2013-11-12T09:14:08-06:00 2012-12-31 990 2012-01-01 160762843 Kenmore Mercy Hospital KENM 7168282993 515 Abbott Road No 500 Buffalo NY 142202039 DAVID P MACHOLZ 7168282974 2013-11-12 2012 2016-03-07 17:11:31Z Joseph D McDonald 2121 Main Street Buffalo NY 14214 152150262 0 X www.chsbuffalo.org X 1957 NY The Catholic Health System (CHS) Mission is to provide quality healthcare Services in an acute care setting. Committed to a common mission, CHS providers continue the healing ministry of Jesus, seeking to improve the health of individuals and communities. We provide high quality service that has reverence, compassion, justice, and excellence. The 2012 Community Service Plan can be found at www.chsbuffalo.org 18 7 1421 393 0 0 73162 311010 137374537 148925847 251069 85333 3617521 2828072 141316289 152150262 0 0 0 0 77700114 83617917 0 0 0 61867564 63598888 139567678 147216805 1748611 4933457 105666087 135346864 92045822 117870939 13620265 17475925 X The Catholic Health System (CHS) Mission is to provide quality healthcare services in an acute care setting. Committed to a common mission, CHS providers continue the healing ministry of Jesus, seeking to improve the health of individuals and communities. We provide high quality service that has reverence, compassion, justice, and excellence. The 2012 Community Service Plan can be found at www.chsbuffalo.org. 0 0 74074630 105071510 Inpatient services provided 2,683 Inpatient Ambulatory Surgery visits, 490 visits for G.I. Lab, and 141 visits for Urology. Inpatient services provided 33,506 acute care patient days and 4,747 medical rehab service days. The Skilled Nursing Facility provided 55,344 days of care. 29031097 41179297 Outpatient services provided 3,369 Outpatient Surgery vistits, 5,152 G.I. visits, 2,016 Interventional Radiology visits and 306 Transfusion visits. Outpatient services also provided 23,870 Emergency Department visits net of admissions and 82,484 Referred Ambulatory visits. 1885884 2675040 Primary Care Centers and Clinics provided 32,234 visits. 104991611 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 0 0 0 0 0 1 1 0 0 0 0 0 1 0 0 0 1 97 0 1421 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 18 7 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X David P Macholz VP FinanceCorporate Controller 7168282974 515 Abbott Road Buffalo NY 142202039 Joseph McDonald 0.00 37.50 X X 0 1471257 38697 Mark Sullivan 0.00 37.50 X X 0 837613 31269 James Millard 37.50 0.00 X X 322272 0 146102 David Macholz 0.00 37.50 X X 0 232233 34122 Dr Michael Albert 0.00 5.00 X 0 32623 0 Dr Paul Anain 0.00 37.50 X 0 224265 12894 Brian Beitz 0.00 1.00 X 0 0 0 Peter Bergmann 0.00 37.50 X 0 433289 33126 Frances Crosby RN PhD 0.00 1.00 X 0 0 0 Richard Curran MD 0.00 1.00 X 0 0 0 Dennis Dombek 0.00 1.00 X 0 0 0 Dr Michael Edbauer 0.00 25.00 X 0 282798 26400 Dr Craig Fetterman 0.00 1.00 X 0 0 0 Christine Kluckhohn 0.00 37.50 X 0 317921 122567 William Lawley Jr 0.00 1.00 X 0 0 0 Judith Maness 0.00 1.00 X 0 0 0 James Manzella 0.00 1.00 X 0 0 0 Michael Montante 0.00 1.00 X 0 0 0 Charles J Urlaub 0.00 37.50 X X 0 477156 36336 Cynthia ZaneEdD 0.00 1.00 X 0 0 0 Monsignor Robert E Zapfel 0.00 1.00 X 0 0 0 James A Dunlop Jr 0.00 37.50 X 0 672603 115267 Dr Brian D'Arcy 0.00 37.50 X 0 578588 37824 Walter Ludwig 37.50 0.00 X 208444 0 31543 Michael Moley 0.00 37.50 X 0 614871 36811 John Stavros 0.00 37.50 X 0 283453 36599 Maria Foti 0.00 37.50 X 0 210430 26939 Bartholomew Rodrigues 0.00 37.50 X 0 224567 34605 Dr Michael Galang 0.00 37.50 X 0 393109 25395 Nancy Sheehan 0.00 37.50 X 0 249445 26369 Richard J Ruh MD 0.00 37.50 X 0 361371 32599 Dr Sanford Pleskow 37.50 0.00 X 170373 0 12574 Dr Nadezhda Polataiko 37.50 0.00 X 166699 0 87243 Dr Brenda Perez 37.50 0.00 X 159173 0 24301 Dr James Fitzpatrick 37.50 0.00 X 157320 0 31102 Dr Qamrunnisa Rahman 37.50 0.00 X 164255 0 81572 1348536 7897592 1122256 35 0 1 0 R & P Oak Hill Development Corporation 3556 Lakeshore Road Suite 620 Buffalo NY 14219 Construction Services 2399613 Siemens Medical Solutions Bank of NY Mellon PO Box 120001 De Dallas TX 75312 Maintenance Services 550959 Telco Construction 500 Buffalo Road East Aurora NY 14052 Construction Services 460445 Sodexho Operations LLC PO Box 360170 Pittsburgh PA 15251 Laundry Services 459732 Buffalo Niagara Hospitalists 2950 Elmwood Avenue/Med Staff Offic Kenmore NY 14217 Physician Services 448438 23 311010 311010 Patient Service Revenu 900099 94927490 94927490 Medicare/Medicaid 900099 53998357 53998357 148925847 85333 85333 257743 0 257743 257743 257743 Meaningful Use 900099 1964766 1964766 Cafeteria 900099 269952 269952 Shared Services 900099 82263 82263 253348 253348 2570329 152150262 148925847 0 2913405 63720377 45374399 18345978 3928772 2797624 1131148 12253680 8725676 3528004 3715088 2645463 1069625 275866 275866 10000 10000 4861726 2201854 2659872 75867 59094 16773 194170 151389 42781 262010 23567 238443 1820838 6441 1814397 19945 14612 5333 32416 17069 15347 1283953 1283953 7516716 4720614 2796102 1028530 586970 441560 Medical Supplies 29116372 29361711 -245339 Purchased Services 10902847 4290290 6612557 Equipment Rental & Main 3239823 1304287 1935536 Shared Services & Dues 1433700 0 1433700 1524109 1140732 383377 147216805 104991611 42225194 0 29570381 46474540 14589083 19376680 1641514 1887486 833296 1754233 99675473 53294426 43627547 46381047 15404268 19472878 105666087 135346864 18399995 22357655 12420239 25724309 10477175 9298824 50748413 60490151 92045822 117870939 X 12839819 16682433 780446 793492 13620265 17475925 105666087 135346864 X 4933457 -1077797 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 235852 235852 56809352 36407061 20402291 7436904 3083950 4352954 27983986 11319885 16664101 7209379 2483530 4725849 46381047 Insurance Recoveries 12863642 Interest in net assets of KMH Foundation 3914838 Due from Affiliates 1516733 Other Receivables 988383 Workers Compensation Funding Surplus 182614 Interest in net assets of CCD Foundation 6668 19472878 Pension Obligation 32597187 Long Term portion of Insurance Liabilities 18688189 Due to Affiliates 7066493 Interest Rate Swap 1830255 Asset Retirement Obligation 155339 Other Long Term Liabilities 152688 60490151 151839252 0 151839252 311010 311010 152150262 147216805 0 147216805 0 147216805 Part XI, Line 4b - Other Adjustments: Contributions from Foundations 311,010. 1 1 1 X 110.000000000000 1 X 500.000000000000 1 1 1 0 1 1 1340470 132241 1208229 0.00820 13007443 8905043 4102400 0.02790 14347913 9037284 5310629 0.03610 729074 729074 0.00500 1151438 1151438 0.00780 235009 235009 0.00160 2115521 2115521 0.01440 16463434 9037284 7426150 0.05050 584 584 0.00000 112489 112489 0.00080 6388 6388 0.00000 324 324 0.00000 4097 4097 0.00000 76013 76013 0.00050 199895 199895 0.00130 1 1792340 825536 29965923 30793066 -827143 X 1 0 1 1 Kenmore Mercy Hospital

2950 Elmwood Avenue Kenmore NY 14217

X X X Ambulatory Surgery, Dental O/P, Pediatric O/P, Audiology O/P, Kenmore Mercy Hospital 1 1 1 110.000000000000 1 500.000000000000 1 X X X X X X 1 1 X X X X X X X 1 0 1 X 0 1 3 Ken-Ton Family Care

300 Two Mile Creek Road Tonawanda NY 14150

Extension Clinic: Pediatric O/P, Prenatal O/P, Primary Medical Care O/P Williamsville Diagnostic Center

400 International Drive Williamsville NY 14221

Extension Clinic: Primary Medical Care, PT O/P, Radiology O/P, CT Scan, MRI McAuley Residence

1503 Military Road Kenmore NY 14217

Long Term Care, Radiology O/P, Clinical Laboratory O/P Part I, Line 6a: The Kenmore Mercy Hospital Community Benefit Report is contained in a report prepared by the Catholic Health System.Part I, Line 6b. Yes, the report is made available to the public by posting on the Catholic Health website www.chsbuffalo.org, as well as the annual submission to NYS for the Community Service Plan. Part I, Line 7: Costing is a full step down methodology of cost from non-revenue producing departments to revenue producing departments', with assignment of cost to individual charge items based on volume and charge amount. All patient accounts are cost with the same methodology regardless of patient type (inpatient, outpatient, emergency room, etc.) or insurance coverage (Medicare, Medicaid, private insurance, uninsured, etc.). Part I, L7 Col(f): Bad debt expenses of $3,789,302 are included in Part IX, line 25, column (A) but subtracted when calculating the percentage in column (f). Part II: Kenmore Mercy Hospital provided Community Building in the form of Economic Development, Community Support, Environmental Improvements, Coalition Building, Community Health Improvement Advocacy, and Workforce Development which improved community leadership by promoting understanding of community healthcare needs and services at various events throughout the community as well as mentoring and education to students regarding healthcare careers. Part III, Line 4: The amount in Part III line 2 is the actual bad debt expenses of $3,789,302 written down to cost, utilizing the Uninsured Ratio of Cost to Charges (RCC) obtained from the full step down methodology of cost described in Part 1, line 7. The amount in Part III line 3 is the estimate of bad debt from uninsured balance which is developed as follows: as policy is to write accounts to bad debt 120 days after discharge, the discharge date period of 10/1/2011 to 9/30/2012 was used to determine the population of uninsured accounts. The balance of these accounts was determined and the RCC was applied to develop the estimate in H Part III Line 3.As our determination of eligibility for the Healthcare Assistance Program (HAP) (Charity Care) is based solely on the presentation for care without insurance, which is now for each account, and use of a sophisticated estimator (PARO) of each guarantor's ability to pay an estimate of "the amount that reasonably could be attributable to patients who likely would qualify for financial assistance under the hospital's charity care policy if sufficient information had been available to make a determination of their eligibility" is not relevant.The organization's financial statements do not include a footnote that describes bad debt expense, but the financial statements account for bad debt expenses in the statement of operations as actual expenses written off and an estimate of future write-offs less any recoveries. Part III, Line 8: The costing methodology used to determine the Medicare Allowable costs is Cost to Charge. The shortfall is not treated as a community benefit. Part V, Section A: Audiology O/P, Clinic Part Time Services, Clinical Laboratory Services, Coronary Care, CT Scanner, Emergency Department, Health Fairs O/P,Intensive Care, Medical Social Services, Medical/Surgical, Nuclear Medicine-Diagnostic, Nuclear Medicine-Therapeutic, Pharmaceutical Service, Physical Medical Rehabilitation, Physical Medicine and Rehabilitation O/P, Primary Medical Care O/P, Radiology - Diagnostic, Renal Dialysis - Acute, Respiratory Care, Therapy - Occupational O/P, Therapy - Physical O/P, Therapy - Speech Language, Pathology Kenmore Mercy Hospital Part V, Section B, Line 14g: Includes information in both English and Spanish on all signage and brochures for financial assistance. Kenmore Mercy Hospital Part V, Section B, Line 20d: Highest volume commercial payor rate Kenmore Mercy Hospital Part V, Section B, Line 22: There are instances where the full charges on the account are equal to or less than the highest volume commercial payor rate. Part VI, Line 2: The Catholic Health System has recently conducted a Community Health Needs Assessment in 2013, which will be reported on the 12/31/2013 990 returns. For the 12/31/2012 990, the assessment conducted in previous years is being reported.In 2009, Kenmore Mercy Hospital, as part of Catholic Health, involved many participants in assessing community health needs including: 1. New York State Department of Health Prevention Agenda for the Healthiest State Erie County Department of Health Catholic Health Kaleida Health Erie County Medical Center Sheehan Memorial Hospital 2. Health Consumers 3. Patients/residents/clients A. Hospital Inpatients and Outpatients B. Nursing Home Residents and Families C. Rehabilitation Patients D. Primary Care Center Patients E. Home Care Clients 4. Physicians 5. External Organizations, such as Academia, Community-based organizations, elected officials, employers and business, Faith based organizations, governmental organizations, media, philanthropists and schools.6. Statistical Resources1. New York State Department of Health Prevention Agenda for the Healthiest State Catholic Health worked in collaboration with the Erie County Department of Health, Kaleida Health, ECMC and Sheehan Memorial on the Erie Co. DOH Prevention Agenda for the Healthiest State. In February 2009, an Erie County Joint Planning Committee formed to identify prevention priorities and strategies to focus on collaboratively over the next 3 years, which included: Chronic Disease, Healthy Mothers, Healthy Babies, Healthy Children, Physical Activity and Nutrition and Tobacco Use.2. Health Consumers In creating the Catholic Health and Kenmore Mercy Hospital strategic plan, input was sought from a variety of constituents including consumers. In August 2008, eight (8) consumer focus groups were conducted asking consumers what they wanted from their patient care experience. These focus groups were created by reaching out to 8,000 area residents who were asked to contact friends/families/neighbors to participate. 3. Patients/residents/clients A. Hospital Inpatients and Outpatients At the time of the assessment, Kenmore Mercy Hospital participated in a regional patient satisfaction survey through a cooperative effort with the Buffalo Niagara Health Quality Coalition and area hospitals. Patient participation was voluntary. This survey took place twice per year. Through hospital admission and outpatient ancillary sites, surveys were distributed to individuals to gain an understanding about their healthcare needs and how well their needs were being met. Currently, Hospital Care Quality Information (HCHAPS) is publicly reported.4. Physicians Kenmore Mercy Hospital surveys its medical staff annually. Physicians are surveyed on issues relating to the quality and efficiency of services offered throughout Catholic Health including at Kenmore Mercy Hospital. 5. External OrganizationsCatholic Health and Kenmore Mercy Hospital also engaged in the P2 Collaborative (Pursuing Perfection) dedicated to improving the health of people across the region. There are more than 200 participant organizations including the provider community, payers, community based organizations, religious organizations, local business, colleges & universities, and governmental agencies. Areas of focus include working with physicians and organizations to enhance access to care and improve efficiency of care and empowering all of the Western New York community to take responsibility for and act on their own wellness.In an effort to engage health care needs at the grass roots level, Catholic Health and Kenmore Mercy Hospital work closely with the following organizations to assess community health need:Niagara Health Quality Coalition, Community Cancer Coalition, American Heart Association, Near East & West Side Task Force, Baker Victory Services, Community Health Center of BuffaloWNY Osteoporosis Resource Ctr., WNY Health Equity Work Group, Living Healthy Task Force of Erie Co., Minority Health Coalition, Buffalo Public Schools Worksite Wellness, Flu CoalitionEvery Parent Influences Children (EPIC), Tobacco Coalition, WNY Coalition for Diabetes, Community Health Foundation, Erie Co. Coalition for Diabetes, WNED Public Television, Catholic Charities, Niagara University6. Statistical ResourcesCatholic Health and Kenmore Mercy Hospital used PQI (Preventable Quality Indicators) to map specific areas by zip code to better understand needs and target for need. We mapped specifically for Congestive Heart Failure, Hypertension, Angina & Diabetes to identify target areas for community education & screening initiatives. Other statistical resources used to assess the needs of the communities served included: "Buffalo Public Schools: Student Body Mass Index", "Erie County Health Assessment Indicators", and "Erie County Health Indicators Profile". Goals/Objectives for the priorities identified for Catholic Health and Kenmore Mercy include: -Increase consumer knowledge and adoption of healthy lifestyle behaviors by encouraging frequent physical activity and healthy nutrition, leading to improved health status and reduced chronic disease prevalence for residents of Buffalo and Erie County. -Increase participants' ability to identify risk factors for cardiovascular disease. -Lower body mass index (BMI) in youth; early identification of adolescents and adults with high blood pressure, high blood cholesterol and high blood glucose through screening and prevention interventions. -Implement a social marketing campaign to positively influence voluntary behavior of target population to take action to maximize health. -Restrict the availability of less healthy foods and beverages in public service venues in Buffalo and Erie County, such as schools, community centers and hospitals.In addition, Catholic Health and Kenmore Mercy utilize resources to manage their public relations and social marketing initiatives (public facing website, Facebook, Twitter, Pinterest, wellness blog, email newsletter, etc.); exponentially increasing the effectiveness of its outreach and the success of its Community Service Plan. 2013 Community Education targets: 10,000 biometric screenings (6,436 in underserved areas); 240 community programs held; 4,328 people in attendance at community programs.Measures of Effectiveness: -Number of educational programs held (240) and number of participants (4,328). Number of visits to website (775,320) -Number of program attendees who attended cardiovascular presentations (895). -Social media metrics: Facebook pages (4), Facebook fans (6,208), Twitter followers (1,607), website visitors (775,320), email newsletter subscribers (631), blog visitors (9,139). -Local government facilities, hospitals and school districts adopt policies that limit the portion size of any entree by either reducing the standard portion size of entrees or offering smaller portion sizes in addition to standard portion sizes. Part VI, Line 3: Kenmore Mercy Hospital informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the Catholic Health System Healthcare Assistance Program (HAP) policy. For example, Kenmore Mercy Hospital has posters and brochures available which include contact information for the Financial Clearance staff in admissions areas, emergency rooms, primary care and outpatient rehabilitation clinics, Revenue Management Center (RMC) and other areas of the organization's facilities where eligible patients are likely to be present; provides information about financial assistance and HAP contact information to patients as part of the intake process; provides financial assistance and HAP contact information to inpatients either during or within 90 days of discharge of their hospital stay; patient bills include the following language: "The Catholic Health System has a Healthcare Assistance Program to assist those in need of financial assistance for qualified patients. If you would like to obtain additional information on the Healthcare Assistance Program, please call (716) 601-3600. Thank you. Our Customer Service area is our front end team to assist all patients in this process." Additionally, we discuss with the patient the availability of various government benefits, such as Medicaid or state programs, and assist the patient with qualification for such programs, where applicable, and there is information about financial aid posted on the Catholic Health System website. Part VI, Line 4: Kenmore Mercy Hospital serves a mostly suburban partially urban service area which is comprised of 84.2% white (non-Hispanic) and 5.5% African-American (non-Hispanic) households. The service area is more elderly than most with 17.1% of the population over the age of 65 compared to a national average of 12.9%. The community consists of fewer households than the national average with annual incomes below $15,000/year at 12.8% compared to a national average of 13%.Although Kenmore Mercy Hospital is not located in a designated Health Professional Shortage Area (HPSA), the hospital draws patients from other HPSAs in the region and one of its extension clinics is in a designated HPSA area. Part VI, Line 5: Catholic Health System's community service activities at the acute facilities include benefits to the broader community, which include non-billed services and provided services paid below costs. Charity care and benefits to the community are provided through long term care facilities, home care programs and Catholic Health system-wide community programs. These programs touch more than 40,000 Western New York residents through community health education programs, health screenings (including: glucose, blood pressure, and cholesterol screenings; and cardiac, stroke, vascular, diabetes, nutrition, stress management, and women's community programming) clinical and support services, clerkships, internships, scholarships, in-kind donations and community support activities. Additionally, thousands of people make unique visits to the Catholic Health website seeking information about an individual or family healthcare issue, and follow Catholic Health on Facebook and Twitter (where daily posts talk to education and prevention of the priority areas) and receive relevant health information through the Catholic Health wellness blog and monthly email newsletter.The governing Board of Directors of Kenmore Mercy Hospital is comprised of community representatives from universities, legal communities, & business leaders. Religious orders are represented, as well as active and retired medical staff members.The Kenmore Mercy Hospital medical staff can be considered an "open" medical staff, as any physician can apply for privileges. Each application is reviewed by a vigorous credentialing verification process. Part VI, Line 6: Kenmore Mercy Hospital is affiliated with the Catholic Health System, Inc., a New York State licensed corporation. Catholic Health System, located in Buffalo, New York exempt from taxation and a charitable organization described in Section 501(c) (3) of the Internal Revenue Code of 1986. Catholic Health is also the parent company of the following New York State corporations: Mercy Hospital of Buffalo, Sisters of Charity Hospital (Main Street Campus) , and Sisters of Charity Hospital (St. Joseph Campus). Its outpatient and post-acute facilities (and services) include Mercy Ambulatory Care Center, Mercy Diagnostic and Treatment Center, Mercy Diagnostic Center, Sheridan Health Care Center, Sisters Central Park Diagnostic Center, Williamsville Diagnostic Center, Kenmore Specialty Center, Ken-Ton Family Care Center, Lovejoy/St. Vincent Health Center, Mercy Comprehensive Care Center, Mercy OB/GYN Center, OLV Family Care Center, Sisters OB/GYN Center, Springville Primary Care Center, Williamsville Primary Care Center, Catholic Health Home Care, St. Elizabeth's Home, St. Vincent's Home, Father Baker Manor, McAuley Residence, Mercy Nursing Facility at OLV, St. Catherine Laboure Health Care Center, and St. Francis of Williamsville. Reports Filed With States Part VI, Line 7 NY 1 X X X X X X 0 1 0 0 0 1 1 0 0 Joseph McDonald 0 691688 0 436815 0 342754 0 23055 0 15642 0 1509954 0 0 Mark Sullivan 0 420019 0 253093 0 164501 0 17302 0 13967 0 868882 0 0 James Millard 223041 0 60186 0 39045 0 145769 0 333 0 468374 0 0 0 David Macholz 0 177154 0 29346 0 25733 0 15747 0 18375 0 266355 0 0 Dr Paul Anain 0 223995 0 0 0 270 0 12631 0 263 0 237159 0 0 Peter Bergmann 0 355818 0 32583 0 44888 0 14545 0 18581 0 466415 0 0 Dr Michael Edbauer 0 207109 0 43465 0 32224 0 13275 0 13125 0 309198 0 0 Christine Kluckhohn 0 249437 0 29277 0 39207 0 103254 0 19313 0 440488 0 0 Charles J Urlaub 0 332714 0 87875 0 56567 0 21316 0 15020 0 513492 0 0 James A Dunlop Jr 0 372610 0 231359 0 68634 0 101350 0 13917 0 787870 0 0 Dr Brian D'Arcy 0 272987 0 29115 0 276486 0 19190 0 18634 0 616412 0 0 Walter Ludwig 150838 0 26195 0 31411 0 13535 0 18008 0 239987 0 0 0 Michael Moley 0 287705 0 145164 0 182002 0 22381 0 14430 0 651682 0 0 John Stavros 0 193171 0 50332 0 39950 0 20253 0 16346 0 320052 0 0 Maria Foti 0 165555 0 11344 0 33531 0 20195 0 6744 0 237369 0 0 Bartholomew Rodrigues 0 153335 0 32085 0 39147 0 16226 0 18379 0 259172 0 0 Dr Michael Galang 0 295137 0 59062 0 38910 0 20397 0 4998 0 418504 0 0 Nancy Sheehan 0 206291 0 16068 0 27086 0 19896 0 6473 0 275814 0 0 Richard J Ruh MD 0 311908 0 0 0 49463 0 17374 0 15225 0 393970 0 0 Dr Sanford Pleskow 146923 0 0 0 23450 0 11795 0 779 0 182947 0 0 0 Dr Nadezhda Polataiko 166492 0 0 0 207 0 69632 0 17611 0 253942 0 0 0 Dr Brenda Perez 125051 0 0 0 34122 0 5393 0 18908 0 183474 0 0 0 Dr James Fitzpatrick 139484 0 17060 0 776 0 14005 0 17097 0 188422 0 0 0 Dr Qamrunnisa Rahman 149633 0 0 0 14622 0 75312 0 6260 0 245827 0 0 0 Part I, Line 4b Certain Officers and Key employees participated in a supplemental nonqualified retirement plan per the terms and conditions of their employment arrangement. Pension Gap CHE SERP Joseph McDonald $26,000 $150,012 Mark Sullivan $39,000 Dr.Brian D'Arcy $9,800 $142,750 Michael Moley $20,697 Peter Bergmann $7,334 Part I, Line 6 The 2012 Incentive payments were dependent upon achieving the Catholic Health System Operating Income target for Catholic Health System participants or the Ministry Operating Income target for Ministry participants. Joseph McDonald $436,815 Mark Sullivan $253,093 James A. Dunlop, Jr. $231,359 Dr. Brian D'Arcy $29,115 Nancy Sheehan $16,068 Michael Moley $145,164 John Stavros $50,332 Christine Kluckhohn $29,277 Maria Foti $11,344 Bartholomew Rodrigues $32,085 Dr. Michael Galang $59,062 Dr. Michael Edbauer $43,465 David Macholz $29,346 Peter Bergmann $32,583 James Millard $60,186 Walter Ludwig $26,195 Dr. James Fitzpatrick $17,060 Charles Urlaub $87,875 A Dormitory Authority of the State of NY 146000293 64983Q5T2 2006-11-29 16730000 Part VI 0 0 0 B Dormitory Authority of the State of NY 146000293 649906J62 2012-07-12 14235000 Part VI 0 0 0 A 16730000 657688 99008 15973304 1998 1 0 1 1 B 14235000 954691 286690 563473 784874 11645272 2013 0 0 0 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 A 0 0 0 0 1 1 JP Morgan Chase NA 15.500000000000 1 0 0 0 0 B 0 0 0 0 0 0 0 0 0 A 0 B 0 Part I A (f) Description of Purpose To refund the New York State Medical Care Facilities Finance Agency FHA - Insured mortgage Project Revenue Bonds, 1995 Series B, which were applied to finance the construction of a three floor patient tower and refinance outstanding indebtedness. Part I B (f) Description of Purpose To finance the cost of construction, reconstruction, and equipping certain improvements to Kenmore's existing approximately 347,661 square foot hospital facility located at 2950 Elmwood Avenue, Kenmore, NY, including a new two-story addition that includes approximately 19,000 square feet on the first floor to house Kenmore's Emergency Department. Part IV (1) The bonds were issued by the Dormitory Authority of the State of New York on November 29, 2006. On or around December 1, 2011, DASNY performed a rebate analysis that indicated no rebate liability had accrued. An analysis completed by the Bond Trustee in October 2012 indicated that DASNY mistakenly excluded from their analysis bond proceeds that had been deposited into the current refunding escrow for the Refunded Bonds. Kenmore Mercy Hospital was first made aware of this error on October 24, 2012. Payment of the rebate, plus interest, was made to the IRS on March 29, 2013, within 180 days of the discovery. Susan Urlaub Wife of Mercy CEO, C.J. Urlaub 76847 Corporate Nurse Educator 0 James Manzella Acute Care Board Member 204991 Key Employee of Manzella Marketing 0 David Zapfel Brother of BOD, Msgr. Robert Zapfel 66713 HR Employee of CHS 0 Kathleen Zapfel Sister-in-law of BOD, Msgr. Robert Zapfel 57335 HR Employee of CHS 0 Susan Gallagher-Stavros Wife of Key Employee, John Stavros 21753 Nurse, McAuley Seton Home Care 0 Marie Packard Daughter of BOD, Dennis Dombek 55983 Mercy Physical Therapist 0 Dr Craig Fetterman Partner of Buffalo Niagara Hospitalists 448438 Acute Care Board Member 0 Form 990, Part VI, Section A, line 6 CHS has three members: Ascension Health, Catholic Health East, and the Diocese of Buffalo, NY. Each member is able to participate equally in electing the governing body, approving significant decisions of the governing body, and in receiving a share of net assets upon dissolution, according to the CHS Bylaws. Form 990, Part VI, Section A, line 7a According to the CHS Bylaws, each member is equally allowed to appoint up to three individuals to act as its representatives on the Corporate Member Board, and in undertaking any action in its capacity as a Member. The Corporate Member Board oversees the governance of the Catholic Health System. Form 990, Part VI, Section A, line 7b Each member is entitled to one vote on each matter properly submitted at any membership meeting, and the members also have reserve powers which allow approval for certain business events and ratification of certain business transactions. Form 990, Part VI, Section B, line 11 Yes, an electronic copy of the Form 990 was provided to the CHS Boards of Directors before it was filed. The CHS Board of Directors has delegated the responsibility to review the 990 to the Audit Committee. The CHS Audit Committee reviewed in detail selected information for all CHS entities. Reviewed with the Audit Committee: 1. Core Form Part IV: Checklist of required schedules 2. Core Form Part VI: Governance, Management and Disclosure 3. Core Form Part VII: Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees and Independent Contractors 4. Schedule H: Hospitals 5. Schedule K: Supplemental information on Tax Exempt Bonds 6. Schedule J: Compensation Information 7. Schedule L: Transactions with Interested Persons 8. Schedule R: Related Organizations and Unrelated Partnerships 9. Process for which remaining Core Form was completed, utilizing audited financial information Form 990, Part VI, Section B, line 12c All associates on the Merit program; all Physicians and Non Physician Practitioners as well as Physician groups who are independent contractors or employees of CHS; and all board members must complete a Conflict of Interest Disclosure Statement (COIDS) in order to fulfill the annual requirements. COIDS are distributed to all parties, as per applicable policy, and once complete are followed up with as follows: 1. Associate and Physician completed COIDS are reviewed and signed off by the manager. If a disclosure is noted, it is discussed with the manager, and the document is forwarded to the Compliance officer who reviews and follows up as appropriate. Once review/follow up is completed the Compliance Officer will sign the COIDS, maintain a copy in the compliance office and return the original to HR for filing in the Personnel file. 2. All board member COIDS are returned to Compliance Officer for review and follow up as warranted. The compliance officer will sign each COIDS and retain on file in the compliance office in a confidential manner. Form 990, Part VI, Section B, line 15 In 2012, the Catholic Health System utilized a Compensation Committee of the Board of Directors to monitor the Executive Compensation as per the Executive Compensation Philosophy and Strategy for the CHS CEO; COO; CFO; CEO's for each Ministry; and all Senior Vice Presidents. The Compensation Committee provides oversight to management decisions which are based on outlines approved by the committee, and performs a review of data. The outcome of these meetings is documented. Form 990, Part VI, Section C, line 19 We make our form 990 open for public inspection upon request. Our website includes an annual report which includes selected financial information. Our financial statements, governing documents and conflict of interest policy are provided upon request according to applicable federal and state laws. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Change in unrestricted interest in KMH Foundation 627,967. Change in Pension Obligation -1,795,460. Distributions to parent & affiliates 99,747. Change in temporarily restricted interest in KMH Foundation,Inc. 13,046. Change in unrealized loss on interest rate swap -23,097. Catholic Health System Inc 515 Abbott Road Buffalo NY 14220 222565278 Health Care Delivery System NY 501c Schedule A line 9 0 Mercy Hospital of Buffalo 565 Abbott Road Buffalo NY 14220 160756336 Acute Care Hospital NY 501c Schedule A line 3 Catholic Health System Inc 0 Sisters of Charity Hospital 2157 Main Street Buffalo NY 14214 160743187 Acute Care Hospital NY 501c Schedule A line 3 Catholic Health System Inc 0 Nazareth Home of the Franciscan Sisters 291 North Street Buffalo NY 14201 160813142 Skilled Nursing Facility NY 501c Schedule A line 9 Catholic Health System Inc 0 St Clare Manor 543 Locust Street Lockport NY 14094 160782647 Skilled Nursing Facility NY 501c Schedule A line 9 Catholic Health System Inc 0 St Elizabeth Home for the Aged 5539 Broadway Lancaster NY 14086 160743154 Adult Home NY 501c Schedule A line 9 Catholic Health System Inc 0 St Francis Home of Williamsville 147 Reist St Williamsville NY 14221 160743153 Skilled Nursing Facility NY 501c Schedule A line 9 Catholic Health System Inc 0 St Francis of Buffalo Inc 34 Benwood Ave Buffalo NY 14214 161523535 Skilled Nursing Facility NY 501c Schedule A line 9 Catholic Health System Inc 0 St Joseph Manor 2211 West State Street Olean NY 14760 160796400 Skilled Nursing Facility NY 501c Schedule A line 9 Catholic Health System Inc 0 St Luke Manor for the Chronically Ill 17 Wiard St Batavia NY 14020 160794811 Skilled Nursing Facility NY 501c Schedule A line 9 Catholic Health System Inc 0 St Mary's Manor 515 6th Street Niagara Falls NY 14301 160924139 Skilled Nursing Facility NY 501c Schedule A line 9 Catholic Health System Inc 0 St Vincent Manor 319 Washington Avenue Dunkirk NY 14048 160743167 Adult Home NY 501c Schedule A line 9 Catholic Health System Inc 0 WNY Catholic Long Term Care Inc 6400 Powers Rd Orchard Park NY 14127 161434368 Skilled Nursing Facility NY 501c Schedule A line 9 Catholic Health System Inc 0 Niagara Homemaker Services (Mercy Home Care) 2875 Union Rd Suite 14 Cheektowaga NY 14227 161317960 Home Care Provider NY 501c Schedule A line 9 Catholic Health System Inc 0 McAuley Seton Home Care 2875 Union Rd Suite 14 Cheektowaga NY 14227 161310062 Home Care Provider NY 501c Schedule A line 9 Catholic Health System Inc 0 Catholic Health System Infusion Pharmacy Inc 2875 Union Road Suite 14 Cheektowaga NY 14227 200198518 Home Care Infusion Services NY 501c Schedule A line 9 Catholic Health System Inc 0 CHS Program of All-Inclusive Care for the Elderly Inc 55 Melroy Avenue Lackawanna NY 14218 261252884 All-inclusive Care for the Elderly NY 501c Schedule A line 3 Catholic Health System Inc 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1