2017-10-30T10:22:00-05:00 2016-12-31 ERNST & YOUNG US LLP 5 TIMES SQUARE NEW YORK NY 10036 990 2016-01-01 150552726 MARGARETVILLE MEMORIAL HOSPITAL % ERIN NAGY MARG 8459436084 42084 STATE ROUTE 28 MARGARETVILLE NY 12445 DAVID SCARPINO CEO 8459436024 2017-10-26 true LAURA KIELCZEWSKI P00740769 2127733000 164.57.159.254 26308520173035000009 2017-10-30 P 050F75853A9F423F493495C03CDD05FDA32C01D0 050F75853A9F423F493495C03CDD05FDA32C01D0 2016 2021-01-29 14:40:06Z DAVID SCARPINO 741 GRANT AVENUE LAKE KATRINE NY 12449 15995198 false X http://www.margaretvillehosp.org/ X 1930 NY TO PROVIDE IMMEDIATE ACCESS TO HIGH QUALITY MEDICAL CARE AND DIAGNOSTIC TESTING SERVICES TO MEDICALLY UNDERSERVED AREAS IN THE CATSKILL MOUNTAINS. 16 12 147 22 0 1752614 2988507 9248871 9053829 75458 362189 535616 1347338 11612559 13751863 0 0 0 0 6712242 7076052 0 0 0 6689303 5799118 13401545 12875170 -1788986 876693 9166004 7183706 8212354 5048393 953650 2135313 X TO PROVIDE IMMEDIATE ACCESS TO HIGH QUALITY MEDICAL CARE AND DIAGNOSTIC TESTING SERVICES TO MEDICALLY UNDERSERVED AREAS IN THE CATSKILL MOUNTAINS. false false 10154924 0 9053829 MARGARETVILLE MEMORIAL HOSPITAL PROVIDES ACUTE HEALTH CARE SERVICES TO RESIDENTS AND VISITORS TO THE CATSKILL REGION. MARGARETVILLE MEMORIAL HOSPITAL RECORDED 1,492 PATIENT DAYS, 4,167 EMERGENCY ROOM VISITS, 163 OUTPATIENT SURGERIES, 238 DISCHARGES AND 84 INFUSION THERAPIES IN 2016. 10154924 true true false true false false false false false false true false false true true false false true false false false false false false true false true true false false true false false false false false false false false false false false false false true true true false false true 32 0 true 147 true false false false false false false false false false false X 16 12 false false true false true true true true true false false true true true true true true false false false NY X ERIN NAGY 8459436084 741 GRANT AVENUE LAKE KATRINE NY 12449 Carey Wagner CHAIR 1.0 4.0 X 0 0 0 JANE Piasek Trustee 1.0 1.0 X 0 0 0 Fred Marguiles Secretary 1.0 1.0 X 0 0 0 Arthur Martello Trustee 1.0 1.0 X 0 0 0 Jenny Morrill-Liddle 1st Vice Chair 1.0 1.0 X 0 0 0 Thomas O'Brien Trustee 1.0 1.0 X 0 0 0 Philip Mehl TRUSTEE (effective 04/16) 1.0 39.0 X 0 50429 5534 David Riordan Trustee 1.0 1.0 X 0 0 0 Nancy Slauson Trustee 1.0 1.0 X 0 0 0 David Scarpino CHIEF EXECUTIVE OFFICER 1.2 36.3 X X 0 490944 23443 Kent Garrett Trustee 1.0 1.0 X 0 0 0 Thomas Collins EX-OFFICIO TRUSTEE 1.0 4.0 X 0 0 0 James Howie Trustee 1.0 1.0 X 0 0 0 Rita Herbst Trustee 1.0 1.0 X 0 0 0 WEYMIN HAGO MD EX-OFFICIO TRUSTEE 1.0 1.0 X 69077 0 0 MARK POHAR TRUSTEE (effective 5/4/16) 18.25 19.25 X 0 140335 19876 CHRISTOPHER ESOLA TRUSTEE (effective 5/1/16) 37.5 0.0 X 0 80179 2475 Patricia Gavis CHIEF FINANCIAL OFFICER 0.5 37.0 X 0 259863 20854 Sandra Horan Chief Nursing Officer 0.0 37.5 X 0 200755 12950 John Finch CIO & CCO (resigned 12/22/16) 1.0 36.5 X 0 237451 33909 Eileen King CLINICAL COORDINATOR 40.0 0.0 X 239167 0 15844 Joseph Marsicovete Chief Operating Officer 3.0 34.5 X 0 296183 16654 Paul Llobet MD Chief Medical Director 5.65 31.85 X 0 312458 1783 Steven Haas FORMER CFO 0.0 0.0 X 0 116471 14919 308244 2185068 168241 1 true true false Laboratory Corp of America PO Box 12140 BURLINGTON NC 27216 Laboratory Services 454858 Seco Physical Occupational Therap PO Box 1046 NORWICH NY 13815 CONSULTING 194926 Llobet Medical PO Box 1020 MARGARETVILLE NY 12455 Medical 143608 MEDICAL STAFFING NETWORK PO Box 840292 DALLAS TX 75284 STAFFING AGENCY 123007 4 0 5000 2847408 136099 0 2988507 NET PATIENT SERVICE REVENUE 621300 9053829 9053829 0 0 9053829 122218 122218 0 0 77504 14974 62530 0 62530 62530 2459271 2219300 239971 239971 239971 38317 9061 29256 29256 0 0 0 0 0 0 PHARMACY REVENUE 446110 502201 0 0 502201 PHARMACY SALES TO EMPLOYEES 446110 337554 0 0 337554 REPAYMENT OF LOAN PROCEEDS 900099 222500 0 0 222500 193297 76625 0 116672 1255552 13751863 9130454 0 1632902 X 0 0 0 0 0 0 0 0 69077 69077 0 0 0 0 0 0 5423315 4099445 1323870 0 17272 12954 4318 0 1195164 896515 298649 0 371224 278418 92806 0 0 0 0 0 595 0 595 0 72479 0 72479 0 23085 0 23085 0 0 0 0 0 0 0 1239617 1094749 144868 0 7538 0 7538 0 565826 224627 341199 0 0 0 0 0 0 0 0 0 102749 2200 100549 0 21437 10 21427 0 0 0 0 0 122006 119887 2119 0 67676 0 67676 0 0 0 0 0 1369834 1369834 0 0 90623 0 90623 0 MEDICAL SUPPLIES 897437 896730 707 0 EQUIPMENT SVCS CONTRACTS 788230 752224 36006 0 PHYSICIAN FEES 300430 254030 46400 0 ALL OTHER EXPENSES 129556 84224 45332 0 12875170 10154924 2720246 0 0 429384 1763237 0 0 182396 40362 946561 872399 0 0 0 0 0 0 210747 248866 144607 133304 21652728 19515619 3206285 2137109 0 0 0 0 0 0 0 0 4046024 1988429 9166004 7183706 2149936 2191385 0 0 1545120 1536554 0 0 0 0 0 0 181303 109528 0 0 4335995 1210926 8212354 5048393 X 1031454 2135313 144696 0 -222500 0 953650 2135313 9166004 7183706 X 876693 -272847 0 0 0 577817 X X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false 0 false 0 false 0 false 0 false 0 false 0 true 23085 23085 false false SCHEDULE C, PART II-B, LINE 1I MARGARETVILLE MEMORIAL HOSPITAL PAYS DUES TO THE IROQUOIS HEALTHCARE ALLIANCE OF NEW YORK STATE (IHA). IN ACCORDANCE WITH SECTION 6033(E) OF THE INTERNAL REVENUE CODE, AND AS REPORTED BY IHA, A PORTION OF THESE DUES ARE ATTRIBUTABLE TO LOBBYING ACTIVITIES. THE LOBBYING ACTIVITIES APPLICABLE TO 2016 IHA ANNUAL DUES WERE $23,085. 0 23128 23128 0 4648500 3845776 802724 0 456812 355058 101754 0 16524288 15314785 1209503 2137109 DUE FROM RELATED PARTIES 1488455 INTEREST IN NA - MH FOUNDATION 329778 OTHER RECEIVABLE 121701 DUE FROM 3RD PARTY PAYORS 44137 ASSETS LIMITED AS TO USE 4358 1988429 0 DUE TO THIRD PARTY PAYORS 1117048 OTHER NON-CURRENT LIABILITIES 93878 1210926 HARVEST MOON 24255 24255 3634 578 2811 FLEA MARKET 14062 14062 120 723 400 795 0 38317 38317 120 4357 978 3606 9061 29256 true true X true X true X true true false true true 132753 16317 116436 0.00960 1898862 1116347 782515 0.06440 2031615 1132664 898951 0.07400 4169 4169 0.00030 4553276 2590645 1962631 0.16150 4557445 2590645 1966800 0.16180 6589060 3723309 2865751 0.23580 true 455441 3752937 3177866 575071 X true true 1 1 MARGARETVILLE MEMORIAL HOSPITAL 42084 STATE ROUTE 28 MARGARETVILLE NY 12455 HTTP://WWW.HAHV.ORG/HAHV/HOME.ASPX 1226701C X X X X MARGARETVILLE MEMORIAL HOSPITAL 1 false false true X X X X X X X X X 16 true true true true X SEE SECTION C X true 16 true SEE SECTION C false true X 150. 300. X X true true X X X true X SEE SECTION C X SEE SECTION C X SEE SECTION C X X X X X X true X false X X true X false false Part V, Section B, Line 5: 2016-2018 CHNA Implementation Plan IN ACCORDANCE WITH THE AFFORDABLE CARE ACT (ACA) OF 2010 AND THE NEW YORK STATE (NYS) HEALTH IMPROVEMENT PLAN'S PREVENTION AGENDA REQUIREMENTS, HEALTHALLIANCE OF THE HUDSON VALLEY (HEALTHALLIANCE), A MEMBER OF THE WESTCHESTER MEDICAL CENTER HEALTH NETWORK (WMCHEALTH), PARTICIPATED WITH OTHER AREA HOSPITALS, PUBLIC AND GOVERNMENT AGENCIES, COMMUNITY PARTNERS AND THE ULSTER COUNTY DEPARTMENT OF HEALTH AND MENTAL HEALTH (UCDOHMH) TO CONDUCT A COMMUNITY HEALTH ASSESSMENT AND DEVELOP A LOCAL COMMUNITY HEALTH IMPROVEMENT PLAN. A WORK GROUP CONSISTING OF UCDOHMH AND LOCAL AREA HOSPITALS MET REGULARLY BEGINNING IN MAY 2016 TO IDENTIFY AND PRIORITIZE COMMUNITY HEALTH NEEDS. THE 2016-2018 COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) AND COMMUNITY HEALTH IMPROVEMENT PLAN IS AN UPDATE TO THE PREVIOUSLY CREATED 2014-2016 CHNA AND COMMUNITY HEALTH IMPROVEMENT PLAN. AS SUCH, THE 2014-2016 PLANS SERVED AS A FOUNDATION FOR CREATING THE 2016-2018 PLANS. PARTNERS MET ON A MONTHLY TO BIMONTHLY BASIS TO ANALYZE DATA SETS AND COMMUNITY STRENGTHS. THE COMMUNITY PARTICIPATED IN THE PROCESS TO PRIORITIZE IMPROVING THE HEALTH OF ULSTER COUNTY BY MEANS OF A COMMUNITY HEALTH SURVEY. HEALTHALLIANCE'S CONTINUING PROGRESS AND MONITORING OF GOALS IDENTIFIED IN THIS CHNA WILL BE MANAGED BY AN INTERNAL COMMUNITY BENEFITS COMMITTEE (CBC). THIS COMMITTEE MET ON APRIL 26, 2016, FOR AN UPDATE BY THE UCDOHMH ON THE NYS PREVENTION AGENDA AND THE PROGRESS MADE SINCE 2013 WHEN THE LAST COMMUNITY SERVICE PLAN WAS WRITTEN, AND TO STRATEGIZE THE 2016-2018 INTERVENTIONS. THE CBC WILL ENGAGE INTERNAL AND EXTERNAL RESOURCES TO DEVELOP AND IMPLEMENT EVIDENCE BASED STRATEGIES ACROSS THE SERVICE AREAS TO DIRECTLY ADDRESS IDENTIFIED HEALTH NEEDS THAT HEALTHALLIANCE WILL PURSUE. CURRENT AND NEW OUTREACH STRATEGIES WILL BE MODIFIED, IF NEEDED, AND DEVELOPED DURING THE CURRENT TERM OF THE 2016-2018 COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA). Part V, Section B, Line 6a: The CHNA was conducted with the following other hospital facilities: HealthAlliance Hospital Broadway Campus and HEALTHALLIANCE HOSPITAL MARY'S AVENUE CAMPUS Part V, Section B, Line 6b: The CHNA was conducted with the following other NON-hospital facilities: Ulster County Department of Health and Mental Health Part V, Section B, Line 7: CHNA Website The hospitals CHNA report is widely available to the public at the below website url: http://hahv.org/hahv/community-service-plan.aspx Part V, Section B, Line 10: Implementation Strategy Website The Hospitals most recently adopted implementation strategy is posted at the below website url: http://hahv.org/hahv/community-service-plan.aspx Part V, Section B, line 11 HEALTHALLIANCE'S CONTINUING PROGRESS AND MONITORING OF GOALS IDENTIFIED IN THE CHNA WILL BE MANAGED BY AN INTERNAL COMMUNITY BENEFITS COMMITTEE (CBC). THIS COMMITTEE MET ON APRIL 26, 2016, FOR AN UPDATE BY THE UCDOHMH ON THE NYS PREVENTION AGENDA AND THE PROGRESS MADE SINCE 2013 WHEN THE LAST COMMUNITY SERVICE PLAN WAS WRITTEN, AND TO STRATEGIZE THE 2016-2018 INTERVENTIONS. THE CBC WILL ENGAGE INTERNAL AND EXTERNAL RESOURCES TO DEVELOP AND IMPLEMENT EVIDENCE BASED STRATEGIES ACROSS THE SERVICE AREAS TO DIRECTLY ADDRESS IDENTIFIED HEALTH NEEDS THAT HEALTHALLIANCE WILL PURSUE. CURRENT AND NEW OUTREACH STRATEGIES WILL BE MODIFIED, IF NEEDED, AND DEVELOPED DURING THE CURRENT TERM OF THE 2016-2018 COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA). Implementation Strategy In accordance with the NYS Prevention Agenda mandate, HealthAlliance will align with UCDOHMH to focus on two priority areas: Prevent Chronic Disease and Promote Mental Health/Prevent Substance Abuse. These priorities consist of focus areas that impact 12 of the 16 health needs identified in the CHNA and will be addressed by HealthAlliance. HEALTH NEEDS IDENTIFIED THE 16 HEALTH NEEDS IDENTIFIED IN THE 2013 CHNA CONTINUE TO BE RELEVANT IN 2016. THE HEALTH NEEDS INCLUDE CANCER, HEART DISEASE, TOBACCO USE, OBESITY AND MENTAL HEALTH, AMONG OTHERS. ACCORDING TO THE 2015 PUBLICATION "ONE REGION, ONE COMMUNITY NEEDS ASSESSMENT", AN EIGHT COUNTY COMMUNITY NEEDS ASSESSMENT OF THE HUDSON VALLEY REGION UNDERTAKEN IN COLLABORATION WITH WESTCHESTER MEDICAL CENTER, THE MONTEFIORE HUDSON VALLEY COLLABORATIVE, REFUAH HEALTH CENTER AND HEALTHALLIANCE OF THE HUDSON VALLEY AS PART OF DSRIP TO EXTENSIVELY ASSESS REGIONAL NEEDS, RANKED THE TOP HEALTH ISSUES IN THE COMMUNITY (OUT OF 17) AS CANCER, OBESITY, MENTAL HEALTH, DIABETES AND HEART DISEASE. THESE INCLUDE THE SAME HEALTH NEEDS IDENTIFIED BY THE COMMUNITY IN THE 2016 ULSTER COUNTY COMMUNITY HEALTH SURVEY (DRUG ABUSE, MENTAL HEALTH AND OBESITY). THESE IDENTIFIED AREAS WILL BE ADDRESSED IN HEALTHALLIANCE'S 2016-2018 IMPLEMENTATION STRATEGY, AFTER WHICH THE NEXT COMMUNITY HEALTH NEEDS ASSESSMENT WILL BE PERFORMED. The Cancer Committee of the HealthAlliance Hospitals Commission on Cancer (COC) Accredited Cancer Program is comprised of physicians, nurses, social workers and other allied health professionals focused on cancer-related care for hospital patients and community members. HealthAlliances Cancer Committee is dedicated to improving survival and quality of life for cancer patients through standard-setting, prevention, research, education and the monitoring of comprehensive quality care. The committee is responsible for planning, initiating, implementing, evaluating and improving all cancer related activities in our facility. The Cancer Committee of the HealthAlliance Hospital established a prevention goal for 2016/2017, and for the 2016-2018 Ulster County Community Service Plan, that is aimed at reducing obesity in an effort to decrease the risk of chronic diseases, including certain forms of cancer. HealthAlliances Oncology Support Program helps to address this by offering ongoing dance and exercise classes, such as yoga, Tai Chi and Smart Bells classes to the general population in an effort to increase physical activity in Ulster County, including those with chronic disease. Monthly plant-based diet cooking classes are also offered in an attempt to increase the consumption of whole grains and plant-based foods. These programs and similar will continue through 2018. In October 2016 the Oncology Support Program also developed the Wellness and Weight Management Series, a free, six-session program that incorporates the services of a dietitian and includes healthy food demonstrations presented at the Reuner Cancer Support House. The goals of the prevention program are to reduce the Body Mass Index (BMI) for participants who are overweight, increase usage of fruits and vegetables and increase physical exercise. The program met three times and was well attended by a range of 6-18 participants at classes. 100% of participants surveyed reported improved health after attending classes as measured by a pre and posttest. Participants reported they were able to identify effective weight loss strategies, understand how to overcome weight management obstacles at work and identify support mechanisms. Additionally during 2016, The Cancer Committee developed a referral form through which health care professionals involved in cancer care can refer patients to the wellness programs available at HealthAlliance Hospital, the Oncology Support Program and in the community. Breast Cancer Screening Program Breast Cancer Screenings are regularly offered at the HealthAlliance Fern Feldman Anolick Center for Breast Health, part of the comprehensive breast care program at HealthAlliance Hospital Marys Avenue Campus. Our integrated practice brings together a multispecialty cancer treatment team of experts to ensure you get the best care available. The experts include breast health specialists, radiation oncologists, medical oncologists, surgeons, plastic surgeons, pathologists, radiologists and a skilled support staff - all working as a multidisciplinary team to provide whole-person care for women. Our certified Breast Patient Navigator ensures seamless, coordinated care among physicians, diagnostic tests and cancer treatments, while offering education, guidance and supporting the patient and HIS/HER family. The center, an FDA certified mammography facility, received certification in mammography, stereotactic biopsy and breast ultrasound from the American College of Radiology and is designated as a Breast Imaging Center of Excellence by the American College of Radiology. The Cancer Committee of HealthAlliance Hospital identified the need to ensure that low income members of Ulster County have access to breast cancer screenings in order to reduce breast cancer mortality in this population. On three occasions in 2016, the Breast Patient Navigator and the manager of the Center for Breast Health conducted outreach to the low income population that accesses the food pantry at Peoples Place. This afforded HealthAlliance the opportunity to identify the barriers to breast cancer screening, help members of the community access breast cancer screening, and guide those 2016 update: HAHV provided professional outreach to the community at PP on six dates during 8/16/16-11/29/16 providing DEX heel scans, Breast Health Outreach and Diabetes Education interacting with 271 participants. Live Well Kingston is a city-endorsed coalition focused on improving active living and healthy eating opportunities in Kingston, NY. It is fiscally sponsored and coordinated by Cornell Cooperative Extension of Ulster County (CCEUC) in accordance with a Memorandum of Understanding with the City of Kingston. The coalition grew out of a four-year partnership initiative to reverse childhood obesity entitled Healthy Kingston for Kids, and funded by the Robert Wood Johnson Foundation. HealthAlliance of the Hudson Valley was a founding funding partner supporting the Live Well Kingston (LWK) coalition in its infancy and in the development of its focus teams and action plans. In 2014, the LWK coalition finalized its Articles of Collaboration, established a leadership team, and determined and formed its priority focus teams. Each focus team is now developing action plans. 2016 Update: > The LWK coalition implemented a communications strategy which included new logos and design for website, social media, brochures and other outreach materials to increase the impact of healthy messaging within the community. > Four focus teams were active in 2015 Age Well, Eat Well, Heal Well and Travel Well. New leadership was recruited for Play Well. > Age Well conducted a series of focus groups at different locations to assess barriers to healthy eating and physical activity. This revealed a need for transportation to healthy activities, including farmers markets and parks, as well as a need for both the availability of internet access and training on how to utilize technology to access resources. Negotiations for Wi-Fi and a computer in the common room of two low income senior residences were successful, and the project is underway. In addition, the Hudson Valley Resource List created by IPRO, was released in August 2016. IPROs list will be used to develop a list inclusive of Ulster County services and opportunities. Transportation needs are in discussion with mangers of the senior residences as well as with Ulster County Area Transit (UCAT) and the City of Kingston bus system. > Eat Well held a retreat for focus team members and invited the Mayor of Kingston. They developed a plan to hold 8-10 listening sessions at multiple sites within Kingston to assess barriers to healthy eating. These are set to begin late fall/early winter of 2016-2017. > Heal Well held a series of Walk and Talk with a Doc, in local parks and trails and, through the winter months, at the indoor track at the YMCA of Kingston and Ulster County. > Play Well has two new co-chairs which include the director of the YMCA of Kingston and Ulster County and the owner of Innate Parkour. They are currently recruiting focus team members and will be developing an action plan in early 2017. > Travel Well, which includes three active transportation groups in Kingston the Kingston Complete Streets Advisory Council, the Kingston Land Trust: Kingston Greenline Committee and Bike Friendly Kingston forwarded several active transportation projects in cooperation with the City of Kingston. These included the Kingston Connectivity Project, the Kingston Point Rail Trail and Complete Streets on Cornell, Foxhall, North Street and Broadway. The Kingston Greenline completed construction on the Trolley Trail portion of the Greenline. Funding has been awarded for other sections of the Greenline and design and construction is in progress. In addition, A SAFE ROUTES TO SCHOOL PROJECT AND THE HUDSON LANDING PROMENADE AND DEVELOPMENT PROJECT ARE UNDERWAY. BIKE FRIENDLY KINGSTON HELD SEVERAL COMMUNITY BIKE RIDES, IMPLEMENTED BICYCLE EDUCATION AND OPENED A REPAIR CAF. THEY ARE CURRENTLY ORGANIZING A BICYCLE AND PEDESTRIAN BICYCLE COUNT ON BROADWAY IN COLLABORATION WITH THE ULSTER COUNTY TRANSPORTATION COUNCIL. > AS A SUCCESSFUL HEALTH COALITION, THE STRUCTURE, FUNCTION, SUCCESSES AND CHALLENGES OF LWK WERE SHARED IN PRESENTATIONS AT SEVERAL CONFERENCES INCLUDING THE 2016 NEW YORK STATE PUBLIC HEALTH ASSOCIATION, THE 2015 AMERICAN PLANNING ASSOCIATION OF THE GREATER METRO AREA AND THE 2015 NEW YORK DASH-NY COALITION CONFERENCE. HEALTH NEEDS NOT ADDRESSED BY HEALTHALLIANCE OF THE HEALTH NEEDS IDENTIFIED BY ULSTER COUNTY, HEALTHALLIANCE IS FOCUSING ON THE PRIORITIES OUTLINED ABOVE. PEDIATRIC ASTHMA HOSPITALIZATIONS, UNPLANNED PREGNANCY, MOTOR VEHICLE CRASH DEATHS AND FALL HOSPITALIZATIONS WERE AMONG THE PRIORITIZED HEALTH NEEDS HEALTHALLIANCE CHOSE NOT TO FOCUS ON. HEALTHALLIANCE DOES NOT POSSESS THE INFRASTRUCTURE AND RESOURCE'S TO AID IN PREVENTION AND CONTINUOUS MEASUREMENT OF THESE HEALTH NEEDS, NOR DOES IT ALIGN WITH NYS PREVENTION AGENDA PRIORITIES. WE RECOGNIZE THAT WE CANNOT PURSUE ALL OF THE IDENTIFIED HEALTH NEEDS AND THAT DECISIONS ARE BASED UPON INTERNAL AND EXTERNAL ASSETS TO SUSTAIN PROGRAMS THAT WOULD MAKE A MEANINGFUL IMPACT. BOARD APPROVAL PRIOR TO FINALIZATION, SUBMISSION AND RELEASE OF THE HOSPITAL'S COMMUNITY SERVICE AND IMPLEMENTATION PLAN, COMMENTS AND INPUT FROM THE BOARD OF DIRECTORS ARE IMPLEMENTED BEFORE FINALIZING. Part V, Section B, Line 16a, b and c:FAP Policy Website The Hospital's financial assistance policy and FAP application are available at the following website: http://hahv.org/hahv/financial-assistance.aspx PART V, SECTION C, LINE 5 IN ACCORDANCE WITH THE AFFORDABLE CARE ACT (ACA) OF 2010 AND THE NEW YORK STATE (NYS) HEALTH IMPROVEMENT PLAN'S PREVENTION AGENDA REQUIREMENTS, HEALTHALLIANCE OF THE HUDSON VALLEY (HEALTHALLIANCE), A MEMBER OF THE WESTCHESTER MEDICAL CENTER HEALTH NETWORK (WMCHEALTH), PARTICIPATED WITH OTHER AREA HOSPITALS, PUBLIC AND GOVERNMENT AGENCIES, COMMUNITY PARTNERS AND THE ULSTER COUNTY DEPARTMENT OF HEALTH AND MENTAL HEALTH (UCDOHMH) TO A COMMUNITY HEALTH ASSESSMENT AND DEVELOP A LOCAL COMMUNITY HEALTH IMPROVEMENT PLAN. A WORK GROUP CONSISTING OF UCDOHMH AND LOCAL AREA HOSPITALS MET REGULARLY BEGINNING IN MAY 2016 TO IDENTIFY AND PRIORITIZE COMMUNITY HEALTH NEEDS. THE 2016-2018 COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) AND COMMUNITY HEALTH IMPROVEMENT PLAN IS AN UPDATE TO THE PREVIOUSLY CREATED 2014-2016 CHNA AND COMMUNITY HEALTH IMPROVEMENT PLAN. AS SUCH, THE 2014-2016 PLANS SERVED AS A FOUNDATION FOR CREATING THE 2016-2018 PLANS. PARTNERS MET ON A MONTHLY TO BIMONTHLY BASIS TO ANALYZE DATA SETS AND COMMUNITY STRENGTHS. THE COMMUNITY PARTICIPATED IN THE PROCESS TO PRIORITIZE IMPROVING THE HEALTH OF ULSTER COUNTY BY MEANS OF A COMMUNITY HEALTH SURVEY. PART V, SECTION C, LINE 11 HEALTHALLIANCE'S CONTINUING PROGRESS AND MONITORING OF GOALS IDENTIFIED IN THE CHNA WILL BE MANAGED BY AN INTERNAL COMMUNITY BENEFITS COMMITTEE (CBC). THIS COMMITTEE MET ON APRIL 26, 2016, FOR AN UPDATE BY THE UCDOHMH ON THE NYS PREVENTION AGENDA AND THE PROGRESS MADE SINCE 2013 WHEN THE LAST COMMUNITY SERVICE PLAN WAS WRITTEN, AND TO STRATEGIZE THE 2016-2018 INTERVENTIONS. THE CBC WILL ENGAGE INTERNAL AND EXTERNAL RESOURCES TO DEVELOP AND IMPLEMENT EVIDENCE BASED STRATEGIES ACROSS THE SERVICE AREAS TO DIRECTLY ADDRESS IDENTIFIED HEALTH NEEDS THAT HEALTHALLIANCE WILL PURSUE. CURRENT AND NEW OUTREACH STRATEGIES WILL BE MODIFIED, IF NEEDED, AND DEVELOPED DURING THE CURRENT TERM OF THE 2016-2018 COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA). HEALTH NEEDS IDENTIFIED THE 16 HEALTH NEEDS IDENTIFIED IN THE 2013 CHNA CONTINUE TO BE RELEVANT IN 2016. THE HEALTH NEEDS INCLUDE CANCER, HEART DISEASE, TOBACCO USE, OBESITY AND MENTAL HEALTH, AMONG OTHERS. ACCORDING TO THE 2015 PUBLICATION "ONE REGION, ONE COMMUNITY NEEDS ASSESSMENT", AN EIGHT COUNTY COMMUNITY NEEDS ASSESSMENT OF THE HUDSON VALLEY REGION UNDERTAKEN IN COLLABORATION WITH: WESTCHESTER MEDICAL CENTER, MONTEFIORE MEDICAL CENTER, REFUAH HEALTH CENTER AND HEALTHALLIANCE OF THE HUDSON VALLEY AS PART OF DSRIP TO EXTENSIVELY ASSESS REGIONAL NEEDS, RANKED THE TOP HEALTH ISSUES IN THE COMMUNITY (OUT OF 17) AS CANCER, OBESITY, MENTAL HEALTH, DIABETES AND HEART DISEASE. THESE INCLUDE THE SAME HEALTH NEEDS IDENTIFIED BY THE COMMUNITY IN THE 2016 ULSTER COUNTY COMMUNITY HEALTH SURVEY (DRUG ABUSE, MENTAL HEALTH AND OBESITY). THESE IDENTIFIED AREAS WILL BE ADDRESSED IN HEALTHALLIANCE'S 2016-2018 IMPLEMENTATION STRATEGY, AFTER WHICH THE NEXT COMMUNITY HEALTH NEEDS ASSESSMENT WILL BE PERFORMED. HEALTH NEEDS NOT ADDRESSED OF THE HEALTH NEEDS IDENTIFIED BY ULSTER COUNTY, HEALTHALLIANCE IS FOCUSING ON THE PRIORITIES OUTLINED ABOVE. PEDIATRIC ASTHMA HOSPITALIZATIONS, UNPLANNED PREGNANCY, MOTOR VEHICLE CRASH DEATHS AND FALL HOSPITALIZATIONS WERE AMONG THE PRIORITIZED HEALTH NEEDS HEALTHALLIANCE CHOSE NOT TO FOCUS ON. HEALTHALLIANCE DOES NOT POSSESS THE INFRASTRUCTURE AND RESOURCE'S TO AID IN PREVENTION AND CONTINUOUS MEASUREMENT OF THESE HEALTH NEEDS, NOR DOES IT ALIGN WITH NYS PREVENTION AGENDA PRIORITIES. WE RECOGNIZE THAT WE CANNOT PURSUE ALL OF THE IDENTIFIED HEA PART I, LINE 7 - EXPLANATION OF COSTING METHODOLOGY Margaretville Memorial Hospitals costing methodology was based upon the internal cost accounting system of the hospital. The cost-to-charge ratio was used for the various sub-line items of line # 7. Part I, Line 7b, Column d In 2015, Margaretville Memorial Hospital incurred expenses related to Medicaid rate adjustments, which it reported on Part I, Line 7b, Column c. However, due to a timing difference, the revenue related to the Medicaid rate adjustments was not received until 2016. As a result, the direct offsetting revenue related to the Medicaid rate adjustments was not reported on Margaretville Memorial Hospitals Schedule H in 2015. Margaretville Memorial Hospital has reported this revenue on Part I, Line 7b, Column d in the current year. PART I, LINE 7G: COST ASSOCIATED WITH PHYSICIAN CLINICS The costs on line 7G include $0 of costs attributable to physician clinics. Part III, Line 2: Methodology Used to Estimate Amount of Bad Debt Expense The amount reported on line 2 is equal to the provision for bad debt expense per the audited financial statements (AFS). The explanation of the methodology used to estimate this amount can be found in Footnote #2 on pages 10-11 of the attached AFS. Part III, Line 4: Description of Bad Debt Expense The text of the footnote that describes bad debt expense can be found on Pages 10-11 of the attached audited financial statements. Part III, Line 8: Costing Methodology Since Margaretville Memorial Hospital is a critical access hospital, the hospital receives 101% of its cost for most of its services; therefore Margaretville should always have a surplus from Medicare. The amount reported on Line 6 was derived by using the Medicare allowable costs as reported on the Medicare cost report and the applicable adjustments from Worksheet A. For 2016, Margaretville Memorial Hospital does not have a loss from Medicare therefore it is not considered a community benefit. PART III LINE 9B: COLLECTION PRACTICES The credit and collection policy for self-pay balances provides that, in some cases, non-insured patients that do not qualify for Medicaid qualify for Charity Care. In those instances, the credit and collection department will follow the guidelines as set forth in the Charity Care policy. The Charity Care policy provides that the financial counselor evaluates the information provided in patients charity care applications in conjunction with Federal income poverty guidelines to determine the write-off percentage. If the patient/guarantor qualifies for charity care based on the sliding scale, the patient will be required to pay the outstanding amount. A payment plan is established not to exceed 10% of the guarantors gross monthly income. PART VI, LINE 2: COMMUNITY NEEDS ASSESSMENT COMMUNITY NEEDS ASSESSMENT IS DONE ON TWO LEVELS. BELOW WE EXPLAIN THE CHNA PROCESS WE ENGAGED IN DURING 2016, THE MACRO LEVEL OF ASSESSMENT THAT OCCURS EVERY THREE YEARS. ON A MICRO LEVEL AND ON AN ONGOING BASIS, STAFF FROM VARIOUS LEVELS OF THE ORGANIZATION ARE ENGAGED OUTSIDE THE WALLS OF THE HOSPITAL IN THE COMMUNITY IMPLEMENTING THE NEEDS THAT WERE GENERATED AS A RESULT OF THE MACRO CHNA ASSESSMENT AND REASSESSING HOW THE VARIOUS PLANS ARE PROGRESSING. STAFF THAT INTERFACE WITH THE COMMUNITY INCLUDE THE CEO WHO MEETS ON AN ONGOING BASIS WITH THE FAITH BASED COMMUNITY, COORDINATORS WHO SERVE ON THE LIVE WELL KINGSTON COMMISSION AND GATHER COMMUNITY INFO FROM THAT MONTHLY MEETING, AND THE COMMUNITY HEALTH COORDINATOR WHO SERVES ON THE HEALTHY ULSTER COUNCIL AND MEETS WITH OTHER AGENCY LEADERS TO LEARN OF COMMUNITY NEEDS. PARTNERS BEGINNING MAY 2016, THE HEALTHALLIANCE COMMUNITY HEALTH COORDINATOR MET WITH THE STAFF OF THE UCDOHMH AND COMMENCED THE COMMUNITY HEALTH NEEDS PLANNING INITIATIVE. ADDITIONAL HEALTH CARE LEADERS WERE INVITED TO PARTICIPATE IN THE INITIATIVE, INCLUDING ELLENVILLE REGIONAL HOSPITAL. MEETINGS WERE HELD MAY 17, MAY 31, JUNE 14, JUNE 28, JULY 26, AUGUST 9, SEPTEMBER 27, OCTOBER 25 AND NOVEMBER 22. THE COMMUNITY PARTICIPATED IN THE PROCESS TO PRIORITIZE IMPROVING THE HEALTH OF THE COUNTY BY MEANS OF A COMMUNITY HEALTH SURVEY THAT WAS DRAFTED AND DISTRIBUTED AS A RESULT OF THESE MEETINGS. IT WAS PROVIDED TO THE COMMUNITY ONLINE AND IN PAPER FORMAT WITH A COLLECTION BOX AT COMMUNITY AGENCIES STRATEGICALLY LOCATED FOR POPULATIONS WITH THE GREATEST NEED. ULTIMATELY, MORE THAN 600 COMMUNITY SURVEYS WERE COLLECTED AND TABULATED. METHODOLOGY AND PROCESS THE PREVIOUS CHNA, DEMOGRAPHIC DATA AND TRENDS, NYS PREVENTION AGENDA DASHBOARD, COUNTY HEALTH RANKINGS, EBRFSS DATA, A REGIONAL COMMUNITY NEEDS ASSESSMENT (CNA) UNDERTAKEN IN COLLABORATION WITH WMCHEALTH, MONTEFIORE MEDICAL CENTER, HEALTHALLIANCE AND AN ULSTER COUNTY COMMUNITY HEALTH SURVEY COMPLETED BY OVER 600 RESIDENTS OF ULSTER COUNTY, WERE USED TO DEVELOP THE CHNA. THE SURVEY WAS AVAILABLE BOTH ONLINE AND IN PAPER COPIES THAT WERE STRATEGICALLY PLACED TO BE ACCESSIBLE TO LOW INCOME, CHRONICALLY ILL AND MINORITY COMMUNITIES WITH THE GREATEST NEED. PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE: The hospital informs the patient of the availability of charity care several ways: 1- Notice is on every patient bill with an application on the back of the bill 2- On the hospital website 3- All members of the Patient Accounting Department are trained to screen patients for Charity Care when discussing bills and concerns regarding inability to pay 4- fliers ARE posted in registration areas of the hospital 5- Registration clerks will identify patients without a pay source and refer the patient to a Financial Counselor and hand the patient a financial assistance form 6- Financial Counselors assist patients in securing Medicaid and screen for Charity Care 7- The Collection agencies that HAHV engages with are aware of the charity care policy and assist patients IN applying up to 180 post placement with them HealthAlliance is committed to: > Providing access to quality healthcare services with compassion, dignity and respect for those we serve, particularly the poor and the underserved in our communities. > Caring for all persons, regardless of their ability to pay for services. > Assisting patients who cannot pay for part or all of the care they receive. > Balancing needed financial assistance for some patients with broader fiscal responsibilities in order to sustain viability and provide the quality and quantity of services for all who may need care in a community. In accordance with AHA recommendations, HealthAlliance adopted the following guiding principles when handling the billing, collection and financial support functions for our patients: > Provide effective communications with patients regarding hospital bills > Make affirmative efforts to help patients apply for public and private financial support programs > Offer financial support to patients with limited means > Implement policies for assisting low-income patients in a consistent manner > Implement fair and consistent billing and collection practices for all patients with patient payment obligations HealthAlliance effectively communicates with patients regarding patient payment obligations. Financial counseling is provided to patients about their payment obligation and hospital bills. Information on hospital-based financial support policies and external programs that provide coverage for services are made available to patients during the pre-registration and registration processes and in response to patients seeking financial assistance. Information regarding the financial assistance is also provided by the onsite financial counseling staff in both inpatient and outpatient areas. Patient accounting also supports the financial counseling program by providing patients with information and applications while handling customer service calls. Our financial counselors and county Medicaid workers also provide guidance regarding the financial assistance program when necessary. Financial assistance is available on the back of every hospital bill as well as the hospital website at http://hahv.org/hahv/financial-assistance.aspx. Financial counselors, both internal staff and a paid external vendor, make affirmative efforts to help patients apply for public and private programs for which they may qualify and that may help them obtain and pay for healthcare services. The hospital has onsite representatives from Fidelis Insurance Company to help patients who are in need of insurance coverage navigate through the application process. The patient does not need to have an account with the hospital; they just have to be in a situation where they are in need of insurance coverage. Fidelis screens the patient to see which plan will fit them and they are certified to enroll the patients in many different insurance policies based on their insurance needs. Every effort is made to determine a patients eligibility prior to or at the time of admission or service. However, determination for financial support can be made during any stage of the patients stay after stabilization or collection cycle. HealthAlliance offers financial support to patients with limited means. This support is available to uninsured and underinsured patients who do not qualify for public programs or other assistance. Notification about financial assistance, including contact information, is available through the hospital website, hospital posters and flyers, financial assistance applications and hospital statements. The FINANCIAL ASSISTANCE POLICY(FAP) and application are available on our website at http://www.hahv.org/hahv/financial-assistance.aspx and are supplied in both English and Spanish as well as plain language summary format. If additional assistance is needed, HealthAlliance offerS translation services for patients. HealthAlliance has an established written policy for the billing, collection and support for patients with payment obligations. The organization makes every effort to adhere to the policy and is committed to implementing and applying the policy for assisting patients with limited means in a professional, consistent manner. Educated staff members work closely with patients (including those working in Patient Registration and Admitting, Financial Assistance, Customer Service, Billing and Collections) about these policies with an emphasis on treating all patients with dignity and respect regardless of their insurance status or their ability to pay for services. All patient registration staff receive in-service training regarding the Financial Assistance Program. Patient Accounting also receives information about the program and how to handle patients seeking financial assistance. Financial counselors receive in depth training to handle financial assistance requests, process applications, and manage outcomes. HealthAlliance of The Hudson Valley provides several options for patients who either do not have insurance coverage or who have inadequate insurance coverage. Our many programs have been very successful and many have taken advantage of our offerings. Often utilized, financial counseling offers a patient the opportunity to speak to a financial counselor to determine what assistance can be accessible based on family income. Patients often shop around for the most economical healthcare and we offer price quotes. This allows the patient to know their financial obligation up front and understand the competitive pricing being offered. Despite millions of dollars of charity care distributed to needy patients every year, a consistent challenge is patients not utilizing the programs we offer. Often they dont want to provide the necessary financial information to initiate the financial aid process. Continual outreach and education is occurring to minimize confusion and improve utilization. HealthAlliance is committed to providing the best possible healthcare and is very sensitive to low income patients ability to pay. Our call center offers the convenience of calling one telephone number for all billing inquiries regardless of which hospital the patient is calling about. We are staffed Monday through Friday, 8AM to 4PM. The Financial Assistance policy was updated November 2016 to conform with the 501(r) requirements. All responses to the questions in Part V sections FAP and Billing and Collections were answered to coincide with this updated policy. PART VI, LINE 4: COMMUNITY INFORMATION Community Description Margaretville Memorial Hospital (Margaretville Hospital), a member of HealthAlliance of the Hudson Valley and the Westchester Medical Center Health Network (WMCHealth) is a rural Critical Access Hospital whose mission is to provide immediate access to high quality medical care and diagnostic testing services to medically underserved areas in the Catskill Mountains. Margaretville Hospital provides linkages to high tech and specialty medical care through an active relationship with HealthAlliance and WMCHealth. Margaretville Hospital is the Delaware County affiliate of HealthAlliance of the Hudson Valley (HealthAlliance), a multi-campus health care system consisting of HealthAlliance Hospitals Marys Ave. and Broadway campuses in Kingston, NY, and Margaretville Hospital, which is co-located on a single campus in Margaretville, NY (Delaware County), with the Mountainside Residential Care Center, a skilled nursing facility. HealthAlliance defines its primary service area by a federal definition that consists of the top 75% of hospital discharges from the lowest number of contiguous zip codes. Margaretville hospital serves the communities of Margaretville, Arkville, Andes, Fleischmanns, Roxbury, Halcott Center, Halcottsville, and New Kingston. Due to the geographical location of acute care hospitals affiliated with HealthAlliance, there are two distinct primary services areas within Ulster and Delaware Counties, though not encompassing all of each county. For operational and community needs development, HealthAlliance regards these two service areas as a single primary service area with the predominant population in Ulster County. However, for the purposes of this document, which will align with the Delaware County Community Health Assessment and the Community Health Improvement Plan, we will present the information pertaining to the Margaretville Hospital service area, located in Delaware County and described in the beginning of this section. Margaretville Hospital Service Area Other community health services and resources available in Delaware County include 20 ambulance services, mostly consisting of volunteer membership. In addition to Margaretville Hospital, there are three other hospitals, operated by two other healthcare systems: Delaware Valley Hospital affiliated with United Health Services, as well as OConnor Hospital and Tri-Town Hospital, both affiliated with the Bassett Healthcare Network. Additionally, there are two nursing homes in the county, 15 primary care offices including health centers and private physician offices, 15 locations and 9 full-time equivalent dentists, and two mental health clinics with multiple locations within the county. Delaware County covers 1,446 square miles in upstate New York, belonging to both the Southern Tier region and the Catskill Mountain range. Delaware County is the fourth largest county in New York by area and is the sixth most rural with a population density of 32.3 persons per square mile. The county includes the Catskill/Delaware Watershed, which is the largest unfiltered drinking water supply in the United States. The watershed region encompasses the central and eastern sections of Delaware County and includes roughly 65% of the countys land area and 11 of its 19 townships. Approximately 55% of Delaware Countys population lies within the Watershed. Based on the 2010 Census, the population of Delaware County is 47,840, 50.2% male and 49.8% female. In 2013, the population decreased to 46,772, representing a 2.3% reduction in population (Table 1). At the time of the 2010 Census, 9,405 people were less than 18 (19.6%), 38,575 were 18 and over (80.4%) and 9,331, were 65 and over (19.4%). It is estimated that 46.5% of the total population is 45 years of age or older. A majority of Delaware County residents over the age of 15 are married (72.5%), followed by never married (42%); separated (2.8%), widowed (2%), and divorced (1.8%) make up a smaller portion of the population. Delaware Countys population is 95% White, 1.9% African-American, 0.2% American Indian/Eskimo, 0.8% Asian, and 3.4% of Hispanic Origin (U.S. Census Bureau, 2010-2014 American Community Survey). In 2015, the median family income in Delaware County, $44,617, is less than New York States at $58,687. According to the NYS Poverty Report released in March 2015, the population below the poverty line was 16.4%, higher than the rate of 15.9% for New York. Notably, the percentage of children living below the poverty line has increased between 2000 and 2013 from 18% to 22%. The communities of Davenport (33.8%) and Walton (35.1%) have the highest rates of child poverty in Delaware County (U.S. Census Bureau, 2009-2013 American Community Survey). Based on the NYS Department of Health Behavioral Health Survey from 2013-2014, 83.9% of the population has healthcare coverage compared to 88.7% in the Southern Tier and 84.7% in the Mohawk Valley region, with only 62.2% of Delaware County adults aged 18-64 visiting a doctor for a routine checkup. Accordingly, 8.7% of residents reported not receiving medical care in the past year because of cost, compared to 10.0% in the Southern Tier, 12.2% in the Mohawk Valley region, and 13.1% in New York State. PART VI, LINE 5: PROMOTION OF COMMUNITY HEALTH: 2016 Progress This has been a year of much change for HealthAlliance and Margaretville Hospital. This year we engaged in assessment and planning for the 2016-2018 Community Service Plan. - On March 30, 2016, Westchester County Health Care Corp. became the sole corporate member of HealthAlliance. This adoption has the potential to significantly increase resources particularly in terms of mental health resources that can be brought to the community. - On May 19, 2016, Margaretville Hospital hired a new executive director, Mark Pohar. Mr. Pohar works with the Community Health Coordinator and the Margaretville Hospital Wellness Committee to gain agreement with regard to the plans for the 2016-2018 Community Service Plan. - Margaretville Hospitals mobile van conducted community outreach at the following community events: Spring on Main Street: 5/14 Fleischmanns Memorial Day Street Fair: 5/28 Margaretville Auxiliary Antique Flea Market: 8/6 Kansas City Society Barbeque Contest/Fleischmann: 8/27 Cauliflower Festival: 9/24 - The Margaretville Hospital Executive Director and the Community Health Coordinator met several times between July and October 2016 to plan for the 2016-2018 Community Service Plan contributions of Margaretville Hospital and HealthAlliance. - Health Fair Prevention Efforts took place on October 7, 2016, and included flu shots, fasting blood sugars, respiratory assessments, bone density testing and community introductions to telemedicine. - Also in October 2016, the following activities have taken plan to contribute to the impact of the previous Community Service Plan: - The Margaretville Hospital executive director has initiated meetings with the school administration of Margaretville schools to discuss the availability of mental health services in the community. - A new psychologist has been hired to begin November 1, 2016. This person will work with the Margaretville Hospital community based on referrals from local school districts and the community. - The release of a public announcement, alerting the community to a new telemedicine program which links Margaretville Hospital to Westchester Medical Center Health Network to bring psychiatric services to the community. Margaretville Hospital will post the Hospital Community Service Plan on HealthAlliances website. News and events related to the interventions will also be posted. The Community Health component of the hospital systems website can be found at: http://www.hahv.org/healthy-neighborhood/community-health/ For the community based strategies, Margaretville Hospital will continue to actively participate in a work group consisting of the Public Health Department and three other local hospitals for the purposes of maintaining engagement with local partners over the next three-year period. Progress will be tracked by the work group. Mid-course corrections will be made based on the discussions surrounding the review of the Community Service Plan and detailed tasks. Anecdotal feedback will be obtained from work group meetings, meetings involving health and wellness groups such as the Rural HealthAlliance, and from patients and individuals participating in interventions. Finally, as available, local, state and national health status indicators will be reviewed. A. Health Needs Addressed by HealthAlliance Priority Area 1: Prevent Chronic Diseases Focus Area 1: Reduce obesity in children and adults. Goal 1: Create community environments that promote and support health food and beverage choices, and physical activity. Outcome Objective: Reduce the percentage of adults ages 18 and older who are obese. Margaretville Hospital will work with the communities in their service area to increase retail availability of affordable healthy foods that meet the needs of communities, especially those with limited access to nutritious foods. The Margaretville Hospital Wellness Committee will recommend healthy vending guidelines that will be adopted by the hospital and impact employees, patients and visitors at the Margaretville Hospital and Mountainside Residential Care Center. Currently under review are vending policies implemented in other locales. Ulster County and the City of Kingston, the primary home of HealthAlliance, have adopted a Healthy Vending Policy. Through this action, Margaretville Hospital expects that the percentage of adults who are obese, ages 18 years and older, will have the option to select lower calorie foods when dining at Margaretville Hospital and Mountainside Residential Care Center. This strategy will help to drive a reduction in obesity statistics. Margaretville Hospital staff will assess the food that is being offered to ensure adherence with newly adopted nutrition vending standards. Goal 2: Expand the role of public and private employers in obesity prevention. Outcome Objective: Increase the percentage of small and medium worksites that offer a comprehensive worksite wellness program for all employees. The hospital has begun to implement an evidence-based wellness program for all employees in cooperation with the participating health plan and community partnerships that include but are not limited to increased opportunities for physical activity; access to and promotion of healthful foods and beverages, and health benefit coverage and/or incentives for obesity prevention. The hospital will implement nutrition and beverage standards in public institutions, worksites and other key locations such as Margaretville Hospital and Mountainside Nursing Home. As a role model, HealthAlliance has begun to implement system-wide changes that incentivize employee participation in a personal health assessment (PHA), annual physical and the adoption of at least one healthy behavior by structuring health insurance rates favorably for those that participate in wellness activities. This may serve as a template for other community organizations that are interested in creating worksite wellness programs. The HealthAlliance administration will review and report data aggregated by CDPHP on employee participation and success. In partnership with the HealthAlliance Employee Wellness Committee, HealthAlliance will offer healthy eating classes and gym memberships at reduced rates. Priority Area 4: Promote Mental Health and Prevent Substance Abuse Focus Area 3: Strengthen infrastructure across systems. Goal 1: Strengthen infrastructure for MEB health promotion and MEB disorder prevention. Outcome Objective: Enhance telemedicine and referral systems to build infrastructure of psychiatric services. Focus Area 2: Prevent Substance Abuse and other Mental Emotional Behavioral Disorders Goal 2: Prevent suicides among youth and adults. Outcome Objective: Decrease age-adjusted suicide rates. Outcome Objective: Decrease the number of suicide attempts. Margaretville Hospital will work with the following entities to achieve the goal of preventing suicides among youth and adults Delaware County Public Health, OConnor Hospital, Tri-Town Regional Hospital and Delaware Valley Hospital. These entities will share data on suicides, attempted suicides and suicidal ideation. Margaretville Hospital will establish telemedicine capabilities with input from WMCHealth to bring psychiatric services to the Delaware County community. Utilizing resources from HealthAlliance and WMCHealth, and with referrals provided to the Margaretville and Roxbury schools, Margaretville Hospital foresees high value and potential in meeting the needs of the identified disparate population. In regards to suicide prevention, the entities described above will take responsibility for the following: - Delaware County Public Health will share data on gender, age and means of suicide deaths with the Delaware County Suicide Prevention Network; - OConnor Hospital will collect the numbers of suicide attempts and ideation statistics from all Emergency Departments in Delaware County. This data will also be reported to the Delaware County Suicide Prevention Network; and - Margaretville Hospital, Tri-Town Regional Medical Center and Delaware Valley Hospital will report the numbers of suicide attempts and suicide ideation to OConnor Hospital, where the complete data will be aggregated. The intended impact behind the collaboration of resources will be to decrease the age-adjusted suicide rate in Delaware County by 10% (from 17.2 to 15.5) per 100,000, and to decrease the number of suicide attempts in Delaware County by December 31, 2018. To strengthen infrastructure for MEB health promotion and MEB behavior prevention, Margaretville Hospital will partner with community organizations and coalitions, as well as the Margaretville Hospital Wellness Committee, Westchester Medical Center psychiatry and psychology departments, the Margaretville and Roxbury schools and potentially other school districts. Also included in this partnership will be Delaware County Public Health and Mental Health. Telemedicine equipment will be operational, and a system PART VI, LINE 6: AFFILIATED HEALTH CARE SYSTEM HAHV is the parent company to affiliate members HA Marys Avenue campus, formerly Benedictine Hospital; Broadway Campus, formerly The Kingston Hospital; Margaretville Memorial Hospital, a rural critical access hospital; Mountainside Residential Care Center, a skilled nursing facility; and HealthAlliance Senior Living Corp, a continuing care retirement community. This integrated healthcare system is committed to providing quality and compassionate medical care for our patients, their families and our community. The consolidation of two acute care hospital campuses was a focus of HAHV when incorporating in 2008, responding directly to New York States Berger Commission mandate to form a corporate alliance between the formerly known Benedictine Hospital and HAHV Broadway Campus to bring down the costs of hospital-based care. In addition to service consolidation between the two Kingston Hospitals, HAHV also committed to streamlining operations and improving care at the other affiliate locations. Despite significant operational improvement and at the suggestion of NYS Department of Health, HAHV joined in 2014 with the Westchester Medical Health Performing Provider System in the Delivery System Reform Incentive Payment (DSRIP) again seeking to transform healthcare delivery to a more effective and efficient model that will benefit Ulster County on many levels. On March 30, 2016, Westchester County Healthcare Corp, through its newly created, wholly owned subsidiary, WMCHealth Ulster, Inc. (WMCHealth-Ulster), became the sole corporate member of HealthAlliance, Inc. HealthAlliance remains an active participant in the WMCHealth Performing Provider System (PPS) within the New York State Delivery System Reform Incentive Program (DSRIP). WMCHealth-Ulster oversees operations at the HealthAlliance campuses. PART VI, Line 7: STATE FILING OF COMMUNITY BENEFIT REPORT NY true false false false false false false false false Sandra Horan Chief Nursing Officer 0 192355 0 0 0 8400 0 4879 0 8071 0 213705 0 0 David Scarpino CHIEF EXECUTIVE OFFICER 0 481380 0 0 0 9564 0 6625 0 16818 0 514387 0 0 John Finch CIO & CCO (resigned 12/22/16) 0 228160 0 0 0 9291 0 12906 0 21003 0 271360 0 0 Steven Haas FORMER CFO 0 0 0 0 0 116471 0 391 0 14528 0 131390 0 0 Eileen King CLINICAL COORDINATOR 238651 0 0 0 516 0 240 0 15604 0 255011 0 0 0 Patricia Gavis CHIEF FINANCIAL OFFICER 0 254438 0 0 0 5425 0 0 0 20854 0 280717 0 0 Joseph Marsicovete Chief Operating Officer 0 288627 0 0 7556 0 6625 0 10029 0 312837 0 0 Paul Llobet MD Chief Medical Director 0 307465 0 0 4993 0 1783 0 0 0 314241 0 0 MARK POHAR TRUSTEE (effective 5/4/16) 0 128672 0 0 0 11663 0 0 0 19876 0 160211 0 0 Schedule J, Part I, line 3 The organization's top management officials (CEO/Executive Director) received compensation from HealthAlliance Hospital Broadway Campus (EIN: 14-1349558), a related organization. HealthAlliance Broadway Campus determines compensation of top management officials through the engagement of an independent compensation consultant performing a compensation study/survey with the goal to target the 50th percentile. Once completed, the findings and recommendations from the consultant are brought to the Compensation Committee of the Board of Directors. This committee shall consist of three (3) directors. They, among other things, shall evaluate the performance of the official, including a review against any pre-established performance goals; review and approve the official's compensation and bonus arrangements; and review all matters involving policies related to equity for executives and employees. Schedule J, Part I, Line 4a STEVEN HAAS RECEIVED SEVERANCE PAYMENTS OF $100,831 IN 2016 FROM A RELATED ORGANIZATION. FORM 990, PART VI, LINE 4 HealthAlliance, Inc. entered into an affiliation agreement with Westchester County Health Care Corporation ("WCHCC"), d/b/a Westchester Medical Center Health Network ("WMC"). WMC Health Network - Ulster, Inc. became the sole corporate member of HealthAlliance Inc. As a result, HealthAlliance, Inc. is considered a blended component unit of WMC, and the governing documents of Margaretville Memorial Hospital were updated to reflect this change. FORM 990, PART VI, LINE 6 HEALTHALLIANCE, INC., WHICH IS A TAX-EXEMPT ORGANIZATION, IS THE SOLE CORPORATE MEMBER OF MARGARETVILLE MEMORIAL HOSPITAL. FORM 990, PART VI, LINE 7A HEALTHALLIANCE, INC., THE SOLE CORPORATE MEMBER OF MARGARETVILLE MEMORIAL HOSPITAL, HAS THE POWER TO ELECT ONE OR MORE MEMBERS OF THE LOCAL GOVERNING BODY OF THE HOSPITAL. FORM 990, PART VI, LINE 7B ALL DECISIONS MADE AT THE LOCAL BOARD LEVEL OF MARGARETVILLE MEMORIAL HOSPITAL, OTHER THAN THOSE RELATED TO QUALITY ASSURANCE AND BUILDING AND GROUNDS, ARE SUBJECT TO APPROVAL BY MEMBERS OF HEALTHALLIANCE, INC. BOARD OF TRUSTEES. THESE DECISIONS INCLUDE ELECTION AND REMOVAL OF MEMBERS OF THE LOCAL LEVEL GOVERNING BODY, APPOINTMENT/REMOVAL OF CORPORATE OFFICERS, APPROVAL OF BYLAW AMENDMENTS, REVIEW OF ANNUAL CAPITAL AND OPERATING BUDGETS, REVIEW AND/OR MODIFICATIONS OF ANY CERTIFICATE OF NEED APPLICATIONS, REVIEW INCURRENCE OF DEBT AND DEVELOP AND IMPLEMENT JOINT MEDICAL STAFF APPOINTMENTS. FORM 990, PART VI, LINE 11B The Form 990 was prepared by our tax advisors together with our finance department with the assistance from various departments throughout the organization. The Form 990 was reviewed by internal leadership. Upon completion of the various reviews, the Form 990 was presented to the board of the organization for approval prior to filing with the IRS. FORM 990, PART VI, LINE 12C The organization monitors and enforces compliance with the Conflict of Interest policy by means of a survey developed and approved by the WMCHealth Chief Compliance Officer. The survey is sent to all trustees, officers, and key executives for completion. All survey responses are reviewed by the Chief Compliance Officer. Any potential conflicts identified in the responses are discussed with senior management and/or referred to the WMCHealth Conflicts of Interest Committee for discussion. Potential actions to be taken in response to a conflict can be one or more of the following: 1) disclosure of the conflict, 2) individual recusal from decisions for transactions where that individual may have a conflict, 3) request in writing the individual alleviate the conflict, or 4) removal of the individual from employment. FORM 990, PART VI, LINE 19 Governing documents, conflicts of interest policy and financial statements are made available to the public upon request. FORM 990, PART IX, LINE 11G FEES FOR OTHER PROFESSIONAL SERVICES - $1,216,532 FORM 990, PART XI, LINE 9 REVERSAL OF FASB REQUIRED ARO LIABILITY . . . . . . . . . $ 722,514 GASB CONVERSION OF TEMPORARILY RESTRICTED NET ASSETS . . . $ (144,697) TOTAL. . . . . . . . . . . . . . . . . . . . . . . . . . . $ 577,817 FORM 990, PART XII, LINE 2C SELECTION PROCESS WAS CHANGED AS BIDS WERE SOLICITED FOR FY2016 AUDIT. WMC HEALTH NETWORK - ROCKLAND INC 100 WOODS ROAD VALHALLA NY 10595 320467873 SUPPORTING NY 501(C)(3) 12A NA false WMC HEALTH NETWORK - ULSTER INC 100 WOODS ROAD VALHALLA NY 10595 320477183 SUPPORTING NY 501(C)(3) 12A WCHCC false WESTCHESTER COUNTY HEALTH CARE CORP 100 WOODS ROAD VALHALLA NY 10595 133964321 HEALTHCARE NY 115 N/A NA false WMC NEW YORK INC 100 WOODS ROAD VALHALLA NY 10595 134107894 FUNDRAISING NY 501(C)(3) 12A WCHCC false NORTH ROAD LHCSA INC 241 NORTH ROAD POUGHKEEPSIE NY 12601 465293268 HOMECARE SVCS NY 501(C)(3) 10 WCHCC false MID-HUDSON VALLEY EARLY EDUCATION CENTER 241 NORTH ROAD POUGHKEEPSIE NY 12601 465534882 PRESCHOOL NY 501(C)(3) 10 WCHCC false WESTCHESTER MEDICAL CENTER FOUNDATION 100 WOODS ROAD VALHALLA NY 10595 134095845 FUNDRAISING NY 501(C)(3) 7 WCHCC false HEALTHALLIANCE INC 741 GRANT AVENUE LAKE KATRINE NY 12449 261850453 SUPPORTING NY 501(C)(3) 12A WCHCC false HEALTHALLIANCE HOSPITAL BROADWAY CAMPUS 396 BROADWAY KINGSTON NY 12401 141349558 EXEMPT HOSP NY 501(C)(3) 3 HA INC true HEALTHALLIANCE HOSP MARY'S AVE CAMPUS 105 MARYS AVENUE KINGSTON NY 12401 141338470 EXEMPT HOSP NY 501(C)(3) 3 HA INC true HEALTHALLIANCE SENIOR LIVING CORP 396 BROADWAY KINGSTON NY 12401 300164277 RTMNT COMM NY 501(C)(3) 10 HA INC true MARGARETVILLE NURSING HOME INC 42158 STATE HIGHWAY 28 MARGARETVILLE NY 12455 223143565 NURSING HOME NY 501(C)(3) 10 MMH true MARGARETVILLE HEALTH FOUNDATION 42084 STATE HIGHWAY 28 MARGARETVILLE NY 12455 261998454 SUPPORT FDN NY 501(C)(3) 12A MMH true FASC FOUNDATION 741 GRANT AVENUE LAKE KATRINE NY 12449 264201295 SUPPORT FDN NY 501(C)(3) 7 HAH BWAY true GOOD SAMARITAN FDN FOR BETTER HEALTH 255 LAFAYETTE AVE SUFFERN NY 10901 133400353 SUPPORT FDN NY 501(C)(3) 7 BSCHSI false BON SECOURS COMMUNITY HOSPITAL FDN 255 LAFAYETTE AVE SUFFERN NY 10901 810667395 SUPPORT FDN NY 501(C)(3) 7 BSCHSI true BON SECOURS WARWICK HEALTH FOUNDATION 255 LAFAYETTE AVE SUFFERN NY 10901 141972807 SUPPORT FDN NY 501(C)(3) 7 BSCHSI true BON SECOURS CHARITY HEALTH SYSTEM INC 255 LAFAYETTE AVE SUFFERN NY 10901 912135195 SUPPORTING NY 501(C)(3) 12C, III-FI WCHCC false HUDSON RIVER WEST INSURANCE (BARBADOS) 38 PINE ROAD BELLEVILLE ST MICHAEL BB CAP INSURANCE BB BSCHSI C CORP true KINGSTON INSURANCE (BARBADOS) LIMITED 38 PINE ROAD BELLEVILLE ST MICHAEL BB CAP INSURANCE BB HEALTHALLIANCE C CORP true NORTHEAST PROVIDER SOLUTIONS INC 100 WOODS ROAD VALHALLA NY 10595 133991673 MSO & HEARING AID NY NA c corp true WMC ADVANCED PHYSICIAN SERVICES PC 19 BRADHURST AVENUE HAWTHORNE NY 10595 264709927 PHYSICIAN OFFICES NY NA c corp true WESTCHESTER MEDICAL REGIONAL PHYS SVCS 241 NORTH ROAD POUGHKEEPSIE NY 10532 465522536 PHYSICIAN OFFICES NY NA c corp true WCHCC (BERMUDA) LIMITED VICTORIA HALL 11 VICTORIA STREET HAMILTON BD CAP INSURANCE BD NA c corp true KINGSTON REGIONAL HEALTH CARE ENTERPRISE 396 BROADWAY KINGSTON NY 12401 161514994 INVESTMENT NY HAH BWAY c corp true MID HUDSON PHYSICIANS PC 396 BROADWAY KINGSTON NY 12401 203564769 MEDICAL SVCS NY HAH BWAY c corp true false false false false false false false false false true true false true false true true false false true MARGARETVILLE NURSING HOME INC O 253430 COST MARGARETVILLE NURSING HOME INC P 154978 COST SCHEDULE R, PART II, Bon Secours Charity Health System, Inc. (BSCHS) Margaretville Memorial Hospital has a brother-sister relationship with BSCHS's six subordinates in a group exemption within BSCHS. SCHEDULE R, PART II, HASLC ON MARCH 24, 2016 HEALTHALLIANCE SENIOR LIVING CORP. (HASLC) BECAME A SELF-SPONSORED CONTINUING CARE RETIREMENT COMMUNITY (CCRC) NAMED WOODLAND POND INC. AND THE RELATIONSHIP WITH HEALTHALLIANCE, INC. AS THE FORMER SOLE CORPORATE MEMBER OF HASLC WAS TERMINATED WITH NO CONSIDERATION PROVIDED BY EITHER PARTY. ALL POWERS PREVIOUSLY HELD BY THE OFFICERS OF THE BOARD OF DIRECTORS OF HEALTHALLIANCE, INC. HAVE BEEN TRANSFERRED TO WOODLAND POND,INC.'S BOARD OF DIRECTORS. THE CHANGE IN OWNERSHIP REQUIRED THE UNAMINOUS APPROVAL OF THE BOARDS OF DIRECTORS OF HEALTHALLIANCE, INC. AND WOODLAND PONDS, INC. AS WELL AS THE NEW YORK STATE DEPARTMENT OF HEALTH, ULSTER COUNTY INDUSTRIAL DEVELOPMENT AGENCY, ULSTER COUNTY CAPITAL RESOURCE CORPORATION, AND BONDHOLDER.