2017-11-13T10:17:58-06:00 2016-12-31 990 2016-01-01 161523353 Mount St Mary's Hospital of Niagara Falls MOUN 7168282974 144 Genesee St Buffalo NY 14203 David P Macholz CHS VP Finance,Corp.Controller 7168282974 2017-11-13 204.68.186.4 2017-11-13 10:16:50 ES P 7A6C0E4E833B5736639BD5417150D578DD5EAFB4 A1FF77BEB3708404F77A91D7B895CEDA7937CD66 2016 2018-03-14 21:41:22Z Joseph D McDonald 144 Genesee Street Buffalo NY 14203 100400696 0 X www.chsbuffalo.org X 1907 NY The Catholic Health System (CHS) Mission is to provide quality healthcare services in an acute care setting. Committed to a common mission, CHS providers 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 2016 Community Service Plan can be found at www.chsbuffalo.org. 11 7 895 240 0 0 0 1432628 92209017 96226820 32150 12598 1437648 2728650 93678815 100400696 0 0 0 0 59044765 64487690 0 0 0 35757873 34411086 94802638 98898776 -1123823 1501920 47446166 50025734 20119146 22846503 27327020 27179231 X The Catholic Health System (CHS) Mission is to provide quality healthcare services in an acute care setting. Committed to a common mission, CHS providers 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 2016 Community Service Plan can be found at www.chsbuffalo.org. 0 0 53482727 60082531 Inpatient Routine/Surgery Visits:Acute Care Patient Days = 19,775Newborn Patient Days = 933Inpatient Surgeries = 2,126 17720322 19907022 Outpatient Routine/Surgery Services:Emergency Visits (Net of Admits) = 18,403Referred Ambulatory Visists = 81,560Operating Room = 3,385G.I. Laboratory = 2,159Interventional Radiology = 423Transfusion = 186 14453674 16237267 Clinic/Primary Care Services:Clinic Visits = 35,948Primary Care Visits = 32,890 85656723 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 82 0 1 895 1 0 0 0 0 0 0 0 0 0 0 0 0 X 11 7 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X X David P Macholz Controller Cathol 7168282974 144 Genesee St Buffalo NY 14203 Mark Sullivan Executive VP/COO 0.00 55.00 X X 0 868844 298589 Gary Tucker Pres. & CEO, Mount St. Mar 55.00 0.00 X X 327138 0 71712 David Macholz Treasurer 0.00 55.00 X X 0 268947 35004 Peter Bergmann Director 0.00 55.00 X 0 436915 35599 Joyce Markiewicz Director 0.00 55.00 X 0 356171 48930 James Millard Director 0.00 55.00 X 0 315450 151407 Charles Urlaub Director/Officer 0.00 55.00 X X 0 435436 39771 Martin Boryszak Director 0.00 55.00 X 0 201548 5587 Lynn Catalano Director 0.00 2.00 X 0 0 0 John Davanzo Director 0.00 2.00 X 0 0 0 Georgiana Ford Esq Director 0.00 2.00 X 0 0 0 Mark Jajkowski Director 0.00 55.00 X 0 98000 0 Raquel Martin DO Director 0.00 2.00 X 0 0 0 Mary Turkiewiecz MD Director 0.00 2.00 X 0 0 0 Katherine Vanderhorst Director 0.00 2.00 X 0 0 0 Monsignor Robert E Zapfel Director 0.00 2.00 X 0 0 0 Brian Beitz Director 0.00 4.00 X 0 0 0 Dr Michael Galang Sr. VP, Chief Information 0.00 55.00 X 0 476331 191735 Joseph McDonald President and CEO, CHS 0.00 55.00 X 0 1392009 382381 James A Dunlop Jr Executive VP, Finance/CFO 0.00 55.00 X 0 739625 344451 Dr Brian D'Arcy Senior VP, Medical Affairs 0.00 55.00 X 0 697837 204522 Dr Michael Edbauer Chief Clinical Officer 0.00 28.00 X 0 187804 153258 Maria Foti Sr. VP, Strategic Planning 0.00 55.00 X 0 347897 151644 Michael Moley Sr. VP, Human Resources 0.00 55.00 X 0 639095 207439 Nancy Sheehan SVP Legal Service, General Counsel 0.00 55.00 X 0 431398 147216 Dr Samuel Sirianni Physician 55.00 X 369689 0 43620 Dr Roger W Rogers Physician 55.00 X 463765 0 33868 Dr Benjamin G Rueda Physician 55.00 X 508003 0 47963 Dr Arif S Syed Physician 55.00 X 510371 0 38387 Dr Parag Parikh Physician 55.00 X 356457 0 30934 2535423 7893307 2664017 59 0 1 0 Trimedx LLC 5451 Lakeview Pkwy S Drive Indianapolis IN 46268 Clinical Engineering Services 1294818 Precision Health Care Services 1160 Southwest 21st Avenue Boca Roton FL 33486 Healthcare Services 897965 Exigence Hospitalist Medical 1 John James Audubon Pkwy Buffalo NY 14228 Physician Services 710560 Atlas Healthcare Linen 414 WTaylor St Syracuse NY 13202 Linen Services 591076 Morrison Management Specialist 400 Northridge Road Suite 600 Sandy Springs GA 30350 Nutrition Services 491913 32 1432628 1432628 All Other Payers 621990 63726101 63726101 Medicare 621990 19017372 19017372 Medicaid 621990 13483347 13483347 96226820 12598 12598 69629 0 69629 69629 69629 Meaningful Use 621990 795003 795003 340B Pharmacy 621990 482926 482926 Cafeteria 722210 364424 364424 1016668 193551 823117 2659021 100400696 97698300 0 1269768 50046523 43918109 6128414 1895340 1686853 208487 12355870 10806045 1549825 189957 169062 20895 54513 54513 7308 7308 3182137 2516393 665744 104733 104733 4213624 2252881 1960743 141816 34522 107294 1401384 1051038 350346 31306 20668 10638 61000 53042 7958 11919 10922 997 3167507 2902468 265039 578858 522265 56593 Medical Supplies 12275872 12150819 125053 Purchased Services 5623675 5011575 612100 Dues and Shared Service 3275482 2354454 921028 Other Supplies Non-Medi 279952 195607 84345 98898776 85656723 13242053 0 4003131 6067089 8790533 10592651 1070267 296864 1765902 1668296 565563 345156 61917994 37918204 24680688 23999790 6570082 7055888 47446166 50025734 9972611 10129282 372539 190106 9773996 12527115 20119146 22846503 X 24030833 24429162 3249249 2702286 46938 47783 27327020 27179231 47446166 50025734 X 1501920 -1649709 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 7308 7308 0 Part II-B, Line 1: Lobbying expenses represent the portion of dues paid to national and state associations that is specifically allocable to lobbying. Mount St. Mary's Hospital of Niagara Falls 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 for public office. 1227100 1227100 30802186 17892596 12909590 29221523 20698659 8522864 667185 -673051 1340236 23999790 Due From Affiliates 275553 Interest in Net Assets of Mount St. Mary's Hospital Foundation 5960995 Insurance Recoveries 819340 7055888 Due to Affiliates 1077332 Long-Term Portion of Insurance Liabilities 2665445 Pension Obligation 763821 Asset Retirement Obligation 380355 Long-Term Portion of EIB Bank 343876 Contingent Liability 7242452 Long-Term Portion of Disposables 53834 12527115 100357032 1304882 1304882 99052150 1348546 1348546 100400696 99892734 993958 993958 98898776 0 98898776 Part XI, Line 2d - Other Adjustments: Childcare Revenue - 605,522 Foundation Revenue - 699,360 Part XI, Line 4b - Other Adjustments: Foundation Contributions - 1,318,546 Grant Income - 30,000 Part XII, Line 2d - Other Adjustments: Childcare Expenses - 629,220 Foundation Expenses (net of eliminations) - 364,738 1 1 X 1 X 1 X 500.000000000000 1 1 1 0 1 1 725650 26393 699257 0.00710 17908846 11410917 6497929 0.06570 18634496 11437310 7197186 0.07280 750997 0 750997 0.00760 951404 0 951404 0.00960 10853935 9259629 1594306 0.01610 123297 0 123297 0.00120 384165 0 384165 0.00390 13063798 9259629 3804169 0.03840 31698294 20696939 11001355 0.11120 7352 7352 0.00010 26009 26009 0.00030 80388 80388 0.00080 13301 13301 0.00010 1662 1662 0.00000 1034 1034 0.00000 129746 129746 0.00130 0 2556472 551015 19154870 16486973 2667897 X 1 1 1 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 Speciality Mount St Mary's Hospital of Niagara Fal 1 0 1 1 X X X X X X X X X 16 1 0 1 1 X http://chsbuffalo.org/Community X 1 16 1 http://www.chsbuffalo.org/Community 0 1 X 200.000000000000 500.000000000000 X X X X X 1 1 X X X X 1 X http://chsbuffalo.org/billing/finance X http://chsbuffalo.org/billing/finance X http://chsbuffalo.org/billing/finance X X X X X X X 1 X 0 X 1 X 0 0 Part V, Section A: CT Scanner Chemical Dependence - IP Rehabilitation O/P Chemical Dependence - Withdrawal O/P Clinic Part Time Services Clinical Laboratory ServiceCoronary Care Emergency Department Health Fairs O/P Intensive Care Lithotripsy Magnetic Resonance Imaging Maternity Medical Services - Primary Care Medical Social Services Medical/Surgical Nuclear Medicine - Diagnostic Nuclear Medicine - Therapeutic Pediatric O/PPharmaceutical Service Radiology - Diagnostic Renal Dialysis - Acute Therapy - Occupational O/P Therapy - Physical O/P Therapy - Speech Language Pathology Mount St. Mary's Hospital of Niagara Falls Part V, Section B, Line 5: To identify and prioritize the MSMH community' s health needs, this Community Health Needs Assessment (CHNA) considered multiple data sources, including written surveys, interviews, focus groups, demographic data, health status indicators, and disease prevalence data. MSMH compiled the data from these sources to arrive at potential priority health needs in the community. MSMH convened meetings with MSMH staff and external healthcare experts (including the Niagara County Department of Health) to share the survey results, discuss the potential priority health needs and to elicit considerations regarding secondary health needs. Collaboration included involvement from other local area local area hospitals, Niagara Falls Memorial, DeGraff Memorial, and Eastern Niagara. A countywide questionnaire was sent in addition to individual surveys sent to community organizations, local health officials and others of varying socioeconomic backgrounds:- Written Survey targeting local community organizations and non-profits that are active in the primary service area - Written Survey targeting local block clubs and church groups active in the primary service area- Focus Group at the Mount St. Mary's Neighborhood Health Center, located in the part of the service area with the lowest per capita income and underserved in a variety of ways- Focus Group at Mount St. Mary's Hospital involving associates- Input from Focus Groups conducted throughout Niagara County by Niagara County DOH- Written Request for input from physicians at Mount St. Mary's- Written Survey conducted by Niagara County Department of Health that was countywide, but also with the ability to gather input from our primary service area.These included members of the Creating a Healthier Niagara Falls Collaborative and Healthy Behaviors Work Group:- Family and Children's Services of Niagara- Niagara County Office of the Aging- American Diabetes Association- Niagara County Department of Mental Health- Buffalo-Niagara YMCA- Planned Parenthood of Niagara- Native American Community Services- Isaiah 61 Project- Roswell Park Cancer Institute/Niagara Falls City Council- Niagara Falls School District/Niagara Falls City CouncilOther groups included:- Mom's Net- Family and Children's Services of Niagara- Heart, Love & Soul Food Pantry- Project Connect Niagara Mount St. Mary's Hospital of Niagara Falls Part V, Section B, Line 6b: Catholic Health System, P2 Collaborative, Niagara County Department of Health and New York State Department of Health Mount St. Mary's Hospital of Niagara Falls Part V, Section B, Line 2: Effective July 1, 2015, Catholic Health and Ascension completed a transaction to transfer ownership/sponsorship of Mount St. Mary's from Ascension to Catholic Health. Ascension was the sponsor of Mount St. Mary's from 2000 to July 1, 2015. Mount St. Mary's Hospital of Niagara Falls Part V, Section B, Line 11: The 2016 Niagara County Community Health Needs Assessment began by bringing together the participants from the 2013 process. This included the Niagara County Department of Health, and representatives of the four hospitals in Niagara County: Mount St. Mary's, Niagara Falls Memorial, DeGraff Memorial, and Eastern Niagara. The process was coordinated by the P2 Collaborative of Western New York.Initial meetings focused on evaluating activities from the 2013 CHNA's and the County Health Department's Community Service Plan priorities. Despite posting our 2013-16 report on our website and providing notice in the media, we did not receive any written input on the report. Subsequent sessions were devoted to developing a countywide questionnaire to survey residents and initiatives to gather as much relevant data as possible from surveys, interviews, and focus groups.As part of this coordinated initiative, Mount St. Mary's worked to develop an updated three-year(2016-2018) Community Health Improvement Plan/Implementation Strategy (CHIP/IS) to continue the collaboration in our community to improve patient care, preventive services, overall health, and quality of life. Our input process covered many segments of the community including individual surveys, community organizations, local health officials and others of varying socioeconomic backgrounds. Through the needs assessment, numerous areas were identified as important and clearly impact the health of the community. Mount St. Mary's identified the "significant" needs as related to the New York State Department of Health Prevention Agenda priorities. Within the "priorities," Mount St. Mary's will address numerous health needs as described in the publicly available CHNA report.Two priorities not specifically addressed in the implementation plan: Neighborhood Safety and Food/Water Safety. We did not address in our plan because of a lack of expertise and resources to effectively address each of the issues. 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. 8 1 - Mount St Mary's Hospital Rehab Svc 1 Columba Drive Niagara Falls NY 14305 Licensed, Extension Clinic: Therapy-Occupational O/P, Therapy-Physical O/P 2 - Mount St Mary's Diagnostic Imaging Svc 7300 Porter Road Niagara Falls NY 12414 Licensed, Extension Clinic: Medical Services-Primary Care 3 - Mount St Mary's Ear Nose and Throat Sv 6941 Elaine Drive Niagara Falls NY 14304 Licensed, Extension Clinic: Primary Medical Care O/P 4 - Mount St Mary's Orthopedic Services and 5320 Military Road Lewiston NY 14092 Licensed, Extension Clinic: Orthopedic Services General,Vascular & Cardiotho 5 - Mount St Mary's Primary Care 1302 Main Street Niagara Falls NY 14301 Extension Clinic: Medical Services O/P, Primary Medical Care O/P, Radiology 6 - Mount St Mary's Neighborhood Health Ctr 3101 Ninth Street Niagara Falls NY 14305 Licensed, Extension Clinic: Medical Social Services O/P, Nutritional O/P 7 - Mount St Mary's Campus Medical Arts Bld 5290 Military Road Suite 8 Lewiston NY 14092 Extension Clinic: Primary Care 8 - Witmer Park Medical Center One Colomba Drive Suite 8 Niagara Falls NY 14304 Extension Clinic: Primary Care 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 Economic Development of $7,352 Community Support of $26,009, Environmental Improvements of $80,388, Leadership development of $13,301, Community health improvement of $1,662, and Workforce development of $1,034. Part III, Line 2: The amount in Part III line 2 is the actual bad debt expenses of $2,556,472. The amount in Part III line 3 is the estimate of bad debt from uninsured balance which is developed as follows: as policy is to write accounts to bad debt 120 days after discharge, the discharge date period of 10/1/2015 to 9/30/2016 was used to determine the population of uninsured accounts. The balance of these accounts was determined and the RCC was applied to develop the estimate in H Part III Line 3. As our determination of eligibility for the Healthcare Assistance Program (HAP) (Charity Care) is based solely on the presentation for care without insurance, which is now for each account, and use of a sophisticated estimator (PARO) of each guarantor's ability to pay an estimate of "the amount that reasonably could be attributable to patients who likely would qualify for financial assistance under the hospital's charity care policy if sufficient information had been available to make a determination of their eligibility" is not relevant. The organization's financial statements do not include a footnote that describes bad debt expense, but the financial statements account for bad debt expenses in the statement of operations as actual expenses written off and an estimate of future write-offs less any recoveries. 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 VI, Line 2: As part of Catholic Health, Mount St. Mary's benefits from information received from 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 Catholic Health Board including Board Committee (e.g. Mission Integration Committee). Examples of other sources of input include input from leadership of Family and Children's Services of Niagara, the Heart, Love and Soul Food Pantry, Stella Niagara Education Center, Catholic Academy of Niagara Falls, March of Dimes, Healthy Moms/Healthy Babies, among others. In each of the organizations listed, a member of the Mount St. Mary's leadership team serves on their board of directors or key committee with consistent dialogue about our services. Part VI, Line 3: Catholic Health's Mount St. Mary's Hospital informs 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 Hospital, like our other facilities, has posters and brochures available, which include eligibility and contact information for the Financial Clearance staff. This information is available in admissions areas, emergency rooms, primary care and outpatient rehabilitation centers, the Revenue Management Center (RMC) and other areas throughout Catholic Health where eligible patients and family members are likely to be present. Catholic Health also provides information about financial assistance and HAP contact information to patients as part of the intake process and during or within 90 days of their discharge from the hospital. To further assist patients, all patient bills include the following language: "The Catholic Health System has a Healthcare Assistance Program to assist those in need of financial assistance for qualified patients. If you would like to obtain additional information on the Healthcare Assistance Program, please call (716) 601-3600. Thank you." For free, confidential assistance in applying for financial aid, patients can also call our Financial Clearance department 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 will also assist them in applying for assistance at the time of registration. Interpreting services are also available for patients who do not speak English. Additionally, as part of our case management services, we 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. There is also information about our financial assistance program in our patient handbooks and posted on the Catholic Health System website. Part VI, Line 4: 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 and the surrounding communities. Our Mission Statement - 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 Catholic Health are in response to identified community needs, and reflect the System's emphasis on caring for the underserved. Catholic Health collaborates with other charitable organizations and social service agencies (i.e. Catholic Charities Spectrum Human Services, Evergreen Health Services, Erie 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 Hospital 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 hospital has a robust health professional education programs and participates in teaching programs for other allied health professionals. Our emergency department is 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, Catholic Health touches tens of thousands of area residents through its community health education programs, health screenings, clinical and support services, and community service activities. Most of these programs are free to encourage participation by people from all walks of life. Catholic Health will continue to meet community needs by providing charity care 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 2016, the Catholic Health System provided more than $115 million in charity care and community benefit activities (including $11 million from Mount St. Mary's) to help make our community a healthier place, especially for the poor and underserved. These activities included: - Spearheading Project Homeless Connect - An outreach initiative to link homeless individuals and families with medical and other support services;- Supporting charitable and educational organizations, like the Buffalo City Mission, Friends of Night People, and the Health Science Charter School that help the poor and vulnerable in our community; - Hosting numerous health education and screening programs to help people learn their health risks and take steps to improve their health; - 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; - Helping refugees access quality medical care through our Primary Care and School Based Health Centers, including the Mercy Comprehensive Care Center in Buffalo's Old First Ward; - Providing free care and services to those in need, like our "Cribs for Kids" program, which helps families provide a safe sleeping environment for their newborns; - Supporting children and families in need through our Reach Out and Read Program; Backpack Program for Kids; and Bridget Closet (clothes for the needy);- Sponsoring programs at the Mercy Comprehensive Care Center, which serve the local community, including refugees from Burma, Somalia, the Middle East, and Nepal ; - Providing services through our Social Work Department, which link patients with necessary services including: ESL (English as a Second Language), job opportunities, substance abuse treatment, health care navigators, senior services, insurance information, parenting assistance and more; and - Supporting nationally recognized "green" initiatives to remain good stewards of our natural resources and protect the environment.In 2016, CHS initiated an ongoing program to provide grants to organizations for Community Benefit projects. $120,154 in total was provided to the following organizations:- Expansion of Food Back pack program at West Hertel School on Buffalo, New York- Healthy Weight management at CHS Primary Care centers in Niagara County- HPV Protection for Adolescents in Niagara County- Medical Mission supplies- Donor Human Milk Depots- Trauma and Trauma Informed Care Training- Safe Start for Newborns- Partnership with Enterprise Charter School and Willie Hutch Jones After School program to enrich critical thinking, creativity and to transfer concepts across contexts in STEM disciplines- Health Science Charter School Community Wellness ProjectAs part of Catholic Health, Mount St. Mary's is supportive of the initiatives above. In addition, other ways the Hospital furthers its exempt purpose by promoting the health of the community include free health screenings (Lipid Panel each February as part of Heart Month and PSA in June as part of a Father's Day promotion) and health fairs as described further in our community benefit report in Schedule 0. The organization extends medical staff privileges to all qualified physicians in its community for many of its departments. The organization applies funding to improvements in patient care, such as the expanded cardiology services Women's Center for Breast Health, and its Center for Women, which provides services at both the main hospital and the Neighborhood Health Center facility in an underserved section of the City of Niagara Falls. Other substantive community benefit initiatives supported by Mount St. Mary's Hospital include: Advanced Directive / MOLST education, Baby and Me Program, Caring Smiles Dental Program, Community Health Fairs, Medicaid Enrollment Assistance, P2 Collaborative for Adult Mental Health and Substance Abuse Screening, Tower Grant for Pediatric Care Coordination, and Transportation Assistance. Part VI, Line 7, Reports Filed With States NY X X X X X X 0 1 0 0 0 0 0 0 0 Mark Sullivan Executive VP/COO 0 573434 0 176409 0 119001 0 273307 0 25282 0 1167433 0 58215 Gary Tucker Pres. & CEO, Mount St. Mar 259019 0 48355 0 19764 0 46832 0 24880 0 398850 0 0 0 David Macholz Treasurer 0 260167 0 0 0 8780 0 9691 0 25313 0 303951 0 0 Peter Bergmann Director 0 408137 0 0 0 28778 0 12153 0 23446 0 472514 0 0 Joyce Markiewicz Director 0 338634 0 0 0 17537 0 31113 0 17817 0 405101 0 0 James Millard Director 0 297882 0 0 0 17568 0 127811 0 23596 0 466857 0 0 Charles Urlaub Director/Officer 0 397617 0 0 0 37819 0 20655 0 19116 0 475207 0 0 Martin Boryszak Director 0 201401 0 0 0 147 0 4887 0 700 0 207135 0 0 Dr Michael Galang Sr. VP, Chief Information 0 353459 0 105025 0 17847 0 182634 0 9101 0 668066 0 34658 Joseph McDonald President and CEO, CHS 0 756655 0 306361 0 328993 0 355355 0 27026 0 1774390 0 101099 James A Dunlop Jr Executive VP, Finance/CFO 0 510950 0 157684 0 70991 0 320331 0 24120 0 1084076 0 52036 Dr Brian D'Arcy Senior VP, Medical Affairs 0 490055 0 151739 0 56043 0 179848 0 24674 0 902359 0 50074 Dr Michael Edbauer Chief Clinical Officer 0 94214 0 83957 0 9633 0 140631 0 12627 0 341062 0 29185 Maria Foti Sr. VP, Strategic Planning 0 259490 0 71592 0 16815 0 141148 0 10496 0 499541 0 23625 Michael Moley Sr. VP, Human Resources 0 377753 0 108014 0 153328 0 187632 0 19807 0 846534 0 35645 Nancy Sheehan SVP Legal Service, General Counsel 0 324583 0 89242 0 17573 0 129403 0 17813 0 578614 0 29450 Dr Samuel Sirianni Physician 335988 0 30579 0 3122 0 15730 0 27890 0 413309 0 0 0 Dr Roger W Rogers Physician 457823 0 5212 0 730 0 11186 0 22682 0 497633 0 0 0 Dr Benjamin G Rueda Physician 501866 0 3960 0 2177 0 18493 0 29470 0 555966 0 0 0 Dr Arif S Syed Physician 477198 0 32575 0 598 0 11562 0 26825 0 548758 0 0 0 Dr Parag Parikh Physician 356089 0 0 0 368 0 4136 0 26798 0 387391 0 0 0 Part I, Line 4b Certain Officers and Key employees participated in a supplemental nonqualified retirement plan. The intention is to provide additional retirement compensation to address any gaps in the compensation limit. Pension Gap Joseph McDonald $26,000.00 Mark Sullivan $19,500.00 Dr. Brian D'Arcy $9,800.00 Peter Bergmann $7,334.00 SERP Joseph McDonald $97,946.00 Certain portions of the incentive compensation paid in 2016 are a result of the targets that were achieved in previous years. Deferred compensation reported in 2016 includes both qualified deferred pension compensation and employer contribution for 403b for certain Sisters of Charity Hospital associates, as well as deferred compensation for the amounts that are able to be estimated in 2016. Actual W-2 compensation paid to the executive is as per Schedule J Part II B. Susan Urlaub Wife of Mercy CEO, C.J. Urlaub 86475 Corporate Nurse educator 0 Kathleen Zapfel Sister-in-law of BOD, Msgr. Robert Zapfel 70649 HR Employee of CHS 0 Form 990, Part VI, Section A, line 6 CHS has two members: Trinity Health, 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 in receiving a share of net 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 alternate 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 Board 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 associates on the Merit program; all Physicians and Non Physician Practitioners as well as Physician groups who are independent contractors or employees of CHS; and all board members must 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 2016, the Catholic Health System utilized a Compensation Committee of the Board of 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: Pension Liability Adjustment -377822. Transfer From Affiliate -1084545. Change in Interest in Foundation -185785. Other -1557. 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 Nazareth Home of Franciscan Sisters 291 North Street Buffalo NY 14201 160813142 Skilled Nursing Facility NY 501(c)(3) Line 10 Catholic Health System Inc 0 St Elizabeth Home for the Aged 5539 Broadway Lancaster NY 14086 160743154 Adult Home NY 501(c)(3) Line 10 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 St Vincent Manor 319 Washington Avenue Dunkirk NY 14048 160743167 Adult Home 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 3 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 KMH Homes Inc 144 Genesee Street Buffalo NY 14203 161387890 Real Estate Holding Company NY 501(c)(3) Line 10 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 12a, I 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 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1