GOUVERNEUR HOSPITAL: Form 990, tax year 2016
View the entire original 990 at ProPublica ↗
- Organization
- GOUVERNEUR HOSPITAL (EIN 46-4249555)
- Tax period
- 2016-01-01 to 2016-12-31
- Filed
- 2017-11-15
- IRS object ID
- 201733199349310248
- Schema version
- 2016v3.0
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule J
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2017-11-15T13:40:48-06:00 | ReturnTs |
| Tax Period End | 2016-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 161226221 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FUST CHARLES CHAMBERS LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 5784 WIDEWATERS PARKWAY | AddressLine1Txt |
| City | SYRACUSE | CityNm |
| State Abbreviation | NY | StateAbbreviationCd |
| ZIP | 13214 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2016-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 464249555 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GOUVERNEUR HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | GOUV | BusinessNameControlTxt |
| Phone | 3152871000 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 77 WEST BARNEY STREET | AddressLine1Txt |
| City | GOUVERNEUR | CityNm |
| State Abbreviation | NY | StateAbbreviationCd |
| ZIP | 13642 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | DAVID BENDER | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 3152871000 | PhoneNum |
| Signature | 2017-11-13 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | THOMAS J GIUFRE | PreparerPersonNm |
| PTIN | P00841958 | PTIN |
| Phone | 3154463600 | PhoneNum |
| Preparation | 2017-11-13 | PreparationDt |
Filing Security Information FilingSecurityInformation
IP Address IPAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| I Pv4 Address | 24.39.85.114 | IPv4AddressTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| IP | 2017-11-13 | IPDt |
| IP Tm | 17:06:00 | IPTm |
| IP Timezone | ES | IPTimezoneCd |
| Filing License Type | P | FilingLicenseTypeCd |
| At Submission Creation Device Id | 517AEBE328CBAAA90E396C2FD1060AA56161F780 | AtSubmissionCreationDeviceId |
| At Submission Filing Device Id | 375090CD680BE658025353FD36A4C812740AAA32 | AtSubmissionFilingDeviceId |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2016 | TaxYr |
| Build TS | 2021-01-29 14:40:06Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | DAVID BENDER | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 77 WEST BARNEY STREET | AddressLine1Txt |
| City | GOUVERNEUR | CityNm |
| State Abbreviation | NY | StateAbbreviationCd |
| ZIP | 13642 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $19,182,104 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.GVNRHOSPITAL.ORG | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 2013 | FormationYr |
| Legal Domicile State | NY | LegalDomicileStateCd |
| Activity Or Mission | OUR MISSION IS TO PROVIDE SKILLED, COMPASSIONATE, COST-EFFECTIVE CARE THAT PROMOTES WELLNESS AND MEETS THE COMMUNITY'S HEALTHCARE NEEDS. | ActivityOrMissionDesc |
| Voting Members Governing Body | 8 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 8 | VotingMembersIndependentCnt |
| Total Employee | 223 | TotalEmployeeCnt |
| Total Volunteers | 15 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $498,099 | PYContributionsGrantsAmt |
| CY Contributions Grants | $599,921 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $16,358,200 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $18,076,448 | CYProgramServiceRevenueAmt |
| PY Investment Income | $38,556 | PYInvestmentIncomeAmt |
| CY Investment Income | $16,665 | CYInvestmentIncomeAmt |
| PY Other Revenue | $690,611 | PYOtherRevenueAmt |
| CY Other Revenue | $489,070 | CYOtherRevenueAmt |
| PY Total Revenue | $17,585,466 | PYTotalRevenueAmt |
| CY Total Revenue | $19,182,104 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $10,089,626 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $10,508,920 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $8,355,398 | PYOtherExpensesAmt |
| CY Other Expenses | $8,217,418 | CYOtherExpensesAmt |
| PY Total Expenses | $18,445,024 | PYTotalExpensesAmt |
| CY Total Expenses | $18,726,338 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | -$859,558 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $455,766 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $9,880,241 | TotalAssetsBOYAmt |
| Total Assets EOY | $11,697,963 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $8,662,398 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $9,267,108 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $1,217,843 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $2,430,855 | NetAssetsOrFundBalancesEOYAmt |
| Mission | OUR MISSION IS TO PROVIDE SKILLED, COMPASSIONATE, COST-EFFECTIVE CARE THAT PROMOTES WELLNESS AND MEETS THE COMMUNITY'S HEALTHCARE NEEDS. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $14,294,162 | ExpenseAmt |
| Revenue | $18,345,859 | RevenueAmt |
| Desc | ACUTE DIRECT PATIENT CARE - INPATIENT, REFERRED AMBULATORY, EMERGENCY CARE AND CLINICS. IN 2016 GOUVERNEUR HOSPITAL SERVED 479 INPATIENTS, HAD 9,404 EMERGENCY ROOM VISITS, AND PATIENT PROCEDURES TOTALED 18,163 INPATIENT AND 109,556 FOR OUTPATIENTS. | Desc |
| Total Program Service Expenses | $14,294,162 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Temp Or Permanent Endowments | Yes (1) | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | Yes (1) | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | Yes (1) | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | Yes (1) | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (1) | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | 0 | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | 0 | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 37 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 223 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 8 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 8 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | Yes (1) | MembersOrStockholdersInd |
| Election Of Board Members | Yes (1) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | Yes (1) | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | Yes (1) | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| States Where Copy Of Return Is Fld | NY | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | ERIC BURCH | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 3152871000 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 77 WEST BARNEY STREET | AddressLine1Txt |
| City | GOUVERNEUR | CityNm |
| State Abbreviation | NY | StateAbbreviationCd |
| ZIP | 13642 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (16 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|
| MICHAEL BURGESS | |||||||
| CHAIRPERSON | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| MARK BRACKETT | |||||||
| SECRETARY/TREASURER | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| ANDREW WILLIAMS MD | |||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| LAUREN FRENCH | |||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| ANDREW LEONARD | |||||||
| CO-CHAIR PERSON | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| ROGER COOK DVM | |||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| CAROLYN PISTOLESI | |||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| MEGAN WHITTON | |||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| MARY JANE GOTHAM | |||||||
| QUALITY ASSURANCE DIRECTOR | 40.00 | Yes (X) | $113,360 | $0 | $10,025 | ||
| RICHARD T LANG | |||||||
| CHIEF FINANCIAL OFFICER | 40.00 | Yes (X) | $138,573 | $0 | $9,154 | ||
| MARLINDA LAVALLEY | |||||||
| CHIEF EXECUTIVE OFFICER | 40.00 | Yes (X) | $168,646 | $0 | $22,076 | ||
| ALICE LOVING | |||||||
| ANESTHESIOLOGIST | 40.00 | $300,596 | $0 | $31,149 | Yes (X) | ||
| NABEEL AL-HUSSEIN | |||||||
| PHYSICIAN | 40.00 | $200,604 | $0 | $13,827 | Yes (X) | ||
| RICHARD CORCORAN | |||||||
| PHYSICIAN ASSISTANT | 40.00 | $153,106 | $0 | $22,643 | Yes (X) | ||
| GERALD L CALABRESE | |||||||
| PHYSICIAN | 40.00 | $130,748 | $0 | $19,938 | Yes (X) | ||
| NICOLE L WEBER | |||||||
| PHYSICIAN | 40.00 | $106,429 | $0 | $954 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,312,062 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $129,766 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 8 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
| Cntrct Rcvd Greater Than100 K | 0 | CntrctRcvdGreaterThan100KCnt |
| Government Grants | $349,127 | GovernmentGrantsAmt |
| All Other Contributions | $250,794 | AllOtherContributionsAmt |
| Total Contributions | $599,921 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (2 entries)
| BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt | DescDesc |
|---|---|---|---|
| 623000 | $17,203,948 | $17,203,948 | |
| 623000 | $872,500 | $872,500 | VAP FUNDS |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $18,076,448 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $16,665 | TotalRevenueColumnAmt |
| Exclusion | $16,665 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $219,659 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $0 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $219,659 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $219,659 | TotalRevenueColumnAmt |
| Exclusion | $219,659 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | CAFETERIA SALES | Desc |
| Business | 900099 | BusinessCd |
| Total Revenue Column | $30,086 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $30,086 | RelatedOrExemptFuncIncomeAmt |
Miscellaneous Revenue MiscellaneousRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $239,325 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $239,325 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $269,411 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $19,182,104 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $18,345,859 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $236,324 | ExclusionAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $461,834 | TotalAmt |
| Program Services | $346,376 | ProgramServicesAmt |
| Management And General | $115,458 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $7,350,857 | TotalAmt |
| Program Services | $5,513,143 | ProgramServicesAmt |
| Management And General | $1,837,714 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $316,825 | TotalAmt |
| Program Services | $237,619 | ProgramServicesAmt |
| Management And General | $79,206 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,770,558 | TotalAmt |
| Program Services | $1,327,919 | ProgramServicesAmt |
| Management And General | $442,639 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $608,846 | TotalAmt |
| Program Services | $456,635 | ProgramServicesAmt |
| Management And General | $152,211 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $20,813 | TotalAmt |
| Program Services | $15,610 | ProgramServicesAmt |
| Management And General | $5,203 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $100,602 | TotalAmt |
| Program Services | $75,452 | ProgramServicesAmt |
| Management And General | $25,150 | ManagementAndGeneralAmt |
Fees For Services Lobbying FeesForServicesLobbyingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $18,721 | TotalAmt |
| Management And General | $18,721 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,652,483 | TotalAmt |
| Program Services | $1,253,403 | ProgramServicesAmt |
| Management And General | $399,080 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $182,473 | TotalAmt |
| Program Services | $136,855 | ProgramServicesAmt |
| Management And General | $45,618 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $419,469 | TotalAmt |
| Program Services | $314,602 | ProgramServicesAmt |
| Management And General | $104,867 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $28,753 | TotalAmt |
| Program Services | $21,565 | ProgramServicesAmt |
| Management And General | $7,188 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $162,698 | TotalAmt |
| Program Services | $122,024 | ProgramServicesAmt |
| Management And General | $40,674 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $718,352 | TotalAmt |
| Program Services | $538,764 | ProgramServicesAmt |
| Management And General | $179,588 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $252,131 | TotalAmt |
| Program Services | $192,099 | ProgramServicesAmt |
| Management And General | $60,032 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (3 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| PROFESSIONAL FEES | $3,620,826 | $2,715,620 | $905,206 |
| BAD DEBT PROVISION | $985,611 | $985,611 | |
| NYS ASSESSMENT FEE | $54,486 | $40,865 | $13,621 |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $18,726,338 | TotalAmt |
| Program Services | $14,294,162 | ProgramServicesAmt |
| Management And General | $4,432,176 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $489,614 | BOYAmt |
| EOY | $745,371 | EOYAmt |
Pledges And Grants Receivable PledgesAndGrantsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $439,632 | BOYAmt |
| EOY | $769,119 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,911,237 | BOYAmt |
| EOY | $2,307,040 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $448,089 | BOYAmt |
| EOY | $416,268 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $129,193 | BOYAmt |
| EOY | $208,901 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $6,823,758 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $1,404,420 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,976,274 | BOYAmt |
| EOY | $5,419,338 | EOYAmt |
Investments Other Securities InvestmentsOtherSecuritiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $543,118 | BOYAmt |
| EOY | $729,953 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $943,084 | BOYAmt |
| EOY | $1,101,973 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,880,241 | BOYAmt |
| EOY | $11,697,963 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,573,387 | BOYAmt |
| EOY | $1,537,946 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,089,011 | BOYAmt |
| EOY | $7,729,162 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $8,662,398 | BOYAmt |
| EOY | $9,267,108 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | -$419,712 | BOYAmt |
| EOY | $18,076 | EOYAmt |
Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $239,671 | BOYAmt |
| EOY | $976,651 | EOYAmt |
Permanently Rstr Net Assets PermanentlyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,397,884 | BOYAmt |
| EOY | $1,436,128 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,217,843 | BOYAmt |
| EOY | $2,430,855 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,880,241 | BOYAmt |
| EOY | $11,697,963 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $455,766 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | $5,439 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | $751,807 | OtherChangesInNetAssetsAmt |
| Info In Schedule O Part XII | Yes (X) | InfoInScheduleOPartXIIInd |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Separate Basis Fincl Stmt | Yes (X) | SeparateBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | 0 | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $18,721 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $18,721 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | 0 | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART II-B, LINE 1: | FormAndLineReferenceDesc |
| Explanation | GOUVERNEUR HOSPITAL, THROUGH ITS MEMBERSHIP OR FEES PAID TO THE FOLLOWING ORGANIZATIONS, INCURRED $18,721 IN LOBBYING EXPENSE IN 2016: $4,548: IROQUOIS HEALTHCARE ALLIANCE $5,478: HANYS ANNUAL MEMBERSHIP DUES $8,695: AMERICAN HOSPITAL ASSOCIATION ANNUAL MEMBERSHIP DUES | ExplanationTxt |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Agent Trustee Etc | 0 | AgentTrusteeEtcInd |
CY Endwmt Fund CYEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $1,637,555 | BeginningYearBalanceAmt |
| Contributions | $1,806,389 | ContributionsAmt |
| Investment Earnings Or Losses | $38,244 | InvestmentEarningsOrLossesAmt |
| Other Expenditures | $1,069,409 | OtherExpendituresAmt |
| End Year Balance | $2,412,779 | EndYearBalanceAmt |
CY Minus1 Yr Endwmt Fund CYMinus1YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $1,672,801 | BeginningYearBalanceAmt |
| Contributions | $61,715 | ContributionsAmt |
| Investment Earnings Or Losses | -$35,323 | InvestmentEarningsOrLossesAmt |
| Other Expenditures | $61,638 | OtherExpendituresAmt |
| End Year Balance | $1,637,555 | EndYearBalanceAmt |
CY Minus2 Yr Endwmt Fund CYMinus2YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $54,334 | BeginningYearBalanceAmt |
| Contributions | $1,878,461 | ContributionsAmt |
| Other Expenditures | $217,009 | OtherExpendituresAmt |
| Administrative Expenses | $42,985 | AdministrativeExpensesAmt |
| End Year Balance | $1,672,801 | EndYearBalanceAmt |
CY Minus3 Yr Endwmt Fund CYMinus3YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributions | $54,334 | ContributionsAmt |
| End Year Balance | $54,334 | EndYearBalanceAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Prmnnt Endowment Balance EOY | 0.59520 | PrmnntEndowmentBalanceEOYPct |
| Term Endowment Balance EOY | 0.40480 | TermEndowmentBalanceEOYPct |
| Endowments Held Unrelated Org | 0 | EndowmentsHeldUnrelatedOrgInd |
| Endowments Held Related Org | 0 | EndowmentsHeldRelatedOrgInd |
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $230,000 | OtherCostOrOtherBasisAmt |
| Book Value | $230,000 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $2,624,783 | OtherCostOrOtherBasisAmt |
| Depreciation | $271,159 | DepreciationAmt |
| Book Value | $2,353,624 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $3,657,553 | OtherCostOrOtherBasisAmt |
| Depreciation | $1,133,261 | DepreciationAmt |
| Book Value | $2,524,292 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $311,422 | OtherCostOrOtherBasisAmt |
| Book Value | $311,422 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $5,419,338 | TotalBookValueLandBuildingsAmt |
Other Securities OtherSecuritiesGrp (2 entries)
| DescDesc | Book ValueBookValueAmt | Method ValuationMethodValuationCd |
|---|---|---|
| SHORT TERM INVESTMENTS | $40,756 | C |
| LONG TERM INVESTMENTS | $689,197 | C |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Securities | $729,953 | TotalBookValueSecuritiesAmt |
Other Assets Org OtherAssetsOrgGrp (2 entries)
| DescDesc | Book ValueBookValueAmt |
|---|---|
| FUNDS HELD IN TRUST BY OTHERS | $981,328 |
| DUE FROM ST. LAWRENCE HEALTH SYSTEMS, INC. | $120,645 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | $1,101,973 | TotalBookValueOtherAssetsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (5 entries)
| DescDesc | AmtAmt |
|---|---|
| DUE TO AFFILIATE | $2,954,349 |
| DUE TO ST. LAWRENCE HEALTH SYSTEM | $4,456,760 |
| DUE TO IBM | $17,620 |
| THIRD PARTY SETTLEMENTS | $220,433 |
| ASSET RETIREMENT OBLIGATION | $80,000 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $7,729,162 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $19,182,104 | TotalRevEtcAuditedFinclStmtAmt |
| Revenue Not Reported | $0 | RevenueNotReportedAmt |
| Revenue Subtotal | $19,182,104 | RevenueSubtotalAmt |
| Revenue Not Reported Fincl Stmt | $0 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $19,182,104 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $18,726,338 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $18,726,338 | ExpensesSubtotalAmt |
| Expenses Not Rpt Fincl Stmt | $0 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $18,726,338 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART V, LINE 4: | THE ORGANIZATION USES THE INCOME FROM THE ENDOWMENT FUNDS FOR GENERAL OPERATING PURPOSES, AND LAWFUL PURPOSES AT THE DISCRETION OF THE BOARD OF DIRECTORS. |
| PART X, LINE 2: | THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES PURSUANT TO SECTION 501(A) OF THE CODE. THE HOSPITAL IS ALSO EXEMPT FROM NEW YORK STATE INCOME TAXES. AS OF DECEMBER 31, 2016, THE HOSPITAL DID NOT HAVE ANY UNRECOGNIZED TAX BENEFITS OR ANY RELATED ACCRUED INTEREST OR PENALTIES. THE TAX YEARS OPEN TO EXAMINATION BY FEDERAL AND NEW YORK STATE TAXING AUTHORITIES ARE 2013 THROUGH 2016. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
Free Care Oth Percentage FreeCareOthPercentageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Free Care Other | 201.000000000000 | FreeCareOtherPct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
Discounted Care Oth Percentage DiscountedCareOthPercentageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Discounted Care Other | 449.000000000000 | DiscountedCareOtherPct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | 0 | ExpensesExceedBudgetInd |
| Annual Community Bnft Report | Yes (1) | AnnualCommunityBnftReportInd |
| Report Publically Available | Yes (1) | ReportPublicallyAvailableInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $437,527 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $35,222 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $402,305 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02270 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $4,773,600 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,136,672 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,636,928 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.14860 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $5,211,127 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,171,894 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $3,039,233 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.17130 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $82,827 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $82,827 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00470 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $82,827 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $82,827 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00470 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $5,293,954 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,171,894 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $3,122,060 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.17600 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $985,611 | BadDebtExpenseAmt |
| Reimbursed By Medicare | $5,471,093 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $5,416,924 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | $54,169 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GOUVERNEUR HOSPITAL | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 77 WEST BARNEY STREET | AddressLine1Txt |
| City | GOUVERNEUR | CityNm |
| State Abbreviation | NY | StateAbbreviationCd |
| ZIP | 13642 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| State License | 4423701C | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GOUVERNEUR HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Prior CHNA Impact | Yes (X) | PriorCHNAImpactInd |
| Other | Yes (X) | OtherInd |
| CHNA Conducted | 14 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | Yes (1) | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | Yes (1) | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | WWW.GVNRHOSPITAL.ORG/ABOUT-OUR-HOSPITAL/ | OwnWebsiteURLTxt |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 14 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | WWW.GVNRHOSPITAL.ORG/ABOUT-OUR-HOSPITAL/ | StrategyWebsiteURLTxt |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 201.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 449.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | WWW.GVNRHOSPITAL.ORG | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | WWW.GVNRHOSPITAL.ORG | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | WWW.GVNRHOSPITAL.ORG | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| Notified FAP Copy Bill Display | Yes (X) | NotifiedFAPCopyBillDisplayInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit Report To Credit Agency | Yes (X) | PermitReportToCreditAgencyInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Processed FAP Application | Yes (X) | ProcessedFAPApplicationInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Look Back Medicare | Yes (X) | LookBackMedicareInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| GOUVERNEUR HOSPITAL | PART V, SECTION B, LINE 5: GOUVERNEUR HOSPITAL'S (GH) MOST RECENT CHNA WAS CONDUCTED BY ITS NEW YORK STATE DSRIP PPS, ADIRONDACK HEALTH INSTITUTE, AS WELL AS ITS LOCAL PARTNERS, THE ST. LAWRENCE COUNTY PUBLIC HEALTH DEPARTMENT AND THE ST. LAWRENCE HEALTH INSTITUTE. GH PARTICIPATES AT THE BOARD LEVEL ON THE ST. LAWRENCE HEALTH INITIATIVE, A NOT-FOR-PROFIT ORGANIZATION COORDINATING HEALTH ASSESSMENT AMONG ALL AREA HEALTH FACILITIES. THIS ORGANIZATION AND OUR DSRIP PPS PROVIDE FORMAL ONGOING COORDINATION OF NEEDS ASSESSMENT AND PROGRAMMING. THE CHNA WAS COMPLETED IN 2014, UPDATED IN 2016, AND TAKES INTO ACCOUNT INPUT FROM PERSONS REPRESENTING THE COMMUNITY PRIMARILY THROUGH A TELEPHONE AND WEB SURVEY CONDUCTED IN THE SUMMER OF 2016 WITH 679 RESPONDENT RESIDENTS OF THE THREE-COUNTY REGION OF ST. LAWRENCE, LEWIS, AND JEFFERSON. GH ALSO SEEKS INPUT FORMALLY THROUGH AN ANNUAL FORUM WITH COMMUNITY LEADERS FROM ALL ACROSS OUR PRIMARY AND SECONDARY SERVICE AREAS, FREQUENT MEETINGS WITH PUBLIC HEALTH OFFICIALS, LOCAL COLLEGE PRESIDENTS, THE LEADERS OF OTHER AREA HEALTH FACILITIES, AND LOCAL GOVERNMENT OFFICIALS. ADDITIONAL INPUT WAS GATHERED FROM HOSPITAL AND HOSPITAL SYSTEM BOARD MEMBERS REPRESENTING PUBLIC HEALTH, DENTISTRY, HOSPICE AND PALLIATIVE CARE, VETERINARY HEALTH, AREA COLLEGES, AND AREA BUSINESSES. IN 2014, GH BECAME AFFILIATED WITH THE ST. LAWRENCE HEALTH SYSTEM PARTNERING WITH CANTON-POTSDAM HOSPITAL. THE COMMUNITY SERVICE INITIATIVES ARE COLLABORATED WITHIN AND TOGETHER UNDER THIS UMBRELLA SYSTEM. |
| GOUVERNEUR HOSPITAL | PART V, SECTION B, LINE 6A: PLEASE SEE LINE 5 EXPLANATION ABOVE. GOUVERNEUR HOSPITAL IS AFFILIATED WITH CANTON-POTSDAM HOSPITAL, AND COMPLETED THE CHNA WITH THE ENTITIES NOTED ABOVE. |
| GOUVERNEUR HOSPITAL | PART V, SECTION B, LINE 6B: PLEASE SEE LINE 5 EXPLANATION ABOVE. GOUVERNEUR HOSPITAL IS AFFILIATED WITH CANTON-POTSDAM HOSPITAL, AND COMPLETED THE CHNA WITH THE ENTITIES NOTED ABOVE. |
| GOUVERNEUR HOSPITAL | PART V, SECTION B, LINE 2: EFFECTIVE JANUARY 1, 2014, GOUVERNEUR HOSPITAL BEGAN OPERATIONS AS A TAX-EXEMPT HOSPITAL REPLACING THE FORMER HOSPITAL, EDWARD JOHN NOBLE HOSPITAL, WHICH CEASED OPERATIONS. |
| GOUVERNEUR HOSPITAL | PART V, SECTION B, LINE 11: GOUVERNEUR HOSPITAL'S CHNA IDENTIFIED CHRONIC DISEASE PREVENTION AND MANAGEMENT AND MENTAL, EMOTIONAL, AND BEHAVIORAL (MEB) HEALTH AS THE TWO HIGHEST PRIORITY AREAS NEEDING TO BE ADDRESSED. WITHIN THESE AREAS, CHILD AND ADOLESCENT OBESITY, HEART FAILURE, DIABETES, AND COPD WERE IDENTIFIED AS THE MOST PRESSING NEEDS IN CHRONIC DISEASE MANAGEMENT; SUBSTANCE ABUSE AND SUICIDE PREVENTION WERE IDENTIFIED AS TOP NEEDS IN THE MEB HEALTH CATEGORY. THESE PRIORITY AREAS DOVETAIL WITH THE HOSPITAL'S STRATEGIC PLAN, THE PRIORITIES OF THE NEW YORK STATE DSRIP PPS PARTNERS IN A NINE-COUNTY NORTHERN NEW YORK REGION THAT ENCOMPASSES ST. LAWRENCE COUNTY, THE PRIORITIES OF THE NEW YORK STATE HEALTHCARE REDESIGN COMMISSION, THE PRIORITIES OF THE NEW YORK STATE PREVENTION AGENDA, AND THE GOALS OF THE AFFORDABLE CARE ACT TO INCREASE ACCESS, REDUCE COSTS, AND IMPROVE QUALITY. SPECIFIC GOALS AND METRICS HAVE BEEN IDENTIFIED AND THE HOSPITAL'S OUTREACH PROGRAMS ARE DESIGNED TO ADDRESS THESE. AMONG THESE PROGRAMS IS AN EXTENSIVE EDUCATION SERIES FOR THE COMMUNITY ON VARIOUS HEALTH ISSUES; EDUCATION TARGETED TO THOSE WITH SPECIFIC DIAGNOSES; SUPPORT FOR OTHER COMMUNITY ORGANIZATIONS, SUCH AS THE GOUVERNEUR AREA CHILDREN'S COALITION, WHICH INCLUDES THE GOUVERNEUR EMS, THE SCHOOL SYSTEM, ALONG WITH GH, FOR INTEGRATING HEALTHY FOOD CHOICES IN CHILDHOOD AND ADOLESCENT ACTIVITIES. |
Supplemental Information Detail SupplementalInformationDetail (10 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 7: | THE COSTING METHODOLOGY USED IN PART I IS THE COST-TO-CHARGE RATIO METHOD. THE RATIO WAS DERIVED FROM EXHIBIT 40 OF THE 2016 ICR. |
| PART I, LN 7 COL(F): | THE AMOUNT REPORTED ON LINE 2 FOR BAD DEBT EXPENSE IS DETERMINED BY COST, AND AGREES TO THE BAD DEBT EXPENSE REPORTED ON THE FINANCIAL STATEMENTS. |
| PART III, LINE 4: | FOOTNOTE FOR ACCOUNTS RECEIVABLE AND ALLOWANCE FOR DOUBTFUL ACCOUNTS: THE HOSPITAL FOOTNOTE DESCRIBING PATIENT ACCOUNTS RECEIVABLE IS IN THE ATTACHED FINANCIAL STATEMENT FOOTNOTE 1(K) ON PAGES 7-9. |
| PART III, LINE 9B: | THE ORGANIZATION APPLIES THE SAME COLLECTION PRINCIPLES TO AMOUNTS DUE FROM PATIENTS WHO HAVE QUALIFIED FOR PERCENTAGE DISCOUNTS BUT STILL HAVE A RESPONSIBILITY FOR A PORTION OF THEIR BILL BASED UPON THE SLIDING FEE SCHEDULE. NO SEPARATE DISTINCTION IS MADE FOR THE APPLICATION OF OUR COLLECTION PROCESSES IN THOSE CASES. |
| PART VI, LINE 2: | PLEASE REFERENCE THE ABOVE REQUIRED DESCRIPTIONS, PART V SECTION B, LINES 5 AND 11. |
| PART VI, LINE 3: | THE ORGANIZATION CONSPICUOUSLY POSTS ITS FINANCIAL ASSISTANCE POLICY IN EACH REGISTRATION/RECEPTION AREA. PATIENTS ARE ENCOURAGED TO APPLY FOR ASSISTANCE AND GIVEN CONTACT INFORMATION AT THESE AREAS. IN ADDITION, ANY PATIENT THAT IS UNINSURED AND ADMITTED TO THE HOSPITAL FOR CARE IS PHYSICALLY VISITED BY A FINANCIAL COUNSELOR, AND AN EXPLANATION OF OUR PROGRAM IS MADE ALONG WITH AN APPLICATION. PATIENTS REQUESTING ASSISTANCE IN THE COMPLETION OF THE APPLICATION ARE GIVEN SUCH. ANY INFORMATION REQUIRED FOR APPLICATION FOR THE NYS MEDICAID APPLICATION PROCESS IS COLLECTED BY OUR FINANCIAL CASE MANAGERS AND COMMUNICATED TO THE APPROPRIATE CASE MANAGERS AT OUR COUNTY DEPARTMENT OF SOCIAL SERVICES FOR DETERMINATION OF MEDICAID ELIGIBILITY. |
| PART VI, LINE 4: | GOUVERNEUR HOSPITAL IS LOCATED IN ST. LAWRENCE COUNTY IN UPSTATE NEW YORK. ST. LAWRENCE COUNTY, THE LARGEST COUNTY IN NEW YORK, IS LOCATED IN THE NORTHERNMOST REACHES OF THE STATE BORDERING ON THE ST. LAWRENCE RIVER AND CANADA. IT IS A RURAL ENVIRONMENT CONSISTING OF 2,685 SQUARE MILES WITH A POPULATION OF APPROXIMATELY 112,000 RESIDENTS.GOUVERNEUR HOSPITAL'S PRIMARY SERVICE AREA INCLUDES APPROXIMATELY 58,000 PEOPLE LIVING IN THE COMMUNITIES OF CANTON, HERMON, RICHVILLE, DEKALB JCT., ANTWERP AND SECONDARY SERVICE DEFINED BY THE TOWNS OF EDWARDS, HARRISVILLE AND INDIAN RIVER. THE SECONDARY SERVICE AREA FOR THE HOSPITAL IS PREDOMINANTLY THE REMAINING COMMUNITIES WITHIN ST. LAWRENCE COUNTY WITH SOME RESIDENTS OF THE WESTERN JEFFERSON COUNTY AREA BEING SERVED. |
| PART VI, LINE 5: | GOUVERNEUR HOSPITAL HELD MANY COMMUNITY ACTIVITIES TO HELP PROMOTE THE HEALTH OF THE COMMUNITY. SOME OF THESE ACTIVITIES INCLUDE BLOOD DRIVES, SCHOOL EDUCATION ACTIVITIES, BREAST CANCER WALKS, AND LUNCH & LEARNS. THE COMMUNITY LUNCH & LEARNS HELD BY GOUVERNEUR HOSPITAL HAD APPROXIMATELY 168 PEOPLE IN ATTENDANCE AND SPOKE TO VARIOUS HEALTH RELATED RISKS AND HOW TO MANAGE THEM. GOUVERNEUR HOSPITAL HAD 63 STUDENTS FROM MULTIPLE COLLEGES AND BOCES PROGRAMS SHADOW EMPLOYEES. GOUVERNEUR HOSPITAL HELD A "LET'S NOT MEET BY ACCIDENT" PROGRAM FOR 182 STUDENTS TO EDUCATE YOUNG DRIVERS ON THE DANGERS OF DWI AND TEXTING WHILE DRIVING. THE HOSPITAL ALSO WORKS WITH THE LOCAL POLICE DEPARTMENT EACH YEAR AND DOES A PROGRAM CALLED OPERATION SAFE CHILD WHERE YOUNG CHILDREN CAN ATTEND AND HAVE A PHOTO ID PLACED ON RECORD. |
| PART VI, LINE 6: | ST. LAWRENCE HEALTH SYSTEM, FORMED DECEMBER 5, 2013, IS OPERATED EXCLUSIVELY FOR THE SOLE CHARITABLE PURPOSE OF BENEFITING AND SUPPORTING GOUVERNEUR HOSPITAL, CANTON-POTSDAM HOSPITAL AND OTHER CORPORATIONS. AMONG OTHER BENEFITS, THE HEALTH SYSTEM MAY PROVIDE ADVICE AND ASSISTANCE CONCERNING LONG AND SHORT-RANGE PLANNING FOR, AND MONITOR AND PROVIDE ADVICE AND ASSISTANCE TO HELP COORDINATE THE ACTIVITIES OF THE SUPPORTED ORGANIZATION IN ELIMINATING DUPLICATIVE FUNCTIONS; PROVIDE MANAGEMENT CONSULTING ASSISTANCE TO THE SUPPORTED ORGANIZATION TO FURTHER IMPROVE AND ADVANCE HEALTH SERVICES TO THE RESIDENTS OF NEW YORK STATE AND COOPERATE WITH THE SUPPORTING ORGANIZATIONS IN CARRYING OUT THEIR CHARITABLE PURPOSES. |
| PART VI, LINE 7, REPORTS FILED WITH STATES | NY |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (5 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| MARLINDA LAVALLEY | ||||||||||||||
| CHIEF EXECUTIVE OFFICER | $168,646 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $22,076 | $0 | $190,722 | $0 | $0 | $0 |
| ALICE LOVING | ||||||||||||||
| ANESTHESIOLOGIST | $300,596 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $31,149 | $0 | $331,745 | $0 | $0 | $0 |
| NABEEL AL-HUSSEIN | ||||||||||||||
| PHYSICIAN | $200,604 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $13,827 | $0 | $214,431 | $0 | $0 | $0 |
| RICHARD CORCORAN | ||||||||||||||
| PHYSICIAN ASSISTANT | $153,106 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $22,643 | $0 | $175,749 | $0 | $0 | $0 |
| GERALD L CALABRESE | ||||||||||||||
| PHYSICIAN | $130,748 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $19,938 | $0 | $150,686 | $0 | $0 | $0 |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (9 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 6 | ST. LAWRENCE HEALTH SYSTEM, INC. IS THE SOLE MEMBER. |
| FORM 990, PART VI, SECTION A, LINE 7A | ST. LAWRENCE HEALTH SYSTEM, INC., AS THE SOLE MEMBER, HAS THE ABILITY TO APPOINT MEMBERS OF THE BOARD OF DIRECTORS. |
| FORM 990, PART VI, SECTION A, LINE 7B | THE MEMBER SHALL HAVE THE FOLLOWING POWERS WITH REGARD TO THE CORPORATION: -APPOINT THE MEMBERS OF THE BOARD OF DIRECTORS; -APPOINT AND REMOVE THE CHIEF EXECUTIVE OFFICER; -APPROVE THE ADOPTION AND AMENDMENT OF BYLAWS; -APPROVE THE ANNUAL OPERATING AND CAPITAL BUDGETS; -APPROVE STRATEGIC PLANS; -APPROVE AND INITIATE THE FILING OF CERTIFICATE OF NEED APPLICATIONS; -REVIEW AND APPROVE THE ANNUAL AUDIT OF THE CORPORATION AND ANY SUBSIDIARY CORPORATIONS; -APPROVE THE DISSOLUTION OF THE CORPORATION; -APPROVE THE SALE, LEASE, MORTGAGE OR ENCUMBRANCE OF ANY ASSET OTHER THAN ANY SALE, LEASE OR MORTGAGE WHICH IS PART OF AN APPROVED BUDGET; -APPROVE THE SALE OR TRANSFER OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE CORPORATION; -APPROVE ANY MERGER, BUSINESS CONSOLIDATION, ACQUISITION OR JOINT VENTURE; -APPROVE THE PURCHASE OR SALE OF PHYSICIAN PRACTICES OTHER THAN ANY PURCHASE OR SALE WHICH IS PART OF AN APPROVED BUDGET; -APPROVE AND MAY INITIATE THE COMMENCEMENT AND SETTLEMENT OF LITIGATION; -APPROVE ANY FILING OF A BANKRUPTCY PETITION; -APPROVE THE INCURRENCE OF ANY DEBT OTHER THAN DEBT WHICH IS INCURRED IN THE ORDINARY COURSE OF BUSINESS AND WHICH IS NOT INCONSISTENT WITH AN APPROVED BUDGET; -APPROVE NEW CLINICAL PROGRAMS OR THE TERMINATION OF EXISTING CLINICAL PROGRAMS OTHER THAN ANY ACTION WHICH IS PART OF AN APPROVED BUDGET; -APPROVE ANY OF THE FOLLOWING AGREEMENTS: (I) MANAGEMENT SERVICES AGREEMENT OTHER THAN ANY AGREEMENT WHICH IS PART OF AN APPROVED BUDGET; (II) CONTRACTS WITH A PHYSICIAN OR A PHYSICIAN GROUP; (III) AGREEMENTS FOR THE OUTSOURCING OF A GOUVERNEUR HOSPITAL SERVICE OR FUNCTION; (IV) COLLECTIVE BARGAINING AGREEMENTS; AND (V) ANY AGREEMENTS TO PARTICIPATE IN A RISK BEARING ARRANGEMENT SUCH AS AN ACCOUNTABLE CARE ORGANIZATION OR A BUNDLED PAYMENT ARRANGEMENT; -INITIATE, NEGOTIATE AND APPROVE MANAGED CARE AGREEMENTS WITH MANAGED CARE ORGANIZATIONS AND OTHER PAYORS OTHER THAN ANY AGREEMENT WHICH IS PART OF AN APPROVED BUDGET; -DEVELOP INTEGRATED SERVICES AND MANDATE PARTICIPATION IN SUCH SERVICES (E.G., FINANCIAL MANAGEMENT, STRATEGIC PLANNING, HUMAN RESOURCES, INFORMATION TECHNOLOGY, LEGAL, QUALITY ASSURANCE, RISK MANAGEMENT, CONTRACTING AND RECRUITMENT); AND -REQUIRE THE GUARANTEE OF LOANS THROUGH AN OBLIGATED GROUP STRUCTURE THAT WILL SUPPORT ACCESS TO CAPITAL AND MAY INCLUDE DEBT SERVICES. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE 990 IS EMAILED TO THE BOARD OF DIRECTORS PRIOR TO THE FILING OF THE RETURN. |
| FORM 990, PART VI, SECTION B, LINE 12C | ON AN ANNUAL BASIS, OFFICERS, DIRECTORS, AND KEY EMPLOYEES ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST STATEMENT. COMPLIANCE WITH THIS REQUIREMENT IS MONITORED BY HOSPITAL ADMINISTRATION. |
| FORM 990, PART VI, SECTION B, LINE 15 | THE CHIEF EXECUTIVE OFFICER IS EVALUATED BY THE ST. LAWRENCE HEALTH SYSTEM CEO. HOSPITAL SENIOR LEADERSHIP IS EVALUATED BY THE HOSPITAL'S CEO. YAFFE AND COMPANY PROVIDES EXECUTIVE COMPENSATION DATA FOR CRITICAL ACCESS HOSPITALS WHICH IS UTILIZED BY THE ST. LAWRENCE HEALTH SYSTEM CEO TO DETERMINE APPROPRIATE COMPENSATION FOR THE HOSPITAL CEO. THE SAME DATA IS UTILIZED BY THE HOSPITAL CEO TO DETERMINE APPROPRIATE COMPENSATION FOR THE HOSPITAL'S SENIOR LEADERSHIP. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. |
| FORM 990, PART XI, LINE 9: | TRANSFER FROM SLHS 713,563. CHANGE IN FAIR VALUE OF PERMANENTLY RESTRICTED FUNDS 38,244. |
| FORM 990, PART XII, LINE 2C: | THE ST. LAWRENCE HEALTH SYSTEM'S AUDIT COMMITTEE ASSUMES RESPONSIBILITY FOR THE SELECTION OF THE INDEPENDENT ACCOUNTANT AND OVERSIGHT OF THE ANNUAL AUDIT. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp (3 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | Exempt Code SectionExemptCodeSectionTxt | Public Charity StatusPublicCharityStatusTxt | Business Name Line1DirectControllingEntityName/BusinessNameLine1Txt | Controlled OrganizationControlledOrganizationInd | Direct Controlling NADirectControllingNACd |
|---|---|---|---|---|---|---|---|---|---|---|---|
| CANTON-POTSDAM HOSPITAL | |||||||||||
| 50 LEROY STREET | POTSDAM | NY | 13676 | 161012691 | HOSPITAL | NY | 501(C)(3) | LINE 3 | ST LAWRENCE HEALTH SYSTEM INC | 0 | |
| ST LAWRENCE HEALTH SYSTEM INC | |||||||||||
| 50 LEROY STREET | POTSDAM | NY | 13676 | 464259168 | PROVIDES SUPPORT TO CANTON-POTSDAM HOSPITAL & AFFILIATES | NY | 501(C)(3) | LINE 12B, II | 0 | N/A | |
| CANTON-POTSDAM MEDICAL PRACTICE PLLC | |||||||||||
| 77 WEST BARNEY STREET | GOUVERNEUR | NY | 13642 | 460714367 | PHYSICIAN SERVICES | NY | 501(C)(3) | LINE 10 | ST LAWRENCE HEALTH SYSTEM INC | 0 | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | 0 | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | Yes (1) | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | Yes (1) | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | 0 | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | Yes (1) | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | 0 | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | 0 | SharingOfFacilitiesInd |
| Paid Employees Sharing | Yes (1) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | Yes (1) | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | Yes (1) | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | Yes (1) | TransferFromOtherOrgInd |