2020-11-16T15:27:23-06:00 2019-12-31 822624857 GRAY & GRAY AND ASSOCIATES CPAS PC 1 MAIN STREET SUITE 101 CANTON NY 136171277 990 2019-01-01 161012691 CANTON-POTSDAM HOSPITAL CANT 3152615103 50 LEROY STREET POTSDAM NY 13676 RICHARD JACOBS CFO 3152615103 2020-11-13 true JOHN J GRAY JR CPA P00076464 3153862925 2020-11-13 2019 2022-09-23 18:48:47Z DONNA MCGREGOR CFO CANTON-POTSDAM HOSPITAL POTSDAM NY 13676 222628676 false X WWW.CPHOSPITAL.ORG X 1920 NY CANTON-POTSDAM HOSPITAL'S MISSION IS TO PROVIDE SKILLED, COMPASSIONATE, COST-EFFECTIVE CARE THAT PROMOTES WELLNESS AND MEETS COMMUNITY NEEDS. 17 7 1498 124 0 1286782 2188095 181604408 193142376 657797 1803975 20907719 24891864 204456706 222026310 0 0 122030768 126390974 0 0 70313975 79653775 192344743 206044749 12111963 15981561 141760114 157784645 64216404 64735800 77543710 93048845 X CANTON-POTSDAM HOSPITAL'S MISSION IS TO PROVIDE SKILLED, COMPASSIONATE COST-EFFECTIVE CARE THAT PROMOTES WELLNESS AND MEETS COMMUNITY NEEDS. false false 102797751 280789378 ACUTE CARE: CANTON-POTSDAM HOSPITAL HAS A TOTAL OF 94 LICENSED BEDS, COMPRISED OF 17 FOR CHEMICAL DEPENDENCY-REHABILITATION, 6 FOR INTENSIVE CARE, 8 FOR MATERNITY AND 63 FOR MEDICAL/SURGICAL. PROFESSIONAL STAFF COVERAGE FOR OUR IN-PATIENT CENSUS IS PROVIDED BY A HOSPITALIST PROGRAM. TOTAL PATIENT DAYS DECREASED BY APPROXIMATELY 10.85% FROM 2018 TO 2019. OBSERVATION CASES INCREASED BY APPROXIMATELY 18.25% FROM 2018 TO 2019. EMERGENCY ROOM VISITS INCREASED BY 4.87% FROM 2018 TO 2019. 44045247 65813424 HOSPITAL BED CLINICS: THERE WAS GROWTH OF THE HOSPITAL BASED CLINICS. THERE WERE 206,297 VISITS IN 2019, COMPARED TO 195,856 IN 2018; ROUGHLY A 5.33% INCREASE. 10102563 23222065 OPERATING ROOM: IN 2019, THE OPERATING ROOM NUMBER OF CASES INCREASED BY APPROXIMATELY 6% COMPARED TO 2018. 8280539 12427529 IN 2019, THE ONCOLOGY VISITS DECREASED APPROXIMATELY 3.68% FROM 10,981 IN 2018 TO 10,577 IN 2019. 8280539 12427529 165226100 true false false true false false false false false true true false false true true true false true false false false false false false false false true true false false true true false false true false false false false false false true false false false false false true true true false false true 238 0 true 1498 true false false false false false false false false false false false false false false X 17 7 false false false false true true true true true false true true true true true true true true true true false NY X DONNA MCGREGOR CANTON-POTSDAM HOSP 3152615451 50 LEROY STREET POTSDAM NY 13676 X JEFFREY HAASBEEK MD MEDICAL DOCT 50.00 0.00 X 883696 0 45193 RAJIV SHAH MD MEDICAL DOCT 50.00 0.00 X 789701 0 38647 THOMAS KNEIFEL MD MEDICAL DOCT 50.00 0.00 X 771146 0 45193 KRIS VANWAGNER MD MEDICAL DOCT 50.00 0.00 X 788264 0 23605 ROBERT CUMMINGS MD MEDICAL DOCT 50.00 0.00 X 739492 0 43422 DAVID ACKER PRESIDENT & 50.00 5.00 X 0 591088 35610 RICHARD JACOBS CFO 50.00 5.00 X 0 346295 31517 RONALD BERRY DIRECTOR 2.00 5.00 X 0 0 0 CATHERINE BLEVINS DIRECTOR 2.00 0.00 X 0 0 0 JUDITH CHASE SECRETARY 4.00 X X 0 0 0 MARK CORNETT CHAIR 4.00 5.00 X X 0 0 0 PAUL COLE DVM DIRECTOR 2.00 0.00 X 0 0 0 DONALD DANGREMOND 2ND VICE CHA 4.00 5.00 X X 0 0 0 ERIN DRAPER DIRECTOR 2.00 0.00 X 0 0 0 BRIAN GARDAM DIRECTOR 2.00 5.00 X 0 0 0 MICHAEL GRIFFIN 1ST VICE CHA 4.00 5.00 X X 0 0 0 JACQUELYN KUNO DIRECTOR 2.00 0.00 X 0 0 0 FLORENCE BERO MD DIRECTOR 2.00 5.00 X 0 0 0 PAUL MCGRATH TREASURER 4.00 X X 0 0 0 EDWARD MUCENSKI DIRECTOR 2.00 5.00 X 0 0 0 LENORE VANDERZEE PHD DIRECTOR 2.00 0.00 X 0 0 0 JOANNE SCOTT DIRECTOR 2.00 0.00 X 0 0 0 JAMES THEODORE DIRECTOR 2.00 5.00 X 0 0 0 RICHARD VANLEUVEN DIRECTOR 2.00 0.00 X 0 0 0 3972299 937383 263187 242 false true false ERDMAN COMPANY 1 ERDMAN PL MADISON WI 53717 CONSTRUCTION 7803887 DANKO CONSTRUCTION CORP PO BOX 239 MASSENA NY 13662 CONSTRUCTION 2126434 MAYO COLLABORATIVE SERVICES INC PO BOX 9146 MINNEAPOLIS MN 554809146 LAB SERVICES 1919425 MORRISON MANAGEMENT SPECIALISTS PO BOX 102289 ATLANTA GA 303682289 STAFFING 840828 KOPP BILLING AGENCY PO BOX 2337 SYRACUSE NY 13220 BILLING 710974 48 2124856 63239 2188095 NET PATIENT SERVICE REVENUE 900099 193142376 193142376 193142376 756677 756677 244511 512477 -267966 -267966 -267966 100333 1036854 89889 10444 1036854 1047298 1047298 340B RETAIL PROGRAM 17696655 17696655 ALL OTHER REVENUE 5620076 5620076 OTHER 1843099 1843099 25159830 222026310 193142376 26695839 102242 82816 19426 102874598 83323701 19550897 4213696 3413094 800602 12813887 10379248 2434639 6386551 5173106 1213445 390481 390481 239896 239896 19959 19959 159238 159238 945190 765604 179586 3761968 3070121 691847 780368 632098 148270 393851 319019 74832 990707 802462 188245 6866657 5561992 1304665 1931146 1564228 366918 SUPPLIES 29507585 23901149 5606436 PURCHASED/CONTRACTED SERV 20292327 16436785 3855542 EQUIPMENT RENTAL & MAINT 7052239 5724142 1328097 MISC. 2753199 2312708 440491 3568964 1604589 1964375 206044749 165226100 40818649 0 3316040 3865438 2147653 1314408 20212682 21247670 2293210 2310027 2442243 3339459 156851775 103341711 40433254 53510064 894657 987553 70020375 71210026 141760114 157784645 28239520 30247832 10559179 9115306 1740615 1342096 23677090 24030566 64216404 64735800 X 76823952 93048845 719758 77543710 93048845 141760114 157784645 X 15981561 -78380 -398046 X false true X true false X false false false false false false false false true 19959 19959 false SCHEDULE C, PART II-B, LINE 1 IROQUOIS HEALTHCARE ALLIANCE: 6,614.00: FEDERAL AND STATE ADVOCACY HANYS ANNUAL MEMBERSHIP DUES: 9,298.00: FEDERAL AND STATE ADVOCACY AMERICAN HOSPITAL ASSOCIATION ANNUAL MEMBERSHIP DUES: 4,047.00: FEDERAL AND STATE ADVOCACY 894657 92896 987553 948837 -54180 894657 907013 41824 948837 894097 12916 907013 909653 -15556 894097 0.73000 0.27000 false false 4534252 4534252 54981751 26892937 28088814 10154239 5454914 4699325 86680407 70993860 15686547 501126 501126 53510064 ASSETS WHOSE USEFUL LIFE IS LIMITED 26759528 INTEREST IN CANTON HOSP FOUNDATION 25165272 OTHER NOTES & LOANS RECEIVABLE (NET) 6228898 DUE FROM ST. LAWRENCE HEALTH SYSTEM 6141171 OTHER ASSETS 4699946 DUE FROM AFFILIATES 1703772 DUE FROM CANTON HOSPITAL FOUNDATION 511439 71210026 ESTIMATED THIRD PARTY SETTLEMENTS 10792763 DUE TO AFFILIATES 6641444 457 & ASSET RETIREMENT OBLIGATION 5757335 INTEREST RATE SWAP 690552 ACCRUED RETIREMENT OBLIGATION 148472 24030566 X 221358582 512477 512477 220846105 1180205 1180205 222026310 206557226 512477 512477 206044749 206044749 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 THAN 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 2019 OR 2018. ON DECEMBER 22, 2017 THE PRESIDENT SIGNED INTO LAW H.R.1, ORIGINALLY KNOWN AS THE TAX CUTS AND JOBS ACT. THE NEW LAW (PUBLIC LAW NO 115-97) INCLUDES SUBSTANTIAL CHANGES TO THE TAXATION OF INDIVIDUALS, BUSINESSES, MULTINATIONAL ENTERPRISES, AND OTHERS. IN ADDITION TO MANY GENERALLY APPLICABLE PROVISIONS THE LAW CONTAINS SEVERAL SPECIFIC PROVISIONS THAT RESULT IN CHANGES TO THE TAX TREATMENT OF TAX-EXEMPT ORGANIZATIONS AND DONORS. THE SYSTEM HAS REVIEWED THESE PROVISIONS AND THE POTENTIAL IMPACT AND CONCLUDED THE ENACTMENT OF H.R.1 DOES NOT HAVE A MATERIAL EFFECT ON THE OPERATIONS OF THE ORGANIZATION. SCHEDULE D, PAGE 4, PART XI, LINE 2D RENTAL EXPENSES 512,477 SCHEDULE D, PAGE 4, PART XI, LINE 4B GIFT AND BEQUESTS: 63,239 CHANGE OF FAIR MARKET VALUE OF INTEREST RATE SWAP -14,719 UNRESTRICTED ENDOWMENT INCOME: 23,793 REALIZED LOSS ON INVESTMENTS: 81,226 OTHER: 1,130,677 NET PERIODIC PENSION (COST) GAIN, NON-SERVICE RELATED -104,011 SCHEDULE D, PAGE 4, PART XII, LINE 2D RENTAL EXPENSES 512,477 true true true X true X true true false true true 501028 501028 0.00240 42659395 22794774 19864621 0.09640 43160423 22794774 20365649 0.09880 275910 275910 0.00130 731931 731931 0.00360 106721 106721 0.00050 1114562 1114562 0.00540 44274985 22794774 21480211 0.10430 627928 627928 0.00300 627928 627928 0.00300 true 5864823 780601 35900220 35496553 403667 X true true 1 1 CANTON-POTSDAM HOSPITAL 50 LEROY STREET POTSDAM NY 13676 WWW.CPHOSPITAL.ORG X X X CANTON-POTSDAM HOSPITAL 1 false false true X X X X X X X X X X 19 true true true true X WWW.CPHOSPITAL.ORG X true 19 false false false true X 100.000000000000 300.000000000000 true true X X X X true X WWW.CPHOSPITAL.ORG X WWW.CPHOSPITAL.ORG X WWW.CPHOSPITAL.ORG X X X X X X true X X false X X true X false true FACILITY 1, CANTON-POTSDAM HOSPITAL - PART V, LINE 3E SEE PART VI FACILITY 1, CANTON-POTSDAM HOSPITAL - PART V, LINE 5 SEE PART VI FACILITY 1, CANTON-POTSDAM HOSPITAL - PART V, LINE 6A SEE PART VI FACILITY 1, CANTON-POTSDAM HOSPITAL - PART V, LINE 6B SEE PART VI FACILITY 1, CANTON-POTSDAM HOSPITAL - PART V, LINE 15E SEE PART VI FACILITY 1, CANTON-POTSDAM HOSPITAL - PART V, LINE 24 SEE PART VI SCHEDULE H, PART VI PART V, 24: THE HOSPITAL USES THE HIGHEST VOLUME COMMERCIAL COVERAGE RATE, FROM BLUE CROSS/BLUE SHIELD, WHICH IS ALSO GENERALLY THE LOWEST RATE CHARGED. 1.REQUIRED DESCRIPTIONS: PART II -COMMUNITY BUILDING ACTIVITIES - THE AMOUNT REPORTED ON PART II LINE 8 REPRESENTS THE INVESTMENT MADE IN RECRUITING NEW HEALTHCARE PRACTITIONERS TO OUR SERVICE AREA DURING 2019. DUE TO ITS INDIGENT POPULATION AND RURAL NATURE, MUCH OF THE REGION SURROUNDING THE HOSPITAL IS DESIGNATED AS A MANPOWER SHORTAGE AREA. PART III, SECTION A, LINES 2 & 3 THE COSTS ON LINE 2 ARE BASED UPON THE MEDICARE ICR FOR 2019 APPLIED TO THE GROSS CHARGES WRITTEN OFF. THE COSTS ON LINE 3 WERE CALCULATED IN ACCORDANCE WITH THE COSTING METHODOLOGY EMPLOYED BY THE NYS DOH BAD DEBT COSTING PROCESS. PART III SECTION A, LINE 4 - PAGE 14 OF THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS (FN4B-PATIENT SERVICE RECEIVABLES) PART III SECTION B, LINE 8 - DESCRIBE THE COSTING METHODOLOGY OR SOURCE USED TO DETERMINE THE AMOUNT REPORTED ON LINE 6 (MCR ALLOWABLE COSTS OF CARE RELATED TO PAYMENTS): COSTS REPORTED ON LINE 6 INCLUDE TOTAL INPATIENT COSTS (ROUTINE, ICU, ANCILLARY AND CAPITAL), OBSERVATIONS COSTS, OUTPATIENT COSTS AND SWING BED COSTS FROM MCR COST REPORT, WORKSHEETS D-1: PART II AND PART IV; WORKSHEET D: PART V; AND WORKSHEET E, E-2 AND 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. PART V SECTION B, 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. THIS YEAR, 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. PART V, SECTION B, LINE 6A&B - PLEASE SEE LINE 5 EXPLANATION ABOVE. PART V SECTION B, 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, OR ORDINANCES. 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. PART V, SECTION B, LINE 6A&B - SEE SEPARATE ATTACHMENT PART V SECTION B, LINE 11 - SEE SEPARATE ATTACHMENT 2.NEEDS ASSESSMENT: PLEASE REFERENCE THE ABOVE REQUIRED DESCRIPTIONS, PART V SECTION B, LINES 5 AND 11B. 3.PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE: THE ORGANIZATION CONSPICUOUSLY POSTS ITS FINANCIAL ASSISTANCE POLICY IN EACH REGISTRATION/RECEPTION AREA. PATIENTS ARE ENCOURAGED TO APPLY FOR ASSISTANCE 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: CANTON-POTSDAM 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 112,000 RESIDENTS. CANTON-POTSDAM HOSPITAL'S PRIMARY SERVICE AREA INCLUDES APPROXIMATELY 58,000 PEOPLE LIVING IN THE COMMUNITIES OF POTSDAM, CANTON AND NEARBY SMALLER COMMUNITIES AND INCLUDES THE STUDENT POPULATION OF FOUR COLLEGES IN CANTON AND POTSDAM. THE SECONDARY SERVICE AREA FOR THE HOSPITAL IS PREDOMINANTLY THE REMAINING COMMUNITIES WITHIN ST. LAWRENCE COUNTY WITH SOME RESIDENTS OF THE WESTERN FRANKLIN COUNTY AREA BEING SERVED. 5.PROMOTION OF COMMUNITY HEALTH: AT THE 2019 HEALTH FAIRS, THE IMAGING DEPARTMENT PROVIDED FREE HEEL BONE DENSITY SCREENING EXAMS TO THE COMMUNITY. THE APPROXIMATE COST FOR THIS SERVICE WAS 118,000. IN ADDITION TO THESE SCREENINGS, THE HOSPITAL HOSTS AND ATTENDS NUMEROUS HEALTH FAIRS THROUGHOUT THE YEAR, ALONG WITH HOSTING EVENTS SUCH AS "ASK THE PHYSICIAN", "PARTNERING IN YOUR CARE" LUNCHEONS AND WOMEN'S WELLNESS DAY EVENTS. THE APPROXIMATE VALUE OF THESE EFFORTS WAS 5,000. THE HOSPITAL'S LIFELINE DEPARTMENT HAS PROVIDED THE COMMUNITY WITH 112 FREE LIFELINE INSTALLS. THE TOTAL COST OF THESE INSTALLS FOR 2019 WAS 3,584. THE HOSPITAL'S BIRTHPLACE PROVIDES CHILDBIRTH CLASSES, BREASTFEEDING CLASSES, EARLY PREGNANCY CLASSES AND INFANT CPR CLASSES. THE APPROXIMATE 2019 COST ASSOCIATED WITH THESE BENEFITS WAS 4,700. THE HOSPITAL CONDUCTS A BREAST CANCER SUPPORT GROUP ONCE A MONTH, AS WELL AS SPONSORS A CANCER SURVIVOR'S DAY AND BREAST CANCER SURVIVOR DINNER. THE HOSPITAL CONDUCTS PERIODIC FREE CANCER SCREENINGS AND PROVIDES THE COMMUNITY INFORMATION AT A VARIETY OF EVENTS. THE TOTAL APPROXIMATE COST OF THESE BREAST CANCER EDUCATION AND AWARENESS ACTIVITIES FOR 2019 WAS 5,700. 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 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 IMPROV X X X X X false false false false false false false false false JEFFREY HAASBEEK MD MEDICAL DOCTOR 883696 13850 31343 928889 RAJIV SHAH MD MEDICAL DOCTOR 789701 13850 24797 828348 THOMAS KNEIFEL MD MEDICAL DOCTOR 771146 13850 31343 816339 KRIS VANWAGNER MD MEDICAL DOCTOR 788264 13850 9755 811869 ROBERT CUMMINGS MD MEDICAL DOCTOR 739492 12079 31343 782914 DAVID ACKER PRESIDENT & CEO 590100 988 19600 16010 626698 RICHARD JACOBS CFO 346295 19600 11917 377812 SCHEDULE J, PART III THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS SEEKS THE INPUT OF A CONSULTING FIRM WITH NATIONAL EXPERIENCE TO REVIEW THE COMPENSATION PACKAGES OFFERED TO TOP MANAGEMENT AND THE REGULATORY COMPLIANCE ISSUES OF NOT-FOR-PROFITS. UPON THE FINDINGS OF THE CONSULTANT AND DELIBERATIONS OF THE COMPENSATION COMMITTEE, THE COMMITTEE WILL THEN MAKE A RECOMMENDATION TO THE FULL BOARD. THE FULL BOARD WILL THEN VOTE ON THE TOP OFFICIAL'S COMPENSATION PACKAGE. THE COMPENSATION OF OTHER KEY EMPLOYEES IS DETERMINED PRIMARILY BY THE WORK OF THE HUMAN RESOURCE DEPARTMENT, THE RECOMMENDATION OF THE VICE PRESIDENT OF HUMAN RESOURCES (HR), AND BY INFORMATION GATHERED FROM INDEPENDENT SURVEY DATA OF NATIONAL AND SURROUNDING MARKETS. THE VICE PRESIDENT OF HUMAN RESOURCES WILL REVIEW THE SURVEY DATA TO ESTIMATE SALARY RANGES AND COMPENSATION PACKAGES. THE VP OF HR MAKES THE RECOMMENDATION TO THE CEO. THE CEO WILL BRING THE INFORMATION TO THE COMPENSATION COMMITTEE. AFTER DELIBERATIONS AND CONSIDERATIONS, THE COMPENSATION COMMITTEE WILL THEN BRING THEIR RECOMMENDATION TO THE FULL BOARD FOR THEIR FINAL APPROVAL. A ST LAWRENCE COUNTY IDC 272614310 2010-08-30 21305500 SEE PART VI false true false A 9165000 20921703 11168176 9590000 2011 true false false true A false false false false false false true A false true false false true false false false true A true PURPOSE OF ISSUE DESCRIPTION ST. LAWRENCE COUNTY IDC SEE PART VI ADDITIONAL INFORMATION ST. LAWRENCE COUNTY IDC CANTON-POTSDAM HOSPITAL FOUNDATION, INC. EIN: 16-1279472 ATTACHMENT TO FORM 990, SCHEDULE K PART VI - SUPPLEMENTAL INFORMATION PART I, LINE A THIS FINANCING CONSISTS OF TWO SERIES OF BONDS - THE 17,720,000 ST. LAWRENCE COUNTY INDUSTRIAL DEVELOPMENT AGENCY CIVIC DEVELOPMENT CORPORATION REVENUE BONDS (CANTON-POTSDAM HOSPITAL), SERIES 2010 (THE "HOSPITAL BONDS") AND 3,585,000 ST. LAWRENCE COUNTY INDUSTRIAL DEVELOPMENT AGENCY CIVIC DEVELOPMENT CORPORATION REVENUE BONDS (CANTON-POTSDAM HOSPITAL FOUNDATION, INC.), SERIES 2010 (THE "FOUNDATION BONDS-; THE FOUNDATION BONDS AND THE HOSPITAL BONDS ARE HEREINAFTER JOINTLY REFERRED TO AS THE "BONDS"). PROCEEDS OF THE HOSPITAL BONDS WERE USED TO FINANCE THE CONSTRUCTION AND EQUIPPING OF HEALTH CARE FACILITIES OWNED BY CANTON-POTSDAM HOSPITAL (THE "HOSPITAL"), AND TO REFUND OUTSTANDING TAX-EXEMPT OBLIGATIONS ISSUED AUGUST 20, 2002 TO FINANCE HOSPITAL FACILITIES. PROCEEDS OF THE FOUNDATION BONDS WERE ISSUED TO FINANCE THE ACQUISITION, CONSTRUCTION AND EQUIPPING OF MEDICAL FACILITIES OWNED BY CANTON-POTSDAM HOSPITAL FOUNDATION, INC. (THE "FOUNDATION") WHICH ARE LEASED TO THE HOSPITAL. THE HOSPITAL BONDS AND FOUNDATION BONDS WERE SOLD AT THE SAME TIME PURSUANT TO A COMMON PLAN OF FINANCING AND WILL BE PAID OUT OF SUBSTANTIALLY THE SAME SOURCE OF FUNDS. THEREFORE, PURSUANT TO TREASURY REGULATION SECTION 1.150-1(C), THE HOSPITAL BONDS AND THE FOUNDATION BONDS ARE TREATED AS A SINGLE ISSUE OF BONDS FOR TAX PURPOSES, IN THE AGGREGATE PRINCIPAL AMOUNT OF 21,305,000. CONSISTENT WITH THE CHARACTERIZATION OF THE BONDS AS A SINGLE ISSUE FOR TAX PURPOSES, THE HOSPITAL BONDS AND FOUNDATION BONDS ARE REPORTED AS A SINGLE ISSUE ON SCHEDULE K TO THE HOSPITAL'S FORM 990. PART II, LINE 3 - TOTAL PROCEEDS OF ISSUE THE BONDS WERE ORIGINALLY ISSUED AS "DRAW-DOWN BONDS" IN THE MAXIMUM PRINCIPAL AMOUNT OF 21,305,000, WHICH REPRESENTS THE ORIGINAL ISSUE PRICE OF THE BONDS REPORTED ON IRS FORM 8038. ULTIMATELY, ONLY 20,921,703 OF BOND PROCEEDS WERE ACTUALLY DRAWN. PART II, LINE 11 - OTHER SPENT PROCEEDS PROCEEDS OF THE BONDS IN THE PRINCIPAL AMOUNT OF 9,590,000 WERE SPENT ON SEPTEMBER 27, 2010 TO REDEEM CERTAIN OUTSTANDING TAX-EXEMPT BONDS ISSUED AUGUST 20, 2002 TO FINANCE HOSPITAL FACILITIES. SEE PART V false SCHEDULE L, PART V OUR ORGANIZATION HAS BUSINESS TRANSACTIONS INVOLVING CERTAIN MEMBERS OF OUR BOARD OF DIRECTORS, WHICH ARE DETAILED BELOW: 1.DONALD DANGREMOND, MICHAEL GRIFFIN, ERIN DRAPER AND PAUL MCGRATH, BOARD MEMBERS, ARE/WERE EMPLOYEES OF CLARKSON UNIVERSITY (CU). OUR ORGANIZATION PROVIDES HEALTHCARE SERVICES AND STAFFS A CLINIC ON THE CU CAMPUS. THE OPERATION COSTS OF THAT CLINIC IN 2019 WERE APPROXIMATELY 476,592 WHICH WERE REIMBURSED BY CU ON A PASS THROUGH BASIS. 2.BRIAN GARDAM, BOARD MEMBER, IS ALSO THE FORMER EXECUTIVE DIRECTOR OF HOSPICE OF PALLIATIVE CARE OF ST. LAWRENCE VALLEY (HOSPICE). CANTON- POTSDAM HOSPITAL CONTRACTS WITH HOSPICE FOR INPATIENT HOSPICE SERVICES FOR SYMPTOM MANAGEMENT AND PAIN CONTROL. BRIAN GARDAM IS ALSO ON THE BOARD OF DIRECTORS FOR NORTHERN LIGHTS HEALTH CARE. 3.DURING 2010, BOND ISSUES WERE OBTAINED FOR CANTON-POTSDAM HOSPITAL FROM COMMUNITY BANK, NA AND KEY BANK, AS DISCLOSED IN SCHEDULE K. THE COMMUNITY BANK, NA PORTION OF THESE BOND ISSUES WERE IN THE AMOUNT OF 3,585,000. IN 2011, THE HOSPITAL WAS ISSUED A MORTGAGE BY COMMUNITY BANK, NA FOR CONSTRUCTION OF THE E.J. NOBEL ANNEX BUILDING, IN THE AMOUNT OF 2,200,000. EDWARD MUCENSKI, BOARD MEMBER, WAS A BOARD MEMBER OF COMMUNITY BANK, NA UNTIL DECEMBER 31, 2017. AS OF DECEMBER 31, 2019 THE HOSPITAL WAS CURRENT ON ANY OBLIGATIONS DUE TO THE BANK. 4.BOARD MEMBER MARK CORNETT IS FORMERLY A CONSULTANT FOR SLIC NETWORK SOLUTIONS. SLIC RENTS OFFICE SPACE AT THE HOSPITAL'S MEDICAL OFFICE BUILDING IN CANTON, NEW YORK. CANTON-POTSDAM HOSPITAL REMITTED APPROXIMATELY 249,390 TO SLIC IN 2019 FOR TELECOMMUNICATION SERVICES. 5.BOARD MEMBER FLORENCE BERO, MD IS IN PRACTICE WITH CANTON FAMILY PHYSICIANS WHICH LEASES SPACE FROM THE HOSPITAL. IN 2019, CPH CHARGED THE PRACTICE 0 FOR RENT. 6.BOARD MEMBER CATHERINE BLEVINS IS EMPLOYED AT SLIC NETWORK SOLUTIONS/NICHOLVILLE TELEPHONE. CANTON-POTSDAM HOSPITAL PAID SLIC 249,390 IN 2019 FOR TELECOMMUNICATION SERVICES. 7.JAMES THEODORE, BOARD MEMBER, IS ALSO THE MORGAN STANLEY SMITH BARNEY LLC FINANCIAL ADVISOR FOR AN ACCOUNT HELD IN THE NAME OF CANTON-POTSDAM HOSPITAL FOUNDATION, INC. (A RELATED TAX-EXEMPT ORGANIZATION). THIS FOUNDATION ACCOUNT IS USED AS A PASS-THROUGH FOR DONATIONS OF STOCK. THE BALANCE IN THIS ACCOUNT AS OF DECEMBER 31, 2019 WAS 0. FORM 990, PAGE 2, PART III, LINE 4D IN 2019, THE ONCOLOGY VISITS DECREASED APPROXIMATELY 3.68% FROM 10,981 IN 2018 TO 10,577 IN 2019. FORM 990, PAGE 6, PART VI, LINE 6 MEMBERS FORM 990, PAGE 6, PART VI, LINE 7A AS PER BYLAWS FORM 990, PAGE 6, PART VI, LINE 7B BOARD APPOINTMENTS FORM 990, PAGE 6, PART VI, LINE 11B THE FORM 990 IS PREPARED BY THE FINANCE DEPARTMENT STAFF MEMBERS. UPON COMPLETION, THE FORM IS SUBMITTTED 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 BOARD MEMBER CONFLICT OF INTEREST DISCLOSURE FORMS ARE COMPLETED AND REVIEWED BY THE BOARD ANNUALLY. FORM 990, PAGE 6, PART VI, LINE 15A LINE 15A: THE AUDIT, COMPLIANCE, AND COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS UTILIZES THE INPUT OF A NATIONAL CONSULTING FIRM WITH EXPERTISE IN EXECUTIVE COMPENSATION TO REVIEW THE COMPENSATION PACKAGES OFFERED TO TOP MANAGEMENT AS WELL AS OUR COMPLIANCE WITH REGULATORY REQUIREMENTS FOR EXECUTIVE COMPENSATION FOR NOT-FOR-PROFIT HOSPITALS. UPON THE FINDINGS OF THE CONSULTANT AND DELIBERATIONS OF THE AUDIT, COMPLIANCE, AND COMPENSATION COMMITTEE, THE COMMITTEE WILL THEN MAKE A RECOMMENDATION TO THE FULL BOARD. THE FULL BOARD WILL THEN VOTE ON THE TOP OFFICIAL'S COMPENSATION PACKAGE. FORM 990, PAGE 6, PART VI, LINE 15B LINE 15B: THE COMPENSATION OF OTHER KEY EMPLOYEES IS DETERMINED PRIMARILY BY INFORMATION GATHERED FROM INDEPENDENT SURVEY DATA FROM NATIONAL AND SURROUNDING MARKETS COORDINATED BY THE HUMAN RESOURCE DEPARTMENT. THE CEO AND VICE PRESIDENT OF HUMAN RESOURCES REVIEW THE SURVEY DATA TO DETERMINE SALARY RANGES AND COMPENSATION PACKAGES. THE CEO BRINGS THE INFORMATION AND FINDINGS TO THE AUDIT, COMPLIANCE, AND COMPENSATION COMMITTEE OF THE BOARD FOR THEIR DELIBERATION AND CONSIDERATION. THE AUDIT, COMPLIANCE, AND COMPENSATION COMMITTEE WILL THEN BRING THEIR RECOMMENDATION TO THE FULL BOARD FOR THEIR FINAL APPROVAL. FORM 990, PAGE 6, PART VI, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9 CONTRIBUTIONS FOR CAPITAL 250,229 TEMPORARILY RESTRICTED CONTRIBUTIONS FOR CAPITAL 72,962 CHANGE IN INTEREST IN NET ASSETS OF CPH FOUNDATION 3,731,555 CHANGE IN FUNDED STATUS OF EMPLOYEE BEN PLAN 487,639 CAPITAL CAMPAIGN GIFTS 0 TRANSFER TO ST. LAWRENCE HEALTH SYSTEM -4,775,073 TRANSFER TO AFFILIATE (CANTON POTSDAM MEDICAL PRAC 0 TRANSFER FROM CPH FOUNDATION 0 AR OF FEDERAL WITHHOLDINGS FROM 2018 -165,358 TOTAL -398,046 CANTON-POTSDAM HOSPITAL FOUNDATION 29 GROVE STREET POTSDAM NY 13676 161279472 PART VII NY 501C3 12A SLHS true CANTON-POTSDAM MEDICAL PRACTICEPLLC PLLC 50 LEROY STREET POTSDAM NY 13676 460714367 PART VII NY 501C3 SLHS true ST LAWRENCE HEALTH SYSTEM 50 LEROY STREET POTSDAM NY 13676 464259168 PART VII NY 501C3 12A N/A false NORTHERN LIGHTS HEALTHCARE PARTNERS 732 FORD STREET OGDENSBURG NY 13669 462500951 PART VII NY 501C3 N/A false GOUVERNEUR HOSPITAL 77 W BARNEY STREET GOUVERNEUR NY 13642 464249555 HOSPITAL NY 501C3 SLHS true false true false false false false false false false true true false true false false true true true false CANTON-POTSDAM MEDICAL PRACTICE PLLC J 2809524 FMV ST LAWRENCE HEALTH SYSTEM INC B CASH EXCHANGED CANTON-POTSDAM HOSPITAL FOUNDATION K 532395 CASH EXCHANGED GOUVERNEUR HOSPITAL INC J 960373 FMV CANTON-POTSDAM HOSPITAL FOUNDATION J 7296 CASH EXCHANGED CANTON-POTSDAM HOSPITAL FOUNDATION R 41746 CASH EXCHANGED CANTON-POTSDAM HOSPITAL FOUNDATION P 7657 CASH EXCHANGED CANTON-POTSDAM HOSPITAL FOUNDATION Q 210092 CASH EXCHANGED CANTON-POTSDAM MEDICAL PRACTICE PLLC J 30330 FMV CANTON-POTSDAM HOSPITAL FOUNDATION M 147530 CASH EXCHANGED GOUVERNEUR HOSPITAL INC K 1064388 FMV ST LAWRENCE HEALTH SYSTEM INC R 4775073 CASH EXCHANGED SCHEDULE R CANTON-POTSDAM HOSPITAL FOUNDATION IS RESPONSIBLE FOR RAISING, INVESTING AND MANAGING FUNDS FOR THE HOSPITAL. CANTON-POTSDAM MEDICAL PRACTICE, PLLC PROVIDES PHYSICIAN SERVICES IN AN OUTPATIENT CLINIC SETTING AS BENEFIT TO THE COMMUNITY AND HOSPITAL. ST. LAWRENCE HEALTH SYSTEM, FORMED DECEMBER 5, 2013, IS OPERATED EXCLUSIVELY FOR THE SOLE CHARITABLE PURPOSE OF BENEFITING AND SUPPORTING CANTON-POTSDAM HOSPITAL AND OTHER AFFILIATED CORPORATIONS. NORTHERN LIGHTS HEALTH CARE PARTNERSHIP, INC. OPERATES A CERTIFIED HOME HEALTH AGENCY. GOUVERNEUR HOSPITAL, INC., A NOT-FOR-PROFIT ORGANIZATION, IS THE AFFILIATE OF CANTON-POTSDAM HOSPITAL, AND SUPPORTED BY THE PARENT ORGANIZATION OF ST. LAWRENCE HEALTH SYSTEM.