2017-01-10T12:32:56-06:00 2015-12-31 990 2015-01-01 161523353 Mount St Mary's Hospital of Niagara Falls MOUN 7168282974 144 Genesee St 4th Floor - Finance Buffalo NY 14203 David P Macholz CHS VP Finance,Corp.Controller 7168282974 2017-01-10 2015 2021-01-29 14:40:06Z X X Mount St Mary's Hospital and Health Joseph D McDonald 144 Genesee Street Buffalo NY 14203 93678815 0 X www.chsbuffalo.org X 1907 NY The Catholic Health System (CHS) Mission is to provide quality healthcare services in an acute care setting. Committed to a common mission, CHS providers continue the healing ministry of Jesus, seeking to improve the health of individuals and communities. We provide high quality service that has reverence, compassion, justice, and excellence. The 2015 Community Service Plan can be found at www.chsbuffalo.org. 13 9 921 230 0 0 803382 0 92112823 92209017 159586 32150 3246306 1437648 96322097 93678815 0 0 0 0 56997901 59044765 0 0 0 36099229 35757873 93097130 94802638 3224967 -1123823 51071072 47446166 41142119 20119146 9928953 27327020 X We are called to continue the healing ministry of Jesus by providing compassionate person-centered care. We will respect the dignity of all, with special concern for those who are poor and vulnerable. 0 0 36877175 46874358 Mount St. Mary's Hospital provides in-patient medical and surgical services to the community, including acute care, cardiac and medical intensive care, telemetry, maternity, pediatrics, palliative care, stroke care and inpatient alcohol & substance abuse rehab. During the calendar year ending December 31, 2015, our Hospital treated 5371 inpatient adults and children in the community for a total of 26,915 patient days of service. A substantial portion of services are provided to the elderly and poor. During the calendar year ending December 31, 2015, approximately 46% of the value of services rendered was to elderly patients under the Medicare program, and approximately 23% of the services were provided to patients who were deemed indigent under state, county, or Hospital guidelines. In the spirit of principles adopted by Catholic Health and our Mount St. Mary's Hospital Board of Trustees, Mount St. Mary's Hospital has taken proactive steps to address those issues that affect accessibility, financing, and delivery of healthcare to all persons, especially those who are uninsured, underinsured, and underserved. All services are designed to provide healing without harm to those we serve. 36367016 46225898 Mount St. Mary's Hospital provides the following outpatient medical services to the community: cardiac services, emergency services, laboratory services, neurology services including EEG and EMG, orthopedic services, pain management, primary care clinic services, radiology services, rehabilitation services, surgical services, physical therapy, occupational therapy, speech therapy, wound care, ENT, neurology, hyperbaric medicine, respiratory therapy and pulmonary function studies. Some of the services listed, such as the primary care clinic services, operate at a deficit but are supported and maintained in order to ensure that all services are available to meet community health care needs. During the calendar year ending December 31, 2015, our Hospital provided 158,458 services to outpatients, including 6772 outpatient surgery patients, 21,331 emergency room visits, 65,877 referred ambulatory patients, and 64,478 clinic visits. 8705493 During the calendar year ending December 31, 2015, the estimated unreimbursed cost of services provided to the elderly, uninsured, and underinsured totaled $8,706,000, including $118,000 cost for charity care, $758,000 in programs for the poor, $698,000 in services to the general community, and $7,132,000 in unpaid cost of public programs. Community benefit programs or activities are those that provide treatment and/or promote health and healing as a response to identified community needs. In efforts to promote healthy living, Mount St. Mary's Hospital has made available the following programs to the community: physical fitness activities, community health programs, medical education, cancer screening programs, heart disease screening programs, support groups and educational classes, CPR and first aid classes, flu shot clinics, nutrition and weight loss management, and smoking cessation, among others. 81949684 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 79 0 1 921 1 0 0 0 0 0 0 0 0 0 0 0 0 X 13 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X X David P Macholz CHS VP Finance C 7168282974 144 Genesee St Buffalo NY 14203 Joseph McDonald President and CEO, CHS 0.00 55.00 X 0 1582915 204904 Mark Sullivan Executive VP/COO 0.00 55.00 X X 0 831321 134963 James A Dunlop Jr Executive VP, Finance/CFO 0.00 55.00 X 0 887602 110616 Dr Brian D'Arcy Senior VP, Medical Affairs 0.00 55.00 X 0 588913 86724 Judith Maness Pres. & CEO, Mount St. Mary's Hospital 55.00 X 299732 0 33736 Gary Tucker Pres. & CEO, Mount St. Mary's Hospital 55.00 X X 440125 0 68790 David Macholz Treasurer 0.00 55.00 X X 0 329578 24203 Stephen Franko III Chief Financial Officer 55.00 X 318571 0 32244 Brian Beitz Director 4.00 X 0 0 0 Peter Bergmann Director 1.00 55.00 X 0 495499 23556 Frances Crosby RN PHD Director 2.00 X 0 0 0 Ricard Curran MD Director 2.00 X 0 0 0 John Davanzo Director 2.00 X 0 0 0 Dr Michael Edbauer Director 0.00 27.50 X 0 362923 70688 Joseph Gelormini MD Director 2.00 X 0 0 0 Mark Jajkowski Director 2.00 X 0 0 0 Joyce Markiewicz Director 0.00 55.00 X 0 367821 35357 Raquel Martin DO Director 2.00 X 0 0 0 James Millard Director 0.00 55.00 X 0 419950 34672 Sherry Pomeroy PhD Director 2.00 X 0 0 0 Mark Sullivan Officer/Director 55.00 X 0 0 0 Gary Tucker Officer/Director 55.00 X 0 0 0 Mary Turkiewiecz MD Director 2.00 X 0 0 0 Charles Urlaub Director 2.00 55.00 X 0 463086 36126 Monsignor Robert E Zapfel Director 2.00 X 0 0 0 Dena Armstrong MSMH BOD 2.00 X 0 0 0 William Bradberry MSMH BOD 2.00 X 0 0 0 Christopher H Brown MSMH BOD 2.00 X 0 0 0 Lloyd W Brown MD MSMH BOD 2.00 X 0 0 0 Anthony Eugeni MSMH BOD 2.00 X 0 0 0 Carmen A Granto MSMH BOD 2.00 X 0 0 0 Donald J Largo Jr MD MSMH BOD 2.00 X 0 0 0 Robert A Minicucci MSMH BOD 2.00 X 0 0 0 Sister Kathleen Natwin DC MSMH BOD 2.00 X 0 0 0 Sister Marilyn Perkins DC MSMH BOD 2.00 X 0 0 0 Robert J Travis MSMH BOD 2.00 X 0 0 0 Michael L Vitch MSMH BOD 2.00 X 0 0 0 Deborah J Winslow-Schaber MSMH BOD 2.00 X 0 0 0 Judith A Maness MSMH BOD 2.00 X 0 0 0 Maria Foti Sr. VP, Strategic Planning 0.00 55.00 X 0 347846 63087 Dr Michael Galang Sr. VP, Chief Information Officer 0.00 55.00 X 0 509718 81005 Michael Moley Sr. VP, Human Resources 55.00 0.00 X 0 687938 105480 Nancy Sheehan SVP Legal Service, General Counsel 0.00 55.00 X 0 380104 52928 Dr Michael Kreymer Physician 55.00 0.00 X 329599 0 40253 Dr Roger W Rogers Physician 55.00 0.00 X 396425 0 32457 Dr Benjamin G Rueda Physician 55.00 0.00 X 477267 0 43943 Dr Arif S Syed Physician 55.00 0.00 X 415036 0 43218 Dr Sharmilee Thota Physician 55.00 0.00 X 336312 0 19506 3013067 8255214 1378456 59 0 1 0 Touchpoint PO Box 102289 Atlanta GA 30368 Consulting Services 1979466 Trimedx LLC PO Box 636129 Cincinnati OH 45263 Consulting Services 1422841 The Peyton Barlow Company 360 Delaware Ave Suite 300 Buffalo NY 14202 Consulting Services 857927 Precision Health Care Services 1160 Southwest 21st Avenue Boca Roton FL 33486 Consulting Services 856055 Exigence Hospitalist Medical Services PO Box 634850 Cincinnati OH 45263 Consulting Services 708182 26 Net Inpatient Services 621990 46425635 46425635 Net Outpatient Services 621990 45783382 45783382 92209017 32150 32150 85410 0 85410 85410 85410 All Other 621990 985777 985777 Cafeteria 722210 366461 366461 1352238 93678815 93280204 0 398611 47487642 42264001 5223641 1057779 941423 116356 7299698 6496731 802967 3199646 2847685 351961 101605 101605 78248 78248 16406 16406 2644259 1888107 756152 261393 261393 4943861 2503121 2440740 -52052 10645 -62697 1430936 1073202 357734 10488 2284 8204 117636 59070 58566 476064 446449 29615 2014302 1888996 125306 612020 537162 74858 Purchased Services 11491623 10227543 1264080 Medical Supplies 10241407 10173153 68254 Other Supplies Non-Medi 1136012 428701 707311 Dues 233665 161411 72254 94802638 81949684 12852954 0 3695187 4003131 8302523 8790533 435749 1070267 1502512 1765902 548222 565563 60808742 36128054 23776533 24680688 12810346 6570082 51071072 47446166 10802635 7147916 30339484 12971230 41142119 20119146 X 3136211 21180240 6792742 6146780 0 0 9928953 27327020 51071072 47446166 X -1123823 -58165 18580055 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 16406 16406 0 Part II-B, Line 1: Lobbying expenses represent the portion of dues paid to national and state associations that is specifically allocable to lobbying. Mount St. Mary's Hospital of Niagara Falls does not participate in or intervene in (including the publishing or distributing of statement) any political campaign on behalf of (or opposition to) any candidate for public office. 1227100 1227100 32895476 18399240 14496236 21432987 14045797 7387190 5253179 3683017 1570162 24680688 Due From Affiliates 265863 Beneficial Interest in Net Assets of Foundation 6147472 Other Assets 156747 6570082 Third Party Liabilities 2824696 Self-Insurance Liability 811600 Other Long Term Liabilities 9334934 12971230 94372267 693451 693451 93678816 0 93678816 95705533 902894 902894 94802639 0 94802639 Part XI, Line 2d - Other Adjustments: Childcare Revenue Foundation Revenue Part XII, Line 2d - Other Adjustments: Childcare Expenses Foundation Expenses (net of eliminations) 1 1 X 1 X 1 X 1 1 1 0 1 1 835591 717249 118342 0.00120 22665833 15605816 7060017 0.07450 147085 75385 71700 0.00080 23648509 16398450 7250059 0.07650 738005 0 738005 0.00780 154432 0 154432 0.00160 1238253 804225 434028 0.00460 166 0 166 0.00000 128803 0 128803 0.00140 2259659 804225 1455434 0.01540 25908168 17202675 8705493 0.09190 186 0 186 0.00000 7317 0 7317 0.00010 289 0 289 0.00000 7792 7792 0.00010 0 2438981 103238 16562420 15545677 1016743 X 1 1 1 1 Mount St Mary's Hospital of Niagara Falls 5300 Military Rd Lewiston NY 14092 www.chsbuffalo.org 3121001H X X X Ambulatory Surgery - Multi Speciality Mount St Mary's Hospital of Niagara Fal 1 0 1 1 X X X X X X X X X 13 1 0 1 1 X http://chsbuffalo.org/Community X 1 13 1 http://www.chsbuffalo.org/Community 0 0 1 X 200.000000000000 300.000000000000 X X X X 1 1 X X X X 1 X http://chsbuffalo.org/billing/finance X http://chsbuffalo.org/billing/finance X http://chsbuffalo.org/billing/finance X X X X X X 1 X 0 X X X X 1 X 0 0 Part V, Section A: CT Scanner Chemical Dependence - IP Rehabilitation O/P Chemical Dependence - Withdrawal O/P Clinic Part Time Services Clinical Laboratory Service Coronary Care Emergency Department Health Fairs O/P Intensive Care Lithotripsy Magnetic Resonance Imaging Maternity Medical Services - Primary Care Medical Social Services Medical/Surgical Nuclear Medicine - Diagnostic Nuclear Medicine - Therapeutic Pediatric O/PPharmaceutical Service Radiology - Diagnostic Renal Dialysis - Acute Therapy - Occupational O/P Therapy - Physical O/P Therapy - Speech Language Pathology Mount St. Mary's Hospital of Niagara Falls Part V, Section B, Line 5: Health awareness and prevention activities are conducted throughout the year targeting priorities identified in numerous community surveys. In calendar year 2012-2013, Mount St. Mary's Hospital (MSMH) conducted a survey with respect to the community's health needs. As noted below, MSMH surveyed community members and visitors to the hospital, community organizations and churches and personally interviewed hospital volunteers while conducting focus groups to discuss survey and interview results. In addition, later in 2013, MSMH compiled and reviewed health data from surveys conducted by the Niagara County Department of Health and data from the New York State Department of Health and amended its plan to add two additional priorities from the NYS Department of Health Prevention Agenda.To identify and prioritize the MSMH community' s health needs, this Community Health Needs Assessment (CHNA) considered multiple data sources, including written surveys, interviews, focus groups, demographic data, health status indicators, and disease prevalence data. MSMH compiled the data from these sources to arrive at potential priority health needs in the community. MSMH convened meetings with MSMH staff and external healthcare experts (including the Niagara County Department of Health) to share the survey results, discuss the potential priority health needs and to elicit considerations regarding secondary health needs. While MSMH initially identified priorities as related to community needs, in 2013 two additional priorities were added from meetings involving other local area local area hospitals and the Niagara County Department of Health. Mount St. Mary's Hospital of Niagara Falls Part V, Section B, Line 6b: Niagara County Department of Health New York State Department of Health Mount St. Mary's Hospital of Niagara Falls Part V, Section B, Line 2: Effective July 1, 2015, Catholic Health and Ascension completed a transaction to transfer ownership/sponsorship of Mount St. Mary's from Ascension to Catholic Health. Ascension was the sponsor of Mount St. Mary's from 2000 to July 1, 2015. Mount St. Mary's Hospital of Niagara Falls Part V, Section B, Line 11: Through the needs assessment, numerous areas were identified as important and clearly impact the health of the community. Mount St. Mary's identified the "significant" needs as the New York State Department of Health Prevention Agenda priorities. Within the "priorities," Mount St. Mary's will address numerous health needs as described in the publicly available CHNA report. Two priorities not addressed not addressed in the implementation plan: Neighborhood Safety and Food/Water Safety. We did not address in our plan because of a lack of expertise and resources to effectively address each of the issues. Mount St. Mary's Hospital of Niagara Falls Part V, Section B, Line 16i: Brochures describing the Financial Assistance Policy and a sign indicating where to call or go to talk to the Financial Counselor, are located at every entry point of the hospital, including all off campus locations, The brochure and application are also posted on the hospital' s website. 8 1 - Mount St Mary's Hospital Rehab Svc 1 Columba Drive Niagara Falls NY 14305 Licensed, Extension Clinic: Therapy-Occupational O/P, Therapy-Physical O/P/ 2 - Mount St Mary's Diagnostic Imaging Svc 7300 Porter Road Niagara Falls NY 12414 Licensed, Extension Clinic: Medical Services-Primary Care 3 - Mount St Mary's Ear Nose and Throat Sv 6941 Elaine Drive Niagara Falls NY 14304 Licensed, Extension Clinic: Primary Medical Care O/P 4 - Mount St Mary's Orthopedic Services 5320 Military Road Lewiston NY 14092 Licensed, Extension Clinic: Orthopedic Services General,Vascular & Cardiotho 5 - Mount St Mary's Primary Care 1302 Main Street Niagara Falls NY 14301 Extension Clinic: Medical Services O/P, Primary Medical Care O/P, Radiology 6 - Mount St Mary's Neighborhood Health Ctr 3101 Ninth Street Niagara Falls NY 14305 Licensed, Extension Clinic: Medical Social Services O/P, Nutritional O/P 7 - Mount St Mary's Campus Medical Arts Bld 5290 Military Road Suite 8 Lewiston NY 14092 Extension Clinic: Primary Care 8 - Witmer Park Medical Center One Colomba Drive Suite 8 Niagara Falls NY 14304 Extension Clinic: Primary Care Part I, Line 7: A cost to charge ratio was used for costing various amounts in the table using a calculation based on Worksheet 2. Part II, Community Building Activities: Community Building Activities for Mount St. Mary's Hospital included Economic Development of $186 and Community Support - Boards and Advisory Councils for $6,795. Part III, Line 2: The provision for doubtful accounts is based upon management's assessment of historical and expected net collections considering economic conditions trends in health care coverage, and other collection indicators, Periodically throughout the year, management assesses the adequacy of the allowance for doubtful accounts based upon historical write-off experience by payer category, including those amounts not covered by insurance. The results of this review are then used to make any modifications to the provision for doubtful accounts to establish an appropriate allowance for uncollectable accounts, After satisfaction of amounts due from insurance and reasonable efforts to collect from the patient have been exhausted, the Hospital may place past due patient balances with collection agencies, subject to the terms of certain restrictions on collection efforts as determined by Ascension Health.Accounts receivable are written off after collection efforts have been followed in accordance with the Hospital's policies,The methodology for determining the allowance for doubtful accounts and related write-offs on uninsured patient accounts has remained consistent with the prior year, The Hospital has not experienced material changes in write-off trends and has not materially changed its charity care policy in 2014,The organization's share of bad debt expense in 2015 was $2,438,981 at charges. Part III, Line 4: The hospital does not have a footnote that describes bad debt in the financial statements. Part III, Line 8: Ascension Health and related health ministries follow the Catholic Health Association {CHA) guidelines for determining community benefit. Part III, Line 9b: The organization has a written debt collection policy that also includes a provision on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance. If a patient qualifies for charity or financial assistance certain collectionpractices do not apply. Part V Section A Line 1 CT Scanner Chemical Dependence - IP Rehabilitation O/P Chemical Dependence - Withdrawal O/P Clinic Part Time Services Clinical Laboratory Service Coronary Care Emergency Department Health Fairs O/P Intensive Care Lithotripsy Magnetic Resonance Imaging Maternity Medical Services - Primary Care Medical Social Services Medical/Surgical Nuclear Medicine - Diagnostic Nuclear Medicine - Therapeutic Pediatric O/P Pharmaceutical Service Radiology - Diagnostic Renal Dialysis - Acute Therapy - Occupational O/P Therapy - Physical O/P Therapy - Speech Language Pathology Part VI, Line 2: As part of Catholic Health, Mount St. Mary's benefits from information received from evaluations administered by the Catholic Health Community Education Department after each class, workshop, or program it sponsors; from input from the physician community during doctor to doctor education programs; from physician and leadership participation in community boards, coalitions and forums to define the health needs of patient populations and seek community solutions; from participation in regional planning initiatives that look at the needs of the broader community; and input from Catholic Health Board including Board Committee (e.g. Mission Integration Committee). Examples of other sources of input include input from leadership of Family and Children's Services of Niagara, the Heart, Love and Soul Food Pantry, Stella Niagara Education Center, Catholic Academy of Niagara Falls, March of Dimes, Healthy Moms/Healthy Babies, among others. In each of the organizations listed, a member of the Mount St. Mary's leadership term serves on their board of directors or key committee with consistent dialogue about our services. Part VI, Line 3: Patients are personally informed of the financial assistance and charity care policies at each inpatient and outpatient entry point of the Hospital by Patient Access representatives, who also direct those individuals requiring further information to the Financial Assistance Counselors. Each entry point of the Hospital and all of its offsite locations have both signs and brochures explaining the Financial Assistance Policy in place.In addition, the Financial Assistance Policy and application have been placed on the homepage of the Hospital's website.Part VI, Line 4: Part VI, Line 4: Mount St. Mary's Primary Service Area includes the City of Niagara Falls (Zip Codes 14301, 14302, 14303, 14304 and 14305), a city of about 49,000 where 60% of the population is on some form of public assistance. The towns of Lewiston (14092, 14107, 14109, and 14132), Niagara (portions of 14304 and 14305), Wheatfield (portions of 14305 and 14120), Grand Island {14072) and Porter (14174) are more suburban and rural areas with slightly higher income levels. Secondary Service Area includes the towns of Wilson (14172) a small agricultural community and Lockport (14094) a nearby city with similar characteristics to Niagara Falls. In general, the primary service area is described as Western Niagara County. Part VI, Line 5: One of the fundamental reasons for the creation of Catholic Health was to ensure the continued viability of faith-based health care to meet the needs of residents in Erie County and the surrounding communities. Our Mission Statement - We are called to reveal the healing love of Jesus to those in need - further articulates why we exist. Integral to this effort is caring for the needs of those who are poor and disadvantaged. The services provided by Catholic Health are in response to identified community needs, and reflect the System's emphasis on caring for the underserved. Catholic Health collaborates with other charitable organizations and social service agencies (i.e. Catholic Charities Spectrum Human Services, Evergreen Health Services, Erie County Department of Health, etc.) , to maximize its ability to provide needed services to the residents of our region.The governing Board of Directors of Mount St. Mary's Hospital is comprised of community representatives from universities, legal communities, and business leaders. Religious orders are represented, as well as active and retired medical staff members. The Mount St. Mary's medical staff is considered an "open" medical staff, as any physician can apply for privileges. Each application is reviewed by a vigorous credentialing verification process. The hospital has a robust health professional education programs and participates in teaching programs for other allied health professionals. Our emergency department is open to all people regardless of their ability to pay. Our primary care centers are strategically located in areas deemed economically disadvantaged or where other medical services are lacking. Each year, Catholic Health touches tens of thousands of area residents through its community health education programs, health screenings, clinical and support services, and community service activities. Most of these programs are free to encourage participation by people from all walks of life. Catholic Health will continue to meet community needs by providing charity care to the uninsured and underinsured, traditional Medicaid services, and community benefit programs, including collaborative community health improvement initiatives, health professional education programs, volunteering and community service activities, and cash and in-kind contributions to community organizations that serve the poor and disadvantaged. In 2015, the Catholic Health System provided more than $100 million in charity care and community benefit activities (including $5 million from Mount St. Mary's) to help make our community a healthier place, especially for the poor and underserved. These activities included: " Spearheading Project Homeless Connect - An outreach initiative to link homeless individuals and families with medical and other support services; " Supporting charitable and educational organizations, like the Buffalo City Mission, Friends of Night People, and the Health Science Charter School that help the poor and vulnerable in our community; " Hosting numerous health education and screening programs to help people learn their health risks and take steps to improve their health; " Offering a Healthcare Assistance Program to ensure that people without insurance or financial means get the care they need; " Providing health and wellness information in places of worship through our Faith Community Nursing program; " Helping refugees access quality medical care through our Primary Care and School Based Health Centers, including the Mercy Comprehensive Care Center in Buffalo's Old First Ward; " Providing free care and services to those in need, like our "Cribs for Kids" program, which helps families provide a safe sleeping environment for their newborns; " Supporting children and families in need through our Reach Out and Read Program; Backpack Program for Kids; and Bridget Closet (clothes for the needy);" Sponsoring programs at the Mercy Comprehensive Care Center, which serve the local community, including refugees from Burma, Somalia, the Middle East, and Nepal ; " Providing services through our Social Work Department, which link patients with necessary services including: ESL (English as a Second Language), job opportunities, substance abuse treatment, health care navigators, senior services, insurance information, parenting assistance and more; and " Supporting nationally recognized "green" initiatives to remain good stewards of our natural resources and protect the environment.As part of Catholic Health, Mount St. Mary's is supportive of the initiatives above. In addition, other ways the Hospital furthers its exempt purpose by promoting the health of the community include free health screenings (Lipid Panel each February as part of Heart Month and PSA in June as part of a Father's Day promotion) and health fairs as described further in our community benefit report in Schedule 0. The organization extends medical staff privileges to all qualified physicians in its community for many of its departments. The organization applies funding to improvements in patient care, such as the expanded cardiology services Women's Center for Breast Health, and its Center for Women, which provides services at both the main hospital and the Neighborhood Health Center facility in an underserved section of the City of Niagara Falls. For Breast Health, Mount St. Mary's has not only raised necessary funds to invest in the first digital mammography units in Niagara County, but an MRI Breast Coil has been secured and capital from Catholic Health will be used to bring 3D Tomosynthesis to Mount St. Mary's and Niagara County. Part VI, Line 6: Mount St. Mary's Hospital of Niagara Falls d/b/a Mount St. Mary's Hospital and Health Center (the Hospital) was a member of Ascension from 2000 to July 2015. Ascension is the sole corporate member and parent organization of Ascension Health, a Catholic, national health system consisting primarily of nonprofit corporations that own and operate local health care facilities, or Health Ministries located in 23 of the United States and the District of Columbia. In July 2015, Mount St. Mary's and Catholic Health worked cooperatively with Ascension to have sponsorship of Mount St. Mary's transferred to Catholic Health. Part VI, Line 7, Reports Filed With States NY X X X X X X 0 1 0 0 0 0 0 0 0 Joseph McDonald President and CEO, CHS 0 740806 0 536131 0 305978 0 180650 0 24254 0 1787819 0 0 Mark Sullivan Executive VP/COO 0 504363 0 208657 0 118301 0 112959 0 22004 0 966284 0 0 James A Dunlop Jr Executive VP, Finance/CFO 0 501920 0 315368 0 70314 0 89631 0 20985 0 998218 0 0 Dr Brian D'Arcy Senior VP, Medical Affairs 0 440939 0 95588 0 52386 0 65094 0 21630 0 675637 0 0 Judith Maness Pres. & CEO, Mount St. Mary's Hospit 288774 0 0 0 10958 0 19955 0 13781 0 333468 0 0 0 Gary Tucker Pres. & CEO, Mount St. Mary's Hospit 243236 0 173623 0 23266 0 43271 0 25519 0 508915 0 0 0 David Macholz Treasurer 0 210123 0 110699 0 8756 0 1925 0 22278 0 353781 0 0 Stephen Franko III Chief Financial Officer 135862 0 164000 0 18709 0 14602 0 17642 0 350815 0 0 0 Peter Bergmann Director 0 403466 0 63731 0 28302 0 3149 0 20407 0 519055 0 0 Dr Michael Edbauer Director 0 238222 0 111206 0 13495 0 59457 0 11231 0 433611 0 0 Joyce Markiewicz Director 0 280167 0 70559 0 17095 0 14186 0 21171 0 403178 0 0 James Millard Director 0 330958 0 71925 0 17067 0 23675 0 10997 0 454622 0 0 Charles Urlaub Director 0 387431 0 40588 0 35067 0 15442 0 20684 0 499212 0 0 Maria Foti Sr. VP, Strategic Planning 0 232624 0 98515 0 16707 0 54191 0 8896 0 410933 0 0 Dr Michael Galang Sr. VP, Chief Information Officer 0 343441 0 149570 0 16707 0 78087 0 2918 0 590723 0 0 Michael Moley Sr. VP, Human Resources 0 351252 0 175656 0 161030 0 82554 0 22926 0 793418 0 0 Nancy Sheehan SVP Legal Service, General Counsel 0 290590 0 72447 0 17067 0 43525 0 9403 0 433032 0 0 Dr Michael Kreymer Physician 319412 0 9890 0 297 0 16490 0 23763 0 369852 0 0 0 Dr Roger W Rogers Physician 395795 0 0 0 630 0 11062 0 21395 0 428882 0 0 0 Dr Benjamin G Rueda Physician 456311 0 18822 0 2134 0 17563 0 26380 0 521210 0 0 0 Dr Arif S Syed Physician 367807 0 46644 0 585 0 16913 0 26305 0 458254 0 0 0 Dr Sharmilee Thota Physician 235601 0 100533 0 178 0 10983 0 8523 0 355818 0 0 0 Part I, Line 4b Certain Officers and Key employees participated in a supplemental nonqualified retirement plan. The intention is to provide additional retirement compensation to address any gaps in the compensation limit. Pension Gap Joseph McDonald $26,000.00 Mark Sullivan $19,500.00 Dr. Brian D'Arcy $9,800.00 Peter Bergmann $7,334.00 SERP Joseph McDonald $94,179.00 Certain portions of the incentive compensation paid in 2015 are a result of the targets that were achieved in 2014. Deferred compensation reported in 2015 includes both qualified deferred pension compensation and employer contribution for 403b for certain Sisters of Charity Hospital associates, as well as deferred compensation for the amounts that are able to be estimated in 2015. Actual W-2 compensation paid to the executive is as per Schedule J Part II B. Susan Urlaub Wife of Mercy CEO, C.J. Urlaub 80304 Corporate Nurse educator 0 Kathleen Zapfel Sister-in-law of BOD, Msgr. Robert Zapfel 65837 HR Employee of CHS 0 990 Page 1 Section B, Schedule J Page 2 Part II An amended 990 return has been prepared to correct the W2 compensation listed on Part II of Schedule J for one officer. The original filing did not have the appropriate breakdown between base compensation and other reportable compensation. Total compensation that was originally submitted was reported accurately. Form 990, Part VI, Section A, line 6 CHS has three members: Ascension Health, Trinity Health, and the Diocese of Buffalo, NY. Each member is able to participate equally in electing the governing body, approving significant decisions of the governing body, and in receiving a share of net assets upon dissolution, according to the CHS Bylaws. Form 990, Part VI, Section A, line 7a According to the CHS Bylaws, each member is equally allowed to appoint up to three individuals to act as its representatives on the Corporate Member Board, and in undertaking any action in its capacity as a Member. The Corporate Member Board oversees the governance of the Catholic Health System. Form 990, Part VI, Section A, line 7b Each member is entitled to one vote on each matter properly submitted at any membership meeting, and the members also have reserve powers which allow approval for certain business events and ratification of certain business transactions. Form 990, Part VI, Section B, line 11 Yes, an electronic copy of the Form 990 was provided to the CHS Boards of Directors before it was filed. The CHS Board of Directors has delegated the responsibility to review the 990 to the Audit Committee. The CHS Audit Committee reviewed in detail selected information for all CHS entities. Reviewed with the Audit Committee: 1. Core Form Part IV: Checklist of required schedules 2. Core Form Part VI: Governance, Management and Disclosure 3. Core Form Part VII: Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees and Independent Contractors 4. Schedule H: Hospitals 5. Schedule K: Supplemental information on Tax Exempt Bonds 6. Schedule J: Compensation Information 7. Schedule L: Transactions with Interested Persons 8. Schedule R: Related Organizations and Unrelated Partnerships 9. Process for which remaining Core Form was completed, utilizing audited financial information Form 990, Part VI, Section B, line 12c All associates on the Merit program; all Physicians and Non Physician Practitioners as well as Physician groups who are independent contractors or employees of CHS; and all board members must complete a Conflict of Interest Disclosure Statement (COIDS) in order to fulfill the annual requirements. COIDS are distributed to all parties, as per applicable policy, and once complete are followed up with as follows: 1. Associate and Physician completed COIDS are reviewed and signed off by the manager. If a disclosure is noted, it is discussed with the manager, and the document is forwarded to the Compliance officer who reviews and follows up as appropriate. Once review/follow up is completed the Compliance Officer will sign the COIDS, maintain a copy in the compliance office and return the original to HR for filing in the Personnel file. 2. All board member COIDS are returned to Compliance Officer for review and follow up as warranted. The compliance officer will sign each COIDS and retain on file in the compliance office in a confidential manner. Form 990, Part VI, Section B, line 15 CHS, in determining the compensation for the CEO, utilizes a process of review and approval, governed by the Board of Directors that includes an outside nationally recognized independent compensation consultant experienced in compensation and benefit matters for non-profit healthcare organizations, and comparability data. In 2015, the Catholic Health System utilized a Compensation Committee of the Board of Directors to monitor the Executive Compensation as per the Executive Compensation Philosophy and Strategy for the CHS CEO and top Senior Executives. Form 990, Part VI, Section C, line 19 We make our form 990 open for public inspection upon request. Our website includes an annual report which includes selected financial information. Our financial statements, governing documents and conflict of interest policy are provided upon request according to applicable federal and state laws. Form 990, Part XI, line 9: Pension Liability Adjustment -3,198,453. Transfer From Affiliate -531,701. Change in Interest in Foundation 2,491,153. Inherent Contribution Gain on Acquisition 20,593,043. Other -773,987. Catholic Health System Inc 144 Genesee Street Buffalo NY 14203 222565278 Health Care Delivery System NY 501(c)(3) Line 9 0 Mercy Hospital of Buffalo 565 Abbott Road Buffalo NY 14220 160756336 Acute Care Hospital NY 501(c)(3) Line 3 Catholic Health System Inc 0 Sisters Of Charity Hospital 2157 Main Street Buffalo NY 14214 160743187 Acute Care Hospital NY 501(c)(3) Line 3 Catholic Health System Inc 0 Kenmore Mercy Hospital 2950 Elmwood Avenue Kenmore NY 14217 160762843 Acute Care Hospital NY 501(c)(3) Line 3 Catholic Health System Inc 0 Nazareth Home of Franciscan Sisters 291 North Street Buffalo NY 14201 160813142 Skilled Nursing Facility NY 501(c)(3) Line 9 Catholic Health System Inc 0 St Elizabeth Home for the Aged 5539 Broadway Lancaster NY 14086 160743154 Adult Home NY 501(c)(3) Line 9 Catholic Health System Inc 0 St Francis Home of Williamsville 147 Reist St Williamsville NY 14221 160743153 Skilled Nursing Facility NY 501(c)(3) Line 9 Catholic Health System Inc 0 St Francis of Buffalo Inc 34 Benwood Ave Buffalo NY 14214 161523535 Skilled Nursing Facility NY 501(c)(3) Line 9 Catholic Health System Inc 0 St Vincent Manor 319 Washington Avenue Dunkirk NY 14048 160743167 Adult Home NY 501(c)(3) Line 9 Catholic Health System Inc 0 WNY Catholic Long Term Care Inc 6400 Powers Rd Orchard Park NY 14127 161434368 Skilled Nursing Facility NY 501(c)(3) Line 9 Catholic Health System Inc 0 Niagara Homemaker Services (Mercy Home Care) 144 Genesee Street buffalo NY 14203 161317960 Home Care Provider NY 501(c)(3) Line 9 Catholic Health System Inc 0 McAuley Seton Home Care 144 Genesee Street Buffalo NY 14203 161310062 Home Care Provider NY 501(c)(3) Line 9 Catholic Health System Inc 0 Catholic Health System Infusion Pharmacy Inc 6350 Transit Road Depew NY 14043 200198518 Home Care Infusion Services NY 501(c)(3) Line 9 Catholic Health System Inc 0 OLV Renaissance Corporation 144 Genesee Street Buffalo NY 14203 200167745 Real Estate Holding Company NY 501(c)(3) Line 9 Catholic Health System Inc 0 CHS Program of All-Inclusive Care for the Elderly Inc 55 Melroy Avenue Lackawanna NY 14218 261252884 All-inclusive Care for the Elderly NY 501(c)(3) Line 3 Catholic Health System Inc 0 Trinity Medical WNY PC 2625 Harlem Rd Cheektowaga NY 14225 272576645 Primary Care Provider NY 501(c)(3) Line 11a, I Catholic Health System Inc 0 KMH Homes Inc 144 Genesee Street Buffalo NY 14203 161387890 Real Estate Holding Company NY 501(c)(3) Line 9 Catholic Health System Inc 0 Mount St Mary's Hospital Foundation Inc 5300 Military Road Lewiston NY 14092 161360884 Foundation NY 501(c)(3) Line 7 Mount St Mary's Hospital of Niagara Falls 0 Mount St Mary's Hospital Child Care Center 5310 Military Road Lewiston NY 14092 161523352 Child Care NY 501(c)(3) Line 9 Catholic Health System Inc 0 Board of Associates of Mount St Mary's Hospital Inc 5300 Military Road Lewiston NY 14092 161582926 Fund Raising NY 501(c)(3) Line 11a, I Mount St Mary's Hospital of Niagara Falls 0 The St Francis Guild of Mount St Mary's Hospital of Niagara Falls Inc 5300 Military Road Lewiston NY 14092 510217790 Fund Raising NY 501(c)(3) Line 11a, I Mount St Mary's Hospital of Niagara Falls 0 Ascension Health Alliance 4600 Edmundson Road St Louis MO 63134 453358926 National Health System MO 501(c)(3) Line 11a, I 0 Ascension Health PO Box 45998 St Louis NY 63145 311662309 National Health System MO 501(c)(3) Line 11a, I Ascension Health Alliance 0 Our Lady of Peace Inc 5285 Lewiston Road Lewiston NY 14092 161608735 Nursing Home NY 501(c)(3) Line 3 Ascension Health Alliance 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1