2013-11-12T15:36:05-06:00 2012-12-31 861065772 Deloitte Tax LLP 250 East Fifth Street Suite 1900 Cincinnati OH 45202 990 2012-01-01 141347719 St Mary's Healthcare STMA 5188421900 427 Guy Park Avenue Amsterdam NY 120101054 Joan Ehlinger 5188421900 2013-11-12 1 Matthew A Montgomery P00492843 5137847100 2012 2016-02-24 21:20:13Z Victor Giulianelli 427 Guy Park Avenue Amsterdam NY 120101054 149354962 0 0928 X www.smha.org X 1903 NY To serve all persons with compassion and excellence, especially those who are vulnerable. 17 13 1828 298 1355666 0 3645338 5422689 132217947 137514057 2620025 4865697 5083483 1248874 143566793 149051317 79584 50325 0 0 83611619 89256871 0 0 0 52527392 48185270 136218595 137492466 7348198 11558851 148447908 158992703 33638340 40866069 114809568 118126634 X Rooted in the healing ministry of Jesus, we dedicate ourselves to serve all persons with compassion and excellence, especially those who are vulnerable. 0 0 116399927 50325 136301161 St. Mary's Healthcare provides a substantial portion of its services to the elderly and poor. During the fiscal year ending December 31, 2012, approximately 35% of the value of services rendered were to elderly patients under the Medicare program and approximately 23% of the services were provided to patients who were deemed indigent under state, county or hospital guidelines. In the spirit of principles adopted by Ascension Health, St. Mary's has taken proactive steps to address those issues that will affect accessibility, the financing, and the delivery of healthcare to all persons, especially the uninsured, underinsured, and the underserved. During the fiscal year ending December 31, 2012, the estimated cost of providing care of persons living in poverty totaled $11.6 million, including $572,000 cost of charity care, $4.7 million in programs for persons living in poverty, and $6.3 million in the unpaid cost of public programs. These amounts vary from Schedule H due to different methods of calculation.In 2012, St. Mary's Healthcare provided health care services to 6,595 inpatients and 405,613 outpatients, and 56,565 days of care to residents of the skilled nursing facility. The inpatient care covered medical/surgical, psychiatric, alcohol rehabilitation, physical rehabilitation, maternity and newborn patients. The outpatient visits included 28,846 emergency visits; 8,626 outpatient surgeries; 161,131 referred visits (including imaging, laboratory, therapies, and cardiac rehab), total other outpatient visits of 26,500 including 3,265 visits to nursing home patients, 8,331 adult day care visits, 10,107 urgent care visits, 3,940 occupational medicine visits and 857 visits to the diabetes center; 61,135 family health center visits; total specialty visits of 21,556 including 4,783 urology health center visits, 2,964 cancer treatment center visits and 1,216 specialty surgical visits; 1,363 prenatal visits; and total mental health and alcohol visits of 95,400 including , 15,376 alcohol clinic visits, and 81,080 mental health clinic visits. St. Mary's Healthcare administers one of the most comprehensive mental health outpatient programs in New York State. In 2012, the Hospital provided a variety of services through various grant-funded programs including psych-social clubs, prevocational/employment assistance programs, mobile geriatric/senior citizen programs, and alcohol intervention service programs. In addition, caring families provided family care services and hospital personnel provided case management counseling under various grant-funded programs. 2206000 Community benefits are programs or activities that provide treatment and/or promote health and healing as a response to identified community needs. In efforts to promote healthy living, St. Mary's Healthcare has made available the following programs to the community: reduced cost programs providing senior citizens with Lifeline equipment enabling them to solicit help should the need arise; community continuing education programs providing information on a variety of subjects including child abuse, day-to-day parenting, seat belt use and safety, smoking cessation, weight loss, and other wellness programs; help and support groups for victims and their family members; and providing meeting facilities for victims of alcohol abuse. 938709 1212896 St. Mary's Healthcare's other program service revenue includes continuing education programs, psychological services provided to Montgomery county, medical director services, cafeteria sales to visitors and employees, and rebates/refunds of expenses. 119544636 1 1 0 1 0 0 0 0 1 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 1 130 0 1 1828 1 1 1 0 0 0 0 0 0 0 0 0 0 X 17 13 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X Joan Ehlinger 5188417434 427 Guy Park Avenue Amsterdam NY 12010 Victor Giulianelli 40.00 1.00 X X 808087 0 26808 Ronald Marsh MD 2.00 1.00 X 78825 0 0 Michael J Pepe 2.00 0.00 X 0 0 0 Sister Lauren VanDermark 2.00 0.00 X 0 0 0 Thomas F Cichy 2.00 0.00 X 0 0 0 Sister Charla Commins CSJ 2.00 0.00 X 0 0 0 John Daly 2.00 0.00 X 0 0 0 Emily T Etzkorn MD 2.00 0.00 X 3692 0 0 Mohammad R Ghazi-Moghadam MD 40.00 1.00 X 222736 0 5915 Vito L Greco 2.00 0.00 X 0 0 0 Sister Nancy Gregg 2.00 0.00 X 0 0 0 Sr Joan Mary Hartigan 2.00 0.00 X 0 0 0 Andrew Heck 2.00 0.00 X 0 0 0 Joan R Pipito 2.00 0.00 X 0 0 0 Brent E Phetteplace 2.00 0.00 X 0 0 0 Michael M Sheridan DO 2.00 0.00 X 0 0 0 Ronald Limoncelli 2.00 0.00 X 0 0 0 John Sagan 40.00 1.00 X 328064 0 22959 Scott Bruce 40.00 1.00 X 315992 0 44846 John Kelley 40.00 0.00 X 238009 0 24321 Timothy Shoen 40.00 0.00 X 396808 0 19948 Michelle Walsh 40.00 0.00 X 224568 0 15601 James Charland MD 40.00 0.00 X 592182 0 14417 Hamid Aziz Rehman MD 40.00 0.00 X 525899 0 0 David Lehr MD 40.00 0.00 X 424812 0 23892 Deborah Sculco 40.00 0.00 X 414652 0 8340 Kendy Verpile 40.00 0.00 X 339134 0 9353 4913460 0 216400 75 0 1 0 Touchpoint Support Services PO Box 102289 Atlanta GA 303682289 Food, Nutritional, & Environmental Svcs 1708501 Atlantic Prof Svcs of Rhode Island Inc PO Box 635998 Cincinnati OH 45263 Medical Services 1681991 Assoc Regional and University Pathololo ARUP Laboratories 500 Chipete Way Salt Lake City UT 84108 Medical Services 699352 Medical Staffing Network PO Box 202996 Dallas TX 753202996 Medical Services 392271 Acute Dialysis Equipment Inc 1288 Simons Road Castleton NY 12033 Medical Services 260550 14 459665 4961250 1774 5422689 Patient Revenue 621990 136301161 136301161 Other Program Service 621990 1212896 1212896 137514057 4978368 4978368 81326 188118 -106792 -106792 -106792 2856 115527 -112671 -112671 -112671 Laboratory Services 621500 945878 945878 Occupational Medicine 621400 269642 269642 Medical Director Servi 623990 102698 102698 37448 37448 1355666 149051317 137514057 1355666 4758905 50325 50325 2777209 344847 2432362 73674538 67684028 5990510 1626228 1495642 130586 6034497 5549927 484570 5144399 4731304 413095 335800 6918 328882 43448 43448 60564 60564 6745154 5960713 784441 755423 162140 593283 17468924 17177347 291577 4652027 3044414 1607613 2650147 2221346 428801 142016 134345 7671 263899 196806 67093 184567 184567 2872607 2872607 4543148 4338706 204442 383575 383575 Repairs & Maintenance 2143894 2054199 89695 0 Provider Tax 1153898 1153898 0 0 Dues & Subscriptions 303753 146650 157103 0 3482426 3091081 391345 137492466 119544636 17947830 0 3527827 6491836 17188135 19222063 1165569 1419014 1417491 1561718 73354311 28037077 46355499 45317234 1099771 1407833 77693616 83573005 148447908 158992703 10758638 13107454 259158 493539 71735 82221 22548809 27182855 33638340 40866069 X 105417179 108075551 2918337 3570648 6474052 6480435 114809568 118126634 148447908 158992703 X 11558851 -239599 -8002186 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 60564 60564 0 Explanation of Lobbying Activities: Part II-B, Line 1: Lobbying expenses include the portion of dues paid to national and state hospital associations that are specifically allocable to lobbying. St. Mary's Healthcare does not participate in or intervene in (including the publishing or distributing of statements) any political campaign on behalf of (or in opposition to) any candidate for public office. 0 71735 10486 82221 1 X 7591798 7591798 49407141 18529181 30877960 34892 15260 19632 15108613 8432169 6676444 1211867 1060467 151400 45317234 Health System Depository Account 71235376 Interest in Net Assets of Foundation 10051084 Other Receivables 945560 Intangible Pension Asset 826563 Third Party Receivable 514422 83573005 Accrued Pension Costs 10627378 Intercompany Debt to Ascension Health 8799147 Third Party Liability 2821526 Asset Retirement Obligation 1500000 Patient Credit Liabilities 1389656 Deferred Revenue - Meaningful Use 1338989 IBNR Liability 325260 Third Party Advance 272000 Other Advances 108899 27182855 Part IV, Line 2b: The Hospital maintains custodial accounts for residents of the skilled nursing facility which totaled $82,221 at 12/31/2012. 1 1 1 X 1 X 0 1 1 0 1 1 768721 108406 660315 0.00480 38234324 31934551 6299773 0.04580 0.00000 39003045 32042957 6960088 0.05060 2754803 163167 2591636 0.01880 693903 0 693903 0.00500 14443406 11199430 3243976 0.02360 0 0 0.00000 441207 0 441207 0.00320 18333319 11362597 6970722 0.05060 57336364 43405554 13930810 0.10120 0.00000 0.00000 15461 15461 0.00010 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 15461 15461 0.00010 0 6918436 1775198 50516120 51098825 -582705 X 1 1 1 1 St Mary's Healthcare

427 Guy Park Avenue Amsterdam NY 120101054

www.smha.org X X X St Mary's Healthcare 1 1 1 200.000000000000 1 300.000000000000 1 X X X X 1 1 X X X X X X 1 0 1 X 0 0 17 St Mary's Healthcare

4988 State Highway 30 Amsterdam NY 12010

Diagnostic Care, Primary Care, Cancer Medicine, and Inpatient Physical Rehab Wilkinson Residential Health Care

Facility 4988 State Highway 30 Amsterdam NY 12010

Residential Health Care Facility Johnstown Family Health Center

700 S Perry Street Johnstown NY 12095

Family Health Center Canajoharie Family Health Center

48 Erie Boulevard Canajoharie NY 13317

Family Health Center Carondelet Family Health Center

380 Guy Park Ave Amsterdam NY 12010

Family Health Center Gloversville Family Health Center

84 E State Street Gloversville NY 12078

Family Health Center St Johnsville Family Health Center

7 Timmerman Ave St Johnsville NY 13452

Family Health Center Northville Family Health Center

331 Bridge Street Northville NY 12134

Family Health Center Amsterdam OBGYN Center

446A Guy Park Ave Amsterdam NY 12010

OB/GYN Center Montgomery County Addiction Services

76 Guy Park Ave Amsterdam NY 12010

Addiction Services Fulton County Day Rehab Addiction Svcs

57 E Fulton Street Gloversville NY 12078

Addiction Rehabilitation Center Children's Mental Health Clinic

8 Northhampton Road Amsterdam NY 12010

Children's Mental Health Center Diagnostic Service Center

110 Holland Circle Drive Amsterdam NY 12010

Diagnostic Care Center Riverfront Diagnostic Service Center

1340 Riverfront Center Amsterdam NY 12010

Diagnostic Care Center Children's Day Treatment Program

234 Lincoln Street Gloversville NY 12078

Children's Treatment Center Social Club North

73 North Main Street Gloversville NY 12078

Human Services Social Club West

17 River Street Nelliston NY 13410

Human Services Part I, Line 7: The cost of providing charity care, means tested government programs, and community benefit programs is estimated using internal cost data and is calculated in compliance with Catholic Health Association (CHA) guidelines. The organization uses a cost accounting system that addresses all patient segments (for example: inpatient, outpatient, emergency room, private insurance, Medicaid, Medicare, uninsured, or self pay). The best available data was used to calculate the amounts reported in the table. For charity care, a specific cost-to-charge ratio was applied; for other categories in the table, a cost accounting system was used. Part I, Line 7g: The organization employs its physicians at physician clinics, so the associated costs and charges relating to those physician services are included in all relevant categories in Part I. Part II: St. Mary's Healthcare provided the following community building activities in 2012:-Donated the use of a "safe house" for victims of domestic violence and provided maintenance and upkeep of the property. -Community health improvement advocacy through brain injury helmet contest. This program partners with local law enforcement to reach out to young students to teach them the importance of wearing helmets to prevent head injury. St. Mary's has been the driver and sponsor of this program for the last 13 years.-In September and March 2012, hosted the Victim Impact Panel in partnership with the Montgomery County District Attorney's office and the Hamilton-Fulton-Montgomery Prevention Council. This is an awareness program for offenders convicted of misdemeanor driving under the influence of alcohol or other drugs. The goal is to help offenders become more aware of the possible consequences of driving while impaired so they may think to make different choices in the future.-In 2012 St. Mary's Healthcare brought together leaders of local community agencies and the Department of Social Services to address the homeless issues in Amsterdam. Through their continued collaboration, funds were raised to purchase a house to be used as a shelter and temporary housing for men, women and families.-Donated appointed staff and funding to the local Habitat for Humanity Chapter. Part III, Line 4: The provision for doubtful accounts is based upon management's assessment of historical and expected net collections considering economic conditions, trends in health care coverage, and other collection indicators. Periodically throughout the year, management assesses the adequacy of the allowance for uncollectible accounts based upon historical write-off experience by payer category, including those amounts not covered by insurance. The results of this review are then used to make any modifications to the provision for doubtful accounts to establish an appropriate allowance for uncollectible accounts. After satisfaction of amounts due from insurance and reasonable efforts to collect from the patient have been exhausted the Hospital may place past due patient balances with collection agencies, subject to the terms of certain restrictions on collection efforts as determined by Ascension Health. Accounts receivable are written off after collection efforts have been followed in accordance with the hospital's policies.The organization's share of bad debt expense in 2012 was $6,918,436 of charges. Part III, Line 8: Ascension Health and related health ministries follow the Catholic Health Association (CHA) guidelines for determining community benefit. CHA community benefit reporting guidelines suggest that Medicare shortfall is not treated as a community benefit. Part III, Line 9b: The organization has a written debt collection policy that also includes a provision on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance. If a patient qualifies for charity or financial assistance, certain collection practices do not apply. Part V: St. Mary's Healthcare consists of two licensed facilities, namely, the Hospital and the Wilkinson Residential Health Care Facility, which is a skilled nursing facility. The Hospital has several locations, including two outpatient alcohol rehabilitation clinics, one diagnostic service center, and seven primary care centers. Part V, Line 14a: Individual letters are mailed to all uninsured patients informing them of the financial assistance programs available. Part V, Line 20d: The maximum amount charged to FAP-eligible individuals is based on the uninsured discount, which is reviewed and updated annually, as applicable. Uninsured patients with the ability to pay will be provided a discount based on the discount provided to the highest-paying payer that accounts for at least three percent of the Hospital's volume or gross patient revenues. In 2012, the Hospital provided discounts to the uninsured equal to 28% of charges for inpatients and 36% of charges for outpatients. Part VI, Line 2: In 2012, the Hospital contracted with Professional Research Consultants, Inc. (PRC) to conduct St. Mary's Healthcare's Community Health Needs Assessment (CHNA). The assessment, made available to the public in March 2013, incorporated data from both quantitative and qualitative sources including random sampling of community members, key informant focus groups and secondary data sources. The focus groups consisted of input from persons who represent the community we serve, including business leaders, community-based and social service agencies, school districts and those with a special knowledge or expertise in public health. The data from this assessment was made available to the public via the hospital's website, http://smha.healthforecast.net and upon request. The hospital also used data from our county health departments' community needs surveys.Additionally, the Hospital sought input from its Board of Trustees, Medical Executive Committee, leadership staff and community partners when completing its annual Integrated Strategic, Operational, and Financial Plan (ISOFP). The ISOFP uses pertinent data and comprehensive feedback to outline current and future critical healthcare needs for the Hospital's service area, as well as the resources needed to address the identified issues. Part VI, Line 3: St. Mary's Healthcare, in keeping with the mission and policies of Ascension Health, strives to maintain a balance between providing care of the poor with the ability of the Hospital to maintain quality health care for the community it serves. As part of its financial assistance policies, the Hospital offers a self pay discount to all uninsured patients as a percentage off the standard charge; the discounts were set at 28% for inpatient services and 36% for outpatient services. In 2012, the discounts provided to the uninsured were approximately $2.6 million. The Carondelet Care assistance program is the next level of financial assistance available to the Hospital's patients. This program is available to all patients who can demonstrate a financial burden associated with their patient responsibility. Financial assistance is provided through collaboration between the health insurance enrollment and financial assistance staff. Although the two departments offer different financial assistance services, the enrollment staff is trained to help those individuals who do not qualify for any government sponsored programs to access the Carondelet Care assistance program. Similarly, the Financial Counselors often refer patients in need of insurance to our Enrollment Specialist. The enrollment staff is available to meet with community members at the main hospital, at our Memorial campus and at all seven of our off-site family health centers. Staff is also trained to refer individuals to free or low cost health care programs within the community if no other options are immediately available. In 2012, 750 individuals were enrolled in health insurance programs as a direct result of these efforts. The Hospital enroller works collaboratively with Fidelis Care, the Cancer Services Program and community agencies to further expand its outreach. Large posters describing the Hospital's willingness to help patients with financial assistance are displayed in all main entrances to the Hospital and the off-site locations, as well as in our multiple registration sites and waiting rooms. The informational posters are in English and Spanish and urge patients to call if they are concerned about bill payment. Translation services are also available as needed via language line telephones and iPad video application.Brochures in English and Spanish are available at all service sites and offer detailed information about the various levels of assistance. In addition to offering discounts, St. Mary's offers options for payment plans and payment schedules. The English and Spanish brochures are also available on the Hospital web site. Information on financial assistance is also contained in the Patient Information Guide given to all inpatients at St. Mary's Healthcare. Part VI, Line 4: St. Mary's Healthcare serves a rural community consisting of Montgomery and Fulton counties in New York State as its primary service area (PSA), and is the only acute care hospital in Montgomery County. On average, 65% of hospital admissions come from Montgomery County, and 26% come from Fulton County. The main hospital campus is located in the city of Amsterdam, though a number of vital services are available on the Memorial campus in the town of Amsterdam. The Hospital operates seven primary care centers; four sites in Montgomery County (two located in Amsterdam, one in Canajoharie and one in St. Johnsville) and three sites in Fulton County (Johnstown, Gloversville and Northville), in addition to a cancer medicine center and specialty practices in general surgery, urology, gastroenterology, obstetrics/gynecology, ophthalmology and pain management. The Hospital's comprehensive behavioral health programs provide extensive mental health and addiction services, including inpatient and outpatient treatment in Montgomery and Fulton Counties. The PSA represents one of the oldest regions in NYS. Estimates indicate that the 65 and older population will continue to grow. According to Thomson Reuters, the only segment of our population showing growth is the 65+, with a growth rate of 9.8%. In fact, within this segment, 85+ shows a 6.7% increase. The unemployment rate in Fulton and Montgomery Counties continues to be among the highest in NYS, exceeding the State average by 1.0%. There are many factors that contribute to the community's poverty levels, including the high school dropout rate in both counties. Reports indicate that 30% of ninth graders entering school will not complete high school in four years in our PSA. The lack of education affects the workforce, contributes to higher unemployment and greater risk of working without health insurance. Forty-five percent of all families in poverty are headed by a single parent with children.Research indicates a decline in the Caucasian population, which is a consistent trend over several years. The Hispanic community is our largest minority community, with the largest concentration within the city of Amsterdam. The 2010 Census indicates that 26.2% of the residents of Amsterdam are identified as Hispanic and according to the estimates this segment of our population will grow by 12.7% in the next five years. The Hospital employs bilingual and bicultural healthcare professionals to meet the needs of the Hispanic community.Health statistics relevant to the community's health status are as follows: Over 70% of the St. Mary's Healthcare Service Area is overweight. Especially alarming is that 38% of our children are overweight. The relationship of being overweight with other health issues such as high blood pressure, chronic depression, arthritis and diabetes are significant. Poor nutritional habits and lack of physical activity are significant contributing factors to the overweight status of our community.Access to quality health care services is important for increasing the quality of life for everyone. It impacts overall physical, social and mental health status; the prevention of disease and disability; quality of life; preventable death and life expectancy. Uninsured individuals comprise 13% of the population in Fulton and Montgomery Counties. Nearly 8% of the population in St. Mary's Healthcare's service area went without any type of healthcare insurance coverage at some point in the past year. Disproportionately, over 16% of those with low-income went without some type of coverage the past year. These numbers are significantly less favorable than the US average of 4.8%. Additionally, nearly 40% of respondents reported some type of difficulty or delays in receiving needed health care in the past year, with those who are uninsured much more likely to report barriers when compared to the insured population. The Hospital serves a disproportionate share of the Medicaid population, and approximately 23% of the total inpatient discharges are Medicaid. Part VI, Line 5: St. Mary's Healthcare promotes the health of its community through various activities, including the following:- St. Mary's made a financial donation to the City of Amsterdam's Bacon Recreational Center. The Center provides year-round recreational facilities for youth and family focusing on health and wellness, physical activity and community pride. Many programs there are no cost, allowing lower-income families to be able to participate without a financial burden. Additionally, the hospital also provides health education programs for the community at the Center.- More than 1,400 people attended free educational programs offered by the Hospital on various topics including Alzheimer's Disease, Childbirth Education, Colon Cancer, Breast Cancer, Bladder Health, Bone and Joint Health, Women's Safety, Brain Injury Awareness, Infant CPR, Lactation Support, Physical Activity and Nutrition, Concussions in Athletes and Designer Drugs.- St. Mary's partnered with our local school districts hosting five school tours in 2012, providing children first-hand knowledge and experience of the operations of a hospital. Our Registered Dieticians participated in school wellness days to teach children about the importance of healthy eating and physical activity. - St. Mary's associates gave back to their community serving on various boards including The Amsterdam Homeless Coalition, Liberty ARC Board, Montgomery County Office for the Aging, The Sanford Home, Montgomery County Habitat for Humanity, the Minority Health Task Force, the Suicide Prevention Task Force, Sexual Assault Task Force, United Way, Regional Chamber of Commerce, Glove City and Amsterdam Rotary, Children's Aid Society, Community Health Center and Fulton County Long-term Care Council Boards. - In 2012, St. Mary's associates gave their time to better the community by participating in walks for Alzheimer's Disease, American Cancer Society's Relay for Life and other awareness walks as well as taking part in clean-up projects in both Fulton and Montgomery Counties.- St. Mary's providers are able to refer uninsured or underinsured patients with medication needs to the Dispensary of Hope program at the Hospital. This program provides free prescription medications to those who lack prescription drug coverage.- Continued to lead the work of the Fullmont Community Health Improvement Coalition, a group of committed partners from local health care entities and community agencies whose mission is to improve the health status for all we serve. During 2012, this group readjusted their focus to respond to the changes of the Affordable Care Law. This group continues to collaborate on a plan to address the needs identified in our 2012 CHNA.- In 2012, we continued our ninth year of distributing educational information on insurance eligibility for children through the school system, public service announcements, advertising and appearances at "back to school" events such as PTA meetings and open houses.- Enrolled 750 persons in State-sponsored insurance programs. - Provided 3,381 life-saving cancer screenings to 863 uninsured individuals through the Cancer Services Program. - Expanded the "Promotora de Salud" program that provides for outreach, education, referral, follow-up, case management and advocacy services to our Latino and migrant community. The goal of the program is to promote needed primary health services and prevention efforts in a culturally appropriate manner. In 2012, nearly 80 migrant clients were provided health care services through this program, most of whom had never seen a healthcare provider before. The Promotora has an average of 250 client contacts/communications per month. Additionally, there are countless other communications, educational trainings, community events, individual and family visits, and service navigation that has been made available by the program. - Maintained the importance of culturally sensitive and accurate communication with Latino patients and patients with limited English proficiency through the use of translation services which include professional phone and video translation services and the translation of key documents. English and Spanish are the most prominent languages spoken in the community, so all signage is posted in both English and Spanish throughout the organization. The iPad video services also serve those who are in need of sign language services.- Developed and distributed 30,000 free copies of a Breast Cancer Awareness/Health Facts Book to the community. - Provided free screenings at various health fairs and community events throughout the year.- Participated in the Fulton and Montgomery County Office for Aging picnics to educate seniors on a variety of wellness topics.- Hosted eight different support groups including the Women's Cancer, Brain Injury, Behavioral/Mental Health, Ostomy, Diabetes, Survivors of a Loved One's Suicide (SOLOS) and Alzheimer's Caregiver Support Groups supporting nearly 250 community members who receive peer support and educational opportunities to manage their concerns. This year we partnered with Community Hospice to add a Grief Support Group.- The Medical Explorers, a group for young adults, meets monthly for education and socialization with the goal of assisting youth to explore the various options in healthcare careers.- Club 60, an educational and social group for seniors aged 60 and above, meets monthly for updates on health-related issues such as the flu vaccine and specialized primary care services. Each event includes the opportunity to ask questions and spend time with the President/CEO or other members of the senior management team.- A majority of the Hospital's Board of Trustees is comprised of persons who reside in the organization's primary service area and are neither employees nor independent contractors of the Hospital, nor family members thereof.- The Hospital established the Carondelet Community Fund, which provides modest assistance to local programs and agencies whose values and mission align with the values of St. Mary's Healthcare. Grants from the fund are made to eligible non-profit community agencies which are located within the service area of St. Mary's Healthcare and which share the values of St. Mary's with an emphasis on service to the poor and vulnerable, and holistic care. The total amount awarded from this fund in 2012 was $10,800. Part VI, Line 6: St. Mary's Healthcare (the Hospital) is a member of Ascension Health. In December 2011, Ascension Health Alliance became the sole corporate member and parent organization of Ascension Health, a Catholic, national health system consisting primarily of nonprofit corporations that own and operate local health care facilities, or Health Ministries, located in 21 of the United States and the District of Columbia. In addition to serving as the sole corporate member of Ascension Health, Ascension Health Alliance serves as the member or shareholder of various other subsidiaries. Ascension Health Alliance, its subsidiaries, and the Health Ministries are referred to collectively from time to time hereafter as the System. Ascension Health Alliance is sponsored by Ascension Health Ministries, a Public Juridic Person. The Participating Entities of Ascension Health Ministries are the Daughters of Charity of St. Vincent de Paul in the United States, St. Louise Province, the Congregation of St. Joseph, the Congregation of the Sisters of St. Joseph of Carondelet, and the Congregation of Alexian Brothers of the Immaculate Conception Province American Province. The Hospital, located in Amsterdam, New York, is a nonprofit acute care hospital. The consolidated financial statements include the Hospital, Medical Services Enhancement, Inc. (MSE), and The Foundation of St. Mary's Hospital at Amsterdam, Inc. (Foundation). MSE operates a medical office building to retain and attract physician specialists to better serve the healthcare needs of the community. The Foundation's primary purpose is to assist the Hospital to develop and expand its services to the community by providing a focal point as the recipient for philanthropic support and by transferring funds to the Hospital. The Hospital provides acute inpatient, inpatient physical rehabilitation, outpatient, and emergency care services for the residents of Montgomery, Fulton, and Hamilton counties. The Hospital also provides an array of Behavioral Health services including inpatient mental health and alcohol rehabilitation plus outpatient mental health and alcohol related services. Admitting physicians are primarily practitioners in the local area. Additionally, the Hospital operates a 160 bed skilled nursing facility which provides housing, healthcare and other related services to residents who are severely limited in their ability to care for themselves due to illness and/or disability, and a medical adult day care program. The Hospital is related to Ascension Health's other sponsored organizations through common control. Substantially all expenses of Ascension Health and its sponsored organizations are related to providing health care services.The System directs its governance and management activities toward strong, vibrant, Catholic Health Ministries united in service and healing and dedicates its resources to spiritually centered care which sustains and improves the health of the individuals and communities it serves. Inaccordance with the System's mission of service to those persons living in poverty and other vulnerable persons, each Health Ministry accepts patients regardless of their ability to pay. The System uses four categories to identify the resources used for the care of persons living in poverty and community benefit programs:- Traditional charity care includes the cost of services provided to persons who cannot afford health care because of inadequate resources and/or who are uninsured or underinsured.- Unpaid cost of public programs, excluding Medicare, represents the unpaid cost of services provided to persons covered by public programs for persons living in poverty and other vulnerable persons.- Cost of other programs for persons living in poverty and other vulnerable persons includes unreimbursed cost of programs intentionally designed to serve persons living in poverty and other vulnerable persons of the community, including substance abusers, the homeless, victims of child abuse, and persons with acquired immune deficiency syndrome.- Community benefit consists of the unreimbursed costs of community benefit programs and services for the general community, not solely for the persons living in poverty, including health promotion and education, health clinics and screenings.Discounts are provided to all uninsured patients in the acute care facility, including those with the means to pay. Discounts provided to those patients who did not qualify for assistance under charity care guidelines are not included in the cost of providing care of persons living in poverty and community benefit programs. The cost of providing care of persons living in poverty and community benefit programs is estimated using internal cost data and is calculated in compliancewith guidelines established by both the Catholic Health Association (CHA) and the Internal Revenue Service (IRS).The amount of traditional charity care provided, determined on the basis of cost, excluding the provision for bad debt expense, was approximately $572 and $563 for the years ended December 31, 2012 and 2011, respectively. The amount of unpaid cost of public programs, cost of otherprograms for persons living in poverty and other vulnerable persons, and community benefit cost are reported in the accompanying supplementary information. Reports Filed With States Part VI, Line 7 NY 1 0 0 Family Care - Entitlement Provider 4 17452 0 Family Care - Entitlement Resident 11 10568 0 ICM - Patient Service Dollars 156 14481 0 SCM - Patient Service Dollars 92 7824 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: The grant funds awarded are to clients of the family care, intensive case management, and supportive case management programs which are administered through the Hospital's behavioral health services division. The amounts are determined based on evaluation of client needs as determined by their individual case managers. All amounts are processed in accordance with the Hospital's disbursements practices which require evidence of supporting documentation for all expenditures, and required approvals. X X X 1 1 X X X X 0 1 0 0 0 0 0 0 0 Victor Giulianelli 332365 0 357250 0 118472 0 5000 0 21808 0 834895 0 0 0 Mohammad R Ghazi-Moghadam MD 205353 0 0 0 17383 0 0 0 5915 0 228651 0 0 0 John Sagan 227822 0 36768 0 63474 0 3880 0 19079 0 351023 0 0 0 Scott Bruce 247873 0 37150 0 30969 0 23746 0 21100 0 360838 0 0 0 John Kelley 155778 0 29631 0 52600 0 3933 0 20388 0 262330 0 0 0 Timothy Shoen 309846 0 36979 0 49983 0 5000 0 14948 0 416756 0 0 0 Michelle Walsh 187352 0 28785 0 8431 0 9034 0 6567 0 240169 0 0 0 James Charland MD 579260 0 0 0 12922 0 0 0 14417 0 606599 0 0 0 Hamid Aziz Rehman MD 525899 0 0 0 0 0 0 0 0 0 525899 0 0 0 David Lehr MD 404482 0 0 0 20330 0 5000 0 18892 0 448704 0 0 0 Deborah Sculco 399106 0 10000 0 5546 0 2461 0 5879 0 422992 0 0 0 Kendy Verpile 250804 0 33528 0 54802 0 1278 0 8075 0 348487 0 0 0 Part I, Line 1a Per St. Mary's Healthcare's accountability plan, spousal travel is reimbursed if there is a business purpose, however the amount reimbursed is also included as income on the individual's W-2. Certain St. Mary's Healthcare employees are reimbursed for cell phone/PDA expense, which is included on the respective employee's W-2. These payments are grossed up to include tax related obligations paid. St. Mary's Healthcare offers a fitness club membership credit to all employees to reimburse half of the cost of a yearly fitness club membership up to $150 per year. Part I, Line 4b Eligible executives participate in a program that provides for supplemental retirement benefits. The payment of benefits under the program, if any, is entirely dependent upon the facts and circumstances under which the executive terminates employment with the organization. Benefits under the program are unfunded and non-vested. Due to the substantial risk of forfeiture provision, there is no guarantee that these executives will ever receive any benefit under the program. Any amount ultimately paid under the program to the executive is reported as compensation on Form 990, Schedule J, Part II, Column B in the year paid. The filing organization contributed to the supplemental nonqualified retirement plan in the amount as noted: Victor Giulianelli - $64,408 John Sagan - $32,354 John Kelly - $26,528 Timothy Shoen - $26,528 Scott Bruce - $10,629 Form 990, Part VI, Section A, line 2 Many of the persons listed on Part VII have a "business relationship" with each other by virtue of sitting on related St. Mary's Healthcare entity boards. Form 990, Part VI, Section A, line 6 St. Mary's Healthcare has a single corporate member, Ascension Health. Form 990, Part VI, Section A, line 7a St. Mary's Healthcare has a single corporate member, Ascension Health, which has the ability to elect members to the governing body of the Hospital. Form 990, Part VI, Section A, line 7b Ascension Health has designed a system of authority matrix which assigns authority for key decisions that are necessary in the operation of the system. Specific areas that are identified in the authority matrix are: new organization & major transactions; governing documents; appointments/removals; evaluation; debt limits; strategic and financial plans; assets; system policies & procedures. These areas are subject to certain levels of approval by Ascension per the system authority matrix. Form 990, Part VI, Section B, line 11 Management, including certain officers, works diligently to complete the Form 990 and attached schedules in a thorough manner. The Board of Trustees has delegated the review of the Form 990 to its Finance Committee. Management presents the Form 990 to Finance Committee Members to review and answer any Committee member's questions. Prior to filing the return, all Board Members are provided the Form 990 and management team members are available to answer any Board Members questions. Form 990, Part VI, Section B, line 12c The organization regularly and consistently monitors and enforces compliance with the conflict of interest policy in that any director, principal officer, or member of a committee with governing board delegated powers, who has a direct or indirect financial interest, must disclose the existence of the financial interest and be given the opportunity to disclose all material facts to the directors and members of the committees with governing board delegated powers considering the proposed transaction or arrangement. The remaining individuals on the governing board or committee will decide if conflicts of interest exist. Each director, principal officer and member of a committee with governing board delegated powers annually signs a statement which affirms such person has received a copy of the conflict of interest policy, has read and understands the policy, has agreed to comply with the policy, and understands that the organization is charitable and in order to maintain its federal tax exemption it must engage primarily in activities which accomplish its tax-exempt purpose. Form 990, Part VI, Section B, line 15 In determining compensation of the organization's CEO, the process included a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision. The executive compensation committee reviewed and approved the compensation. In the review of the compensation, the CEO was compared to CEOs at other hospitals who hold the same title. During the review and approval of the compensation, documentation of the decision was recorded in the board minutes. The individual was not present when his compensation was decided. In determining compensation of other officers or key employees of the organization, the process included a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision. The Executive Compensation Committee reviewed and approved the compensation. In the review of the compensation, the other officers or key employees of the organization were compared to other hospitals' employees who hold the same title. During the review and approval of the compensation, documentation of the decision was recorded in the board minutes. Form 990, Part VI, Section C, line 19 The organization will provide any documents open to public inspection upon request. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Change in Temporary and permanently restricted interest in Foundation 658,694. FAS 158 Pension Adjustment -8,871,091. Other 210,211. Explanation of Compensation for Ronald Marsh, M.D.: Form 990, Part VII, Section A: During 2012 and 2011, the Hospital paid Ronald Marsh, M.D. for services rendered in his role as surgeon of the Hospital, not for his duties as a board member. Explanation of Compensation for Emily Etzkorn, M.D.: Form 990, Part VII, Section A: During 2012 and 2011, the Hospital paid Emily Etzkorn, M.D. for services rendered in her role as surgeon of the Hospital, not for her duties as a board member. Explanation of Compensation for Mohammad Ghazi-Moghadam, M.D.: Form 990, Part VII, Section A: During 2012, the Hospital paid Mohammad R. Ghazi-Moghadam, M.D. for services rendered in his role as a physician of the Hospital, not for his duties as a board member. Ascension Health PO Box 45998 St Louis MO 63145 311662309 National Health System MO 501(c)(3) Line 11, Type I: 509 Ascension Health Alliance 0 Medical Services Enhancement Inc 425 Guy Park Avenue Amsterdam NY 12010 141776546 Rental of Medical and Office Space NY 501(c)(25) N/A St Mary's Healthcare 1 The Foundation of St Mary's Hospital at Amsterdam Inc 427 Guy Park Avenue Amsterdam NY 12010 133254655 Supporting Organization NY 501(c)(3) Line 11, Type III-FI N/A 1 0 0 1 1 0 0 0 0 0 0 1 0 0 0 0 1 1 1 0 Medical Services Enhancement Inc J 281290 Actual amount paid or transferred Medical Services Enhancement Inc D 202735 Actual amount paid or transferred The Foundation of St Mary's Hospital at Amsterdam Inc C 459665 Actual amount paid or transferred The Foundation of St Mary's Hospital at Amsterdam Inc P 171884 Actual amount paid or transferred Ascension Health O 5512809 Actual amount paid or transferred Ascension Health D 69363 Actual amount paid or transferred Ascension Health Q 3010368 Actual amount paid or transferred