2020-11-16T12:44:35-06:00 2019-12-31 822624857 GRAY & GRAY AND ASSOCIATES CPAS PC 1 MAIN STREET SUITE 101 CANTON NY 136171277 990 2019-01-01 464249555 GOUVERNEUR HOSPITAL GOUV 3152871000 77 WEST BARNEY STREET GOUVERNEUR NY 13642 ERIC BURCH CEO 3152871000 2020-11-13 JOHN J GRAY JR CPA P00076464 3153862925 2020-11-13 64.88.174.3 2020-11-16 12:44:35 CS P 5AD7CE22C8D8FEE865ED4FE35A3226D1F0874B8F 7CC34E0763C8963CB33744DE705BAE3AB1C43AEB 2019 2021-01-29 14:40:06Z ERIC BURCH 77 WEST BARNEY STREET GOUVERNEUR NY 13642 25874309 false X WWW.GVNRHOSPITAL.ORG X 2013 NY OUR MISSION IS TO PROVIDE SKILLED, COMPASSIONATE, COST-EFFECTIVE CARE THAT PROMOTES WELLNESS AND MEETS THE COMMUNITY'S HEALTHCARE NEEDS. 10 6 264 4 0 519308 83371 21223585 22898581 34456 72371 1733716 2463380 23511065 25517703 0 0 13392481 14049641 0 0 9139405 9843180 22531886 23892821 979179 1624882 14515079 16154381 8921591 8777531 5593488 7376850 X OUR MISSION IS TO PROVIDE SKILLED, COMPASSIONATE, COST-EFFECTIVE CARE THAT PROMOTES WELLNESS AND MEETS THE COMMUNITY'S HEALTHCARE NEEDS. true false 13458146 36095102 GOUVERNEUR HOSPITAL HAS A TOTAL OF 25 LICENSED BEDS, COMPRISED OF SWING, ALC, MED-SURG AND DETOXIFICATION. IN 2019, THERE WERE TOTAL PATIENT DAYS OF 5,392, 286 OBSERVATION CASES AND 914 DISCHARGES. 2170277 8693772 IN 2019, THE ER VISITS INCREASED APPROXIMATELY .63% FROM 9,820 IN 2018 TO 9,882 IN 2019. 1406932 1582095 THERE WAS AN INCREASE DUE TO THE ADDITION OF A SUBSTANCE ABUSE CLINIC IN 2019. THERE WERE 9,444 VISITS IN 2019, COMPARED TO 9,277 IN 2018, ROUGHLY A 2% INCREASE. 925366 1633088 THERE WAS DECREASE IN SURGERIES PERFORMED IN 2019. THERE WERE 617 SURGERIES IN 2019, COMPARED TO 704 IN 2018, ROUGHLY AN 12% DECREASE. 925366 1633088 17960721 true true 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 false false false false false false false true false false false false false true false false false true 62 0 true 264 true false false false false false false false false false false false false false false X 10 6 false false false false true true true true true false true true true true true true true true true true false NY X KELLY CICCHINELLI 3152871000 77 WEST BARNEY STREET GOUVERNEUR NY 13642 ALICE LOVING MD ANESTHESIOLO 40.00 X 325810 0 29677 ERIC BURCH CEO 16.00 42.00 X 0 320846 14968 ISMENE N MARAVEGIAS MD PHYSICIAN 40.00 0.00 X 265810 0 22084 RICHARD CORCORAN RPA PHYSICIAN AS 40.00 0.00 X 148174 0 23869 NICOLE L WEBER MD PHYSICIAN 40.00 0.00 X 157444 0 3171 KELLY CICCHINELLI CONTROLLER 32.00 18.00 X 0 132392 7086 AMANDA HANCE NURSE PRACTI 40.00 0.00 X 121254 0 15117 CHRISTINE BETRUS TRUSTEE 1.00 0.00 X 0 0 0 MARK BRACKETT SECRETARY/TR 1.00 0.00 X X 0 0 0 MICHAEL BURGESS CHAIRPERSON 1.00 0.00 X X 0 0 0 ROGER COOK DVM TRUSTEE 1.00 0.00 X 0 0 0 LAUREN FRENCH TRUSTEE 1.00 0.00 X 0 0 0 KURT HALLIDAY TRUSTEE 1.00 0.00 X 0 0 0 ANDREW LEONARD VICE CHAIR 1.00 0.00 X X 0 0 0 ANDREW WILLIAMS MD TRUSTEE 1.00 0.00 X 0 0 0 CAROLYN PISTOLESI TRUSTEE 1.00 0.00 X 0 0 0 RYAN SCHERMERHORN TRUSTEE 1.00 0.00 X 0 0 0 1018492 453238 115972 14 false true false CANTON-POTSDAM HOSPITAL 50 LEROY STREET POTSDAM NY 13676 STAFFING 2554544 DELPHI HOSPITALIST SERVICES LLC 1160 CHILI AVE SUITE 200 ROCHESTER NY 14624 HOSPITALIST 1062807 ST LAWRENCE HEALTH SYSTEM 50 LEROY STREET POTSDAM NY 13676 STAFFING 840453 ENI MECHANICAL INC 39 SOUTH GORDON STREET GOUVERNEUR NY 13642 CONTRACTOR 306014 MORRISON MANAGEMENT SPECIALISTS PO BOX 102289 ATLANTA GA 303682289 STAFFING 130531 7 83371 83371 NET PATIENT REVENUE 623000 22655425 22655425 VAP GRANT 623000 243156 243156 22898581 41103 41103 221730 329959 -108229 -108229 -108229 39515 18400 26647 12868 18400 31268 31268 CPH BILLABLE 1008813 1008813 OTHER 903909 903909 340B PROGRAM 604439 604439 54448 54448 2571609 25517703 25470190 -35858 118898 89174 29724 10567103 7925327 2641776 413784 310338 103446 2181029 1635772 545257 768827 576620 192207 51763 51763 115140 115140 4495 4495 72474 54355 18119 373901 314894 59007 41330 30998 10332 42537 31903 10634 150687 113015 37672 1159692 976677 183015 280224 236001 44223 PURCHASED SERVICES 4309725 3232293 1077432 SUPPLIES 1644961 1233720 411241 EQUIPMENT RENTAL 958671 791877 166794 MISCELLANEOUS 323064 242298 80766 314516 165459 149057 23892821 17960721 5932100 0 926842 2255748 1026775 42911 2489308 3285137 427859 445053 186714 108231 12464995 5057936 7230929 7407059 546506 624786 1680146 1985456 14515079 16154381 1421980 1843962 404206 395565 7095405 6538004 8921591 8777531 X 4047126 5483175 1546362 1893675 5593488 7376850 14515079 16154381 X 1624882 158480 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 19308 19308 false SCHEDULE C, PART IV GOUVERNEUR HOSPITAL, THROUGH ITS MEMBERSHIP OR FEES PAID IN 2019 TO THE FOLLOWING ORGANIZATIONS, INCURRED 19,308 IN LOBBYING EXPENSES: 4,719: IROQUOIS HEALTHCARE ALLIANCE-FEDERAL AND STATE ADVOCACY 6,342: HANYS ANNUAL MEMBERSHIP DUES-FEDERAL AND STATE ADVOCACY 8,247: AMERICAN HOSPITAL ASSOCIATION ANNUAL MEMBERSHIP DUES-FEDERAL AND STATE ADVOCACY 1908169 -14494 1893675 2534689 -626520 1908169 2412779 121910 2534689 1637555 1806389 38244 1069409 2412779 1672801 61715 -35323 61638 1637555 0.72000 0.28000 false false 647398 647398 5322084 1237571 4084513 6266696 3820365 2446331 228817 228817 7407059 FUNDS HELD IN TRUST BY OTHERS 1099605 OTHER NOTES AND LOANS REC (NET) 476032 DUE FROM AFFILIATES 409819 1985456 ASSET RETIREMENT OBLIGATION 3841675 DUE TO AFFILIATES 1932531 EST THIRD-PARTY PAYOR SETTLEMENTS 763798 6538004 X 25584936 329959 329959 25254977 262726 262726 25517703 24222780 329959 329959 23892821 23892821 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 2019 OR 2018. SCHEDULE D, PAGE 4, PART XI, LINE 2D RENT EXPENSES 329,959 SCHEDULE D, PAGE 4, PART XI, LINE 4B NON OPERATING GAINS/LOSSES 262,726 SCHEDULE D, PAGE 4, PART XII, LINE 2D RENT EXPENSES 329,959 true true X true X 2.010000000000 true X true true false true true 21274 -1202 22476 0.00090 7435615 4936448 2499167 0.10460 7456889 4935246 2521643 0.10550 11352 11352 0.00050 41266 41266 0.00170 10522 10522 0.00040 63140 63140 0.00260 7520029 4935246 2584783 0.10820 6288 6288 0.00030 6288 6288 0.00030 true 1149643 17980 4293313 6352587 -2059274 X true true 1 1 GOUVERNEUR HOSPITAL 77 WEST BARNEY STREET GOUVERNEUR NY 13642 WW.GVNRHOSPITAL.ORG/ABOUT-OUR-HOSPITAL X GOUVERNEUR HOSPITAL 1 false false true X X X X X X X X X X 19 true true true true X WW.GVNRHOSPITAL.ORG/ABOUT-OUR-HOSPITAL true 19 true WWW.GVNRHOSPITAL.ORG/ABOUT-OUR-HOSPITA false false true X 201.000000000000 300.000000000000 true true X X X true X WWW.GVNRHOSPITAL.ORG/ABOUT-OUR-HOSPITA X WWW.GVNRHOSPITAL.ORG/ABOUT-OUR-HOSPITA X WWW.GVNRHOSPITAL.ORG/ABOUT-OUR-HOSPITA X X X X true X X false X X true X false false 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. 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. 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. 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: 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: GOUVERNEUR HOSPITAL HELD MANY COMMUNITY ACTIVITIES TO HELP PROMOTE THE HEALTH OF THE COMMUNITY. SOME OF THESE ACTIVITIES INCLUDE BLOOD DRIVES, GOLF TOURNAMENT, SCHOOL EDUCATION ACTIVITIES, AND LUNCH & LEARNS. THE COMMUNITY LUNCH & LEARNS HELD BY GOUVERNEUR HOSPITAL HAD APPROXIMATELY 173 PEOPLE IN ATTENDANCE AND SPOKE TO VARIOUS HEALTH RELATED RISKS AND HOW TO MANAGE THEM. GOUVERNEUR HOSPITAL HAD 50 STUDENTS FROM MULTIPLE COLLEGES AND BOCES PROGRAMS SHADOW EMPLOYEES. GOUVERNEUR HOSPITAL HELD A "LET'S NOT MEET BY ACCIDENT" PROGRAM FOR 269 STUDENTS TO EDUCATE YOUNG DRIVERS ON THE DANGERS OF DWI AND TEXTING WHILE DRIVING. 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, 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. 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 AT DECEMBER 31, 2019 AND 2018, SIGNIFICANT CONCENTRATIONS OF PATIENT ACCOUNTS RECEIVABLE ARE AS FOLLOWS: 2019 2018 MEDICARE 18% 29% MEDICAID 29 18 COMMERCIAL CARRIERS AND MEDICARE AND MEDICAID MANAGED CARE AND OTHER THIRD PARTY PAYORS 37 45 NO-FAULT AND WORKERS COMPENSATION 5 1 PRIVATE PAY 11 7 ===== ===== 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 X false false false false false false false false false ALICE LOVING MD ANESTHESIOLOGIST 325810 14000 15677 355487 ERIC BURCH CEO 320846 14000 968 335814 ISMENE N MARAVEGIAS MD PHYSICIAN 265810 3981 18103 287894 RICHARD CORCORAN RPA PHYSICIAN ASSISTANT 148174 7678 16191 172043 NICOLE L WEBER MD PHYSICIAN 157444 3113 58 160615 SEE PART V BELOW false SCHEDULE L, PART V 1.GOUVERNEUR HOSPITAL CONFLICT OF INTEREST: MICHAEL BURGESS, BOARD MEMBER FOR GH, IS ALSO VICE PRESIDENT OF PLANNING AND TREASURY AT KPH HEALTH SERVICES. KPH HEALTH SERVICES MAKES PAYMENTS TO GH FOR THE 340B PROGRAM. 604,439 IN PAYMENTS WERE MADE IN 2019. 2.MARK BRACKETT, BOARD MEMBER FOR GH, IS A BOARD MEMBER OF KINNEY DRUGS FOUNDATION AND ST. LAWRENCE COUNTY CANCER FUND. 5,000 IN PAYMENTS FROM THE ST. LAWRENCE COUNTY CANCER FUND IN 2019. 3.ANDREW LEONARD, BOARD MEMBER FOR GH, IS ALSO THE PRESIDENT OF ENI MECHANICAL INC. IN 2019, ENI MECHANICAL WAS PAID 306,014 FOR SERVICES. 4.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 2019, THE COMMUNITY HEALTH CENTER PAID RENT FOR SPACE AT GH IN THE AMOUNT OF 118,125. FORM 990, PAGE 2, PART III, LINE 2 THE HOSPITAL ADDED AN OUTPATIENT SUBSTANCE USE CLINIC IN 2019. FORM 990, PAGE 2, PART III, LINE 4D THERE WAS DECREASE IN SURGERIES PERFORMED IN 2019. THERE WERE 617 SURGERIES IN 2019, COMPARED TO 704 IN 2018, ROUGHLY AN 12% 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 172,974 NET ASSETS REALEASED FROM RESTRICTIONS FOR CAPITAL -108,469 RESTRICTED CONTRIBUTIONS - NET -14,494 CHANGE IN FAIR VALUE OF FUNDS HELD IN TRUST BY OTH 108,469 CHANGE IN NET UNREALIZED GAIN ON INVESTMENTS 0 TRANSFER TO ST.LAWRENCE HEALTH SYSTEM 0 TOTAL 158,480 CANTON-POTSDAM HOSPITAL 50 LEROY STREET POTSDAM NY 13676 161012691 HOSPITAL NY 501C 3 SLHS 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 true CANTON-POTSDAM HOSPITAL FOUNDATION 50 LEROY STREET POTSDAM NY 13676 161279472 FOUNDATION NY 501C 3 SLHS true false false true false false false false false false true true false true false false true false false false CANTON-POTSDAM HOSPITAL FOUNDATION M 102371 CASH EXCHANGED CANTON-POTSDAM HOSPITAL I 1008813 FMV CANTON-POTSDAM HOSPITAL J 55575 FMV SLHS K 25790 FMV SLHS P 382908 FMV SLHS C 48021 CASH EXCHANGED CANTON-POTSDAM HOSPITAL K 960373 FMV