GOUVERNEUR HOSPITAL: Form 990, tax year 2020
View the entire original 990 at ProPublica ↗
- Organization
- GOUVERNEUR HOSPITAL (EIN 46-4249555)
- Tax period
- 2020-01-01 to 2020-12-31
- Filed
- 2021-11-15
- IRS object ID
- 202103199349325020
- Schema version
- 2020v4.0
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule J
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2021-11-15T16:35:04-06:00 | ReturnTs |
| Tax Period End | 2020-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 822624857 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GRAY & GRAY AND ASSOCIATES CPAS PC | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1 MAIN STREET SUITE 101 | AddressLine1Txt |
| City | CANTON | CityNm |
| State Abbreviation | NY | StateAbbreviationCd |
| ZIP | 136171277 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2020-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 464249555 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GOUVERNEUR HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | GOUV | BusinessNameControlTxt |
| Phone | 3152871000 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 77 WEST BARNEY STREET | AddressLine1Txt |
| City | GOUVERNEUR | CityNm |
| State Abbreviation | NY | StateAbbreviationCd |
| ZIP | 13642 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | KELLY CICCHINELLI | PersonNm |
| Person Title | CONTROLLER | PersonTitleTxt |
| Phone | 3152871000 | PhoneNum |
| Signature | 2021-10-18 | SignatureDt |
Signing Officer SigningOfficerGrp
Person Full Name PersonFullName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person First | KELLY | PersonFirstNm |
| Person Last | CICCHINELLI | PersonLastNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| SSN | 999009999 | SSN |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | JOHN J GRAY JR CPA | PreparerPersonNm |
| PTIN | P00076464 | PTIN |
| Phone | 3153862925 | PhoneNum |
| Preparation | 2021-11-15 | PreparationDt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2020 | TaxYr |
| Build TS | 2022-09-23 18:48:47Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | KELLY CICCHINELLI | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 77 WEST BARNEY STREET | AddressLine1Txt |
| City | GOUVERNEUR | CityNm |
| State Abbreviation | NY | StateAbbreviationCd |
| ZIP | 13642 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $30,616,735 | GrossReceiptsAmt |
| Group Return For Affiliates | false | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.GVNRHOSPITAL.ORG | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 2013 | FormationYr |
| Legal Domicile State | NY | LegalDomicileStateCd |
| Activity Or Mission | OUR MISSION IS TO PROVIDE SKILLED, COMPASSIONATE, COST-EFFECTIVE CARE THAT PROMOTES WELLNESS AND MEETS THE COMMUNITY'S HEALTHCARE NEEDS. | ActivityOrMissionDesc |
| Voting Members Governing Body | 9 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 6 | VotingMembersIndependentCnt |
| Total Employee | 259 | TotalEmployeeCnt |
| Total Volunteers | 2 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| PY Contributions Grants | $83,371 | PYContributionsGrantsAmt |
| CY Contributions Grants | $4,303,619 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $22,898,581 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $23,768,257 | CYProgramServiceRevenueAmt |
| PY Investment Income | $72,371 | PYInvestmentIncomeAmt |
| CY Investment Income | $53,221 | CYInvestmentIncomeAmt |
| PY Other Revenue | $2,463,380 | PYOtherRevenueAmt |
| CY Other Revenue | $2,191,901 | CYOtherRevenueAmt |
| PY Total Revenue | $25,517,703 | PYTotalRevenueAmt |
| CY Total Revenue | $30,316,998 | CYTotalRevenueAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $14,049,641 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $14,419,741 | CYSalariesCompEmpBnftPaidAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $9,843,180 | PYOtherExpensesAmt |
| CY Other Expenses | $11,183,858 | CYOtherExpensesAmt |
| PY Total Expenses | $23,892,821 | PYTotalExpensesAmt |
| CY Total Expenses | $25,603,599 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $1,624,882 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $4,713,399 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $16,154,381 | TotalAssetsBOYAmt |
| Total Assets EOY | $21,451,302 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $8,777,531 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $8,974,904 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $7,376,850 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $12,476,398 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | OUR MISSION IS TO PROVIDE SKILLED, COMPASSIONATE, COST-EFFECTIVE CARE THAT PROMOTES WELLNESS AND MEETS THE COMMUNITY'S HEALTHCARE NEEDS. | MissionDesc |
| Significant New Program Srvc | false | SignificantNewProgramSrvcInd |
| Significant Change | false | SignificantChangeInd |
| Expense | $15,108,071 | ExpenseAmt |
| Revenue | $32,988,681 | RevenueAmt |
| Desc | GOUVERNEUR HOSPITAL HAS A TOTAL OF 25 LICENSED BEDS, COMPRISED OF SWING, ALC, MED-SURG AND DETOXIFICATION. IN 2020, THERE WERE TOTAL PATIENT DAYS OF 5,720, 224 OBSERVATION CASES AND 933 DISCHARGES. | Desc |
Prog Srvc Accom Acty2 ProgSrvcAccomActy2Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $2,263,280 | ExpenseAmt |
| Revenue | $7,657,315 | RevenueAmt |
| Desc | IN 2020, THE ER VISITS DECREASED APPROXIMATELY 28% FROM 9,882 IN 2019 TO 7,151 IN 2020. | Desc |
Prog Srvc Accom Acty3 ProgSrvcAccomActy3Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $1,396,658 | ExpenseAmt |
| Revenue | $1,857,098 | RevenueAmt |
| Desc | THERE WAS A DECREASE DUE TO THE CLOSURE OF THE ANTWERP CLINIC AND THE IMPACT OF COVID. THERE WERE 8,506 VISITS IN 2020 COMPARED TO 9,444 IN 2019, ROUGHLY A 10% DECREASE. | Desc |
Prog Srvc Accom Acty Other ProgSrvcAccomActyOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $436,402 | ExpenseAmt |
| Revenue | $644,608 | RevenueAmt |
| Desc | THERE WAS DECREASE IN SURGERIES PERFORMED IN 2020. THERE WERE 202 SURGERIES IN 2020, COMPARED TO 617 IN 2019, ROUGHLY A 67% DECREASE. | Desc |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Prog Srvc Expense | $436,402 | TotalOtherProgSrvcExpenseAmt |
| Total Other Prog Srvc Revenue | $644,608 | TotalOtherProgSrvcRevenueAmt |
| Total Program Service Expenses | $19,204,411 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (true) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (true) | ScheduleBRequiredInd |
| Political Campaign Acty | false | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (true) | LobbyingActivitiesInd |
| Subject To Proxy Tax | false | SubjectToProxyTaxInd |
| Donor Advised Fund | false | DonorAdvisedFundInd |
| Conservation Easements | false | ConservationEasementsInd |
| Collections Of Art | false | CollectionsOfArtInd |
| Credit Counseling | false | CreditCounselingInd |
| Donor Rstr Or Quasi Endowments | Yes (true) | DonorRstrOrQuasiEndowmentsInd |
| Report Land Building Equipment | Yes (true) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | false | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | false | ReportProgramRelatedInvstInd |
| Report Other Assets | Yes (true) | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (true) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (true) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | false | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (true) | ConsolidatedAuditFinclStmtInd |
| School Operating | false | SchoolOperatingInd |
| Foreign Office | false | ForeignOfficeInd |
| Foreign Activities | false | ForeignActivitiesInd |
| More Than5000 K To Org | false | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | false | MoreThan5000KToIndividualsInd |
| Professional Fundraising | false | ProfessionalFundraisingInd |
| Fundraising Activities | false | FundraisingActivitiesInd |
| Gaming Activities | false | GamingActivitiesInd |
| Operate Hospital | Yes (true) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (true) | AuditedFinancialStmtAttInd |
| Grants To Organizations | false | GrantsToOrganizationsInd |
| Grants To Individuals | false | GrantsToIndividualsInd |
| Schedule J Required | Yes (true) | ScheduleJRequiredInd |
| Tax Exempt Bonds | false | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | false | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | false | PYExcessBenefitTransInd |
| Loan Outstanding | false | LoanOutstandingInd |
| Grant To Related Person | false | GrantToRelatedPersonInd |
| Business Rln With Org Mem | Yes (true) | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | false | BusinessRlnWithFamMemInd |
| Business Rln With35 Ctrl Ent | Yes (true) | BusinessRlnWith35CtrlEntInd |
| Deductible Non Cash Contri | false | DeductibleNonCashContriInd |
| Deductible Art Contribution | false | DeductibleArtContributionInd |
| Terminate Operations | false | TerminateOperationsInd |
| Partial Liquidation | false | PartialLiquidationInd |
| Disregarded Entity | false | DisregardedEntityInd |
| Related Entity | Yes (true) | RelatedEntityInd |
| Related Organization Ctrl Ent | false | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | false | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | false | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (true) | ScheduleORequiredInd |
| IRP Document | 53 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (true) | BackupWthldComplianceInd |
| Employee | 259 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (true) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | false | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | false | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | false | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | false | TaxablePartyNotificationInd |
| Nondeductible Contributions | false | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | false | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | false | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | false | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | false | PayPremiumsPrsnlBnftCntrctInd |
| Form8899 Filedind | false | Form8899Filedind |
| Form1098 C Filed | false | Form1098CFiledInd |
| Indoor Tanning Services | false | IndoorTanningServicesInd |
| Subj To Tax Rmnrtn Ex Prcht Pymt | false | SubjToTaxRmnrtnExPrchtPymtInd |
| Subject To Excs Tax Net Invst Inc | false | SubjectToExcsTaxNetInvstIncInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 9 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 6 | IndependentVotingMemberCnt |
| Family Or Business Rln | false | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | false | DelegationOfMgmtDutiesInd |
| Change To Org Documents | false | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | false | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | Yes (true) | MembersOrStockholdersInd |
| Election Of Board Members | Yes (true) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | Yes (true) | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (true) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (true) | MinutesOfCommitteesInd |
| Officer Mailing Address | false | OfficerMailingAddressInd |
| Local Chapters | Yes (true) | LocalChaptersInd |
| Policies Reference Chapters | Yes (true) | PoliciesReferenceChaptersInd |
| Form990 Provided To Gvrn Body | Yes (true) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (true) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (true) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (true) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (true) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (true) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (true) | CompensationProcessCEOInd |
| Compensation Process Other | Yes (true) | CompensationProcessOtherInd |
| Investment In Joint Venture | false | InvestmentInJointVentureInd |
| States Where Copy Of Return Is Fld | NY | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | KELLY CICCHINELLI | PersonNm |
| Phone | 3152871000 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 77 WEST BARNEY STREET | AddressLine1Txt |
| City | GOUVERNEUR | CityNm |
| State Abbreviation | NY | StateAbbreviationCd |
| ZIP | 13642 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (15 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd |
|---|---|---|---|---|---|---|---|---|
| ERIC BURCH | ||||||||
| CEO | 16.00 | 42.00 | Yes (X) | $0 | $338,872 | $14,769 | ||
| PAYAM HADIAN MD | ||||||||
| PHYSICIAN | 40.00 | $288,730 | $0 | $28,878 | Yes (X) | |||
| ISMENE N MARAVEGIAS MD | ||||||||
| PHYSICIAN | 40.00 | $272,085 | $0 | $29,623 | Yes (X) | |||
| KELLY CICCHINELLI | ||||||||
| CONTROLLER | 18.00 | 32.00 | Yes (X) | $0 | $175,594 | $33,076 | ||
| RICHARD CORCORAN RPA | ||||||||
| PHYSICIAN AS | 40.00 | $168,113 | $0 | $28,523 | Yes (X) | |||
| MICHAEL KIGER | ||||||||
| PHYSICIAN AS | 40.00 | $156,662 | $0 | $15,241 | Yes (X) | |||
| ANDREW WILLIAMS MD | ||||||||
| TRUSTEE | 1.00 | $0 | $81,600 | $0 | Yes (X) | |||
| CHRISTINE BETRUS | ||||||||
| TRUSTEE | 1.00 | $0 | $0 | $0 | Yes (X) | |||
| MARK BRACKETT | ||||||||
| SECRETARY/TR | 1.00 | Yes (X) | $0 | $0 | $0 | Yes (X) | ||
| ROGER COOK DVM | ||||||||
| TRUSTEE | 1.00 | $0 | $0 | $0 | Yes (X) | |||
| KURT HALLIDAY | ||||||||
| TRUSTEE | 1.00 | $0 | $0 | $0 | Yes (X) | |||
| ANDREW LEORNARD | ||||||||
| CHAIRPERSON | 1.00 | Yes (X) | $0 | $0 | $0 | Yes (X) | ||
| CAROLYN PISTOLESI | ||||||||
| TRUSTEE | 1.00 | $0 | $0 | $0 | Yes (X) | |||
| RYAN SCHERMERHORN | ||||||||
| TRUSTEE | 1.00 | $0 | $0 | $0 | Yes (X) | |||
| THEODORE TOTTEN | ||||||||
| TRUSTEE | 1.00 | $0 | $0 | $0 | Yes (X) | |||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $885,590 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $596,066 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $150,110 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 13 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | false | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (true) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | false | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| CANTON-POTSDAM HOSPITAL | |||||
| 50 LEROY STREET | POTSDAM | NY | 13676 | STAFFING | $2,937,441 |
| DELPHI HOSPITALIST SERVICES LLC | |||||
| 1160 CHILI AVE SUITE 200 | ROCHESTER | NY | 14624 | HOSPITALIST | $1,382,422 |
| ST LAWRENCE HEALTH SYSTEM | |||||
| 50 LEROY STREET | POTSDAM | NY | 13676 | STAFFING | $1,136,765 |
| MORRISON MANAGEMENT SPECIALISTS | |||||
| PO BOX 102289 | ATLANTA | GA | 303682289 | STAFFING | $439,993 |
| THE PIKE COMPANY INC | |||||
| 1 CIRCLE STEET | ROCHESTER | NY | 14607 | CONTRACTOR | $247,601 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 8 | CntrctRcvdGreaterThan100KCnt |
| Government Grants | $4,083,301 | GovernmentGrantsAmt |
| All Other Contributions | $220,318 | AllOtherContributionsAmt |
| Total Contributions | $4,303,619 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (2 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| NET PATIENT REVENUE | 623000 | $22,001,138 | $22,001,138 |
| VAP GRANT | 623000 | $1,767,119 | $1,767,119 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $23,768,257 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $29,822 | TotalRevenueColumnAmt |
| Exclusion | $29,822 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $196,815 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $292,463 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | -$95,648 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -$95,648 | TotalRevenueColumnAmt |
| Exclusion | -$95,648 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $23,673 | SecuritiesAmt |
| Other | $7,000 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $7,274 | SecuritiesAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $16,399 | SecuritiesAmt |
| Other | $7,000 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $23,399 | TotalRevenueColumnAmt |
| Exclusion | $23,399 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp (3 entries)
| DescDesc | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|
| CPH BILLABLE | $1,171,306 | $1,171,306 |
| OTHER | $648,409 | $648,409 |
| 340B PROGRAM | $449,019 | $449,019 |
Miscellaneous Revenue MiscellaneousRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $18,815 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $18,815 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $2,287,549 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $30,316,998 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $26,055,806 | RelatedOrExemptFuncIncomeAmt |
| Exclusion | -$42,427 | ExclusionAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $85,766 | TotalAmt |
| Program Services | $64,324 | ProgramServicesAmt |
| Management And General | $21,442 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $10,481,346 | TotalAmt |
| Program Services | $7,861,010 | ProgramServicesAmt |
| Management And General | $2,620,336 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $419,667 | TotalAmt |
| Program Services | $314,750 | ProgramServicesAmt |
| Management And General | $104,917 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,748,218 | TotalAmt |
| Program Services | $2,061,164 | ProgramServicesAmt |
| Management And General | $687,054 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $684,744 | TotalAmt |
| Program Services | $513,558 | ProgramServicesAmt |
| Management And General | $171,186 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $77,206 | TotalAmt |
| Management And General | $77,206 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $118,390 | TotalAmt |
| Management And General | $118,390 | ManagementAndGeneralAmt |
Fees For Services Lobbying FeesForServicesLobbyingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,590 | TotalAmt |
| Management And General | $3,590 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $61,140 | TotalAmt |
| Program Services | $45,855 | ProgramServicesAmt |
| Management And General | $15,285 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $358,176 | TotalAmt |
| Program Services | $296,770 | ProgramServicesAmt |
| Management And General | $61,406 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $15,174 | TotalAmt |
| Program Services | $11,380 | ProgramServicesAmt |
| Management And General | $3,794 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $11,382 | TotalAmt |
| Program Services | $8,536 | ProgramServicesAmt |
| Management And General | $2,846 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $138,234 | TotalAmt |
| Program Services | $103,675 | ProgramServicesAmt |
| Management And General | $34,559 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,155,859 | TotalAmt |
| Program Services | $957,694 | ProgramServicesAmt |
| Management And General | $198,165 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $243,942 | TotalAmt |
| Program Services | $202,120 | ProgramServicesAmt |
| Management And General | $41,822 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| PURCHASED SERVICES | $5,511,189 | $4,133,392 | $1,377,797 |
| SUPPLIES | $1,859,731 | $1,394,798 | $464,933 |
| EQUIPMENT RENTAL | $1,086,054 | $888,743 | $197,311 |
| MISCELLANEOUS | $239,362 | $179,521 | $59,841 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $304,429 | TotalAmt |
| Program Services | $167,121 | ProgramServicesAmt |
| Management And General | $137,308 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $25,603,599 | TotalAmt |
| Program Services | $19,204,411 | ProgramServicesAmt |
| Management And General | $6,399,188 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,255,748 | BOYAmt |
| EOY | $7,657,357 | EOYAmt |
Pledges And Grants Receivable PledgesAndGrantsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $42,911 | BOYAmt |
| EOY | $1,236,772 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,285,137 | BOYAmt |
| EOY | $2,348,016 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $445,053 | BOYAmt |
| EOY | $469,383 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $108,231 | BOYAmt |
| EOY | $150,277 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $13,487,066 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $6,334,860 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,407,059 | BOYAmt |
| EOY | $7,152,206 | EOYAmt |
Investments Other Securities InvestmentsOtherSecuritiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $624,786 | BOYAmt |
| EOY | $666,222 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,985,456 | BOYAmt |
| EOY | $1,771,069 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $16,154,381 | BOYAmt |
| EOY | $21,451,302 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,843,962 | BOYAmt |
| EOY | $2,236,434 | EOYAmt |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $395,565 | BOYAmt |
| EOY | $348,336 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,538,004 | BOYAmt |
| EOY | $6,390,134 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $8,777,531 | BOYAmt |
| EOY | $8,974,904 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows FASB117 | Yes (X) | OrganizationFollowsFASB117Ind |
No Donor Restriction Net Assets NoDonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,483,175 | BOYAmt |
| EOY | $10,942,930 | EOYAmt |
Donor Restriction Net Assets DonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,893,675 | BOYAmt |
| EOY | $1,533,468 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,376,850 | BOYAmt |
| EOY | $12,476,398 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $16,154,381 | BOYAmt |
| EOY | $21,451,302 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $4,713,399 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | $386,149 | OtherChangesInNetAssetsAmt |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | false | AccountantCompileOrReviewInd |
| FS Audited | Yes (true) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (true) | AuditCommitteeInd |
| Federal Grant Audit Required | false | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | false | VolunteersInd |
| Paid Staff Or Management | false | PaidStaffOrManagementInd |
| Media Advertisements | false | MediaAdvertisementsInd |
| Mailings Members | false | MailingsMembersInd |
| Publications Or Broadcast | false | PublicationsOrBroadcastInd |
| Grants Other Organizations | false | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | false | DirectContactLegislatorsInd |
| Rallies Demonstrations | false | RalliesDemonstrationsInd |
| Other Activities | Yes (true) | OtherActivitiesInd |
| Other Activities | $16,759 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $16,759 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | false | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | SCHEDULE C, PART IV | FormAndLineReferenceDesc |
| Explanation | GOUVERNEUR HOSPITAL, THROUGH ITS MEMBERSHIP OR FEES PAID IN 2020 TO THE FOLLOWING ORGANIZATIONS, INCURRED 16,759 IN LOBBYING EXPENSES: 1,324: IROQUOIS HEALTHCARE ALLIANCE-FEDERAL AND STATE ADVOCACY 6,941: HANYS ANNUAL MEMBERSHIP DUES-FEDERAL AND STATE ADVOCACY 8,494: AMERICAN HOSPITAL ASSOCIATION ANNUAL MEMBERSHIP DUES-FEDERAL AND STATE ADVOCACY | ExplanationTxt |
Schedule D IRS990ScheduleD
CY Endwmt Fund CYEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $1,893,675 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | $1,600 | InvestmentEarningsOrLossesAmt |
| End Year Balance | $1,895,275 | EndYearBalanceAmt |
CY Minus1 Yr Endwmt Fund CYMinus1YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $1,908,169 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | -$14,494 | InvestmentEarningsOrLossesAmt |
| End Year Balance | $1,893,675 | EndYearBalanceAmt |
CY Minus2 Yr Endwmt Fund CYMinus2YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $2,534,689 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | -$626,520 | InvestmentEarningsOrLossesAmt |
| End Year Balance | $1,908,169 | EndYearBalanceAmt |
CY Minus3 Yr Endwmt Fund CYMinus3YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $2,412,779 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | $121,910 | InvestmentEarningsOrLossesAmt |
| End Year Balance | $2,534,689 | EndYearBalanceAmt |
CY Minus4 Yr Endwmt Fund CYMinus4YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $1,637,555 | BeginningYearBalanceAmt |
| Contributions | $1,806,389 | ContributionsAmt |
| Investment Earnings Or Losses | $38,244 | InvestmentEarningsOrLossesAmt |
| Other Expenditures | $1,069,409 | OtherExpendituresAmt |
| End Year Balance | $2,412,779 | EndYearBalanceAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Prmnnt Endowment Balance EOY | 0.72000 | PrmnntEndowmentBalanceEOYPct |
| Term Endowment Balance EOY | 0.28000 | TermEndowmentBalanceEOYPct |
| Endowments Held Unrelated Org | false | EndowmentsHeldUnrelatedOrgInd |
| Endowments Held Related Org | false | EndowmentsHeldRelatedOrgInd |
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $648,713 | OtherCostOrOtherBasisAmt |
| Book Value | $648,713 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $5,640,611 | OtherCostOrOtherBasisAmt |
| Depreciation | $1,651,937 | DepreciationAmt |
| Book Value | $3,988,674 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $6,785,748 | OtherCostOrOtherBasisAmt |
| Depreciation | $4,682,923 | DepreciationAmt |
| Book Value | $2,102,825 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $411,994 | OtherCostOrOtherBasisAmt |
| Book Value | $411,994 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $7,152,206 | TotalBookValueLandBuildingsAmt |
Other Assets Org OtherAssetsOrgGrp (3 entries)
| DescDesc | Book ValueBookValueAmt |
|---|---|
| FUNDS HELD IN TRUST BY OTHERS | $1,162,749 |
| DUE FROM AFFILIATES | $499,471 |
| OTHER NOTES AND LOANS REC (NET) | $108,849 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | $1,771,069 | TotalBookValueOtherAssetsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (3 entries)
| DescDesc | AmtAmt |
|---|---|
| ASSET RETIREMENT OBLIGATION | $3,622,973 |
| EST. THIRD-PARTY PAYOR SETTLEMENTS | $2,617,591 |
| DUE TO AFFILIATES | $149,570 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $6,390,134 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $30,457,729 | TotalRevEtcAuditedFinclStmtAmt |
| Other Revenue | $292,463 | OtherRevenueAmt |
| Revenue Not Reported | $292,463 | RevenueNotReportedAmt |
| Revenue Subtotal | $30,165,266 | RevenueSubtotalAmt |
| Other Revenues Not Included | $151,732 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | $151,732 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $30,316,998 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $25,896,062 | TotExpnsEtcAuditedFinclStmtAmt |
| Other Expenses Included | $292,463 | OtherExpensesIncludedAmt |
| Expenses Not Reported | $292,463 | ExpensesNotReportedAmt |
| Expenses Subtotal | $25,603,599 | ExpensesSubtotalAmt |
| Total Expenses Per Form990 | $25,603,599 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| SCHEDULE D, PAGE 2, PART V, LINE 4 | THE ORGANIZATION USES THE INCOME FROM THE ENDOWMENT FUNDS FOR GENERAL OPERATING PURPOSES AND LAWFUL PURPOSES AT THE DISCRETION OF THE BOARD OF DIRECTORS. |
| SCHEDULE D, PAGE 3, PART X | THE SYSTEM AND ITS AFFILIATES ARE NOT FOR PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE CODE)AND ARE EXEMPT FROM FEDERAL INCOME TAX ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE SYSTEM AND AFFILIATES RECOGNIZE THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THEN NOT OF BEING SUSTAINED. RECOGNIZED INCOME TAX POSITIONS ARE MEASURED AT THE LARGEST AMOUNT THAT IS GREATER THAN FIFTY PERCENT LIKELY OF BEING REALIZED UPON SETTLEMENT. CHANGES IN RECOGNIZATION IN MEASUREMENT ARE REFLECTED IN THE PERIOD IN WHICH THE CHANGE IN JUDGEMENT OCCURS. THE SYSTEM AND AFFILIATES DID NOT RECOGNIZE THE EFFECT OF ANY UNCERTAIN INCOME TAX POSITIONS IN EITHER 2020 OR 2019. |
| SCHEDULE D, PAGE 4, PART XI, LINE 2D | RENT EXPENSES 292,463 |
| SCHEDULE D, PAGE 4, PART XI, LINE 4B | NON OPERATING GAINS/LOSSES 151,732 |
| SCHEDULE D, PAGE 4, PART XII, LINE 2D | RENT EXPENSES 292,463 |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (true) | FinancialAssistancePolicyInd |
| Written Policy | Yes (true) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (true) | FPGReferenceFreeCareInd |
Free Care Oth Percentage FreeCareOthPercentageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Free Care Other | 2.010000000000 | FreeCareOtherPct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| FPG Reference Discounted Care | Yes (true) | FPGReferenceDiscountedCareInd |
| Percent300 | Yes (X) | Percent300Ind |
| Free Care Medically Indigent | Yes (true) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (true) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | false | ExpensesExceedBudgetInd |
| Annual Community Bnft Report | Yes (true) | AnnualCommunityBnftReportInd |
| Report Publically Available | Yes (true) | ReportPublicallyAvailableInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $7,513 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | -$299 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $7,812 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00030 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $8,265,038 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $5,836,188 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,428,850 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.09490 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $8,272,551 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $5,835,889 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,436,662 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.09520 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $17,440 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $17,440 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00070 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $32,369 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $32,369 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00130 | TotalExpensePct |
Cash And In Kind Contributions CashAndInKindContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $823 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $823 | NetCommunityBenefitExpnsAmt |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $50,632 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $50,632 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00200 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $8,323,183 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $5,835,889 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,487,294 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.09710 | TotalExpensePct |
Workforce Development WorkforceDevelopmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $20,177 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $20,177 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00080 | TotalExpensePct |
Total Communtity Building Acty TotalCommuntityBuildingActyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $20,177 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $20,177 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00080 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (true) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $746,171 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $16,465 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $4,480,425 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $6,134,041 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$1,653,616 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (true) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (true) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GOUVERNEUR HOSPITAL | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 77 WEST BARNEY STREET | AddressLine1Txt |
| City | GOUVERNEUR | CityNm |
| State Abbreviation | NY | StateAbbreviationCd |
| ZIP | 13642 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.STLAWRENCEHEALTHSYSTEM.ORG/GOUVERN | WebsiteAddressTxt |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GOUVERNEUR HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | false | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | false | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (true) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Prior CHNA Impact | Yes (X) | PriorCHNAImpactInd |
| Other | Yes (X) | OtherInd |
| CHNA Conducted | 19 | CHNAConductedYr |
| Take Into Account Others Input | Yes (true) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | Yes (true) | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | Yes (true) | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (true) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | WWW.STLAWRENCEHEALTHSYSTEM.ORG/GOUVERN | OwnWebsiteURLTxt |
| Implementation Strategy Adopt | Yes (true) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 19 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (true) | StrategyPostedWebsiteInd |
| Strategy Website URL | WWW.STLAWRENCEHEALTHSYSTEM.ORG/GOUVERN | StrategyWebsiteURLTxt |
| Strategy Attached | false | StrategyAttachedInd |
| Organization Incur Excise Tax | false | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (true) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 201.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 300.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Explained Basis | Yes (true) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (true) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Includes Publicity Measures | Yes (true) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | WWW.STLAWRENCEHEALTHSYSTEM.ORG/GOUVERN | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | WWW.STLAWRENCEHEALTHSYSTEM.ORG/GOUVERN | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | WWW.STLAWRENCEHEALTHSYSTEM.ORG/GOUVERN | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| Notified FAP Copy Bill Display | Yes (X) | NotifiedFAPCopyBillDisplayInd |
| FAP Actions On Nonpayment | Yes (true) | FAPActionsOnNonpaymentInd |
| Permit Report To Credit Agency | Yes (X) | PermitReportToCreditAgencyInd |
| Permit Legal Judicial Process | Yes (X) | PermitLegalJudicialProcessInd |
| Collection Activities | false | CollectionActivitiesInd |
| Provided Written Notice | Yes (X) | ProvidedWrittenNoticeInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Nondis Emergency Care Policy | Yes (true) | NondisEmergencyCarePolicyInd |
| Look Back Medicare | Yes (X) | LookBackMedicareInd |
| Amounts Generally Billed | false | AmountsGenerallyBilledInd |
| Gross Charges | false | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FACILITY 1, GOUVERNEUR HOSPITAL - PART V, LINE 3E | GOUVERNEUR HOSPITAL'S CHNA IDENTIFIED CHRONIC DISEASE PREVENTION AND MANAGEMENT AND MENTAL, EMOTIONAL, AND BEHAVIORAL (MEB) HEALTH AS THE TWO HIGHEST PRIORITY AREAS NEEDING TO BE ADDRESSED. |
| FACILITY 1, GOUVERNEUR HOSPITAL - PART V, LINE 5 | THE ST. LAWRENCE COUNTY COMMUNITY HEALTH IMPROVEMENT COALITION, BRIDGE TO WELLNESS, IS AN ACTIVE COMMITTEE WITH FIFTY-FOUR PARTICIPATING ORGANIZATIONS INCLUDING PUBLIC HEALTH, HIGHER EDUCATION, HOSPITALS, HEALTH CENTERS, AND COMMUNITY BASED ORGANIZATIONS. MEETINGS ARE FACILITATED BY THE ST. LAWRENCE COUNTY HEALTH INITIATIVE, INC, AND THE LOCAL PUBLIC HEALTH DEPARTMENT. PARTNERS WORK COLLABORATIVELY TO PLAN, IMPLEMENT AND OVERSEE THE ST. LAWRENCE COUNTY COMMUNITY HEALTH IMPROVEMENT PLAN AND HOSPITAL COMMUNITY SERVICE PLANS. BRIDGE TO WELLNESS AGAIN PARTNERED WITH THE FORT DRUM REGIONAL HEALTH PLANNING ORGANIZATION (FDRHPO) TO DEVELOP AN APPROPRIATE REGIONAL NEEDS ASSESSMENT THAT WOULD GUIDE A STRONG DATA DRIVEN HEALTH IMPROVEMENT PLAN FOR ST. LAWRENCE COUNTY. THIS 'COMMUNITY HEALTH SURVEY' IS INCORPORATED INTO A COMMUNITY HEALTH ASSESSMENT USING NEW YORK STATE AND NATIONAL DATA SOURCES. IN EACH PRIORITY AREA, EDUCATION TO AND INVOLVEMENT FROM THE COMMUNITY AT LARGE IS INTEGRAL TO THE SUCCESS OF EACH INTERVENTION. THE PARTNERS WILL OVERSEE AND GOVERN THE EVALUATION OF THIS PLAN ON A MONTHLY BASIS. CONCURRENTLY, PARTNERS WILL BE EVALUATING THE COALITION ITSELF, WITH THE ULTIMATE GOAL OF INCREASING PARTNER ENGAGEMENT AND STREAMLINING PLAN IMPLEMENTATION. BRIDGE TO WELLNESS PARTNERS WILL DISSEMINATE REGULAR REPORTS ON THE PROGRESS OF THE WORK TO THE COMMUNITY THROUGH ONLINE MEDIA, PRINT PUBLICATIONS, RADIO AND IN PERSON EDUCATION. |
| FACILITY 1, GOUVERNEUR HOSPITAL - PART V, LINE 6A | PLEASE SEE LINE 5 EXPLANATION ABOVE. GOUVERNEUR HOSPITAL IS AFFILIATED WITH CANTON-POTSDAM HOSPITAL, AND COMPLETED THE CHNA WITH THE ENTITIES NOTED ABOVE. |
| FACILITY 1, GOUVERNEUR HOSPITAL - PART V, LINE 6B | 2. NEEDS ASSESSMENT: PLEASE REFERENCE THE ABOVE REQUIRED DESCRIPTIONS, PART V SECTION B, LINES 5 AND 11 ABOVE. 3. PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE: THE ORGANIZATION CONSPICUOUSLY POSTS ITS FINANCIAL ASSISTANCE POLICY IN EACH REGISTRATION/RECEPTION AREA AND WE ALSO HAVE FINANCIAL ASSISTANCE LANGUAGE ON THE BACK OF ALL OUR STATEMENTS AS WELL. PATIENTS ARE ENCOURAGED TO APPLY FORASSISTANCE AND GIVEN CONTACT INFORMATION AT THESE AREAS. IN ADDITION, ANY PATIENT THAT IS UNINSURED AND ADMITTED TO THE HOSPITAL FOR CARE IS PHYSICALLY VISITED BY A FINANCIAL COUNSELOR, AND AN EXPLANATION OF OUR PROGRAM IS MADE ALONG WITH AN APPLICATION. PATIENTS REQUESTING ASSISTANCE IN THE COMPLETION OF THE APPLICATION ARE GIVEN SUCH. ANY INFORMATION REQUIRED FOR APPLICATION FOR THE NYS MEDICAID APPLICATION PROCESS IS COLLECTED BY OUR FINANCIAL CASE MANAGERS AND COMMUNICATED TO THE APPROPRIATE CASE MANAGERS AT OUR COUNTY DEPARTMENT OF SOCIAL SERVICES FOR DETERMINATION OF MEDICAID ELIGIBILITY 4.COMMUNITY INFORMATION: GOUVERNEUR HOSPITAL IS LOCATED IN ST. LAWRENCE COUNTY IN UPSTATE NEW YORK. ST. LAWRENCE COUNTY, THE LARGEST COUNTY IN NEW YORK, IS LOCATED IN THE NORTHERNMOST REACHES OF THE STATE BORDERING ON THE ST. LAWRENCE RIVER AND CANADA. IT IS A RURAL ENVIRONMENT CONSISTING OF 2,685 SQUARE MILES WITH A POPULATION OF APPROXIMATELY 107,700 RESIDENTS. GOUVERNEUR HOSPITAL'S PRIMARY SERVICE AREA INCLUDES APPROXIMATELY 28,800 PEOPLE LIVING IN THE COMMUNITIES OF GOUVERNEUR, EDWARDS, RICHVILLE, HARRISVILLE, ANTWERP, DEKALB AND A PORTION OF CANTON. ITS SECONDARY SERVICE AREA INCLUDES THE TOWNS OF HERMON, INDIAN RIVER AND PORTIONS OF COMMUNITIES WITHIN ST. LAWRENCE AND WESTERN JEFFERSON COUNTIES. 5. PROMOTION OF COMMUNITY HEALTH: DUE TO COVID RESTRICTIONS, GOUVERNEUR HOSPITAL HELD FEWER COMMUNITY ACTIVITIES IN 2020. ACTIVITIES INCLUDED BLOOD DRIVES, COVID TEST SITES AND VACCINATION CLINICS. GOUVERNEUR HOSPITAL HAD 53 STUDENTS FROM MULTIPLE COLLEGES FOR SHADOWING AND MEDICAL ROTATION ACTIVITIES. 6. AFFILIATED HEALTH CARE SYSTEM: ST. LAWRENCE HEALTH SYSTEM, FORMED DECEMBER 5, 2013, IS OPERATED EXCLUSIVELY FOR THE SOLE CHARITABLE PURPOSE OF BENEFITING AND SUPPORTING GOUVERNEUR HOSPITAL, CANTON-POTSDAM HOSPITAL AND OTHER CORPORATIONS. AMONG OTHER BENEFITS, THE HEALTH SYSTEM MAY PROVIDE ADVICE AND ASSISTANCE CONCERNING LONG AND SHORT-RANGE PLANNING FOR, AND MONITOR AND PROVIDE ADVICE AND ASSISTANCE TO HELP COORDINATE THE ACTIVITIES OF THE SUPPORTED ORGANIZATION IN ELIMINATING DUPLICATIVE FUNCTIONS; PROVIDE MANAGEMENT CONSULTING ASSISTANCE TO THE SUPPORTED ORGANIZATION TO FURTHER IMPROVE AND ADVANCE HEALTH SERVICES TO THE RESIDENTS OF NEW YORK STATE AND COOPERATE WITH THE SUPPORTING ORGANIZATIONS IN CARRYING OUT THEIR CHARITABLE PURPOSES. 7. STATE FILING OF COMMUNITY BENEFIT REPORT: OUR COMMUNITY BENEFIT REPORT IS FILED ANNUALLY WITH NEW YORK STATE. |
| FACILITY 1, GOUVERNEUR HOSPITAL - PART V, LINE 11 | CONSIDERING THE ASSESSMENT RESULTS AND THE CAPACITY OF THE REGION, BRIDGE TO WELLNESS IDENTIFIED 'PREVENT CHRONIC DISEASE- AND 'PROMOTE WELL-BEING AND PREVENT MENTAL SUBSTANCE USE DISORDERS' AS PRIORITIES FOR THE 2019-2021 PLAN. THESE ARE SIMILAR TO THE PRIORITIES THE COALITION IDENTIFIED IN 2016, AS THE COALITION HOPES TO BUILD UPON SUCCESSES ACHIEVED THROUGHOUT THE LAST ROUND. THE 2019 PLAN IS STREAMLINED AND IDENTIFIES ADDITIONAL OPPORTUNITIES TO IMPROVE THE HEALTH OF TARGETED RESIDENTS. THE COALITION RESEARCHED INTERVENTIONS GROUNDED IN EVIDENCE AND SELECTED ACTIVITIES TO INCLUDE ENVIRONMENTAL, SYSTEMS AND POLICY CHANGE. SEVERAL OF THE INTERVENTIONS SELECTED WILL ADDRESS MULTIPLE GOALS, WHICH ALLOWS FOR MORE FOCUS AND EFFORT IN ONE INTERVENTION WHILE REACHING MORE THAN ONE DELIVERABLE. THE FOLLOWING PRIORITIES FOCUS AREAS, AND INTERVENTIONS WERE IDENTIFIED: 1. PREVENT CHRONIC DISEASES: A.HEALTHY EATING AND FOOD SECURITY I.WORKSITE NUTRITION PROGRAMS DESIGNED TO IMPROVE HEALTH BEHAVIORS AND RESULTS. B.PHYSICAL ACTIVITY I.IMPLEMENT A COMBINATION OF ONE OR MORE NEW OR IMPROVED PEDESTRIAN,BICYCLE, OR TRANSIT TRANSPORTATION SYSTEM COMPONENTS WITH NEW OR IMPROVED LAND USE OR ENVIRONMENTAL DESIGN COMPONENTS THROUGH COMPREHENSIVE MASTER/TRANSPORTATION PLANS OR COMPLETE STREETS RESOLUTIONS, POLICIES, ORORDINANCES. II.IMPLEMENT A COMBINATION OF WORKSITE-BASED PHYSICAL ACTIVITY POLICIES,PROGRAMS, OR BEST PRACTICES THROUGH MULTI-COMPONENT WORKSITE PHYSICAL ACTIVITY AND/OR NUTRITION PROGRAMS. C.PREVENTATIVE CARE AND MANAGEMENT I.EXPAND ACCESS TO EVIDENCE-BASED SELF-MANAGEMENT INTERVENTIONS FOR INDIVIDUALS WITH CHRONIC DISEASE WHOSE CONDITION IS NOT WELL CONTROLLED WITH GUIDELINES-BASED MEDICAL MANAGEMENT ALONE. II.EXPAND ACCESS TO THE NATIONAL DIABETES PREVENTION PROGRAM. 2.PROMOTE WELL-BEING AND PREVENT MENTAL AND SUBSTANCE USE DISORDERS A.PREVENT MENTAL AND SUBSTANCE USER DISORDERS I.INCREASE AVAILABILITY OF AND LINKAGES TO MEDICATION-ASSISTED TREATMENT (MAT) INCLUDING BUPRENORPHINE. II.PROMOTE AND ENCOURAGE PRESCRIBER EDUCATION AND FAMILIARITY WITH OPIOID PRESCRIBING GUIDELINES AND LIMITS AS IMPOSED BY NEW YORK STATE (NYS) STATUTES AND REGULATIONS. |
Supplemental Information Detail SupplementalInformationDetail (4 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| SCHEDULE H, PART III, LINE 2 | THIS COST REPRESENTS BAD DEBT EXPENSE INCLUDED IN THE HOSPITAL'S AUDITED F/S. |
| SCHEDULE H, PART III, LINE 3 | COST OF CHARITY CARE AS REPORTED ON THE FACILITY'S ICR. |
| SCHEDULE H, PART III, LINE 4 | BAD DEBT EXPENSE FOOTNOTE TO FINANCIAL STATEMENTS AT DECEMBER 31, 2020 AND 2019, SIGNIFICANT CONCENTRATIONS OF PATIENT ACCOUNTS RECEIVABLE ARE AS FOLLOWS: 2020 2019 MEDICARE 33% 18% MEDICAID 22 29 COMMERCIAL CARRIERS 28 37 NO-FAULT AND WORKER'S COMPENSATION 4 5 PRIVATE PAY 13 11 ===== ==== 100% 100% |
| SCHEDULE H, PART III, LINE 9B | PART III, SECTION B, LINE 8: COSTS REPORTED ON LINE 6 INCLUDE TOTAL INPATIENT COSTS (ROUTINE, ANCILLARY AND CAPITAL), OBSERVATION COSTS, OUTPATIENT COSTS AND SWING BED COSTS FROM THE MCR COST REPORT (WORKSHEET D-1: PART II AND PART IV; WORKSHEET D: PART V; WORKSHEET E-2 AND WORKSHEET D-3). PART III SECTION C, LINE 9B - THE ORGANIZATION APPLIES THE SAME COLLECTION PRINCIPLES TO AMOUNTS DUE FROM PATIENTS WHO HAVE QUALIFIED FOR PERCENTAGE DISCOUNTS BUT STILL HAVE A RESPONSIBILITY FOR A PORTION OF THEIR BILL BASED UPON THE SLIDING FEE SCHEDULE. NO SEPARATE DISTINCTION IS MADE FOR THE APPLICATION OF OUR COLLECTION PROCESSES IN THOSE CASES |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Severance Payment | false | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | false | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | false | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | false | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | false | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | false | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | false | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | false | AnyNonFixedPaymentsInd |
| Initial Contract Exception | false | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (6 entries)
| TitleTitleTxt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt |
|---|---|---|---|---|---|---|---|---|
| ERIC BURCH | ||||||||
| CEO | $338,872 | $13,246 | $1,523 | $353,641 | ||||
| PAYAM HADIAN MD | ||||||||
| PHYSICIAN | $288,730 | $7,500 | $21,378 | $317,608 | ||||
| ISMENE N MARAVEGIAS MD | ||||||||
| PHYSICIAN | $272,085 | $10,352 | $19,271 | $301,708 | ||||
| KELLY CICCHINELLI | ||||||||
| CONTROLLER | $175,594 | $7,478 | $25,598 | $208,670 | ||||
| RICHARD CORCORAN RPA | ||||||||
| PHYSICIAN ASSISTANT | $168,113 | $8,363 | $20,160 | $196,636 | ||||
| MICHAEL KIGER | ||||||||
| PHYSICIAN ASSISTANT | $156,662 | $4,522 | $10,719 | $171,903 | ||||
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp
Name Of Interested NameOfInterested
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | SEE PART V BELOW | PersonNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Sharing Of Revenues | false | SharingOfRevenuesInd |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | SCHEDULE L, PART V | FormAndLineReferenceDesc |
| Explanation | 1. ANDREW WILLIAMS MD, IS A BOARD MEMBER OF GH AND IS ALSO ON THE BOARD FOR THE COMMUNITY HEALTH CENTER OF THE NORTH COUNTRY, ST. LAWRENCE COUNTY BOARD OF HEALTH. DR. WILLIAMS IS ALSO AN EMPLOYEE OF CANTON-POTSDAM HOSPITAL, AN AFFILIATED HOSPITAL OF GH. IN 2020, THE COMMUNITY HEALTH CENTER PAID RENT FOR SPACE AT GH IN THE AMOUNT OF 118,125. DR. WILLIAMS IS ALSO PAID A 81,600 MEDICAL DIRECTORSHIP WITH A RELATED ORGANIZATION. 2.ANDREW LEONARD, BOARD MEMBER FOR GH, IS ALSO THE PRESIDENT OF ENI MECHANICAL INC. IN 2020, ENI MECHANICAL WAS PAID 219,547 FOR SERVICES. 3.MARK BRACKETT, BOARD MEMBER FOR GH, IS ALSO THE DIRECTOR OF THE KINNEY DRUGS FOUNDATION. KPH HEALTH SERVICES MADE PAYMENTS TO GH FOR THE 340B PROGRAM IN THE AMOUNT OF 443,952 IN 2020. | ExplanationTxt |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (10 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PAGE 2, PART III, LINE 4D | THERE WAS DECREASE IN SURGERIES PERFORMED IN 2020. THERE WERE 202 SURGERIES IN 2020, COMPARED TO 617 IN 2019, ROUGHLY A 67% DECREASE. |
| FORM 990, PAGE 6, PART VI, LINE 6 | ST. LAWRENCE HEALTH SYSTEM, INC. IS A SOLE MEMBER. |
| FORM 990, PAGE 6, PART VI, LINE 7A | ST. LAWRENCE HEALTH SYSTEM, INC. IS A SOLE MEMBER, AND HAS THE ABILITY TO APPOINT MEMBERS OF THE BOARD OF DIRECTORS. |
| FORM 990, PAGE 6, PART VI, LINE 7B | THE MEMBERS SHALL HAVE THE FOLLOWING POWERS WITH REGARD TO THE CORPORATION: -APPOINT THE MEMBERS OF THE BOARD OF DIRECTORS. -APPOINT AND REMOVE THE CHIEF EXECUTIVE OFFICER. -APPROVE THE ADOPTION AND AMENDMENT OF BYLAWS. -APPROVE THE ANNUAL OPERATING AND CAPITAL BUDGETS. -APPROVE STRATEGIC PLANS. -APPROVE AND INITIATE THE FILING OF CERTIFICATE OF NEED APPLICATIONS. -REVIEW AND APPROVE THE ANNUAL AUDIT OF THE CORPORATION AND ANY SUBSIDIARY CORPORATIONS. -APPROVE THE DISSOLUTION OF THE CORPORATION. -APPROVE THE SALE, LEASE, MORTGAGE OR ENCUMBRANCE OF ANY ASSET OTHER THAN ANY SALE, LEASE OR MORTGAGE WHICH IS PART OF AN APPROVED BUDGET. -APPROVE THE SALE OR TRANSFER OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE CORPORATIONS. -APPROVE ANY MERGER, BUSINESS CONSOLIDATION, ACQUISITION OR JOINT VENTURE. -APPROVE THE PURCHASE OR SALE OF PHYSICIAN PRACTICES OTHER THAN ANY PURCHASE OR SALE WHICH IS PART OF AN APPROVED BUDGET. -APPROVE AND MAY INITIATE THE COMMENCEMENT AND SETTLEMENT OF LITIGATION. -APPROVE ANY FILING OF BANKRUPTCY PETITION. -APPROVE THE INCURRENCE OF ANY DEBT OTHER THAN DEBT WHICH IS INCURRED IN THE ORDINARY COURSE OF BUSINESS AND WHICH IS NOT INCONSISTENT WITH AN APPROVED BUDGET. -APPROVE NEW CLINICAL PROGRAMS OR THE TERMINATION OF EXISTING CLINICAL PROGRAMS OTHER THAN ANY ACTION WHICH IS PART OF AN APPROVED BUDGET. -APPROVE ANY OF THE FOLLOWING AGREEMENTS: (I) MANAGEMENT SERVICES AGREEMENTS OTHER THAN ANY AGREEMENT WHICH IS PART OF AN APPROVED BUDGET. (II) CONTRACTS WITH A PHYSICIAN OR A PHYSICIAN GROUP. (III) AGREEMENTS FOR THE OUTSOURCING OF A GOUVERNEUR HOSPITAL SERVICE OR FUNCTION. (IV) COLLECTIVE BARGAINING AGREEMENTS, AND (V) ANY AGREEMENTS TO PARTICIPATE IN A RISK BEARING ARRANGEMENT SUCH AS AN ACCOUNTABLE CARE ORGANIZATION OR A BUNDLED PAYMENT ARRANGEMENT. -INITIATE, NEGOTIATE, AND APPROVE MANAGED CARE AGREEMENTS WITH MANAGED CARE ORGANIZATIONS AND OTHER PAYORS OTHER THAN ANY AGREEMENT WHICH IS PART OF AN APPROVED BUDGET. -DEVELOP INTEGRATED SERVICES AND MANDATE PARTICIPATION IN SUCH SERVICES (E.G., FINANCIAL MANAGEMENT, LEGAL, QUALITY ASSURANCE, RISK MANAGEMENT, CONTRACTING, AND RECRUITMENT) -REQUIRE THE GUARANTEE OF LOANS THROUGH AN OBLIGATED GROUP STRUCTURE THAT WILL SUPPORT ACCESS TO CAPITAL AND INCLUDE DEBT SERVICES. |
| FORM 990, PAGE 6, PART VI, LINE 11B | THE FORM 990 IS PREPARED BY THE FINANCE DEPARTMENT STAFF MEMBERS. UPON COMPLETION, THE FORM IS SUBMITTED TO A CPA FIRM FOR REVIEW AND PREPARED FOR FILING. A COPY OF THE DRAFT RETURN IS THEN REVIEWED BY THE SYSTEM CFO AND SYSTEM CONTROLLER. AFTER REVIEW, ANY CHANGES ARE MADE AND A COPY IS PRESENTED TO THE BOARD OF DIRECTORS FOR THEIR REVIEW, COMMENTS AND APPROVAL (PRIOR TO IRS SUBMISSION). |
| FORM 990, PAGE 6, PART VI, LINE 12C | ON AN ANNUAL BASIS, OFFICERS, DIRECTORS, AND KEY EMPLOYEES ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST STATEMENT. COMPLIANCE WITH THIS REQUIREMENT IS MONITORED BY THE HOSPITAL ADMINISTRATION. |
| FORM 990, PAGE 6, PART VI, LINE 15A | THE CHIEF EXECUTIVE OFFICER IS EVALUATED BY THE ST. LAWRENCE HEALTH SYSTEM CEO. HOSPITAL SENIOR LEADERSHIP IS EVALUATED BY THE HOSPITAL'S CEO. YAFFE AND COMPANY PROVIDES EXECUTIVE COMPENSATION DATA FOR CRITICAL ACCESS HOSPITALS WHICH IS UTILIZED BY THE ST. LAWRENCE HEALTH SYSTEM CEO TO DETERMINE APPROPRIATE COMPENSATION FOR THE HOSPITAL'S CEO. THE SAME DATA IS UTILIZED BY THE HOSPITAL'S CEO TO DETERMINE APPROPRIATE COMPENSATION FOR THE HOSPITAL'S SENIOR LEADERSHIP. |
| FORM 990, PAGE 6, PART VI, LINE 15B | THE CHIEF EXECUTIVE OFFICER IS EVALUATED BY THE ST. LAWRENCE HEALTH SYSTEM CEO. HOSPITAL SENIOR LEADERSHIP IS EVALUATED BY THE HOSPITAL'S CEO. YAFFE AND COMPANY PROVIDES EXECUTIVE COMPENSATION DATA FOR CRITICAL ACCESS HOSPITALS WHICH IS UTILIZED BY THE ST. LAWRENCE HEALTH SYSTEM CEO TO DETERMINE APPROPRIATE COMPENSATION FOR THE HOSPITAL'S CEO. THE SAME DATA IS UTILIZED BY THE HOSPITAL'S CEO TO DETERMINE APPROPRIATE COMPENSATION FOR THE HOSPITAL'S SENIOR LEADERSHIP. |
| FORM 990, PAGE 6, PART VI, LINE 19 | THE HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENT AVAILABLE TO THE PUBLIC UPON REQUEST. |
| FORM 990, PART XI, LINE 9 | CONTRIBUTIONS FOR CAPITAL ACQUISITIONS 384,548 NET ASSETS REALEASED FROM RESTRICTIONS FOR CAPITAL -63,145 RESTRICTED CONTRIBUTIONS - NET 1,601 CHANGE IN FAIR VALUE OF FUNDS HELD IN TRUST BY OTH 63,145 CHANGE IN NET UNREALIZED GAIN ON INVESTMENTS 0 TRANSFER TO ST.LAWRENCE HEALTH SYSTEM 0 TOTAL 386,149 |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp (4 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | Exempt Code SectionExemptCodeSectionTxt | Public Charity StatusPublicCharityStatusTxt | Business Name Line1DirectControllingEntityName/BusinessNameLine1Txt | Controlled OrganizationControlledOrganizationInd |
|---|---|---|---|---|---|---|---|---|---|---|
| CANTON-POTSDAM HOSPITAL | ||||||||||
| 50 LEROY STREET | POTSDAM | NY | 13676 | 161012691 | HOSPITAL | NY | 501C | 3 | SLHS | Yes (true) |
| ST LAWRENCE HEALTH SYSTEM INC | ||||||||||
| 50 LEROY STREET | POTSDAM | NY | 13676 | 464259168 | HEALTHCARE | NY | 501C | 3 | NA | false |
| CANTON-POTSDAM MEDICAL PRACTICE PL | ||||||||||
| 50 LEROY STREET | POTSDAM | NY | 13676 | 460714367 | CLINIC | NY | 501C | 3 | SLHS | Yes (true) |
| CANTON-POTSDAM HOSPITAL FOUNDATION | ||||||||||
| 50 LEROY STREET | POTSDAM | NY | 13676 | 161279472 | FOUNDATION | NY | 501C | 3 | SLHS | Yes (true) |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | false | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | false | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | Yes (true) | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | false | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | false | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | false | DivRelatedOrganizationInd |
| Asset Sale To Other Org | false | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | false | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | false | AssetExchangeInd |
| Rental Of Facilities To Oth Org | Yes (true) | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | Yes (true) | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | false | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | Yes (true) | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | false | SharingOfFacilitiesInd |
| Paid Employees Sharing | false | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | Yes (true) | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | false | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | false | TransferToOtherOrgInd |
| Transfer From Other Org | false | TransferFromOtherOrgInd |
Transactions Related Org TransactionsRelatedOrgGrp (5 entries)
| Transaction TypeTransactionTypeTxt | InvolvedInvolvedAmt | Method Of Amount DeterminationMethodOfAmountDeterminationTxt |
|---|---|---|
| CANTON-POTSDAM HOSPITAL FOUNDATION | ||
| M | $56,829 | CASH EXCHANGED |
| CANTON-POTSDAM HOSPITAL | ||
| I | $1,171,306 | FMV |
| CANTON-POTSDAM HOSPITAL | ||
| J | $55,575 | FMV |
| SLHS | ||
| P | $713,547 | FMV |
| CANTON-POTSDAM HOSPITAL | ||
| K | $888,206 | FMV |
Comments