2016-08-08T13:36:44-05:00 2015-12-31 160765486 LUMSDEN & MCCORMICK LLP 369 FRANKLIN STREET BUFFALO NY 14202 990 2015-01-01 160743301 BROOKS MEMORIAL HOSPITAL BROO 7163661111 529 CENTRAL AVENUE DUNKIRK NY 14048 MARY E LAROWE CHIEF EXECUTIVE OFFICER 7163661111 2016-08-01 1 MICHAEL J GRIMALDI P01295846 7168563300 2015 2016-12-15 16:53:06Z MARY E LAROWE 529 CENTRAL AVENUE DUNKIRK NY 14048 43212106 0 X WWW.BROOKSHOSPITAL.ORG X 1898 NY AN ACUTE CARE HOSPITAL SERVING PRIMARILY RESIDENTS OF NORTHERN CHAUTAUQUA COUNTY. 9 9 465 22 0 0 437128 336699 40731166 40888854 90768 -1135 718423 1967898 41977485 43192316 0 0 0 0 23389846 22064752 0 0 0 22450692 24621701 45840538 46686453 -3863053 -3494137 23409085 17679926 10084854 11546939 13324231 6132987 SEE SCHEDULE O FOR FULL MISSION STATEMENT. 0 0 18132068 16213907 NURSING SERVICES - PROVISION OF DAILY CARE INCLUDING INPATIENT AND OUTPATIENT SERVICES WITHIN THE INSTITUTION 18635295 24674947 OTHER PROFESSIONAL SERVICES - ANCILLARY SERVICES PROVIDED WITHIN THE FACILITY INCLUDING LABORATORY, RADIOLOGY, INHALATION THERAPY, ETC. 36767363 1 1 0 0 0 0 0 0 0 1 1 1 0 1 1 1 1 0 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 65 0 1 465 1 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X X JEFFREY MORGAN 7163637212 529 CENTRAL AVENUE DUNKIRK NY 14048 CHRISTOPHER LANSKI CHAIRMAN 2.00 X X 0 0 0 ANDREW BURR CHAIRMAN ELECT 2.00 X X 0 0 0 LOUIS DIPALMA TREASURER 2.00 X X 0 0 0 DR VIRGINIA S HORVATH SECRETARY 2.00 X X 0 0 0 WALTER GOTOWKA MEMBER 2.00 X 0 0 0 RICHARD MILAZZO MD MEMBER 2.00 X 0 0 0 G JAY BISHOP MD MEMBER 2.00 X 4400 0 0 FELIXBERTO COSICO JR MD FCCP MEMBER 2.00 X 1800 0 0 STEVEN PRZYBYLA MEMBER 2.00 X 0 0 0 JOHN GARY RHODES INTERIM CEO 22.00 X 0 0 0 JEFFREY MORGAN VP FINANCE/CFO 40.00 X 241260 0 18746 A JACK DAVIS VP ADMINISTRATIVE SERVICES 40.00 X 170261 0 9336 JARROD JOHNSON COO 40.00 X 83883 0 4508 JODI WITHERELL VP QUALITY/SAFETY 40.00 X 163684 0 17759 JONATHAN LAWRENCE FORMER CEO 0.00 X 130079 0 6597 795367 0 56946 3 1 1 0 PREMIER ANESTHESIA 2655 NORTHWINDS PARKWAY ALPHARETTA GA 30009 MEDICAL SERVICES 653731 LABORATORY CORPORATION OF AMERICA PO BOX 12140 BURLINGTON NC 27216 LAB SERVICES 634884 CHAUTAUQUA PROFESSIONAL MEDICAL SERVICE 12 CENTER STREET SUITE 4 FREDONIA NY 14063 PHYSICIAN SERVICES 604287 REVENUE CYCLE SOLUTIONS TWO GATEWAY CENTER 603 STANWIX STR PITTSBURGH PA 15222 CONSULTING 545499 UPMC PO BOX 223270 PITTSBURGH PA 15251 MANAGEMENT SERVICES 409284 11 269196 67503 336699 PATIENT SERVICE REVENUE 621990 40888854 40888854 40888854 4514 4514 4181 0 4181 4181 4181 14141 19790 -5649 -5649 -5649 NEW YORK STATE DOH VAPAP GRANTS 900099 1266848 1266848 PHONE, TELEVISION & MISC 900099 257406 257406 MEALS ON WHEELS 900099 218250 218250 221213 221213 1963717 43192316 40888854 0 1966763 715636 6200 709436 16641080 13974864 2666216 1219235 842594 376641 2214621 1509184 705437 1274180 859226 414954 2086095 2086095 55982 55982 10210957 9345907 865050 971433 249872 721561 528182 396136 132046 9481 9481 79618 79618 5628 5628 1918128 1534502 383626 420973 266898 154075 MEDICAL SPECIALIST FEES 2491740 2491740 PURCHASED SERVICES 2050777 1511798 538979 CONTRACT LABOR 1977811 1977811 PROVISION FOR BAD DEBTS 1685242 1685242 129654 30143 99511 46686453 36767363 9919090 0 1398902 1334110 252707 5055189 3979855 1266201 1328071 368495 425096 50099867 42241682 8802193 7858185 3094487 1402568 1172503 1768343 1582106 23409085 17679926 6353861 6128913 19372 47218 3711621 5370808 10084854 11546939 X 11921663 4960484 645359 415294 757209 757209 13324231 6132987 23409085 17679926 X -3494137 -38923 -3658184 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1402568 -34735 195330 1172503 1645716 59794 302942 1402568 1427234 218482 1645716 1414171 13063 1427234 1412273 1898 1414171 0.65000 0.35000 1 0 399331 399331 10479473 8688320 1791153 1127455 857729 269726 38093608 32695633 5397975 7858185 FUNDS HELD IN TRUST 1172503 F 1172503 ADVANCES TO RELATED PARTIES 1582106 1582106 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 850904 ACCRUED PENSION LIABILITY 4519904 5370808 X 41512723 -1685242 -1685242 43197965 -5649 -5649 43192316 45006860 5649 5649 45001211 1685242 1685242 46686453 PART X, LINE 2: THE HOSPITAL IS A 501(C)(3) ORGANIZATION EXEMPT FROM INCOME TAXES UNDER SECTION 501(A) OF THE INTERNAL REVENUE CODE. THE HOSPITAL BELIEVES IT IS NO LONGER SUBJECT TO EXAMINATION BY FEDERAL OR STATE TAXING AUTHORITIES FOR YEARS ENDED PRIOR TO DECEMBER 31, 2012. PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS -1,685,242. PART XI, LINE 4B - OTHER ADJUSTMENTS: LOSS ON DISPOSAL OF PROPERTY AND EQUIPMENT -5,649. PART XII, LINE 2D - OTHER ADJUSTMENTS: LOSS ON DISPOSAL OF PROPERTY AND EQUIPMENT 5,649. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 1,685,242. 1 1 1 X 1 X 1 1 0 0 481474 23393 458081 0.01020 11014317 7447783 3566534 0.07930 45203 20870 24333 0.00050 11540994 7492046 4048948 0.09000 46649 46649 0.00100 8576 8576 0.00020 2328880 1804188 524692 0.01170 10 10 0.00000 2384115 1804188 579927 0.01290 13925109 9296234 4628875 0.10290 1173 1173 0.00000 1173 1173 0 651942 7339895 7662425 -322530 X 1 1 1 1 BROOKS MEMORIAL HOSPITAL 529 CENTRAL AVENUE DUNKIRK NY 14048 X X X RENAL DIALYSIS BROOKS MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 13 1 1 1 1 X HTTP://WWW.CO.CHAUTAUQUA.NY.US/241/PUBLIC-HEALTH X 0 0 1 X 100.000000000000 300.000000000000 X X X X X 1 1 X X X 1 X HTTP://WWW.BROOKSHOSPITAL.ORG X X X X X 1 1 X X X X X X X 1 X X 0 1 BROOKS MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: THE CHNA UTILIZED A THREE PRONGED APPROACH TO GAUGE HEALTH ISSUES, INCLUDING INPUT FROM COMMUNITY MEMBERS, DATA FROM NYSDOH AND OTHER HEALTH RESOURCES, AND INPUT FROM LOCAL CONTENT EXPERTS.COMMUNITY MEMBERS:THE LINK FOR THE SURVEY WAS WIDELY DISTRIBUTED THROUGH FACEBOOK, THE CCDHHS WEBSITE, WAS FEATURED IN A PRESS RELEASE TO LOCAL NEWSPAPERS, AND SENT ELECTRONICALLY TO A NUMBER OF EMPLOYEE AND COMMUNITY-BASED EMAIL DISTRIBUTION LISTS. ALL CCCHPT PARTNERS PARTICIPATED IN ELECTRONIC DISTRIBUTION OF THE SURVEY. THE WEB-BASED FORMAT SUCCESSFULLY REACHED WHITE, MIDDLE CLASS, EMPLOYED, AND INSURED RESIDENTS. PAPER COPIES OF THE SURVEY WERE MADE AVAILABLE THROUGHOUT THE COMMUNITY TO REACH SPECIAL POPULATION GROUPS, WHO WERE LESS LIKELY TO RESPOND TO THE WEB-BASED SURVEY.IN ORDER TO OBTAIN INPUT FROM HARD TO REACH RESIDENTS, THE CCCHPT MADE EFFORTS TO TARGET THE FOLLOWING POPULATION GROUPS:* CHAUTAUQUA COUNTY'S NEW FEDERALLY QUALIFIED HEALTH CENTER - THE CHAUTAUQUA CENTER B33 SERVES A PRIMARILY HISPANIC PATIENT POPULATION. CENTER STAFF ASSISTED PATIENTS IN FILLING OUT THE SURVEYS AND ALSO PROVIDED TRANSLATION SERVICES.* PAPER COPIES OF THE SURVEY WERE PROVIDED TO THE LOCAL AMISH POPULATION AT CANCER SERVICES PROGRAM CLINICS IN SHERMAN AND CLYMER, AND WERE ALSO SHARED BY EMPLOYEES WITH THEIR AMISH FRIENDS.* PAPER COPIES OF THE SURVEY WERE PROVIDED TO INMATES OF THE CHAUTAUQUA COUNTY JAIL TO GAIN INPUT FROM INCARCERATED RESIDENTS. JAIL STAFF ASSISTED IN THIS PROCESS BY ENCOURAGING PARTICIPATION AND PROVIDING ASSISTANCE WHEN NECESSARY.* PAPER COPIES OF THE SURVEY WERE AVAILABLE TO LOW-INCOME RESIDENTS IN CCDHHS TEMPORARY ASSISTANCE OFFICES, THE REPRODUCTIVE HEALTH CLINICS, THE FEDERALLY QUALIFIED HEALTH CENTER, HOSPITAL EMERGENCY ROOMS, AND MENTAL HEALTH CLINICS.COMMUNITY MEMBERS' PERCEPTIONS OF HEALTH ISSUES WERE ALSO GATHERED AT THREE "COMMUNITY CONVERSATIONS" SPONSORED BY THE P2 COLLABORATIVE OF WNY AND THE CHAUTAUQUA COUNTY HEALTH NETWORK. THESE CONVERSATIONS SPANNED CHAUTAUQUA COUNTY'S GEOGRAPHIC AND CULTURAL SEPARATIONS, COVERING THE "NORTH COUNTY" IN DUNKIRK, THE "SOUTH COUNTY" IN JAMESTOWN, AND THE "WEST COUNTY" IN WESTFIELD.EXPERTS CONSULTED:A STAKEHOLDERS MEETING INVOLVED EXPERTS THROUGHOUT THE COUNTY, INCLUDING:BROOKS MEMORIAL HOSPITAL - THERESA SCHRANTZCHAUTAUQUA ALCOHOL AND SUBSTANCE ABUSE COUNCIL - KATHLEEN COLBYCHAUTAUQUA COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES - JULIE APPERSON, ANGELA SWARTZMAN, BREEANNE AGETTCHAUTAUQUA COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES, CANCER SERVICES PROGRAM - DARLENE ROWECHAUTAUQUA COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES, EARLY INTERVENTION PROGRAM - DENISE NICHOLSCHAUTAUQUA COUNTY DEPARTMENT OF MENTAL HYGIENE - BRIANA POST, PAT BRINKMANCHAUTAUQUA COUNTY HEALTH NETWORK - KERRI BROWN, ANN ABDELLA, JANET FORBESCHAUTAUQUA LAKE CHILD CARE CENTER - BETH STARKSCHAUTAUQUA OPPORTUNITIES INC. - TARRA JOHNSON, JEN IRWINDELPHI HEALTH CARE PARTNERS - MELISSA BOCKEASTSIDE YMCA - MAX MARTINJAMESTOWN PSYCHIATRIC - SANDRA DOHLJAMESTOWN TREATMENT COURT, 8TH JUDICIAL DISTRICT - CATHY NEWTONLAKE ERIE REGIONAL HEALTH SYSTEM - SCOTT BUTLER, KIMBERLY MABENP2 OF WNY - MARISSA SLEVARTHE CHAUTAUQUA CENTER - MIKE PEASEWCA HOSPITAL - TONI DEANGELO, LINDA JOHNSON, ANDY O'BRIEN, MARY BOSEKWESTFIELD MEMORIAL HOSPITAL - PATTY BALLMAN, KIM GREINERYMCA OF JAMESTOWN - MEG PICKARD BROOKS MEMORIAL HOSPITAL PART V, SECTION B, LINE 6A: TLC HEALTH NETWORKWCA HOSPITALWESTFIELD MEMORIAL HOSPITAL BROOKS MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: CHAUTAUQUA COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICESCHAUTAUQUA COUNTY HEALTH NETWORK (CCHN)P2 COLLABORATIVE OF WNYTHE CHAUTAUQUA CENTERCHAUTAUQUA COUNTY DEPARTMENT OF MENTAL HYGIENE BROOKS MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: NEEDS IDENTIFIED:1. PREVENT CHRONIC DISEASE; FOCUS - OBESITY IN ADULTS & CHILDREN.BROOKS MEMORIAL HOSPITAL'S DIETITIAN TAKES REFERRALS FROM PHYSICIANS, PROVIDING A FULL ASSESSMENT AND NUTRITIONAL EDUCATION TO OUTPATIENTS. THE DIETITIAN ALSO ATTENDS LOCAL HEALTH FAIRS AND PROVIDES NUTRITIONAL INFORMATION. THE HOSPITAL'S DIABETIC COUNSELOR FACILITATES A MONTHLY SUPPORT GROUP FOR DIABETICS.2. PROMOTE HEALTH WOMEN, INFANTS & CHILDREN; FOCUS - PRECONCEPTION AND REPRODUCTIVE HEALTH, AND MATERNAL AND INFANT HEALTH.THE BROOKS MEMORIAL HOSPITAL DIRECTOR OF OBSTETRICS CONDUCTS EXPECTANT PARENT CLASSES 4 TIMES A YEAR. SHE IS ALSO A CERTIFIED LACTATION COUNSELOR AND WORKS WITH THE COUNTY TO PROMOTE BREAST FEEDING. THE HOSPITAL HAS WORKED WITH NEW YORK STATE TO ENSURE HEARING SCREENINGS ARE DONE ON NEWBORNS, AND WAS RECOGNIZED FOR THE HIGH COMPLETION PERCENTAGE FOR THESE TESTS.3. PROMOTE MENTAL HEALTH AND PREVENT SUBSTANCE ABUSE; FOCUS - STRENGTHEN INFRASTRUCTURE ACROSS SYSTEMS.BROOKS MEMORIAL HOSPITAL HAS WORKED WITH CHAUTAUQUA ALCOHOLISM & SUBSTANCE ABUSE COUNCIL WITH APPLICATION FOR A GRANT TO TREAT SUBSTANCE ABUSE ON MENTAL HEALTH DIAGNOSES SEEN IN THE EMERGENCY ROOM. PATIENTS SEEN IN THE ER RECEIVE REFERRALS FOR FURTHER TREATMENT/COUNSELING. BROOKS MEMORIAL HOSPITAL PART V, SECTION B, LINE 19D: USE AN EARLY OUT THIRD PARTY TO CONTACT PATIENTS BY TELEPHONE AFTER ACCOUNTS ARE OVER 60 DAYS. ACCOUNTS ARE RETURNED TO THE HOSPITAL FOR DISPOSITION. BROOKS MEMORIAL HOSPITAL PART V, SECTION B, LINE 22D: THE MAXIMUM AMOUNT A PATIENT WILL BE CHARGED IS DETERMINED BASED ON THE HIGHER OF: MEDICARE RATES, MEDICAID RATES, OR RATES PAID BY THE HIGHEST VOLUME COMMERCIAL PAYOR BASED ON THE TYPE OF SERVICE PROVIDED. BROOKS MEMORIAL HOSPITAL PART V, SECTION B, LINE 24: PATIENTS WHO DO NOT APPLY FOR FINANCIAL ASSISTANCE OR REQUEST A REDUCTION TO THEIR BILL WILL BE CHARGED THE GROSS CHARGE FOR SERVICES PROVIDED. PART I, LINE 3C: THE USE OF SIGNIFICANT ASSETS TO BE TAKEN INTO ACCOUNT IN DETERMINING THE AMOUNT A PATIENT WILL PAY FOR MEDICAL SERVICES WILL APPLY ONLY TO THOSE PATIENTS WHOSE INCOME EXCEEDS 150% OF THE FEDERAL POVERTY GUIDELINES. THE NEXT STEP WILL BE TO DETERMINE IF A PATIENT HAS ANY AVAILABLE ASSETS, WHICH CAN BE USED TO SATISFY OUTSTANDING MEDICAL EXPENSES. THOSE TOTAL AVAILABLE ASSETS WILL INCLUDE, BUT NOT BE LIMITED TO, ASSETS IDENTIFIED AS CASH AND THOSE CONVERTIBLE TO CASH AND UNNECESSARY FOR THE PATIENT'S NORMAL LIVING EXPENSES. THE PATIENT'S TOTAL ASSETS TO BE CONSIDERED FOR PAYMENT WILL BE EXPECTED TO BE APPLIED TO THE MEDICAL SERVICES BASED ON THE TABLE THAT FOLLOWS THIS PARAGRAPH. THE REMAINING MEDICAL EXPENSE BALANCE WILL BE DISCOUNTED ACCORDING TO THE PATIENT'S ELIGIBILITY DETERMINATION IN SECTION (II). IF THE % OF THE FEDERAL POVERTY INCOME GUIDELINES IS 300% OR LESS THE MAXIMUM AMOUNT OF ASSETS TO BE USED FOR THE PAYMENT OF AN INDIVIDUAL ACCOUNT WILL NOT EXCEED THE "HIGHEST VOLUME PAYOR", AS DEFINED BY NEW YORK STATE PUBLIC HEALTH LAWS OF 2006 CHAPTER 57 SECTION 2807-K SUBDIVISION 9-A, AMOUNT FOR THAT ACCOUNT. ASSETS NOT INCLUDED IN THIS DETERMINATION WILL BE THE: "PATIENT'S" RESIDENCE, ASSETS HELD IN A TAX-DEFERRED OR COMPARABLE RETIREMENT SAVINGS ACCOUNT, COLLEGE SAVINGS ACCOUNTS, OR VEHICLES USED REGULARLY BY A PATIENT OR IMMEDIATE FAMILY MEMBERS. ASSETS NOT UNDER CONSIDERATION AS A SOURCE OF AVAILABLE ASSETS, SUCH AS, THE PRIMARY RESIDENCE ARE SUBJECT TO ANY LEGAL ACTION THAT DOES NOT FORCE THE SALE OR FORECLOSURE OF SUCH PROPERTIES. THE PATIENT'S TOTAL AVAILABLE ASSETS WILL BE REDUCED ACCORDING TO THE NEW YORK STATE ASSET LEVELS TO ARRIVE AT THE TOTAL ASSETS TO BE CONSIDERED.NEW YORK STATE GUIDELINES (THESE LEVELS ARE PUBLISHED BY NYS ANNUALLY)HOUSEHOLD SIZE ASSET LEVELS1 $11,7702 $15,9303 $20,0904 $24,2505 $28,4106 $32,5707 $36,7308 $40,8909 $45,05010 $49,210EACH ADDITIONAL PERSON $ 4,160BROOKS MEMORIAL HOSPITALTOTAL ASSETS CONSIDERED EXPECTED % OF ASSETS TO BE USED FOR PAYMENT < $ 1,000 10%$ 1,000 - $ 2,000 15%$ 2,001 - $ 3,000 20%$ 3,000 - $ 5,000 25%$ 5,001 - $ 7,500 30%$ 7,501 - $10,000 40%$10,001 - $25,000 50%$25,001 - NO LIMIT 60%THE MAXIMUM CHARGE AMOUNT AS DESCRIBED ABOVE WILL BE ADJUSTED ACCORDING TO THE FEDERAL POVERTY GUIDELINES INCOME LEVELS AS FOLLOWS:- 0% TO 100% OF THE FPL WILL BE REDUCED TO THE LESSER OF THE "NOMINAL PAYMENT AMOUNT OR THE MAXIMUM CHARGE AMOUNT.- 101% TO 150% OF THE FPL WILL BE REDUCED ON A SLIDING SCALE NOT TO EXCEED 20% OF THE MAXIMUM CHARGE AMOUNT, BUT NOT LESS THAN THE "NOMINAL PAYMENT AMOUNT" UNLESS THE MAXIMUM CHARGE AMOUNT IS LOWER.- 151% TO 250% OF THE FPL WILL BE REDUCED ON A SLIDING SCALE INCREASING FROM THE 20% TO 100% OF THE MAXIMUM CHARGE AMOUNT, BUT NOT LESS THAN THE "NOMINAL PAYMENT AMOUNT" UNLESS THE MAXIMUM CHARGE AMOUNT IS LOWER.- 251% TO 300% OF THE FPL THE CHARGE WILL BE EQUAL TO THE MAXIMUM CHARGE AMOUNT.- 301% TO UNLIMITED % WILL RESULT IN THE BROOKS MEMORIAL HOSPITAL STANDARD CHARGE AMOUNT FOR THAT SERVICE REDUCED BY 25%, BUT NOT LESS THAN THE MAXIMUM CHARGE AMOUNT FOR THAT TYPE OF SERVICE. PART I, LINE 7: RCC USED AS CALCULATED IN WORKSHEET 2. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 1,685,242. PART II, COMMUNITY BUILDING ACTIVITIES: BROOKS MEMORIAL HOSPITAL ACTIVELY PARTICIPATES IN LOCAL INITIATIVES INVOLVING THE RURAL HEALTH CONSORTIUM AND CHAUTAUQUA COUNTY HEALTH NETWORK. AS A PARTICIPANT IN THESE ORGANIZATIONS THE HOSPITAL IS ABLE TO ASSESS NEED, IMPLEMENT PROGRAMS AND INTERVENTIONS AND FACILITATE COMMUNITY BUILDING AROUND EMERGING HEALTH RELATED ISSUES TO IMPROVE HEALTH OUTCOMES FOR LOCAL AND UNDERSERVED COMMUNITIES. PART III, LINE 2: RCC USED AS CALCULATED IN WORKSHEET 2 FOR PART III, LINE 2 TO CALCULATE BAD DEBT COST. PATIENT PAYMENTS AND DISCOUNTS ARE NOT COUNTED TOWARD BAD DEBT IF POSTED PRIOR TO AN ACCOUNT BEING TRANSFERRED TO BAD DEBT. ONCE IN BAD DEBT, PATIENT PAYMENTS AND DISCOUNTS ARE USED TO REDUCE BAD DEBT. PART III, LINE 3: THERE WERE NO PATIENTS TURNED OVER TO BAD DEBT WHO QUALIFIED FOR CHARITY CARE.PATIENTS ELIGIBLE FOR CHARITY CARE WHO OWED BALANCES WERE NOT TURNED OVER TO BAD DEBT EVEN THOUGH THEY DID NOT PAY THEIR BALANCES. BAD DEBTS ARE INCLUDED AS A COMMUNITY BENEFIT COST BECAUSE A HIGH PROPORTION OF BAD DEBT DERIVES FROM PATIENTS WHO ARE NOT ABLE TO PAY FOR SERVICES AND THAT THE PROVISION OF SUCH SERVICES AT A LOSS CONSTITUTES A FORM OF COMMUNITY BENEFIT. IT IS DIFFICULT FOR A HOSPITAL TO DISTINGUISH THESE PATIENTS WHO FAIL TO RESPOND TO ANY COMMUNICATION AND/OR EFFORT TO DETERMINE ELIGIBILITY FOR CHARITY CARE. PART III, LINE 4: FOOTNOTE TO AUDITED FINANCIAL STATEMENTS: PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF PATIENT ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO HAVE FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 8: THE ALLOWABLE MEDICARE COSTS WERE TAKEN DIRECTLY FROM COST REPORT WORKSHEET D. IRS REV. RUL. 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENT HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THIS IMPLIES THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT.IN THIS COMMUNITY, MEDICARE IS THE LARGEST PAYER, AND THE HOSPITAL MUST ACCEPT THESE PATIENTS REGARDLESS OF WHETHER THEY MAKE A SURPLUS OR DEFICIT FROM PROVIDING SUCH SERVICES. IF THE MEDICARE PARTICIPATION IS PREMISED ON THIS FACT, THEN PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES WHICH IS A COMMUNITY BENEFIT.THERE ARE A NUMBER OF LOW-INCOME CONSUMERS RECEIVING MEDICARE.THE ELDERLY ARE OFTEN AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE SERVICES, CMS WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY.MEDICARE PAYMENT ANOMALIES MAY BE PRESENT IN SOME STATES SO EVEN VERY EFFICIENT HOSPITALS ARE UNABLE TO AVOID LOSSES. THUS, LOSSES MAY NOT BE INDICATIVE OF INEFFICIENCY BUT RATHER PROVISION OF A COMMUNITY BENEFIT. PART III, LINE 9B: A PATIENT WHO IS APPROVED FOR FINANCIAL ASSISTANCE IS ELIGIBLE FOR A PERIOD OF 6 MONTHS FROM THE DATE OF NOTIFICATION. ALL ACCOUNTS FOR THE PATIENT, COVERED BY THE APPLICATION AND DURING THE ELIGIBILITY PERIOD, WILL BE ADJUSTED BASED ON THE LEVEL OF FINANCIAL ASSISTANCE AWARDED. ANY PAYMENTS RECEIVED FROM THE PATIENT ON ACCOUNTS COVERED BY THE APPLICATION OR DURING THE ELIGIBILITY PERIOD WILL BE REFUNDED BASED ON THE LEVEL OF FINANCIAL ASSISTANCE AWARDED. PART VI, LINE 2: THE HOSPITAL PARTICIPATES WITH OTHER HEALTHCARE PROVIDERS AND INTERESTED PARTIES IN THE CHAUTAUQUA COUNTY COMMUNITY HEALTH PLANNING TEAM (CCCHPT), THE CHAUTAUQUA COUNTY HEALTH NETWORK AND THE CHAUTAUQUA HEALTH ACTION TEAM TO ASSESS THE NEED REGIONALLY. IN 2013 AN EXTENSIVE COMMUNITY HEALTH NEEDS ASSESSMENT WAS PERFORMED. SEE SECTION V, PARTS B AND C FOR ADDITIONAL INFORMATION ON THE CHNA.THE HOSPITAL ALSO UTILIZES PATIENT SATISFACTION SURVEY TOOLS AND LOCAL PUBLIC INFORMATION PERTAINING TO POPULATION CHARACTERISTICS AND HEALTH STATUS. PART VI, LINE 3: 1. INFORMATION ABOUT THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY IS PROVIDED UPON ADMISSION, IS POSTED ON THE HOSPITAL WEBSITE, THROUGHOUT THE HOSPITAL, AND PROVIDED THROUGH THE CHAUTAUQUA COUNTY HEALTH NETWORK. STAFF IN THE HOSPITAL HAVE ALSO BEEN IN-SERVICED ABOUT THE FINANCIAL ASSISTANCE PROGRAM SO THAT THEY CAN PROVIDE INFORMATION TO PATIENTS AS WELL.2. BROOKS MEMORIAL HOSPITAL HAS ARRANGED WITH AN AGENCY TO FACILITATE ENROLLING IN THE MEDICAID PROGRAM. THE AGENCY WILL PROVIDE EDUCATION, ASSISTANCE IN COMPLETING THE APPLICATION, AND REPRESENT THE PATIENT AT THE MEDICAID AGENCY. IN ADDITION, THE AGENCY ASSISTS WITH ENROLLMENT THROUGH THE STATE'S INSURANCE EXCHANGE SITE.3. FINANCIAL ASSISTANCE PROGRAM - BROOKS MEMORIAL HOSPITAL CONTINUES TO EDUCATE AND PROVIDE FINANCIAL ASSISTANCE OPTIONS FOR THOSE THAT ARE UNINSURED OR UNABLE TO PAY. IN ADDITION TO THE HOSPITAL'S OWN FINANCIAL ASSISTANCE POLICY BROCHURE, BUSINESS OFFICE PERSONNEL WILL CONTINUE TO DISTRIBUTE BROCHURES DEVELOPED BY CCHN TO ASSIST THE UNINSURED OR UNDERINSURED TO FIND AFFORDABLE HEALTHCARE. PATIENT FINANCIAL SERVICES STAFF WILL CONTINUE TO BE EDUCATED REGARDING ALL AVAILABLE ASSISTANCE IN OBTAINING HEALTH INSURANCE. PART VI, LINE 4: THE HOSPITAL'S PRIMARY SERVICE AREA IS NORTHERN CHAUTAUQUA COUNTY IN NEW YORK AND INCLUDES THE CITY & TOWN OF DUNKIRK, VILLAGES OF FREDONIA, BROCTON, CASSADAGA, FORESTVILLE, AND THE TOWNS OF POMFRET, PORTLAND, STOCKTON, SHERIDAN, AND ARKWRIGHT. THE SECONDARY SERVICE AREA INCLUDES THE TOWNS OF HANOVER, CHERRY CREEK, VILLENOVA AND WESTFIELD. 44% OF THE POPULATION RESIDES IN RURAL AREAS. IN THE COUNTY, 18.5% OF THE POPULATION IS 65 AND OLDER. THE AFRICAN AMERICAN POPULATION IS 2.7% OF TOTAL POPULATION AND THE HISPANIC POPULATION IS 7.2% OF THE TOTAL POPULATION. 7.6% OF THE POPULATION'S PRIMARY LANGUAGE IS NOT ENGLISH. PERSONS UNDER THE AGE OF 65 WITHOUT HEALTH INSURANCE COMPRISE 7.9% OF THE TOTAL POPULATION. PART VI, LINE 5: THE BOARD OF TRUSTEES IS A COMMUNITY BOARD, MADE UP ENTIRELY OF CIVIC AND COMMUNITY LEADERS, WHO SERVE VOLUNTARILY. THE BOARD APPOINTS THE CEO, APPROVES BUDGETS, DEVELOPS STRATEGIC PLANS AND PROVIDES OVERSIGHT FOR THE HOSPITAL IN GENERAL. POTENTIAL CONFLICT OF INTEREST BETWEEN BOARD MEMBERS AND THE HOSPITAL ARE REVIEWED ANNUALLY.THE HOSPITAL'S MEDICAL STAFF IS COMPRISED OF QUALIFIED PHYSICIANS FROM WITHIN THE COMMUNITY. THE HOSPITAL CONTRACTS DIRECTLY ONLY FOR EMERGENCY ROOM PHYSICIANS, A PATHOLOGIST, A RADIOLOGIST, AN ANESTHESIOLOGIST AND HOSPITALIST PHYSICIANS, BUT DOES NOT EMPLOY ANY PHYSICIANS.THE HOSPITAL OPERATES A FULL-TIME EMERGENCY ROOM OPEN TO ALL PATIENTS, REGARDLESS OF THEIR ABILITY TO PAY. PATIENTS COME TO THE EMERGENCY ROOM BY THEIR OWN TRANSPORTATION OR BY AMBULANCE FROM EITHER A LOCAL FIRE DEPARTMENT OR AN INDEPENDENT AMBULANCE BUSINESS THAT SERVES THE ENTIRE COUNTY. IN ORDER TO ENSURE 24 HOUR PHYSICIAN COVERAGE IN THE ER, THE HOSPITAL PROVIDES A SUBSIDY TO THE ER PHYSICIAN GROUP. NON EMERGENCY CARE IS PROVIDED BASED UPON PHYSICIAN ORDERS TO ALL PATIENTS, REGARDLESS OF THEIR ABILITY TO PAY.SURPLUS FUNDS ARE INVESTED IN MEDICAL EQUIPMENT UPGRADES AND NEW TECHNOLOGIES THROUGH A CAPITAL BUDGET PROCESS. THERE ARE NO "OWNERS OR STOCKHOLDERS SO NO SURPLUS FUNDS ARE PAID OUT TO OWNERS OR STOCKHOLDERS.THE HOSPITAL WORKS TO ENSURE AN ADEQUATE BLOOD SUPPLY IN THE COMMUNITY AND SURROUNDING AREAS BY HOSTING MONTHLY BLOOD DRIVES IN COOPERATION WITH THE COMMUNITY BLOOD BANK.SOME YEARS AGO THE HOSPITAL IDENTIFIED THE NEED FOR DIALYSIS IN THE COMMUNITY. IN 2009 THE HOSPITAL REPLACED THE EXISTING 10 STATIONS AND ADDED 4 ADDITIONAL STATIONS AS THE TARGETED POPULATION CONTINUES TO GROW. THIS SERVICE OPERATES AT A LOSS, YET THE HOSPITAL CONTINUES TO PROVIDE THIS SERVICE. THE HOSPITAL STRIVES TO IMPROVE THE QUALITY OF PATIENT CARE BY A VARIETY OF ACCREDITATIONS, SURVEYS AND BENCHMARKS INCLUDING:THE HOSPITAL IS ACCREDITED THROUGH DNV, THE AMERICAN COLLEGE OF RADIOLOGY FOR MAMMOGRAPHY, MRI, CT SCAN, NUCLEAR MEDICINE AND ULTRASOUND, AND THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION FOR THE CARDIAC REHABILITATION DEPARTMENT. IN 2014, THE HOSPITAL RECEIVED ACCREDITATION FOR THE SLEEP LAB. THE HOSPITAL TAKES A PROACTIVE APPROACH TO THE PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS, INCLUDING:- INSTITUTION WIDE PROGRAM TO PROMOTE EFFECTIVE HAND WASHING- INSTITUTION WIDE PROGRAM TO REDUCE CATHETER RELATED URINARY TRACT INFECTIONS- INSTITUTION WIDE PROGRAM TO REDUCE CENTRAL LINE INFECTIONS- INSTITUTION WIDE PROGRAM TO REDUCE VENTILATOR-ASSOCIATED INFECTIONS THE HOSPITAL MEETS OR EXCEEDS NATIONAL AND STATE BENCHMARKS FOR THE USE OF ANTIBIOTICS RELATED TO SURGERY.THE HOSPITAL EXCEEDS NATIONAL AND STATE BENCHMARKS FOR THE PREVENTION OF BLOOD CLOTS AFTER SURGERY.THE HOSPITAL UTILIZES BAR CODE MEDICATION ADMINISTRATION TO REDUCE/ELIMINATE MEDICATION ERRORS.THE HOSPITAL USES PATIENT SURVEYS THROUGH BOTH PRESS GANEY AND HCAHPS. AREAS THAT MEASURED BELOW AVERAGE ARE REVIEWED WEEKLY AND BEING ADDRESSED THROUGH:- HOURLY ROUNDING- PRE-OPERATIVE JOINT EDUCATION CLASSES- SURGICAL AMBASSADOR PROGRAM- POST DISCHARGE CALLS TO ASSURE PATIENTS UNDERSTAND THEIR MEDICATION INSTRUCTIONS- CUSTOMER SERVICE TRAINING PART VI, LINE 6: BROOKS MEMORIAL HOSPITAL IS THE ONLY HOSPITAL WITHIN LAKE ERIE REGIONAL HEALTH SYSTEM BUT WORKS CLOSELY WITH COMMUNITY ORGANIZATIONS BOTH IN DETERMINING THE HEALTH NEEDS OF THE COMMUNITIES SERVED AS WELL AS DECIDING HOW BEST TO MEET THESE NEEDS. OFFICIALS FROM THE HOSPITAL HAVE BEEN SELECTED TO WORK ON VARIOUS PROJECTS TO FURTHER THIS CAUSE, INCLUDING RESEARCING COMMUNITY HEALTH NEEDS, WORKING WITH LOCAL HEALTH ORGANIZATIONS THROUGHOUT THE COUNTY AND BEYOND, DEVELOPING A FREE COMMUNITY WELLNESS PROGRAM CALLED HEALTHQUEST WNY, PROMOTING HEALTHQUEST WNY AND OTHER HEALTH RELATED EVENTS, DEVELOPING AND PROMOTING HEALTHY LIFESTYLE CLASSES AT OUR FACILITIES, REACHING OUT TO IDENTIFIED POPULATIONS OF NEED, AND MORE. PART VI, LINE 7, REPORTS FILED WITH STATES NY X X 1 0 0 0 0 0 0 0 0 JEFFREY MORGAN VP FINANCE/CFO 241260 0 0 0 0 0 12137 0 6609 0 260006 0 0 0 A JACK DAVIS VP ADMINISTRATIVE SERVICES 170261 0 0 0 0 0 8513 0 823 0 179597 0 0 0 JODI WITHERELL VP QUALITY/SAFETY 163684 0 0 0 0 0 8403 0 9356 0 181443 0 0 0 JONATHAN LAWRENCE FORMER CEO 130079 0 0 0 0 0 6355 0 242 0 136676 0 0 0 PART I, LINE 4A SEVERANCE PAYMENTS TO JONATHAN LAWRENCE TOTALED $128,484 IN 2015. PART III, LINE I MISSION TO SERVE OUR COMMUNITIES BY PROVIDING ACCESS TO HIGH QUALITY PERSONALIZED HEALTHCARE VISION OUR VISION IS TO BE A MODEL HEALTH CENTER BY CONTINUALLY LEARNING AND PROVIDING EXTRAORDINARY CARE IN ALL ITS DIMENSIONS: CLINICAL EXCELLENCE: WE WILL DELIVER THE BEST CLINICAL CARE IN A CONSISTENT, INTEGRATED WAY. PATIENT ENGAGEMENT: WE WILL PROVIDE A COMPASSIONATE HEALING EXPERIENCE, AND WE WILL ENGAGE PATIENTS IN DECISIONS ABOUT THEIR HEALTH AND CARE. OPERATIONAL EFFECTIVENESS: WE WILL BE WISE AND CAREFUL STEWARDS OF OUR RESOURCES TO ENABLE EXTRAORDINARY CARE. PHYSICIAN ENGAGEMENT: WE WILL CREATE SYSTEMS AND PROCESSES THAT HELP OUR PHYSICIANS BEST SERVE THEIR PATIENTS. COMMUNITY STEWARDSHIP: WE ARE COMMITTED TO SERVING THE DIVERSE NEEDS OF THE REGION, AND TO PROVIDE GENERALLY AVAILABLE MEDICAL SERVICES TO ALL RESIDENTS, REGARDLESS OF ABILITY TO PAY. EMPLOYEE ENGAGEMENT: WE VALUE OUR EMPLOYEES AS OUR MOST IMPORTANT RESOURCE. VALUES - I CARE INTEGRITY OUR ACTIONS ARE GUIDED BY OUR ETHICAL COMMITMENTS - IN PUBLIC INTERACTIONS AND PRIVATE ACTIONS, WE DEDICATE OURSELVES TO SERVICE IN THE BEST INTERESTS OF OUR PATIENTS, THEIR FAMILIES, OUR HOSPITAL AND OUR COMMUNITY. - WE FOLLOW THROUGH ON OUR COMMITMENTS, HOLDING OURSELVES ACCOUNTABLE TO FULFILL OUR PROFESSIONAL OBLIGATIONS. - WHEN WE RECOGNIZE SOMETHING SEEMS WRONG, INAPPROPRIATE OR INCONSISTENT WITH OUR VALUES OR STANDARDS, WE PROACTIVELY SPEAK UP AND TAKE POSITIVE ACTION. - WE ACT WITH OPENNESS, HONESTY, TRANSPARENCY AND TRUSTWORTHINESS IN OUR COMMUNICATION. -AT ALL TIMES WE RESPECT THE DIGNITY, PRIVACY AND CONFIDENTIALITY OF THOSE WE SERVE. COMPASSION WE PROVIDE EXCELLENCE WITH PERSONAL KINDNESS - WITH UNDERSTANDING AND EMPATHY, WE ANTICIPATE THE NEEDS OF OTHERS AND ACT TO APPROPRIATELY AND MEANINGFULLY MEET THESE NEEDS. - BY ACTIVELY LISTENING TO THE PERSPECTIVES, VALUES AND NEEDS OF OTHERS, WE ACT TO BUILD BRIDGES TOWARD WHOLENESS. - OUR INTERACTIONS ARE CHARACTERIZED BY RESPECT, COURTESY, WARMTH AND PROFESSIONAL DIGNITY. - WE MAINTAIN AN ENGAGED, FOCUSED AND PERSONAL PRESENCE WHILE IN SERVICE TO OTHERS, CREATING AND SUSTAINING A THERAPEUTIC MILIEU ACCOUNTABILITY WE TAKE RESPONSIBILITY FOR PERSONAL AND TEAM ACTIONS - WE FULLY ADOPT AND EMBRACE OUR CORE PROFESSIONAL IDENTITY AS THOSE WHOSE TALENTS ARE PLACED IN THE SERVICE OF OTHERS FOR THEIR BENEFIT. - IN ALL OUR INTERACTIONS WE DEMONSTRATE THE HIGHEST PROFESSIONAL STANDARDS OF ETHICS, KNOWLEDGE, SKILL AND COMPETENCE IN DECISION-MAKING AND WORK PERFORMANCE. - IN OUR APPEARANCE, DEMEANOR AND DEPORTMENT WE CONTINUOUSLY SEEK TO CONVEY A PROFESSIONAL IMAGE. - WE APPROACH CHALLENGES IN A MANNER THAT REFLECTS PROFESSIONAL MATURITY, CONFIDENCE AND RESPECT. RESPECT WE ADVOCATE FOR THE DIGNITY OF OTHERS - IN OUR BEHAVIOR TOWARD OTHERS, WE DEMONSTRATE RESPECT FOR THE PERSONAL AUTONOMY, INTRINSIC DIGNITY AND WORTH, AND INDIVIDUAL UNIQUENESS OF EACH PERSON WE SERVE, AND THOSE WITH WHOM WE SERVE. - WE VALUE THE RICH DIVERSITY OF PERSONAL EXPERIENCE, CULTURAL INSIGHT, PROFESSIONAL IDENTITY AND TRAINING IN ACHIEVING COLLABORATIVE GOALS. - WE DEMONSTRATE OUR CONSIDERATION FOR OTHERS BY REGARDING WITH EMPATHY THE FEELINGS AND NEEDS OF OTHERS, AND REGARDING WITH INSIGHT THE EFFECT ON OTHERS OF OUR OWN BEHAVIOR. - WE ACTIVELY SEEK OUT OPPORTUNITIES TO DEMONSTRATE OUR REGARD AND APPRECIATION FOR OTHERS. EXCELLENCE - WE CONTINUOUSLY CHALLENGE THE STATUS QUO IN THE RELENTLESS PURSUIT OF EXCELLENCE. - WE UTILIZE QUANTITATIVE AND QUALITATIVE INFORMATION TO FORM THE BASIS FOR MEASURABLE AND DEMONSTRABLE IMPROVEMENTS IN OUTCOMES. - EACH OF US DEMONSTRATES A PERSONAL COMMITMENT TO THE HIGHEST STANDARDS OF SAFETY, QUALITY AND SERVICE. - INDIVIDUALLY, AND AS HIGH PERFORMING TEAMS, WE CONSCIENTIOUSLY WORK TO BETTER OUR BEST ON A DAILY BASIS. - WE ACTIVELY EMBRACE CHANGE IN THE CONTINUOUS PURSUIT OF INNOVATION AND SUPERIOR CARE. FORM 990, PART VI, SECTION A, LINE 6 LAKE ERIE REGIONAL HEALTH SYSTEM OF NEW YORK IS THE SOLE CORPORATE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B THE DECISIONS OF THE GOVERNING BODY ARE SUBJECT TO APPROVAL OF BOARD MEMBERS. FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS PREPARED AND REVIEWED BY VARIOUS INDIVIDUALS WITHIN MANAGEMENT AND PROVIDED TO THE GOVERNING BODY PREVIOUS TO ITS FILING WHEN TIME ALLOWS OR AT ITS NEXT MEETING WHEN TIME DOES NOT PERMIT REVIEW PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C DEPARTMENT MANAGERS, ADMINISTRATION, BOARD MEMBERS, AND MATERIAL MANAGEMENT EMPLOYEES SIGN A CONFLICT OF INTEREST STATEMENT ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION B, LINE 15 THE PRESIDENT/CEO'S COMPENSATION IS REVIEWED AND APPROVED BY THE EXECUTIVE COMMITTEE OF THE BOARD. WAGES AND INCREASES ARE COMPARED TO INDUSTRY STANDARDS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC ON THE HOSPITAL WEBSITE (WWW.BROOKSMEMORIAL.ORG) AND CERTAIN DOCUMENTS ARE AVAILABLE AT THE HOSPITAL AND AT PHYSICIANS' OFFICES. FORM 990, PART XI, LINE 9: NET CHANGE IN FUNDS HELD IN TRUST -34,735. PENSION LIABILITY ADJUSTMENT -1,430,174. CONTRIBUTIONS TO AFFILIATES - ESTIMATED ADVANCES ALLOWANCES -2,193,275. FORM 990, PART XII, LINE 2C: THE BOARD OF TRUSTEES ASSUME RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND THE SELECTION OF AN INDEPENDENT ACCOUNTANT. LAKE ERIE REGIONAL HEALTH SYSTEM OF NEW YORK 529 CENTRAL AVENUE DUNKIRK NY 14048 262778107 SOLE MEMBER OF HOSPITAL NY 501(C)(3) LINE 11C, III-FI N/A 0 LAKE ERIE MEDICAL SERVICES PC 529 CENTRAL AVENUE DUNKIRK NY 14048 452832259 PHYSICIAN GROUP NY LAKE ERIE REGIONAL HEALTH SYSTEM OF NEW YORK C 0 0 0 0 1 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0