2023-11-14T13:48:25-06:00 2022-12-31 161226221 FUSTCHARLES LLP 220 S WARREN STREET SYRACUSE NY 13202 990 2022-01-01 900909506 CLIFTON-FINE HEALTH CARE CORPORATION CLIF 3158483351 1014 OSWEGATCHIE TRAIL STAR LAKE NY 13690 DIERDRA SORRELL CEO 3158483351 2023-11-13 1 DIERDRA SORRELL 999009999 1 PATRICK CAPELLA P01359200 3154463600 2023-11-13 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z DIERDRA SORRELL 1014 OSWEGATCHIE TRAIL STAR LAKE NY 13690 9819352 0 X WWW.CLIFTONFINEHOPSITAL.ORG X 2012 NY SEE SCHEDULE OTHE PURPOSE FOR WHICH THE CORPORATION WAS ORGANIZED IS TO OWN AND OPERATE THE HEALTH CARE FACILITY KNOWN AS "CLIFTON-FINE HOSPITAL". CLIFTON-FINE HEALTH CARE CORPORATION IS A CRITICAL ACCESS HOSPITAL WHICH PROVIDES HEALTH CARE SERVICES FOR THE BENEFIT OF THE RESIDENTS OF THE STATE OF NEW YORK AND THE TOWNS OF CLIFTON AND FINE, INCLUDING PERSONS IN NEED OF HEALTH CARE SERVICES WITHOUT THE ABILITY TO PAY AS REQUIRED BY LAW. 12 11 110 16 0 0 1576879 395310 9743571 9135764 4014 52787 1237426 235491 12561890 9819352 0 0 0 0 5262254 5990991 0 0 0 4699553 5400621 9961807 11391612 2600083 -1572260 13740997 9465538 5771890 3209562 7969107 6255976 X SEE SCHEDULE OTHE PURPOSE FOR WHICH THE CORPORATION WAS ORGANIZED IS TO OWN AND OPERATE THE HEALTH CARE FACILITY KNOWN AS "CLIFTON-FINE HOSPITAL". CLIFTON-FINE HEALTH CARE CORPORATION IS A CRITICAL ACCESS HOSPITAL WHICH PROVIDES HEALTH CARE SERVICES FOR THE BENEFIT OF THE RESIDENTS OF THE STATE OF NEW YORK AND THE TOWNS OF CLIFTON AND FINE, INCLUDING PERSONS IN NEED OF HEALTH CARE SERVICES WITHOUT THE ABILITY TO PAY AS REQUIRED BY LAW. 0 0 9470855 9371255 A CRITICAL ACCESS HOSPITAL PROVIDING HEALTH CARE SERVICES FOR THE BENEFIT OF THE RESIDENTS OF THE STATE OF NEW YORK AND THE TOWNS OF CLIFTON AND FINE. 9470855 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 6 0 1 110 1 0 0 0 0 0 0 0 0 0 0 0 0 X 12 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X DIERDRA SORRELL CEO 3158484260 1014 OSWEGATCHIE TRAIL RD STAR LAKE NY 13690 THOMAS SAUTER CHAIRPERSON 1.00 X X 0 0 0 LEEANN SHORT VICE-CHAIR 1.00 X X 0 0 0 DAVID DAUT SECRETARY 1.00 X X 0 0 0 THOMAS CARMAN BOARD MEMBER 1.00 43.50 X 0 880166 57874 ALLEN DITCH BOARD MEMBER 1.00 X 0 0 0 SADIE HALL BOARD MEMBER 1.00 X 0 0 0 CRIS NARGI BOARD MEMBER 1.00 X 0 0 0 CHUCK HOOVEN BOARD MEMBER 1.00 X 0 0 0 JOHN WHEELER BOARD MEMBER 1.00 X 0 0 0 HALSEY BAGG BOARD MEMBER 1.00 X 0 0 0 MAJONICA DRAKE BOARD MEMBER 1.00 X 0 0 0 JOHN BURNS BOARD MEMBER 1.00 X 0 0 0 DIERDRA SORRELL CEO/EX-OFFICIO 39.00 1.00 X X 0 184995 31789 MAXINE BRIGGS CFO/TREASURER 1.00 39.00 X X 0 453847 46030 DAVID I MICHAELSON DOCTOR 40.00 X 233945 0 12259 JACQUELINE C SNYDER PHYSICIAN ASSISTANT 40.00 X 165246 0 8005 MATTHEW ZEGIL NURSE PRACTITIONER 40.00 X 195655 0 13337 BRITTANI BICKEL PHYSICIAN ASSISTANT 40.00 X 154098 0 4136 BYRON EVANS PHYSICIAN ASSISTANT 40.00 X 124800 0 1810 873744 1519008 175240 5 0 1 0 APOGEE MEDICAL MANAGEMENT 15059 N SCOTTSDALE ROAD SUITE 600 SCOTTSDALE AZ 85254 MEDICAL SERVICES 845455 SAMARITAN MEDICAL CENTER 830 WASHINGTON STREET WATERTOWN NY 13601 MEDICAL SERVICES 663557 WESTWAYS STAFFING SERVICES INC 790 THE CITY DR S STE 180 ORANGE CA 92868 STAFFING SERVICES 334877 MEDEFIS CONSOLIDATED 2121 N 117TH AVE STE 200 OMAHA NE 68164 BILLING SERVICES 246300 ESP PERSONNEL 72030 METROPLEX DR THOUSAND PALMS CA 92276 STAFFING SERVICES 210611 5 65561 261685 68064 395310 NET PATIENT REVENUE 900099 9135764 9135764 9135764 52787 52787 OTHER OPERATING REV 900099 137439 137439 340B REVENUE 900099 98052 98052 235491 9819352 9371255 0 52787 X 4966626 4507641 458985 84559 76745 7814 584433 530423 54010 355373 335460 19913 9082 9082 161845 161845 6035 6035 2792209 2101838 690371 23287 23287 99236 82108 17128 173715 143733 29982 250944 207632 43312 18887 15627 3260 63234 5019 58215 325592 302850 22742 127252 127252 MEDICAL SUPPLIES 1212847 1090292 122555 BAD DEBT 57146 57146 LICENSES AND DUES 45323 37500 7823 NYS CASH RECEIPTS ASSES 33987 33987 11391612 9470855 1920757 0 5999089 2054734 713912 2581322 407483 482113 2322771 1119967 228606 225775 328495 175130 9760481 7799187 2005316 1961294 1735325 865203 13740997 9465538 3489918 1149836 890652 801711 1391320 1258015 5771890 3209562 X 6801221 5149581 1167886 1106395 7969107 6255976 13740997 9465538 -1572260 -140871 0 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 6035 6035 0 PART II-B, LINE 1: THE HOSPITAL PAID 6,035 IN DUES TO THE HEALTHCARE ASSOCIATION OF NEW YORK STATE (HANYS). 1167886 329749 391240 1106395 636137 1576879 1045130 1167886 624282 3564738 3552883 636137 680172 296932 352822 624282 675048 277887 272763 680172 0.02504 0.97496 0 0 2222 2222 3668566 2679460 989106 733097 176018 557079 5356596 4943709 412887 1961294 INSURANCE BENEFIT RECEIVABLE 265203 DUE FROM AFFILIATES 600000 865203 CONTRACT LIABILITY - MEDICARE 265203 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS, NET 992812 1258015 X PART X, LINE 2: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AND HAS BEEN RECOGNIZED AS TAX-EXEMPT PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AS OF DECEMBER 31, 2022 AND 2021, THE HOSPITAL DID NOT HAVE ANY UNRECOGNIZED TAX BENEFITS OR ANY RELATED ACCRUED INTEREST OR PENALTIES. THE TAX YEARS OPEN TO EXAMINATION BY FEDERAL AND STATE TAXING AUTHORITIES ARE 2019 THROUGH 2022. THE HOSPITAL DOES NOT ANTICIPATE THAT THE TOTAL UNRECOGNIZED TAX BENEFITS WILL CHANGE IN THE NEXT TWELVE MONTHS. 1 1 X 1 X 1 X 1 1 1 0 0 133846 116979 16867 0.00160 1700916 1830386 0 0.00000 1298309 1141093 157216 0.01460 3133071 3088458 174083 0.01620 3133071 3088458 174083 0.01620 1 625077 4812 4058853 4367083 -308230 X 1 0 1 1 CLIFTON-FINE HEALTH CARE CORPORATION 1014 OSWEGATCHIE TRAIL STAR LAKE NY 13690 X X X X CLIFTON-FINE HEALTH CARE CORPORATION 1 0 0 1 X X X X X X X X X 22 1 1 1 1 X HTTP://SAMARITANHEALTH.COM/LOCATION/CLIFTON-FINE-HOSPITAL/ X WWW.STLAWCO.ORG/DEPARTMENTS/PUBLICHEALTH/ X 1 22 1 HTTP://WWW.SAMARITANHEALTH.COM/LOCATION/CLIFTON-FINE-HOSPITAL/ 0 1 X 200.000000000000 300.000000000000 X X 1 1 X X X X 1 X HTTP://SAMARITANHEALTH.COM/LOCATION/CLIFTON-FINE-HOSPITAL/ X HTTP://SAMARITANHEALTH.COM/LOCATION/CLIFTON-FINE-HOSPITAL/ X HTTP://SAMARITANHEALTH.COM/LOCATION/CLIFTON-FINE-HOSPITAL/ X X X X X 1 X 0 X 1 X 0 1 CLIFTON-FINE HEALTH CARE CORPORATION PART V, SECTION B, LINE 5: FORMAL SURVEYS OF LOCAL RESIDENTS, CREATED BY ST. LAWRENCE COUNTY COLLEGES. CLIFTON-FINE HEALTH CARE CORPORATION PART V, SECTION B, LINE 6A: OTHER HOSPITALS INVOLVED THROUGH THE NORTH COUNTRY INITIATIVE - CLAXTON HEPBURN MEDICAL CENTER, MASSENA MEMORIAL HOSPITAL, GOUVERNEUR HOSPITAL, AND CANTON POTSDAM HOSPITAL CLIFTON-FINE HEALTH CARE CORPORATION PART V, SECTION B, LINE 6B: THE HOSPITAL'S CHNA WAS DEVELOPED IN PARTNERSHIP WITH THE ST. LAWRENCE HEALTH INITIATIVE, ST. LAWRENCE COUNTY PUBLIC HEALTH, OTHER AREA HOSPITALS, ST. LAWRENCE COUNTY SUICIDE PREVENTION COALITION, ST. LAWRENCE COUNTY COLLEGES AND UNIVERSITITES, AND COMMUNITY-BASED ORGANIZATIONS. CLIFTON-FINE HEALTH CARE CORPORATION PART V, SECTION B, LINE 11: A THREE YEAR ACTION PLAN WAS DEVELOPED AS PART OF THE CHNA ACCOMPLISHMENTS, THE PLAN INCLUDES: 1.) ADDITION OF MENTAL HEALTH SERVICE INTEGRATED INTO PRIMARY CARE. THIS INCLUDES A LICENSED MENTAL HEALTH COUNSELOR AND A LICENSED CLINICAL SOCIAL WORKER. 2.) COMMUNITY WELLNESS COMMITTEE MADE UP OF HOSPITAL STAFF AND COMMUNITY VOLUNTEERS. ACTIVITIES INCLUDE "WEIGHT WATCHERS" PROGRAM, EXERCISE CLASSES, AND HEALTHY EATING EDUCATIONAL PROGRAMS. CLIFTON-FINE HEALTH CARE CORPORATION PART V, SECTION B, LINE 13B: BY HOUSEHOLD INCOME AS A PERCENTAGE OF FPL. CLIFTON-FINE HEALTH CARE CORPORATION PART V, SECTION B, LINE 24: YES IF THAT PATIENT HAD HEALTH INSURANCE AND WE WERE DISCOUNTING A CO-PAY OR DEDUCTIBLE. PART I, LINE 3C: THE HOSPITAL OFFERS FINANCIAL ASSISTANCE TO EACH PATIENT WITH A HOUSEHOLD INCOME GREATER THAN 200% AND LESS THAN 400% OF THE FEDERAL POVERTY LEVEL ESTABLISHED BY THE FEDERAL GOVERNMENT (THE FPL) IF SUCH INDIVIDUAL HAS NO INSURANCE OR HAS EXHAUSTED HIS OR HER HEALTH INSURANCE BENEFITS FOR EMERGENCY OR OTHER MEDICALLY NECESSARY HOSPITAL CARE AND IS UNABLE TO PAY THE FULL CHARGES FOR THOSE SERVICES. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 625,077. PART III, LINE 2: CFH'S BAD DEBT EXPENSE IS CONFIGURED THROUGH THE ORGANIZATIONS INTERNAL OPERATION SYSTEM, CPSI. PART III, LINE 3: CLIFTON-FINE HOSPITAL'S BAD DEBT EXPENSE IS CONFIGURED THROUGH THE ORGANIZATIONS INTERNAL OPERATING SYSTEM, CPSI. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLES ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTABLILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS AND FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL). THE HOSPITAL RECORDS A PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. PART III, LINE 8: DUE TO THE COMMUNITY'S LARGE MEDICARE POPULATION, THE TOTAL SHORTFALL IS CONSIDERED TO BE PART OF THE COMMUNITY BENEFIT EXPENSE. PART III, LINE 9B: OUR POLICY STATES THE PERCENTAGE TO WHICH THE PATIENTS ACCOUNT WILL BE REDUCED BY AND IT ALSO STATES ACTIONS THAT WILL BE TAKEN IF THE PATIENT ACCOUNT IS NOT PAID. PART VI, LINE 2: THE ORGANIZATION ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES THROUGH MONTHLY SURVEYS. PART VI, LINE 3: POSTERS ARE PUT THROUGHOUT THE FACILITY, ESPECIALLY IN THE WAITING AREAS AND IN REGISTRATION, NOTING THE CHARITY CARE ASSISTANCE POLICY. INFORMATION IS ALSO GIVEN TO THOSE THAT DO NOT HAVE INSURANCE IF INQUIRING. PART VI, LINE 4: FINE COMMUNITY IS LOCATED IN THE RURAL, NORTHWEST PORTION OF NEW YORK STATE'S ADIRONDACK PARK. THE HOSPITAL IS LOCATED IN SOUTHERN ST. LAWRENCE COUNTY AND SERVICES THE TOWNSHIPS OF CLIFTON, FINE AND THE SURROUNDING AREA. WE HAVE APPROXIMATELY 6,700 YEAR-ROUND RESIDENTS. THE POPULATION EXPANDS BY APPROXIMATELY 30% IN THE SUMMER MONTHS. PART VI, LINE 5: WE ARE PARTICIPATING IN A COMMUNITY NEEDS SURVEY. WE OFFER SEVERAL COMMUNITY WELLNESS PROGRAMS, AND WE HAVE SEVERAL PLANNED OVER THE NEXT COUPLE OF YEARS CENTERING ON WOMEN'S HEALTH, CHILDREN AND WE ARE CURRENTLY OFFERING WELLNESS EXAMS TO THE VETERANS IN OUR COMMUNITY. PART VI, LINE 6: PASSIVE PARENT MODEL WITH SAMARITAN MEDICAL CENTER, SAMARITAN MEDICAL CENTER HELPS WITH THE IMPLEMENTATION PLAN. PART VI, LINE 7, REPORTS FILED WITH STATES NY X 0 0 0 0 0 0 0 0 0 THOMAS CARMAN BOARD MEMBER 0 699733 0 174933 0 5500 0 11200 0 46674 0 938040 0 0 MAXINE BRIGGS CFO/TREASURER 0 433347 0 0 0 20500 0 17300 0 28730 0 499877 0 0 DAVID I MICHAELSON DOCTOR 233945 0 0 0 0 0 3392 0 8867 0 246204 0 0 0 DIERDRA SORRELL CEO/EX-OFFICIO 0 184995 0 0 0 0 0 3700 0 28089 0 216784 0 0 MATTHEW ZEGIL NURSE PRACTITIONER 195655 0 0 0 0 0 2837 0 10500 0 208992 0 0 0 JACQUELINE C SNYDER PHYSICIAN ASSISTANT 165246 0 0 0 0 0 2396 0 5609 0 173251 0 0 0 BRITTANI BICKEL PHYSICIAN ASSISTANT 154098 0 0 0 0 0 2234 0 1902 0 158234 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 SAMARITAN MEDICAL CENTER IS THE SOLE MEMBER OF CLIFTON-FINE HEALTH CARE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A AS THE SOLE MEMBER, SAMARITAN MEDICAL CENTER CAN APPOINT ONE OR MORE MEMBERS OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B SAMARITAN MEDICAL CENTER, AS THE SOLE CORPORATE MEMBER, ALSO HAS THE RIGHT TO APPROVE SIGNIFICANT DECISIONS OF THE ORGANIZATION'S GOVERNING BODY, INCLUDING AMENDMENT OF BYLAWS AND GOVERNING DOCUMENTS AND CHANGE OF MEMBERS OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11B THE 990 WAS REVIEWED IN DETAIL BY MANAGEMENT AND THE FINAL 990 WAS E-MAILED TO THE BOARD PRIOR TO THE NOVEMBER 15, 2023 FILING DATE. FORM 990, PART VI, SECTION B, LINE 12C CLIFTON-FINE HEALTH CARE CORPORATION REQUIRES ALL BOARD MEMBERS TO DISCLOSE ANNUALLY INTERESTS THAT COULD GIVE RISE TO CONFLICTS. THE CONFLICT OF INTEREST STATEMENTS ARE SUMMARIZED AND REVIEWED BY THE EXECUTIVE COMMITTEE TO IDENTIFY POTENTIAL CONFLICTS OF INTERESTS. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS UTILIZED COMPENSATION COMPARABILITY DATA AND THE BOARD APPROVES THE COMPENSATION FOR THE CEO. THE CEO DETERMINES THE COMPENSATION OF THE KEY EMPLOYEES OF THE ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 19 CLIFTON-FINE HEALTH CARE CORPORATION WILL MAKE ITS GOVERNING DOCUMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G LAB & MEDICAL EXPENSES: PROGRAM SERVICE EXPENSES 2,101,838. MANAGEMENT AND GENERAL EXPENSES 690,371. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,792,209. FORM 990, PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. WILDERNESS HEALTHCARE FOUNDATION 1014 OSWEGATCHIE TRAIL STAR LAKE NY 13690 223235671 TO PROVIDE FUNDS TO OR FOR THE BENEFIT OF CLIFTON-FINE HOSPITAL. NY 501(C)(3) LINE 11 CLIFTON-FINE HEALTH CARE CORPORATION 0 SAMARITAN MEDICAL CENTER 830 WASHINGTON STREET WATERTOWN NY 13601 150533577 HOSPITAL NY 501(C)(3) LINE 3 SCH A N/A 0 SAMARITAN KEEP NURSING HOME 133 PRATT STREET WATERTOWN NY 13601 160969838 SKILLED NURSING FACILITY NY 501(C)(3) LINE 3 SCH A SAMARITAN MEDICAL CENTER 0 EDWARD J NOBLE HOSPITAL 104 PADDOCK STREET SUIT 104 WATERTOWN NY 13601 237227989 HOSPITAL NY 501(C)(3) LINE 3 SCH A SAMARITAN MEDICAL CENTER 0 SAMARITAN SENIOR VILLAGE INC 22691 CAMPUS DRIVE WATERTOWN NY 13601 454913668 SENIOR CITIZEN COMMUNITY NY 501(C)(3) LINE 3 SCH A SAMARITAN MEDICAL CENTER 0 SMC FOUNDATION OF NNY INC 830 WASHINGTON STREET WATERTOWN NY 13601 161490523 PROVIDES FUNDS FOR SMC AND AFFILIATES NY 501(C)(3) LINE 7 SCH A SAMARITAN MEDICAL CENTER 0 SAMARITAN HOME HEALTH 165 COLEMAN AVENUE WATERTOWN NY 13601 461043637 CERTIFIED HOME HEALTH AGENCY NY 501(C)(3) LINE 10 SCH A SAMARITAN MEDICAL CENTER 0 SAMARITAN MEDICAL PRACTICE PC 830 WASHINGTON STREET WATERTOWN NY 13601 261528342 PHYSICIAN MEDICAL PRACTICE NY 501(C)(3) SCHED A, PART 1, LN3 SAMARITAN MEDICAL CENTER 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0