2011-11-15T08:05:47-06:00 2010-12-31 LUMSDEN & MCCORMICK LLP 403 MAIN ST SUITE 430 BUFFALO NY 14203 990 2010-01-01 160743301 BROOKS MEMORIAL HOSPITAL BROO 7163661111 529 CENTRAL AVENUE DUNKIRK NY 14048 JONATHAN I LAWRENCE 7163661111 2011-11-14 1 MICHAEL J GRIMALDI 7168563300 2010 2016-02-24 21:20:13Z JONATHAN I LAWRENCE 529 CENTRAL AVENUE DUNKIRK NY 14048 44943218 0 X WWW.BROOKSHOSPITAL.ORG X 1898 NY AN ACUTE CARE HOSPITAL SERVING PRIMARILY RESIDENTS OF NORTHERN CHAUTAUQUA COUNTY 18 18 538 34 4850 3503 753232 388899 40926064 40946341 33758 345236 787261 733891 42500315 42414367 0 0 0 0 21408145 22333813 0 0 0 18377029 18626409 39785174 40960222 2715141 1454145 31779593 32993278 6061272 5240302 25718321 27752976 SEE SCHEDULE O BELOW FOR FULL MISSION STATEMENT. 0 0 16513080 20365827 NURSING SERVICES - PROVISION OF DAILY CARE INCLUDING INPATIENT AND OUTPATIENT SERVICES WITHIN THE INSTITUTION 16971375 20777258 OTHER PROFESSIONAL SERVICES - ANCILLARY SERVICES PROVIDED WITHIN THE FACILITY INCLUDING LABORATORY, RADIOLOGY, INHALATION THERAPY, ETC. 33484455 1 1 0 0 0 0 0 0 1 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1 60 0 1 538 1 1 1 0 0 0 0 0 0 0 0 0 X 18 18 0 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X RALPH T WEBDALE 7163637212 529 CENTRAL AVENUE DUNKIRK NY 14048 CHRISTOPHER LANSKI 2.00 X X 0 0 0 TIMOTHY COOPER 2.00 X X 0 0 0 BRIAN FENZL 2.00 X X 0 0 0 LOUIS DIPALMA 2.00 X X 0 0 0 EUGENE BAILEN 2.00 X 0 0 0 WALTER GOTOWKA 2.00 X 0 0 0 RICHARD MILAZZO MD 2.00 X 0 0 0 DENNIS HEFNER PHD 2.00 X 0 0 0 DANA ANDERSON MD 2.00 X 0 0 0 THOMAS POSTLE 2.00 X 0 0 0 THOMAS SYROCZYNSKI 2.00 X 0 0 0 JAMES WILD 2.00 X 0 0 0 VIRGINIA COOPER 2.00 X 0 0 0 G JAY BISHOP MD 2.00 X 0 0 0 KEVIN OUWELEEN MD 2.00 X 0 0 0 DR SUSAN MCNAMARA 2.00 X 0 0 0 CRAIG BROWN 2.00 X 0 0 0 JOHN TALLETT 2.00 X 0 0 0 JONATHAN I LAWRENCE 40.00 X 397373 0 21457 RALPH T WEBDALE 40.00 X 104185 0 14295 TERESA LARSON 40.00 X 81090 0 15898 SALLIE PIAZZA 40.00 X 84238 0 11500 JOAN VANDETTE 40.00 X 70946 0 15374 737832 0 78524 1 0 1 0 LABORATORY CORPORATION OF AMERICA PO BOX 12140 BURLINGTON NC 27216 LAB SERVICES 387148 SUNBELT STAFFING PO BOX 1024640 ATLANTA GA 30368 AGENCY STAFFING 262869 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 100833 4 293778 95121 388899 PATIENT SERVICE REVENU 900099 40946341 40946341 40946341 173280 173280 18960 18960 18960 18960 2681134 19673 2490838 38013 190296 -18340 171956 171956 MEALS ON WHEELS 900099 222609 222609 CAFETERIA 900099 175233 175233 DISCOUNTS 900099 122388 122388 194701 74356 4850 115495 714931 42414367 41143085 4850 877533 816356 816356 16937719 14669104 2268615 956712 669331 287381 2348944 1601657 747287 1274082 854110 419972 30963 30963 196062 196062 13615 13615 10327893 9342756 985137 629781 629781 573156 429867 143289 70499 58371 12128 7686 7686 2450898 1955829 495069 399976 297728 102248 PROVISION FOR BAD DEBTS 1346495 1320366 26129 PURCHASED SERVICES 1108721 877554 231167 CONTRACT LABOR 797662 797662 MEDICAL SPECIALIST FEES 587934 587934 OTHER MISCELLANEOUS EXP 85068 14500 70568 40960222 33484455 7475767 0 4644400 3329406 3332523 4771344 26129 3154296 3701737 1281819 1289019 525425 551439 48387115 36235943 12886521 12151172 4648362 5786888 1280118 1412273 31779593 32993278 3171263 3277213 357758 108253 2532251 1854836 6061272 5240302 X 24934983 26995767 26129 0 757209 757209 25718321 27752976 31779593 32993278 X 1454145 580510 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1203740 114893 1318633 1007106 196634 1203740 1360203 14306 -367403 1007106 0.25000 0.75000 0 0 240363 240363 10401503 7753974 2647529 847329 701896 145433 36832825 27780073 9052752 65095 65095 12151172 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 723868 ACCRUED PENSION LIABILITY 1130968 1854836 42414367 40960222 1454145 214625 365885 580510 2034655 42388238 0 42388238 26129 26129 42414367 40934093 0 40934093 26129 26129 40960222 PART XI, LINE 8 - OTHER ADJUSTMENTS: ADJUSTMENT TO BENEFICIAL INTEREST IN TRUSTS 132,155. PENSION LIABILITY ADJUSTMENT 233,730. PART XII, LINE 4B - OTHER ADJUSTMENTS: CAPITAL CAMPAIGN - BAD DEBT EXPENSE 26,129. PART XIII, LINE 4B - OTHER ADJUSTMENTS: CAPITAL CAMPAIGN - BAD DEBT EXPENSE 26,129. 1 1 1 X 1 X 1 1 0 1 1 342455 91609 250846 0.00610 7339457 7279812 59645 0.00150 7681912 7371421 310491 0.00760 45891 45891 0.00110 32197 32197 0.00080 3389243 2394629 994614 0.02430 1153 1153 0.00000 3468484 2394629 1073855 0.02620 11150396 9766050 1384346 0.03380 1225 1225 0.00000 1487 1487 0.00000 21928 21928 0.00050 24640 24640 0.00050 0 621636 7624249 6835439 788810 X 1 1 1 1 BROOKS MEMORIAL HOSPITAL

529 CENTRAL AVENUE DUNKIRK NY 14048

X X X RENAL DIALYSIS BROOKS MEMORIAL HOSPITAL 1 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 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.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 - N/A PART I, LINE 7 COLUMN F BAD DEBT EXPENSE WAS NOT SUBTRACTED FROM THE AMOUNT ON FORM 990, PART XI, LINE 25, COLUMN A TO GET THIS PERCENTAGE. PART II: BROOKS MEMORIAL HOSPITAL IS IN A MEDICALLY UNDERSERVED AREA. SIGNIFICANT ONGOING EFFORTS AT PHYSICIAN RECRUITMENT CONSTITUTE THE BULK OF THE EXPENSE IN COMMUNITY BUILDING ACTIVITIES FOR WORKFORCE DEVELOPMENT. CURRENT PHYSICIAN SHORTAGES INCLUDE PRIMARY CARE, PEDIATRICS, OBSTETRICS, SURGERY, ORTHOPEDIC AND UROLOGY.UNDER COALITION BUILDING BROOKS MEMORIAL HOSPITAL IS AN ACTIVE MEMBER OF THE COUNTY WIDE DIABETES TASK FORCE. THE GOALS OF THIS ORGANIZAION ARE TO IDENTIFY PROBLEMS, PROPOSE AND IMPLEMENT CHANGES THAT AFFECT THE SYSTEM, PROMOTE GOOD HEALTH, ENCOURAGE PREVENTION, IMPROVE MANAGEMENT AND CREATE AWARENESS. PART III, LINE 4: PATIENT PAYMENTS AND DISCOUNTS ARE NOT COUNTED TOWARD BAD DEBT IF POSTED PRIOR TO AN ACCOUNT BEING TRANSFERRED TO BAD DEBT. ONCE IN BAD DEBT, PATIENT PAYMENTS AND DISCOUNTS ARE USED TO REDUCE BAD DEBT.PATIENT ACCOUNTS IN BAD DEBT THAT MAY HAVE BEEN ELIGIBLE FOR CHARITY CARE WERE DETERMINED BASED ON PRIOR ELIGIBILITY FOR CHARITY CARE OR FROM CREDIT CHECKS.FOOTNOTE TO AUDITED FINANCIAL STATEMENTS: THE HOSPITAL PROVIDES AN ALLOWANCE FOR DOUBTFUL COLLECTIONS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS. PART III, LINE 8: THE ALLOWABLE MEDICARE COST WERE TAKEN DIRECTLY FROM COST REPORT WORKSHEET E FOR PART A AND PART B. 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. BROOKS MEMORIAL HOSPITAL PART V, SECTION B, LINE 16E: 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 19D: 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 21: PATIENTS WHO DO NOT APPLY FOR FINANCIAL ASSISTANCE OR REQUEST A REDUCTION TO THEIR BILL WILL BE CHARGED THE GROSS CHARGE FOR SERVICSE PROVIDED. PART VI, LINE 2: THE HOSPITAL PARTICIPATES WITH OTHER HEALTHCARE PROVIDERS AND INTERESTED PARTIES IN THE CHAUTAUQUA COUNTY COMMUNITY HEALTH PLANNING TEAM (CCCHPT) TO ASSESS NEED REGIONALLY. THE HOSPITAL ALSO UTILIZES PATIENT SATISFACTION SURVEY TOOLS AND LOCAL PUBLIC INFORMATION PERTAINING TO POPULATION CHARACTERISTICS AND HEALTH STATUS. AT MONTHLY PUBLIC PRESENTATIONS OF HEALTH TOPICS, PROGRAM EVALUATION FORMS REQUEST INPUT FROM THE ATTENDEES FOR NEEDED SERVICES AND TOPICS. 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. IN THE HOSPITAL'S IMMEDIATE MUNICIPALITY 15.3% OF THE POPULATION IS 65 OR OLDER, 25.9% IS UNDER 20 YEARS OLD. 6.1% IS AFRICAN AMERICAN AND 26.4% IS HISPANIC. PART VI, LINE 6: 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. 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.BROOKS MEMORIAL HOSPITAL IS IN A MEDICALLY UNDERSERVED AREA. SIGNIFICANT ONGOING EFFORTS AT PHYSICIAN RECRUITMENT ARE EXPENDED. CURRENT PHYSICIAN SHORTAGES INCLUDE PRIMARY CARE, PEDIATRICS, OBSTETRICS, SURGERY, ORTHOPEDIC AND UROLOGY.THE HOSPITAL IS AN ACTIVE MEMBER OF THE COUNTY WIDE DIABETES TASK FORCE. THE GOALS OF THIS ORGANIZAION ARE TO IDENTIFY PROBLEMS, PROPOSE AND IMPLEMENT CHANGES THAT AFFECT THE SYSTEM, PROMOTE GOOD HEALTH, ENCOURAGE PREVENTION, IMPROVE MANAGEMENT AND CREATE AWARENESS.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 JCAHO, THE AMERICAN COLLEGE OF RADIOLOGY FOR MAMMOGRAPHY, MRI, CT SCAN, NUCLEAR MEDICINE AND ULTRASOUND, THE AMERICAN COLLEGE OF RADIATION ONCOLOGY, 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 URINARY TRACT INFECTIONS- INSTITUTION WIDE PROGRAM TO REDUCE CENTRAL LINE INFECTIONS- INSTITUTION WIDE PROGRAM TO REDUCE VENTILATOR-ASSOCIATED INFECTIONS. IN 2009 THE HOSPITAL HAD NO ICU DEVICE 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 HCAPHS. 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 7: N/A REPORTS FILED WITH STATES PART VI, LINE 7 NY X X 0 0 0 0 0 0 0 0 0 JONATHAN I LAWRENCE 397373 0 0 0 0 0 16500 0 4957 0 418830 0 0 0 WALTER GOTOWKA BOARD MEMBER OF THE PARTNER WITH LAWLEY INSURANCE - VENDOR OF THE HOSPITAL 59714 THE HOSPITAL PURCHASES INSURANCE FROM LAWLEY INSURANCE, WHERE MR. GOTOWKA IS A BRANCH PARTNER. 0 BRIAN FENZL BOARD MEMBER OF THE HO EMPLOYED BY M&T INSURANCE AGENCY - VENDOR OF THE HOSPITAL 12438 THE HOSPITAL MAINTAINS THEIR BOARD AND OFFICERS INSURANCE THROUGH M&T INSURANCE AGENCY WHERE MR. FENZL IS EMPLOYED 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 REVIEWED BY THE BOARD AND THE FINANCE COMMITTEE 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 EXECUTIVE DIRECTOR'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 THROUGH AN ANNUAL INSERT IN THE LOCAL NEWSPAPERS, ON THE HOSPITAL WEBSITE (WWW.BROOKSHOSPITAL.ORG) AND CERTAIN DOCUMENTS ARE AVAILABLE AT THE HOSPITAL AND AT PHYSICIANS' OFFICES. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 214,625. ADJUSTMENT TO BENEFICIAL INTEREST IN TRUSTS 132,155. PENSION LIABILITY ADJUSTMENT 233,730. TOTAL TO FORM 990, PART XI, LINE 5: 580,510. PART I, PART XI THE BOARD OF TRUSTEES ASSUME RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND THE SELECTION OF AN INDEPENDENT ACCOUNTANT. FULL MISSION STATEMENT 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 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 TLC HEALTH NETWORK N 209415 COMPENSATION