2016-01-15T12:38:05-06:00 2014-12-31 161226221 FUST CHARLES CHAMBERS LLP 5784 WIDEWATERS PARKWAY SYRACUSE NY 13214 990 2014-01-01 464249555 GOUVERNEUR HOSPITAL GOUV 3152871000 77 WEST BARNEY STREET GOUVERNEUR NY 13642 MARLINDA LAVALLEY CEO 3152871000 2016-01-15 1 JOSEPH J SCHLEGEL P00301329 3154463600 2014 2016-04-25 22:37:26Z X MARLINDA LAVALLEY 77 WEST BARNEY STREET GOUVERNEUR NY 13642 20538727 0 X WWW.GVNRHOSPITAL.ORG X 2013 NY OUR MISSION IS TO PROVIDE SKILLED, COMPASSIONATE, COST-EFFECTIVE CARE THAT PROMOTES WELLNESS AND MEETS THE COMMUNITY'S HEALTHCARE NEEDS. 7 7 229 12 0 0 0 5632119 0 14548041 0 14278 0 344289 0 20538727 0 0 0 0 0 9762775 0 0 0 0 8626699 0 18389474 0 2149253 6880748 9074063 9009753 8593646 -2129005 480417 OUR MISSION IS TO PROVIDE SKILLED, COMPASSIONATE, COST-EFFECTIVE CARE THAT PROMOTES WELLNESS AND MEETS THE COMMUNITY'S HEALTHCARE NEEDS. 0 0 14169922 14674175 ACUTE DIRECT PATIENT CARE - INPATIENT, REFERRED AMBULATORY, EMERGENCY CARE AND CLINICS. IN 2014 GOUVERNEUR HOSPITAL SERVED 485 INPATIENTS, HAD 8,497 EMERGENCY ROOM VISITS, AND PATIENT PROCEDURES TOTALED 13,937 INPATIENT AND 107,779 FOR OUTPATIENTS. 14169922 1 1 0 1 0 0 0 0 0 1 1 1 0 1 1 1 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 15 0 1 229 1 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X RICHARD T LANG 3152871000 77 WEST BARNEY STREET GOUVERNEUR NY 13642 MICHAEL BURGESS CHAIRPERSON 1.00 X X 0 0 0 NICHOLAS GARDNER DDS VICE CHAIRPERSON 1.00 X X 0 0 0 MARK BRACKETT SECRETARY/TREASURER 1.00 X X 0 0 0 ANDREW WILLIAMS MD DIRECTOR 1.00 X 0 0 0 LAUREN FRENCH DIRECTOR 1.00 X 0 0 0 ANDREW LEONARD DIRECTOR 1.00 X 0 0 0 ROGER COOK DVM DIRECTOR 1.00 X 0 0 0 MARY JANE GOTHAM QUALITY ASSURANCE DIRECTOR 40.00 X 103681 0 10498 RICHARD T LANG CHIEF FINANCIAL OFFICER 40.00 X 129390 0 15941 MARLINDA LAVALLEY CHIEF EXECUTIVE OFFICER 40.00 X 147348 0 16068 ALICE LOVING ANESTHESIOLOGIST 40.00 X 286239 0 23518 NABEEL AL-HUSSEIN PHYSICIAN 40.00 X 241605 0 22875 RICHARD CORCORAN PHYSICIAN ASSISTANT 40.00 X 138729 0 11487 1046992 0 100387 6 0 1 0 0 92593 4038524 1501002 5632119 PATIENT SERVICE REVENUE 623000 14548041 14548041 14548041 14278 14278 218155 0 218155 218155 218155 CAFETERIA SALES 900099 32376 32376 93758 93758 126134 20538727 14674175 0 232433 422926 317195 105731 6427081 5010621 1416460 260794 195595 65199 2094186 1588784 505402 557788 418341 139447 353212 353212 108096 108096 2981569 2236177 745392 170836 128127 42709 487905 365929 121976 27726 20794 6932 200060 200060 211049 158287 52762 184926 138694 46232 PROFESSIONAL FEES 2040007 1530005 510002 BAD DEBT PROVISION 1673546 1673546 PHYSICIAN PRACTICE 144849 144849 NYS ASSESSMENT FEE 42918 42918 18389474 14169922 4219552 0 293821 402280 1202753 387059 1762896 2379605 373885 410283 46474 80037 4159201 211049 2929799 3948152 158703 488240 112417 978407 6880748 9074063 0 1558052 9009753 7035594 9009753 8593646 X -2183339 -1192384 54334 239594 0 1433207 -2129005 480417 6880748 9074063 X 2149253 3154 457015 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5120 5120 0 PART II-B, LINE 1: GOUVERNEUR HOSPITAL, THROUGH ITS MEMBERSHIP OR FEES PAID TO THE FOLLOWING ORGANIZATIONS, INCURRED $5,120 IN LOBBYING EXPENSE IN 2014: $1,649: IROQUOIS HEALTHCARE ALLIANCE $1,941: HANYS ANNUAL MEMBERSHIP DUES $1,530: AMERICAN HOSPITAL ASSOCIATION ANNUAL MEMBERSHIP DUES 0 54334 1878461 217009 42985 1672801 0 54334 54334 0.85680 0.14320 0 0 230000 230000 1436626 35794 1400832 1662403 174406 1487997 830172 849 829323 3948152 SHORT TERM INVESTMENTS 33440 C LONG TERM INVESTMENTS 454800 C 488240 FUNDS HELD IN TRUST BY OTHERS 978407 978407 DUE TO AFFILIATE 1676378 DUE TO ST. LAWRENCE HEALTH SYSTEM 4834776 DUE TO IBM 319657 THIRD PARTY SETTLEMENTS 188429 DUE TO NAVITAS 16354 7035594 X 20508298 0 20508298 30429 30429 20538727 18359045 0 18359045 30429 30429 18389474 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, 2014, 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 AND 2014. PART XI, LINE 4B - OTHER ADJUSTMENTS: NEW YORK STATE SCHOOL BASED GRANT 30,429. PART XII, LINE 4B - OTHER ADJUSTMENTS: NEW YORK STATE SCHOOL BASED GRANT 30,429. 1 1 X 1 X 201.000000000000 1 X 449.000000000000 1 1 0 0 566198 370028 196170 0.01070 4147832 1994982 2152850 0.11710 4714030 2365010 2349020 0.12780 59862 59862 0.00330 59862 59862 0.00330 4773892 2365010 2408882 0.13110 1 1473964 0 4527812 4482982 44830 X 1 1 1 1 GOUVERNEUR HOSPITAL 77 WEST BARNEY STREET GOUVERNEUR NY 13642 4423701C X X X X GOUVERNEUR HOSPITAL 1 1 1 0 0 1 X 201.000000000000 449.000000000000 X 1 1 X X X 1 X X X X 1 X 0 X X X 1 X 0 0 GOUVERNEUR HOSPITAL PART V, SECTION B, LINE 6A: CANTON POTSDAM HOSPITAL, PUBLIC HEALTH, CLIFTON FINE HOSPITAL, CLAXTON HEPBURN MEDICAL CENTER, COUNTY OF ST. LAWRENCE, MASSENA MEMORIAL HOSPITAL, ST. LAWRENCE COUNTY HEALTH INTIATIVE. 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 22D: A SLIDING FEE/ CHARITY CARE POLICY IS USED. PART I, LINE 7: THE COSTING METHODOLOGY USED IN PART I IS THE COST-TO-CHARGE RATIO METHOD. THE RATIO WAS DERIVED FROM EXHIBIT 49 OF THE 2014 ICR. PART III, LINE 4: THE AMOUNT REPORTED ON LINE 2 FOR BAD DEBT EXPENSE IS DETERMINTED BY COST, AND AGREES TO THE BAD DEBT EXPENSE REPORTED ON THE FINANCIAL STATEMENTS.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 9-11. PART III, LINE 9B: THE PATIENT FINANCIAL SERVICES DEPARTMENT WILL MAKE INTERMITTENT ATTEMPTS TO CONTACT PATIENTS WITH NO INSURANCE REGARDING FINANCIAL ASSISTANCE OPTIONS. A PATIENT ACCOUNT IS NOT REFERRED TO COLLECTION SERVICES UNTIL AT LEAST 120 DAYS AFTER THE DATE OF SERVICE/DISCHARGE OR AFTER AN APPLICATION FOR FINANCIAL ASSISTANCE HAS BEEN ACCEPTED/DENIED BY THE FACILITY, WHICHEVER IS LONGER. BILLS AND COLLECTION NOTICES WILL ROUTINELY BE HELD ONCE A PATIENT HAS INITIATED THE APPLICATION PROCESS FOR FINANCIAL ASSISTANCE. PART VI, LINE 2: THE HOSPITAL ASSESSES THE NEEDS OF THE COMMUNITY THROUGH COLLABORATION WITH THE ST. LAWRENCE HEALTH SYSTEM AND CONSULTATION WITH COMMUNITY GROUPS, LOCAL GOVERNMENT ENTITIES, EMPLOYEES AND VOLUNTEERS, HEALTHCARE PRACTITIONERS, AND THE HOSPITAL AUXILIARY. PART VI, LINE 3: WE HAVE A FINANCIAL ASSISTANCE POLICY AVAILABLE IN THE ER, WAITING ROOM PATIENT REGISTRATION, PATIENT ACCOUNTING OFFICE, AND OUTPATIENT CLINICS, AND IT IS PRINTED ON THE PATIENT BILLS THAT WE OFFER FINANCIAL ASSISTANCE. PART VI, LINE 4: GOUVERNEUR HOSPITAL IS A CRITICAL ACCESS HOSPITAL THAT SERVES A LARGE GEOGRAPHICAL AREA OF SOUTHERN ST. LAWRENCE, WEST LEWIS AND NOTHERN JEFFERSON COUNTIES. THE POPULATION SERVICE AREA IS 22,000 AND THE PRIMARY INDUSTRIES ARE AGRICULTURE, MINING (LEAD, ZINC, TALC, IRON ORE) WITH HEADQUARTERS FOR A REGIONAL RETAIL DRUG STORE. PART VI, LINE 5: GOUVERNEUR HOSPITAL PROVIDES CONTINUOUS COMMUNITY FORUMS ON CURRENT HEALTH CARE TOPICS. WE WORK CLOSELY WITH THE GOUVERNEUR RESCUE SQUAD FOR VARIOUS CATEGORIES OF EMT TRAINING. HOSPICE ACTIVITIES, MOMS-TO-BE PROGRAM, WEIGHT WATCHERS, BREAST CANCER SURVIVORS, EACH OF THESE UTILIZE THE EDUCATION PROGRAM TO MAINTAIN THESE COMMUNITY SERVICE PROGRAMS. 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 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 ORGANIZATION IN CARRYING OUT THEIR CHARITABLE PURPOSES. PART VI, LINE 7, REPORTS FILED WITH STATES NY X 0 0 0 0 0 0 0 0 0 MARY JANE GOTHAM QUALITY ASSURANCE DIRECTOR 103681 0 0 0 0 0 0 0 10498 0 114179 0 0 0 RICHARD T LANG CHIEF FINANCIAL OFFICER 129390 0 0 0 0 0 0 0 15941 0 145331 0 0 0 MARLINDA LAVALLEY CHIEF EXECUTIVE OFFICER 147348 0 0 0 0 0 0 0 16068 0 163416 0 0 0 ALICE LOVING ANESTHESIOLOGIST 286239 0 0 0 0 0 0 0 23518 0 309757 0 0 0 NABEEL AL-HUSSEIN PHYSICIAN 241605 0 0 0 0 0 0 0 22875 0 264480 0 0 0 RICHARD CORCORAN PHYSICIAN ASSISTANT 138729 0 0 0 0 0 0 0 11487 0 150216 0 0 0 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 11 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: CHANGE IN FAIR VALUE OF PERMANENTLY RESTRICTED FUNDS HELD IN TRUST BY OTHER -42,985. TRANSFER FROM ST. LAWRENCE HEALTH SYSTEM, INC. 500,000. 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. AMENDED RETURN: THE 2014 FORM 990 IS BEING AMENDED TO REFLECT THE SUBSEQUENT FILING OF THE INITIAL 2013 FORM 990. THE HOSPITAL REPLACED EDWARD JOHN NOBLE HOSPITAL AND THE ASSUMED LIABILITIES WERE REPORTED ON THE 2013 RETURN. THEREFORE, THE 2014 RETURN IS NO LONGER MARKED INITIAL AND THE 2013 INCOME AND EXPENSES HAVE BEEN REMOVED AS OPERATIONS DID NOT BEGIN UNTIL JANUARY 1, 2014. 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 11B, II N/A 0 CANTON-POTSDAM MEDICAL PRACTICE PLLC 77 WEST BARNEY STREET GOUVERNEUR NY 13642 460714367 PHYSICIAN SERVICES NY 501(C)(3) LINE 9 ST LAWRENCE HEALTH SYSTEM INC 0 0 0 1 0 1 0 0 0 0 0 1 0 0 0 1 1 1 0 0