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PART V, SECTION B, LINE 5: TO DETERMINE THE MOST RELEVANT HEALTH ISSUES IN CHAUTAUQUA COUNTY, THE CHAUTAUQUA COUNTY COMMUNITY HEALTH PLANNING TEAM (CCCHPT) UTILIZED THREE STRATEGIES: INPUT FROM COMMUNITY MEMBERS, SECONDARY DATA FROM NYSDOH AND OTHER HEALTH RESOURCES, AND INPUT FROM LOCAL CONTENT AREA EXPERTS ACROSS A BROAD RANGE OF AGENCIES AND ORGANIZATIONS INCLUDING THOSE PROVIDING DIRECT HEALTH SERVICES, ADDICTION SERVICES, AGING, SOCIAL SERVICES, AND EDUCATION.COMMUNITY MEMBERS:THE CHAUTAUQUA COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES (CCDHHS) CONDUCTED A COMMUNITY HEALTH SURVEY FROM JANUARY THROUGH APRIL, 2022 TO GATHER INFORMATION ABOUT CHAUTAUQUA COUNTY'S CURRENT HEALTH STATUS, NEEDS, AND ISSUES. THE INPUT PROVIDED BY RESIDENTS HAS INFORMED OUR COMMUNITY HEALTH ASSESSMENT AND COMMUNITY HEALTH IMPROVEMENT PLANS BY JUSTIFYING HOW AND WHERE RESOURCES SHOULD BE USED. ALL COUNTY RESIDENTS WERE ENCOURAGED TO PARTICIPATE IN THE PROCESS BY TAKING THE SURVEY, WHICH WAS AVAILABLE IN ENGLISH AND SPANISH, AND PAPER AND ELECTRONIC VERSIONS. THE SURVEY WAS PROMOTED IN A VARIETY OF WAYS INCLUDING BUT NOT LIMITED TO PRESS RELEASES, MEDIA NOTIFICATION, CHAUTAUQUA COUNTY WEBSITE, PARTNER AGENCY SHARING, AND DISTRIBUTION THROUGH SENIOR MEAL DELIVERIES, SOCIAL MEDIA, EMAIL BLASTS, AND MORE. THE SURVEY TOOK 5-10 MINUTES TO COMPLETE. ALL INDIVIDUAL RESPONSES WERE CONFIDENTIAL. SURVEY RESPONDENTS HAD THE OPPORTUNITY TO PROVIDE CONTACT INFORMATION (NOT LINKED TO SURVEY ANSWERS) TO BE ENTERED TO WIN ONE OF FIVE $40 AMAZON GIFT CARDS THAT WERE GIVEN AWAY BY RANDOM DRAWING.AFTER IDENTIFYING POTENTIAL HEALTH IMPROVEMENT STRATEGIES FOR THE PROPOSED COLLABORATIVE PRIORITY AREAS, THE CCDHHS REACHED OUT TO THE CCCHPT AND HELD ONE-ON-ONE CONVERSATIONS WITH LOCAL CONTENT AREA EXPERTS TO ENSURE THAT THESE STRATEGIES WERE LOGICAL IN THE CONTEXT OF THE COMMUNITY AND CURRENT EFFORTS.EXPERTS CONSULTED:THE 2022-2024 COMMUNITY HEALTH ASSESSMENT PROCESS INVOLVED A GREAT DEAL OF COLLABORATION WITH LOCAL HOSPITALS AND COMMUNITY PARTNERS. CCCHPT FIRST CONVENED DURING THE 2020-2013 JOINT COMMUNITY HEALTH ASSESSMENT/COMMUNITY SERVICE PLAN PROCESS AND ONCE AGAIN JOINED FORCES TO PROVIDE IMPORTANT INPUT TO THIS PROCESS. INDIVIDUAL MEETINGS WERE HELD WITH ADDITIONAL PARTNERS TO IDENTIFY COMMUNITY NEEDS.THE CCCHPT CORE GROUP INCLUDED THE FOLLOWING ORGANIZATIONS AND REPRESENTATIVES:- BROOKS-TLC HOSPITAL SYSTEM, INC. - TRACY STEVENS, DIRECTOR OF PRIMARY CARE- CHAUTAUQUA COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES - BREEANNE AGETT, EPIDEMIOLOGIST; SHELLY WELLS, PUBLIC HEALTH PLANNER; CHRISTINE SCHUYLER, DIRECTOR OF HEALTH AND HUMAN SERVICES- CHAUTAUQUA COUNTY DEPARTMENT OF MENTAL HYGIENE - CARMELO HERNANDEZ, DIRECTOR OF MENTAL HYGIENE; RACHEL MEMBER-LUDWIG, PROJECT COORDINATOR- CHAUTAUQUA COUNTY HEALTH NETWORK - JIM SHERRY, EXECUTIVE DIRECTOR- THE CHAUTAUQUA CENTER - MICHAEL PEASE, EXECUTIVE DIRECTOR- UPMC CHAUTAUQUA - CECIL MILLER, ADMINISTRATOR; TONI DEANGELO, DIRECTOR OF COMMUNITY WELLNESS- ALLEGHENY HEALTH NETWORK WESTFIELD MEMORIAL HOSPITAL - RODNEY BUCHANAN, HOSPITAL ADMINISTRATOR BROOKS-TLC HOSPITAL SYSTEM, INC. PART V, SECTION B, LINE 6A: UPMC CHAUTAUQUAAHN WESTFIELD MEMORIAL HOSPITAL BROOKS-TLC HOSPITAL SYSTEM, INC. PART V, SECTION B, LINE 6B: THE HEALTH FOUNDATION FOR WESTERN & CENTRAL NEW YORK'S 2022 REPORT COMMUNITY HEALTH NEEDS AND OPPORTUNITIES IN WNY'S SOUTHERN TIER; AND THE 2021 CHAUTAUQUA COUNTY COMMUNITY-LEVEL YOUTH DEVELOPMENT EVALUATION (CLYDE) SURVEY. NEW YORK STATE COMMUNITY HEALTH INDICATOR REPORTS ALSO INFORM OUR CHIP FOCUS AREA OF INTERVENTION. BROOKS-TLC HOSPITAL SYSTEM, INC. PART V, SECTION B, LINE 11: NEEDS IDENTIFIED:1. PREVENT CHRONIC DISEASE; FOCUS - OBESITY IN ADULTS & CHILDREN.BROOKS-TLC HOSPITAL SYSTEM, INC.'S DIETITIAN PROVIDES A FULL ASSESSMENT/CONSULTATION TO INPATIENTS.2. PROMOTE HEALTH WOMEN, INFANTS & CHILDREN. INPATIENT OBSTETRIC SERVIES HAVE BEEN TEMPORARILY SUSPENDED SINCE OCTOBER 4, 2021 DUE TO STAFFING CHALLENGES DESPITE ONGOING RECRUITMENT EFFORTS. PRECIPITOUS DELIVERIES ARE MANAGED THROUGH THE EMERGENCY DEPARTMENT.3. PROMOTE MENTAL HEALTH AND PREVENT SUBSTANCE ABUSE; FOCUS - STRENGTHEN INFRASTRUCTURE ACROSS SYSTEMS.BROOKS-TLC HOSPITAL SYSTEM, INC. COORDINATES WITH ITS OUTPATIENT SUBSTANCE USE DISORDER CLINICS OR THROUGH COMMUNICATION WITH CHAUTAUQUA SUBSTANCE ABUSE RESPONSE PARTNERSHIP TO TREAT SUBSTANCE ABUSE ON MENTAL HEALTH DIAGNOSES SEEN IN THE EMERGENCY ROOM. PATIENTS SEEN IN THE ER RECEIVE REFERRALS FOR FUTHER TREATMENT/COUNSELING TO ITS OUTPATIENT SUD CLINICS, MENTAL HEALTH AMERICA , PEER RECOVERY SUPPORT SERVICES, CHAUTAUQUA COUNTY MOBILE CRISIS TEAM, AND NY MATTERS. BROOKS-TLC HOSPITAL SYSTEM, INC. PART V, SECTION B, LINE 24: PATIENTS WHO DO NOT APPLY FOR FINANCIAL ASSISTANCE OR REQUEST A REDUCTION TO THEIR BILL WILL BE CHARGED THE GROSS CHARGE FOR SERVICES PROVIDED. PART I, LINE 7: RCC USED AS CALCULATED IN WORKSHEET 2. PART II, COMMUNITY BUILDING ACTIVITIES: BROOKS-TLC HOSPITAL SYSTEM, INC. ACTIVELY PARTICIPATES IN LOCAL INITIATIVES INVOLVING CHAUTAUQUA COUNTY HEALTH NETWORK. AS A PARTICIPANT IN THESE ORGANIZATIONS THE HOSPITAL IS ABLE TO ASSESS NEED, IMPLEMENT PROGRAMS AND INTERVENTIONS AND FACILITATE COMMUNITY BUILDING AROUND EMERGING HEALTH RELATED ISSUES TO IMPROVE HEALTH OUTCOMES FOR LOCAL AND UNDERSERVED COMMUNITIES. PART III, LINE 2: RCC USED AS CALCULATED IN WORKSHEET 2 FOR PART III, LINE 2 TO CALCULATE BAD DEBT COST. PATIENT PAYMENTS AND DISCOUNTS ARE NOT COUNTED TOWARD BAD DEBT IF POSTED PRIOR TO AN ACCOUNT BEING TRANSFERRED TO BAD DEBT. ONCE IN BAD DEBT, PATIENT PAYMENTS AND DISCOUNTS ARE USED TO REDUCE BAD DEBT. PART III, LINE 3: THERE WERE NO PATIENTS TURNED OVER TO BAD DEBT WHO QUALIFIED FOR CHARITY CARE. PATIENTS ELIGIBLE FOR CHARITY CARE WHO OWED BALANCES WERE NOT TURNED OVER TO BAD DEBT EVEN THOUGH THEY DID NOT PAY THEIR BALANCES. BAD DEBTS ARE INCLUDED AS A COMMUNITY BENEFIT COST BECAUSE A HIGH PROPORTION OF BAD DEBT DERIVES FROM PATIENTS WHO ARE NOT ABLE TO PAY FOR SERVICES AND THAT THE PROVISION OF SUCH SERVICES AT A LOSS CONSTITUTES A FORM OF COMMUNITY BENEFIT. IT IS DIFFICULT FOR A HOSPITAL TO DISTINGUISH THESE PATIENTS WHO FAIL TO RESPOND TO ANY COMMUNICATION AND/OR EFFORT TO DETERMINE ELIGIBILITY FOR CHARITY CARE. PART III, LINE 8: THE ALLOWABLE MEDICARE COSTS WERE TAKEN DIRECTLY FROM COST REPORT WORKSHEET D. IRS REV. RUL. 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENT HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THIS IMPLIES THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT.IN THIS COMMUNITY, MEDICARE IS THE LARGEST PAYER, AND THE HOSPITAL MUST ACCEPT THESE PATIENTS REGARDLESS OF WHETHER THEY MAKE A SURPLUS OR DEFICIT FROM PROVIDING SUCH SERVICES. IF THE MEDICARE PARTICIPATION IS PREMISED ON THIS FACT, THEN PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES WHICH IS A COMMUNITY BENEFIT.THERE ARE A NUMBER OF LOW-INCOME CONSUMERS RECEIVING MEDICARE.THE ELDERLY ARE OFTEN AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE SERVICES, CMS WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY.MEDICARE PAYMENT ANOMALIES MAY BE PRESENT IN SOME STATES SO EVEN VERY EFFICIENT HOSPITALS ARE UNABLE TO AVOID LOSSES. THUS, LOSSES MAY NOT BE INDICATIVE OF INEFFICIENCY BUT RATHER PROVISION OF A COMMUNITY BENEFIT. PART III, LINE 9B: PATIENTS THAT QUALIFY FOR THE FAP OUTSTANDING BALANCES ARE SUBJECT TO COLLECTION PRACTICES AS DEFINED IN THE FAP POLICY. IF AFTER COLLECTION ATTEMPTS, THE PATIENT CANNOT PAY THE BALANCE, THE HOSPITAL WILL WORK WITH THE PATIENT ON A PAYMENT PLAN. PART VI, LINE 2: THE HOSPITAL PARTICIPATES WITH OTHER HEALTHCARE PROVIDERS AND INTERESTED PARTIES IN THE CHAUTAUQUA COUNTY COMMUNITY HEALTH PLANNING TEAM (CCCHPT), THE CHAUTAUQUA CENTER, THE RESOURCE CENTER, CHAUTAUQUA COUNTY OFFICE FOR THE AGING, PREVENTION WORKS, CHAUTAUQUA COUNTY MENTAL HYGIENE, CHAUTAUQUA HEALTH NETWORK, CHAUTAUQUA HOSPICE AND PALLIATIVE CARE, AND THE CHAUTAUQUA COUNTY TRANSPORTATION COALITION, TO ASSESS THE NEED REGIONALLY. IN 2021 AN EXTENSIVE COMMUNITY HEALTH NEEDS ASSESSMENT WAS PERFORMED. SEE SECTION V, PARTS B AND C FOR ADDITIONAL INFORMATION ON THE CHNA.THE HOSPITAL ALSO UTILIZES PATIENT SATISFACTION SURVEY TOOLS AND LOCAL PUBLIC INFORMATION PERTAINING TO POPULATION CHARACTERISTICS AND HEALTH STATUS. PART VI, LINE 3: 1. INFORMATION ABOUT THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY IS PROVIDED UPON ADMISSION, IS POSTED ON THE HOSPITAL WEBSITE, THROUGHOUT THE HOSPITAL, AND PROVIDED THROUGH THE CHAUTAUQUA COUNTY HEALTH NETWORK. STAFF IN THE HOSPITAL HAVE ALSO BEEN IN-SERVICED ABOUT THE FINANCIAL ASSISTANCE PROGRAM SO THAT THEY CAN PROVIDE INFORMATION TO PATIENTS AS WELL.2. BROOKS-TLC HOSPITAL SYSTEM, INC. HAS ARRANGED WITH AN AGENCY TO FACILITATE ENROLLING IN THE MEDICAID PROGRAM. THE AGENCY WILL PROVIDE EDUCATION, ASSISTANCE IN COMPLETING THE APPLICATION, AND REPRESENTS THE PATIENT AT THE MEDICAID AGENCY. IN ADDITION, THE AGENCY ASSISTS WITH ENROLLMENT THROUGH THE STATE'S INSURANCE EXCHANGE SITE.3. FINANCIAL ASSISTANCE PROGRAM - BROOKS-TLC HOSPTIAL SYSTEM, INC. CONTINUES TO EDUCATE AND PROVIDE FINANCIAL ASSISTANCE OPTIONS FOR THOSE THAT ARE UNINSURED OR UNABLE TO PAY. IN ADDITION TO THE HOSPITAL'S OWN FINANCIAL ASSISTANCE POLICY BROCHURE, BUSINESS OFFICE PERSONNEL WILL CONTINUE TO DISTRIBUTE BROCHURES DEVELOPED BY CCHN TO ASSIST THE UNINSURED OR UNDERINSURED TO FIND AFFORDABLE HEALTHCARE. PATIENT FINANCIAL SERVICES STAFF WILL CONTINUE TO BE EDUCATED REGARDING ALL AVAILABLE ASSISTANCE IN OBTAINING HEALTH INSURANCE. PART VI, LINE 4: THE HOSPITAL'S PRIMARY SERVICE AREA IS NORTHERN CHAUTAUQUA COUNTY IN NEW YORK AND INCLUDES THE CITY & TOWN OF DUNKIRK, VILLAGES OF FREDONIA, BROCTON, CASSADAGA, FORESTVILLE, AND THE TOWNS OF POMFRET, PORTLAND, STOCKTON, SHERIDAN, AND ARKWRIGHT. THE SECONDARY SERVICE AREA INCLUDES THE TOWNS OF HANOVER, CHERRY CREEK, VILLENOVA AND WESTFIELD. PART VI, LINE 5: THE BOARD OF TRUSTEES IS A COMMUNITY BOARD, MADE UP ENTIRELY OF CIVIC AND COMMUNITY LEADERS, WHO SERVE VOLUNTARILY. THE BOARD APPOINTS THE CEO, APPROVES BUDGETS, DEVELOPS STRATEGIC PLANS AND PROVIDES OVERSIGHT FOR THE HOSPITAL IN GENERAL. POTENTIAL CONFLICT OF INTEREST BETWEEN BOARD MEMBERS AND THE HOSPITAL ARE REVIEWED ANNUALLY.THE HOSPITAL'S MEDICAL STAFF IS COMPRISED OF QUALIFIED PHYSICIANS FROM WITHIN THE COMMUNITY. THE HOSPITAL CONTRACTS DIRECTLY FOR EMERGENCY ROOM PHYSICIANS, A PATHOLOGIST, A RADIOLOGIST, AN ANESTHESIOLOGIST, AND HOSPITALIST PHYSICIANS, AND EMPLOYS PHYSICIANS FOR THE PRIMARY CARE AND OUTPATIENT SUBSTANCE USE DISORDER CLINICS AND THE HOSPITALIST PROGRAM.THE HOSPITAL OPERATES A FULL-TIME EMERGENCY ROOM OPEN TO ALL PATIENTS, REGARDLESS OF THEIR ABILITY TO PAY. PATIENTS COME TO THE EMERGENCY ROOM BY THEIR OWN TRANSPORTATION OR BY AMBULANCE FROM EITHER A LOCAL FIRE DEPARTMENT OR AN INDEPENDENT AMBULANCE BUSINESS THAT SERVES THE ENTIRE COUNTY. IN ORDER TO ENSURE 24 HOUR PHYSICIAN COVERAGE IN THE ER, THE HOSPITAL PROVIDES A SUBSIDY TO THE ER PHYSICIAN GROUP. NON EMERGENCY CARE IS PROVIDED BASED UPON PHYSICIAN ORDERS TO ALL PATIENTS, REGARDLESS OF THEIR ABILITY TO PAY.SURPLUS FUNDS ARE INVESTED IN MEDICAL EQUIPMENT UPGRADES AND NEW TECHNOLOGIES THROUGH A CAPITAL BUDGET PROCESS. THERE ARE NO "OWNERS OR STOCKHOLDERS SO NO SURPLUS FUNDS ARE PAID OUT TO OWNERS OR STOCKHOLDERS.THE HOSPITAL WORKS TO ENSURE AN ADEQUATE BLOOD SUPPLY IN THE COMMUNITY AND SURROUNDING AREAS BY HOSTING PERIODIC BLOOD DRIVES IN COOPERATION WITH CONNECT LIFE. THE HOSPITAL STRIVES TO IMPROVE THE QUALITY OF PATIENT CARE BY A VARIETY OF ACCREDITATIONS, SURVEYS AND BENCHMARKS INCLUDING:THE HOSPITAL IS ACCREDITED THROUGH DNV, THE AMERICAN COLLEGE OF RADIOLOGY FOR MAMMOGRAPHY, MRI, CT SCAN, NUCLEAR MEDICINE AND ULTRASOUND, AND THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION FOR THE CARDIAC REHABILITATION DEPARTMENT. THE HOSPITAL TAKES A PROACTIVE APPROACH TO THE PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS, INCLUDING:- INSTITUTION WIDE PROGRAM TO PROMOTE EFFECTIVE HAND WASHING- INSTITUTION WIDE PROGRAM TO REDUCE CATHETER RELATED URINARY TRACT INFECTIONS- INSTITUTION WIDE PROGRAM TO REDUCE CENTRAL LINE INFECTIONS- INSTITUTION WIDE PROGRAM TO REDUCE VENTILATOR-ASSOCIATED INFECTIONS THE HOSPITAL MEETS OR EXCEEDS NATIONAL AND STATE BENCHMARKS FOR THE USE OF ANTIBIOTICS RELATED TO SURGERY.THE HOSPITAL EXCEEDS NATIONAL AND STATE BENCHMARKS FOR THE PREVENTION OF BLOOD CLOTS AFTER SURGERY.THE HOSPITAL UTILIZES BAR CODE MEDICATION ADMINISTRATION TO REDUCE/ELIMINATE MEDICATION ERRORS.THE HOSPITAL USES PATIENT SURVEYS THROUGH BOTH PRESS GANEY AND HCAHPS. AREAS THAT MEASURED BELOW AVERAGE ARE REVIEWED WEEKLY AND BEING ADDRESSED THROUGH:- BEDSIDE REPORT- POST DISCHARGE CALLS TO ASSURE PATIENTS UNDERSTAND THEIR MEDICATION INSTRUCTIONS- CUSTOMER SERVICE TRAINING PART VI, LINE 6: BROOKS-TLC HOSPITAL SYSTEM, INC. WORKS CLOSELY WITH COMMUNITY ORGANIZATIONS BOTH IN DETERMINING THE HEALTH NEEDS OF THE COMMUNITIES SERVED AS WELL AS DECIDING HOW BEST TO MEET THESE NEEDS. OFFICIALS FROM THE HOSPITAL HAVE BEEN SELECTED TO WORK ON VARIOUS PROJECTS TO FURTHER THIS CAUSE, INCLUDING RESEARCING COMMUNITY HEALTH NEEDS, WORKING WITH LOCAL HEALTH ORGANIZATIONS THROUGHOUT THE COUNTY AND BEYOND, DEVELOPING A FREE COMMUNITY WELLNESS PROGRAM CALLED HEALTHQUEST WNY, PROMOTING HEALTHQUEST WNY AND OTHER HEALTH RELATED EVENTS, DEVELOPING AND PROMOTING HEALTHY LIFESTYLE CLASSES AT OUR FACILITIES, REACHING OUT TO IDENTIFIED POPULATIONS OF NEED, AND MORE. PART VI, LINE 7, REPORTS FILED WITH STATES NY X 0 0 0 0 0 0 0 0 0 JULIE MORTON CHIEF NURSING OFFICER 230786 0 0 0 0 0 9649 0 1665 0 242100 0 0 0 NAJMUL KHAN PHYSICIAN 299142 0 0 0 0 0 14686 0 12709 0 326537 0 0 0 KENNETH LONG REGISTERED NURSE 122163 0 0 0 0 0 15715 0 15348 0 153226 0 0 0 DAVID HALLASEY-ROBERTS PHYSICIAN 132772 0 0 0 0 0 6669 0 18612 0 158053 0 0 0 LISA BARONE DIRECTOR OF INFECTION CONT 136263 0 0 0 0 0 6434 0 8994 0 151691 0 0 0 CAROLINE FEARMAN REGISTERED NURSE 130723 0 0 0 0 0 13359 0 11932 0 156014 0 0 0 PART III, LINE I MISSION TO PROVIDE HIGH VALUE CARE TO ADVANCE HEALTH AND WELLNESS. VISION TO BE TRUSTED FOR PROVIDING THE BEST QUALITY AND COMPASSIONATE CARE FOR A HEALTHIER COMMUNITY. CLINICAL EXCELLENCE: WE WILL DELIVER THE BEST CLINICAL CARE IN A CONSISTENT, INTEGRATED WAY. PATIENT ENGAGEMENT: WE WILL PROVIDE A COMPASSIONATE HEALING EXPERIENCE, AND WE WILL ENGAGE PATIENTS IN DECISIONS ABOUT THEIR HEALTH AND CARE. OPERATIONAL EFFECTIVENESS: WE WILL BE WISE AND CAREFUL STEWARDS OF OUR RESOURCES TO ENABLE EXTRAORDINARY CARE. PHYSICIAN ENGAGEMENT: WE WILL CREATE SYSTEMS AND PROCESSES THAT HELP OUR PHYSICIANS BEST SERVE THEIR PATIENTS. COMMUNITY STEWARDSHIP: WE ARE COMMITTED TO SERVING THE DIVERSE NEEDS OF THE REGION, AND TO PROVIDE GENERALLY AVAILABLE MEDICAL SERVICES TO ALL RESIDENTS, REGARDLESS OF ABILITY TO PAY. EMPLOYEE ENGAGEMENT: WE VALUE OUR EMPLOYEES AS OUR MOST IMPORTANT RESOURCE. VALUES - I CARE INTEGRITY OUR ACTIONS ARE GUIDED BY OUR ETHICAL COMMITMENTS - IN PUBLIC INTERACTIONS AND PRIVATE ACTIONS, WE DEDICATE OURSELVES TO SERVICE IN THE BEST INTERESTS OF OUR PATIENTS, THEIR FAMILIES, OUR HOSPITAL AND OUR COMMUNITY. - WE FOLLOW THROUGH ON OUR COMMITMENTS, HOLDING OURSELVES ACCOUNTABLE TO FULFILL OUR PROFESSIONAL OBLIGATIONS. - WHEN WE RECOGNIZE SOMETHING SEEMS WRONG, INAPPROPRIATE OR INCONSISTENT WITH OUR VALUES OR STANDARDS, WE PROACTIVELY SPEAK UP AND TAKE POSITIVE ACTION. - WE ACT WITH OPENNESS, HONESTY, TRANSPARENCY AND TRUSTWORTHINESS IN OUR COMMUNICATION. -AT ALL TIMES WE RESPECT THE DIGNITY, PRIVACY AND CONFIDENTIALITY OF THOSE WE SERVE. COMPASSION WE PROVIDE EXCELLENCE WITH PERSONAL KINDNESS - WITH UNDERSTANDING AND EMPATHY, WE ANTICIPATE THE NEEDS OF OTHERS AND ACT TO APPROPRIATELY AND MEANINGFULLY MEET THESE NEEDS. - BY ACTIVELY LISTENING TO THE PERSPECTIVES, VALUES AND NEEDS OF OTHERS, WE ACT TO BUILD BRIDGES TOWARD WHOLENESS. - OUR INTERACTIONS ARE CHARACTERIZED BY RESPECT, COURTESY, WARMTH AND PROFESSIONAL DIGNITY. - WE MAINTAIN AN ENGAGED, FOCUSED AND PERSONAL PRESENCE WHILE IN SERVICE TO OTHERS, CREATING AND SUSTAINING A THERAPEUTIC MILIEU. ACCOUNTABILITY WE TAKE RESPONSIBILITY FOR PERSONAL AND TEAM ACTIONS - WE FULLY ADOPT AND EMBRACE OUR CORE PROFESSIONAL IDENTITY AS THOSE WHOSE TALENTS ARE PLACED IN THE SERVICE OF OTHERS FOR THEIR BENEFIT. - IN ALL OUR INTERACTIONS WE DEMONSTRATE THE HIGHEST PROFESSIONAL STANDARDS OF ETHICS, KNOWLEDGE, SKILL AND COMPETENCE IN DECISION-MAKING AND WORK PERFORMANCE. - IN OUR APPEARANCE, DEMEANOR AND DEPORTMENT WE CONTINUOUSLY SEEK TO CONVEY A PROFESSIONAL IMAGE. - WE APPROACH CHALLENGES IN A MANNER THAT REFLECTS PROFESSIONAL MATURITY, CONFIDENCE AND RESPECT. RESPECT WE ADVOCATE FOR THE DIGNITY OF OTHERS - IN OUR BEHAVIOR TOWARD OTHERS, WE DEMONSTRATE RESPECT FOR THE PERSONAL AUTONOMY, INTRINSIC DIGNITY AND WORTH, AND INDIVIDUAL UNIQUENESS OF EACH PERSON WE SERVE, AND THOSE WITH WHOM WE SERVE. - WE VALUE THE RICH DIVERSITY OF PERSONAL EXPERIENCE, CULTURAL INSIGHT, PROFESSIONAL IDENTITY AND TRAINING IN ACHIEVING COLLABORATIVE GOALS. - WE DEMONSTRATE OUR CONSIDERATION FOR OTHERS BY REGARDING WITH EMPATHY THE FEELINGS AND NEEDS OF OTHERS, AND REGARDING WITH INSIGHT THE EFFECT ON OTHERS OF OUR OWN BEHAVIOR. - WE ACTIVELY SEEK OUT OPPORTUNITIES TO DEMONSTRATE OUR REGARD AND APPRECIATION FOR OTHERS. EXCELLENCE COMMITMENT TO QUALITY, INNOVATION AND CONTINUOUS IMPROVEMENTS - WE CONTINUOUSLY CHALLENGE THE STATUS QUO IN THE RELENTLESS PURSUIT OF EXCELLENCE. - WE UTILIZE QUANTITATIVE AND QUALITATIVE INFORMATION TO FORM THE BASIS FOR MEASURABLE AND DEMONSTRABLE IMPROVEMENTS IN OUTCOMES. - EACH OF US DEMONSTRATES A PERSONAL COMMITMENT TO THE HIGHEST STANDARDS OF SAFETY, QUALITY AND SERVICE. - INDIVIDUALLY, AND AS HIGH PERFORMING TEAMS, WE CONSCIENTIOUSLY WORK TO BETTER OUR BEST ON A DAILY BASIS. - WE ACTIVELY EMBRACE CHANGE IN THE CONTINUOUS PURSUIT OF INNOVATION AND SUPERIOR CARE. FORM 990, PART VI, SECTION A, LINE 7B THE DECISIONS OF THE GOVERNING BODY ARE SUBJECT TO APPROVAL OF BOARD MEMBERS. FORM 990, PART VI, SECTION B, LINE 11B THE 990 IS PREPARED AND REVIEWED BY VARIOUS INDIVIDUALS WITHIN MANAGEMENT AND PROVIDED TO THE GOVERNING BODY PREVIOUS TO ITS FILING WHEN TIME ALLOWS OR AT ITS NEXT MEETING WHEN TIME DOES NOT PERMIT REVIEW PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C DEPARTMENT MANAGERS, ADMINISTRATION, BOARD MEMBERS, AND MATERIAL MANAGEMENT EMPLOYEES SIGN A CONFLICT OF INTEREST STATEMENT ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION B, LINE 15 THE PRESIDENT/CEO'S AND OTHER EXECUTIVES' COMPENSATION IS REVIEWED AND APPROVED BY THE EXECUTIVE COMMITTEE OF THE BOARD. WAGES AND INCREASES ARE COMPARED TO INDUSTRY STANDARDS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC ON THE HOSPITAL WEBSITE (WWW.BROOKSHOSPITAL.ORG) AND CERTAIN DOCUMENTS ARE AVAILABLE AT THE HOSPITAL AND AT PHYSICIANS' OFFICES. FORM 990, PART IX, LINE 11G COLLECTION FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 194,503. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 194,503. PHYSICIAN AND OTHER HEALTHCARE PROVIDER FEES: PROGRAM SERVICE EXPENSES 5,037,369. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,037,369. PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 844,875. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 844,875. SERVICE CONTRACTS: PROGRAM SERVICE EXPENSES 836,921. MANAGEMENT AND GENERAL EXPENSES 156,591. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 993,512. MAINTENANCE CONTRACTS: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 1,093,724. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,093,724. FORM 990, PART XI, LINE 9: NET CHANGE IN FUNDS HELD IN TRUST 627,231. PENSION LIABILITY ADJUSTMENT -274,374. FORM 990, PART XII, LINE 2C THE BOARD OF DIRECTORS ASSUME RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND THE SELECTION OF AN INDEPENDENT ACCOUNTANT. LAKE SHORE NURSING HOME INC 845 ROUTES 5 20 IRVING NY 14081 160976895 SKILLED NURSING FACILITY NY 501(C)(3) LINE 3 BROOKS-TLC HEALTH SYSTEM INC 0 LSP CORPORATION 845 ROUTES 5 20 IRVING NY 14081 222827314 REAL ESTATE - MEDICAL AND ADMINISTRATIVE OFFICE FACILITY NY 501(C)(3) LINE 3 BROOKS-TLC HEALTH SYSTEM INC 0 LAKE ERIE MEDICAL SERVICES PC 529 CENTRAL AVENUE DUNKIRK NY 14048 452832259 PHYSICIAN GROUP NY C 0 0 0 0 1 0 0 0 0 0 1 0 1 1 1 0 1 1 0 0