2017-11-02T14:03:00-05:00 2016-12-31 161226221 FUST CHARLES CHAMBERS LLP 5784 WIDEWATERS PARKWAY SYRACUSE NY 13214 990 2016-01-01 161471634 ROME MEMORIAL HOSPITAL ROME 1500 NORTH JAMES STREET ROME NY 13440 DEWEY ROWLANDS CFO/VP FINANCE 3153387000 2017-10-30 1 ANGELA M FRANCO P00589741 3154463600 2017-10-30 24.39.85.114 2017-10-30 17:23:33 ED P 9ED0318F8F0D15647C4BFB992883BD7B1D0B79EC 315614A2A569D91B0F4A84342C1D145A8997199D 2016 2021-01-29 14:40:06Z DAVID LUNDQUIST 1500 NORTH JAMES STREET ROME NY 13440 100600348 0 X ROMEHOSPITAL.ORG X 1995 NY PROVIDE QUALITY HEALTHCARE WITH COMPASSION. 9 7 1202 212 361303 0 3545638 19064968 78849856 79995161 423755 145849 1262912 1079829 84082161 100285807 0 0 0 0 45313153 45702829 0 0 0 39093368 39785087 84406521 85487916 -324360 14797891 51442183 55648804 36097713 25230438 15344470 30418366 X ABOUT ROME MEMORIAL HOSPITAL: OVERALL, ROME MEMORIAL HOSPITAL PROVIDES INPATIENT, OUTPATIENT, SKILLED NURSING, AND EMERGENCY CARE SERVICES PRIMARILY FOR THE RESIDENTS OF ROME AND THE SURROUNDING AREAS. 0 0 28867915 27326276 INPATIENT CARE SERVICES, INPATIENT NURSING UNITS CONSIST OF THE FOLLOWING:INTENSIVE CARE-2ND FLOOR, MATERNITY-4TH FLOOR, 2 EAST MEDICAL/SURGICAL-2ND FLOOR, 2 NORTH MEDICAL/SURGICAL WITH CARDIAC MONITORING-2ND FLOOR, PEDIATRICS-2ND FLOOR, AND SENIOR BEHAVIORIAL HEALTH- 2ND FLOOR.2016 INPATIENT DISCHARGES: 4,0152016 BIRTHS: 5212016 PATIENT DAYS: 17,900 8550623 7189781 RESIDENTIAL HEALTHCARE FACILITY (RHCF)BECAUSE OF OUR COMMITTMENT TO SERVE THE UNIQUE NEEDS OF SENIORS, WE HAVE AN 80-BED RESIDENTIAL HEALTH CARE FACILITY AND INPATIENT UNIT FOR SENIOR BEHAVIORIAL HEALTH CARE. OUR RESIDENTIAL HEALTHCARE FACILITY CONSISTS OF THE FOLLOWING: LONG-TERM NURSING HOME CARE, SHORT-TERM SUB-ACUTE REHABILITATION, AND RESPITE CARE- ALL LOCATED ON THE 3RD FLOOR.2016 PATIENT DAYS = 28,0902016 OCCUPANCY PERCENTAGE = 95.94% 7623145 10896992 EMERGENCY DEPARTMENT (ED)ROME MEMORIAL HOSPITAL EMERGENCY DEPARTMENT IS A SAFETY NET FOR THE MOST VULNERABLE POPULATIONS IN THE COMMUNITY. IN 2016, APPROXIMATELY 47% OF THE PATIENTS TREATED WERE LISTED AS UNINSURED OR UNDER INSURED. FOR LOWER LEVEL EMERGENCY DEPARTMENT VISITS, THIS POPULATION REPRESENTED MORE THAN 60% OF THE VISITS BECAUSE MANY PRIMARY CARE PHYSICIANS DO NOT ACCEPT MEDICAID.2016 ED ADMISSIONS: 3,5772016 ED VISITS: 30,677 24628448 34582112 ALL OTHER ACHIEVEMENTS PROVIDE QUALITY, COMPASSIONATE CARE IN A SAFE ENVIRONMENT TO SERVE THE HEALTHCARE NEEDS OF THE PEOPLE OF ROME AND THE SURROUNDING COMMUNITIES. 24628448 34582112 69670131 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 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 39 0 1 1202 1 1 1 0 0 0 0 0 0 0 0 0 X 9 7 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 NY X DEWEY ROWLANDS - ROME MEMORIAL HOSPITAL 3153387024 1500 NORTH JAMES STREET ROME NY 13440 CHESTER PATRICK MD CHAIRMAN 2.00 X X 0 0 0 LYNN REESE VICE CHAIRMAN 2.00 X X 0 0 0 DARLENE BURNS SECRETARY (3/1/16 - 12/31/16) 2.00 X X 0 0 0 JULIE GROW-DENTON TREASURER 2.00 X X 0 0 0 ANKUR DESAI MD DIRECTOR 2.00 X 0 0 0 DAVID NOLAN DIRECTOR 2.00 X 0 0 0 DENNIS SURACE DIRECTOR 2.00 X 0 0 0 KIM COOK DIRECTOR 2.00 X 0 0 0 W ROBERT HERRMANN DIRECTOR 2.00 X 0 0 0 ANKUR DESAI MD INTERIM CMO 20.00 X X 28344 0 0 DAVID LUNDQUIST CEO 55.00 X 286876 0 1045 DARLENE BURNS INTERIM CEO (1/1/16 - 2/28/16) 55.00 X 88846 0 144 DEWEY ROWLANDS CFO 55.00 X 207343 0 7740 BENJAMIN SOMMER PHYSICIAN 55.00 X 196281 0 7722 BRUCE PETERSON AVP/CIO 55.00 X 154036 0 945 MARK SNYDERMAN VP OUTPATIENT SERVICES 55.00 X 151043 0 3224 DURINDA DURR VP CLINICAL SERVICES 55.00 X 141658 0 4141 SCOTT BURNS DIRECTOR OF PHARMACY 55.00 X 137344 0 7626 1391771 0 32587 39 0 1 0 CENTREX CLINICAL LABS INC 28 CAMPION RD NEW HARTFORD NY 13413 LAB SERVICES 4187515 EAGLE HOSPITAL PHYSICIANS LLC 16000 NORTH DALLAS PARKWAY SUITE 4 DALLAS TX 75248 HOSPITALIST SERVICES 1688346 MCKESSON PO BOX 98347 CHICAGO IL 606938347 HEALTHCARE INFORMATION TECHNOLOGY 798854 STAT STAFF PROFESSIONALS 18 DIVISION STREET SARATOGA SPRINGS NY 12866 NURSE STAFFING 750154 CENTURY LINEN & UNIFORM 335 NORTH MAIN STREET GLOVERSVILLE NY 12078 LAUNDRY SERVICES 420661 20 100484 18870227 94257 19064968 INPATIENT SERVICES 622110 27326276 27326276 EMERGENCY DEPARTMENT 621990 10896992 10896992 RESIDENTIAL HEALTHCARE FACILITY 623990 7189781 7189781 34582112 34582112 79995161 78040 78040 42829 12933 29896 29896 29896 298550 70867 292696 8912 5854 61955 67809 67809 CAFETERIA SALES 722514 285302 285302 ACCOUNTING & CONSULTING 541200 202127 202127 HOUSEKEEPING 561720 106140 106140 456364 53036 403328 1049933 100285807 79995161 361303 864375 X 620337 620337 37925479 33664473 4261006 363908 318264 45644 3922725 3911459 11266 2870380 2507192 363188 229436 229436 97500 97500 22529 22529 10263547 9766864 496683 121289 1385 119904 327973 156493 171480 1426030 83009 1343021 1046448 895112 151336 83510 79109 4401 70875 68696 2179 358372 358372 3681730 2064689 1617041 735080 735080 SUPPLIES 5037687 4875380 162307 BAD DEBT EXPENSE 4396358 4396358 PHARMACY 2982106 2982106 PURCHASE SERVICES 2608214 2220687 387527 6296403 1678855 4617548 85487916 69670131 15817785 0 1927830 6007556 7786086 6641852 811378 1136883 1700601 1718359 2525686 3666603 82283398 53992056 29572669 28291342 1454626 1660002 5663307 6526207 51442183 55648804 10755690 11137768 10493545 4630000 10218478 14092670 36097713 25230438 X 14592915 29714081 165614 118344 585941 585941 15344470 30418366 51442183 55648804 X 14797891 53781 222224 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 17449 0 0 17449 0 PART II-B, LINE 1: $17,449 REPRESENTS THE PORTION OF THE 2016 MEMBERSHIP DUES OF HANYS, AHA, AND IROQUOIS HEALTHCARE ALLIANCE, THAT RMH IS A MEMBER OF, THAT HAS BEEN DEEMED TO BE RELATED TO LOBBYING EXPENSES. THESE EXPENDITURES ARE DEFINED AS DIRECT COMMUNICATIONS WITH CERTAIN MEMBERS OF FEDERAL, STATE, OR LOCAL GOVERNMENTS TO INFLUENCE LEGISLATION. 751555 -12601 34669 704285 747775 102327 98547 751555 925258 -151437 26045 747775 953476 -2031 26187 925258 643953 314851 5328 953476 0.83200 0.16800 0 0 43685607 22270869 21414738 2475341 2240983 234358 33289056 27256947 6032109 2833394 2223257 610137 28291342 NET ASSETS OF FOUNDATION 905071 OTHER LONG TERM ASSETS 5533867 BOND AMORTIZATION 87269 6526207 OTHER LIABILITIES 7481871 THIRD-PARTY PAYABLE, NET 5841844 DUE TO RELATED ENTITIES 768955 14092670 X PART V, LINE 4: INTENDED USE OF ENDOWMENT FUND IS THAT THE PRINCIPLE CAN BE INVESTED, WHILE KEPT INTACT IN PERPETUITY; ONLY THE INCOME GENERATED CAN BE USED BY THE ORGANIZATION. PART X, LINE 2: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE. THE HOSPITAL IS SUBJECT TO FEDERAL INCOME TAXES ON UNRELATED BUSINESS INCOME UNDER SECTION 511 OF THE INTERNAL REVENUE CODE. AS OF DECEMBER 31, 2016 AND 2015, THE HOSPITAL DID NOT HAVE ANY UNRECOGNIZED TAX BENEFITS OR ANY RELATED ACCRUED INTEREST OR PENALTIES. THE TAX YEARS OPEN TO EXAMINATION BY FEDERAL AND STATE TAXING AUTHORITIES ARE 2013 THROUGH 2016. THE HOSPITAL DOES NOT ANTICIPATE THAT THE TOTAL UNRECOGNIZED TAX BENEFITS WILL CHANGE IN THE NEXT TWELVE MONTHS. 1 1 1 X 1 X 1 1 1 0 1 1 700789 323508 377281 0.00470 20952683 17759596 3193087 0.03940 325896 125060 200836 0.00250 21979368 18208164 3771204 0.04660 119200 7219 111981 0.00140 37072 28773 8299 0.00010 156272 35992 120280 0.00150 22135640 18244156 3891484 0.04810 15749 15749 0.00020 15749 15749 0.00020 0 1198093 113337 20175284 33914790 -13739506 X 1 0 1 GRIFFIS EYE CENTER LLC SEE SCHEDULE R PART VII 0.30000 0.00000 0.70000 1 1 ROME MEMORIAL HOSPITAL 1500 NORTH JAMES STREET ROME NY 13440 X X X ROME MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 16 1 1 1 1 X WWW.ROMEHOSPITAL.ORG X WWW.OCGOV.NET X 1 16 1 WWW.ROMEHOSPITAL.ORG 0 1 X 100.000000000000 300.000000000000 1 1 X X X X 1 X WWW.ROMEHOSPITAL.ORG X WWW.ROMEHOSPITAL.ORG X WWW.ROMEHOSPITAL.ORG X X X X X X 1 X 0 X X X 1 X 0 0 ROME MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: THIS 2016-2018 ONEIDA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA)/COMMUNITY SERVICE PLAN (CSP) AND COMMUNITY HEALTH IMPROVEMENT PLAN (CHIP) IS AN APPENDIX AND UPDATE TO THE COMPREHENSIVE 2013-2017 ONEIDA COUNTY CHA/CSP AND CHIP. THE REPORT SUMMARIZES THE HEALTH STATUS OF THE COMMUNITY AND PUBLIC HEALTH AND HOSPITAL PREVENTION AGENDA HEALTH IMPROVEMENT GOALS FOR THE RESIDENTS OF THE COUNTY OF ONEIDA.A VARIETY OF DATA SOURCES WERE USED TO IDENTIFY AND CONFIRM PRIORITIES INCLUDING: THE NYS PREVENTION AGENDA DASHBOARD, HEALTHECONNECTIONS, NEW YORK STATE QUITLINE PARTNERS REPORTS, ONEIDA COUNTY TEEN ASSESSMENT PROJECT (TAP), AND THE PEDIATRIC NUTRITION SURVEILLANCE SYSTEM (PEDNSS) REPORTS. THE PLANNING TEAM ALSO REVIEWED DATA FROM THE JOHN SNOW, INC. COMMUNITY HEALTH ASSESSMENT FOR THE CENTRAL NEW YORK CARE COLLABORATIVE (CNYCC), THE COUNTY HEALTH RANKINGS, AND BRIDGES COMMUNITY SURVEY. THE PLANNING TEAM WORKED TO SOLICIT FEEDBACK FROM COMMUNITY MEMBERS THROUGHOUT THE YEAR. ROME MEMORIAL HOSPITAL HOSTED A COMMUNITY FORUM TO SOLICIT FEEDBACK FROM COMMUNITY MEMBERS AND PARTICIPATED IN THE CITY OF ROME'S HUD COMMUNITY NEEDS ASSESSMENT. ACCESS TO SPECIALTY, PRIMARY, URGENT CARE AND BEHAVIORAL HEALTH SERVICES WERE THE MAIN COMMUNITY NEEDS IDENTIFIED. ADDITIONALLY, THE PLANNING TEAM REVIEWED THE FINDINGS FROM THE CENTRAL NY CARE COLLABORATIVE (CNYCC) NEEDS ASSESSMENT IN WHICH SOME ITS KEY FINDINGS AND RECOMMENDATIONS ARE ADDRESSED IN THE SELECTED CHIP INTERVENTIONS AND TARGET POPULATIONS. FINALLY, THE ONEIDA COUNTY HEALTH DEPARTMENT ASKED SPECIFIC QUESTIONS AT HEALTH FAIRS AND EVENTS WHERE ITS STAFF INTERACTS WITH THE PUBLIC.THE ONEIDA COUNTY COMMUNITY HEALTH ASSESSMENT/COMMUNITY SERVICE PLAN & COMMUNITY HEALTH IMPROVEMENT PLAN (CHA/CSP/CHIP) PLANNING TEAM IDENTIFIED THE FOLLOWING AS ITS TOP TWO PREVENTION AGENDA PRIORITIES FOR THE 2016-2018 UPDATE: PREVENT CHRONIC DISEASES PROMOTE HEALTHY WOMEN, INFANTS AND CHILDREN THE PRIORITY AREAS HAVE REMAINED THE SAME SINCE 2013, HOWEVER THERE ARE SOME ADDITIONAL AREAS IDENTIFIED. THE PRIORITY TO PREVENT CHRONIC DISEASES IS BEING ADDRESSED THROUGH A FOCUS ON TOBACCO CESSATION. WE CONTINUE TO ADDRESS POLICIES PROMOTING USE OF THE NYS QUITLINE WITH PROVIDERS AND HAVE EXPANDED OUR INITIATIVE TO ALIGN WITH THE CENTRAL NEW YORK CARE COLLABORATIVE DSRIP CARDIOVASCULAR DISEASE MANAGEMENT (CVD) INITIATIVE REFERENCING THE TOBACCO STANDARDS OF CARE. WITHIN ITS LARGER GOAL OF PROMOTING TOBACCO USE CESSATION AMONG ADULTS, WE HAVE EXPANDED TO PREVENTING INITIATION OF TOBACCO USE BY YOUTH AND YOUNG ADULTS. EMERGING ISSUES INCLUDE THE USE OF E-CIGARETTES AS A METHOD TO QUIT, THE TREND OF YOUTH STARTING WITH E-CIGARETTES, AND WE HAVE FOUND AN INCREASE IN COMMUNITY INTEREST IN CESSATION CLASSES THAT WE HAVE NOT SEEN IN THE PAST. ROME MEMORIAL HOSPITAL'S EFFORTS TO IMPROVE COMMUNITY HEALTH EXTEND BEYOND THE TWO PRIORITIES IDENTIFIED THROUGH THE CHA/CSP/CHIP PROCESS. SOME OF THE HOSPITAL'S ADDITIONAL INITIATIVES INCLUDE:-OFFERING FREE HEALTH SCREENINGS AT AREA HEALTH FAIRS TO DETECT HIGH BLOOD PRESSURE, HIGH CHOLESTEROL, DEPRESSION AND OBESITY.-CONDUCTING COLORECTAL HEALTH SCREENINGS EACH MARCH TO PROMOTE EARLY DETECTION OF CANCER.-CONDUCTING PSA SCREENINGS FOR THE EARLY DETECTION OF PROSTATE CANCER.-OFFERING FREE BLOOD PRESSURE SCREENINGS MONTHLY AT AREA PHARMACIES AND SENIOR CENTERS TO PROVIDE ONGOING MONITORING FOR PATIENTS THAT SUFFER FROM HIGH BLOOD PRESSURE AND EARLY DETECTION FOR THOSE WHO ARE AT RISK.-OFFERING FREE TYPE 2 DIABETES EDUCATION CLASSES EVERY MONTH FOR DIABETICS AND THEIR FAMILIES. THE NURSE EDUCATOR COVERS EXERCISE, DIET AND MEDICATION MANAGEMENT TO HELP NEWLY DIAGNOSED DIABETICS UNDERSTAND HOW TO MANAGE CONTROLLABLE RISK FACTORS AND PREVENT FUTURE COMPLICATIONS.-SPONSORING HEALTH LECTURES AT THE HOSPITAL AND PROVIDING SPEAKERS AND DISPLAYS FOR LOCAL ORGANIZATIONS AND BUSINESSES TO PROMOTE EARLY DETECTION, TREATMENT AND MANAGEMENT OF CHRONIC DISEASE.-PARTICIPATING WITH THE CANCER SERVICES PROGRAM TO PROVIDE FREE MAMMOGRAPHY SCREENING FOR THE UNINSURED AND UNDERINSURED TO PROMOTE EARLY DETECTION. THE NURSE NAVIGATOR FROM THE HOSPITAL'S BREAST CENTER WORKS CLOSELY WITH THE CSP TO HELP SECURE ADDITIONAL RESOURCES FOR UNDERSERVED WOMEN DIAGNOSED WITH BREAST CANCER.-CONDUCTING FLU VACCINATION CLINICS TO PROTECT RESIDENTS FROM THE FLU AND PREVENT UNNECESSARY HOSPITALIZATIONS.-INVESTING SIGNIFICANT RESOURCES TO RECRUIT ADDITIONAL PROVIDERS TO THE ROME AREA TO SOLVE THE PHYSICIAN SHORTAGE CONCERNS.-INVESTING PLANNING RESOURCES TO EXPAND ACCESS TO ESSENTIAL HEALTH CARE SERVICES IN 2017 INCLUDING MEDICATION ASSISTED TREATMENT AND URGENT CARE.-SPONSORING SUPPORT GROUPS FOR FAMILIES DEALING WITH ADDICTION AND CHRONIC DISEASE.-PARTICIPATING WITH THE CENTRAL NEW YORK CARE COLLABORATIVE IN SUPPORT OF THE DELIVERY SYSTEM REFORM INCENTIVE PAYMENT PROGRAM (DSRIP), AN INITIATIVE TO TRANSFORM THE HEALTH SYSTEM OF NEW YORK STATE, WITH THE GOALS OF REDUCING AVOIDABLE HOSPITAL USE AND IMPROVING HEALTH AND PUBLIC HEALTH MEASURES. -SEEKING PATIENT CENTERED MEDICAL HOME CERTIFICATION TO ENHANCE CARE COORDINATION IN THE HOSPITAL'S PRIMARY CARE PRACTICES-IMPLEMENTING STRATEGIES TO REDUCE HEALTH ACQUIRED INFECTIONS.-PROVIDING SMOKING CESSATION EDUCATION TO REDUCE THE MORTALITY AND MORBIDITY ASSOCIATED WITH SMOKING.-PROVIDING HEALTH INFORMATION THROUGH QUARTERLY NEWSLETTERS TO SENIORS.THE 2016-2018 CHNA OUTLINING THE PRIORITIES AND THE IMPACT OF PREVIOUS IMPLEMENTATION STRATEGIES IS AVAILABLE ONLINE AT WWW.ROMEHOSPITAL.ORG. ROME MEMORIAL HOSPITAL PART V, SECTION B, LINE 6A: THE 2016 CHNA WAS CONDUCTED IN COLLABORATION WITH MOHAWK VALLEY HEALTH SYSTEM (FAXTON-ST. LUKE'S HOSPITAL AND ST. ELIZABETH'S MEDICAL CENTER). ROME MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: THE 2016 CHNA WAS CONDUCTED IN CONJUNCTION WITH ONEIDA COUNTY HEALTH DEPARTMENT AND COMMUNITY ORGANIZATIONS THAT REPRESENTED THE BROAD INTERESTS OF THE POPULATIONS SERVED BY THE COUNTY'S HOSPITALS. ROME MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: ROME MEMORIAL HOSPITAL ADDRESSES THE SIGNIFICANT HEALTHCARE NEEDS OF THE COMMUNITY THROUGH ITS CONTINUUM OF HEALTHCARE SERVICES/PROGRAMS AND RELATIONSHIPS WITH COMMUNITY PARTNERS. THE COMMUNITY HOSPITAL HAS 130 LICENSED ACUTE CARE BEDS, AN 80-BED SKILLED NURSING FACILITY, A BROAD ARRAY OF OUTPATIENT SERVICES AND THREE ARTICLE 28 PRIMARY CARE PRACTICES. IN ADDITION, THE HOSPITAL PROVIDES ESSENTIAL ACCESS TO PRIMARY CARE AND SPECIALTY PHYSICIAN SERVICES THROUGH TWO AFFILIATED CAPTIVE PCS.THE DATA FROM THE CHA GUIDES THE HOSPITAL IN THE DEVELOPMENT OF TACTICS IN SUPPORT OF ITS STRATEGIC PLAN, WHICH IS ORGANIZED UNDER THE FOLLOWING PILLARS: FOSTER A CULTURE OF QUALITY AND PATIENT SAFETY. FOSTER A CULTURE OF EXCEPTIONAL SERVICE. OPTIMIZE FINANCIAL PERFORMANCE. RECRUIT, DEVELOP AND RETAIN EXCEPTIONAL PEOPLE. IDENTIFY GROWTH OPPORTUNITIES CONSISTENT WITH THE HOSPITAL'S MISSION.UNMET COMMUNITY NEEDS ARE DUE TO A SHORTAGE OF PROVIDERS AND LIMITED FINANCIAL RESOURCES. 13 1 - COMMUNITY RECOVERY CENTER 264 W DOMINICK STREET ROME NY 13440 SUBSTANCE ABUSE COUNSELING 2 - MOHAWK VALLEY RADIATION MEDICINE 107 E CHESTNUT STREET ROME NY 13440 RADIATION ONCOLOGY 3 - PHYSICAL THERAPY 107 E CHESTNUT STREET ROME NY 13440 OFFSITE PHYSICAL THERAPY SERVICES 4 - BOONVILLE FAMILY CARE 13407 STATE ROUTE 12 BOONVILLE NY 13309 PRIMARY CARE SERVICES 5 - LABORATORY COLLECTION SITE 1801 BLACK RIVER BLVD ROME NY 13440 OFFSITE LAB COLLECTION SITE 6 - LABORATORY COLLECTION SITE 1617 N JAMES STREET ROME NY 13440 OFFSITE LAB COLLECTION SITE 7 - LABORATORY COLLECTION SITE 13407 STATE ROUTE 12 BOONVILLE NY 13309 OFFSITE LAB COLLECTION SITE 8 - MEDICAL IMAGING 1801 BLACK RIVER BLVD ROME NY 13440 OFFSITE RADIOLOGY SERVICES 9 - MEDICAL IMAGING 107 E CHESTNUT STREET ROME NY 13440 OFFSITE RADIOLOGY SERVICES 10 - PRENATAL CARE CENTER 155 WEST DOMINICK STREET ROME NY 13440 OFFSITE PRENATAL CARE SERVICES 11 - DELTA MEDICAL CENTER 1819 BLACK RIVER BLVD ROME NY 13440 PRIMARY CARE SERVICES 12 - REGIONAL WOUND CARE CENTER 267 HILL ROAD ROME NY 13441 ADVANCED WOUND CARE AND HYPERBARIC OXYGEN TREATMENT 13 - CAMDEN FAMILY CARE 5 MASONIC AVENUE CAMDEN NY 13316 PRIMARY CARE SERVICES PART I, LINE 6A: THE COMBINED ONEIDA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA)/COMMUNITY SERVICE PLAN (CSP) AND COMMUNITY HEALTH IMPROVEMENT PLAN (CHIP) IS POSTED ON ROME MEMORIAL HOSPITAL'S WEBSITE AT WWW.ROMEHOSPITAL.ORG. PART I, LINE 7: FINANCIAL ASSISTANCE AT COST (7A), UNREIMBURSED MEDICAID (7B) AND UNREIMBURSED COSTS - OTHER MEANS TESTED GOVERNMENT PROGRAMS (7C) WERE CALCULATED BY USING A COST TO CHARGE RATIO. THIS COST TO CHARGE RATIO WAS DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES, SUPPLIED BY THE IRS. OTHER BENEFITS (7E & 7F) WERE CALCULATED BY DETERMINING ACTUAL COSTS AND ACTUAL REVENUE PER EVENT.THE MAIN SOURCE OR GUIDE OF HOW CALCULATIONS WERE DETERMINED WAS BY UTILIZING THE WORKSHEETS PROVIDED BY THE IRS AND THEN ADJUSTING ACCORDING TO ROME HOSPITAL SPECIFICS (IE. USING ACTUAL COSTS VS. COST TO CHARGE RATIO AS MENTIONED ABOVE). PART I, LN 7 COL(F): PERCENT OF TOTAL EXPENSE IS CALCULATED BY USING THE DENOMINATOR OF THE TOTAL FUNCTIONAL EXPENSES LESS BAD DEBT EXPENSE OF $4,396,358 (PER AUDITED FINANCIAL STATEMENTS). PART II, COMMUNITY BUILDING ACTIVITIES: ROME MEMORIAL HOSPITAL PARTICIPATES IN NUMEROUS COMMUNITY COMMITTEES INVOLVED IN ENHANCING HEALTHCARE OUTCOMES THROUGH PREVENTION, EARLY DETECTION AND INTERVENTION, AS WELL AS EMERGENCY PREPAREDNESS ACTIVITIES TO ENSURE A COORDINATED RESPONSE IN AN EVENT OF A DISASTER. HOSPITAL EXPERTS ARE CALLED UPON TO PARTICIPATE IN INITIATIVES TO ADDRESS DOMESTIC VIOLENCE, TEENAGE PREGNANCY, SUBSTANCE ABUSE AND LITERACY.ROME MEMORIAL HOSPITAL IS ALSO ONE OF 11 HOSPITALS THAT ARE MEMBERS OF THE CENTRAL NEW YORK CARE COLLABORATIVE (CNYCC), WHICH HAS IDENTIFIED 11 DSRIP PROJECTS TO ADDRESS GAPS IN CARE AND IMPROVE OUTCOMES INCLUDING: EXPANDING CAPACITY, ESPECIALLY FOR PRIMARY AND BEHAVIORAL HEALTH SERVICES, AND IMPLEMENTING CARE MANAGEMENT, CARE COORDINATION, AND POPULATION HEALTH INITIATIVES. ROME MEMORIAL HOSPITAL IS A PARTNER IN 5 OF THE 11 PROJECTS.RECRUITING PHYSICIANS AND OTHER HEALTH PROFESSIONALS TO ENHANCE ACCESS TO CARE IS ONE OF THE HOSPITAL'S MOST SIGNIFICANT INVESTMENTS IN COMMUNITY BUILDING ACTIVITIES. WITH EXISTING PROVIDER SHORTAGES, MANY PRACTICES ARE NOT ACCEPTING NEW PATIENTS AND SEVERAL PRIMARY CARE PHYSICIANS WITH LARGE PATIENT PANELS ARE NEARING RETIREMENT, WHICH WILL ONLY EXACERBATE THE PROBLEM. PART III, LINE 2: BAD DEBT EXPENSE IS CALCULATED BASED ON THE TOTAL BAD DEBT ATTRIBUTABLE TO PATIENT ACCOUNTS. FOR 2016, TOTAL BAD DEBT IS $4,396,358 (PER AUDITED FINANCIAL STATEMENTS). THE RATIO OF PATIENT CARE COST TO CHARGES FROM THE INSTITUTIONAL COST REPORT IS THEN APPLIED TO THE TOTAL BAD DEBT. FOR 2016, THAT PERCENTAGE IS 27.25. THE CALCULATED AMOUNT IS THE ESTIMATED COST OF BAD DEBT ATTRIBUTABLE TO PATIENT ACCOUNTS. PART III, LINE 3: TO DETERMINE THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY, THE TOTAL PERCENTAGE OF FINANCIAL ASSISTANCE PROVIDED TO PATIENTS IS APPLIED TO THE CALCULATED BAD DEBT EXPENSE. FOR 2016, THE TOTAL PERCENTAGE OF FINANCIAL AID PROVIDED IS 9.46%. APPLYING THAT PERCENTAGE AGAINST THE CALCULATED BAD DEBT EXPENSE IN PART III LINE 2 RESULTS IN THE ESTIMATED AMOUNT OF BAD DEBT EXPENSE ATTRIBUTED TO FINANCIAL AID ELIGIBLE PATIENTS. PART III, LINE 4: SEE AUDITED FINANCIAL STATEMENTS PAGES 11 THROUGH 13 FOR CURRENT FOOTNOTE LANGUAGE THAT DESCRIBES BAD DEBT. PART III, LINE 6; COSTING METHODOLOGY AND SOURCE:2016 ICR EXHIBIT 46 AND TENTATIVE MEDICARE SETTLEMENT RATES PART III, LINE 8: FINANCIAL AID PROGRAM THE SHORTFALL IN QUESTION 7 SHOULD BE TREATED AS COMMUNITY BENEFIT AS MEDICARE REIMBURSEMENTS FAIL TO COVER THE COSTS OF PROVIDING CARE TO MEDICARE BENEFICIARIES. DESPITE EFFORTS TO IMPROVE EFFICIENCY, EXPENSES FOR TECHNOLOGY, PHARMACEUTICAL, AND SALARY AND BENEFITS CONTINUE TO ESCALATE. THE HOSPITALS BAD DEBT EXPENSES IS IMPACTED BY THE SOCIOECONOMICS OF THE COMMUNITY. THE MEDIAN HOUSEHOLD INCOME FOR ONEIDA COUNTY IS LOWER THAN THE STATE AVERAGE AND NEARLY 16% OF THE POPULATION LIVES BELOW THE POVERTY LINE. ALTHOUGH PEOPLE MAY HAVE INSURANCE, THEIR OUT-OF-POCKET COSTS ARE HIGH BECAUSE EMPLOYERS HAVE RAISED THEIR DEDUCTIBLES OR CO-PAYMENTS, OR REDUCED WHAT THEIR PLANS COVER.TO HELP THOSE WHO ARE UNINSURED LEARN MORE ABOUT POSSIBLE OPTIONS, THE HOSPITAL'S PATIENT REGISTRATION DEPARTMENT PROVIDES INFORMATION FROM INSURERS WHICH OFFER FREE OR LOW-COST HEALTH INSURANCE THROUGH NEW YORK STATE'S CHILD HEALTH PLUS AND FAMILY HEALTH PLUS, ALONG WITH SPACE FOR REPRESENTATIVES TO ANSWER QUESTIONS AND ENROLL ELIGIBLE RESIDENTS.IN ADDITION, THE HOSPITAL HAS PARTNERED WITH THE MOHAWK VALLEY PERINATAL NETWORK, WHOSE FACILITATED ENROLLER CAN ASSIST INDIVIDUALS IN APPLYING FOR COVERAGE FROM CHILD HEALTH PLUS, FAMILY HEALTH PLUS, AND MEDICAID. IN ADDITION TO HELPING PEOPLE OBTAIN INSURANCE COVERAGE, THE HOSPITAL ALSO PROVIDES A FINANCIAL ASSISTANCE PROGRAM AND WORKS WITH PATIENTS TO SET UP AFFORDABLE PAYMENT PLANS.FINANCIAL ASSISTANCE BROCHURES ARE LOCATED IN THE HOSPITAL'S WAITING AREAS AND APPLICATIONS ARE AVAILABLE ON THE WEBSITE. RMH DISCOUNTS PATIENT ACCOUNTS UP TO 100% DEPENDING UPON FAMILY INCOME IN COMPARISON TO THE FEDERAL POVERTY LEVEL. DISCOUNTS ARE BASED UPON THE BLUE CROSS RATE, OUR HIGHEST VOLUME PAYER. ROME MEMORIAL HOSPITAL OFFERS DISCOUNTS TO THE UNINSURED/UNDERINSURED WHOSE INCOME IS UP TO 300% OF THE FEDERAL POVERTY LEVEL.BECAUSE LACK OF AWARENESS IS ONE OF THE BIGGEST BARRIERS, RMH PROVIDES INFORMATION ABOUT AVAILABLE PROGRAMS AT HEALTH FAIRS AND OTHER OUTREACH ACTIVITIES.CHANGES (ACTUAL OR POTENTIAL) IMPACTING COMMUNITY HEALTH, PROVISION OF CHARITY CARE, AND ACCESS TO SERVICES: REIMBURSEMENTS THAT FAIL TO KEEP PACE WITH RISING EXPENSES AND THE CONTINUED GROWTH IN UNCOMPENSATED CARE ARE SIGNIFICANT CHALLENGES THAT NEW YORK'S HOSPITALS FACE, INCLUDING RMH. OTHER CHALLENGES INCLUDE THE ESCALATION OF COSTS FOR DRUGS DUE TO INFLATION AND HAVING TO FIND ALTERNATE SUPPLIERS BECAUSE OF MANUFACTURER PRODUCTION SHORTAGES, SERVICES AND BAD DEBT, AND INVESTMENTS REQUIRED TO COMPLY WITH MANDATES. HERE ARE JUST A FEW EXAMPLES OF OUR CHALLENGES:UNCOMPENSATED CARE: THE COST OF FREE SERVICES PROVIDED TO OUR COMMUNITY REMAINS HIGH WITH THE RISE IN HIGH-DEDUCTIBLE PLANS AND THE APPROXIMATELY 8% OF RESIDENTS WHO ARE UNINSURED. IN 2016, ROME MEMORIAL HOSPITAL'S BAD DEBT AND CHARITY CARE TOTALED $5.8 MILLION. PHYSICIAN SHORTAGES: ROME MEMORIAL HOSPITAL HAS BEEN SUCCESSFUL IN RECRUITING SEVERAL NEW PHYSICIANS TO THE COMMUNITY, BUT AT A GREAT COST. TODAY'S PHYSICIAN WANTS TO BE EMPLOYED SO THEY DON'T HAVE TO BEAR THE RISK OF OPENING A NEW PRACTICE OR MANAGE THE ADMINISTRATIVE ASPECTS OF MEDICINE. ALTHOUGH THEY PROVIDE CRITICAL ACCESS TO CARE, THESE PRACTICES STRUGGLE TO BREAK EVEN. LACK OF PRIMARY CARE: PATIENTS WHO DON'T HAVE INSURANCE OR WHO ARE COVERED BY MEDICAID OFTEN DON'T HAVE A REGULAR PHYSICIAN FOR PREVENTATIVE CARE OR TO MANAGE CHRONIC CONDITIONS. AS A RESULT, THEY USE THE EMERGENCY DEPARTMENT AS THEIR PRIMARY CARE OR DELAY CARE UNTIL THEIR CONDITION IS MORE CRITICAL AND MORE EXPENSIVE TO TREAT. SINCE ROME MEMORIAL HOSPITAL'S NEW EMERGENCY DEPARTMENT OPENED, THE NUMBER OF PATIENT VISITS HAS STEADILY INCREASED FROM 19,000 IN 2006 TO 30,677 IN 2016. MANY PHYSICIANS DON'T ACCEPT MEDICAID PATIENTS BECAUSE OF LOW REIMBURSEMENT RATES. IN ADDITION, SENIORS MAY SOON FACE THE SAME ACCESS PROBLEMS IF CUTS TO PHYSICIAN MEDICARE RATES ARE IMPLEMENTED. PHARMACEUTICALS: THE HOSPITAL CONTINUES TO SEE SIGNIFICANT INCREASE IN DRUG COSTS DUE TO INFLATION AND MANUFACTURER PRODUCTION SHORTAGES. IN MANY CASES, THESE SHORTAGES FORCE US TO TURN TO ALTERNATE SUPPLIERS, WHO CHARGE A PREMIUM PRICE. INTERPRETER SERVICES: AS OUR POPULATION BECOMES MORE DIVERSE WITH BURMESE AND BOSNIAN REFUGEES AND SPANISH SPEAKING RESIDENTS, THERE IS A GREATER DEMAND FOR INTERPRETER SERVICES. DDSO POPULATION: THE HIGH CONCENTRATION OF DDSO CLIENTS IN ONEIDA COUNTY AND ROME PLACES A UNIQUE BURDEN ON ROME MEMORIAL HOSPITAL. WHEN DDSO CLIENTS REQUIRE HOSPITALIZATION, THEIR CASES ARE OFTEN VERY COMPLEX AND THEIR LENGTH OF STAY IS NEARLY TWICE AS LONG AS THE AVERAGE PATIENT. AS A RESULT, THE HOSPITAL IS ONCE AGAIN FACED WITH ABSORBING THE FINANCIAL LOSS OF CARING FOR THESE PATIENTS. PROGRAM VIABILITY: AS A RESULT OF THESE SIGNIFICANT FINANCIAL CHALLENGES, RMH CONTINUALLY EVALUATES THE VIABILITY OF SOME OF ITS SERVICES. AS A PART OF THE EVALUATION, RMH ASSESSES THE NUMBER OF PEOPLE SERVED AND AVAILABILITY OF OTHER SERVICES TO ADDRESS THE COMMUNITY NEED, IN ADDITION TO THE FINANCIAL BURDEN ON THE HOSPITAL.TRANSITION TO VALUE BASED PAYMENTS: TO PREPARE FOR NEW PAYMENT MODELS THAT REWARD QUALITY AND EFFICIENCY, PROVIDERS NEED TO MAKE INVESTMENTS IN SOPHISTICATED ANALYTICS TO MANAGE RISK AND CARE MANAGERS TO BETTER COORDINATE CARE. PART VI, LINE 2: LINE 2 - ALWAYS ASSESSING NEEDS:IN ADDITION TO THE FORMAL CHNA REPORTED IN PART V, SECTION B, ROME MEMORIAL HOSPITAL CONTINUALLY ASSESSES THE COMMUNITY'S NEEDS THROUGH ONGOING OBSERVATION AND PARTICIPATION IN COMMUNITY COMMITTEES AND ORGANIZATIONS THAT REPRESENT A BROAD SEGMENT OF THE POPULATION. IN ADDITION, THE HOSPITAL ENCOURAGES COMMUNITY INPUT THROUGH ITS WEBSITE AND PATIENT ENGAGEMENT SURVEYS. PART VI, LINE 3: LINE 3 - PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE:TO ENSURE THAT PATIENTS ARE AWARE OF THE FINANCIAL ASSISTANCE PROGRAM, PATIENTS ARE NOTIFIED THE FOLLOWING WAYS:-THE PATIENT GUIDE, WHICH IS GIVEN TO ALL INPATIENTS AND OBSERVATION PATIENTS, INCLUDES THE PLAIN LANGUAGE SUMMARY OF THE POLICY.- A PAPER COPY OF THE PLAIN LANGUAGE SUMMARY IS OFFERED TO ALL OUTPATIENTS.-SIGNAGE IS LOCATED AT ALL INTAKE AREAS INCLUDING OFF-SITE CLINICS/LOCATIONS AND WITHIN THE BUSINESS OFFICE. THESE AREAS HAVE PAPER COPIES AVAILABLE TO THE PUBLIC IN PERSON AND BY MAIL.-ALL BILLING STATEMENTS AND COLLECTION LETTERS NOTIFY PATIENTS ON HOW TO OBTAIN MORE INFORMATION ON FINANCIAL ASSISTANCE VIA PHONE OR INTERNET.-BROCHURES/PLAIN LANGUAGE SUMMARIES ARE PROVIDED TO LOCAL COMMUNITY ORGANIZATIONS THAT SERVE INDIVIDUALS MOST LIKELY TO NEED FINANCIAL ASSISTANCE. PART VI, LINE 4: LINE 4 - COMMUNITY INFORMATION:ROME MEMORIAL HOSPITAL PROVIDES HEALTHCARE SERVICES TO APPROXIMATELY 68,000 RESIDENTS IN ROME AND THE SURROUNDING RURAL COMMUNITIES IN ONEIDA COUNTY. FOR SELECTED SPECIALTIES, SUCH AS SENIOR BEHAVIORAL HEALTH CARE, ROME MEMORIAL HOSPITAL'S SERVICE AREA EXTENDS INTO THE SURROUNDING COUNTIES OF MADISON, HERKIMER LEWIS AND ONONDAGA.ROME MEMORIAL HOSPITAL'S PRIMARY SERVICE AREA INCLUDES: ROME, CAMDEN, BOONVILLE, BLOSSVALE, REMSEN, TABERG, HOLLAND PATENT, ORISKANY, LEE CENTER, FORESTPORT, AVA, WESTMORELAND, SYLVAN BEACH, WESTERNVILLE, WEST LEYDEN, STITTVILLE, NORTH BAY, WOODGATE, PROSPECT, AND WESTDALE.RESIDENTS FROM ROME'S 13440 ZIP CODE WITH A POPULATION OF APPROXIMATELY 43,000 COMPRISE MORE THAN 55% OF RMH'S INPATIENT DISCHARGES. THE SURROUNDING COMMUNITIES ARE MOSTLY RURAL, WITH CAMDEN (POPULATION OF 6,460) AND BOONVILLE (POPULATION OF 5,889) AS THE TWO LARGEST TOWNS LOCATED IN THE PRIMARY SERVICES AREA.BASED ON THE 2010 CENSUS, THE POPULATION OF ONEIDA COUNTY IS 234,878. 21.4% OF THE POPULATION IS UNDER AGE 18 AND 16.8% IS 65 AND OLDER. THE POPULATION IS 88.7% WHITE, 6.6% AFRICAN AMERICAN AND 3.1 % ASIAN. 4.9% IDENTIFY THEMSELVES AS HISPANIC OR LATINO.ROME MEMORIAL HOSPITAL AND ITS AFFILIATES SERVE AS A SAFETY NET FOR A REGION THAT IS SOCIOECONOMICALLY CHALLENGED. APPROXIMATELY 17,750 MEDICAID BENEFICIARIES RESIDE IN ZIP CODES THAT COMPRISE THE HOSPITAL'S PRIMARY SERVICE AREA. AT $44,694, THE MEDIAN HOUSEHOLD INCOME IN ROME IS LESS THAN ONEIDA COUNTY'S MEDIAN INCOME OF $48,931 AND IS LESS THAN NEW YORK STATE'S AT $58,687. IN ROME, 17% OF THE POPULATION LIVES BELOW THE POVERTY LINE. THERE IS AN EDUCATIONAL ATTAINMENT GAP IN ROME WITH ONLY 19.5% OF RESIDENTS AGE 25+ EARNING A BACHELOR'S DEGREE OR HIGHER, COMPARED TO 33.7% IN NEW YORK STATE.ROME MEMORIAL HOSPITAL IS THE ONLY HOSPITAL IN THE CITY OF ROME. THERE ARE TWO HOSPITALS IN SOUTHERN ONEIDA COUNTY (ST. ELIZABETH MEDICAL CENTER AND FAXTON-ST. LUKE'S HEALTHCARE).LACK OF ACCESS TO CARE IS LARGELY DUE TO PROVIDER SHORTAGES IN THE HEALTH PROFESSIONAL SHORTAGE AREA (HPSA). MEDICAID ELIGIBLE - ONEIDA COUNTY MENTAL HEALTH PROFESSIONAL SHORTAGE AREA (ID#736999360I) AND THE MEDICAID-ELIGIBLE-ROME PRIMARY CARE SERVICE AREA HPSA (ID#136999363J), THE MEDICAID-ELIGIBLE-BOONVILLE PRIMARY CARE SERVICE AREA HPSA (ID# 13699936N1), AND THE CAMDEN SERVICE AREA HPSA (ID#13699936J1). PART VI, LINE 5: LINE 5 - PROMOTION OF COMMUNITY HEALTH:ADDITIONAL WAYS THE HOSPITAL DEMONSTRATES ITS EXEMPT PURPOSE:1.ROME MEMORIAL HOSPITAL PROVIDES EMERGENCY SERVICES TO EVERYONE REGARDLESS OF ABILITY TO PAY.2.THE HOSPITAL'S INDEPENDENT GOVERNING BODY IS COMPRISED OF INDIVIDUALS WHO RESIDE OR WORK IN THE PRIMARY SERVICE AREA TO REPRESENT THE INTERESTS OF THE COMMUNITY.3.THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY.4.THE HOSPITAL USES ANY SURPLUS FUNDS TO IMPROVE CARE, EXPAND FACILITIES, RECRUIT STAFF AND ADVANCE MEDICAL TRAINING AND COMMUNITY EDUCATION. PART VI, LINE 6: LINE 6 - AFFILIATED HEALTH CARE SYSTEM:ROME MEMORIAL HOSPITAL, INC. (THE "HOSPITAL") IS A NEW YORK STATE NOT-FOR-PROFIT CORPORATION AND TAX EXEMPT UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE ("IRC"), AND IS PART OF THE FOLLOWING CORPORATE STRUCTURE: GREATER ROME AFFILIATES, INC. ("GRA"), A NEW YORK STATE NOT-FOR-PROFIT CORPORATION, TAX EXEMPT UNDER SECTION 501(C)(3) OF THE IRC, IS THE SOLE CORPORATE MEMBER, AND THEREFORE, THE "PARENT" OF THE HOSPITAL, AS WELL AS ROME MEMORIAL PROPERTIES, INC., A NEW YORK STATE NOT-FOR-PROFIT CORPORATION, TAX EXEMPT UNDER SECTION 501(C)(3) OF THE IRC. GRA IS ALSO THE SOLE SHAREHOLDER OF RMH SERVICES, INC., A NEW YORK STATE BUSINESS CORPORATION, WHICH WAS ESTABLISHED TO UNDERTAKE CERTAIN FOR-PROFIT BUSINESS ACTIVITIES AND WHICH HAS AN EQUITY OWNERSHIP INTEREST IN, AND IS A MEMBER OF, THREE NEW YORK STATE LIMITED LIABILITY COMPANIES: 1819 BLACK RIVER ASSOCIATES, LLC; CHESTNUT COMMONS, LLC; AND RMH RETAIL PHARMACY, LLC. MEMBERS OF THE HOSPITAL'S BOARD OF TRUSTEES AND ADMINISTRATIVE STAFF HAVE OVERLAPPING RESPONSIBILITIES ON THE BOARDS OF THE AFFILIATED CORPORATIONS TO ENSURE THAT THE HOSPITAL'S BEST INTERESTS ARE BEING SERVED. ROME MEMORIAL HOSPITAL FOUNDATION, INC., A NEW YORK STATE NOT-FOR-PROFIT CORPORATION, TAX EXEMPT UNDER SECTION 501(C)(3) OF THE IRC, IS A SEPARATE CORPORATION ESTABLISHED FOR THE SOLE PURPOSE OF CONDUCTING FUND RAISING ACTIVITIES ON BEHALF OF THE HOSPITAL, INCLUDING THE RECEIPT OF GIFTS AND BEQUESTS ON BEHALF OF THE HOSPITAL, INVESTING SUCH ASSETS, AND TRANSFERRING THEM TO THE HOSPITAL IN SUPPORT OF ITS MISSION. IT IS GOVERNED BY A SEPARATE BOARD OF DIRECTORS, WHICH HAS AMONG ITS MEMBERS HOSPITAL TRUSTEES AND MEMBERS OF THE HOSPITAL'S MEDICAL STAFF.THE SYSTEM ALSO INCLUDES TWO CAPTIVE PROFESSIONAL CORPORATIONS, INCLUDING ROME MEDICAL GROUP, P.C., A MULTI-PHYSICIAN PRIMARY CARE PRACTICE, AND ROME MEDICAL PRACTICE, P.C., A MULTI-PHYSICIAN, SPECIALTY GROUP. THE PCS ARE THE VEHICLES THROUGH WHICH PHYSICIANS ARE EMPLOYED TO SERVE THE COMMUNITY. IN TODAY'S ENVIRONMENT, MANY PHYSICIANS PREFER TO BE EMPLOYED VS. GOING OUT IN PRIVATE PRACTICE. PART VI, LINE 7, REPORTS FILED WITH STATES NY X 1 1 X X X X 0 0 0 0 0 0 0 0 0 DAVID LUNDQUIST CEO 286876 0 0 0 0 0 0 0 1045 0 287921 0 0 0 DEWEY ROWLANDS CFO 207343 0 0 0 0 0 0 0 7740 0 215083 0 0 0 BENJAMIN SOMMER PHYSICIAN 196281 0 0 0 0 0 0 0 7722 0 204003 0 0 0 BRUCE PETERSON AVP/CIO 154036 0 0 0 0 0 0 0 945 0 154981 0 0 0 MARK SNYDERMAN VP OUTPATIENT SERVICES 151043 0 0 0 0 0 0 0 3224 0 154267 0 0 0 PART I, LINE 1A TYPE OF BENEFIT: PAYMENT OF 2016 MEMBERSHIP DUES AND GENERAL MAINTENANCE FEE FOR SOCIAL CLUB, AS AGREED UPON IN EMPLOYMENT CONTRACT. PERSON WHO RECEIVED BENEFIT: DAVID LUNDQUIST, CEO THIS BENEFIT WAS TREATED AS TAXABLE COMPENSATION IN 2016 FOR PERSON LISTED ABOVE. SCOTT BURNS SON OF INTERIM CEO 144194 COMPENSATION 0 SCOTT A GWILT SON IN LAW OF BOARD DIRECTOR 39961 COMPENSATION 0 FORM 990, PART VI, SECTION A, LINE 6 GREATER ROME AFFILIATES IS THE SOLE MEMBER OF ROME MEMORIAL HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A PER THE HOSPITAL BY-LAWS "THE SOLE CORPORATE MEMBER OF THE CORPORATION SHALL BE GREATER ROME AFFILIATES, INC. WHICH SHALL ACT HEREUNDER AS SUCH MEMBER BY DULY AUTHORIZED RESOLUTION OF ITS BOARD OF DIRECTORS AND WHICH SHALL COMMUNICATE ITS ACTIONS TO THIS BOARD THROUGH ITS PRESIDENT OR OTHER DULY AUTHORIZED OFFICER." GREATER ROME AFFILIATES APPOINTS THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11B THE COMPLETED 2016 990 WAS PRESENTED TO THE BOARD BY THE CFO OF THE HOSPITAL AT ITS SEPTEMBER 2017 BOARD MEETING. FORM 990, PART VI, SECTION B, LINE 12C CONSISTENT WITH ROME HOSPITAL'S GIFTS, GRATUITIES AND CONFLICT OF INTEREST POLICY, THE COMPLIANCE OFFICER OF RMH HAS A CONFLICT OF INTEREST DISCLOSURE FORM COMPLETED ON AN ANNUAL BASIS BY ALL OFFICERS, DIRECTORS AND MANAGEMENT PERSONNEL. THE COMPLIANCE OFFICER COLLECTS AND REVIEWS THE BOARD OF TRUSTEES/FOUNDATION BOARD INTEREST DISCLOSURE FORMS ON AN ANNUAL BASIS. THE INFORMATION GATHERED ON THE DISCLOSURE IS REVIEWED AND ANY CONFLICTS ARE COMMUNICATED TO THE PRESIDENT/CEO, COMPLIANCE BOARD, AND BOARD OF TRUSTEES TO ENSURE ALL HOSPITAL TRANSACTION/BUSINESS ACTIVITIES ARE CONDUCTED IN A MANNER THAT IS FREE FROM UNLAWFUL OR OTHERWISE INAPPROPRIATE OFFERS OR SOLICITATIONS OF IMPROPER INDUCEMENTS IN EXCHANGE FOR INFLUENCE OR ASSISTANCE IN A TRANSACTION. POTENTIAL CONFLICTS THAT MAY ARISE THROUGHOUT THE YEAR ARE BROUGHT TO THE ATTENTION OF THE COMPLIANCE OFFICER AND PRESIDENT/CEO FOR REVIEW. ANY IDENTIFIED CONFLICTS ARE THEN REVIEWED AT THE CORPORATE COMPLIANCE COMMITTEE AND BY THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION B, LINE 15 USE OF IROQUOIS DATA, ASSOCIATION FOR HEALTHCARE PHILANTHROPY SALARY DATA, AND THE ROME HOSPITAL HUMAN RESOURCE DEPARTMENT ARE UTILIZED TO DETERMINE COMPENSATION FOR THE ORGANIZATION'S EMPLOYEES. FORM 990, PART VI, SECTION C, LINE 18 FORMS ARE AVAILABLE UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 FORMS ARE AVAILABLE FOR PUBLIC INSPECTION UPON REQUEST OR THROUGH WWW.GUIDESTAR.ORG- A WEBSITE THAT PROVIDES NON-PROFIT INFORMATION TO THE PUBLIC. RMH MAKES ITS GOVERNING DOCUMENTS (BY - LAWS) AND CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC THROUGH RMH WEBSITE - WWW.ROMEHOSPITAL.ORG. ALSO, FINANCIAL FACTS AND FIGURES AND ECONOMIC IMPACT REPORTS CAN BE FOUND ON THIS WEBSITE. FORM 990, PART IX, LINE 11G LAB SERVICES: PROGRAM SERVICE EXPENSES 4,187,515. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,187,515. PHYSICIANS: PROGRAM SERVICE EXPENSES 2,702,418. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,702,418. NURSE STAFFING: PROGRAM SERVICE EXPENSES 1,031,389. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,031,389. SERVICE CONTRACT: PROGRAM SERVICE EXPENSES 1,153,833. MANAGEMENT AND GENERAL EXPENSES 404,408. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,558,241. CONSULTING: PROGRAM SERVICE EXPENSES 691,709. MANAGEMENT AND GENERAL EXPENSES 92,275. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 783,984. FORM 990, PART XI, LINE 9: CHANGE IN UNRESTRICTED INTEREST IN FOUNDATION 98,089. BOOK/TAX DIFFERENCE OF GRIFFIS EYE CENTER 144,135. CHANGE IN TEMPORARY INTEREST IN FOUNDATION -20,000. GREATER ROME AFFILIATES 1500 N JAMES STREET ROME NY 13440 161508597 PARENT CORPORATION NY 501C3 LINE 12A, I 0 ROME MEMORIAL PROPERTIES 1500 N JAMES STREET ROME NY 13440 161492003 SUPPORT HOSPITAL ACTIVITIES NY 501C3 3 GRA 0 RMH SERVICES INC 1500 N JAMES STREET ROME NY 13440 161490045 FOR PROFIT NY GREATER ROME AFFILIATES C -236945 2215666 1.00000 0 ROME MEDICAL GROUP 1801 BLACK RIVER BLVD ROME NY 13440 161464822 CAPTIVE P.C. NY ROME MEMORIAL HOSPITAL C 0 ROME MEDICAL PRACTICE 1500 N JAMES STREET ROME NY 13440 203827393 CAPTIVE P.C. NY ROME MEMORIAL HOSPITAL C 0 0 0 1 0 1 0 0 0 0 1 1 1 0 0 1 1 1 0 0