2025-11-12T13:52:11-06:00 2024-12-31 990 2024-01-01 161523353 Mount St Mary's Hospital of Niagara Falls MOUN 7168282974 144 Genesee St Buffalo NY 14203 Russell Edwards VP Finance/Corp. Controller 7169232968 2025-11-12 0 2024 2025-03-06 01:10:19Z Joyce Markiewicz 144 Genesee Street Administration 6th Floor Buffalo NY 14203 160280004 0 X www.chsbuffalo.org X 1907 NY The Mission of Mount St. Mary's Hospital of Niagara Falls, as part of the Catholic Health System (CHS) in Western New York, is to provide quality healthcare services in an acute care setting. Committed to a common mission, the providers of Mount St. Mary's Hospital of Niagara Falls continue the healing ministry of Jesus, seeking to improve the health of individuals and communities. We provide high quality service that has reverence, compassion, justice, and excellence. The 2024 Community Service Plan can be found at https://www.chsbuffalo.org/about-us/community 14 11 892 13 0 0 32935068 24656558 109911271 131660445 129941 168966 6584905 3794035 149561185 160280004 0 0 0 0 69957625 69614859 0 0 0 61511497 65051050 131469122 134665909 18092063 25614095 139539911 161924107 123948593 122145390 15591318 39778717 X The Mission of Mount St. Mary's Hospital of Niagara Falls, as part of the Catholic Health System (CHS) in Western New York, is to provide quality healthcare services in an acute care setting. Committed to a common mission, the providers of Mount St. Mary's Hospital continue the healing ministry of Jesus, seeking to improve the health of individuals and communities. We provide high quality service that has reverence, compassion, justice, and excellence. The 2024 Community Service Plan can be found at https://www.chsbuffalo.org/about-us/community 0 0 31138704 36850694 Inpatient Routine/Surgery Visits:Acute Care Patient Days = 8,160Inpatient Surgeries = 4 67109570 79419946 Outpatient Routine/Surgery Services:Emergency Visits (Net of Admits) = 36,636Referred Ambulatory Visits = 94,217Operating Room = 8Interventional Radiology = 382Niagara Regional Surgery Center = 4,734 13004331 15389806 Clinic/Primary Care Services:Clinic Visits = 32,592Primary Care Visits = 16,261 111252605 1 1 0 1 0 0 0 0 0 0 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 1 1 0 0 0 0 0 0 1 0 1 0 1 55 0 1 892 1 0 0 0 0 0 0 0 0 0 0 X 14 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X X Russell Edwards VP FinanceCorp Controller CHS 7169232968 144 Genesee Street Buffalo NY 14203 Joyce Markiewicz President & CEO Administration CH 0.00 55.00 X X 0 1851882 60318 Leonardo Sette-Camara General Counsel 0.00 55.00 X X 0 442007 32513 Russell Edwards VP Finance & Corporate Con 0.00 55.00 X X 0 275197 11913 Douglas Bean Director 0.00 4.00 X 0 0 0 Anthony Burgio Director 0.00 4.00 X 0 0 0 Adam Dean Director 0.00 4.00 X 0 0 0 Carol Heckman Esq Director 0.00 8.00 X 0 0 0 Sister Marcia Ann Fiutko Director 0.00 4.00 X 0 0 0 Nelson J Grimm PhD Director 0.00 4.00 X 0 0 0 Toni Murphy DO Director 0.00 4.00 X 0 0 0 Monsignor Robert E Zapfel Director - Vice Chair 0.00 4.00 X 0 0 0 David Godfrey Director 0.00 4.00 X 0 0 0 R Keith Felstead DO Director 0.00 4.00 X 0 0 0 Alexis Agnello Director - Chair 0.00 4.00 X 0 0 0 James M Garvey Executive VP, COO 0.00 55.00 X 0 993464 44425 David Macholz Chief Finance Officer 0.00 55.00 X 0 868881 29130 Dr Michael Galang Senior VP, Chief Information Officer 0.00 55.00 X 0 660017 46689 Bartholomew Rodrigues Executive VP, Chief Mission and Ethics Officer 0.00 55.00 X 0 397474 59780 Rebecca McCormick Boyle Chief Integration Officer 0.00 55.00 X 0 318098 2654 Hans Cassagnol Chief Physician Executive 0.00 55.00 X 0 242649 7378 Victor Filadora Chief Physician Executive 0.00 55.00 X 0 208244 156 Catherine Mohr Chief Nursing Officer 0.00 55.00 X 0 194891 8172 Martin Boryszak Senior VP of Acute Care & President Mercy Hospital 0.00 55.00 X 0 796697 30697 Charles Urlaub Senior VP of Strategic Growth and Partnerships 0.00 55.00 X 0 608916 53386 Laura Cianflone Senior VP of Human Resources 0.00 55.00 X 0 573155 31866 Lisa Cilano Senior VP, RMC & Business 0.00 55.00 X 0 444768 15686 Thomas Gleason Senior VP Home and Community Based Care 0.00 55.00 X 0 420621 37238 Megan Aldrich President of Sisters of Charity Hospital 0.00 55.00 X 0 254335 236 Walter Ludwig President & CEO KMH 0.00 55.00 X 0 430281 58002 Dr Parag Parikh Physician 55.00 0.00 X 730318 0 37451 Dr Stephen Watkins Physician 55.00 0.00 X 658559 0 14639 Dr Robert Taylor Physician 55.00 0.00 X 461874 0 28594 Dr Joseph Andrzejewski Physician 55.00 0.00 X 430647 0 27109 Dr Kafai Lai Physician 55.00 0.00 X 432023 0 17633 Mark Sullivan President CHS - Former 0.00 0.00 X 0 1851336 13203 2713421 11832913 668868 119 1 1 0 THE PIKE COMPANY INC 1 Circle Street Rochester NY 14607 Construction Services 7624224 TRIMEDX LLC 5451 LAKEVIEW PKWY S DRIVE INDIANAPOLIS IN 46268 Healthcare Services 1107873 BUFFALO NIAGARA HOSPITALISTS 2950 Elmwood Ave/Med Staff Office Kenmore NY 14217 Physician Services 970000 UNIVERSITY EMERGENCY MEDICAL 462 Grider St Buffalo Buffalo NY 14215 Emergency Services 920000 IR MUELLER CORP 789 Colvin Blvd Buffalo NY 14217 Security Services 711878 24 15069619 9586939 24656558 Medicare/Medicaid 621990 87184451 87184451 All Other Payers 621990 44475994 44475994 131660445 168966 64147 104819 45488 0 45488 45488 45488 340B Pharmacy 621990 1986658 1986658 CHS Shared Services 621990 370180 370180 Cafeteria Revenue 621990 226854 226854 1164855 1164855 3748547 160280004 135246285 0 377161 56306586 50296634 6009952 1686523 1506510 180013 8038924 7180880 858044 3582826 3200409 382417 -320251 17238 -337489 7655570 6418489 1237081 91910 12709 79201 4218869 2399085 1819784 95984 14275 81709 1492637 1119478 373159 23997 7124 16873 1843 1843 2595331 43481 2551850 6498281 5114587 1383694 2652298 2125920 526378 Dues and Shared Service 18596646 13761517 4835129 Medical Supplies 14223973 14207699 16274 Purchased Services 5655310 2445601 3209709 Other Supplies Non-Medi 1568652 1379126 189526 134665909 111252605 23413304 0 4380 8419 12064692 33702091 16933802 15531891 1813266 1831807 126434 87878 164610494 71851972 94042677 92758522 4950 4950 14549710 17998549 139539911 161924107 22778285 17593510 3423177 49598155 54554079 416596 1527007 51155557 45047617 123948593 122145390 X 13673360 37860759 1917958 1917958 15591318 39778717 139539911 161924107 X 25614095 -1426697 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2574 2574 0 Part II-B, Line 1: Other lobbying activities: Lobbying expenses of $2,574 represent the total of dues paid to national and state associations that is specifically allocable to lobbying. Mount St. Mary's Hospital does not participate in or intervene in (including the publishing or distributing of statement) any political campaign on behalf of (or opposition to) any candidate. 2084436 2084436 96538197 28205265 68332932 10956711 3365776 7590935 52826159 40580760 12245399 2204991 -299829 2504820 92758522 Due From Affiliates 611668 Interest in Net Assets of MSM Foundation 7675443 Insurance Recoveries 4685167 Other Receivables 174016 Operating Lease Right of Use Assets 486328 Obligated FEMA Revenues 4365927 17998549 Due to Affiliates 20276597 L/T General Liab/Workers Comp IBNR 13072799 Long-Term Pension Obligations 3119777 Asset Retirement Obligation 4859530 Long-Term Portion of EIB Bank 80818 Contingent Performance Obligation 4508596 Operating Lease Liabilities 494897 Debt Issuance Costs -1365397 45047617 154145366 1839278 1839278 152306088 7973916 7973916 160280004 136113174 1447266 1447266 134665908 0 134665908 Part XI, Line 2d - Other Adjustments: Childcare Revenue - 865,703. Foundation Revenue - (net of eliminations) 973,575. Part XI, Line 4b - Other Adjustments: Contributions from Foundation 7,973,916. Part XII, Line 2d - Other Adjustments: Childcare Expenses 983,002. Foundation Expenses (net of eliminations) 464,264. 1 1 X 1 X 1 X 1 1 1 0 1 1 1963789 49645 1914144 0.01250 39974325 41448364 0 0.00000 41938114 41498009 1914144 0.01250 11812 11812 0.00010 755 755 0.00000 23372391 20327011 3045380 0.01990 284 284 0.00000 20024 20024 0.00010 23405266 20327011 3078255 0.02010 65343380 61825020 4992399 0.03260 1029 1029 0.00000 1029 1029 0.00000 0 12926251 13443612 -517361 X 1 1 2 1 Mount St Mary's Hospital of Niagara Falls 5300 Military Rd Lewiston NY 14092 www.chsbuffalo.org 3121001H X X X Ambulatory Surgery - Multi Specialty 2 Lockport Memorial Hospital 6001 Shimer Dr Lockport NY 14094 www.chsbuffalo.org X X X Cardiac Care Mount St Mary's Hospital of Niagara Fal 1 1 1 1 X X X X X X X X X 22 1 1 1 1 X https://www.chsbuffalo.org/mission/social-responsibility-community-benefit X 1 22 1 https://www.chsbuffalo.org/mission/social-responsibility-community-benefit 0 1 X 200.000000000000 400.000000000000 X X X X 1 1 X X X X 1 X www.chsbuffalo.org/billing-insurance/financial-assistance X www.chsbuffalo.org/sites/default/files/files/billing/catholic-healt X www.chsbuffalo.org/sites/default/files/files/billing/catholic-healt X X X X X X X 1 X 0 X 1 X 0 0 Part V, Section A: Mount St. Mary's Hospital of Niagara Falls:Ambulatory Surgery - Multi Specialty Chemical Dependence - Rehabilitation Chemical Dependence - Withdrawal O/PClinic Part Time ServicesClinical Laboratory ServiceCoronary CareEmergency Department Intensive CareLevel I Perinatal Care Lithotripsy MaternityMedical Services - Other Medical Specialties Medical Services - Primary CareMedical Social Services Medical/Surgical Nuclear Medicine - Diagnostic Nuclear Medicine - Therapeutic Radiology - Diagnostic Renal Dialysis - AcuteStroke Center Therapy - Occupational O/P Therapy - Speech Language Pathology O/PLockport Memorial Hospital:Cardiac CareClinical Laboratory ServiceEmergency DepartmentMedical Services Other Medical SpecialtiesMedical Services Primary CareMedical/SurgicalNuclear Medicine - DiagnosticPodiatry O/PRadiology DiagnosticRespiratory CareTherapy Physical I/P Mount St. Mary's Hospital of Niagara Falls Part V, Section B, Line 2: Hospital was in construction and placed into service in 2023. Mount St. Mary's Hospital of Niagara Falls Part V, Section B, Line 5: - Niagara County Health Department Assessed resources and determined that they would extend the 2019-- 2021 Priorities for the 2022-2024 cycle due to the COVID-19 pandemic.- CHNA/CHIP Steering Committee Monthly meetings held starting in February 2022. Delayed start due to resource allocation as a result of global COVID-19 pandemic.- Three Surveys Conducted Consumer, Provider, and Community Based Organizations- Consumer survey late March 2022 through mid-June 2022 2,329 respondents, reviewed by zip code toensure equitable geographic input- Provider Survey Conducted in May 2022, 49 responses received- Niagara Falls Health Equity Task Force survey Conducted in May 2022, 10 respondents- Focus Groups April 2022 through June 2022, 5 groups for a total of 61 participants- Findings of surveys and focus groups were compiled and reviewed by the Steering Committee which iscomprised of the hospitals, county representatives, and other community organizations who each thendisseminate results with their networks, county contacts, and other organizations (i.e., Niagara Falls HealthEquity Task Force). The results continue to be shared with county and community leaders as the countyworks to support residents during this unprecedented time.- Catholic Health CHNA Summit June 13, 2022. Health system clinical and non-clinical leaders were invitedto review and approve priorities identified through above processes.- Catholic Health Board Strategic Planning Committee Meeting July 11, 2022. Health priorities were sharedwith the committee for review and comment.- Catholic Health Mission Integration Committee September 7, 2022. The 2022-2024 health priorities and initiatives were presented and the reporting dashboard was discussed.- Niagara County Community Health Stakeholder Meeting September 12, 2022. Priorities reviewed andpotential interventions and strategies to target focus areas identified.- Catholic Health Ministry Services Board Meeting November 17, 2022. The CHNA reports and CHIP for eachof the hospitals were presented and approved by the board members.- Catholic Health Board of Directors were informed of the Ministry Services Board's approval of the 2022-2024CHNA reports and CHIP during the December 1, 2022 Board of Directors meeting.- All reports have been published electronically on the Catholic Health website (chsbuffalo.org) with hardcopies available upon request from the Catholic Health Mission Integration office. Mount St. Mary's Hospital of Niagara Falls Part V, Section B, Line 6a: Bernadette Franjoine Catholic Health bfranjoine@chsbuffalo.orgLauri McCoy Catholic Health lmccoy1@chsbuffalo.orgCarolyn Moore Eastern Niagara Hospital cmoore@enhs.orgAnnette Andrews Kaleida Health aandrews@kaleidahealth.orgBrian Meade Kaleida Health bmeade@kaleidahealth.orgKathleen Tompkins Kaleida Health ktompkins@kaleidahealth.orgStacy Knott Niagara County Department of Health stacy.knott@niagaracounty.comRobert Mowery Niagara Falls Memorial Medical Center robert.mowery@nfmmc.orgAlessandra Duarte Population Health Collaborative of WNY aduarte@phcwny.org Mount St. Mary's Hospital of Niagara Falls Part V, Section B, Line 6b: Heather Cruz NCDMH (contracted) heather.cruz@niagaracounty.comAdrienne Kasbaum Niagara County Department of Health adrienne.kasbaum@niagaracounty.comCathy Hoy-Patterson Niagara County Department of Health cathy.hoy-patterson@niagaracounty.comDan Stapleton Niagara County Department of Health dan.stapleton@niagaracounty.comJacquelyn Langdon Niagara County Department of Health jacquelyn.langdon@niagaracounty.comTracy Fricano-Chalmers Niagara County Department of Health tracy.fricanochalmers@niagaracounty.comVictoria Pearson Niagara County Department of Health victoria.pearson@niagaracounty.comKaren Hall Population Health Collaborative of WNY khall@phcwny.org Mount St. Mary's Hospital of Niagara Falls Part V, Section B, Line 11: Catholic Health 2022-2024 Prevention Agenda Priorities and DisparityIn collaboration with the Niagara County Department of Health and other community partners, the following priorities, goals, focus areas and interventions were selected for the Catholic Health Community Health Improvement Plans. Priority Area #1 and Priority Area #2 were priorities identified by the Niagara County Department of Health and selected for our community collaboration. Catholic Health is required to align with at least two county Priority Areas as part of the CHNA process. Of note, the Erie County Department of Health identified the same priorities.Priority Area #1: Prevent Chronic DiseasesDisparity: SocioeconomicFocus Area 1: Healthy Eating and Food SecurityOverarching Goal: Reduce obesity and the risk of chronic diseaseGoal 1.13: Increase the percentage of adults with perceived food securityPriority Area #2: Promote Well-Being and Prevent Mental and Substance Use DisordersDisparity: SocioeconomicFocus Area 1: Promote Well-BeingGoal 1.2: Facilitate supportive environments that promote respect and dignity for people of all agesGoal 2.2: Prevent opioid and other substance misuse and deathsFocus Area 2: Prevent Mental and Substance Use DisordersGoal 2.2: Prevent opioid and other substance misuse and deathsPriority Area #3: Promote Healthy Women, Infants, and ChildrenDisparity: EthnicityFocus Area 1: Maternal and Women's HealthGoal 1.2: Reduce maternal mortality and morbidityFocus Area 2: Perinatal and Infant HealthGoal 2.2: Increase breastfeedingA comprehensive review of outcome data from a variety of state and national resources were reviewed as part of the CHNA process. Primary resources utilized included the New York Prevention Agenda Dashboard, data from the United States census reporting, the University of Wisconsin's Population Health Institute's County Health Rankings and Roadmaps, as well as others. Due to the proximity and nature of the interrelationships between Erie and Niagara counties, as well as the reach of the Catholic Health service area and goal for high level of inclusivity for community health, data from both counties is represented in the following report. This provides a more comprehensive view of the overall service area while still allowing county specific needs to be identified.The overall assessment process is a collaborative effort between Catholic Health, Niagara County Department of Health, and other local organizations and hospitals. More than 15 organizations directly participated in planning meetings and feedback sessions and over 1,300 residents responded to the CHNA survey. Input was also solicited from a broad range of other community organizations, individuals, and groups. This input helped validate and bring focus to areas of specific need and disparity, as well as helped prioritize interventions to address the needs of those we serve. The completed assessment and analysis of the data provided a framework for the health system's overall implementation plan to support priority needs that were identified for the community over the next three years.chs.buffalo.org | 9The progress and overall improvement related to the Prevention Agenda priorities in the Catholic Health improvement plan will be monitored by the internal leaders who are coordinating the interventions identified by the teams to support the priorities identified and as outlined on the CHIP template provided by the New York State Department of Health. Catholic Health will submit updates on progress towards each intervention annually, or as requested. The county's steering committee representatives will also continue to meet at least annually and review progress as well as explore new opportunities to collaborate on to support the priority areas. The Prevention Agenda Dashboard will continue to serve as the primary resource to track latest available trending details and monitor outcome data.While Catholic Health is committed to serving the community through the CHNA priorities in this report, thereare a number of needs that were not incorporated into Catholic Health's individual 2022-2024 CommunityHealth Improvement Plan at this time for one or more of the following reasons: Requires resources that Catholic Health does not currently have available without compromising otherimportant initiatives. Is being targeted or addressed by other entities within the community. Was deemed not as impactful on the overall health of the community as compared to other identified needs.Should community circumstances change or additional resources become available, Catholic Health willconsider incorporating other initiatives into its plan. The Community Health Needs Assessment and Community Health Improvement Plan processes are linked directly to requirements specified by the Federal Internal Revenue Service and the New York State Department of Health. Under the Patient Protection and Affordable Care Act of 2010, the Internal Revenue Service requires all state-licensed, tax-exempt hospitals to develop a Community Health Needs Assessment and Community Health Improvement Plan to maintain their Internal Revenue Code Section 501(c)(3) tax-exempt status. Similarly, New York State requires hospitals and local health departments to collaborate within their community to identify local health priorities and to plan and implement a strategy for local health.Part V, line 7A Page 8: https://www.chsbuffalo.org/mission/social-responsibility-community-benefit Part V, line 10a Page 8: https://www.chsbuffalo.org/mission/social-responsibility-community-benefit Mount St. Mary's Hospital of Niagara Falls Part V, Section B, Line 16j: Includes information in both English and Spanish on all signage and brochures for financial assistance. 10 1 - Mount St Mary's Hospital Rehab Services 1 Columba Drive Niagara Falls NY 14305 Medical Services - Primary Care Therapy - Occupational O/P Therapy - Physica 2 - Mount St Mary's Diagnostic Imaging Serv 7300 Porter Road Niagara Falls NY 14304 Medical Services- Primary Care 3 - Mount St Mary's Ear Nose and Throat Se 6941 Elaine Drive Niagara Falls NY 14304 Medical Services- Primary Care 4 - Mount St Mary's Orthopedic Services 5320 Military Road Lewiston NY 14092 Medical Services- Primary Care 5 - Mount St Mary's Primary Care Extension 1302 Main Street Niagara Falls NY 14301 Medical Social Services O/P Primary Medical Care O/P Radiology - Diagnostic 6 - Mount St Mary's Neighborhood Health Cent 3101 Ninth Street Niagara Falls NY 14305 Medical Social Services O/P Nutritional O/P Prenatal O/P Primary Medical Car 7 - Mount St Mary's Health Center Lockport 6000 Brockton Drive Lockport NY 14094 Medical Services - Other Medical Specialties Medical Services - Primary Care 8 - Mount St Mary's Neurology Center 4600 Military Road Niagara Falls NY 14305 Medical Services - Other Medical Specialties- 9 - Mount St Mary's Campus Medical Arts Bui 5290 Military Road Suite 8 Niagara Falls NY 14092 Medical Services- Primary Care 10 - Niagara Ambulatory Surgery Center 5875 S Transit Rd Lockport NY 14094 Ambulatory Surgery Multi Specialty O/P Part I, Line 6a: Mount St. Mary's Community Benefit Report is contained in the annual report prepared by the Catholic Health System. Part I, Line 7: Costing is a full step down methodology of cost from non-revenue producing departments to revenue producing departments', with assignment of cost to individual charge items based on volume and charge amount. All patient accounts are cost with the same methodology regardless of patient type (inpatient, outpatient, emergency room, etc.) or insurance coverage (Medicare, Medicaid, private insurance, uninsured, etc.). Part II, Community Building Activities: Community Building Activities for Mount St. Mary's Hospital included workforce development of $1,029. Part III, Line 2: The Hospital did not report bad debt on their financial statements, as they adopted ASU 2014-09 Revenue from Contracts with Customers in 2018. Upon adoption, the majority of what was previously classified as provision for bad debts and presented as a reduction to net patient service revenue on the statement of operations and changes in net assets is treated as an implicit price concession that reduces the transacton price, which is reported as net patient service revenue. Part III, Line 3: The Hospital did not report bad debt on their financial statements, as they adopted ASU 2014-09 Revenue from Contracts with Customers in 2018. Upon adoption, the majority of what was previously classified as provision for bad debts and presented as a reduction to net patient service revenue on the statement of operations and changes in net assets is treated as an implicit price concession that reduces the transacton price, which is reported as net patient service revenue. Part III, Line 4: The hospital does not have a footnote that describes bad debt in the financial statements. Part III, Line 8: Mount St. Mary's Hospital does not treat Medicare shortfall as a community benefit, as serving Medicare patients is not a differentiating feature of tax-exempt healthcare organizations. The existing community benefit framework allows community benefit programs that serve the Medicare population to be counted in other community benefit categories. Part III, Line 9b: The hospital's collection policies contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance. The hospital has implemented billing and collection practices for patient payment obligations that are fair, consistent, and compliant with state and federal regulations and no extraordinary collection practices are followed. Part III, Line 2 The Hospital did not report bad debt on their financial statements, as they adopted ASU 2014-09 Revenue from Contracts with Customers in 2018. Upon adoption, the majority of what was previously classified as provision for bad debts and presented as a reduction to net patient service revenue on the statement of operations and changes in net assets is treated as an implicit price concession that reduces the transacton price, which is reported as net patient service revenue. Part III, Line 8 Part II line 4. The hospital does not have a footnote that describes bad debt in the financial statements. Part III, Line 3 The Hospital did not report bad debt on their financial statements, as they adopted ASU 2014-09 Revenue from Contracts with Customers in 2018. Upon adoption, the majority of what was previously classified as provision for bad debts and presented as a reduction to net patient service revenue on the statement of operations and changes in net assets is treated as an implicit price concession that reduces the transacton price, which is reported as net patient service revenue. Part VI, Line 2: As part of Catholic Health, Mount St. Mary's Hospital benefits from information received from a key stakeholders engaged in the facilities health ministry. This includes the voice of associate through requests and information received from Catholic Health associates via formal and informal conversations in their departments and requests for assistance through the Helping Hands fund. In addition evaluations administered by the Catholic Health Community Education Department after each class, workshop, or program it sponsors; from input from the physician community during doctor to doctor education programs; from physician and leadership participation in community boards, coalitions and forums to define the health needs of patient populations and seek community solutions; from participation in regional planning initiatives that look at the needs of the broader community; and input from the Catholic Health Board including Board Committee (e.g. Mission Integration Committee). Examples of other sources of input include engagement from a number of countywide, city/town, and regional organizations. Those organizations include the Niagara Falls Health Equity Task Force, Niagara and Lockport School Districts, Niagara Falls' Heart, Love and Soul Food Pantry, Pinnacle Community Services, Niagara County Department of Health, Niagara County Department of Mental Health and Substance Abuse and many others. In each of these organizations, representatives from Mount St. Mary's as well as Catholic Health are actively engaged and in many cases serve on boards or key committee with consistent dialogue about our services. The facility is an active partner in a number of county initiatives as well as the state required Community Health Needs Assessment process. This results in comprehensive geographic reaches and significant collaborative work specifically with the Niagara County Department of Health. Part VI, Line 3: Catholic Health's Mount St. Mary's inform and educate patients and persons who may be billed for medical services about their eligibility for assistance under federal, state, or local government programs or our own Healthcare Assistance Program (HAP) in a variety of ways. For example, Mount St. Mary's, like our other Catholic Health facilities, has posters and brochures available, which include eligibility and contact information for the Patient Financial Services Team. This information is available in admissions areas, emergency rooms, primary care and outpatient rehabilitation centers, the Administrative and Regional Training Center (ARTC) and other areas throughout Catholic Health where eligible patients and family members are likely to be present. This information is also on the website https://www.chsbuffalo.org/billing-insurance/financial-assistanceand includes general information, our policy and application and is translated in Spanish and Arabic. In addition, information on financial assistance is included on our website.Mount St. Mary's also provides information about financial assistance and Healthcare Assistance program (HAP) contact information to patients as part of the intake process and during or within 90 days of their discharge from the hospital via patient statements or outreach. To further assist patients, all patient bills include the following language: "If you need financial assistance: Catholic Health offers a healthcare assistance program to help those in need. For more details please visit www.chsbuffalo.org/financial assistance, or call our Patient Financial Services Team at (716) 601-3600". For free, confidential assistance in applying for financial assistance, patients can also call our Patient Financial Services team at 716-601-3600. A counselor will work with them to see if they qualify for free or low-cost insurance or other financial assistance. For patients who do not have insurance and need care at a Catholic Health hospital, a registration clerk can put the patient in touch with one of our Certified Application Counselors. Interpreting services are also available for patients who do not speak English. We offer case management services, and our Certified Application Counselors who discuss with patients the availability of various government benefits, such as Medicaid or other state and federal programs, and assist patients and families with eligibility and applications when necessary. Part VI, Line 4: Catholic Health is a not-for-profit integrated healthcare delivery system that operates four acute careoperations in Erie County and one in neighboring Niagara County. The Niagara County facility, Mount St.Mary's, provides services for residents from the county's cities, towns and the many rural areas in thecounty. In addition, Catholic Health has Home and Community Based Care, Primary Care Centers, as well as Diagnostic and Testing Centers that serve Niagara County residents. The health system is in the process of building a new neighborhood hospital that will be a campus of Mount St. Mary's to address needs in the eastern part of the county. The present hospital operating in the city of Lockport is in bankruptcy and likely closing in mid-2023. The local and state officials have been engaged and partnering with Catholic Health to ensure the 85,000 residents in that part of the county do not lose access to health care. This has resulted in the development of a new hospital concept for that part of Niagara County. The target populations include our general community population including those who may be at risk or disadvantaged. Niagara County is one of the 62 counties that comprise the State of New York. Niagara County has a total area of 522 square miles. It consists of 3 cities (Niagara Falls, North Tonawanda and Lockport) and 12 towns (Cambria, Hartland, Lewiston, Lockport, Newfane, Niagara, Pendleton, Porter, Royalton, Somerset, Wheatfield and Wilson.) It is also the most western part of New York State and is bordered by Lake Ontario on its northern border and the Niagara River (Canada) on its western border.Mount St. Mary's Primary Service Area includes the City of Niagara Falls (Zip Codes 14301, 14302, 14303, 14304 and 14305), a city of about 49,000 where 60% of the population is on some form of public assistance. The towns of Lewiston (14092, 14107, 14109, and 14132), Niagara (portions of 14304 and 14305), Wheatfield (portions of 14305 and 14120), Grand Island {14072) and Porter (14174) are more suburban and rural areas with slightly higher income levels. Secondary Service Area includes the towns of Wilson (14172) a small agricultural community and Lockport (14094) a nearby city with similar characteristics to Niagara Falls. In general, the primary service area is described as Western Niagara County. Part VI, Line 5: One of the fundamental reasons for the creation of Catholic Health was to ensure the continued viability of faith-based health care to meet the needs of residents in Erie County, Niagara County and the surrounding communities. The Mission statement of Mount St. Mary's, as part of Catholic Health - We are called to reveal the healing love of Jesus to those in need further articulates why we exist. Integral to this effort is caring for the needs of those who are poor and disadvantaged. The services provided by Mount St. Mary's are in response to identified community needs and reflect the Hospitals' emphasis on caring for the underserved. The Hospital collaborates with other charitable organizations and social service agencies (i.e. Catholic Charities, Spectrum Human Services, Evergreen Health Services, Erie County Department of Health, Niagara County Department of Health, etc.), to maximize its ability to provide needed services to the residents of our region.The governing Board of Directors of Mount St. Mary's is comprised of community representatives from universities, legal communities, and business leaders. Religious orders are represented, as well as active and retired medical staff members. The Mount St. Mary's medical staff is considered an "open" medical staff, as any physician can apply for privileges. Each application is reviewed by a vigorous credentialing verification process. The hospitals have robust health professional education programs. Mercy Hospital and Sisters Hospital are physician teaching facilities. All sites participate in teaching programs for other allied health professionals. Our six emergency departments are open to all people regardless of their ability to pay. Our primary care centers are strategically located in areas deemed economically disadvantaged or where other medical services are lacking. Each year, Mount St. Mary's, as part of Catholic Health touches thousands of area residents through its community health education programs, health screenings, clinical and support services, and community service activities. Most of these program are free to encourage participation by people from all walks of life. Programs offered also include those that are in alignment with state prevention priorities. Catholic Health continues to meet community needs by making charity care a priority and available to the uninsured and underinsured, traditional Medicaid services, and community benefit programs, including collaborative community health improvement initiatives, health professional education programs, volunteering and community service activities, and cash and in-kind contributions to community organizations that serve the poor and disadvantaged. In 2024, the Catholic Health System provided more than $160 million in charity care and community benefit activities to help make our WNY community a healthier place, especially for the poor and underserved. These activities included: Supporting Project Homeless Connect An outreach initiative to link homeless individuals and families with medical and other support services; Offering a Healthcare Assistance Program to ensure that people without insurance or financial means get the care they need; Providing health and wellness information in places of worship through our Faith Community Nursing program; Supporting nationally recognized "green" initiatives to remain good stewards of our natural resources and protect the environment. Part VI, Line 6: N/A Part VI, Line 7, Reports Filed With States NY X X X X X X 1 0 0 0 0 0 0 0 0 Joyce Markiewicz President & CEO Administration CH 0 1167389 0 328497 0 355996 0 42024 0 18294 0 1912200 0 0 Mark Sullivan President CHS - Former 0 23881 0 437996 0 1389459 0 -5091 0 18294 0 1864539 0 0 James M Garvey Executive VP, COO 0 749131 0 217317 0 27016 0 30098 0 14327 0 1037889 0 0 David Macholz Chief Finance Officer 0 659506 0 191383 0 17992 0 11153 0 17977 0 898011 0 0 Martin Boryszak Senior VP of Acute Care & President 0 611486 0 168006 0 17205 0 5886 0 24811 0 827394 0 0 Dr Parag Parikh Physician 729498 0 0 0 820 0 12839 0 24612 0 767769 0 0 0 Dr Michael Galang Senior VP, Chief Information Officer 0 496435 0 143738 0 19844 0 37537 0 9152 0 706706 0 0 Dr Stephen Watkins Physician 658079 0 0 0 480 0 5533 0 9106 0 673198 0 0 0 Charles Urlaub Senior VP of Strategic Growth and Pa 0 472358 0 113777 0 22781 0 44256 0 9130 0 662302 0 0 Laura Cianflone Senior VP of Human Resources 0 429844 0 126316 0 16995 0 7170 0 24696 0 605021 0 0 Dr Robert Taylor Physician 461549 0 0 0 325 0 3982 0 24612 0 490468 0 0 0 Walter Ludwig President & CEO KMH 0 356965 0 52246 0 21070 0 40312 0 17690 0 488283 0 0 Leonardo Sette-Camara General Counsel 0 354360 0 87084 0 563 0 7889 0 24624 0 474520 0 0 Lisa Cilano Senior VP, RMC & Business 0 184412 0 83873 0 176483 0 6720 0 8966 0 460454 0 0 Thomas Gleason Senior VP Home and Community Based C 0 324272 0 79287 0 17062 0 12647 0 24591 0 457859 0 0 Dr Joseph Andrzejewski Physician 430334 0 0 0 313 0 2507 0 24602 0 457756 0 0 0 Bartholomew Rodrigues Executive VP, Chief Mission and Ethi 0 292830 0 86362 0 18282 0 35215 0 24565 0 457254 0 0 Dr Kafai Lai Physician 431445 0 0 0 578 0 8598 0 9035 0 449656 0 0 0 Rebecca McCormick Boyle Chief Integration Officer 0 133034 0 60140 0 124924 0 2405 0 249 0 320752 0 0 Russell Edwards VP Finance & Corporate Con 0 240176 0 34790 0 231 0 3004 0 8909 0 287110 0 0 Megan Aldrich President of Sisters of Charity Hosp 0 232500 0 0 0 21835 0 0 0 236 0 254571 0 0 Hans Cassagnol Chief Physician Executive 0 106191 0 0 0 136458 0 -2196 0 9574 0 250027 0 0 Victor Filadora Chief Physician Executive 0 179984 0 0 0 28260 0 0 0 156 0 208400 0 0 Catherine Mohr Chief Nursing Officer 0 166631 0 0 0 28260 0 0 0 8172 0 203063 0 0 Part I, Line 4a Severance Payments were made to: Mark Sullivan: $1,122,099.94 Rebecca McCormick-Boyle: $117,304.56 Hans Cassagnol: $133,023.28 Lisa Cilano: $166,159.14 Part II Column C: The change in present value shown for each participant represents the change in the actuarial value of the accrued benefit, whether or not funded, vested or subject to substantial risk of forfeiture. Note that the change in present value is partly due to changes in the discount rate and, for those accruing under the cash balance formula, the assumptions for future cash balance interest crediting rates and factors applicable to annuity conversions. A Dormitory Authority of the State of New York 146000293 64990GHM2 2019-04-25 5441567 See Part VI 0 0 0 B Niagara Area Development Corporation 900764545 653541BJ0 2022-03-22 49384521 See Part VI 0 0 0 A 5441567 59977 5327015 54575 2019 0 0 0 1 B 49384521 4771428 2963144 1112093 40537856 2023 0 0 1 1 A 0 0 0 0 0 0 1 B 0 0 0 0 0 0 1 A 0 1 0 0 1 0 0 1 1 B 0 1 0 0 0 0 0 1 A 1 B 1 Part I A (f) Series A Proceeds of bonds used to (i) finance portions of certain improvements, equipment and strategic investments, including but not limited to a new electronic medical records system, maternity services renovations and new sterile processing department. Series B Proceeds of bonds used to (i) finance portions of certain improvements, equipment and strategic investments, including but not limited to a new electronic medical records system, maternity services renovations and new sterile processing department. Part I B (f) Proceeds of bonds used to finance portions of certain improvements, equipment and strategic investments, including but not limited to, construction of Lockport Memorial Hospital. Part II C (3) Proceed amount varies with the bond issue amount due to cumulative investment earnings Susan Urlaub Wife of MSM CEO, C.J. Urlaub 108146 Clinical Documentation Specialist, SCH/SJC 0 Rachel Markiewicz Daughter in Law of Chief Business Development Officer Pre, Joyce Markiewicz 73083 Social Worker, MSW 0 Carrie Sette-Camara Wife of Key Employee, Leonardo Sette-Camara 123606 Director Public and Media Relations 0 Diana Sedita Sister of Key Employee, Laura Cianflone 150070 Director Marketing & Communications 0 Form 990, Part VI, Section A, line 6 CHS has two members: The Franciscan Sisters of St. Joseph of Hamburg, NY, and the Diocese of Buffalo, NY. Each member is able to participate equally in electing the governing body, approving significant decisions of the governing body, and have the power to approve any plan of dissolution of the corporation and the distribution of the assets upon dissolution, according to the CHS Bylaws. Form 990, Part VI, Section A, line 7a According to the CHS Bylaws, each member is equally allowed to appoint one representative and one alternative representative to serve on the Corporate Member Council and to serve as a voting director on the Catholic Health System Board of Directors. Form 990, Part VI, Section A, line 7b Yes, the corporate members do have reserve powers. Form 990, Part VI, Section B, line 11b Yes, an electronic copy of the Form 990 was provided to the CHS Boards of Directors before it was filed. The CHS Board of Directors has delegated the responsibility to review the 990 to the Audit Committee. The CHS Audit Committee reviewed in detail selected information for all CHS entities that file a 990. Reviewed with the Audit Committee: 1. Core Form Part IV: Checklist of required schedules 2. Core Form Part VI: Governance, Management and Disclosure 3. Core Form Part VII: Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees and Independent Contractors 4. Schedule H: Hospitals 5. Schedule K: Supplemental information on Tax Exempt Bonds 6. Schedule J: Compensation Information 7. Schedule L: Transactions with Interested Persons 8. Schedule R: Related Organizations and Unrelated Partnerships 9. Process for which remaining Core Form was completed, utilizing audited financial information Form 990, Part VI, Section B, line 12c All officers, directors, and key employees complete a Conflict of Interest Disclosure Statement (COIDS) in order to fulfill the annual requirements. COIDS are distributed to all parties, as per applicable policy, and once complete are followed up with as follows: 1. Associate and Physician completed COIDS are reviewed and signed off by the manager. If a disclosure is noted, it is discussed with the manager, and the document is forwarded to the Compliance officer who reviews and follows up as appropriate. Once review/follow up is completed the Compliance Officer will sign the COIDS, maintain a copy in the compliance office and return the original to HR for filing in the Personnel file. 2. All board member COIDS are returned to Compliance Officer for review and follow up as warranted. The compliance officer will sign each COIDS and retain on file in the compliance office in a confidential manner. Form 990, Part VI, Section B, line 15 CHS, in determining the compensation for the CEO, utilizes a process of review and approval, governed by the Board of Directors that includes an outside nationally recognized independent compensation consultant experienced in compensation and benefit matters for non-profit healthcare organizations, and comparability data. In 2024, the Catholic Health System utilized a Compensation Committee of the corporation Directors to monitor the Executive Compensation as per the Executive Compensation Philosophy and Strategy for the CHS CEO and top Senior Executives Form 990, Part VI, Section C, line 19 We make our form 990 open for public inspection upon request. Our website includes an annual report which includes selected financial information. Our financial statements, governing documents and conflict of interest policy are provided upon request according to applicable federal and state laws. Form 990, Part XI, line 9: Change in Pension Obligation, other than Net Periodic Cost -77,876. Change in Unrestricted Interest in Mount St. Mary's Foundation 477,535. Change in Restricted Interest in Mount St. Mary's Foundation -1,826,356. Catholic Health System Inc 144 Genesee Street Buffalo NY 14203 222565278 Health Care Delivery System NY 501(c)(3) Line 10 0 Mercy Hospital of Buffalo 565 Abbott Road Buffalo NY 14220 160756336 Acute Care Hospital NY 501(c)(3) Line 3 Catholic Health System Inc 0 Sisters of Charity Hospital 2157 Main Street Buffalo NY 14214 160743187 Acute Care Hospital NY 501(c)(3) Line 3 Catholic Health System Inc 0 Kenmore Mercy Hospital 2950 Elmwood Avenue Kenmore NY 14217 160762843 Acute Care Hospital NY 501(c)(3) Line 3 Catholic Health System Inc 0 St Francis Home of Williamsville 147 Reist St Williamsville NY 14221 160743153 Skilled Nursing Facility NY 501(c)(3) Line 10 Catholic Health System Inc 0 St Francis of Buffalo Inc 34 Benwood Ave Buffalo NY 14214 161523535 Skilled Nursing Facility NY 501(c)(3) Line 10 Catholic Health System Inc 0 WNY Catholic Long Term Care Inc 6400 Powers Rd Orchard Park NY 14127 161434368 Skilled Nursing Facility NY 501(c)(3) Line 10 Catholic Health System Inc 0 Niagara Homemaker Services (Mercy Home Care) 144 Genesee Street Buffalo NY 14203 161317960 Home Care Provider NY 501(c)(3) Line 10 Catholic Health System Inc 0 McAuley Seton Home Care 144 Genesee Street Buffalo NY 14203 161310062 Home Care Provider NY 501(c)(3) Line 10 Catholic Health System Inc 0 Catholic Health System Infusion Pharmacy Inc 6350 Transit Road Depew NY 14043 200198518 Home Care Infusion Services NY 501(c)(3) Line 10 Catholic Health System Inc 0 OLV Renaissance Corporation 144 Genesee Street Buffalo NY 14203 200167745 Real Estate Holding Company NY 501(c)(3) Line 10 Catholic Health System Inc 0 CHS Program of All-Inclusive Care for the Elderly Inc 55 Melroy Avenue Lackawanna NY 14218 261252884 All-inclusive Care for the Elderly NY 501(c)(3) Line 10 Catholic Health System Inc 0 Trinity Medical WNY PC 2625 Harlem Rd Cheektowaga NY 14225 272576645 Primary Care Provider NY 501(c)(3) Line 12a, I Catholic Health System Inc 0 Mount St Mary's Hospital Foundation Inc 5300 Military Road Lewiston NY 14092 161360884 Foundation NY 501(c)(3) Line 7 Mount St Mary's Hospital of Niagara Falls 0 Mount St Mary's Hospital Child Care Center 5310 Military Road Lewiston NY 14092 161523352 Child Care NY 501(c)(3) Line 10 Catholic Health System Inc 0 Board of Associates of Mount St Mary's Hospital Inc 5300 Military Road Lewiston NY 14092 161582926 Fund Raising NY 501(c)(3) Line 12c, III-FI Mount St Mary's Hospital of Niagara Falls 0 The St Francis Guild of Mount St Mary's Hospital of Niagara Falls Inc 5300 Military Road Lewiston NY 14092 510217790 Fund Raising NY 501(c)(3) Line 12a, I Mount St Mary's Hospital of Niagara Falls 0 The Foundation of Catholic Health 144 Genesee Street Buffalo NY 14203 991027626 Foundation NY 501(c)(3) Line 7 Catholic Health System Inc 0 CATHOLIC HEALTH ORTHOPEDIC MANAGEMENT COMPANY LLC 144 Genesee Street Buffalo NY 14203 843844132 General Purpose NY Related 19000 25590 0 0 0.25000 0 0 1 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 CATHOLIC HEALTH ORTHOPEDIC MANAGEMENT COMPANY LLC P Cash