MATTER BE BROUGHT TO A VOTE, THE AFFECTED DIRECTOR SHALL NOT VOTE ON IT. IN THE EVENT THE CONFLICT OF INTEREST AFFECTS THE CHAIRMAN, THE CHAIRMAN-ELECT IN EMPOWERED AND SHALL REQUIRE THAT THE CHAIRMAN REMOVE HIMSELF IN THE SAME MANNER, AND FOR THE DURATION OF DISCUSSION AND ACTION ON THE MATTER THE CHAIRMAN-ELECT SHALL PRESIDE. SHOULD THE CHAIRMAN-ELECT POSITION BE VACANT, THE MOST SENIOR MEMBER OF THE EXECUTIVE COMMITTEE WILL ASSUME THIS RESPONSIBILITY. IF THE MATTER IS THE ITEM OF BUSINESS FOR WHICH A SPECIAL MEETING OF THE BOARD WAS CALLED, THE AFFECTED DIRECTOR SHALL NOT BE COUNTED TO ESTABLISH A QUORUM, NOR SHALL HE PARTICIPATE IN THE DELIBERATIONS OR VOTE ON IT. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE COMMITTEE OF THE HOSPITAL D/B/A THE EXECUTIVE COMPENSATION COMMITTEE (THE COMMITTEE) IS APPOINTED BY THE BOARD OF DIRECTORS TO ASSIST THE BOARD IN ESTABLISHING AND OVERSEEING THE EXECUTIVE COMPENSATION PROGRAM OF THE HOSPITAL. THE COMMITTEE IS RESPONSIBLE FOR ADHERING TO THE OVERALL COMPENSATION PHILOSOPHY OF THE HOSPITAL. THE COMPENSATION PHILOSOPHY IS A TOTAL COMPENSATION CONCEPT THAT WILL EMPLOY A COMBINATION OF BASE SALARY, VARIABLE OPPORTUNITY, FLEXIBLE BENEFITS, DEFERRED COMPENSATION AND OTHER PERQUISITES AS MAY BE NEEDED FROM TIME TO TIME TO MAINTAIN A COMPETITIVE POSITION WITH PEER INSTITUTIONS IN THE REGION. FORM 990, PART VI, SECTION C, LINE 19 THE HOSPITAL HAS AVAILABLE, UPON REQUEST TO ADMINISTRATION, ITS MOST RECENTLY FILED FORM 990, GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS. THE HOSPITAL ALSO REPORTS ANNUALLY ITS COMMUNITY BENEFIT EFFORTS AND ISSUES ANNUAL REPORT THAT INCLUDES FINANCIAL AND OTHER INFORMATION OF INTEREST TO THE PUBLIC. FORM 990, PART IX, LINE 11G PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 12,136,754. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 12,136,754. CONSULTING: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 1,025,161. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,025,161. MAINTENANCE CONTRACTS: PROGRAM SERVICE EXPENSES 69,311. MANAGEMENT AND GENERAL EXPENSES 5,345,803. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,415,114. BUILDING AND EQUIPMENT MAINTENANCE AND REPAIRS: PROGRAM SERVICE EXPENSES 1,170,393. MANAGEMENT AND GENERAL EXPENSES 165,125. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,335,518. OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 17,013,817. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 17,013,817. COLLECTION FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 630,948. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 630,948. NON-HEALTHCARE PROVIDER FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 6,843,195. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 6,843,195. FORM 990, PART XI, LINE 9: PENSION LIABILITY ADJUSTMENT -9,296,002. NET ASSETS CONTRIBUTIONS -106,529. NET DEPRECIATION OF FUNDS HELD IN TRUST AND FOUNDATION 651,036. FORM 990, PART XII, LINE 2C THE AUDIT AND COMPLIANCE COMMITTEE ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT, AS WELL AS THE CHOICE OF AN INDEPENDENT ACCOUNTANT. THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. AS PART OF KALEIDA HEALTH, THE FINANCIAL STATEMENTS OF OLEAN GENERAL HOSPITAL ARE PART OF THE CONSOLIDATED STATEMENTS ISSUED BY KALEIDA HEALTH. ADDITIONAL INFORMATION IS CONTAINED WITHIN THE KALEIDA HEALTH LONG-FORM REPORT. ANY AUDIT ISSUES RAISED BY THE KALEIDA HEALTH AUDITORS ARE REVIEWED BY THE OGH AUDIT AND COMPLIANCE COMMITTEE. KALEIDA HEALTH HAS AN AUDIT AND COMPLIANCE COMMITTEE THAT OVERSEES THE PROCESS AND SELECTED THE INDEPENDENT ACCOUNTANT. OLEAN GENERAL HOSPITAL FOUNDATION 515 MAIN STREET OLEAN NY 14760 161497087 FUNDRAISING NY 501(C)(3) PF N/A 0 UPPER ALLEGHENY HEALTH SYSTEM INC 515 MAIN STREET OLEAN NY 14760 271255425 SOLE CORP MEMBER OF OLEAN GENERAL HOSPITAL NY 501(C)(3) LINE 12B, II N/A 0 HEALTH SYSTEM PHYSICIAN PC 515 MAIN STREET OLEAN NY 14760 464304317 PHYSICIAN GROUP NY 501(C)(3) LINE 11 N/A 0 BRADFORD REGIONAL MEDICAL SERVICES 116 INTERSTATE PARKWAY BRADFORD PA 16701 232875157 PHYSICIAN MEDICAL CARE PA 501(C)(3) LINE 3 N/A 0 BRADFORD HOSPITAL FOUNDATION 116 INTERSTATE PARKWAY BRADFORD PA 16701 251612399 FUNDRAISING PA 501(C)(3) LINE 12B, II N/A 0 OLEAN GENERAL HEALTHCARE SYSTEMS LLC 85 WOODRIDGE DRIVE AMHERST NY 14228 161544460 PROVIDER OF DURABLE MEDICAL EQUIPMENT, HOME CARE PRODUCTS, AND SERVICES NY N/A OLEAN GENERAL SERVICES CORP 515 MAIN STREET OLEAN NY 14760 161447054 JOINT VENTURE HOLDING COMPANY NY OLEAN GENERAL HOSPITAL C 1.00000 0 1 1 1 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0