2014-11-06T11:50:02-06:00 2013-12-31 160765486 LUMSDEN & MCCORMICK LLP 369 FRANKLIN STREET BUFFALO NY 14202 990 2013-01-01 160743301 BROOKS MEMORIAL HOSPITAL BROO 7163661111 529 CENTRAL AVENUE DUNKIRK NY 14048 J GARY RHODES INTERIM CEO 7163661111 2014-10-30 1 MICHAEL J GRIMALDI P01295846 7168563300 2013 2015-11-30 17:44:51Z J GARY RHODES 529 CENTRAL AVENUE DUNKIRK NY 14048 51003323 0 X WWW.LAKEERIEHEALTH.ORG X 1898 NY AN ACUTE CARE HOSPITAL SERVING PRIMARILY RESIDENTS OF NORTHERN CHAUTAUQUA COUNTY. 13 10 513 34 -664 -914 211447 286526 41280676 40499712 316523 1113992 1264094 1710138 43072740 43610368 0 0 0 0 25527393 25050563 0 0 0 19879795 20313989 45407188 45364552 -2334448 -1754184 33294269 28222556 11084059 11113695 22210210 17108861 SEE SCHEDULE O BELOW FOR FULL MISSION STATEMENT. 0 0 17154478 16059598 NURSING SERVICES - PROVISION OF DAILY CARE INCLUDING INPATIENT AND OUTPATIENT SERVICES WITHIN THE INSTITUTION 17630574 24440114 OTHER PROFESSIONAL SERVICES - ANCILLARY SERVICES PROVIDED WITHIN THE FACILITY INCLUDING LABORATORY, RADIOLOGY, INHALATION THERAPY, ETC. 34785052 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 1 0 0 0 0 0 0 1 0 0 0 1 61 0 1 513 1 0 0 0 0 0 0 0 0 0 0 X 13 10 0 0 0 0 1 0 1 1 1 0 0 0 1 1 1 1 1 1 1 0 NY X J GARY RHODES 7163661111 529 CENTRAL AVENUE DUNKIRK NY 14048 CHRISTOPHER LANSKI CHAIRMAN 2.00 X X 0 0 0 TIMOTHY COOPER CHAIRMAN ELECT 2.00 X X 0 0 0 ANDREW BURR SECRETARY 2.00 X X 0 0 0 LOUIS DIPALMA TREASURER 2.00 X X 0 0 0 EUGENE BAILEN MEMBER 2.00 X 0 0 0 WALTER GOTOWKA MEMBER 2.00 X 0 0 0 RICHARD MILAZZO MD MEMBER 2.00 X 0 0 11231 DR VIRGINIA S HORVATH MEMBER 2.00 X 0 0 0 THOMAS POSTLE MEMBER 2.00 X 0 0 0 JAMES WILD MD MEMBER 2.00 30.00 X 0 0 46125 VIRGINIA COOPER MEMBER 2.00 X 0 0 0 G JAY BISHOP MD MEMBER 2.00 X 4400 0 14894 SUSAN MCNAMARA PHD MEMBER 2.00 X 0 0 0 JONATHAN I LAWRENCE PRESIDENT AND CEO 20.00 20.00 X 213729 232877 39543 KENNETH D CRONE CFO 20.00 20.00 X 79167 79168 14746 JARROD JOHNSON COO 20.00 20.00 X 156622 14370 30987 A JACK DAVIS VP ADMIN SUPPORT SERVICES 20.00 20.00 X 64871 58854 5413 TERESA LARSON VP RISK MGMT/CORP COMPLIANCE 20.00 20.00 X 81708 47376 21693 SALLIE PIAZZA VP NURSING/DIRECTOR - QUALITY 20.00 20.00 X 83333 10464 19620 MARY STAPLES VP QA/RISK MANAGEMENT 20.00 20.00 X 78237 71316 8511 THOMAS EAST VP INFORMATION TECHNOLOGY 20.00 20.00 X 69717 74803 16400 JEFFREY MORGAN INTERIM CFO 20.00 20.00 X 161628 0 518 SCOTT BUTLER DIRECTOR, BUSINESS DEVELOPMENT 20.00 20.00 X 35262 35262 17176 1028674 624490 246857 3 0 1 0 DR JOHN OROSZ 3425 WEBSTER ROAD FREDONIA NY 14063 PATHOLOGIST/LAB MED DIRECTOR 230000 DR RAJIV PARIKH 1134 CENTRAL AVENUE DUNKIRK NY 14048 INPATIENT PEDIATRICIAN 110000 2 145136 141390 286526 PATIENT SERVICE REVENUE 621990 40499712 40499712 40499712 99313 99313 12983 0 12983 12983 12983 8406434 1200 7363553 29402 1042881 -28202 1014679 1014679 LAB SERVICES 900099 574710 574710 MEANINGFUL USE INCENTIVE 900099 440040 440040 MEALS ON WHEELS 900099 239838 239838 442567 -664 443231 1697155 43610368 40499712 -664 2824794 1170189 30525 1139664 18500430 15522077 2978353 1300637 882461 418176 2684971 1803625 881346 1394336 901988 492348 1280413 1280413 39527 39527 9994852 9057674 937178 745826 745826 601395 429784 171611 21759 21759 114254 63941 50313 8321 8321 2555396 2040983 514413 540774 399576 141198 PURCHASED SERVICES 1324602 921064 403538 PROVISION FOR BAD DEBTS 1068622 1068622 MEDICAL SPECIALIST FEES 950063 950063 CONTRACT LABOR 944955 704348 240607 123230 123230 45364552 34785052 10579500 0 896432 1116099 4590694 898597 4167073 4520831 1271967 1280579 366631 356150 50389052 40402387 11859047 9986665 6675341 5552887 1427234 1645716 2039850 2865032 33294269 28222556 4321521 5144795 312684 158900 6449854 5810000 11084059 11113695 X 20782976 15463145 670025 888507 757209 757209 22210210 17108861 33294269 28222556 X -1754184 183269 -3530434 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1427234 218482 1645716 1414171 13063 1427234 1412273 1898 1414171 1280118 132155 1412273 1066646 213472 1280118 0.54000 0.46000 1 0 401330 401330 10473923 8386527 2087396 1128665 775021 353644 38373550 31240839 7132711 11584 11584 9986665 FUNDS HELD IN TRUST 1645716 F 1645716 ADVANCES TO RELATED PARTIES 2865032 2865032 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 1877889 ACCRUED PENSION LIABILITY 3932111 5810000 X 42569948 -1068622 -1068622 43638570 -28202 -28202 43610368 44324132 28202 28202 44295930 1068622 1068622 45364552 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, 2010. PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS -1,068,622. PART XI, LINE 4B - OTHER ADJUSTMENTS: LOSS ON DISPOSAL OF PROPERTY AND EQUIPMENT -28,202. PART XII, LINE 2D - OTHER ADJUSTMENTS: LOSS ON DISPOSAL OF PROPERTY AND EQUIPMENT 28,202. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 1,068,622. 1 1 1 X 1 X 1 1 0 1 1 471659 39138 432521 0.00980 8453324 6878614 1574710 0.03550 172004 125704 46300 0.00100 9096987 7043456 2053531 0.04630 41767 41767 0.00090 25418 25418 0.00060 4281668 2609370 1672298 0.03780 50 50 0.00000 4348903 2609370 1739533 0.03930 13445890 9652826 3793064 0.08560 663 663 0.00000 737 737 0.00000 1400 1400 0 605169 6461129 6992274 -531145 X 1 1 1 1 BROOKS MEMORIAL HOSPITAL 529 CENTRAL AVENUE DUNKIRK NY 14048 X X X RENAL DIALYSIS BROOKS MEMORIAL HOSPITAL 1 1 X X X X X X X X X 13 1 1 1 X HTTP://WWW.CO.CHAUTAUQUA.NY.US/241/PUBLIC-HEAL X X X X X X X X 1 0 1 1 100.000000000000 1 300.000000000000 1 X X X X X X X 1 1 X X X X X X 1 X X 1 X X X X X 1 X X 0 1 BROOKS MEMORIAL HOSPITAL PART V, SECTION B, LINE 3: 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 4: BROOKS MEMORIAL HOSPITALTLC HEALTH NETWORKWCA HOSPITALWESTFIELD MEMORIAL HOSPITAL BROOKS MEMORIAL HOSPITAL PART V, SECTION B, LINE 17E: 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 20D: 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 22: 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 PATIENTS 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 NYS PUBLIC HEALTH LAW 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 WILL BE PUBLISHED BY NYS ANNUALLY)HOUSEHOLD SIZE ASSET LEVELS1 $ 9,6002 $14,1003 $16,2154 $18,3305 $20,4456 $22,5607 $24,6758 $26,7909 $28,90510 $31,020EACH ADDITIONAL PERSON $ 2,115BROOKS 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 6A: N/A PART I, LINE 7: RCC USED AS CALCULATED IN WORKSHEET 2. PART I, LINE 7G: PHYSICIAN CLINIC NOT INCLUDED IN SUBSIDIED SERVICES - N/A. 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 $ 1,068,622. PART II, COMMUNITY BUILDING ACTIVITIES: BROOKS MEMORIAL HOSPITAL ACTIVELY PARTICIPATES IN LOCAL INITIATIVES INVOLVING THE INDUSTRIAL DEVELOPMENT AGENCY AND THE COUNTY CHAMBER OF COMMERCE. AS A PARTICIPANT IN THESE ORGANIZATIONS THE HOSPITAL IS ABLE TO IMPACT ECONOMIC DEVELOPMENT BY IDENTIFYING HEALTH SERVICES AVAILABLE TO NEW INDUSTRY AND HEALTH SERVICES NEEDED IN THE BROADER COMMUNITY. 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.WHY BAD DEBT SHOULD BE INCLUDED AS A COMMUNITY BENEFIT COST: 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 CONSISTITUTES A FORM OF COMMUNITY BENEFIT. IT IS DIFFICULT FOR A HOSPITAL TO DISTINGUISH THESE PATIENTS WHO FAIL TO RESPOND TO ANY COMMUNICATION AND/OR EFFFORT TO DETERMINE ELIGIBILITY FOR COMMUNITY CARE. PART III, LINE 8: THE ALLOWABLE MEDICARE COST 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 A FACILITATED ENROLLER FROM FIDELIS IN THE HOSPITAL EVERY THURSDAY FROM 1-4 PM, OFFERING ASSISTANCE TO THE PUBLIC.3. 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.4. BROOKS MEMORIAL HOSPITAL CONTINUES TO MAKE REFERRALS TO THE GET COVERED HELPLINE.5. FINANCIAL ASSISTANCE PROGRAM - CONTINUE 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, 16.4% OF THE POPULATION IS 65 AND OLDER, AND WITH THE AVERAGE AGE AT 40.5. 3.6% ARE AFRICAN AMERICAN. THE HISPANIC POPULATION IS 5.9% 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 AND A PATHOLOGIST 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 INVEST IN IT.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. 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 IMPLEMENTED 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: ALL OF THE HOSPITALS AND FACILITIES WITHIN LAKE ERIE REGIONAL HEALTH SYSTEM WORK CLOSELY TOGETHER BOTH IN DETERMINING THE HEALTH NEEDS OF THE COMMUNITIES SERVED AND DECIDING HOW BEST TO MEET THOSE NEEDS. OFFICIALS FROM BOTH HOSPITALS HAVE BEEN SELECTED TO WORK TOGETHER ON VARIOUS PROJECTS TO FURTHER THIS CAUSE, INCLUDING RESEARCHING COMMUNITY HEALTH NEEDS, WORKING WITH LOCAL HEALTH ORGANIZATIONS THROUGHOUT THE COUNTY AND BEYOND, DELEVELOPING A FREE COMMUNITY WELLNESS PROGRAM CALLED HEALTHQUEST WNY, PROMOTING HEALTHQUEST WNY AND OTHER HEALTH RELATED EVENTS, DEVELOPING AND PROMOTING HEALTHY LIFESTYLE CLASSES AT EACH OF OUR FACILITIES, REACHING OUT TO IDENTIFIED POPULATIONS OF NEED, AND MORE. THIS ALLOWS THE FACILITIES WITHIN THE SYSTEM TO MORE EVENLY SHARE THE BURDEN OF PROVIDING SUCH INFORMATION AND SERVICES WHILE ALSO ALLOWING US TO EXTEND OUR REACH FURTHER OUT INTO THE COMMUNITY THAN WE WOULD BE ABLE TO DO INDIVIDUALLY AND WITH FEWER UNNECESSARY REDUNDANCIES. PART VI, LINE 7, REPORTS FILED WITH STATES NY X X 0 0 0 0 0 0 0 0 0 JONATHAN I LAWRENCE PRESIDENT AND CEO 213729 221441 0 0 0 11436 8750 8750 7711 14332 230190 255959 0 0 KENNETH D CRONE CFO 79167 79168 0 0 0 0 3216 3216 4157 4157 86540 86541 0 0 JARROD JOHNSON COO 156367 14365 0 0 255 5 8118 173 22400 296 187140 14839 0 0 TERESA LARSON VP RISK MGMT/CORP COMPLIANCE 81329 46996 0 0 379 380 3198 3197 10391 4907 95297 55480 0 0 MARY STAPLES VP QA/RISK MANAGEMENT 77477 70677 0 0 760 639 0 0 5451 3060 83688 74376 0 0 THOMAS EAST VP INFORMATION TECHNOLOGY 67250 72412 0 0 2467 2391 0 0 10815 5585 80532 80388 0 0 JEFFREY MORGAN INTERIM CFO 158154 0 0 0 3474 0 0 0 518 0 162146 0 0 0 KEVIN WILD ADMIN. FELLOW AND SON OF BOARD MEMBER 48660 KEVIN WILD IS AN ADMINISTRATIVE FELLOW AND A SON OF BOARD MEMBER DR. JAMES WILD. OF THE AMOUNT PAID TO KEVIN, $35,973 WAS A SHARED COST WITH A RELATED ORGANIZATION. 0 FORM 990, PART VI, SECTION A, LINE 6 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.LAKEERIEHEALTH.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 218,482. PENSION LIABILITY ADJUSTMENT 1,020,461. CONTRIBUTIONS TO AFFILIATES - ESTIMATED ADVANCES ALLOWANCES -4,769,377. 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. PART III, LINE I BROOKS MEMORIAL HOSPITAL IS A PRIMARY ACUTE CARE HOSPITAL DEDICATED TO PROVIDING QUALITY HEALTH CARE SERVICES TO CONTINUOUSLY IMPROVE THE HEALTH OF PEOPLE IN WESTERN NEW YORK. TO ACCOMPLISH THIS MISSION: S.E.R.V.E. WE WILL CONTINUE TO SUPPORT THE COMMUNITY/PATIENT BY PROVIDING A BROAD ARRAY OF SERVICES TO MEET THEIR PRIMARY HEALTH CARE AND WELLNESS NEEDS, WHILE SHARING OUR SPECIAL SERVICE CAPABILITIES TO BENEFIT OUR REGION. WE WILL CONTINUE TO PROVIDE NEEDED EDUCATION ON WELLNESS AND HEALTH TO OUR PATIENTS AND COMMUNITY. WE WILL FOSTER THIS THROUGH THE DEVELOPMENT AND PROFESSIONAL GROWTH OF ALL EMPLOYEES. WE WILL REMAIN DEDICATED TO PROVIDING QUALITY HEALTH CARE THROUGH QUALITY PEOPLE. WE WILL TREAT EACH PERSON (PATIENT, FAMILY, PHYSICIAN, EMPLOYEE, AND VISITOR) WITH REVERENCE AND RESPECT, WITHOUT DISCRIMINATION ON THE BASIS OF RACE, CREED, RELIGION, NATIONALITY, SEX, AGE, FINANCIAL CLASS OR ANY OTHER BASIS. WE WILL ACTIVELY WORK WITH THE PHYSICIANS TO FULFILL OUR COMMON GOAL OF PROVIDING QUALITY PATIENT CARE. WE WILL VALUE ALL MEMBERS OF THE HEALTH CARE SYSTEM. WE WILL CONTINUE TO WORK WITH PATIENTS, FAMILIES, PHYSICIANS, HOSPITAL STAFF AND CLERGY AS A TEAM. WE WILL STRIVE TO CONTINUOUSLY IMPROVE THE QUALITY OF SERVICE TO THE COMMUNITY BY MEETING AND EXCEEDING THE NEEDS OF THE WHOLE PERSON IN A COMPASSIONATE, SAFE, MODERN, AND EFFICIENT MANNER. WE WILL SEEK LONG-TERM, MUTUALLY BENEFICIAL RELATIONSHIPS TO DELIVER QUALITY HEALTH CARE. WE WILL MONITOR, EVALUATE AND UPDATE SERVICES AND SYSTEMS AS NEEDS CHANGE, SO AS TO CONTINUE TO PROVIDE QUALITY HEALTH CARE, WHILE BEING FISCALLY RESPONSIBLE TO ENABLE US TO ACCOMPLISH THIS MISSION. TLC HEALTH NETWORK 12644 SENECA ROAD IRVING NY 140819716 160772474 HOSPITAL NY 501(C)(3) LINE 3 N/A 0 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 0 0 0 1 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0