2018-08-08T12:09:26-04:00 2017-12-31 822624857 GRAY & GRAY AND ASSOCIATES CPAS PC 1 MAIN STREET SUITE 101 CANTON NY 136171277 990 2017-01-01 464249555 GOUVERNEUR HOSPITAL GOUV 3152871000 77 WEST BARNEY STREET GOUVERNEUR NY 13642 DAVID BENDER CEO CEO 3152871000 2018-08-01 JOHN J GRAY JR CPA P00076464 3153862925 2018-08-01 2017 2022-09-23 18:48:47Z DAVID BENDER CEO 77 WEST BARNEY STREET GOUVERNEUR NY 13642 20636611 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. 8 4 244 2 0 599921 77149 18076448 18347130 16665 34695 489070 1958650 19182104 20417624 0 0 10508920 12250672 0 0 8217418 8322595 18726338 20573267 455766 -155643 11697963 12847542 9267108 8795533 2430855 4052009 X OUR MISSION IS TO PROVIDE SKILLED, COMPASSIONATE, COST-EFFECTIVE CARE THAT PROMOTES WELLNESS AND MEETS THE COMMUNITY'S HEALTHCARE NEEDS. false false 10406050 28242440 GOUVERNEUR HOSPITAL HAS A TOTAL OF 25 LICENSED BEDS, COMPRISED OF SWING, ALC, AND MED-SURG. IN 2017, THERE WERE TOTAL PATIENT DAYS OF 2,344, 308 OBSERVATION CASES AND 391 DISCHARGES. 2277285 7871951 IN 2017, THE ER VISITS SLIGHTLY DECREASED APPROXIMATELY .35% FROM 9,404 IN 2016 TO 9,371 IN 2017. 1167835 2051362 THERE WAS SIGNIFICANT GROWTH OF THE HOSPITAL CLINICS. THERE WERE 9,664 VISITS IN 2017, COMPARED TO 9,089 IN 2016, ROUGHLY A 6% INCREASE. 986547 1737870 THERE WAS SIGNIFICANT GROWTH IN SURGERIES PERFORMED IN 2017. THERE WERE 642 SURGERIES IN 2017, COMPARED TO 383 IN 2016, ROUGHLY AN 40% INCREASE. 986547 1737870 14837717 true false false true false false false false false true true true false true true true true 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 38 0 true 244 true false false false false false false false false false false false false X 8 4 false false false false true true true true true false true true true true true true true true true true false NY X ERIC BURCH 3152871000 77 WEST BARNEY STREET GOUVERNEUR NY 13642 X MICHAEL BURGESS CHAIRPERSON 1.00 X X 0 0 0 MEGAN WHITTON TRUSTEE 1.00 X 0 0 0 CAROLYN PISTOLESI TRUSTEE 1.00 X 0 0 0 ROGER COOK DVM TRUSTEE 1.00 X 0 0 0 ANDREW LEONARD CO-CHAIRPERS 1.00 X X 0 0 0 LAUREN FRENCH TRUSTEE 1.00 X 0 0 0 ANDREW WILLIAMS MD TRUSTEE 1.00 X 0 0 0 MARK BRACKETT SECRETARY/TR 1.00 X X 0 0 0 ERIC BURCH CFO 8.00 50.00 X 0 267355 12707 DAVID BENDER CEO CEO 40.00 X 231619 0 26538 NICOLE L WEBER MD PHYSICIAN 40.00 X 337288 0 14013 ALICE LOVING MD ANESTHESIOLO 40.00 X 299998 0 28003 RICHARD CORCORAN RPA PHYSICIAN AS 40.00 X 174006 0 21447 MICHAEL A KIGER RPA PHYSICIAN AS 40.00 X 164132 0 16085 ISMENE N MARAVEGIAS MD PHYSICIAN 40.00 X 155452 0 14149 1362495 267355 132942 6 false true false THE PIKE COMPANY INC 1 CIRCLE STEET ROCHESTER NY 14607 CONTRACTOR 1408964 CANTON-POTSDAM HOSPITAL 50 LEROY STREET POTSDAM NY 13676 STAFFING 1312390 DELPHI HOSPITALIST SERVICES LLC 1160 CHILI AVE SUITE 200 ROCHESTER NY 14624 HOSPITALIST 408068 BROOKS WASHBURN ARCHITECT PC 22 DEPOT STREET SUITE 16 POTSDAM NY 13676 ARCHITECT 175540 FUSION MEDICAL STAFFING LLC PO BOX 82674 LINCOLN NE 685012674 PHARMACY 152857 6 9816 67333 77149 NET PATIENT REVENUE 623000 17951171 17951171 VAP GRANT 623000 395959 395959 18347130 33695 33695 219858 218987 871 871 871 1000 1000 1000 1000 CPH BILLABLE 868718 868718 OTHER 741692 741692 340B PROGRAM 342071 342071 5298 5298 1957779 20417624 20304909 35566 544076 408057 136019 8863680 6647760 2215920 365718 274289 91429 1811006 1358254 452752 666192 499644 166548 83220 83220 169399 169399 4712 4712 167640 167640 195578 146684 48894 350816 293312 57504 26099 19574 6525 11258 8443 2815 153200 114900 38300 955982 799283 156699 254680 212934 41746 PURCHASED SERVICES 2366141 1774606 591535 SUPPLIES 1381912 1036434 345478 PROFESSIONAL/CONSULT FEES 1210772 302693 908079 EQUIPMENT RENTAL 552663 437944 114719 438523 335266 103257 20573267 14837717 5735550 0 745371 200618 769119 552113 2307040 1679338 416268 373848 208901 137841 9674519 2470133 5419338 7204386 729953 735518 1101973 1963880 11697963 12847542 1537946 2275015 12649 7729162 6507869 9267108 8795533 X 18076 1517320 976651 1032317 1436128 1502372 2430855 4052009 11697963 12847542 -155643 1776797 X false true X true false X false false false false false false false false true 18569 18569 false SCHEDULE C, PART IV GOUVERNEUR HOSPITAL, THROUGH ITS MEMBERSHIP OR FEES PAID IN 2017 TO THE FOLLOWING ORGANIZATIONS, INCURRED 18,569 IN LOBBYING EXPENSES: 4,719: IROQUOIS HEALTHCARE ALLIANCE-FEDERAL AND STATE ADVOCACY 6,000: HANYS ANNUAL MEMBERSHIP DUES-FEDERAL AND STATE ADVOCACY 7,850: AMERICAN HOSPITAL ASSOCIATION ANNUAL MEMBERSHIP DUES-FEDERAL AND STATE ADVOCACY 2412779 121910 2534689 1637555 1806389 38244 1069409 2412779 1672801 61715 -35323 61638 1637555 54334 1878461 217009 42985 1672801 54334 54334 0.59000 0.41000 false false 647398 647398 4364040 452985 3911055 4633375 2017148 2616227 29706 29706 7204386 ASSETS WHOSE USE IS LIMITED 692380 C INVESTMENTS 43138 F 735518 FUNDS HELD IN TRUST BY OTHERS 1047572 OTHER NOTES AND LOANS RECEIVABLE 838193 DUE FROM AFFILIATES 78115 1963880 ASSET RETIREMENT OBLIGATION 4258349 DUE TO AFFILIATES 2718419 ESTIMATED THIRD PARTY SETTLEMENTS -468899 6507869 X 20636611 218987 218987 20417624 20417624 20792254 218987 218987 20573267 20573267 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 THE FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE SYSTEM AND ITS 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 RECOGNITION IN MEASUREMENT ARE REFLECTED IN THE PERIOD IN WHICH THE CHANGE IN JUDGEMENT OCCURS. THE SYSTEM AND ITS AFFILIATES DID NOT RECOGNIZE THE EFFECT OF ANY UNCERTAIN INCOME TAX POSITIONS IN EITHER 2017 OR 2016. 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 THEIR DONORS. THE SYSTEM HAS REVIEWED THESE PROVISIONS AND THE POTENTIAL IMPACT AND CONCLUDED THE ENACTMENT OF H.R.1 WILL NOT HAVE A MATERIAL EFFECT ON THE OPERATIONS OF THE ORGANIZATION SCHEDULE D, PAGE 4, PART XI, LINE 2D 218,987 SCHEDULE D, PAGE 4, PART XII, LINE 2D RENT EXPENSES 218,987 true true X true X 2.010000000000 true X true true false true true 18684 1193 17491 0.00090 6141702 2593323 3548379 0.17250 6160386 2594516 3565870 0.17340 16527 16527 0.00080 50573 50573 0.00240 592 592 67692 67692 0.00320 6228078 2594516 3633562 0.17660 true 476683 11052 4366752 6090660 -1723908 X true true 1 1 GOUVERNEUR HOSPITAL 77 WEST BARNEY STREET GOUVERNEUR NY 13642 WW.GVNRHOSPITAL.ORG/ABOUT-OUR-HOSPITAL X X X X GOUVERNEUR HOSPITAL 1 false false true X X X X X X X X X 14 true true true true X WW.GVNRHOSPITAL.ORG/ABOUT-OUR-HOSPITAL true 14 true WWW.GVNRHOSPITAL.ORG/ABOUT-OUR-HOSPITA 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 false X X true X false false FACILITY 1, GOUVERNEUR HOSPITAL - PART V, LINE 3J PLEASE REFERENCE THE ABOVE REQUIRED DESCRIPTIONS, PART V SECTION B, LINES 5 AND 11. FACILITY 1, GOUVERNEUR HOSPITAL - PART V, LINE 5 GOUVERNEUR HOSPITAL'S (GH) MOST RECENT CHNA WAS CONDUCTED BY ITS NEW YORK STATE DSRIP PPS, ADIRONDACK HEALTH INSTITUTE, AS WELL AS ITS LOCAL PARTNERS, THE ST. LAWRENCE COUNTY PUBLIC HEALTH DEPARTMENT AND THE ST. LAWRENCE HEALTH INSTITUTE. GH PARTICIPATES AT THE BOARD LEVEL ON THE ST. LAWRENCE HEALTH INITIATIVE, A NOT-FOR-PROFIT ORGANIZATION COORDINATING HEALTH ASSESSMENT AMONG ALL AREA HEALTH FACILITIES. THIS ORGANIZATION AND OUR DSRIP PPS PROVIDE FORMAL ONGOING COORDINATION OF NEEDS ASSESSMENT AND PROGRAMMING. THE CHNA WAS COMPLETED IN 2014 AND UPDATED IN 2017. GH ALSO SEEKS INPUT FORMALLY THROUGH AN ANNUAL FORUM WITH COMMUNITY LEADERS FROM ALL ACROSS OUR PRIMARY AND SECONDARY SERVICE AREAS, FREQUENT MEETINGS WITH PUBLIC HEALTH OFFICIALS, LOCAL COLLEGE PRESIDENTS, THE LEADERS OF OTHER AREA HEALTH FACILITIES, AND LOCAL GOVERNMENT OFFICIALS. ADDITIONAL INPUT WAS GATHERED FROM HOSPITAL AND HOSPITAL SYSTEM BOARD MEMBERS REPRESENTING PUBLIC HEALTH, DENTISTRY, HOSPICE AND PALLIATIVE CARE, VETERINARY HEALTH, AREA COLLEGES, AND AREA BUSINESSES. IN 2014, GH BECAME AFFILIATED WITH THE ST. LAWRENCE HEALTH SYSTEM PARTNERING WITH CANTON-POTSDAM HOSPITAL. THE COMMUNITY SERVICE INITIATIVES ARE COLLABORATED WITHIN AND TOGETHER UNDER THIS UMBRELLA SYSTEM. CURRENTLY, THE NEW CHNA IS UNDER WAY BY THE NEW YORK STATE DSRIP PPS, ADIRONDACK HEALTH INSTITUTE AND THE FORT DRUM REGIONAL HEALTH PLANNING ORGANIZATION (FDRHPO), ALONG WITH LOCAL PARTNERS, ST LAWRENCE COUNTY PUBLIC HEALTH AND THE HEALTH INITIATIVE FOR THE NEXT 4 YEAR CYCLE. 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 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 112,000 RESIDENTS. GOUVERNEUR HOSPITAL'S PRIMARY SERVICE AREA IS APPROXIMATELY 20,000 PEOPLE, CONSISTING OF THE COMMUNITIES OF GOUVERNEUR, RICHVILLE, DEKALB JCT., EDWARDS, ANTWERP, HARRISVILLE AND HERMON. THE SECONDARY SERVICE AREA FOR THE HOSPITAL IS PREDOMINANTLY THE REMAINING COMMUNITIES WITHIN ST. LAWRENCE COUNTY WITH SOME RESIDENTS OF THE WESTERN JEFFERSON COUNTY AREA BEING SERVED. 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, SCHOOL EDUCATION ACTIVITIES, BREAST CANCER WALKS, AND LUNCH & LEARNS. THE COMMUNITY LUNCH & LEARNS HELD BY GOUVERNEUR HOSPITAL HAD APPROXIMATELY 168 PEOPLE IN ATTENDANCE AND SPOKE TO VARIOUS HEALTH RELATED RISKS AND HOW TO MANAGE THEM. GOUVERNEUR HOSPITAL HAD 63 STUDENTS FROM MULTIPLE COLLEGES AND BOCES PROGRAMS SHADOW EMPLOYEES. GOUVERNEUR HOSPITAL HELD A "LET'S NOT MEET BY ACCIDENT" PROGRAM FOR 182 STUDENTS TO EDUCATE YOUNG DRIVERS ON THE DANGERS OF DWI AND TEXTING WHILE DRIVING. THE HOSPITAL ALSO WORKS WITH THE LOCAL POLICE DEPARTMENT EACH YEAR AND DOES A PROGRAM CALLED OPERATION SAFE CHILD WHERE YOUNG CHILDREN CAN ATTEND AND HAVE A PHOTO ID PLACED ON RECORD. 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 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. WITHIN THESE AREAS, CHILD AND ADOLESCENT OBESITY, HEART FAILURE, DIABETES, AND COPD WERE IDENTIFIED AS THE MOST PRESSING NEEDS IN CHRONIC DISEASE MANAGEMENT; SUBSTANCE ABUSE AND SUICIDE PREVENTION WERE IDENTIFIED AS TOP NEEDS IN THE MEB HEALTH CATEGORY. THESE PRIORITY AREAS DOVETAIL WITH THE HOSPITAL'S STRATEGIC PLAN, THE PRIORITIES OF THE NEW YORK STATE DSRIP PPS PARTNERS IN A NINE-COUNTY NORTHERN NEW YORK REGION THAT ENCOMPASSES ST. LAWRENCE COUNTY, THE PRIORITIES OF THE NEW YORK STATE HEALTHCARE REDESIGN COMMISSION, THE PRIORITIES OF THE NEW YORK STATE PREVENTION AGENDA, AND THE GOALS OF THE AFFORDABLE CARE ACT TO INCREASE ACCESS, REDUCE COSTS, AND IMPROVE QUALITY. SPECIFIC GOALS AND METRICS HAVE BEEN IDENTIFIED AND THE HOSPITAL'S OUTREACH PROGRAMS ARE DESIGNED TO ADDRESS THESE. AMONG THESE PROGRAMS IS AN EXTENSIVE EDUCATION SERIES FOR THE COMMUNITY ON VARIOUS HEALTH ISSUES; EDUCATION TARGETED TO THOSE WITH SPECIFIC DIAGNOSES; SUPPORT FOR OTHER COMMUNITY ORGANIZATIONS, SUCH AS COLLABORATING WITH THE HEALTH INITIATIVE TO IMPLEMENT SERVICES AND ASSIST IN THE MAKING AN IMPACT ON REDUCTION OF THE OPIOID EPIDEMIC IN OUR COMMUNITIES. PART III, LINE 9B - COLLECTION PRACTICES EXPLANATION PART III, SECTION A, LINES 2 & 3: THE COSTS ON LINE 2 ARE BASED UPON THE MCR ICR FOR 2017 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, 4: PAGE 14 OF THE AUDITED FINANCIAL STATEMENTS (FN 3-PATIENT ACCOUNTS RECEIVABLE AND RELATED ALLOWANCE FOR ESTIMATED UNCOLLECTIBLE ACCOUNTS). 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 ERIC BURCH CFO 267355 11715 992 280062 DAVID BENDER CEO CEO 231619 11256 15282 258157 NICOLE L WEBER MD PHYSICIAN 337288 13400 613 351301 ALICE LOVING MD ANESTHESIOLOGIST 299998 13400 14603 328001 RICHARD CORCORAN RPA PHYSICIAN ASSISTANT 174006 8567 12880 195453 MICHAEL A KIGER RPA PHYSICIAN ASSISTANT 164132 7875 8210 180217 ISMENE N MARAVEGIAS MD PHYSICIAN 155452 2821 11328 169601 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. 342,071 IN PAYMENTS WERE MADE IN 2017. 2. MARK BRACKETT, BOARD MEMBER FOR GH, IS A BOARD MEMBER OF KINNEY DRUGS FOUNDATION. MARK IS ALSO A BOARD MEMBER OF THE ST. LAWRENCE COUNTY CANCER FUND. IN 2017, KINNEY DRUGS DONATED 52,500 TO GH AND THE CANCER FOUNDATION DONATED 22,500. 3. ANDREW LEONARD, BOARD MEMBER FOR GH, IS ALSO THE PRESIDENT OF ENI MECHANICAL INC. IN 2017, ENI MECHANICAL WAS PAID 31,992 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. DR. WILLIAMS IS ALSO AN EMPLOYEE OF CANTON-POTSDAM HOSPITAL, AN AFFILIATED HOSPITAL OF GH. IN 2017, THE COMMUNITY HEALTH CENTER PAID RENT FOR SPACE AT GH IN THE AMOUNT OF 118,125. FORM 990, PAGE 2, PART III, LINE 4D THERE WAS SIGNIFICANT GROWTH IN SURGERIES PERFORMED IN 2017. THERE WERE 642 SURGERIES IN 2017, COMPARED TO 383 IN 2016, ROUGHLY AN 40% INCREASE. 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 990 IS EMAILED TO THE BOARD OF DIRECTORS FOR THEIR REVIEW PRIOR TO THE FILING OF THE RETURN. 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 X 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 1,500,000 NET ASSETS REALEASED FROM RESTRICTIONS FOR CAPITAL 154,886 RESTRICTED CONTRIBUTIONS 432,082 NET ASSETS RELEASED FROM RESTRICTIONS -376,416 CHANGE IN FAIR VALUE OF FUNDS HELD IN TRUST BY OTH 66,245 TOTAL 1,776,797 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 J 55575 FMV CANTON-POTSDAM HOSPITAL J 868717 FMV SLHS K 154742 FMV SLHS P 319217 FMV SLHS C 1500000 CASH EXCHANGED CANTON-POTSDAM HOSPITAL K 1149205 FMV CANTON-POTSDAM HOSPITAL FOUNDATION M 232301 CASH EXCHANGED