2019-11-14T10:09:04-06:00 2018-12-31 271728945 PKF O'CONNOR DAVIES LLP 500 MAMARONECK AVENUE HARRISON NY 105281633 990 2018-01-01 134111638 WESTCHESTER-ELLENVILLE REGIONAL HOSPITAL INC WEST 8456476400 10 HEALTHY WAY ELLENVILLE NY 12428 BOB RUE CFO 8456476400 2019-11-14 1 GARRETT M HIGGINS P00543209 9143818900 2019-11-11 65.51.112.58 2019-11-14 10:09:00 ES P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 9616F4B14A694591D1E716C270910E6FA5556DA3 2018 2020-03-31 21:24:44Z ELLENVILLE REGIONAL HOSPITAL STEVEN KELLEY 10 HEALTHY WAY ELLENVILLE NY 12428 24001520 0 X WWW.ELLENVILLEREGIONAL.ORG X 2000 NY ELLENVILLE REGIONAL HOSPITAL PROVIDES EXCEPTIONAL HEALTH CARE SERVICES TO ALL PEOPLE WHO LIVE IN, WORK IN AND VISIT OUR SURROUNDING COMMUNITIES. THIS HEALTH CARE IS DELIVERED WITH COMPASSION AND RESPECT BASED ON OUR COMMITMENT TO IMPROVING OUR COMMUNITY HEALTH THROUGH EXCELLENCE, INNOVATION AND STATE-OF-THE-ART TECHNOLOGIES. 11 10 260 41 0 0 842446 887731 18089423 19574911 133158 200887 319355 599450 19384382 21262979 0 0 0 0 11338698 12040763 0 31000 31000 7484054 8180443 18822752 20252206 561630 1010773 20928305 22115033 5892792 6492307 15035513 15622726 X ELLENVILLE REGIONAL HOSPITAL PROVIDES EXCEPTIONAL HEALTH CARE SERVICES TO ALL PEOPLE WHO LIVE IN, WORK IN AND VISIT OUR SURROUNDING COMMUNITIES. THIS HEALTH CARE IS DELIVERED WITH COMPASSION AND RESPECT BASED ON OUR COMMITMENT TO IMPROVING OUR COMMUNITY HEALTH THROUGH EXCELLENCE, INNOVATION AND STATE-OF-THE-ART TECHNOLOGIES. 0 0 4003241 3708218 IN-PATIENT DEPARTMENTS (MED/SURG AND SWING REHAB) & AMBULATORY SURGERY (OR): IN 2018, THE HOSPITAL AND THE FOUNDATION SUPPORTED OUR STAFF WITH TUITION ASSISTANCE AND REIMBURSEMENT FOR EDUCATION RELATED TO HEALTH CARE SERVICES. THIS GENEROUS ASSISTANCE MADE IT POSSIBLE FOR ONE OF OUR FULL-TIME NURSES TO OBTAIN HIS BSN. OUR FACILITY PRIDES IN SERVING AS A TEACHING HOSPITAL AND HOSTING STUDENTS FROM MANY SCHOOLS SUCH AS SULLIVAN COUNTY COMMUNITY COLLEGE AND THE BOCES NEW VISIONS PROGRAM. (SEE CONTINUATION ON SCHEDULE O)THE COHORT OF STUDENTS BENEFITED FROM WORKING SIDE BY SIDE WITH OUR SKILLED AND COMPASSIONATE CLINICAL TEAM AND OBSERVING THE DELIVERY OF EXCEPTIONAL CARE IN OUR INPATIENT UNIT. ONCE AGAIN, MANY MEMBERS OF NEIGHBORING COMMUNITIES UTILIZED THE SERVICES OF OUR SUB ACUTE REHABILITATION UNIT AND SUCCESSFULLY TRANSITIONED BACK HOME RATHER THAN GOING INTO LONG-TERM CARE FACILITIES. WE ARE PROUD TO REPORT THAT OUR RETURN TO HOME RATE FOR 2018 WAS 78.3%. THESE POSITIVE OUTCOMES ARE THE PRODUCT OF OUTSTANDING WORK AND DEDICATION. THE MULTIDISCIPLINARY TEAM BEHIND SUCH SUCCESS IS MADE UP OF NURSING, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH-LANGUAGE PATHOLOGY, SOCIALIZATION ACTIVITIES, AND A REGISTERED DIETITIAN. THE 2016 LEFT VENTRICULAR ASSIST DEVICE (LVAD) PROGRAM DEVELOPED IN COLLABORATION WITH WESTCHESTER MEDICAL CENTER CONTINUES STRONG. IN 2018, WE CONTINUED TO SERVE LVAD (LEFT VENTRICULAR ASSISTIVE DEVICE) PATIENTS AND THEIR FAMILIES IN OUR SUB ACUTE REHABILITATION UNIT. PATIENT SAFETY CONTINUES TO BE A PARAMOUNT FOCUS IN OUR FACILITY. WE PROMOTE MEDICATION SAFETY BY SCANNING MEDICATIONS BEFORE ADMINISTRATION, VERIFICATION OF PATIENT IDENTIFICATION, AND ONGOING PATIENT EDUCATION. WE ALSO ENGAGE IN PRACTICES THAT SUPPORT A SAFE ENVIRONMENT FOR OUR STAFF AS WELL AS OUR PATIENTS. PATIENT MOBILITY IS A MASSIVE COMPONENT OF REHABILITATION. THE SAFE PATIENT HANDLING COMMITTEE IS A MULTIDISCIPLINARY TEAM COMPRISED OF MEMBERS OF OUR NURSING, REHABILITATION, RADIOLOGY, QUALITY, AND FACILITIES STAFF. THE COMMITTEE HAS MADE A TREMENDOUS EFFORT TO DELIVER GUIDANCE AND TRAINING STAFF ON TRANSFERS, BODY MECHANICS, AND USE OF ASSISTIVE DEVICES. THEY HAVE DONE THIS VERY EFFECTIVELY BY INCORPORATING EVIDENCE-BASED PRACTICES IN OUR EVERYDAY TASKS AND ROUTINES. THE COMMITTEE HAS SCHEDULED MEETINGS EVERY OTHER MONTH TO DISCUSS EDUCATIONAL NEEDS AND PROVIDE HANDS-ON TRAINING TO ALL CLINICAL STAFF. STAFF EDUCATION IS ALSO AN ESSENTIAL ELEMENT IN MAINTAINING AND PROMOTING CLINICAL COMPETENCY. ONE HUNDRED PERCENT OF OUR REGISTERED NURSES MAINTAIN CERTIFICATION IN BASIC AND ADVANCED LIFE SUPPORT THROUGH THE AMERICAN HEART ASSOCIATION AND TELEMETRY. OUR NURSE EDUCATOR PROVIDES EDUCATION OPPORTUNITIES VIA IN-SERVICES, WEBINARS, LECTURES, AND SCHOLARLY ARTICLES. THE ACADEMIC OFFERINGS ENSURE OUR CLINICAL STAFF IS KNOWLEDGEABLE ON CURRENT TRENDS AND STANDARDS OF CARE. WE LINK ALL NEW HIRES WITH AN EXPERIENCED PRECEPTOR AND ADJUST THE ORIENTATION PROCESS TO MEET THE NEEDS OF EACH INDIVIDUAL. IN OUR FACILITY, EDUCATION DELIVERY INVOLVES EVERYONE. THE NURSE EDUCATOR COLLABORATES WITH NURSING LEADERSHIP TEAM, DIRECTOR OF PHARMACY, DIRECTOR OF REHABILITATION SERVICES, CLINICAL IT APPLICATIONS SPECIALIST, AND THE MANAGER OF RESPIRATORY SERVICES TO OFFER COMPREHENSIVE ANNUAL EDUCATION FOR ALL NURSING STAFF. 3021249 8085251 EMERGENCY DEPARTMENT:ELLENVILLE REGIONAL HOSPITAL EMERGENCY DEPARTMENT IS A VITAL NEED WITHIN OUR COMMUNITY. A RURAL SETTING CAN MAKE IT DIFFICULT FOR RESIDENTS TO ACCESS HIGH-QUALITY CARE. BY COMBINING QUALITY CARE, EVIDENCE-BASED RESEARCH, EXCELLENT NURSING SKILLS, AND EXPANDING OUR CLINICAL EDUCATION PROGRAMS, THE EMERGENCY DEPARTMENT AT ELLENVILLE REGIONAL HOSPITAL MADE IT OUR GOAL TO IMPROVE PATIENT OUTCOMES ACROSS THE CARE SPECTRUM. (SEE CONTINUATION ON SCHEDULE O)IN 2018, 12,676 PATIENTS RECEIVED TREATMENT IN THE EMERGENCY ROOM AT ELLENVILLE REGIONAL. AS IN PREVIOUS YEARS, WE ARE PROUD TO SAY, WE HAVE CONSISTENTLY PROVIDED EXCELLENT CARE IN A MUCH MORE EXPEDIENT MANNER THAN OTHER EMERGENCY DEPARTMENTS ACROSS THE COUNTRY. OUR 2018 AVERAGE FOR ARRIVAL TO TRIAGE IS AT A STELLAR 7 MINUTES. ADDITIONALLY, THE AVERAGE LENGTH OF STAY IS AT 107 MINUTES, 5 MINUTES FASTER THAN 2017. ALL OF THIS HAS BEEN POSSIBLE BECAUSE OF OUTSTANDING NURSES, PCTS, ED PROVIDERS, LAB, RADIOLOGY AND OTHER ANCILLARY STAFF AND THEIR ABILITY TO APPLY CRITICAL THINKING, DETERMINE PATIENT CARE NEEDS, AND EFFICIENTLY COMPLETE REQUIRED TASKS.OUR PATIENTS AND THE COMMUNITY HAVE ALWAYS BEEN OUR TOP PRIORITY. IMPROVING PATIENT OUTCOMES HAS BEEN AT THE FOREFRONT OF OUR GOALS. IN 2018, WHICH RESULTED IN 2 SEPARATE COLLABORATIVE PROJECTS, OUR MAX (MEDICAID ACCELERATED EXCHANGE) SERIES PROGRAM AND AHA MISSION LIFELINE: CORONARY ARTERY DISEASE, BOTH CONTINUED FROM 2017. OUR THIRD INITIATIVE FOR 2018, A CONTINUING MEDICAL EDUCATION PROGRAM, WAS GEARED TOWARDS PROVIDING EDUCATION AND TRAINING TO OUR COLLEAGUES IN THE COMMUNITY, OUR LOCAL EMS PROFESSIONALS. OUR MAX SERIES PROJECT STARTED IN 2015 HAS BEEN A NOTABLE PROGRAM WITH EXEMPLARY RESULTS. IN 2018, WE CONTINUED TO EXPAND ON OUR EFFORTS BY TRACKING THE PATIENT COHORT AND CONNECTING THEM WITH CARE MANAGERS AND COMMUNITY SERVICES, AND IN UTILIZING TREATMENT SERVICES TO ADDRESS CHRONIC MEDICAL PROBLEMS WITHOUT USING OPIATES. IN 2018, WE SAW A 67% DECLINE IN THE NUMBER OF ER VISITS AND A 92% DECLINE IN OPIATE ADMINISTRATION FOR THE COHORT. WE HAVE INCORPORATED SOME OF THE SAME MEASURES WITH OUR GENERAL PATIENT POPULATION TO DECREASE THE OVERALL RATE OF OPIATE ADMINISTRATIONS AS WELL. IN 2018, WE CONTINUED OUR EFFORTS IN IMPROVING PATIENT OUTCOMES FOR A PATIENT SUFFERING FROM ACUTE MYOCARDIAL INFARCTIONS THROUGH OUR COLLABORATION WITH THE AMERICAN HEART ASSOCIATION'S MISSION LIFELINE INITIATIVES. OUR STAFF DISPLAY AUTONOMOUS CRITICAL THINKING SKILLS AND CONTINUE TO PROVIDE EXPEDIENT CARE TO PATIENTS SUSPECTED OF HAVING CARDIAC-RELATED SYMPTOMS. RAPID TRIAGE, OBTAINING EKG'S IN UNDER 10 MINUTES, AND A STRONG WORKING RELATIONSHIP WITH TERTIARY FACILITIES HAS ALLOWED US TO IDENTIFY, TREAT EFFECTIVELY, AND TRANSFER PATIENTS EXPERIENCING A MYOCARDIAL INFARCTION. INCORPORATING ADDITIONAL SYMPTOMS INTO THE CRITERIA FOR EKG'S ALLOWED FOR EARLIER IDENTIFICATION FOR THOSE WITH ATYPICAL SYMPTOMS AND PRESENTATION. COLLABORATING WITH OUR LOCAL EMS PROFESSIONALS AND PROVIDING THEM WITH THE NECESSARY EDUCATION RELEVANT TO THEIR CERTIFICATIONS WAS OUR THIRD GOAL FOR 2018. EMS PERSONNEL ARE OFTEN THE FIRST PEOPLE TO INTERACT WITH PATIENTS. THEY PROVIDE A UNIQUE VIEWPOINT OF THE PATIENT AS THEY OFTEN SEE WHERE AND HOW THE PATIENT LIVES. EACH MEMBER OF THE EMS TEAM IS VITAL IN DELIVERING EXCELLENT PATIENT OUTCOMES. THE CONTINUING MEDICAL EDUCATION PROGRAM THROUGH THE HOSPITAL PROVIDES THE REQUIRED EDUCATION LOCALLY, IN THEIR COMMUNITY, SO THEY ARE NOT TRAVELING FAR TO MAINTAIN THEIR CERTIFICATIONS. ADDITIONALLY, THE TRAINING PROVIDED ENSURES COLLABORATION WITH PATIENT CARE METHODS AND STANDARDS AND OUR GOALS FOR TREATMENT OF SPECIFIC CONDITIONS. IT ALSO HELPS IMPROVE THE NURSE/MEDIC RELATIONSHIP, WHICH HELPS IMPROVE PATIENT OUTCOMES. 2374194 2749089 RADIOLOGY:IN 2018, RADIOLOGY WENT LIVE WITH A NEW HOLOGIC SELENIA DIMENSION MAMMOGRAPHY UNIT WITH TOMOSYNTHESIS CAPABILITY. WE PROVIDE TOMOSYNTHESIS AS OUR STANDARD OF CARE, AND EXCITING NEW TECHNOLOGY IS USED TO COMPLETE ALL SCREENING MAMMOGRAMS. WE RENEWED OUR AMERICAN COLLEGE OF RADIOLOGY, DEPARTMENT OF HEALTH AND MAMMOGRAPHY QUALITY STANDARDS ACT AND PROGRAM ACCREDITATION AND CERTIFICATION WITH THE NEW UNIT. (SEE CONTINUATION ON SCHEDULE O)IN 2018, OUR VOLUME REMAINED CLOSE TO 15,000 EXAMS, ABOUT 500 MORE THAN IN 2017. GAINS WERE MAINLY IN CARDIOLOGY AND COMPUTERIZED TOMOGRAPHY (CT). WE ALSO PERFORMED OVER 800 MAMMOGRAMS, APPROXIMATELY DOUBLING THE 2017 VOLUME.CARDIOLOGY EXPERIENCED GOOD GROWTH AS WELL. WE INCREASED THE NUMBER OF DAYS FOR ON-SITE ACCESS TO CARDIOLOGISTS. WE PURCHASED NEW EQUIPMENT TO ALLOW MORE PATIENTS TO STAY IN THE AREA FOR THE TREATMENT THEY NEED AND NOT NEED TO TRAVEL TO FACILITIES FARTHER AWAY. WE NOW PERFORM BOTH ANKLE BRACHIAL INDEX AND PULSE VOLUME RECORDING EXAMS ON SITE. WE ALSO ADDED LUMASON, AN ULTRASOUND CONTRAST AGENT TO OUR FORMULARY, WHICH FURTHER ENABLES US TO TREAT OUR PATIENTS HERE. WE SAW ABOUT A 25% INCREASE IN GENERAL ECHOCARDIOGRAMS.WE ADDED STAFF TO MRI AND INCREASED AFTER-HOURS AVAILABILITY FOR PATIENTS WITH DIFFERENT WORK SCHEDULES. APPROXIMATELY 10% GAIN IN VOLUME OF MRI EXAMS. WE ALSO REDUCED NO-SHOWS BY ACTIVELY CALLING PATIENTS WITH REMINDERS AS WELL AS OFFERING SOLUTIONS FOR HIGH CO-PAYMENTS. OUR PATIENTS ARE EXPERIENCING A VIRTUALLY 0% "CLAUSTRO" RATE DUE TO LARGE-BORE MRI AND SKILLED STAFF THAT ARE COMPASSIONATE AND WELL FAMILIAR WITH PATIENTS' FEARFUL OF THE MRI TUBE. ALL THESE FACTORS CONTRIBUTED TO FEWER CANCELLATIONS.WE ALSO PERFORMED TEN TIMES MORE FLUOROSCOPY AND OR CASES IN 2018 COMPARED TO 2017. 7033649 5032353 THE HOSPITAL ALSO PROVIDES AMBULATORY SURGERY, LAB SERVICES, IV THERAPY, PHYSICAL THERAPY, CARDIAC REHAB, AND PRESCRIPTION DRUGS TO OUR PATIENTS. 7033649 5032353 16432333 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 31 0 260 1 0 0 0 0 0 0 0 0 0 0 0 0 X 11 10 0 0 1 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 NY X X BOB RUE CFO 8456476400 10 HEALTHY WAY ELLENVILLE NY 12428 REVEREND JULIUS A COLLINS JR CHAIRPERSON 4.00 X X 0 0 0 MYRNA JARGOWSKY VICE CHAIRPERSON 2.00 5.00 X X 0 0 0 WILLIAM D BROWN TREASURER 3.00 5.00 X X 0 0 0 JOHN B GILLETTE SECRETARY 3.00 X X 0 0 0 NEIL CALMAN MD BOARD MEMBER 2.00 X 0 0 0 PHILIP COOMBE III BOARD MEMBER 2.00 5.00 X 0 0 0 CHUCK DAVIDSON BOARD MEMBER THRU 02/28/18 2.00 5.00 X 0 0 0 BOB DONALDSON NP-C BOARD MEMBER 2.00 X 0 0 0 DAVID EIKSZTA BOARD MEMBER 2.00 5.00 X 0 0 0 JULIE C LONSTEIN BOARD MEMBER 2.00 X 0 0 0 RAYMOND MATTHEWS BOARD MEMBER 2.00 5.00 X 0 0 0 STEFAN RAU MD BOARD MEMBER THRU 01/31/18 2.00 X 0 0 0 STEVEN KELLEY PRESIDENT & CEO 36.00 5.00 X X 356563 0 103100 BOB RUE CFO 36.00 5.00 X 160983 0 34106 ASHIMA BUTLER VP & CHIEF OPERATING OFFICER 36.00 X 160288 0 33290 MARTHA TOALA REGISTERED NURSE 36.00 X 145219 0 26150 DEBORAH BRIGGS VP OF HR, MARKETING & VOLUNTEERS 36.00 5.00 X 130758 0 6274 MICHAEL STEARNS DIRECTOR OF PHARMACY 36.00 X 127643 0 26150 THERESA AVERSANO DIR OF REHABILITATION SVCS & CARDIAC REHAB 40.00 X 126465 0 26150 1207919 0 255220 15 0 1 0 THE INSTITUTE FOR FAMILY HEALTH 2006 MADISON AVENUE NEW YORK NY 10035 PHYSICIAN SERVICES 442854 CONSTABLE CUSTODIAL SERVICES INC PO BOX 1115 LIBERTY NY 12754 CUSTODIAL SERVICES 295500 LAB CORP OF AMERICA PO BOX 12140 BURLINGTON NC 272162140 LAB SERVICES 278391 EMERGENCY MEDICAL ASSOCIATION OF NY 7032 COLLECTION CENTER DRIVE CHICAGO IL 60693 PHYSICIAN SERVICES 243800 UNITEX TEXTILE RENTAL SERVICES INC 401 SOUTH MACQUESTEN PARKWAY MOUNT VERNON NY 10550 LAUNDRY/LINEN SERVICE 109247 7 814657 73074 887731 PATIENT SERVICE REVENUE 622110 19574911 19574911 19574911 118688 118688 35035 20740 14295 14295 14295 2800000 2717801 82199 82199 82199 INSURANCE SETTLEMENT 900099 457517 457517 CAFETERIA INCOME 900099 49773 49773 WATER DAMAGE CLAIM 900099 33745 33745 44120 44120 585155 21262979 19574911 0 800337 674752 546549 128203 9263215 7503205 1760010 32663 26457 6206 1223872 991336 232536 846261 685471 160790 22415 18156 4259 93112 75421 17691 5330 5330 31000 31000 447185 362220 84965 52759 42735 10024 1692913 1353357 339556 259786 210427 49359 113590 92008 21582 3068 2485 583 956628 774869 181759 333892 270453 63439 CONTRACTED & PURCHASED 1863559 1534593 328966 BAD DEBTS 1176629 953070 223559 PRESCRIPTION DRUGS 568392 460398 107994 RURAL HEALTH NETWORK DE 264542 264542 326643 264581 62062 20252206 16432333 3788873 31000 448772 620437 2910189 2818606 2057139 2164546 107171 110601 286478 333084 17688204 8516723 9406364 9171481 4047903 5213505 1664289 1682773 20928305 22115033 2003174 2036966 518364 518364 142747 0 3228507 3936977 5892792 6492307 X 14213290 14677579 822223 945147 15035513 15622726 20928305 22115033 X 1010773 -512352 88792 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5330 5330 1 PART II-B, LINE 1: PORTION OF HEALTHCARE ASSOCIATION OF NYS MEMBERSHIP DUES THAT IS ATTRIBUTABLE TO LOBBYING. 8776692 3296149 5480543 8425621 5051947 3373674 485891 168627 317264 9171481 INTEREST IN NET ASSETS OF ELLENVILLE REGIONAL HOSPITAL FOUNDATION 936700 INVESTMENT IN ELLENVILLE REGIONAL FAMILY HEALTH PROPERTIES 117715 OTHER RECEIVABLE 154005 INSURANCE RECOVERY RECEIVABLE 474353 1682773 ESTIMATED THIRD PARTY PAYOR LIABILITY 3462624 INSURANCE CLAIM LIABILITY 474353 3936977 X 19532968 -512352 20740 -491612 20024580 1238399 1238399 21262979 19074203 60396 60396 19013807 1238399 1238399 20252206 PART X, LINE 2: THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY WHEN THEY ARE MORE LIKELY THAN NOT TO BE SUSTAINED. MANAGEMENT HAS DETERMINED THAT THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS THAT WOULD REQUIRE FINANCIAL STATEMENT RECOGNITION AND/OR DISCLOSURE. THE HOSPITAL IS NO LONGER SUBJECT TO EXAMINATION BY APPLICABLE TAXING JURISDICTIONS FOR PERIODS PRIOR TO 2015. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENT EXPENSES REPORTED ON PART VIII, LINE 6B 20,740. PART XI, LINE 4B - OTHER ADJUSTMENTS: RECLASS OF BAD DEBT 1,176,629. RECLASS OF GRANT INCOME 61,770. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENT EXPENSES REPORTED ON PART VIII, LINE 6B 20,740. EXPENSES ATTRIBUTED TO CONSOLIDATED ENTITIES 14,656. EQUITY TRANSFER 25,000. PART XII, LINE 4B - OTHER ADJUSTMENTS: RECLASS OF BAD DEBT 1,176,629. RECLASS OF GRANT INCOME 61,770. X X X 1 ONE RIVER GRANT 250 JORDAN ROAD STE 2 TROY NY 12180 GRANT WRITER 0 0 31000 -31000 31000 -31000 NY SCHEDULE G, PART I, LINE 2B, COLUMN (V) ELLENVILLE REGIONAL HOSPITAL HIRED ONE RIVER GRANTS FOR THE PRODUCTION OF A GRANT REQUEST TO THE NEW YORK STATE DEPARTMENT OF HEALTH, IN RESPONSE TO THE "STATEWIDE HEALTH CARE FACILITY TRANSFORMATION II PROGRAM". ONE RIVER GRANTS IS ENTITLED TO $4,000 FOR CONSULTATION IN DEVELOPING THE GRANT APPLICATION. IN ADDITION, WRITER(S) WILL RECEIVE $150 PER HOUR FOR DRAFTING THE PROPOSALS, BUDGETS, ATTACHMENTS TO THE GRANT, AND/OR RELATED MATERIALS. 1 1 1 X 1 X 1 0 1 1 1572169 1572169 0.07760 4852387 1840625 3011762 0.14870 128752 128752 0.00640 6553308 1840625 4712683 0.23270 5324552 4099143 1225409 0.06050 5324552 4099143 1225409 0.06050 11877860 5939768 5938092 0.29320 1 558096 196997 8664990 8624598 40392 X 1 0 1 1 WESTCHESTER-ELLENVILLE HOSPITAL INC 10 HEALTHY WAY ELLENVILLE NY 12428 WWW.ELLENVILLEREGIONAL.ORG 5526700C X X X X WESTCHESTER-ELLENVILLE HOSPITAL INC 1 0 0 1 X X X X X X X X X 16 1 0 1 1 X SEE PART V, PAGE 8 X 1 16 1 SEE PART V, PAGE 8 0 1 X 100.000000000000 300.000000000000 1 1 X X X 1 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X X X X X X 0 1 X X X X 1 X 0 0 WESTCHESTER-ELLENVILLE HOSPITAL, INC. PART V, SECTION B, LINE 5: TO ENGAGE THE COMMUNITY IN THE SELECTION OF HEALTH PRIORITIES FOR 2016 - 2018, THE ULSTER COUNTY DEPARTMENT OF HEALTH AND MENTAL HEALTH (UCDOHMH) TOOK THE LEAD, WITH PARTNERS HEALTHALLIANCE OF THE HUDSON VALLEY AND ELLENVILLE REGIONAL HOSPITAL, IN THE ORGANIZATION AND EXECUTION OF A COUNTY-WIDE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA). A COMMUNITY HEALTH NEEDS ASSESSMENT SURVEY WAS USED TO DETERMINE EXISTING PRIORITIES AND TO HELP DEVELOP NEW EVIDENCE-BASED STRATEGIES TO ADDRESS THEM. AVAILABLE IN BOTH ENGLISH AND SPANISH FROM JULY THROUGH SEPTEMBER 2016 IN PRINT AND ELECTRONIC FORMATS, IT WAS WIDELY DISTRIBUTED THROUGHOUT ULSTER COUNTY WITH EFFORTS MADE TO REACH LOW-INCOME, MINORITY AND CHRONICALLY ILL COMMUNITY MEMBERS. MORE THAN 600 COMPLETED SURVEYS WERE COLLECTED AND ANALYZED.ADDITIONALLY, THE HEALTHY ULSTER COUNCIL, A BROAD-BASED COALITION FORMED BY REPRESENTATIVES FROM A VARIETY OF ORGANIZATIONS AND AGENCIES IN 2010, HAS BEEN ONGOING IN ITS WORK OF FOCUSING ON HEALTH PROBLEMS IN ULSTER COUNTY AND WAYS TO IMPROVE HEALTH OUTCOMES. REGULAR MEETINGS OF THE COALITION, ALONG WITH PRESENTATIONS AND DISCUSSIONS, HAVE KEPT THE LARGER COMMUNITY, INCLUDING ELLENVILLE AND THE TOWN OF WAWARSING, INVOLVED IN THE PROCESS OF TRACKING HEALTH CONCERNS AND SOLUTIONS. WESTCHESTER-ELLENVILLE HOSPITAL, INC. PART V, SECTION B, LINE 6B: 1) HEALTH ALLIANCE OF THE HUDSON VALLEY2) ULSTER COUNTY DEPARTMENT OF HEALTH AND MENTAL HEALTH WESTCHESTER-ELLENVILLE HOSPITAL, INC. PART V, SECTION B, LINE 11: ERH COLLABORATES WITH THE IFH TO IMPROVE BLOOD SUGAR, LIPID AND HYPERTENSION LEVELS IN PATIENTS WITH DIABETES AND PRE-DIABETES IN AN OUTPATIENT SETTING, FOCUSING ON IMPROVED SELF-MANAGEMENT AND ADHERENCE, HEALTHY EATING AND INCREASED PHYSICAL ACTIVITY. ADULT ERH EMERGENCY DEPARTMENT PATIENTS PRESENTING WITH SYMPTOMS OF DIABETES OR PRE-DIABETES, SUCH AS AN ELEVATED BLOOD SUGAR, OR HYPERGLYCEMIA ARE REFERRED TO IFH'S ON SITE CERTIFIED DIABETES EDUCATORS AND HEALTH COACHES (WITH PATIENT'S PERMISSION) UPON DISCHARGE. PATIENTS WITH DIABETES THAT ARE NOT PATIENTS OF THE IFH ARE INVITED TO PARTICIPATE IN THE EVIDENCE-BASED STANFORD UNIVERSITY DIABETES SELF-MANAGEMENT PROGRAM. PATIENTS OF IFH, OR PATIENTS WHO HAVE NO PRIMARY CARE PROVIDER, WITH DIABETES ARE OFFERED AN APPOINTMENT WITH A PRIMARY CARE PROVIDER AND A DIABETES EDUCATOR. ALL PATIENTS WITH PRE-DIABETES ARE INVITED TO PARTICIPATE IN THE NATIONAL DIABETES PREVENTION PROGRAM, A CDC EVIDENCE-BASED WORKSHOP. IN ADDITION, EMERGENCY DEPARTMENT TESTING, SUCH AS BLOOD WORK AND EKG RESULTS, ARE SENT TO IFH TO ASSIST IN THE CONTINUITY OF CARE. FOR ALL OTHER PATIENTS WITH LONG TERM ILLNESS, A REFERRAL TO THE CHRONIC DISEASE SELF-MANAGEMENT PROGRAMS (CDSMP) IS OFFERED. IN ADDITION, ALL PATIENTS WITH ELEVATED GLUCOSE LEVELS THAT DO NOT HAVE DIABETES ARE INVITED TO PARTICIPATE IN THE NATIONAL DIABETES PREVENTION PROGRAM (NDPP).ALONG WITH OBSERVING AN OVERALL RISE IN OPIOID USE IN ULSTER AND ADJACENT COUNTIES, ELLENVILLE REGIONAL HOSPITAL NOTICED THAT A SMALL PERCENTAGE OF ED USERS ACCOUNT FOR A DISPROPORTIONATE NUMBER OF ED VISITS. UTILIZATION OF THE ED BY THESE PATIENTS IS DRIVEN BY CHRONIC PAIN WHICH HAS RESULTED IN THE ADMINISTRATION AND/OR PRESCRIPTION OF OPIATES. THIS FOCUS AREA INCLUDED IDENTIFYING A COHORT OF 64 SUPER UTILIZERS AND CREATING AN ALTERNATIVE CARE DELIVERY MODEL FOR CHRONIC PAIN PATIENTS SO THAT VISITS TO THE ED BY THESE SUPER UTILIZERS WOULD DROP ALONG WITH THE ADMINISTRATION OF OPIOIDS TO SUPER UTILIZERS. IN ADDITION, CARE NAVIGATOR SERVICES FROM THE INSTITUTE FOR FAMILY HEALTH ARE UTILIZED TO LINK MEMBERS OF THIS COHORT TO NEEDED COMMUNITY SERVICES SUCH AS HOUSING, PRIMARY CARE, BEHAVIORAL HEALTH PROVIDERS AND HOME HEALTH ASSISTANCE. OF THE COHORT OF 64 PATIENTS, THERE WAS A 97% REDUCTION IN OPIOID ADMINISTRATION THROUGH OUR ED, AND A 84% DECREASE IN VISITS TO OUR ED. PART V, LINE 7, CHNA REPORT WEBSITE: HTTPS://ULSTERCOUNTYNY.GOV/SITES/DEFAULT/FILES/ULSTER%20CHA%20CHIP%202016-18%20TO%20NYS.PDF PART V, LINE 10, IMPLEMENTATION STRATEGY WEBSITE: HTTP://WWW.ELLENVILLEREGIONAL.ORG/WP-CONTENT/UPLOADS/ELLENVILLE-REGIONAL-HOSPITAL-COMMUNITY-SERVICE-PLAN-2016-2018.PDF PART V, SECTION B, LINE 16A: HTTP://WWW.ELLENVILLEREGIONAL.ORG/2018-ERH-SUMMARY-AND-ENGLISH-APP-WITH-INSTRUCTIONS-ENGLISH/HTTP://WWW.ELLENVILLEREGIONAL.ORG/2018-ERH-POLICY-SUMMARY-AND-FA-APPSPANISH/ PART V, SECTION B, LINE 16B&C: HTTP://WWW.ELLENVILLEREGIONAL.ORG/2018-ERH-SUMMARY-AND-ENGLISH-APP-WITH-INSTRUCTIONS-ENGLISH/HTTP://WWW.ELLENVILLEREGIONAL.ORG/2018-ERH-POLICY-SUMMARY-AND-FA-APPSPANISH/ PART II, COMMUNITY BUILDING ACTIVITIES: THE BOARD OF TRUSTEES OF ERH IS COMPRISED OF ELEVEN MEMBERS; TEN OF THESE MEMBERS ARE VERY VISIBLE IN THE COMMUNITY AND ARE A DIRECT LINK FOR PATIENTS TO THE HOSPITAL ADMINISTRATION. ELLENVILLE REGIONAL HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED LICENSED MEDICAL PROVIDERS IN OUR COMMUNITY, FOR ALL OUR DEPARTMENTS. ERH HAS PARTNERED WITH CATSKILL HUDSON AREA HEALTH EDUCATION CENTER AND THE INSTITUTE FOR FAMILY HEALTH TO RECRUIT PRIMARY CARE PHYSICIANS. ELLENVILLE REGIONAL HOSPITAL APPLIES ANY SURPLUS FUNDS TO IMPROVING THE QUALITY OF CARE FOR ALL PATIENTS. PART III, LINE 2: THE COST TO CHARGE RATIO DERIVED FROM THE NYS INSTITUTIONAL COST REPORT WAS APPLIED TO THE BAD DEBT EXPENSE. PART III, LINE 3: THE COST TO CHARGE RATIO DERIVED FROM THE NYS INSTITUTIONAL COST REPORT WAS APPLIED TO THE BAD DEBT EXPENSE FOR FINANCIAL ASSISTANCE DISCOUNT. SCHEDULE H, PART II: ELLENVILLE REGIONAL HOSPITAL IS A MEMBER OF THE WAWARSING COUNCIL OF AGENCIES, AN INTER-AGENCY WHOSE MISSION IS TO WORK IN PARTNERSHIP WITH ORGANIZATIONS TO PROMOTE HEALTH AND WELLNESS BY IDENTIFYING AND ADDRESSING GAPS IN SERVICES, PROVIDING INFORMATION AND EDUCATION, AND BRINGING SERVICES TOGETHER FOR THE WAWARSING/ELLENVILLE COMMUNITY. AS A MEMBER OF THE COUNCIL, WE HELP TO PLAN AND IMPLEMENT COMMUNITY PROJECTS PRESENTED BY THE COUNCIL. FOR EXAMPLE, THE WAWARSING CARES PROJECT, FREE TO THE COMMUNITY, FOCUSES ON VARIOUS GROUPS WITHIN THE COMMUNITY, SUCH AS WAWARSING CARES FOR WOMEN AND WAWARSING CARES FOR TEENS. THESE EVENTS PROMOTE WELLNESS AND PROVIDE ACCESS TO HEALTH AND SOCIAL SERVICES FOR THE TARGET GROUP. OTHER PROJECTS THAT WE SHARE IN INCLUDE A FREE COMMUNITY RESOURCE GUIDE BOOKMARK, WHICH PROVIDES A LISTING AND CONTACT INFORMATION OF ALL MEMBERS OF THE COUNCIL AND A FREE COMMUNITY BABY SHOWER WHERE BABY ITEMS AND INFORMATION ARE AVAILABLE FOR FREE TO THE PUBLIC. THE COUNCIL CONTINUES TO MEET ON A MONTHLY BASIS OR MORE OFTEN IF A PROJECT IS BEING UNDERTAKEN. MEMBERS OF THE COUNCIL ALSO HOST A WEEKLY TV SHOW ON A LOCAL CABLE ACCESS CHANNEL THROUGH THE ELLENVILLE CENTRAL SCHOOL MEDIA DEPARTMENT.OUR APPROACH TO POPULATION HEALTH AIMS TO IMPROVE THE HEALTH OF ALL MEMBERS OF OUR COMMUNITY. ONE EXAMPLE IS OUR HEALTHY HEARTS INITIATIVE, WHICH IS FOCUSED ON PATIENTS WHO HAVE RISK FACTORS FOR DEVELOPING CARDIOVASCULAR DISEASE BUT HAVE NOT YET BEEN DIAGNOSED. WE OFFER CARE COORDINATION WITH A COMMUNITY HEALTH WORKER, WHICH INCLUDES PROGRAMMING SUCH AS OUR FARMACY, YOGA CLASSES, WALKING GROUPS, FOOD DEMONSTRATIONS AND MORE. ALL FREE TO THE COMMUNITY.WE ALSO WORK IN CONCERT WITH THE INSTITUTE FOR FAMILY HEALTH (IFH), A FEDERALLY QUALIFIED HEALTH CENTER LOCATED ON THE HOSPITAL'S CAMPUS, ON SUCH WELLNESS INITIATIVES AS OUR ANNUAL HARVEST HEALTH FAIR. THE HARVEST HEALTH FAIR IS A FREE COMMUNITY HEALTH EVENT LOCATED ON OUR CAMPUS WHICH PROVIDES HEALTH SCREENINGS, SUCH AS BLOOD PRESSURE, GLUCOSE, AND MENTAL HEALTH SCREENINGS FOR ADULTS. CHILDREN'S RESOURCES INCLUDE ASTHMA AWARENESS ACTIVITIES. DIABETES EDUCATION AND PHARMACY CONSULTATIONS ARE ALSO AVAILABLE. IN ADDITION, WE COLLABORATE WITH THE ELLENVILLE WAWARSING YOUTH COMMISSION, THE ELLENVILLE POLICE DEPARTMENT, ELLENVILLE AND NAPANOCH FIRE DEPARTMENTS, THE ULSTER COUNTY SHERIFF'S DEPARTMENT AND THE ELLENVILLE RESCUE SQUAD TO PROVIDE FREE YOUTH ACTIVITIES, FREE CAR SAFETY SEAT CHECKS, AND FREE BIKE HELMETS AT THE FAIR. MEMBERS OF THE WAWARSING COUNCIL ARE ALSO INVITED TO PARTICIPATE AND SHARE THEIR RESOURCES WITH THE ATTENDEES. APPROXIMATELY 150 ADULTS AND CHILDREN ATTEND THE FAIR.IN OUR EFFORTS TO HELP TO REDUCE AND PREVENT CHRONIC DISEASE, INCLUDING DIABETES AND HYPERTENSION, THE HOSPITAL PHARMACIST, REGISTERED DIETICIAN AND OUTPATIENT CLINICAL STAFF CONTINUE OUTREACH EFFORTS INCLUDING FREE MONTHLY BLOOD PRESSURE AND GLUCOSE CLINICS FOR THE COMMUNITY AND A FLU SHOT CLINIC. WE ALSO PARTICIPATE IN OR HOST VARIOUS HEALTH FAIRS THROUGHOUT THE YEAR. IN ADDITION, WE PROVIDE A LOVE YOUR HEART DAY EVENT AROUND VALENTINE'S DAY WHICH INCLUDES A FREE ROUNDTABLE DISCUSSION WITH OUR CARDIOLOGIST OVER LUNCH AND PRESENTATIONS BY OUR DIRECTOR OF REHAB AND REGISTERED DIETITIAN. FREE BLOOD PRESSURE AND GLUCOSE SCREENINGS ARE PROVIDED, AS WELL AS WELLNESS BROCHURES, ETC.OUR EMERGENCY DEPARTMENT PROVIDERS REFER PATIENTS WHO ARE DIABETIC OR PRE-DIABETIC, AND DO NOT HAVE A PRIMARY CARE PROVIDER, TO THE IFH FOR CARE. PATIENTS SEEN IN THE EMERGENCY DEPARTMENT AND WHO MEET THE CRITERIA, ARE REFERRED TO THE MENTAL HEALTH STAFF AT IFH, WHO PROVIDE A WARM HANDOFF FOR PATIENTS WHO SCREENED POSITIVE FOR DEPRESSION OR SUICIDAL INDICATORS.ERH CONTINUES TO WORK COLLABORATIVELY WITH THE WAWARSING COUNCIL OF AGENCIES AND ULSTER COUNTY DEPARTMENT OF HEALTH TO ADDRESS TEEN PREGNANCY, TEEN SEXUAL ACTIVITY AND SEX EDUCATION. OUR PARTNER, THE IFH, SITUATED ON OUR CAMPUS, OFFERS TEEN SERVICES.WE ARE IMPROVING THE OUTCOMES FOR OUR INPATIENTS THROUGH OUR SWING BED OUTCOMES IMPROVEMENT PROJECT, WHICH HAS BEEN DEVELOPED TO BE ABLE TO QUANTIFY OUR SUB-ACUTE REHAB (SWING BED) PATIENT'S FUNCTIONAL OUTCOMES FROM ADMISSION TO DISCHARGE. A MEASUREMENT TOOL WAS CREATED UTILIZING THE BARTHEL INDEX OF ACTIVITIES OF DAILY LIVING. THIS PROJECT INVOLVES MULTIPLE DISCIPLINES INCLUDING NURSING AND REHAB. ONE OF THE MAIN GOALS OF THE PROJECT IS TO IMPROVE THE FUNCTIONAL INDEPENDENCE OF OUR SWING BED PATIENTS SO THAT THEY ARE DISCHARGED TO HOME, NOT A NURSING HOME. THIS PROJECT HAS BECOME A STATEWIDE MODEL FOR CAH FACILITIES. THE UNIVERSITY OF MINNESOTA IS CURRENTLY BUILDING ON THIS FOUNDATION MEASURING QUALITY OUTCOMES IN A NATIONAL PROJECT SPONSORED BY HRSA. NYS OUTCOMES WERE SIGNIFICANTLY HIGHER THAN ANY OTHER STATE IN PRELIMINARY RESULTS. ERH PARTICIPATED IN THE WESTCHESTER DSRIP AND OUR PROJECT FOCUSED ON REDUCING THE USE OF OPIOIDS BY CHRONIC PAIN PATIENTS SEEN IN OUR EMERGENCY DEPARTMENT. THE LEADERSHIP STAFF OF ELLENVILLE REGIONAL HOSPITAL AND THE INSTITUTE FOR FAMILY HEALTH DEVELOPED NEW AND INNOVATIVE PROTOCOLS TO ADDRESS CHRONIC PAIN PATIENTS WHO PRESENT OFTEN IN THE EMERGENCY DEPARTMENT SEEKING PAIN RELIEF. CHRONIC PAIN PATIENTS IN MANY CASES HAVE DEVELOPED ADDICTION TO OPIATE BASED PAIN RELIEVERS. THE MODEL INCLUDES A COMPLETE REDESIGN OF TREATMENT PROTOCOLS IN THE EMERGENCY DEPARTMENT UTILIZING NON-ADDICTIVE PAIN MEDICATIONS. THE RESULT HAS BEEN A DRAMATIC REDUCTION OF OPIATE PRESCRIBING IN THE EMERGENCY DEPARTMENT. THE PROTOCOL ALSO INCLUDES A "WARM" HANDOFF/REFERRAL TO A PATIENT CARE NAVIGATOR WHO HELPS THE PATIENT GET INTO PRIMARY CARE AT THE INSTITUTE OR OTHER COMMUNITY-BASED PROVIDERS. THE PRIMARY CARE TREATMENT PLAN INCLUDES FOUR PATHWAYS TO ADDRESS:1. MEDICAL ISSUES WITH A FOCUS ON TRANSITIONING AWAY FROM OPIATES2. A PSYCHIATRIC PATHWAY TO ADDRESS ADDICTION3. AN INTERVENTION PATHWAY TO ADDRESS PAIN AT ITS SOURCE4. A PSYCHO/SOCIAL PATHWAY TO ADDRESS THE NUMEROUS OTHER PROBLEMS THAT PATIENTS WITH CHRONIC PAIN AND ADDICTION SUFFER WITH.THE RESULTS OF THE DSRIP OPIATE REDUCTION PROJECT HAVE BEEN 97% REDUCTIONS IN ADMINISTRATION OF OPIATES IN THE EMERGENCY DEPARTMENT AND 84% REDUCTION OF EMERGENCY DEPARTMENT VISITS FOR THIS POPULATION. IN ADDITION, THERE HAS BEEN SUCCESS IN TRANSITIONING PATIENTS TO SAFER PAIN REGIMENS AND IMPROVED HEALTH. (SEE PART V, SECTION B, LINE 11 FOR ADDITIONAL INFORMATION).ERH CONTINUES TO OFFER SERVICES FOR INPATIENT AND OUTPATIENT MEDICATION RECONCILIATION AND EDUCATION REGARDING SAFE USE OF MEDICATIONS. ERH HAS A ROBUST SYSTEM TO IDENTIFY AND REPORT ANY MEDICATION ERRORS AND NEAR MISSES. SOURCES AND PROBABLE CAUSES OF THE ABOVE ARE IDENTIFIED THROUGH A FOCUSED REVIEW BY AN INTERDISCIPLINARY COMMITTEE. ERH HAS BEEN ABLE TO ESTABLISH A SEAMLESS PROCESS OF MEDICATION MANAGEMENT FOR PATIENTS TRANSITIONING FROM THE HOSPITAL TO ANOTHER CARE SETTING WITHIN OR OUTSIDE THE HOSPITAL. PROVIDERS USE OUR MEDICATION RECONCILIATION FORMS AS A TRUSTED SOURCE WITH UP TO DATE MEDICATIONS FOR THEIR PATIENTS. PLEASE SEE BELOW FOR PROGRESS.WE CONTINUE TO ASSIST WITH THE CONTINUING EDUCATION NEEDS OF OUR EMS COMMUNITY, INCLUDING OFFERING BLS, ACLS AND PALS COURSES TO THEM AT NO CHARGE AND CME CLASSES IN CONCERT WITH THE HUDSON VALLEY REGIONAL EMERGENCY MEDICAL ADVISORY COMMITTEE. IN FEBRUARY 2017, WE IMPLEMENTED A NEW HOUSE-WIDE ELECTRONIC HEALTH RECORDS SYSTEM TO HELP US DELIVER HIGH QUALITY CARE TO OUR PATIENTS. WE HAVE ALSO PARTNERED WITH THE IFH TO IMPLEMENT EPICCARE LINK, A SECURE PROGRAM THAT PERMITS US TO SHARE CRITICAL MEDICAL INFORMATION FOR MUTUAL PATIENTS. THIS NEW COLLABORATION MEANS THAT AUTHORIZED EMERGENCY DEPARTMENT STAFF CAN ACCESS PATIENTS' MEDICAL RECORDS FROM THE ELLENVILLE FAMILY HEALTH CENTER, OPERATED BY THE INSTITUTE, TO VIEW THEIR CURRENT MEDICATION LIST, PRIOR MEDICAL HISTORY AND KNOWN ALLERGIES. IN ADDITION, THE ED STAFF CAN SCAN THE PATIENT'S LABORATORY, EKG AND RADIOLOGY RESULTS INTO THE INSTITUTE'S PATIENT'S ELECTRONIC MEDICAL RECORD. WE ARE THE FIRST EMERGENCY DEPARTMENT IN THE COUNTRY TO WORK COLLABORATIVELY WITH PRIMARY CARE PROVIDERS UNDER THE EPICCARE LINK PROGRAM, PROVIDING PRIMARY CARE PROVIDERS AND HOSPITAL STAFF WITH TOOLS TO ENHANCE THE QUALITY AND SAFETY OF CARE FOR OUR MUTUAL PATIENTS. PART III, LINE 4: AFS FOOTNOTE: "PATIENT ACCOUNTS RECEIVABLE FROM THIRD-PARTY PROGRAMS FOR WHICH THE HOSPITAL RECEIVES PAYMENT UNDER VARIOUS REIMBURSEMENT FORMULAE OR NEGOTIATED RATES ARE STATED AT THE ESTIMATED NET AMOUNTS RECEIVABLE FROM SUCH PAYORS, WHICH ARE GENERALLY LESS THAN THE HOSPITAL'S ESTABLISHED BILLING RATES. ADDITIONS TO THE ALLOWANCE FOR DOUBTFUL ACCOUNTS RESULT FROM THE PROVISION FOR BAD DEBTS. ACCOUNTS WRITTEN OFF AS UNCOLLECTIBLE AND RECOVERIES ON SUCH ACCOUNTS ARE RECORDED IN THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE AMOUNT OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS, BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN MEDICARE, AND MEDICAID HEALTHCARE COVERAGE AND OTHER COLLECTION INDICATORS." BAD DEBT EXPENSE PER THE AUDITED FINANCIAL STATEMENT IS $1,176,629. THE COST TO CHARGE RATIO DERIVED FROM THE NYS INSTITUTIONAL COST REPORT WAS APPLIED TO THE BAD DEBT EXPENSE PER THE AUDITED FINANCIAL STATEMENTS TO DETERMINE THE AMOUNT REPORTED IN PART III, LINE 2. PART III, LINE 8: THE AMOUNT ON LINE 6 WAS DERIVED BY USING THE MEDICARE ALLOWABLE COSTS AS REPORTED ON THE HOSPITAL'S NYS INSTITUTIONAL COST REPORT AND THE APPLICABLE ADJUSTMENTS FROM WORKSHEET B. PART VI, LINE 2: VARIOUS METHODS ARE USED BY ELLENVILLE REGIONAL HOSPITAL TO ASSESS THE HEALTH NEEDS OF THE COMMUNITY. ELLENVILLE REGIONAL HOSPITAL SEEKS THE VIEWS OF COMMUNITY MEMBERS TO GAIN THEIR THOUGHTS REGARDING THE HEALTH CARE IN THEIR COMMUNITY AND GAIN FEEDBACK REGARDING ERH SERVICES. THE BOARD OF TRUSTEES OF ERH IS COMPRISED OF TEN MEMBERS; NINE OF THESE MEMBERS ARE VERY VISIBLE IN THE COMMUNITY AND ARE A DIRECT LINK FOR PATIENTS TO THE HOSPITAL ADMINISTRATION. COMMUNITY FEEDBACK IS A TOPIC OF DISCUSSION AT MOST BOARD MEETINGS. THE PRESIDENT AND CEO OF ERH, STEVEN L. KELLEY, IS A PROMINENT MEMBER OF THE COMMUNITY. MR. KELLEY AND OTHER MEMBERS OF THE ADMINISTRATIVE TEAM BELONG TO NUMEROUS ORGANIZATIONS, SERVE ON OTHER NOT-FOR-PROFIT BOARDS, AND ARE ACTIVE PARTICIPANTS. PATIENT SATISFACTION QUESTIONNAIRES ARE DONE BY ALL CLINICAL DEPARTMENTS. IN 2018, ERH RECEIVED 4,233 PATIENT SATISFACTION SURVEYS. THESE QUESTIONNAIRES PROVIDE VALUABLE FEEDBACK FROM THE POPULATION THAT UTILIZES THE HOSPITAL SERVICES. IN ADDITION, STATISTICAL DATA, FROM STATE AND COUNTY DATABASES, IS CONTINUALLY ANALYZED LOOKING FOR TRENDS AND CHANGES IN DEMOGRAPHIC MAKEUP OF OUR PATIENTS. IN ADDITION, COMMUNITY CONVERSATIONS (FORUMS) ARE HELD ANNUALLY, TO GATHER FEEDBACK ON THE STATUS OF HEALTH FROM COMMUNITY RESIDENTS. THE MAY 2018 FORUM HAD 59 RESIDENTS IN ATTENDANCE. WE ALSO MONITOR THE TOP TEN INPATIENT DIAGNOSIS ANNUALLY SO WE CAN PLAN OUR SERVICES AROUND THOSE DISEASES WHICH ARE MOST PREVALENT IN OUR LOCAL COMMUNITY. ERH WORKS CLOSELY WITH AN FQHC ON OUR CAMPUS. THE CEO OF ERH SITS ON THEIR BOARD OF DIRECTORS AND THE CEO OF THE FQHC SITS ON THE ERH BOARD. THIS COLLABORATIVE WORKING ARRANGEMENT HAS BEEN INVALUABLE IN ASSESSING THE NEEDS OF THE MEDICAL PROVIDERS IN THE COMMUNITY AS WELL AS THE PATIENTS IN THE COMMUNITY. AS A MEMBER OF THE WESTCHESTER DSRIP, WE ALSO PARTICIPATED IN A COMMUNITY HEALTH NEEDS ASSESSMENT. PART VI, LINE 3: BY VIRTUE OF ITS EXEMPTION FROM FEDERAL AND STATE TAXES AND AS PART OF THE HOSPITAL'S MISSION TO SERVE THE HEALTHCARE NEEDS OF THE COMMUNITY, ERH PROVIDES CARE TO ALL PATIENTS IN NEED WITHOUT REGARD FOR THEIR ABILITY TO PAY. ELLENVILLE REGIONAL HOSPITAL (ERH) INFORMS ITS PATIENTS OF AVAILABILITY OF FINANCIAL ASSISTANCE IN SEVERAL WAYS. SIGNS ARE POSTED IN REGISTRATION AND INFORMATION ON FINANCIAL ASSISTANCE IS LOCATED ON OUR WEBSITE. THESE SIGNS DIRECT THE PATIENTS TO SPEAK WITH DESIGNATED PATIENT FINANCIAL SERVICES REPRESENTATIVES. ALL PATIENTS WITHOUT INSURANCE ARE GIVEN A PACKET THAT INCLUDES A CHARITY CARE APPLICATION AND ARE ALSO AVAILABLE UPON REQUEST BY THE PATIENT. PATIENT STATEMENTS ALSO INCLUDE CONTACT INFORMATION REGARDING FINANCIAL ASSISTANCE. IN ADDITION, MEDICAID APPLICATIONS ARE MADE AVAILABLE AT THE TIME OF REGISTRATION. PART VI, LINE 4: ELLENVILLE REGIONAL HOSPITAL'S PRIMARY SERVICE AREA HAS REMAINED UNCHANGED FOR 2018 PLANNING PURPOSES. ERH IS A NON-PROFIT SOLE PROVIDER HOSPITAL FOR ELLENVILLE AND ITS SURROUNDING COMMUNITIES LOCATED BETWEEN SHAWANGUNK RIDGE AND THE CATSKILL MOUNTAIN RANGE. THESE COMMUNITIES INCLUDE ALL OR PARTS OF THE TOWNS OF WAWARSING, ROCHESTER, PINE BUSH, MAMAKATING, NEVERSINK, MARBLETOWN AND FALLSBURG/WOODBOURNE. ERH IS GEOGRAPHICALLY ISOLATED WITH ITS POPULATION CENTER CONSISTING OF 37% NON-WHITE POPULATION AND A 20% BELOW POVERTY LEVEL ACCORDING TO THE US CENSUS BUREAU. THE NEAREST HOSPITAL IS OVER 25 MILES AWAY ON MOSTLY SECONDARY ROADS AND, DUE TO THE RURAL GEOGRAPHICAL ISOLATION; ERH SERVES A CRUCIAL NEED FOR THE COMMUNITY. IT IS ALSO A TEACHING HOSPITAL WITH EDUCATIONAL PROGRAMS FOR RESIDENTS, MEDICAL STUDENTS, PHARMACISTS, PHYSICAL THERAPISTS, PHYSICAL THERAPIST ASSISTANTS, OCCUPATIONAL THERAPISTS, OCCUPATIONAL THERAPY ASSISTANTS, RADIOLOGY TECHNICIANS, NURSE PRACTITIONERS, REGISTERED NURSES, PHYSICIAN ASSISTANTS, PHLEBOTOMISTS, HIGH SCHOOL NEW VISION STUDENTS AND MORE.ERH WAS GRANTED CRITICAL ACCESS HOSPITAL (CAH) STATUS IN 2004 AND HAS 25 INPATIENT BEDS. THESE BEDS CAN BE USED FOR EITHER ACUTE CARE OR SWING BUT MAY NOT EXCEED 25. THIS IS EXTREMELY IMPORTANT SINCE THE HOSPITAL IS LOCATED IN BOTH A FEDERALLY DESIGNATED HEALTH PROFESSIONAL SHORTAGE AREA (HPSA) AND MEDICALLY UNDERSERVED AREA (MUA). THERE WOULD BE A SIGNIFICANT PROBLEM WITH UNINSURED AND UNDER INSURED HAVING ACCESS TO QUALITY HEALTHCARE WITHOUT THE PRESENCE OF ERH.LOCATED WITHIN ULSTER COUNTY, THE TOWN OF WAWARSING IS SITUATED IN THE MID-HUDSON VALLEY, APPROXIMATELY 90 MILES NORTHWEST OF NEW YORK CITY. ACCORDING TO THE 2010 CENSUS, THE TOWN OF WAWARSING HAD 13,157 PEOPLE, WITH A MEDIAN AGE OF 40.1, 11,091 HOUSEHOLDS, AND 2,946 FAMILIES RESIDING IN THE TOWN, WHICH INCLUDES THE VILLAGE OF ELLENVILLE. PER THE 2017 AMERICAN COMMUNITY SURVEY, THE TOWN OF WAWARSING HAS A POPULATION OF 13,004, OF WHICH 4,097 RESIDE WITHIN THE VILLAGE OF ELLENVILLE.CENSUS DATA INDICATES THAT OF THE WAWARSING POPULATION 63% IDENTIFY AS WHITE, 9% IDENTIFY AS BLACK, AND 4% IDENTIFY AS TWO OR MORE RACES; WITH 21% OF RESIDENTS IDENTIFYING AS LATINO, AND 14% OF INDIVIDUALS SPEAKING SPANISH AT HOME. VETERANS REPRESENT 5.6% OF THE POPULATION.CHILDREN UNDER 18 ACCOUNT FOR 18.8% OF THE POPULATION, ADULTS AGE 18 TO 64 ACCOUNT FOR 66% OF THE POPULATION, AND FEMALES OF ALL AGES ACCOUNT FOR 44% OF THE POPULATION. IN THE TOWN OF WAWARSING, 17.9% OF INDIVIDUALS LIVE BELOW THE POVERTY LINE, WHICH INCLUDES 23% OF CHILDREN UNDER THE AGE OF 18. ELLENVILLE CENTRAL SCHOOL DISTRICT HAD 1,631 STUDENTS ENROLLED FOR THE 2018-19 SCHOOL YEAR, 71% OF WHOM WERE ECONOMICALLY DISADVANTAGED. ROUGHLY, 16% OF RESIDENTS HAVE LESS THAN A HIGH SCHOOL EDUCATION.THE UNEMPLOYMENT RATE FOR THE CIVILIAN LABOR FORCE IN WAWARSING IS 9.6%, WITH A SIGNIFICANTLY HIGHER UNEMPLOYMENT RATE FOR INDIVIDUALS 20-24 (32%), AND A SIGNIFICANTLY LOWER RATE FOR INDIVIDUALS 25-29 YEARS OLD (1.9%). IN THE TOWN OF WAWARSING, 17.9% OF INDIVIDUALS LIVE BELOW THE POVERTY LINE, WHICH INCLUDES 23% OF CHILDREN UNDER THE AGE OF 18, AND 18.8% OF SENIORS. 47.9% OF INDIVIDUALS BELOW THE POVERTY LEVEL DID NOT WORK IN THE PAST 12 MONTHS. 83.8% OF THE POPULATION HAS A HIGH SCHOOL DIPLOMA (OR EQUIVALENT), HOWEVER RATES DIFFER SIGNIFICANTLY FOR MALES AND FEMALES, WITH ONLY 3% OF 25+ FEMALES HAVING LESS THAN A HIGH SCHOOL DIPLOMA, BUT 18% OF 25+ MALES HAVING LESS THAN A HIGH SCHOOL DIPLOMA. 18.2% OF THE POPULATION HAS A BACHELOR'S DEGREE OR HIGHER.WAWARSING HAS A TOTAL OF 6,299 HOUSING UNITS, 65% OF WHICH ARE SINGLE UNITE, 71.9% OF WHICH ARE OCCUPIED, AND 28.1% ARE VACANT. OF THE 4,530 OCCUPIED HOUSEHOLDS 60% ARE DEFINED AS 'FAMILY HOUSEHOLDS' (2,719); 29.1% (1,319) HAVE RELATED CHILDREN UNDER 18 YEARS OLD, AND 9.3% (421) ARE SINGLE FEMALE WITH CHILD(REN) HOUSEHOLDS. ABOUT 44% OF THE POPULATION IS MARRIED. THE AVERAGE HOUSEHOLD SIZE WAS 2.4, AND THE AVERAGE FAMILY SIZE 2.96.IN THE VILLAGE OF ELLENVILLE, THE LARGEST POPULATION CENTER (4,097) IN THE TOWN OF WAWARSING, THE MEDIAN AGE IS 37 YEARS, WITH 41.5% OF THE POPULATION BEING UNDER THE AGE OF 25. THE POPULATION IS 52% MALE. ETHNIC RACIAL DEMOGRAPHICS INCLUDE 58.4% WHITE, 7.9% BLACK, AND 4% TWO OR MORE RACES; WITH 29.4% OF THE POPULATION IDENTIFYING AS LATINO. JUST OVER 16% OF THE POPULATION SPEAKS A LANGUAGE OTHER THAN ENGLISH AT HOME, PREDOMINANTLY SPANISH. ACCORDING TO THE 2010 CENSUS, THERE WERE 4,135 PEOPLE IN THE VILLAGE OF ELLENVILLE, INDICATING THE POPULATION HAS CONTINUED TO DECREASE.OVER 12% OF RESIDENTS IN THE VILLAGE ARE UNEMPLOYED AND ROUGHLY, 18% HAVE LESS THAN A HIGH SCHOOL EDUCATION. THE UNEMPLOYMENT RATE FOR INDIVIDUALS 30-34 IS HIGHER THAN THE VILLAGE RATE, AT 21.2%. FOR INDIVIDUALS WITHOUT A HIGH SCHOOL DEGREE, THE RATE IS EVEN HIGHER, AT 25.5%. VETERANS REPRESENT 3.4% OF THE POPULATION. IN THE 12428 ZIP CODE AREA, WHICH INCLUDES THE VILLAGE OF ELLENVILLE, OVER 40% OF RESIDENTS ARE LOW-INCOME AND MORE THAN 18.9% LIVE BELOW THE POVERTY LINE, WITH 24% OF CHILDREN LIVING IN POVERTY, AND 37% OF SENIORS LIVING IN POVERTY.PER THE 2017 ACS 5-YEAR ESTIMATES, THERE ARE 1,841 HOUSEHOLDS IN THE VILLAGE, 53% OF WHICH ARE SINGLE UNIT, AND 85.1% (1,566) OF WHICH ARE OCCUPIED. 39.9% OF HOMEOWNERS AND 54.3% OF RENTERS HAVE MONTHLY HOUSING COSTS THAT EXCEED 35% OF THE HOUSEHOLD INCOME. OF OCCUPIED UNITS, 63% ARE CONSIDERED 'FAMILY HOUSEHOLDS' (50% OF WHICH ARE ESTIMATED TO BE SINGLE PARENT HOUSEHOLDS), AND 21.9% OF OCCUPIED UNITS WERE DEFINED AS FEMALE HOUSEHOLDER WITH NO MALE PRESENT. ABOUT 50% OF THE POPULATION IS MARRIED. OF OCCUPIED UNITS, 29.1 % HAD RELATED CHILDREN UNDER THE AGE OF 18 LIVING WITH THEM, 24.8% OF HOUSEHOLDS HAVE INDIVIDUALS AGE 65 OR OLDER. AVERAGE HOUSEHOLD SIZE 2.6 AND AVERAGE FAMILY SIZE 3.4.ERH'S CATCHMENT AREA INCLUDES AN EXCEPTIONALLY LARGE IMPOVERISHED POPULATION. FOR EXAMPLE, ELLENVILLE AND WAWARSING HAVE MEDIAN HOUSEHOLD INCOMES (TOWN $46,889 AND VILLAGE $45,531) THAT ARE SUBSTANTIALLY LOWER THAN (ABOUT THREE-QUARTERS) THE ULSTER COUNTY MEDIAN HOUSEHOLD INCOME OF $61,652 AND THE NYS MEDIAN HOUSEHOLD INCOME OF $62,765 (ACS 2017).WHEN LOOKING AT THE HEALTH OF THE COMMUNITY IN THE ELLENVILLE/WAWARSING AREA, IT IS IMPORTANT TO NOTE THAT THE ELLENVILLE FAMILY HEALTH CENTER (IFH), A PRIMARY CARE HEALTH CENTER WHICH IS OPERATED BY THE INSTITUTE FOR FAMILY HEALTH, ONE OF THE LARGEST FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) IN NEW YORK STATE, IS ALSO LOCATED ON THE ERH CAMPUS. THE INSTITUTE IS COMMITTED TO PROVIDING HIGH-QUALITY, AFFORDABLE HEALTH CARE FOR ALL. IT STRIVES FOR EXCELLENCE AT EACH OF ITS 26 PRACTICES, WHILE ACCEPTING ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. THE ELLENVILLE IFH OFFERS PRIMARY CARE, MENTAL HEALTH CARE, DENTAL AND SOCIAL WORK SERVICES, ALONG WITH MANY OTHER HEALTH SERVICES FOR PATIENTS OF ALL AGES. AS PART OF A FEDERALLY QUALIFIED COMMUNITY HEALTH CENTER NETWORK, IT MEETS NATIONAL STANDARDS FOR AFFORDABLE, ACCESSIBLE AND COMPREHENSIVE HEALTH CARE SERVICES. THE CENTER IS ACCREDITED BY THE JOINT COMMISSION AND RECOGNIZED BY THE NATIONAL COMMITTEE FOR QUALITY ASSURANCE AS A LEVEL 3 PATIENT-CENTERED MEDICAL HOME; THE HIGHEST RECOGNITION AVAILABLE. THE IFH SEES APPROXIMATELY 3,600 PATIENTS PER YEAR AND OFFERS SAME-DAY APPOINTMENTS. ACCORDING TO THE INSTITUTE OF FAMILY HEALTH, A FEDERALLY QUALIFIED HEALTHCARE CENTER'S ELLENVILLE SITE DATA, NEARLY 59% OF HEALTH CENTER PATIENTS RESIDING IN THE 12428 ZIP CODE RECEIVE MEDICAID OR OTHER PUBLIC INSURANCE, AND 7.6% ARE UNINSURED. FURTHERMORE, ROUGHLY 10% OF ADULTS IN THE ZIP CODE HAVE NO USUAL SOURCE OF CARE. THE SAME PERCENTAGE OF ADULTS HAVE DELAYED OR NOT SOUGHT CARE DUE TO HIGH COST.WAWARSING AND THE VILLAGE OF ELLENVILLE WERE PREVIOUSLY HOME TO SEVERAL MANUFACTURING BUSINESSES, INCLUDING IMPERIAL SCHRADE AND HYDRO ALUMINUM, WHICH EMPLOYED MANY RESIDENTS. THE SURROUNDING AREA ALSO BOASTED SEVERAL LARGE RESORT HOTELS. HOWEVER, SINCE THE MID-1990S, THE ELLENVILLE COMMUNITY HAS LOST OVER 2,000 JOBS, DUE IN PART TO THESE BUSINESSES CLOSING THEIR DOORS AND A SIGNIFICANT DECLINE IN THE TOURIST INDUSTRY IN THE AREA. THE TOWN AND VILLAGE STRUGGLE WITH THE ISSUES THAT ACCOMPANY POVERTY AND UNEMPLOYMENT IN RURAL AREAS. OVER 12% OF RESIDENTS IN THE VILLAGE ARE UNEMPLOYED AND MAJOR EMPLOYERS THAT CONTINUE TO SUPPORT THE RESIDENTS OF THE REGION ARE THE NYS DEPARTMENT OF CORRECTIONS, ELLENVILLE CENTRAL SCHOOL DISTRICT AND ELLENVILLE REGIONAL HOSPITAL. PART VI, LINE 7, REPORTS FILED WITH STATES NY PART VI, LINE 4, CONTINUATION AN AFFORDABLE SENIOR HOUSING PROJECT, WHICH IS A JOINT VENTURE BETWEEN THE HOSPITAL AND WARWICK PROPERTIES, INC., IS LOCATED ON THE ELLENVILLE REGIONAL HOSPITAL CAMPUS. ALL THREE PHASES OF THE PROJECT REMAIN FULLY OCCUPIED, WITH APPROXIMATELY 156 SENIOR CITIZENS LIVING INDEPENDENTLY IN ONE-BEDROOM APARTMENTS. FUNDING WAS SECURED FOR THE PROJECT FROM THE NEW YORK STATE DIVISION OF HOUSING'S COMMUNITY RENEWAL HOUSING TRUST FUND. THE PARTNERSHIP SPONSORING THE HOUSING PROJECT IS DEVELOPING PLANS TO BUILD ADDITIONAL AFFORDABLE HOUSING CLOSE TO THE HOSPITAL, TARGETING SENIORS, SPECIAL NEEDS POPULATIONS AND POSSIBLY RETURNING VETS. X X X X 0 0 0 0 0 0 0 1 0 STEVEN KELLEY PRESIDENT & CEO 327200 0 28500 0 863 0 103100 0 0 0 459663 0 0 0 BOB RUE CFO 150427 0 10000 0 556 0 7956 0 26150 0 195089 0 0 0 ASHIMA BUTLER VP & CHIEF OPERATING OFFICER 137210 0 20000 0 3078 0 7140 0 26150 0 193578 0 0 0 MARTHA TOALA REGISTERED NURSE 143855 0 1325 0 39 0 0 0 26150 0 171369 0 0 0 MICHAEL STEARNS DIRECTOR OF PHARMACY 121852 0 5250 0 541 0 0 0 26150 0 153793 0 0 0 THERESA AVERSANO DIR OF REHABILITATION SVCS & CARDIAC REHAB 119393 0 7000 0 72 0 0 0 26150 0 152615 0 0 0 PART I, LINE 7 STEVEN KELLEY RECEIVED A BONUS OF $28,500 IN 2018 THAT WAS DETERMINED BY THE BOARD'S DISCRETION. BOB RUE, MICHAEL STEARNS, ASHIMA BUTLER, MARTHA TOALA, DEBORAH BRIGGS AND THERESA AVERSANO ALSO RECEIVED A BONUS IN 2018 THAT WAS BASED ON PERSONAL PERFORMANCE AND THE AMOUNT WAS DETERMINED BY THE CEO. THE BONUS WAS TREATED AS TAXABLE COMPENSATION TO THE RECIPIENT. FORM 990, PART VI, SECTION A, LINE 4 DURING 2018, THE ORGANIZATION AMENDED BYLAW TO CHANGE THE COMPOSITION OF THE GOVERNING BODY'S VOTING MEMBERS AS THE FOLLOWING: THE BOARD SHALL CONSIST OF ELEVEN (11) TRUSTEES, ALL OF WHOM SHALL BE RESIDENTS OF ULSTER COUNTY. FOUR (4) EX OFFICIO SEATS ON THE BOARD SHALL BE RESERVED FOR: 1) THE PRESIDENT & CEO OF THE HOSPITAL; 2) THE CHAIR OF THE FOUNDATION BOARD OF DIRECTORS, OR DESIGNEE; 3) THE PRESIDENT & CEO OR DESIGNEE OF THE INSTITUTE FOR FAMILY HEALTH; AND 4) THE PRESIDENT OF THE MEDICAL STAFF. FORM 990, PART VI, SECTION B, LINE 11B THE WESTCHESTER-ELLENVILLE REGIONAL HOSPITAL INC. HAS ITS FORM 990 PREPARED BY AN OUTSIDE ACCOUNTING FIRM AND HAS ESTABLISHED THE FOLLOWING REVIEW PROCESS TO ENSURE THAT THE INFORMATION REPORTED IS COMPLETE AND ACCURATE. WHEN THE FORM 990 HAS BEEN PREPARED, REVIEWED BY MANAGEMENT AND IS READY TO BE FILED WITH THE INTERNAL REVENUE SERVICE, IT IS ELECTRONICALLY SENT TO THE BOARD MEMBERS OF THE ORGANIZATION FOR ANY COMMENTS. ANY COMMENTS ARE THEN GROUPED, SUMMARIZED AND PROVIDED TO THE OUTSIDE ACCOUNTANTS. EACH ISSUE IS DOCUMENTED AND ADDRESSED UNTIL THE RETURN IS FINALIZED AND APPROVED FOR FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY APPLIES TO THE FOLLOWING "PERSONNEL" OF THE HOSPITAL: MEMBERS OF THE BOARD OF TRUSTEES, OFFICERS, "SENIOR MANAGEMENT" (DEFINED TO BE THE PRESIDENT AND CHIEF EXECUTIVE OFFICER, SENIOR VICE PRESIDENTS AND VICE PRESIDENTS), ASSISTANT VICE PRESIDENTS, DEPARTMENT HEADS, AND OTHER EMPLOYEES (INCLUDING PHYSICIANS) WHO ARE IN A POSITION TO INFLUENCE ANY SUBSTANTIVE BUSINESS DECISION BETWEEN THE HOSPITAL AND A VENDOR. A DISCLOSURE STATEMENT MUST BE COMPLETED ANNUALLY BY THE APPLICABLE PERSONNEL STATING IF THEY ARE AWARE OF ANY ACTUAL OR POTENTIAL CONFLICTS. IF DURING THE YEAR, ANY MEMBER OF THE BOARD OF TRUSTEES, MEDICAL STAFF MEMBER OR EMPLOYEE BECOMES AWARE OF A CONFLICT, THEY SHALL PROMPTLY DISCLOSE IN WRITING TO THE ADMINISTRATOR OR PRESIDENT OF THE BOARD OF TRUSTEES ANY ACTUAL OR CONTEMPLATED TRANSACTION WHICH POSES A CONFLICT OF INTEREST. THE REPORT SHALL CONTAIN A STATEMENT OF ALL MATERIAL FACTS AS TO THE RELATIONSHIP OR INTEREST WHICH CREATES THE POSSIBLE CONFLICT OF INTEREST. THE DISCLOSURE OF ANY ACTUAL OR POTENTIAL CONFLICT OF INTEREST WILL BE CONSIDERED BY THE BOARD OF TRUSTEES, WHICH WILL DETERMINE WHETHER THE ACTUAL OR POTENTIAL CONFLICT OF INTEREST WILL HAVE AN ADVERSE EFFECT ON THE FACILITY. THE BOARD OF TRUSTEES WILL CAUSE NOTICE TO BE GIVEN TO THE DISCLOSING PERSON, IN WRITING, OF THE DETERMINATION AND WHETHER THE SITUATION MAY BE ALLOWED TO CONTINUE OR SHOULD BE TERMINATED, AND OF ANY OTHER ACTION THAT WILL BE TAKEN BY THE BOARD OF TRUSTEES OR SHOULD BE TAKEN BY THE BOARD MEMBER, MEDICAL STAFF MEMBER OR EMPLOYEE. FORM 990, PART VI, SECTION B, LINE 15A THE COMPENSATION COMMITTEE IS PROVIDED AN INDEPENDENT REPORT OF COMPARABLE HOSPITAL SALARY FOR THE CEO. THE COMPENSATION COMMITTEE ALSO REVIEWS VARIOUS PERFORMANCE MEASURES AND OTHER INFORMATION AND ARRIVES AT A SALARY AND BENEFIT PACKAGE FOR THE CEO. COMPENSATION FOR CEO IS DECIDED IN EXECUTIVE SESSION, AND DOCUMENTED IN THE MINUTES. THIS PROCESS WAS LAST UNDERTAKEN IN 2018. THE DIRECTOR OF HUMAN RESOURCES OBTAINS SALARY INFORMATION FROM AN INDEPENDENT SOURCE FOR LOCAL COMPARABLE HOSPITALS FOR EACH HIGHER LEVEL POSITION AT THE HOSPITAL. THE INDEPENDENT INFORMATION CONTAINS SALARY LEVELS FOR EACH POSITION AT THE 25TH, 50TH AND 75TH PERCENTILE. THE CEO THEN CONSIDERS THIS INFORMATION AND THE PERFORMANCE FOR EACH OF THESE EMPLOYEES AND ARRIVES AT THE APPROPRIATE SALARY LEVEL. THIS PROCESS WAS LAST UNDERTAKEN IN 2018. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS FORM 990 AND FORM 1023 AVAILABLE FOR PUBLIC INSPECTION AS REQUIRED UNDER SECTION 6104 OF THE INTERNAL REVENUE CODE. THE RETURN IS POSTED ON GUIDESTAR.ORG AND OTHER SIMILAR TYPES OF WEBSITES. IN ADDITION, THE FINANCIAL STATEMENTS, CONFLICT OF INTEREST POLICY, ARTICLES OF INCORPORATION, FORM 990, FORM 1023, AND BY-LAWS ARE ALSO AVAILABLE UPON WRITTEN REQUEST OR BY CALLING THE ORGANIZATION DIRECTLY. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN NET ASSETS OF ELLENVILLE REGIONAL HOSPITAL FOUNDATION 121,120. CHANGE IN EQUITY INVESTMENT IN ELLENVILLE REGIONAL FAMILY HEALTH PROPERTIES -7,328. EQUITY TRANSFER -25,000. FORM 990, PART XII, LINE 2C THE ORGANIZATION HAS A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS DID NOT CHANGE FROM THE PRIOR YEAR. ELLENVILLE REGIONAL HOSPITAL FOUNDATION INC 10 HEALTHY WAY ELLENVILLE NY 124285612 371562427 TO SUPPORT WESTCHESTER-ELLENVILLE HOSPITAL INC. NY 501(C)(3) LINE 7 WESTCHESTER-ELLENVILLE HOSPITAL INC 1 ELLENVILLE REGIONAL SENIOR HOUSING DEVELOPMENT FUND COMPANY INC 10 HEALTHY WAY ELLENVILLE NY 124285612 261411484 TO PROVIDE LOW INCOME HOUSING NY WESTCHESTER-ELLENVILLE REGIONAL HOSPITAL INC C 1.00000 1 ELLENVILLE II REGIONAL SENIOR HOUSING DEVELOPMENT FUND COMPANY INC 10 HEALTHY WAY ELLENVILLE NY 124285612 270754224 TO PROVIDE LOW INCOME HOUSING NY WESTCHESTER-ELLENVILLE REGIONAL HOSPITAL INC C 1.00000 1 ELLENVILLE III REGIONAL SENIOR HOUSING DEVELOPMENT FUND COMPANY INC 10 HEALTHY WAY ELLENVILLE NY 124285612 300649484 TO PROVIDE LOW INCOME HOUSING NY WESTCHESTER-ELLENVILLE REGIONAL HOSPITAL INC C 1.00000 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0