2017-11-13T15:40:17-06:00 2016-12-31 PricewaterhouseCoopers LLP 300 Madison Avenue New York NY 10017 990 2016-01-01 111888924 GOOD SAMARITAN HOSPITAL MEDICAL CENTER % CHS SERVICES GOOD 6313763000 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 THOMAS OCKERS EXEC VP & CAO 5167051919 2017-11-08 true LAURA J PARELLO P01080295 6464713000 155.201.188.12 13049920173175000048 2017-11-13 P A47FF8DD5715699DF48307C25ACEE32075633D08 061919171EF570F7EF91D6556883685BED3C11EB 2016 2018-03-14 21:41:22Z ALAN D GUERCI MD 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 657886608 false 0928 X HTTP://GOODSAMARITAN.CHSLI.ORG/ X 1959 NY CHSLI AND ITS MEMBERS, AS A MINISTRY OF THE CATHOLIC CHURCH, CONTINUE CHRIST'S HEALING MISSION, BY PROMOTING EXCELLENCE IN CARE AND COMMITTING ITSELF TO THOSE IN NEED. 23 22 4109 507 1627910 -829606 2818750 1797293 542429871 600980336 1877578 2329357 18280426 13149395 565406625 618256381 304839 1988114 0 0 303833255 311620667 0 0 0 250129041 270223695 554267135 583832476 11139490 34423905 465129473 515158689 250686968 264083142 214442505 251075547 X GOOD SAMARITAN HOSPITAL MEDICAL CENTER, A MEMBER OF CATHOLIC HEALTH SERVICES OF LONG ISLAND, AS A MINISTRY OF THE CATHOLIC CHURCH, CONTINUES CHRIST'S HEALING MISSION, PROMOTES EXCELLENCE IN CARE, AND COMMITS ITSELF TO THOSE IN NEED. CHS AFFIRMS THE SANCTITY OF LIFE, AND ADVOCATES FOR THE POOR AND UNDERSERVED, AND SERVES THE COMMON GOOD. IT CONDUCTS ITS HEALTHCARE PRACTICE, BUSINESS, EDUCATION AND INNOVATION WITH JUSTICE, INTEGRITY AND RESPECT FOR THE DIGNITY OF EACH PERSON. false false 514204417 1988114 591445529 GOOD SAMARITAN HOSPITAL MEDICAL CENTER IS A 437 BED MEDICAL CENTER LOCATED ON THE SOUTH SHORE OF LONG ISLAND IN WEST ISLIP, NEW YORK. A PREMIER HEALTHCARE FACILITY, PROVIDING QUALITY AND COST EFFECTIVE HEALTH CARE SERVICES EXTENDING ACROSS THE CONTINUUM OF CARE TO ALL DISCIPLINES, BOTH FOR INPATIENTS AND OUTPATIENTS. IN 2016 THE MEDICAL CENTER PROVIDED INPATIENT SERVICES FOR 27,439 DISCHARGED INDIVIDUALS, MANAGED 89,896 EMERGENCY DEPARTMENT VISITS AND 22,421 CLINIC VISITS. THE MEDICAL CENTER PROVIDES CARE REGARDLESS OF THE INDIVIDUAL'S ABILITY TO PAY AND ALONG WITH COMMUNITY SERVICE AND CHARITABLE ACTIVITIES. 7342550 0 10781062 GOOD SAMARITAN NURSING HOME IS LOCATED ON THE SOUTH SHORE OF LONG ISLAND IN SAYVILLE, NEW YORK. THE 100 BED FACILITY HAS BEEN PART OF GOOD SAMARITAN HOSPITAL MEDICAL CENTER SINCE 1980. THE RESIDENT POPULATION OF THE NURSING HOME IS MEDICALLY COMPLEX AND REQUIRES FULL-TIME CARE. SKILLED NURSING CARE AT THE FACILITY PROVIDES ONGOING MEDICALLY COMPLEX CARE ALONG WITH GERIATRIC CARE, REHABILITATIVE CARE, AND DEMENTIA DISEASE CARE. 2016 PATIENT DAYS FOR THE NURSING HOME TOTALED 35,641. 521546967 true true false true false false false false false false true false false true true true false true false false false false false false false false true true true false true false false false false false false false true false false false false false true true true false false true 295 0 true 4109 true true true false false false false false false false false false X 23 22 false false false false true true true true true false false true true true true true true true true true true X CHS SERVICES 5167051919 992 NORTH VILLAGE AVE ROCKVILLE CENTRE NY 11570 X SALVATORE SODANO CHAIRMAN 2.0 0.0 X X 0 0 0 BRIAN MCGUIRE VICE CHAIR 2.0 0.0 X X 0 0 0 JOSEPH TANTILLO SECRETARY 2.0 0.0 X X 0 0 0 CHRIS PASCUCCI TREASURER 2.0 0.0 X X 0 0 0 BARBARA ELLEN BLACK TRUSTEE 2.0 0.0 X 0 0 0 VIRGINIA EWEN TRUSTEE 2.0 0.0 X 0 0 0 FRANK L KURRE TRUSTEE 2.0 0.0 X 0 0 0 REV MSGR ROBERT MORRISEY TRUSTEE 2.0 0.0 X 0 0 0 DANIEL T ROWE TRUSTEE 2.0 0.0 X 0 0 0 JOHN WAGNER TRUSTEE 2.0 0.0 X 0 0 0 REV JAMES VLAUN TRUSTEE 2.0 0.0 X 0 0 0 KEVIN J CONWAY TRUSTEE 2.0 0.0 X 0 0 0 PETER D'ANGELO TRUSTEE 2.0 0.0 X 0 0 0 REV PETER DUGANDZIC TRUSTEE 2.0 0.0 X 0 0 0 BRIAN P HEHIR TRUSTEE 2.0 0.0 X 0 0 0 HON ANTHONY MARANO TRUSTEE 2.0 0.0 X 0 0 0 STEPHEN F MCLOUGHLIN TRUSTEE 2.0 0.0 X 0 0 0 JEROME POLLER TRUSTEE 2.0 0.0 X 0 0 0 JOHN FRANCFORT MD TRUSTEE 2.0 0.0 X 0 0 0 ALEXANDER HAZELTON TRUSTEE 2.0 0.0 X 0 0 0 WILLIAM WARD TRUSTEE 2.0 0.0 X 0 0 0 ROBERT ZUCCARO TRUSTEE 2.0 0.0 X 0 0 0 ALAN D GUERCI MD PRESIDENT & CEO 50.0 0.0 X X 0 2595065 360447 DANIEL DEBARBA EVP & CFO (EFFECTIVE 6/6/16) 50.0 0.0 X 0 591354 37422 THOMAS OCKERS EXEC VP & CAO 50.0 0.0 X 496560 0 32337 NANCY SIMMONS CAO 50.0 0.0 X 106655 0 65122 WILLIAM C ARMSTRONG SVP FINANCE 50.0 0.0 X 0 1552126 188843 DONALD TEPLITZ CHIEF MEDICAL OFFICER 50.0 0.0 X 582185 0 51953 NEIL LOBO PHYSICIAN 50.0 0.0 X 1094980 0 52057 KOUROSH ADHAMI PHYSICIAN 50.0 0.0 X 1097357 0 51745 BABAK DANESH PHYSICIAN 50.0 0.0 X 1063955 0 23838 JAMES KOHLROSER PHYSICIAN 50.0 0.0 X 1094018 0 54607 PANKAJ SINGHAL PHYSICIAN 50.0 0.0 X 969644 0 20292 JEROME WEINER FORMER CHIEF MEDICAL OFFICER 0.0 0.0 X 525271 0 19283 7030625 4738545 957946 708 true true false PROGRESSIVE EMERGENCY PHYSICIANS PL 1236 RXR PLAZA UNIONDALE NY 11556 PHYSICIAN SERVICES 17502598 MEDICAL SOLUTIONS 9101 WESTERN AVENUE SUITE 101 OMAHA NE 68114 NURSING SERVICES 1927959 TOTAL HEALTHCARE STAFFING LI PO BOX 823461 PHILADELPHIA PA 19182 NURSING SERVICES 1321527 MAJESTIC PROP MGT AAF CAPTREE 60 CUTTERMILL RD GREAT NECK NY 11021 RENT 919051 COLUMBIA PARTNERS LLC 161 STILLWELL LA LAUREL HOLLOW NY 11792 RENT 782120 44 74 63483 1625392 108344 1797293 NET PATIENT SERVICE REVENUE - HOSPITAL 623990 590199274 590199274 NET PATIENT SERVICE REV. - NURSING HOME 623000 10781062 10781062 600980336 2167186 2167186 0 0 1794101 1794101 0 1794101 1794101 39792398 39630227 162171 162171 162171 0 0 0 0 0 0 0 0 0 PHYSICIAN SERVICES REVENUE 621110 1246255 1246255 COFFEE SHOP & CAFETERIA 900099 1639797 1639797 LAB SERVICES 621500 7784360 1627910 6156450 684882 684882 11355294 618256381 602226591 1627910 12604587 1988114 1988114 0 0 0 1334812 634138 700674 0 233681099 219751645 13929454 19139358 17947901 1191457 38352844 35648745 2704099 19112554 17922766 1189788 501090 81841 419249 186907 186907 28987 28987 96180 96180 0 0 32033480 29155864 2877616 1743254 162076 1581178 8498500 5629922 2868578 0 0 7609422 6714628 894794 266248 244663 21585 0 0 395786 395786 23646266 23646266 22095020 18545945 3549075 14623424 14623424 MEDICAL SUPPLIES EXPENSE 85465375 85465375 CHS SERVICES 38825649 17380010 21445639 EQUIPMENT SERVICE CONTRACTS 6810150 6810150 HOME OFFICE ALLOCATION 7991630 7991630 19406327 18797708 608619 583832476 521546967 62285509 0 30148709 34943965 46859396 73004492 0 0 60784217 74073195 0 0 0 0 0 0 6881966 6645479 4161119 6049496 485486266 321384821 168610360 164101445 45179748 45331645 0 0 0 0 0 0 102503958 111008972 465129473 515158689 66543006 69005371 0 0 0 0 5290025 5084943 0 0 0 0 1990155 2020993 0 0 176863782 187971835 250686968 264083142 X 212820473 249469573 1622032 1605974 0 0 214442505 251075547 465129473 515158689 X 34423905 2196137 13000 X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 96180 96180 false PART II-B, LINE 1 - OTHER LOBBYING ACTIVITIES AMOUNT REFLECTS PORTION OF TRADE ASSOCIATION DUES WHICH WERE USED FOR LEGISLATIVE LOBBYING ON THE BEHALF OF THE HEALTHCARE INDUSTRY THOSE TRADE ASSOCIATIONS REPRESENT. 5039490 5039490 245778437 138763344 107015093 11185572 9714879 1470693 222115678 172906598 49209080 1367089 1367089 164101445 OTHER RECEIVABLES 2757798 DUE FROM RELATED PARTIES 25797192 INSURANCE CLAIMS RECEIVABLE 81333791 GOODWILL ISLAND DIGESTIVE 1120191 111008972 0 THIRD PARTY PAYOR LIABILITY 26251696 SELF INSURANCE RESERVE-MALPRAC 84667931 SELF INSURANCE RESERVE-LIABILI 45807196 OTHER NON-CURRENT LIABILITIES 13479766 DUE TO RELATED PARTIES 17765246 187971835 X PART X, OTHER LIABILITIES - LINE 2, FIN 48 FOOTNOTE CHS AND MOST OF ITS SUBSIDIARIES ARE EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE OF 1986, AS AMENDED. CHS ACCOUNTS FOR UNCERTAIN TAX POSITIONS IN ACCORDANCE WITH THE ACCOUNTING STANDARDS CODIFICATION TOPIC 740, INCOME TAXES. MANAGEMENT ANNUALLY REVIEWS ITS TAX POSITIONS AND HAS DETERMINED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS THAT REQUIRE RECOGNITION IN THE CONSOLIDATED FINANCIAL STATEMENTS, USING A THRESHOLD OF MORE LIKELY THAN NOT OF BEING SUSTAINED. true true X true X 300. true X true true true false true true 9053504 7559545 1493959 0.00260 77006837 63037940 13968897 0.02390 11531868 10109163 1422705 0.00240 97592209 80706648 16885561 0.02890 844608 0 844608 0.00140 8915989 5250178 3665811 0.00630 519922 0 519922 0.00090 10280519 5250178 5030341 0.00860 107872728 85956826 21915902 0.03750 true 16810909 142034385 155581515 -13547130 X true true 1 1 GOOD SAMARITAN HOSPITAL MEDICAL CTR 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 HTTP://GOODSAMARITAN.CHSLI.ORG/ 5154001H X X X X HOSPITAL GOOD SAMARITAN HOSPITAL MED CTR 1 false false true X X X X X X X X 16 true true true true X goodsamaritan.chsli.org/ X www.chsli.org true 16 true www.chsli.org false true X 300. 400. X X X true true X X X true X www.chsli.org X www.chsli.org X www.chsli.org X X X X X X true X false X X X X X true X false false PART V, SECTION B, LINE 5 GOOD SAMARITAN HOSPITAL CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) IN ASSOCIATION WITH LONG ISLAND HEALTH COLLABORATIVE (LIHC) MEMBERS. THE LIHC IS A PARTNERSHIP OF LONG ISLAND'S HOSPITALS, COUNTY HEALTH DEPARTMENTS, HEALTH PROVIDERS, COMMUNITY-BASED SOCIAL AND HUMAN SERVICE ORGANIZATIONS, ACADEMIC INSTITUTIONS, HEALTH PLANS, LOCAL GOVERNMENT AND THE BUSINESS SECTOR, ALL ENGAGED IN IMPROVING THE HEALTH OF LONG ISLANDERS. THE LIHC IS THE MAIN WORKING GROUP ASSOCIATED WITH CARRYING OUT THE GOALS OF THE LONG ISLAND POPULATION HEALTH IMPROVEMENT PROGRAM. IN 2016, MEMBERS OF LIHC REVIEWED EXTENSIVE DATA SETS SELECTED FROM BOTH PRIMARY AND SECONDARY DATA SOURCES TO IDENTIFY AND CONFIRM PREVENTION AGENDA PRIORITIES FOR THE 2016-2018 COMMUNITY HEALTH NEEDS ASSESSMENT CYCLE. PRIMARY DATA SOURCES COLLECTED AND ANALYZED INCLUDE THE LONG ISLAND COMMUNITY HEALTH ASSESSMENT SURVEY, QUALITATIVE DATA FROM COMMUNITY-BASED ORGANIZATION SUMMIT EVENTS, AND THE LIHC WELLNESS SURVEY. THE BROAD COMMUNITY WAS ENGAGED IN ASSESSMENT EFFORTS THROUGH THE DISTRIBUTION AND COMPLETION OF THE PREVENTION AGENDA COMMUNITY MEMBER SURVEYS. THIS TOOL WAS DEVELOPED IN COLLABORATION WITH COMMUNITY PARTNERS FROM THE LIHC. DATA FROM THIS SURVEY WERE COLLECTED AUGUST 1, 2015 THROUGH APRIL 30, 2016 THROUGH DISTRIBUTION AND PROMOTION OF THIS SURVEY THROUGHOUT A WIDE RANGE OF SOCIAL SERVICE LOCATIONS, INCLUDING GOOD SAMARITAN HOSPITAL, DOCTORS OFFICES, HEALTH DEPARTMENTS, LIBRARIES, SCHOOLS, INSURANCE ENROLLMENT SITES AND COMMUNITY-BASED ORGANIZATIONS. THIS INCLUDES THE MEDICALLY UNDERSERVED COMMUNITIES OF BAY SHORE, WYANDANCH, BRENTWOOD AND CENTRAL ISLIP. GOOD SAMARITAN HOSPITAL PROMOTES THE SURVEY THROUGH SOCIAL MEDIA LINKS, ON ITS WEBSITE, AND BY DISTRIBUTING SURVEYS AT HEALTH FAIRS AND OTHER CONSUMER-ORIENTED EVENTS. PART V, SECTION B, LINE 6A BROOKHAVEN MEMORIAL HOSPITAL, HUNTINGTON HOSPITAL, JOHN T. MATHER MEMORIAL HOSPITAL PECONIC BAY MEDICAL CENTER, GOOD SAMARITAN HOSPITAL MEDICAL CENTER, ST. CATHERINE OF SIENA MEDICAL CENTER, SOUTHAMPTON HOSPITAL, SOUTHSIDE HOSPITAL, STONY BROOK UNIVERSITY HOSPITAL AND VETERANS AFFAIRS MEDICAL CENTER. PART V, SECTION B, LINE 6B THE HOSPITALS CHNA WAS ALSO CONDUCTED WITH NASSAU AND SUFFOLK HEALTH DEPARTMENTS, STONY BROOK UNIVERSITY AND MORE THAN 40 COMMUNITY-BASED ORGANIZATIONS, COLLECTIVELY KNOWN AS THE LONG ISLAND HEALTH COLLABORATIVE (LIHC). PART V, SECTION B, LINE 11 GOOD SAMARITAN HOSPITAL AND LIHC COMMUNITY PARTNERS SELECTED CHRONIC DISEASE AS THE PRIORITY AREA WITH A FOCUS ON (1) OBESITY AND (2) PREVENTIVE CARE AND MANAGEMENT FOR THE 2016-2018 CYCLE. MENTAL HEALTH WILL BE HIGHLIGHTED WITHIN ALL INTERVENTION STRATEGIES. PRIORITY 1: OBESITY THE HOSPITAL IS IMPROVING COMMUNITY HEALTH BY WORKING TO REDUCE THE INCIDENCE OF OBESITY AND RELATED CO-MORBIDITIES SUCH AS HEART DISEASE AND DIABETES BY PROVIDING INDIVIDUALS WITH THE TOOLS AND KNOWLEDGE TO POSITIVELY IMPACT FOOD CHOICES AND ACTIVITY LEVELS. THE HEALTHIER FAMILIES PROGRAM IS A FREE, 10-WEEK EDUCATIONAL SERIES THAT PROMOTES A HEALTHY LIFESTYLE OFFERED IN COLLABORATION WITH THE IDENTIFIED, UNDERSERVED AREA IN THE BAY SHORE SCHOOL DISTRICT AND THE BAY SHORE WELLNESS ALLIANCE, FOR CHILDREN IN GRADES 3-5 WHO HAVE BEEN DESIGNATED AS AT-RISK FOR FUTURE OBESITY-RELATED HEALTH ISSUES. IN 2016, 20 FAMILIES WERE ENROLLED IN THE PROGRAM. AT LEAST 50% OF THE STUDENTS DEMONSTRATED RELEVANT IMPROVEMENT IN HEIGHT/WEIGHT/BMI AT THE END OF THE 10 WEEK SESSION. IN A SURVEY OF STUDENTS AND PARENTS, MORE THAN 90% DEMONSTRATED A GREATER KNOWLEDGE AND AWARENESS OF THE IMPORTANCE OF A HEALTHY LIFESTYLE AND THE NEED FOR ITS CONTINUATION AND 80% OF STUDENT PARTICIPANTS ACHIEVED A SET GOAL OF 500 MINUTES OF EXERCISE BY THE CONCLUSION OF THE HEALTHIER FAMILY SESSION. THE HEALTHIER FAMILIES PROGRAM WILL CONTINUE IN 2017. IN PLANNING FOR GROWTH AND EXPANSION OF THIS EDUCATIONAL PROGRAM, A SECOND REGISTERED DIETITIAN, AS WELL AS ANCILLARY PERSONNEL WERE MENTORED. FREE BARIATRIC EDUCATIONAL SEMINARS ARE HELD MONTHLY, HOSTED BY ONE OF THREE GOOD SAMARITAN BARIATRIC SURGEONS. IN 2016, 471 PEOPLE ATTENDED THE BARIATRIC SEMINARS OFFERED AT THE HOSPITAL. GOOD SAMARITAN OFFERS FREE BARIATRIC SUPPORT GROUPS TWICE A MONTH, FACILITATED BY A REGISTERED NURSE AND VISITED BY A LICENSED SOCIAL WORKER WITH A BACKGROUND IN EATING DISORDERS. THESE GROUPS HELP PATIENTS PREPARE FOR SURGERY AND MAKE THE NECESSARY CHANGES TO BE SUCCESSFUL IN THEIR JOURNEY TOWARD A HEALTHIER LIFESTYLE. IN ADDITION, POST-SURGERY PATIENTS RECEIVE THE SUPPORT NEEDED TO CONTINUE TO MAINTAIN A HEALTHY LIFESTYLE FOLLOWING WEIGHT LOSS SURGERY. THE AVERAGE NUMBER OF ATTENDEES AT AN EVENING MEETING IS 36, OF WHICH 16 NEW PARTICIPANTS WOULD BE PRE-SURGICAL. THE AVERAGE NUMBER OF ATTENDEES AT AN AFTERNOON MEETING IS 23, OF WHICH 9 WOULD BE PRE-SURGICAL. IN 2016, GOOD SAMARITAN OFFERED THE NEW YORK STATE 16-WEEK DIABETES PREVENTION PROGRAM IN COLLABORATION WITH THE NEW YORK STATE DEPARTMENT OF HEALTH. THE DIABETES PREVENTION PROGRAM STARTED WITH 18 PARTICIPANTS, HOWEVER, 2 WERE ELIMINATED DUE TO HEALTH CONDITIONS WHICH PREVENTED CONTINUATION OF THE PROGRAM. A THIRD PARTICIPANT COULD NOT CONTINUE DUE TO TRANSPORTATION DIFFICULTIES. A TOTAL OF 15 PARTICIPANTS COMPLETED THE PROGRAM, INCLUDING POST CORE SESSIONS. THE AVERAGE WEIGHT LOSS WAS 9.5 POUNDS, WHICH IS 2.5 LESS POUNDS THAN THE YEAR BEFORE, AND ALL 15 PARTICIPANTS REACHED THE GOAL OF 150 MINUTES A WEEK OF PHYSICAL ACTIVITY. GOOD SAMARITAN HOSPITAL PARTICIPATES IN THE AMERICAN HEART ASSOCIATION HEART WALK, THE LONG ISLAND MARCUM WORKPLACE CHALLENGE - A 3.5-MILE RUN-WALK FOR CHARITY - AND THE AMERICAN CANCER SOCIETYS MAKING STRIDES AGAINST BREAST CANCER WALK. THESE EVENTS ENCOURAGE WALKING FOR PHYSICAL ACTIVITY AND GOOD HEALTH FOR EMPLOYEES AND THE COMMUNITY. EDUCATIONAL MATERIALS ARE OFFERED AT EACH EVENT. CHS WAS THE MEDAL OF HONOR TITLE SPONSOR FOR THE SECOND CONSECUTIVE YEAR SERVING AGAIN AS THE OFFICIAL RACE MEDICINE PROVIDER FOR THE 2016 CHS SUFFOLK COUNTY MARATHON AND FREEDOM FEST. THE NET PROCEEDS FROM THE ANNUAL EVENT BENEFITS LOCAL VETERANS SERVICES ORGANIZATIONS. THERE WERE 33 GOOD SAMARITAN EMPLOYEES WHO WORKED IN THE RACE MEDICINE TENT, 9 PARTICIPATED IN THE MARATHON, AND 4 WORKED AT THE FREEDOM FEST. PRIORITY 2: PREVENTIVE CARE AND MANAGEMENT IN 2016, GOOD SAMARITAN HOSPITAL HOSTED A FREE "OPEN YOUR HEART TO HEALTH" EVENT AT WESTFIELD SOUTH SHORE MALL IN BAY SHORE IN PROXIMITY TO MEDICALLY UNDERSERVED COMMUNITIES. MORE THAN 500 COMMUNITY MEMBERS HAD THE OPPORTUNITY TO TALK TO CARDIOLOGISTS, REGISTERED DIETITIANS, CARDIOLOGY TECHNOLOGISTS, AND NURSES OFFERING INFORMATION ON CARDIAC HEALTH AND PREVENTION IN ADDITION TO BLOOD PRESSURE, PULMONARY FUNCTION AND CHOLESTEROL SCREENINGS. CHOLESTEROL SCREENINGS WERE PROVIDED TO 95 INDIVIDUALS; 45 HAD ABNORMAL ELEVATED RESULTS AND WERE REFERRED TO THEIR PHYSICIANS FOR FOLLOW-UP CARE. BMI SCREENINGS WERE PROVIDED TO 67 INDIVIDUALS AND 71 BLOOD PRESSURE SCREENINGS WERE PROVIDED. ELEVEN INDIVIDUALS HAD ELEVATED BLOOD PRESSURE AND WERE REFERRED TO THEIR PHYSICIAN FOR FOLLOW-UP CARE. FLU VACCINATIONS WERE PROVIDED TO 19 ADULTS. IN 2016, HEALTH CARE PROFESSIONALS PARTICIPATED IN FREE, COMMUNITY-BASED SCREENINGS FOR CHOLESTEROL AND HIGH BLOOD PRESSURE HELD AT LOCAL LIBRARIES, STREET FAIRS AND FESTIVALS, AND COMMUNITY AND HOSPITAL-BASED HEALTH FAIRS. A TOTAL OF 429 SCREENINGS WERE PROVIDED, INCLUDING 51 BLOOD PRESSURE SCREENINGS AT THE WEST ISLIP LIBRARY, CONDUCTED ON THE FIRST WEDNESDAY OF EACH MONTH. IN JANUARY 2016, IN CONJUNCTION WITH THE SUFFOLK COUNTY DEPARTMENT OF HEALTH (SCDOH), GOOD SAMARITAN OFFERED "LEARN TO BE TOBACCO FREE," A SIX-WEEK SMOKING CESSATION PROGRAM, AT THE LONG ISLAND CANCER HELP AND WELLNESS CENTER IN BAY SHORE. OF THE 12 WHO ATTENDED, 10 WERE CERTIFIED (ATTENDING 4 OUT OF THE 6 CLASSES) AND 5 QUIT SMOKING AS OF THE LAST SESSION, ESTABLISHING A 50% QUIT RATE. CONTACT INFORMATION FOR THE SCDOH WAS MADE AVAILABLE TO PARTICIPANTS FOR ADDITIONAL ASSISTANCE WITH SMOKING CESSATION. GOOD SAMARITAN HOSPITAL OFFERED FREE COMMUNITY LECTURES HIGHLIGHTING NUTRITION AND CARDIOLOGY, AND PROVIDED SPEAKERS AND INFORMATION ON THE IMPORTANCE OF NUTRITION, HEART HEALTH, AND DIABETES. FREE BMI AND BLOOD PRESSURE SCREENINGS WERE OFFERED. A TOTAL OF 109 BLOOD PRESSURE AND 32 BMI SCREENINGS WERE PROVIDED AT THE COMMUNITY LECTURES. GOOD SAMARITAN STAFF VOLUNTEERED AT CHS HEALTHY SUNDAYS COMMUNITY OUTREACH EVENTS HELD IN UNDERSERVED CHURCHES, OFFERING FREE HEALTH SCREENINGS AND PROVIDING EDUCATIONAL MATERIALS ON PREVENTIVE HEALTH. IN 2016, 8 EVENTS WERE HELD WITH 408 SCREENINGS, INCLUDING 166 BLOOD PRESSURE, 215 CHOLESTEROL, 87 BMI, AND 142 FLU VACCINATIONS. REFERRALS FOR FREE FOLLOW-UP CARE AT THE BISHOP MCHUGH HEALTH CENTER WERE DELIVERED TO 24 INDIVIDUALS. IN 2016, A FAMILY WELLNESS FAIR WAS HELD FOCUSING ON WOMEN AND CHILDRENS HEALTH. HEALTH EDUCATION MATERIAL WAS GIVEN TO ALL ATTENDEES. GOOD SAMARITAN HOSPITAL POSTS EDUCATIONAL VIDEOS ON YOUTUBE.COM/GSHMC ON VARIOUS TOPICS SUCH AS GENETIC COUNSELING, COLON CANCER PREVENTION AND DIAGNOSIS, AND OTHERS. IN 2016, GOOD SAMARITAN HOSPITAL OFFERED A FREE CARDIAC REHABILITATION SUPPORT GROUP AND A PULMONARY DISEASE SUPPORT GROUP. FREE GOOD SAM UNIVERSITY COMMUNITY LECTURES WERE OFFERED IN 2016. THERE WERE 601 ATTENDEES AT 6 WORKSHOPS/LECTURES ON TOPICS, INCLUDING "TAKE THE BREAST CARE OF YOURSELF," "WHATS IN YOUR GENES?CANCER. PRIORITY 3: MENTAL HEALTH THE HOSPITAL IS PROVIDING TARGETED POPULATIONS WITH INFORMATION ABOUT THE SIGNS AND SYMPTOMS OF MENTAL HEALTH AND SUBSTANCE ABUSE ISSUES (OFTEN OCCURRING CONCOMITANTLY WITH A CHRONIC DISEASE) AND OFFERING LINKS TO COMMUNITY-BASED CLINICAL PROGRAMS AND SERVICES. WHEN A LACK OF ACCESS TO MENTAL HEALTH RESOURCES IS IDENTIFIED, GOOD SAMARITAN HOSPITAL PROVIDES INFORMATION ON AND REFERS PATIENTS TO THE EXTENSIVE MENTAL HEALTH SERVICES AVAILABLE WITHIN CHS AND ITS PARTNERS. IF NOT AVAILABLE WITHIN CHS, GOOD SAMARITAN HOSPITAL WILL USE LIHCS DATABASE TO IDENTIFY OR RECOMMEND A SUITABLE OPTION. THE NEW CHS MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES GUIDE IS AVAILABLE THROUGHOUT THE HOSPITAL AND AT ALL GOOD SAMARITAN HOSPITAL OUTREACH EVENTS. PART V, SECTION B, LINE 20E GOOD SAMARITAN HOSPITAL MEDICAL CENTER HAS POSTED MULTILINGUAL NOTICES ABOUT ITS CHARITY CARE POLICIES IN SEVERAL PROMINENT LOCATIONS WITHIN GOOD SAMARITAN HOSPITAL MEDICAL CENTER, INCLUDING, BUT NOT LIMITED TO, THE EMERGENCY DEPARTMENT, BILLING OFFICE, WAITING ROOMS FOR PURPOSES OF ADMISSIONS, AND THE INPATIENT AND OUTPATIENT REGISTRATION AREA. SAID NOTICES ARE PUBLISHED IN ENGLISH AND SPANISH AND ARE CLEARLY VISIBLE TO THE PUBLIC. GOOD SAMARITAN HOSPITAL MEDICAL CENTER HAS POSTED ITS CHARITY CARE POLICY SUMMARY ON ITS WEBSITE. 1 GOOD SAMARITAN NURSING HOME 101 ELM STREET SAYVILLE NY 11782 SKILLED NURSING FACILITY PART I, LINE 7 - RATIO OF PATIENT CARE COST TO CHARGES WORKSHEET RATIO OF PATIENT CARE COST TO CHARGES WORKSHEET (WORKSHEET 2 ) AS PRESCRIBED BY THE IRS INSTRUCTIONS TO SCHEDULE H FORM 990 WAS THE METHODOLOGY USED TO CALCULATE THE AMOUNTS REPORTED IN PART I, LINE 7 CHARITY CARE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST LINES 7A, 7B AND 7C AND 7D. ALL OTHER LINES INCLUDE COSTS THAT WERE DERIVED BASED ON THE RCC METHODOLOGY OR ACTUAL COSTS FOR THE SERVICES AS TRACKED BY HOSPITAL PERSONNEL UTILIZING DIRECT HOURLY LABOR COSTS, FRINGES AND SUPPLY COSTS. PART I, LINE 7A, COLUMN (D) DIRECT OFFSETTING REVENUES REPRESENT DISTRIBUTIONS FROM THE NEW YORK STATE (NYS) INDIGENT CARE POOL (ICP) WHICH IS SHOWN NET OF HOSPITAL CONTRIBUTIONS TO THE STATEWIDE POOL. THE FORMULA EMPLOYED BY NYS TO DETERMINE DISTRIBUTIONS TO HOSPITALS FROM THE ICP IS COMPLEX AND IS DERIVED FROM A HOSPITAL'S "NEED" CALCULATION. THIS CALCULATION CONSIDERS 100% OF A HOSPITAL'S "NEED" BASED ON A "UNITS OF SERVICE" METHODOLOGY FOR UNINSURED PATIENTS. THE CALCULATION ALSO MAKES ADJUSTMENTS BASED ON THE PROPORTION OF MEDICAID ELIGIBLE PATIENTS TREATED AT THE FACILITY. THE HOSPITAL HAS APPORTIONED THE ICP REVENUE BETWEEN BAD DEBT AND CHARITY CARE FOR REPORTING ON LINE 7A BASED ON THE PROPORTION OF EACH TO THE TOTAL OF ACTUAL BAD DEBT AND CHARITY CARE FOR 2016. PART III, LINE 2,3 - BAD DEBT AS COMMUNITY BENEFIT AS PART OF ITS TAX EXEMPT PURPOSE, GOOD SAMARITAN HOSPITAL MEDICAL CENTER PROVIDES ACCESS TO MEDICALLY NECESSARY CARE FOR EMERGENCY AND NON-ELECTIVE PATIENTS, REGARDLESS OF AGE, GENDER, GEOGRAPHIC LOCATION, OR CULTURAL BACKGROUND. GOOD SAMARITAN HOSPITAL MEDICAL CENTER TREATS EMERGENCY AND NON-ELECTIVE PATIENTS REGARDLESS OF WHETHER THEY HAVE THIRD-PARTY COVERAGE OR THE ABILITY TO PAY. BY PROVIDING HEALTH CARE TO ALL WHO REQUIRE EMERGENCY OR NON-ELECTIVE CARE IN A NON-DISCRIMINATORY MANNER, GOOD SAMARITAN HOSPITAL MEDICAL CENTER IS PROVIDING HEALTH CARE TO THE BROAD COMMUNITY IT SERVES. A PATIENT'S PORTION OF A BILL THAT REMAINS UNPAID FOR A CERTAIN STIPULATED TIME PERIOD IS WHOLLY OR PARTIALLY CLASSIFIED AS BAD DEBT. BAD DEBTS ASSOCIATED WITH PATIENTS WHO HAVE RECEIVED CARE FROM GOOD SAMARITAN HOSPITAL MEDICAL CENTER SHOULD BE CONSIDERED TO BE COMMUNITY BENEFIT SINCE CHARITABLE HOSPITALS EXIST TO PROVIDE SUCH CARE IN PURSUIT OF THEIR TAX EXEMPT PURPOSE, WHICH IS MEETING THE NEED FOR EMERGENCY AND NON-ELECTIVE MEDICAL CARE SERVICES IN THE COMMUNITY. PART III, LINES 2 AND 4 - TEXT OF FOOTNOTE DISCUSSING BAD DEBT THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING HISTORICAL BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE AND OTHER COLLECTION INDICATORS. MANAGEMENT PERIODICALLY ASSESSES THE ADEQUACY OF THIS ALLOWANCE BASED UPON HISTORICAL WRITE OFF EXPERIENCE BY PAYOR CATEGORY. THE RESULTS OF THESE REVIEWS ARE USED TO MODIFY, AS NECESSARY, THE PROVISION FOR BAD DEBTS AND TO ESTABLISH APPROPRIATE ALLOWANCES FOR UNCOLLECTIBLE PATIENT ACCOUNTS RECEIVABLE. AFTER SATISFACTION OF AMOUNTS DUE FROM INSURANCE, THE MEDICAL CENTER FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PATIENT BALANCES WITH COLLECTION AGENCIES, SUBJECT TO CERTAIN RESTRICTIONS ON COLLECTION EFFORTS AS DETERMINED BY CHS POLICY. ACCOUNT BALANCES ARE CHARGED OFF AGAINST THE ALLOWANCE AFTER ALL MEANS OF COLLECTION HAVE BEEN EXHAUSTED AND THE POTENTIAL FOR RECOVERY IS CONSIDERED REMOTE. THE HOSPITAL DOES NOT HAVE ANY OFF-BALANCE-SHEET CREDIT EXPOSURE RELATED TO ITS PATIENT ACCOUNTS RECEIVABLE. PART III, LINE 8 - COSTING METHODOLOGY THE MEDICARE REVENUE AND ALLOWABLE COSTS SHOWN ON PART III SECTION B LINE 5 WERE DERIVED FROM THE AS FILED 2016 CMS-2552 (MEDICARE COST REPORT). MEDICARE REVENUE IS BASED ON THE MEDICARE PROVIDER STATISTICAL AND REIMBURSEMENT REPORT AND MEDICARE COSTS ARE DEVELOPED UTILIZING A RATIO OF MEDICARE ALLOWABLE COSTS TO CHARGES METHODOLOGY. AMOUNTS SHOWN FOR TOTAL REVENUE RECEIVED AND MEDICARE ALLOWABLE COSTS ARE NET OF ANY AMOUNTS ALREADY INCLUDED WITHIN PART I, LINE 7, PRIMARILY IN SUBSIDIZED HEALTH SERVICES. PART III, LINE 8 - MEDICARE SHORTFALL AS COMMUNITY BENEFIT LOSSES ON TREATING MEDICARE BENEFICIARIES SHOULD BE INCLUDED AS A COMMUNITY BENEFIT IN THEIR ENTIRETY. THIS REPRESENTS THE AMOUNT BY WHICH COSTS TO DELIVER CARE TO MEDICARE RECIPIENTS EXCEEDS THE LEVEL OF PAYMENT. GOOD SAMARITAN BEARS THE BURDEN OF NOT ONLY PROVIDING THE BEST AND MOST ADVANCED MEDICAL CARE POSSIBLE TO THE COMMUNITY BUT ALSO DOING SO WITH NO RECOURSE IN OBTAINING PAYMENT FOR THE COST OF PROVIDING CARE IN EXCESS OF THE MEDICARE PAYMENT. AS MEDICARE REVENUE DECLINES AND THE COST TO PROVIDE CUTTING-EDGE CARE TO THE COMMUNITY INCREASES, THE HOSPITAL WILL CARRY THE BURDEN. AS A PARTICIPATING PROVIDER AND A CHARITABLE ORGANIZATION, MEDICARE PATIENTS, THE MAJORITY OF WHOM ARE ELDERLY AND DISABLED ARE NOT TURNED AWAY. GOOD SAMARITAN WILL CONTINUE TO BEAR THE LOSS IN PROVIDING THE BEST CARE POSSIBLE TO THE LOCAL COMMUNITY. PART III, LINE 9B THE HOSPITAL'S CHARITY CARE POLICY DESCRIBES THE POLICIES AND PROCEDURES RELATING TO THE PROVISION OF CHARITY CARE TO PERSONS WHO ARE UNABLE TO PAY FOR ALL OR A PORTION OF THEIR BILL. NO INDIVIDUAL WILL BE DENIED MEDICALLY NECESSARY HOSPITAL SERVICES BASED ON A DEMONSTRATED INABILITY TO PAY FOR THOSE SERVICES. IN ADDITION, UPON APPLYING FOR CHARITY CARE, EACH PATIENT AND PATIENT GUARANTOR'S ABILITY TO PAY WILL BE ASSESSED. ELIGIBILITY FOR ASSISTANCE: A REASONABLE REVIEW SHALL BE PERFORMED PRIOR TO TURNING AN ACCOUNT OVER TO A THIRD-PARTY COLLECTION AGENT AND PRIOR TO INSTITUTING ANY LEGAL ACTION FOR NON-PAYMENT, TO ASSURE THAT THE PATIENT AND PATIENT GUARANTOR ARE NOT ELIGIBLE FOR ANY ASSISTANCE PROGRAM (I.E. MEDICAID) AND DO NOT QUALIFY FOR COVERAGE THROUGH THE CHS CHARITY CARE POLICY. AFTER HAVING BEEN TURNED OVER TO A THIRD-PARTY COLLECTION AGENT, ANY ACCOUNT THAT SUBSEQUENTLY IS DETERMINED TO MEET THE CHARITY CARE CRITERIA SHALL BE RETURNED IMMEDIATELY BY THE THIRD-PARTY COLLECTION AGENT FOR APPROPRIATE FOLLOW-UP. THE THIRD-PARTY COLLECTION AGENT SHALL ADVISE THE PATIENT/GUARANTOR OF THE HOSPITAL'S CHARITY CARE POLICY AND RETURN THE ACCOUNT IMMEDIATELY IF IT IS DETERMINED THAT THE QUALIFICATIONS ARE MET. PART VI, LINE 2 - ASSESSMENT OF COMMUNITY NEEDS AND GOALS COMMUNITY HEALTH NEEDS ARE ASSESSED ON A CONTINUAL BASIS, DURING MEETINGS OF THE HOSPITAL'S COMMUNITY HEALTH AND EDUCATION DEPARTMENT MEETINGS, AT COLLABORATIVE SESSIONS WITH MEMBER HOSPITALS OF CATHOLIC HEALTH SERVICES OF LONG ISLAND (CHS), AND WITH PARTNERS AT COMMUNITY AGENCIES AND ORGANIZATIONS THAT ARE PART OF THE LONG ISLAND HEALTH COLLABORATIVE (LIHC). THE LIHC COMMUNITY HEALTH ASSESSMENT SURVEYS ARE OFFERED YEAR-ROUND AT MULTIPLE OUTREACH SITES IN THE COMMUNITY. BY DISTRIBUTING COMMUNITY NEEDS SURVEYS (AVAILABLE IN ENGLISH, SPANISH, POLISH, AND HAITAIN CREOLE) TO PARTICIPANTS AT SCREENING SITES, EVERY POINT OF CONTACT SERVES AS AN OPPORTUNITY TO REQUEST FEEDBACK ON HOW THE HOSPITAL CAN BETTER MEET THE NEEDS OF THE COMMUNITY. THESE EVENTS ARE PROMOTED IN THE COMMUNITY SURROUNDING THE OUTREACH SITE AND ON CHS'S WEBSITE. GOOD SAMARITAN HOSPITAL CONTINUES TO COLLABORATE WITH OTHER HOSPITALS, LOCAL HEALTH DEPARTMENTS, HEALTH CARE PROVIDERS, PUBLIC HEALTH SPECIALISTS FROM ACADEMIC INSTITUTIONS, AND COMMUNITY-BASED ORGANIZATIONS AT LIHC EVENTS. LIHC'S WEBSITE OFFERS COMPREHENSIVE INFORMATION TO PROMOTE GOOD HEALTH AND PREVENT CHRONIC DISEASE. IN ADDITION TO PROVIDING NUMEROUS RESOURCES SUCH AS HEALTH PROGRAM INVENTORIES, HEALTH INSURANCE INFORMATION AND EDUCATIONAL VIDEOS, LIHC AND ITS MEMBERS HAVE ORGANIZED WALKING PROGRAMS, AND DEVELOPED A UNIVERSAL SCREENING TOOL TO HELP MEASURE THE EFFECTIVENESS OF COMMUNITY HEALTH EFFORTS. MORE INFORMATION CAN BE FOUND AT WWW.LIHEALTHCOLLAB.ORG. ADDITIONALLY, COMMUNITY NEEDS SURVEYS ARE COMPLETED BY PARTICIPANTS ATTENDING THE HOSPITAL'S HEALTH SCREENINGS AT LIBRARIES AND SENIOR CENTERS THROUGHOUT THE COUNTY. PART VI, LINE 3 - COMMUNICATION OF FINANCIAL ASSISTANCE POLICY 1. SINCE IT IS THE DUTY OF THE MEDICAL CENTER TO ENSURE THAT EVERY PATIENT IS MADE AWARE OF THE EXISTENCE OF THE MEDICAL CENTER'S CHARITY CARE POLICY, ALL EMPLOYEES IN THE SCHEDULING, PATIENT ACCESS, PATIENT FINANCIAL SERVICES AND EMERGENCY DEPARTMENTS HAVE BEEN FULLY VERSED IN THE MEDICAL CENTER'S CHARITY CARE POLICY, HAVE ACCESS TO THE CHARITY CARE APPLICATION FORMS, AND ARE ABLE TO DIRECT QUESTIONS TO THE APPROPRIATE HOSPITAL REPRESENTATIVES. 2. THE MEDICAL CENTER HAS POSTED MULTILINGUAL NOTICES AS TO ANY POLICIES ON CHARITY CARE IN SEVERAL PROMINENT LOCATIONS WITHIN THE MEDICAL CENTER INCLUDING, BUT NOT LIMITED TO, THE EMERGENCY DEPARTMENT, BILLING OFFICE, WAITING ROOMS FOR PURPOSES OF ADMISSIONS, AND THE INPATIENT AND OUTPATIENT REGISTRATION AREA. SAID NOTICES ARE PUBLISHED IN ENGLISH AND SPANISH, AND ARE CLEARLY VISIBLE TO THE PUBLIC FROM THE LOCATION AT WHICH THEY ARE POSTED. 3. THE MEDICAL CENTER PROVIDES PATIENTS, IN A TIMELY MANNER, A SUMMARY OF ITS CHARITY CARE POLICY UPON REQUEST. THE SUMMARY, AT A MINIMUM, PROVIDES SPECIFIC INFORMATION AS TO INCOME LEVELS USED TO DETERMINE ELIGIBILITY AND THE MEANS OF APPLYING FOR ASSISTANCE. THIS SUMMARY IS WRITTEN AT OR BELOW A SIXTH GRADE READING LEVEL. 4. THE MEDICAL CENTER HAS POSTED ITS CHARITY CARE POLICY SUMMARY ON ITS WEBSITE. 5. THE MEDICAL CENTER PROVIDES ALL PATIENTS ACCESS TO INTERPRETERS TO ASSIST THEM IN UNDERSTANDING THE MEDICAL CENTER'S CHARITY CARE PROGRAM IN THE LANGUAGE SPOKEN BY THE PATIENT DURING ANY PRE-ADMISSION, ADMISSION, AND DISCHARGE PROCESS. 6. ON ALL BILLS AND STATEMENTS SENT TO PATIENTS, INFORMATION IS INCLUDED REGARDING THE AVAILABILITY OF VARIOUS FINANCIAL ASSISTANCE PROGRAMS, INCLUDING CHARITY CARE, AND A CONTACT NUMBER TO CALL TO OBTAIN FURTHER DETAILS. THIS INFORMATION IS AVAILABLE AT OR BELOW A SIXTH GRADE READING LEVEL. PART VI, LINE 4 - COMMUNITY INFORMATION GOOD SAMARITANS PRIMARY SERVICE AREA INCLUDES: AMITYVILLE, BABYLON, NORTH BABYLON, WEST BABYLON, BAY SHORE, BRENTWOOD, COPIAGUE, DEER PARK, LINDENHURST, WEST ISLIP, CENTRAL ISLIP, EAST ISLIP, SAYVILLE, OAKDALE, AND WYANDANCH. THE SECONDARY CATCHMENT AREA COMPRISES BRIGHTWATERS, MASSAPEQUA, ISLIP TERRACE, BOHEMIA, DIX HILLS, PATCHOGUE, AND RONKONKOMA. THE MAJORITY OF THE SERVICE AREA POPULATION AGE IS 35 YEARS AND OLDER. THE SERVICE AREA POPULATION HAS A LIMITED ENGLISH PROFICIENCY RATE OF 16.52%, WHICH IS HIGHER THAN THAT OF SUFFOLK COUNTY AND NYS, AND REFLECTS THE SELECT, UNDERSERVED COMMUNITIES OF BAY SHORE, WYANDANCH, BRENTWOOD, AND CENTRAL ISLIP. THE TARGETED POPULATION ALSO INDICATES HIGHER RATES OF OBESITY WHEN COMPARED TO THE STATE. PART VI, LINE 5 - PROMOTION OF COMMUNITY HEALTH GOOD SAMARITAN HOSPITAL MEDICAL CENTER (GOOD SAMARITAN) IS A NOT-FOR-PROFIT COMPREHENSIVE HEALTH CARE FACILITY RENDERING INPATIENT, AMBULATORY, AND EMERGENCY MEDICAL CARE TO THE COMMUNITY. IN ADDITION, GOOD SAMARITAN OPERATES A NURSING HOME AND THE BISHOP MCHUGH HEALTH CENTER IN BABYLON, WHICH CARES FOR MEDICALLY UNDESERVED RESIDENTS. IN 2016, THE HEALTH CENTER HAD SEVERAL HUNDRED PATIENT VISITS. GOOD SAMARITAN HOLDS AN ANNUAL CANCER SURVIVORS' DAY IN NOVEMBER WITH HUNDREDS OF PARTICIPANTS ATTENDING. THE EVENT HONORS CANCER SURVIVORS AND THEIR FAMILIES FOR THEIR STRENGTH AND COURAGE AND THE CONTRIBUTIONS OF THEIR FAMILIES AND FRIENDS. GOOD SAMARITAN'S CANCER SURVIVORS' DAY IS DESIGNED TO BRING TOGETHER PEOPLE WHOSE LIVES HAVE BEEN TOUCHED BY CANCER, AND TO PROVIDE INSPIRATION AND HOPE FOR LIFE AFTER A DIAGNOSIS OF CANCER. GOOD SAMARITAN CONTINUES TO OFFER A CHILD PASSENGER SAFETY PROGRAM TO PROMOTE THE PROPER INSTALLATION OF CHILD SAFETY SEATS AND BOOSTER SEATS. GOOD SAMARITAN SERVES AS A COMMUNITY RESOURCE FOR CHILD PASSENGER SAFETY AND PROVIDES EDUCATION TO PARENTS BY APPOINTMENT ON PROPER TECHNIQUES FOR TRANSPORTING CHILDREN, ALONG WITH FREE CHILD SAFETY SEAT CHECKS. GOOD SAMARITAN HOSTS BLOOD DRIVES THROUGHOUT THE YEAR. DONORS INCLUDE GOOD SAMARITAN STAFF AND COMMUNITY MEMBERS. ALSO, GOOD SAMARITAN CONDUCTS HEALTH FAIRS AT LOCAL SCHOOLS, SENIOR CENTERS, AND OTHER VENUES, PROVIDING FREE CHOLESTEROL, BLOOD PRESSURE, AND OTHER SCREENINGS AS WELL AS EDUCATIONAL INFORMATION TO THE COMMUNITY. "LEARN TO BE TOBACCO FREE", BREATHE FREELY INFORMATION REGARDING THE HOSPITALS SMOKING CESSATION PROGRAMS, OFFERED SEVERAL TIMES A YEAR, APPEARS IN THE COMMUNITY NEWSLETTER AND ON THE HOSPITALS WEBSITE. EDUCATIONAL MATERIAL ON THIS TOPIC IS AVAILABLE AT COMMUNITY LECTURES AND OTHER OUTREACH EVENTS. INPATIENTS IDENTIFIED AS SMOKERS DURING ASSESSMENT RECEIVE EDUCATION ON SMOKING CESSATION, BROCHURES, COUNSELLING RESOURCES, AND REFERRALS TO SUPPORT GROUPS. MEDICATION PATCHES FOR SYMPTOM RELIEF ARE ALSO OFFERED. VICTIMS OF SEXUAL ASSAULT HAVE SPECIAL AND SERIOUS MEDICAL NEEDS THAT MUST BE ADDRESSED PROMPTLY, WITH EXPERTISE AND SENSITIVITY, WHILE SIMULTANEOUSLY ENSURING THE ACCURATE AND APPROPRIATE COLLECTION OF FORENSIC EVIDENCE. TO THAT END, GOOD SAMARITAN DEVELOPED THE SEXUAL ASSAULT FORENSIC EXAMINER PROGRAM (SAFE). THE SAFE CENTER IS AN EXTENSION OF THE EMERGENCY DEPARTMENT, PROVIDING A PRIVATE AND SUPPORTIVE SETTING TO ALL VICTIMS TO ENSURE THE PROPER EVALUATION, TREATMENT, AND REFERRAL FOR FOLLOW UP. IN ADDITION, APPROPRIATE EVIDENCE COLLECTION AND DOCUMENTATION IS ALSO COMPLETED IN THIS SETTING. HEALTH REFERRAL LINE IN 2016, THERE WERE A TOTAL OF 21,639 RECORDED REQUESTS BY THE COMMUNITY REGARDING PHYSICIAN REFERRALS, SPECIALTY DEPARTMENT AND SERVICES INFORMATION, COMMUNITY LECTURES, HEALTH AND WELLNESS FAIRS, HEALTH SCREENINGS, AND SPECIAL EVENTS. GOOD SAMARITAN HOSPITAL MEDICAL CENTER PARTICIPATES IN THE COMPREHENSIVE CARE FOR JOINT REPLACEMENT (CJR) MODEL. THE CJR MODEL AIMS TO SUPPORT BETTER AND MORE EFFICIENT CARE FOR BENEFICIARIES UNDERGOING THE MOST COMMON INPATIENT SURGERIES FOR MEDICARE BENEFICIARIES: HIP AND KNEE REPLACEMENTS (ALSO CALLED LOWER EXTREMITY JOINT REPLACEMENTS ON LEJR). PART VI, LINE 6 - AFFILIATED HEALTHCARE SYSTEM GOOD SAMARITAN HOSPITAL MEDICAL CENTER (GOOD SAMARITAN) IS AN ACUTE CARE HOSPITAL WHICH IS LOCATED ON A SINGLE CAMPUS IN WEST ISLIP, NY, AND A SKILLED NURSING FACILITY ON A SEPARATE CAMPUS IN SAYVILLE, NY. ALONG WITH THE AFOREMENTIONED COMMUNITY PROGRAMS, GOOD SAMARITAN THROUGH ITS DAILY OPERATIONS, PROVIDES TO THE AREA ACUTE, EMERGENT, AND OUTPATIENT CARE. GOOD SAMARITAN IS A MEMBER OF CATHOLIC HEALTH SYSTEM OF LONG ISLAND (D/B/A/ CATHOLIC HEALTH SERVICES OF LONG ISLAND)(CHS), WHICH IS A NEW YORK, NOT-FOR-PROFIT CORPORATION ORGANIZED TO SERVE AS THE COORDINATING BODY OF AN INTEGRATED NETWORK OF PROVIDERS SERVING NASSAU AND SUFFOLK COUNTIES. CHS IS SPONSORED BY THE ROMAN CATHOLIC DIOCESE OF ROCKVILLE CENTRE. AS OF DECEMBER 31, 2016, CHS COMPRISED SIX HOSPITALS (MERCY MEDICAL CENTER, ST. FRANCIS HOSPITAL, AND ST. JOSEPH HOSPITAL IN NASSAU COUNTY, AND GOOD SAMARITAN HOSPITAL MEDICAL CENTER, ST. CHARLES HOSPITAL, AND ST. CATHERINE OF SIENA MEDICAL CENTER IN SUFFOLK COUNTY), AS WELL AS THREE NURSING HOMES (ST. CATHERINE OF SIENA NURSING AND REHABILITATION CARE CENTER, GOOD SAMARITAN NURSING HOME, AND OUR LADY OF CONSOLATION NURSING AND REHABILITATIVE CARE CENTER, ALL IN SUFFOLK COUNTY), A REGIONAL HOME CARE AND HOSPICE NETWORK, AND A COMMUNITY-BASED AGENCY FOR PERSONS WITH SPECIAL NEEDS. WITH MORE THAN 17,500 STAFF AND 4,300 MEDICAL STAFF WORKING THROUGHOUT THE SYSTEM, CHS PROVIDES THE REGION'S FINEST HEALTH AND HUMAN SERVICES. OUR MISSION STATES: CATHOLIC HEALTH SERVICES OF LONG ISLAND (CHS), AS A MINISTRY OF THE CATHOLIC CHURCH, CONTINUES CHRIST'S HEALING MISSION, PROMOTES EXCELLENCE IN CARE AND COMMITS ITSELF TO THOSE IN NEED. CHS AFFIRMS THE SANCTITY OF LIFE, ADVOCATES FOR THE POOR AND UNDERSERVED, AND SERVES THE COMMON GOOD. IT CONDUCTS ITS HEALTH CARE PRACTICE, BUSINESS, EDUCATION AND INNOVATION WITH JUSTICE, INTEGRITY AND RESPECT FOR THE DIGNITY OF EACH PERSON. MEMBER ORGANIZATIONS OF CHS OFFER VIRTUALLY EVERY MEDICAL SPECIALTY AND CLINICAL SERVICE, AND SHARE A DEDICATION TO CONTINUOUSLY UPGRADE THE SCOPE, QUALITY AND ACCESSIBILITY OF CARE. ALL OF CHS'S MEMBER ORGANIZATIONS HAVE RETAINED THEIR INDIVIDUAL LINKS TO THEIR HISTORY AND THEIR DISTINCTIVE PERSONALITIES, AS WELL AS THE SERVICE SPECIALTIES WHICH THEY ARE KNOWN FOR, THUS EMBEDDING THE ORGANIZATION IN THE COMMUNITY AND SERVING IT EFFECTIVELY. CHS ENTITIES PROVIDE AN ABUNDANCE OF EDUCATION AND SUPPORT GROUPS, PROVIDES FREE HEALTH SCREENINGS THROUGH ITS HEALTHY SUNDAYS PROGRAMS, HEALTH FAIRS, AND OTHER PROGRAMS. SINCE 1907, CATHOLIC HEALTH SERVICES HAS BUILT A DISTINGUISHED TRADITION OF OPERATING COMMUNITY-BASED HOSPITALS AND HUMAN SERVICE ORGANIZATIONS WITH THE PRIMARY OBJECTIVE OF IMPROVING THE COMMUNITYS HEALTH. TO FURTHER THE MISSION OF BRINGING CARE TO THE COMMUNITY, CHS AND ITS MEMBER HOSPITALS, TOGETHER WITH A NUMBER OF OTHER HEALTH CARE PROVIDERS ON LONG ISLAND, ENTERED INTO A PARTNERSHIP AGREEMENT, WHICH OPERATES AS THE LONG ISLAND HEALTH NETWORK (LIHN). LIHN WAS CREATED TO ESTABLISH A COMPREHENSIVE AND EFFICIENT HOSPITAL NETWORK IN NASSAU AND SUFFOLK COUNTIES WORKING TO, AMONG OTHER THINGS, IMPROVE QUALITY OF CARE, FACILITATE CLINICAL INTEGRATION, BENCHMARK BEST PRACTICES AND REDUCE LENGTH OF STAY AND COSTS. true CATHOLIC HEALTH SERVICES OF LONG ISLAND 992 N VILLAGE AVE ROCKVILLE CNTR ROCKVILLE CENTRE NY 11570 113403968 501(C)(3) 1988114 NONE NONE OUTPATIENT CENTERS 1 PART I, LINE 2 - PROCEDURE FOR MONITORING GRANT FUND USE CHS SERVICES, A RELATED ENTITY, MAINTAINS THE BOOKS AND RECORDS FOR GOOD SAMARITAN HOSPITAL AND CATHOLIC HEALTH SERVICES OF LONG ISLAND AND IS THEREFORE ABLE TO MONITOR THAT CATHOLIC HEALTH SERVICES OF LONG ISLAND USES THE GRANT FUNDS FOR MISSION SPONSORSHIP, OUTPATIENT CENTERS, GRANTS TO UNDERSERVED COMMUNITIES AND CAPITAL SUPPORT. PART II, LINE 1, COLUMN (H) NAMES OF ORGANIZATION OR GOVERNMENT: CATHOLIC HEALTH SYSTEM OF LONG ISLAND (H) PURPOSE OF GRANT: 1) SUPPORT TO CATHOLIC HEALTH SYSTEM OF LONG ISLAND AS A PASS THROUGH TO PROVIDE GENERAL SUPPORT TO THE CATHOLIC MINISTRIES OF THE DIOCESE OF ROCKVILLE CENTRE IN CONNECTION WITH THE FORMATION OF YOUTH AND ADULTS IN THE FAITH, PROMOTION OF THE DIGNITY OF LIFE, PROMOTION OF QUALITY EDUCATION FOR YOUNG PEOPLE, AND FOSTERING OF VOCATIONS FOR THE PRIESTHOOD; 2) PROVIDE SUPPORT TO CATHOLIC HEALTH SYSTEM OF LONG ISLAND TO FUND OUTPATIENT CENTERS THAT PROVIDE CHARITY CARE TO THOSE CENTERS COMMUNITIES; AND 3) TO FUND SUPPORT PROVIDED THROUGH THE CATHOLIC HEALTH SERVICES OF LONG ISLAND CAREGIVERS FUND. THE CATHOLIC HEALTH SERVICES OF LONG ISLAND CAREGIVERS FUND WAS FORMED WITH THE MISSION TO ASSIST OUR FELLOW CAREGIVERS ON THE FRONT LINES, HERE AND ABROAD, WHO STRUGGLE JUST TO OBTAIN BASIC RESOURCES TO PROVIDE CARE TO THOSE DESPERATELY IN NEED. X X X X X X true true false false false false false false false ALAN D GUERCI MD PRESIDENT & CEO 0 1382345 0 410000 0 802720 0 327174 0 33273 0 2955512 0 767223 DANIEL DEBARBA EVP & CFO (EFFECTIVE 6/6/16) 0 460115 0 115000 0 16239 0 21174 0 16248 0 628776 0 0 THOMAS OCKERS EXEC VP & CAO 488637 0 0 0 7923 0 21969 0 10368 0 528897 0 0 0 NANCY SIMMONS CAO 29331 0 75000 0 2324 0 63445 0 1677 0 171777 0 0 0 DONALD TEPLITZ CHIEF MEDICAL OFFICER 509786 0 70000 0 2399 0 21969 0 29984 0 634138 0 0 0 NEIL LOBO PHYSICIAN 743128 0 350610 0 1242 0 21969 0 30088 0 1147037 0 0 0 KOUROSH ADHAMI PHYSICIAN 745505 0 350610 0 1242 0 21969 0 29776 0 1149102 0 0 0 BABAK DANESH PHYSICIAN 749500 0 313610 0 845 0 21969 0 1869 0 1087793 0 0 0 JAMES KOHLROSER PHYSICIAN 742598 0 350610 0 810 0 21969 0 32638 0 1148625 0 0 0 PANKAJ SINGHAL PHYSICIAN 969260 0 0 0 384 0 0 0 20292 0 989936 0 0 0 JEROME WEINER FORMER CHIEF MEDICAL OFFICER 0 0 0 0 525271 0 0 0 19283 0 544554 0 528441 0 WILLIAM C ARMSTRONG SVP FINANCE 0 665953 0 200000 0 686173 0 158174 0 30669 0 1740969 0 664661 PART I, LINE 4A - SEVERANCE PAYMENT Jerome Weiner, Former CMO, received payment of severance of $528,441 during 2016. Medical benefits were also included during 2016. PART I, LINE 4B - SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN The following individuals participated in the supplemental non-qualified retirement plan. The amounts below are included on Schedule J, Part II, Column C. Alan Guerci $306,000 participation in the plan William Armstrong $137,000 participation in the plan Nancy Simmons $61,000 Participation in the plan The deferred compensation in column C for these individuals includes both qualified and non-qualified retirement plans. The following individuals vested in the supplemental non-qualified retirement plan. The amounts below are included on Schedule J, Part II, Column B (III). These amounts include a tax gross up. Alan Guerci $767,223, vested in plan. William Armstrong $664,661, vested in plan. The amounts outlined herein were included in each individual's 2016 Form W-2, Box 5 as taxable wages because they are vested, but are not distributed until retirement. PART II - REPORTING OF TOP FINANCIAL OFFICIAL WILLIAM ARMSTRONG WAS REPORTED AS AN OFFICER IN 2015 AS THE TOP FINANCIAL OFFICIAL IN HIS ROLE AS INTERIM CFO. EFFECTIVE 6/6/16, DANIEL DEBARBA BECAME THE TOP FINANCIAL OFFICER AS CFO, AND WILLIAM ARMSTRONG RESUMED HIS ROLE AS SVP OF FINANCE. SOUTHWEST SUFFOLK MEDICAL PC SEE PART V 4616362 SEE PART V SAMARITAN MEDICAL SERVICES PC SEE PART V 3101105 SEE PART V CARDIAC EKG INTERPRETATION PC SEE PART V 522200 SEE PART V SCHEDULE L, PART IV, LINE (1) COLUMN (B) RELATIONSHIP Entity more than 35% owned by Donald Teplitz, Key Employee. SCHEDULE L, PART IV, LINE (1) COLUMN (D) DESCRIPTION OF TRANSACTION Subsidy for PC operating losses. SCHEDULE L, PART IV, LINE (2) COLUMN (B) RELATIONSHIP Entity more than 35% owned by Donald Teplitz, Key Employee. SCHEDULE L, PART IV, LINE (2) COLUMN (D) DESCRIPTION OF TRANSACTION Subsidy for PC operating losses. SCHEDULE L, PART IV, LINE (3) COLUMN (B) RELATIONSHIP Entity more than 35% owned by Donald Teplitz, Key Employee. SCHEDULE L, PART IV, LINE (3) COLUMN (D) DESCRIPTION OF TRANSACTION Subsidy for PC operating losses. FORM 990, PART VI, LINE 6 - MEMBERS OF THE ORGANIZATION THE SOLE MEMBER OF GOOD SAMARITAN HOSPITAL IS CATHOLIC HEALTH SYSTEM OF LONG ISLAND, (D/B/A/ CATHOLIC HEALTH SERVICES OF LONG ISLAND)(CHS). CHS IS A NEW YORK NOT-FOR-PROFIT CORPORATION ORGANIZED TO SERVE AS THE COORDINATING BODY OF AN INTEGRATED NETWORK OF HEALTHCARE PROVIDERS. CHS IS SPONSORED BY THE ROMAN CATHOLIC DIOCESE OF ROCKVILLE CENTER (DIOCESE). FORM 990, PART VI, LINE 7A - ELECTION OF THE GOVERNING BODY CHS IS THE SOLE MEMBER AND ESTABLISHED CO-OPERATOR OF GOOD SAMARITAN HOSPITAL MEDICAL CENTER, AND AS SUCH HAS THE RIGHT TO APPOINT THE GOVERNING BODY. FORM 990, PART VI, LINE 7B - DECISIONS OF THE GOVERNING BODY AS THE SOLE MEMBER OF GOOD SAMARITAN HOSPITAL MEDICAL CENTER, CHS IS REQUIRED TO APPROVE CERTAIN DECISIONS MADE BY THE GOVERNING BODY OF GOOD SAMARITAN HOSPITAL. THE GOVERNING BODY OF GOOD SAMARITAN HOSPITAL IS THE SAME AS THAT OF CHS. FORM 990, PART VI, LINE 11B - REVIEW PROCESS FOR FORM 990 THE FORM 990 AND RELATED SCHEDULES ARE COMPLETED BY OUTSIDE TAX ADVISORS AND REVIEWED INTERNALLY BY MANAGEMENT. THE FINAL DRAFT OF THE FORM 990 IS THEN PROVIDED TO ALL VOTING MEMBERS OF THE BOARD, AND PRESENTED TO THE COMPLIANCE AND AUDIT COMMITTEE (THE COMMITTEE) OF THE BOARD OF DIRECTORS OF CHS, WHICH HAS BEEN DELEGATED THE FORM 990 REVIEW FUNCTION BY THE BOARD. UPON REVIEW AND RECOMMENDATION OF THE COMMITTEE, THE FORM 990 IS THEN SENT TO THE BOARD FOR APPROVAL. UPON BOARD APPROVAL, THE FORM 990 IS SUBMITTED TO THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, LINE 12C - CONFLICT OF INTEREST DISCLOSURE IN ACCORDANCE WITH THE CONFLICT OF INTEREST POLICY (THE POLICY) BY BOARD AND BOARD COMMITTEE MEMBERS, EMPLOYEES AND OTHERS THAT SATISFY THE CRITERIA TO BE CONSIDERED AN INTERESTED PERSON IS SUBMITTED UPON HIRE OR APPOINTMENT AND ANNUALLY THEREAFTER. SUCH INDIVIDUALS HAVE A CONTINUING OBLIGATION TO UPDATE THE INFORMATION PROVIDED DURING THE COURSE OF THE YEAR. A SUMMARY OF DISCLOSURES IS PROVIDED TO THE CHS COMPLIANCE AND AUDIT COMMITTEE BY CHS' COMPLIANCE OFFICER. ALL DISCLOSURES ARE INVESTIGATED AND INFORMATION RELATED TO THE DISCLOSURE IS GATHERED AND SUMMARIZED AND INCLUDED WITH THE SUMMARY OF DISCLOSURES. UPON REVIEW OF THE SUMMARY OF DISCLOSURES, THE CHS COMPLIANCE AND AUDIT COMMITTEE SHALL REPORT ITS FINDINGS TO THE CHS BOARD OF DIRECTORS. THE BOARD SHALL DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS BASED ON THE CRITERIA CONTAINED IN THE POLICY. IF A CONFLICT OF INTEREST IS IDENTIFIED AND A MAJORITY OF THE BOARD OR BOARD COMMITTEE AGREES THAT THE TRANSACTION OR ARRANGEMENT IS IN THE BEST INTEREST OF CHS AND WISHES TO GO FORWARD WITH IT, THE CHAIR OF THE BOARD OF DIRECTORS SHALL PROVIDE A WRITTEN REQUEST TO THE CHAIR OF THE CHS COMPLIANCE AND AUDIT COMMITTEE, DELINEATING THE TRANSACTION AND CONFLICT AND PROVIDING REASONS WHY THE BOARD AGREES THAT THE TRANSACTION OR ARRANGEMENT IS IN THE BEST INTEREST OF CHS, CERTIFIES THAT CHS CANNOT SECURE SIMILAR SERVICES FROM AN ORGANIZATION WITHOUT A CONFLICT, AND WISHES TO GO FORWARD WITH IT. THE PERSON DETERMINED TO HAVE A CONFLICT OF INTEREST MUST RECUSE HIM/HERSELF FROM ANY DECISION MAKING OR VOTING ON THE INTEREST THAT GAVE RISE TO THE CONFLICT. FORM 990, PART VI, LINE 15 - COMPENSATION POLICY THE CHIEF ADMINISTRATIVE OFFICER SUBMITS FOR APPROVAL TO THE SYSTEM CEO RECOMMENDATIONS FOR BASE SALARY ADJUSTMENTS AND INCENTIVE AWARDS FOR "DISQUALIFIED PERSONS" AS DEFINED IN THE CHS EXECUTIVE COMPENSATION POLICY (COMPENSATION POLICY). THE COMPENSATION POLICY DEFINES A "DISQUALIFIED PERSON" AS A PERSON IN A POSITION TO EXERCISE SUBSTANTIAL INFLUENCE OVER THE AFFAIRS OF CHS OR AN OPERATING ENTITY, AND IS EITHER A) A VOTING MEMBER OF THE BOARD OF DIRECTORS OR BOARD OF TRUSTEES; B) THE ENTITY'S PRESIDENT, CHIEF EXECUTIVE OFFICER (CEO), AND CHIEF OPERATING OFFICERS (COO) OR PERSONS HOLDING EQUIVALENT POSITIONS; C) THE ENTITY'S TREASURERS AND CHIEF FINANCIAL OFFICERS (CFO); D) THE PERSON'S COMPENSATION IS PRIMARILY BASED ON REVENUES DERIVED FROM ACTIVITIES OF CHS OR AN OPERATING ENTITY, OR OF A PARTICULAR DEPARTMENT OR FUNCTION OF CHS OR AN OPERATING ENTITY, THAT THE PERSON CONTROLS; E) THE PERSON HAS OR SHARES AUTHORITY TO CONTROL OR DETERMINE A SUBSTANTIAL PORTION OF CHS OR AN OPERATING ENTITY'S CAPITAL EXPENDITURES, OPERATING BUDGET, OR COMPENSATION FOR OTHER EMPLOYEES; F) THE PERSON MANAGES A DEPARTMENT OR ACTIVITY OF CHS OR AN OPERATING ENTITY THAT REPRESENTS A SUBSTANTIAL PORTION OF THE ACTIVITIES, ASSETS, INCOME, OR EXPENSES OF CHS OR AN OPERATING ENTITY, COMPARED TO THE ORGANIZATION AS A WHOLE; OR G) FAMILY MEMBERS OF ANY OF THOSE DESCRIBED IN THE PRECEDING D, E, OR F. ONCE APPROVED BY THE CHS CEO, THESE RECOMMENDATIONS ARE SENT TO THE EXECUTIVE COMPENSATION COMMITTEE OF THE CHS BOARD OF DIRECTORS FOR REVIEW. THE EXECUTIVE COMPENSATION COMMITTEE, WITH AN INDEPENDENT COMPENSATION CONSULTANT ENGAGED BY THE BOARD, WILL REVIEW PROPOSED SALARY ADJUSTMENTS AND INCENTIVE AWARDS TO ENSURE REASONABLENESS BY REVIEWING COMPARABLE TOTAL COMPENSATION DATA (INCLUDING INCENTIVES) PAID TO SIMILARLY SITUATED EXECUTIVES AT THE MEDIAN OF THE DEFINED MARKETPLACE WITH POSSIBLE ADJUSTMENT MADE FOR SPECIAL SKILL, EXPERIENCE, COMPETENCE AND PERFORMANCE, INCLUDING CONTRIBUTION TO THE SYSTEM AS A WHOLE. REVIEWS ARE PERFORMED ANNUALLY BY AN INDEPENDENT CONSULTANT. THE COMPENSATION COMMITTEE SETS STANDARDS TO ENSURE THAT THE CRITERIA USED TO DETERMINE INCENTIVE COMPENSATION ARE SPECIFIC, OBJECTIVE, MEASUREABLE AND RELATED TO INDICATORS OF PERFORMANCE. BASED ON THE INFORMATION PROVIDED, THE COMMITTEE WILL THEN MAKE ITS RECOMMENDATION TO THE CHS BOARD OF DIRECTORS. FORM 990, PART VI, LINE 19 - DOCUMENTS AVAILABLE FOR PUBLIC INSPECTION GOVERNING DOCUMENTS-CERTIFICATE OF INCORPORATION FILED WITH NYS DEPARTMENT OF STATE; CONFLICT OF INTEREST POLICY IS NOT MADE PUBLICLY AVAILABLE; CHS CONSOLIDATED FINANCIAL STATEMENTS ARE AVAILABLE AT DAC BOND. FORM 990, PART VII, SECTION A - LINE 1A HOURS FOR TRUSTEES ARE THE ESTIMATED WEEKLY HOURS (2.0) TRUSTEES CONTRIBUTE TO THIS AND ALL OTHER RELATED ORGANIZATIONS, NOT NECESSARILY EQUALLY BUT IN THE PROPORTION NECESSARY, FOR WHICH THEY RECEIVE NO COMPENSATION. ALAN D. GUERCI, PRESIDENT & CEO - THE TOTAL HOURS WORKED REPORTED REFLECTS TIME WORKED AS AN OFFICER FOR ALL OF THE FOLLOWING RELATED ENTITIES: CHS SERVICES, INC. (11-3555766); RVC INSURANCE COMPANY, INC. (20-8067039); CATHOLIC HEALTH SYSTEMS OF LONG ISLAND (11-3403968); ST FRANCIS HOSPITAL (11-2050523); ST FRANCIS HOSPITAL RESEARCH & EDUCATION CORPORATION, INC. (11-3090867); ST FRANCIS HOSPITAL FOUNDATION (11-2916033); MERCY MEDICAL CENTER (11-1635088); WSNCHS NORTH, INC. (11-3438973); GOOD SAMARITAN HOSPITAL MEDICAL CENTER (11-1888924); GOOD SAMARITAN SELF INSURANCE AGAINST MALPRACTICE (11-2537396); SIENA VILLAGE (06-1569129); ST. CATHERINE OF SIENA MEDICAL CENTER (06-1562701); ST. CHARLES HOSPITAL (11-1871039). THOMAS OCKERS, EXEC VP & CAO - THE TOTAL HOURS WORKED REPORTED (50.0) REFLECTS TIME WORKED AS AN OFFICER FOR ALL OF THE FOLLOWING RELATED ENTITIES: GOOD SAMARITAN HOSPITAL MEDICAL CENTER (11-1888924); GOOD SAMARITAN HOSPITAL FOUNDATION (77-0611240); GOOD SAMARITAN SELF INSURANCE AGAINST MALPRACTICE (11-2537396). NANCY SIMMONS, CAO - THE TOTAL HOURS WORKED REPORTED (50.0) REFLECTS TIME WORKED AS AN OFFICER FOR ALL OF THE FOLLOWING RELATED ENTITIES: GOOD SAMARITAN HOSPITAL MEDICAL CENTER (11-1888924); GOOD SAMARITAN HOSPITAL FOUNDATION (77-0611240); GOOD SAMARITAN SELF INSURANCE AGAINST MALPRACTICE (11-2537396). WILLIAM ARMSTRONG, SR VP FINANCE - THE TOTAL HOURS WORKED REPORTED REFLECTS TIME WORKED AS AN OFFICER OR HIGHEST PAID EMPLOYEE FOR ALL OF THE FOLLOWING RELATED ENTITIES: CHS SERVICES, INC. (11-3555766); ST FRANCIS HOSPITAL (11-2050523); ST FRANCIS HOSPITAL RESEARCH & EDUCATION CORPORATION, INC. (11-3090867); ST FRANCIS HOSPITAL FOUNDATION (11-2916033); MERCY MEDICAL CENTER (11-1635088); WSNCHS NORTH, INC. (11-3438973); GOOD SAMARITAN HOSPITAL MEDICAL CENTER (11-1888924); ST. CATHERINE OF SIENA MEDICAL CENTER (06-1562701); ST. CHARLES HOSPITAL (11-1871039); ST. CHARLES HOSPITAL FOUNDATION (41-2076312); SIENA VILLAGE, INC. (06-1569129); GOOD SAMARITAN SELF INSURANCE AGAINST MALPRACTICE (11-2537396) AND GOOD SAMARITAN HOSPITAL FOUNDATION (77-0611240). DANIEL DEBARBA, EVP & CFO - THE TOTAL HOURS WORKED REPORTED REFLECTS TIME WORKED AS AN OFFICER FOR ALL OF THE FOLLOWING RELATED ENTITIES: CHS SERVICES, INC. (11-3555766); ST FRANCIS HOSPITAL (11-2050523); ST FRANCIS HOSPITAL RESEARCH & EDUCATION CORPORATION, INC. (11-3090867); ST FRANCIS HOSPITAL FOUNDATION (11-2916033); MERCY MEDICAL CENTER (11-1635088); WSNCHS NORTH, INC. (11-3438973); GOOD SAMARITAN HOSPITAL MEDICAL CENTER (11-1888924); ST. CATHERINE OF SIENA MEDICAL CENTER (06-1562701); ST. CHARLES HOSPITAL (11-1871039); ST. CHARLES HOSPITAL FOUNDATION (41-2076312); SIENA VILLAGE, INC. (06-1569129); GOOD SAMARITAN SELF INSURANCE AGAINST MALPRACTICE (11-2537396); GOOD SAMARITAN HOSPITAL FOUNDATION (77-0611240); ST. CATHERINE OF SIENA MEDICAL CENTER FDOUNDATION (27-1459941); CATHOLIC HEALTH SYSTEM OF LONG ISLAND (11-3403968) AND RVC INSURANCE COMPANY INC. (20-8067039) FORM 990, PART X, LINE 20 - TAX EXEMPT BOND LIABILITIES THE TAX-EXEMPT BOND ISSUANCES REFLECTED ON PART X, LINE 20 ARE ISSUED ON BEHALF OF THE CATHOLIC HEALTH SERVICES OF LONG ISLAND OBLIGATED GROUP PROJECT WHICH INCLUDES THE FILING ENTITY AND RELATED ENTITIES. THREE BONDS WERE ISSUED TO THE OBLIGATED GROUP, SUFFOLK COUNTY ECONOMIC DEVELOPMENT CORPORATION (SERIES 2011 SUFFOLK BONDS), SUFFOLK COUNTY ECONOMIC DEVELOPMENT CORPORATION (SERIES 2014C SUFFOLK BONDS) AND NASSAU COUNTY LOCAL ECONOMIC ASSISTANCE AND FINANCING CORPORATION (SERIES 2011 NASSAU BONDS). THE BONDS ARE REPORTED ON SCHEDULE K OF THE PARENT ORGANIZATION, CATHOLIC HEALTH SERVICES OF LONG ISLAND. FORM 990, PART XI, LINE 9 - CHANGES IN NET ASSETS POST RETIREMENT BENEFIT PLAN CHANGE: $13,000 CATHOLIC HEALTH SYSTEM OF LONG ISLAND 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 113403968 SUPPORT ORG NY 501(C)(3) 12A- I NA false CHS SERVICES INC 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 113555766 SUPPORT ORG NY 501(C)(3) 12B- II CHSLI true CHS AMBULANCE SERVICES INC 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 141801961 DORMANT NY 501(C)(3) 3 CHSLI false GOOD SAMARITAN SELF INSURANCE AGAINST MALPRACTICE 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 112537396 SELF INSURANC NY 501(C)(3) 12A- I GOOD SAMARTN true MARYHAVEN TRANSPORTATION SERVICES 51 TERRYVILLE ROAD PORT JEFFERSN ST NY 11776 113434776 TRANSPORTATIO NY 501(C)(3) 12A- I MARYHAVENCTR false MARYHAVEN CENTER OF HOPE 51 TERRYVILLE ROAD PORT JEFFERSN ST NY 11776 112861698 Prgm-disabled NY 501(C)(3) 10 CHSLI false MARYHAVEN SCHOOL CORPORATION 51 TERRYVILLE ROAD PORT JEFFERSN ST NY 11776 112861690 Schl-disabled NY 501(C)(3) 2 MARYHAVENCTR false THE CENTER OF HOPE FOUNDATION 51 TERRYVILLE ROAD PORT JEFFERSN ST NY 11776 113638367 SUPPORT ORG NY 501(C)(3) 12A- I MARYHAVENCTR false MERCY MEDICAL CENTER 1000 NORTH VILLAGE AVENUE ROCKVILLE CTR NY 11570 111635088 HOSPITAL NY 501(C)(3) 3 CHSLI true CATHOLIC HOME CARE 110 BI-COUNTY BLVD SUITE 114 FARMINGDALE NY 11735 112126736 HOME CARE NY 501(C)(3) 10 CHSLI false OUR LADY OF CONSOLATION GERIATRIC CARE 111 BEACH DRIVE WEST ISLIP NY 11795 113284066 LT NURSE CARE NY 501(C)(3) 10 CHSLI false RIVERHEAD HOSTEL HOLDING CORPORATION 51 TERRYVILLE ROAD PORT JEFFERSN ST NY 11776 112499790 RENTING NY 501(C)(2) MARYHAVENCTR false SIENA VILLAGE INC 2000 BISHOPS ROAD SMITHTOWN NY 11787 061569129 SR HOUSING NY 501(C)(3) 10 STCATHERINE true ST CATHERINE OF SIENA MEDICAL CENTER 50 ROUTE 25A SMITHTOWN NY 11787 061562701 HOSPITAL NY 501(C)(3) 3 CHSLI true ST CHARLES HOSPITAL 200 BELLE TERRE ROAD PORT JEFFERSN ST NY 11777 111871039 HOSPITAL NY 501(C)(3) 3 CHSLI true CHS HOME SUPPORT SERVICES INC 15 POWER DRIVE HAUPPAUGE NY 11788 113594561 RESP THERAPY NY 501(C)(3) 10 CATHHOMECARE false ST FRANCIS HOSPITAL 100 PORT WASHINGTON BLVD ROSLYN NY 11576 112050523 HOSPITAL NY 501(C)(3) 3 CHSLI true ST FRANCIS HOSPITAL FOUNDATION 100 PORT WASHINGTON BLVD ROSLYN NY 11576 112916033 SUPPORT ORG NY 501(C)(3) 12A- I ST FRANCIS false ST FRANCIS HOSPITAL RESEARCH & EDUCATIO 100 PORT WASHINGTON BLVD ROSLYN NY 11576 113090867 RESEARCH ORG NY 501(C)(3) 12A- I ST FRANCIS true WSNCHS NORTH INC 4295 HEMPSTEAD TURNPIKE BETHPAGE NY 11714 113438973 HOSPITAL NY 501(C)(3) 3 CHSLI true THE ST CHARLES CORPORATION 200 BELLE TERRE ROAD PORT JEFFERSN ST NY 11777 112983148 SUPPORT ORG NY 501(C)(3) 12A- I CHSLI false THE SAMARITAN CORPORATION 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 112716640 SUPPORT ORG NY 501(C)(3) 12A- I CHSLI false WISDOM GARDENS HOUSING DEVELOPMENT FUND 51 TERRYVILLE ROAD PORT JEFFERSN ST NY 11776 113559713 SR HOUSING NY 501(C)(3) 10 MARYHAVENCTR false GOOD SHEPHERD HOSPICE 110 BI-COUNTY BLVD SUITE 114 FARMINGDALE NY 11735 112958438 HOSPICE SVC NY 501(C)(3) 10 CHSLI false ST CHARLES HOSPITAL FOUNDATION 200 BELLE TERRE ROAD PORT JEFFERSON NY 11777 412076312 SUPPORT ORG NY 501(C)(3) 12A- I ST CHARLES false GOOD SAMARITAN HOSPITAL FOUNDATION 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 770611240 SUPPORT ORG NY 501(C)(3) 12A- I GOOD SAMARTN true MERCY MEDICAL CENTER FOUNDATION 1000 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 550813603 SUPPORT ORG NY 501(C)(3) 12A- I MERCY MEDCTR false ST CATHERINE OF SIENA MEDICAL CTR FDN 50 ROUTE 25A SMITHTOWN NY 11787 271459941 SUPPORT ORG NY 501(C)(3) 12A- I STCATHERINE true CHS HOME CARE AND HOSPICE FOUNDATION 110 BI-COUNTY BLVD SUITE 114 FARMINGDALE NY 11735 452907761 SUPPORT ORG NY 501(C)(3) 12A- I CATHHOMECARE false GOOD SHEPHERD HOSPICE FOUNDATION 110 BI-COUNTY BLVD SUITE 114 FARMINGDALE NY 11735 263169427 SUPPORT ORG NY 501(C)(3) 12A- I GOODSHEPHERD false OUR LADY OF CONSOLATION FOUNDATION 111 BEACH DRIVE WEST ISLIP NY 11795 450517566 SUPPORT ORG NY 501(C)(3) 12A- I OURLADYOFC false RVC SUPPORT 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 271531084 REAL ESTATE NY 501(C)(3) 12A- I CHSLI false ST FRANCIS CARDIOVASCULAR PHYSICIANS P 100 PORT WASHINGTON BLVD ROSLYN NY 11576 113613997 HEALTHCARESVC NY 501(C)(3) 12A- I ST FRANCIS false RVC INSURANCE COMPANYINC 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 208067039 CAPTIVE INS NY 501(C)(3) 12B- II CHSLI false SAMARITAN EMERGENCY MEDICAL SERVICES PC 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 208243412 HEALTHCARESVC NY 501(C)(4) GOOD SAMARTN true ST JOSEPH HOSPITAL FOUNDATION 992 N VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 472353387 SUPPORT ORG NY 501(C)(3) 12A- I WSNCHS NORTH false BIPO HOLDINGS LLC 1600 STEWART AVE WESTBURY NY WESTBURY NY 11590 464763720 PHYSICIAN ASSN NY NA N/A IDHC LLC 2500 YORK RDJAMISONPA 18929 JAMISON PA 18929 452411095 HEALTH SERVICES PA GSH RELATED 1534996 498884 false 0 false 0.51000 BEACON HEALTH PTNRS 1600 STEWART AVE WESTBURY NY WESTBURY NY 11590 454229842 HEALTHCARE NY NA N/A WISDOM GARDENS LP 51 TERRYVILLE RD PORT JEFFERSON NY 11776 113567947 SR HOUSING NY NA N/A RADIOLOGY CONSULTING OF LONG ISLANDPLLC 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 421646134 HEALTHCARE SVC NY GOOD SAMARITAN C-CORP false SAMARITAN PEDIATRIC SERVICES PC 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 208180263 HEALTHCARE SVC NY GOOD SAMARITAN C-CORP false SAMARITAN MEDICAL SERVICES PC 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 208088453 HEALTHCARE SVC NY GOOD SAMARITAN C-CORP false SOUTHWEST SUFFOLK MEDICAL PC 580 UNION BOULEVARD WEST ISLIP NY 11795 061603195 HEALTHCARE SVC NY GOOD SAMARITAN C-CORP false CARDIAC EKG INTERPRETATION PC 992 N VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 112924518 HEALTHCARE SVC NY GOOD SAMARITAN C-CORP false LI REGIONAL ARTHRITIS & OSTEOPOROSIS CAR 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 208964140 HEALTHCARE SVC NY GOOD SAMARITAN C-CORP false SAMARITAN MANAGEMENT SERVICES 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 112838185 HEALTHCARE SVC NY CHSLI C-CORP false ADVANCED REHABILIATION MEDICINE PLLC 200 BELLE TERRE ROAD PORT JEFFERSON NY 11777 113640709 HEALTHCARE SVC NY STCHARLES HOSP C-CORP false ST FRANCIS CARDIAC PREVENTION SERVICES 100 PORT WASHINGTON BLVD ROSLYN NY 11576 113224885 HEALTHCARE SVC NY STFRANCIS HOSP C-CORP false SOUTH SHORE PRACTICE MANAGEMENT 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 113307977 HEALTHCARE SVC NY SAMARITAN MGMT C-CORP false SAMARITAN HOME CARE AMERICA 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 113319259 HEALTHCARE SVC NY SAMARITAN MGMT C-CORP false MERCY INTERNAL MEDICINE PC 992 N VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 510639649 HEALTHCARE SVC NY MERCY MED CTR C-CORP false LONG ISLAND EMERGENCY CARE PC 1000 N VILLAGE AVE ROCKVILLE NY 11571 113633515 PHYSICIAN SVC NY MERCY MED CTR S-CORP false false true true true true false false false true true false true true true true true true true true CHS SERVICES LMPR 2350187 COST MERCY MEDICAL CENTER LM 39891 COST ST FRANCIS HOSPITAL LM 145793 COST ST CHARLES HOSPITAL LM 562259 COST ST CATHERINE OF SIENA MEDICAL CENTER LM 606805 COST WSNCHS NORTH LM 564025 COST GOOD SAMARITAN HOSPITAL FOUNDATION C 63483 COST SAMARITAN EMERGENCY MEDICAL SERVICES LMQ 287345 COST IDHC LLC S 1216052 COST SCHEDULE R, PART IV FOR ALL PROFESSIONAL CORPORATIONS REPORTED ON SCHEDULE R, PART IV, THE PHYSICIAN IS THE SOLE SHAREHOLDER OF THE ENTITY AND THE DIRECT CONTROLLING ENTITY REPORTED IN COLUMN (D) IS THE BENEFICIAL OWNER. THIS STRUCTURE IS CONSISTENT WITH THE NEW YORK CORPORATE PRACTICE OF MEDICINE.