2016-11-14T15:10:31-06:00 2015-12-31 161226221 FUST CHARLES CHAMBERS LLP 5784 WIDEWATERS PARKWAY SYRACUSE NY 13214 990 2015-01-01 150533578 LITTLE FALLS HOSPITAL LITT 3158231000 140 BURWELL STREET LITTLE FALLS NY 13365 JAMES VIELKIND CFO 3158231000 2016-11-11 1 JOSEPH J SCHLEGEL P00301329 3154463600 2015 2017-02-10 21:41:12Z JAMES VIELKIND 140 BURWELL STREET LITTLE FALLS NY 13365 32378491 0 X LFHNY.ORG X 1893 NY LITTLE FALLS HOSPITAL IS A CRITICAL ACCESS HOSPITAL PROVIDING ACCESS TO HEALTH CARE SERVICES TO RESIDENTS OF HERKIMER COUNTY, AND WESTERN PORTIONS OF MONTGOMERY AND FULTON COUNTIES. LITTLE FALLS HOSPITAL EMERGENCY DEPARTMENT IS STAFFED WITH PHYSICIANS ON A 24/7 BASIS. TWENTY FIVE BEDS ARE USED FOR INPATIENT AND SKILLED NURSING CARE. AMBULATORY SURGERY SERVICES ARE PROVIDED FOR A VARIETY OF SPECIALTIES. PERFORMANCE IMPROVEMENT AND HIGH QUALITY OF CARE IS DEMONSTRATED WITHIN THE HOSPITAL CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS (HCAHPS) AS REPORTED ON MEDICARE.GOV HOSPITAL COMPARE. 16 12 351 21 0 0 444943 292825 30787727 30806653 188122 121364 0 0 31420792 31220842 0 0 0 0 14488258 14552467 0 0 65310 16701974 17660445 31190232 32212912 230560 -992070 35894698 33563535 12574417 11695823 23320281 21867712 X LITTLE FALLS HOSPITAL IS A VOLUNTARY, NOT-FOR-PROFIT COMMUNITY HEALTHCARE SYSTEM WHOSE MISSION IS TO OFFER QUALITY CARE WITH COMPASSION, TO ALL WHO NEED OUR SERVICES. 0 0 8496733 8475695 INPATIENT SERVICESTHE INPATIENT OCCUPANCY RATE FOR INPATIENT AND OBSERVATION SERVICES WAS 68% FOR AN AVERAGE DAILY INPATIENT DAILY CENSUS OF 17 PATIENTS. AS A CRITICAL ACCESS HOSPITAL (CAH) PROVIDER, OUR INPATIENT DAILY CENSUS IS LIMITED TO 25 PATIENTS PER DAY. IN 2015, LITTLE FALLS HOSPITAL ACHIEVEDACCREDITATION BY THE JOINT COMMISSION INDICATING A HIGH PROFIENCY IN DELIVERING SAFE PATIENT CARE. THE HOSPITAL WAS ALSO RATED A FIVE STAR (*****) HOSPITAL BY "HOSPITAL CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS" (HCAHPS). A FIVE STAR RATING INDICATES HIGH PATIENT SATISFACTION IN THEIR PATIENT CARE AS MEASURED BY PATIENT SURVEY INSTRUMENTS. THE HOSPITAL ACHIEVED A 7% ACUTE CARE READMISSION RATE, WHICH WAS APPROXIMATELY 20% LOWER THAN 2014. THIS INITIATIVE AND OTHER CARE TRANSFORMATION INTERVENTIONS ARE IMPROVING THE HEALTHCARE FOR OUR COMMUNITIES. 8647299 8734980 LITTLE FALLS HOSPITAL OPERATES AN EMERGENCY DEPARTMENT WITH TWENTY FOUR HOURS OF PHYSICIAN COVERAGE, SEVEN DAYS PER WEEK. THE EMERGENCY DEPARTMENT PROVIDED ACCESS TO CARE FOR APPROXIMATELY 15,000 PATIENTS IN 2015. THESE SERVICES ARE PROVIDED TO ALL PATIENTS REGARDLESS OF ABILITY TO PAY. OUR EMERGENCY DEPARTMENT LEARNED AND IMPLEMENTED "LEAN SIX SIGMA" TECHNIQUES TO RE-DESIGN PROCESSES FOR IMPROVING PATIENT TIMELINESS OF RECEIVING CARE. THESE VALUE ADDED ACTIVITIES ARE CONSISTENT WITH THE CHANGING PAYMENT SYSTEMS TO TRANSFORM TO A "PAY FOR PERFORMANCE" INSTEAD OF THE CURRENT STATUS OF REIMBURSEMENT RECONIZED AS "FEE FOR SERVICE". INITIATIVES WITH MEDICAID HMO'S AND CONSUMER EDUCATION ON ALTERNATIVE SERVICE LOCATIONS INSTEAD OF THE EMERGENCY DEPARTMENT CONTINUED IN 2015. THESE CARE RE-DESIGN MEASURES ARE CONSISTENT WITH NYS DEPARTMENT OF HEALTH MEDICAID CARE RE-DESIGN INITIATIVES, ADMINISTERED UNDER THE "DELIVERY SYSTEM REFORM INCENTIVE PAYMENT (DSRIP) PROGRAM". A GOAL OF THIS PROGRAM IS TO REDUCE BY 25% OVER FIVE YEARS, AVOIDABLE HOSPITAL EMERGENCY DEPARTMENT VISITS AND HOSPITAL ADMISSIONS. 7946134 10298545 TOTAL AMBULATORY OUTPATIENT SERVICE VISITS WERE APPROXIMATELY 33,000 IN 2015. THESE AMBULATORY SERVICE SERVICES INCLUDE REHAB / WELLNESS PROGRAM, AMBULATORY SURGERY / GI SERVICES, WOMENS IMAGING SERVICE, DIAGNOSTIC IMAGING SERVICES, AND PRIMARY CARE SERVICES. OUR DOLGEVILLE AND NEWPORT HEALTH CENTERS AND AMBULATORY SURGERY PROGRAM WERE RECONIZED AS "GUARDIAN OF EXCELLENCE AWARD" BY PRESS GANEY. THIS AWARD RECOGNIZES SERVICE PERFORMANCE WHEREBY PATIENT SATISFACTION WAS MEASURED AT A LEVEL OF 95% OF PEERS WITHIN A FOUR QUARTER MEASUREMENT PERIOD. IN 2015 OUR DOLGEVILLE HEALTH CENTER FORMALIZED CARE COORDINATION SERVICES TO IMPROVE USE OF SERVICES NEEDED BY CHRONIC CARE PATIENTS. CARE COORDINATION IS A PROVEN PATIENT CARE IMPROVEMENT INTERVENTION RECONIZED BY THE NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA) AND WILL SUPPORT THE DEVELOPMENT OF OUR FUTURE PATIENT CENTERED MEDICAL HOME (PCMH) AT OUR DOLGEVILLE AND NEWPORT HEALTH CENTERS. 2739152 3297433 THE HOSPITAL CONTINUED EFFORTS WITH SUPPORTING OUR ROLE AS A NYS DEFINED SAFETY-NET PROVIDER. IN 2015 WE RECEIVED VITAL ACCESS PROVIDER (VAP) AWARDS TO STRENGTHEN OUR PATIENT DELIVERY SYSTEMS. SOME OF THESE INITIATIVES CONTINUE TO RELY ON RECRUITMENT OF PRIMARY CARE PROVIDERS TO OUR REGION. WE ARE ALSO A PARTNER IN THE LEATHERSTOCKING COLLABORATIVE HEALTH PARTNERS (LCHP), LLC WHOSE ACTIVITIES ARE ASSOCIATED WITH COORDINATING IMPROVEMENTS IN POPULATION HEALTH OUTCOMES OUTLINED IN THE NYS DEPARTMENT OF HEALTH "DELIVERY SYSTEM REFORM INCENTIVE PAYMENT" PROGRAM. IN 2015 LITTLE FALLS HOSPITAL RECEIVED FUNDING FOR OUR INITIATIVES OF $66,000. 2739152 3297433 27829318 1 1 0 0 0 0 0 0 0 1 1 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 32 0 1 351 1 0 0 0 0 0 0 0 0 0 0 X 16 12 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X JAMES G VIELKIND 3158235281 140 BURWELL STREET LITTLE FALLS NY 13365 JOHN D BULLIS CHAIRMAN 2.00 1.50 X X 0 0 0 JOAN S CONBOY TRUSTEE 2.00 X 0 0 0 TIMOTHY DALY SECOND VICE CHAIRMAN 2.00 X X 0 0 0 ANTHONY DELUCA FIRST VICE CHAIRMAN 2.00 X X 0 0 0 JOY MALONE TRUSTEE 2.00 X 0 0 0 GERARD J SNYDER SECRETARY 2.00 X X 0 0 0 JENNIFER VANWAGONER TRUSTEE 2.00 X 0 0 0 RANBIR SODHI MD TRUSTEE 2.00 X 0 0 0 AUGUST LEINHART MD TRUSTEE 2.00 40.00 X 0 359745 21671 KEVIN CROSLEY TRUSTEE 2.00 X 0 0 0 JUSTIN R HUMMEL TRUSTEE 2.00 X 0 0 0 AMY GRACE MD PRESIDENT OF MEDICAL STAFF 2.00 40.00 X X 1500 204125 13919 ROBERT CASULLO TRUSTEE 2.00 X 0 0 0 DUANE SIDNEY TRUSTEE 2.00 X 0 0 0 LISA BETRUS THIRD VICE CHAIRMAN 2.00 X X 0 180551 15282 MICHAEL TENGERES TREASURER 0.00 40.00 X X 0 316107 1538 MICHAEL OGDEN PRESIDENT & CEO 40.00 X 0 182256 8558 JAMES G VIELKIND CHIEF FINANCIAL OFFICER 40.00 X 134249 0 5576 RICHARD NOCELLA PRIMARY CARE PHYSICIAN 40.00 X 140907 0 4441 NICHOLAS NICOLETTA FORMER TREASURER 0.00 0.00 X 0 83046 1546 276656 1325830 72531 2 1 1 0 DM CONSULTING PO BOX 4715 UTICA NY 13504 INFORMATION TECHNOLOGY 117832 SIMPLEX GRINNEL 6731 COLLAMER ROAD SUITE 4 SYRACUSE NY 13057 LIFE SAFETY SYSTEMS 104999 2 67673 225152 292825 OUTPATIENT SERVICES 623000 20927768 20927768 INPATIENT HOSPITAL 621930 8475695 8475695 OTHER OPERATING REVENUE 900099 822219 822219 PROGRAM SERVICE LEASE 532000 443276 443276 HOSPITAL CAFETERIA 900099 137695 137695 30806653 14272 14272 1264741 1157649 107092 107092 107092 31220842 30806653 0 121364 141325 1500 139825 11362087 9794073 1521130 46884 565078 485982 76770 2326 1634467 1392627 235174 6666 849510 723723 122323 3464 23100 19692 3408 76278 15256 61022 348808 249386 99422 30337 30337 2268528 2190713 76407 1408 1204502 1061528 142974 628210 547093 80583 534 28810 16365 11598 847 48813 15205 33608 200464 176869 23580 15 2269663 2002525 266972 166 295638 278253 17385 PURCHASED MEDICAL SERVI 6156171 6156171 ADMINISTRATIVE SERVICES 1989825 841568 1148257 PROVISION FOR BAD DEBT 1483959 1483959 NEW YORK STATE ASSESSME 88828 88828 518511 257665 257846 3000 32212912 27829318 4318284 65310 303056 551280 1520456 1431115 384934 426099 3119017 3250169 467466 473166 1431115 333851 42263927 23447999 19829176 18815928 2653184 2145739 2948053 2843182 1908664 1726281 1329577 1566725 35894698 33563535 2943565 3211744 593821 655303 6008689 5387347 3028342 2441429 12574417 11695823 X 18729570 17407027 3691012 3595399 899699 865286 23320281 21867712 35894698 33563535 X -992070 -208754 -251745 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 5021 5021 0 PART II-B, LINE 1: A PERCENTAGE OF MEMBERSHIP DUES PAID TO HEALTHCARE ASSOCIATION OF NEW YORK STATE (28.0%), IROQUOIS HEALTHCARE ALLIANCE (36.3%) 4590711 14514 -144539 4460686 4263576 137 326998 4590711 10099410 720 361656 6198210 4263576 12753313 12870 1085526 3752299 10099410 12156996 623347 -27030 12753313 0.19390 0.80610 0 1 1 380386 380386 29156030 13614941 15541089 12359111 9833058 2526053 368400 368400 18815928 MARY LEARY CHARITABLE REMAINDER TR 1371407 F ELSA O'BRIEN CHARITABLE REMAINER TR 1471775 F 2843182 DIRECT FINANCE LEASE 1726281 C 1726281 ACCRUED PENSION LIABILITY 2253619 OTHER LIABILITIES 187810 2441429 X 31220842 0 31220842 0 31220842 32212912 0 32212912 0 32212912 PART V, LINE 4: ENDOWMENT FUNDS DISTRIBUTE INCOME FOR PURPOSES OF CAPITAL INVESTMENT. TEMPORARY ENDOWMENTS ARE USED BASED ON THE INTENT OF THE DONATION WHICH IS TYPICALLY FOR CAPITAL INVESTMENTS. PART X, LINE 2: THE HOSPITAL QUALIFIES AS AN ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE. AS OF DECEMBER 31, 2015 AND 2014, 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 NEW YORK STATE TAXING AUTHORITIES ARE 2012 THROUGH 2015. PART VI, LINE 1E OTHER INCLUDES $368,400 FOR ITEMS NOT PLACED IN SERVICE ON 12/31/2015. 1 1 1 X 300.000000000000 0 1 1 0 1 1 145 184158 149254 34904 0.00110 14015 5849677 2795446 3054231 0.09900 14160 6033835 2944700 3089135 0.10010 40447 1129 39318 0.00130 44 46472 46472 0.00150 2660 483965 279307 204658 0.00640 2704 570884 280436 290448 0.00920 16864 6604719 3225136 3379583 0.10930 3420 3420 0.00010 50846 50846 0.00170 54266 54266 0.00180 1 1483959 17423 9377400 9478700 -101300 X 1 1 1 1 LITTLE FALLS HOSPITAL 140 BURWELL STREET LITTLE FALLS NY 13365 LFHNY.ORG 2129700H X X INCLUDES 25 INPATIENT BEDS, LITTLE FALLS HOSPITAL 1 0 0 1 X X X X X X X X 13 1 1 1 1 X WWW.LFHNY.ORG X WWW.BASSETT.ORG X 1 13 1 WWW.LFHNY.ORG 0 0 1 X 300.000000000000 1 1 X X X X 1 X LFHNY.ORG X LFHNY.ORG X LFHNY.ORG X X X X X 1 X 0 X X X X X 1 X 0 0 PART V, SECTION A: LITTLE FALLS HOSPITAL HAS PRIMARY CARE HEALTH CENTERS IN DOLGEVILLE, NY (ZIP CODE 13329) AND NEWPORT, NY (ZIP CODE 13416). EXTENDED EVENING HOURS ARE PROVIDED TWO NIGHTS PER WEEK IN THE DOLGEVILLE, NY PRIMARY CARE CENTER. LITTLE FALLS HOSPITAL PART V, SECTION B, LINE 6A: THE COMMUNITY HEALTH NEEDS ASSESSMENT WAS DEVELOPED AS PART OF A MULTI-HOSPITAL PLANNING PROCESS. THE HOSPITALS INCLUDED IN THIS PLANNING PROCESS ARE: BASSETT MEDICAL CENTER, COOPERSTOWN NEW YORK; AUREILA OSBORN FOX MEMORIAL HOSPITAL, ONEONTA NEW YORK; TRI TOWN REGIONAL HOSPITAL, SYNDEY NEW YORK; COBLESKILL REGIONAL HOSPITAL, COBLESKILL NEW YORK; AND O'CONNOR HOSPITAL, DELHI NEW YORK. LITTLE FALLS HOSPITAL PART V, SECTION B, LINE 6B: HERKIMER COUNTY PUBLIC HEALTH, HERKIMER HEALTHNET, TRI-COUNTY MEDICAL, AT HOME CARE, UNITED WAY, VALLEY HEALTH SERVICES, HERKIMER COUNTY MENTAL HEALTH, HERKIMER COUNTY WIC, HERKIMER ARC, HERKIMER COUNTY CATHOLIC CHARITIES, BASSETT MEDICAL CENTER AND RURAL HEALTH DEVELOPMENT. LITTLE FALLS HOSPITAL PART V, SECTION B, LINE 11: OUR COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) FOCUSED ON NEEDS FOR PREVENTING CHRONIC DISEASE AND IMPROVING ACCESS FOR PRIMARY CARE. DESPITE THE ADDITION OF TWO NEW PRIMARY CARE PROVIDERS IN 2014, A NEED FOR THREE MORE PRIMARY PROVIDERS EXISTS. THE DEVELOPMENT OF PRIMARY CARE IN OUR SERVICE AREA IS IN COLLABORATION WITH THE BASSETT HEALTHCARE NETWORK.PREVENTION OF CHRONIC DISEASE WAS IDENTIFIED AS A SECOND GOAL IN OUR 2013 COMMUNITY HEALTH NEEDS ASSESSMENT. IN PARTNERSHIP WITH THESE COMMUNITY AGENCIES DEVELOPMENT OF DIABETES PROGRAMS AND PREVENTATIVE HEALTH AWARENESS PROGRAMS WERE PROVIDED IN 2015. ELEMENTS OF THESE PROGRAMS WERE HEALTH EDUCATION AND MEASUREMENT OF THEIR IMPROVED INDICATORS DURING SIXTEEN WEEK PROGRAMS. DIABETES EDUCATION PROGRAM AWARENESS WAS ALSO PROVIDED TO PRIMARY CARE PROVIDERS SO THEIR PATIENTS COULD BENEFIT FROM THESE INTERVENTION PROGRAMS. OTHER PREVENTATIVE HEALTH INTERVENTIONS INCLUDED ADDITIONAL ACCESS FOR SCREENING RATES FOR CANCER IN COORDINATION WITH HERKIMER / ONEIDA / MADISON COUNTIES CANCER SERVICE PROGRAM, AND PRIMARY CARE PROVIDERS FOCUS ON ACCESSING PATIENTS HISTORY WELLNESS VISIT SCREENINGS. INCREASING AWARENESS WITH HEALTH EDUCATION AND PROGRAM SERVICES AWARENESS FOR OUR RESIDENTS CONTINUES TO BE DEVELOPED WITHIN OUR COMMUNITY PARTNERSHIP. LITTLE FALLS HOSPITAL ALSO BECAME A PARTNER IN THE LEATHERSTOCKING COLLABORATIVE HEALTH PARTNERS (LHCP), LLC. THIS ORGANIZATION REPRESENTS A REGIONAL ORGANIZATION, ESTABLISHED IN PARTNERSHIP WITH NYS DEPARTMENT OF HEALTH, UNDER A CMS REFERENCED AS DELIVERY SYSTEM REFORM INCENTIVE PAYMENT (DSRIP). THIS PROGRAM IS DESIGNED FOR CARE TRANSITION TEAMS TO WORK ON ELEVEN PROJECTS FOR THE PURPOSE OF REDUCING UNNECCESSARY VISITS TO EMERGENCY DEPARTMENTS AND UNNECCESSARY INPATIENT ADMISSIONS. IN 2015 OUR INTIATIVES FOR DSRIP WERE AS FOLLOWS:1.)ORGANIZING THE DOLGEVILLE AND NEWPORT HEALTH CENTERS AS "PATIENT CENTERED MEDICAL HOMES"(PCMH). ACHIEVING PCMH WILL BE COMPLETED IN 2017 BASED ON AN APPLICATION PROCESS AND APPROVAL BY A NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA). DURING THIS APPLICATION PROCESS, FOCUS ON PATIENT CASE MANAGEMENT, CARE COORDINATION, TEAM-BASED CARE, AND IMPROVING USES OF THE ELECTRONIC HEALTH RECORD, ARE MAJOR PERFORMANCE IMPROVEMENTS FOR PATIENT CARE. IN 2015 OUR HEALTH CENTERS PERFORMED APPROXIMATELY 1,000 WELLNESS VISITS REPRESENTING A NINE PERCENT INCREASE FROM 2014.2.)EDUCATING HEALTH CENTER PROVIDERS ON USING ASTHMA TREATMENT PLANS TO SUPPORT PATIENTS. IMPROVE ACCESS TO ASTHMA SPECIALISTS WITH THE ELECTRONIC HEALTH RECORD FOR SHARING CARE PLANS. IN 2015, THE PROVIDER EDUCATION WAS COMPLETED AND NEW ELECTRONIC HEALTH RECORD ASTHMA TREATMENT TEMPLATES WERE BEING TESTED. 3.) ENGAGING PATIENTS WITHOUT INSURANCE AND ENROLLING THESE PATIENTS IN A NYS HEALTH MARKETPLACE HEALTH PLAN. WE SAW SUCCESS IN 2015 WITH MORE PATIENTS ENROLLED IN MEDICAID OR A HEALTH MARKETPLACE PLAN RESULTING IN A DECLINE OF 17% FOR PATIENT BAD DEBT.4.)LITTLE FALLS HOSPITAL CONTINUED TO LEARN AND DEVELOP STRATEGIES FOR SUPPORTING PATIENTS IN THEIR HOME AFTER A HOSPITAL DISCHARGE. THIS PROGRAM IMPROVED PATIENT SAFETY AND REDUCED OUR RE-ADMISSION RATE TO APPROXIMATELY 7% IN 2015 COMPARED TO 9.5% IN 2014. ADDITIONAL PATIENT CARE IMPROVEMENT TOOLS ARE BEING DEVELOPED IN COORDINATION WITH THE LEATHERSTOCKING COLLABORATIVE HEALTH PARTNERS (LCHP), LLC TO CONTINUE OUR EFFORTS FOR PROVIDING THE HIGHEST QUALITY OF CARE FOR OUR PATIENTS. WE HAVE IDENTIFIED THE DIFFICULTY IN RECRUITING PRIMARY CARE PROVIDERS TO OUR REGION AS A POTENTIAL BARRIER TO MEETING OUR GOALS. THERE REMAINS A SHORTAGE OF AVAILABLE PRIMARY CARE PROVIDERS AND ATTRITION WITH AGING OF PROVIDERS REMAINS A CHALLENGE IN OUR PLANNING. LITTLE FALLS HOSPITAL PART V, SECTION B, LINE 20E: LITTLE FALLS HOSPITAL PROVIDED MAILING INFORMATION TO UNINSURED PATIENTS FOR ENROLLING IN AN AFFORDABLE CARE ACT INSURANCE PRODUCT SPONSORED BY THE NYS HEALTH MARKETPLACE. LITTLE FALLS HOSPITAL ALSO ASSISTED PATIENTS WITH THE COMPLETION OF APPLICATIONS FOR ENROLLMENT INTO NYS MARKETPLACE PLANS. IN 2015 35 PATIENTS WERE ENROLLED BY A LITTLE FALLS HOSPITAL EMPLOYED FACILITATOR INTO A NYS MARKETPLACE PLAN. LITTLE FALLS HOSPITAL PART V, SECTION B, LINE 22D: LITTLE FALLS HOSPITAL CHARGES UNIFORM CHARGES TO ALL PAYERS REGARDLESS OF RESPONSIBLE PARTY FOR THE BILL. FOR QUALIFIED UNINSURED WITHIN 300% OF FEDERAL POVERTY GUIDELINES, A 100% DISCOUNT FROM CHARGES IS APPLIED. PART V, SECTION B, LINE 14 LITTLE FALLS HOSPITAL CHARGES FOR SERVICES BASED ON RELATIONSHIPS OF COST OF SERVICES AND AGGREGATE MARGINS REQUIRED FOR HEALTHCARE SERVICES. 2 1 - DOLGEVILLE HEALTH CENTER 9 GIBSON STREET DOLGEVILLE NY 13329 CLINIC 2 - NEWPORT HEALTH CENTER BRIDGE STREET NEWPORT NY 13416 CLINIC PART I, LINE 3C: LITTLE FALLS HOSPITAL DID NOT PROVIDE CHARITY CARE OR DISCOUNTED CARE TO PATIENTS WITH INSURANCE BENEFITS. PART I, LINE 7: COST FOR CHARITY CARE PATIENTS WAS CALCULATED USING RATIO OF COST TO CHARGES. COST ASSOCIATED WITH MEDICAID AND MEDICAID HMO PROGRAMS REPRESENTS AGGREGATE ALLOWABLE COST AND TOTAL GROSS CHARGES USED TO CALCULATE A FACILITY LEVEL COST TO CHARGE RATIO. THIS FACILITY LEVEL COST TO CHARGE RATIO WAS APPLIED TO TOTAL MEDICAID AND MEDICAID HMO CHARGES TO ARRIVE AT TOTAL MEDICAID COST. PART I, LINE 7G: LITTLE FALLS HOSPITAL OPERATES TWO PRIMARY CARE HEALTH CENTERS LOCATED IN DOLGEVILLE AND NEWPORT NEW YORK. THESE CENTERS PROVIDE PRIMARY CARE SERVICES INCLUDING VACCINATIONS, WELL CARE VISITS, AND PRIMARY CARE FOLLOW-UP APPOINTMENTS. USING AN ELECTRONIC HEALTH RECORD ENABLES PATIENTS TO HAVE ACCESS TO THEIR PERSONAL HEALTH INFORMATION IN A TIMELY MANNER. THROUGH AN ELECTONIC HEALTH RECORD SYSTEM, PATIENTS CAN ELECT TO HAVE PORTAL ACCESS FOR PORTIONS OF THEIR PERSONAL HEALTH INFORMATION. PART I, LN 7 COL(F): LITTLE FALLS HOSPITAL EXCLUDED $1,483,959 OF BAD DEBT EXPENSE TO CALCULATE COST OF PATIENT CARE. PART II, COMMUNITY BUILDING ACTIVITIES: COMMUNITY BUILDING ACTIVITIES ARE ASSOCIATED WITH LITTLE FALLS HOSPITAL WORKING WITH COMMUNITY BUSINESSES THROUGH OUR MEMBERSHIP WITH LOCAL AGENCIES, SUCH AS THE HERKIMER CHAMBER OF COMMERCE, HERKIMER COUNTY HEALTHNET, AND THE AREA HEALTH EDUCATION CENTERS (AHEC). THESE ACTIVITIES ALLOW FOR DIALOG ON CURRENT HEALTHCARE TOPICS, INSURANCE PROGRAMS, AND RECRUITMENT OF FUTURE EMPLOYEES. LITTLE FALLS HOSPITAL COLLABORATES WITH BASSETT MEDICAL CENTER ON RECRUITMENT INITIATIVES FOCUSING ON PRIMARY CARE. HERKIMER COUNTY HAS ONE OF THE LOWEST RATIO'S OF PRIMARY CARE PROVIDERS TO RESIDENTS IN NEW YORK STATE. IN 2014 WE HAD SUCCESS IN RECRUITING TWO NEW PHYSICIAN PRIMARY CARE PROVIDES, WHILE LOSING ONE PRIMARY CARE PROVIDER FOR A NET GAIN OF ONE PHYSICIAN PROVIDER. IN 2015 THESE RECRUITMENT INITIATIVES CONTINUED BY REACHING OUT TO RESIDENCY PROGRAMS SPECIALIZING IN PRIMARY CARE. PART III, LINE 3: AN ESTIMATE FOR POTENTIAL CHARITY CARE WAS BASED ON THE DENIED APPLICATIONS PROCESSED IN 2015 COMPARED WITH THOSE APPROVED APPLICATIONS. THIS AMOUNTED TO A 14.6% DENIAL RATE FOR CHARITY CARE APPLICATIONS WHICH IF APPROVED WOULD HAVE INCREASED THE AMOUNT OF CHARITY CARE AT COSTED AMOUNTS BY $17,423. PART III, LINE 4: THE HOSPITAL FOOTNOTE DESCRIBING PATIENT ACCOUNTS RECEIVABLES IS IN THE ATTACHED AUDITED FINANCIAL STATEMENTS NOTE (1)(J) PAGES 7 - 9. PART III, LINE 8: IN 2015, OUR OPERATING DEFICIT, WITH THE MEDICARE PART A&B PROGRAMS, WAS $101,300. MEDICARE REPRESENTS APPROXIMATELY 33% OF OUR TOTAL REVENUE. (NOTE: EXCLUDING MEDICARE PART C AND D) AS A CRITICAL ACCESS HOSPITAL (CAH). THIS SHORTFALL IS DIFFICULT TO FUND AS OUR SERVICES ARE PROVIDED AS A NEW YORK STATE DEFINED SAFETY NET PROVIDER. OUR SAFETY NET HOSPITAL STATUS INDICATES WE ARE A NYS RURAL PROVIDER WITH A GREATER THAN 30% THRESHOLD FOR MEDICAID UTILIZATION OF OUR SERVICES. OUR HIGH VOLUME OF MEDICAID IS REPRESENTED ON SCHEDULE H LINE 7B. PART III, LINE 9B: THE COLLECTION AND CHARITY CARE POLICY SPECIFIES THAT ACCOUNTS WITH ACTIVE CARE APPLICATIONS WILL NOT GO TO COLLECTION AGENCIES WHILE IN REVIEW. PART VI, LINE 2: A. COMMUNITY HEALTH NEEDS ASSESSMENT DEVELOPMENT PROCESSTHE PROCESS FOR DEVELOPING THIS COMMUNITY HEALTH NEEDS ASSESSMENT ENTAILED THE COMPLETION OF A FOURTEEN-STEP PROCESS OVER A PERIOD FROM APRIL 2012 TO MARCH 2013. THE PROCESS BEGAN WITH THE DEVELOPMENT AND AGREEMENT ON A WORK PLAN FOR THE PROJECT THAT DEFINED BOTH ITS SCOPE AND TIME FRAME. IT INVOLVED GAINING A COMMON UNDERSTANDING OF THE PROJECT AND THE NECESSARY BUY-IN FOR ITS COMPLETION AND INCLUDED CHARGING A BASSETT NETWORK-WIDE ADVISORY GROUP WITH PROVIDING OVERALL GUIDANCE FOR DEVELOPING THE CHNA. THIS GROUP INCLUDED REPRESENTATION FROM EACH OF THE SIX HOSPITALS. IN ADDITION TO PROVIDING OVERALL GUIDANCE DURING THE PROCESS, THE ADVISORY GROUP WAS CHARGED WITH: - AGREEING ON A COMMON TEMPLATE FOR A COMMUNITY HEALTH NEEDS ASSESSMENT AS A METHOD FOR INTEGRATING THE DATA AND INFORMATION FROM THE COMMUNITY SERVICE PLAN AND COUNTY COMMUNITY HEALTH ASSESSMENTS;- CONSIDERING CURRENT HEALTH PRIORITIES OF THE COMMUNITY SERVICE PLAN AND RELATED COMMUNITY HEALTH ASSESSMENTS;- CONSIDERING THE DATA AND FINDINGS FROM THE UPSTATE HEALTH AND WELLNESS SURVEY;- SELECTION OF FUTURE HEALTH PRIORITIES FOR THIS COMMUNITY HEALTH NEEDS ASSESSMENT;- IDENTIFYING TARGETED OBJECTIVES FOR ADDRESSING SELECTED HEALTH PRIORITIES;- APPROVING THE CHNA AND RECOMMENDATION FOR PUBLICATION AND DISSEMINATION;- CONSIDERING PUBLIC AND KEY STAKEHOLDER INPUT ON THE CHNA;- REVIEWING AND ADVISING ON IMPLEMENTATION STRATEGIES BASED ON THE CHNA; AND - APPROVING A FINAL CHNA AND IS REPORT FOR SUBMISSION TO THE RESPECTIVE BOARDS OF THE SIX BASSETT HEALTHCARE NETWORK HOSPITALSONCE THE DRAFT CHNA WAS APPROVED BY THE BASSETT NETWORK-WIDE ADVISORY GROUP, IT WAS PUBLISHED ON EACH RESPECTIVE HOSPITAL'S WEBSITE, AS WELL AS ON THE BASSETT HEALTHCARE NETWORK WEBSITE. IT WAS ALSO DISTRIBUTED TO KEY STAKEHOLDERS IN THE AREA. THIS WAS FOLLOWED BY A MEETING WITH KEY STAKEHOLDERS IN THE LITTLE FALLS HOSPITAL SERVICE AREA. KEY STAKEHOLDERS INCLUDED REPRESENTATIVES OF AREA COMMUNITIES, SOCIAL SERVICES, PUBLIC HEALTH, HOSPITALS AND OTHER AREA HEALTH PROVIDERS. B. PRIMARY INFORMATION AND DATA SOURCESTHIS COMMUNITY HEALTH NEEDS ASSESSMENT IS BASED ON AND INCORPORATES EFFORTS OF LITTLE FALLS HOSPITAL, BASSETT HEALTHCARE AND SERVICE AREA COUNTY HEALTH DEPARTMENTS TO IDENTIFY COMMUNITY HEALTH NEEDS AS REQUIRED BY THE NEW YORK STATE DEPARTMENT OF HEALTH. SPECIFICALLY THROUGH LITTLE FALLS HOSPITAL'S COMMUNITY SERVICE PLAN FOR 2011-2012 AND HERKIMER, FULTON AND MONTGOMERY COUNTIES' COMMUNITY HEALTH ASSESSMENT FOR 2010-2013. IT ALSO DRAWS UPON THE UPSTATE HEALTH AND WELLNESS SURVEY CONDUCTED IN 2009 BY BASSETT'S RURAL RESEARCH INSTITUTE. THE UPSTATE HEALTH AND WELLNESS SURVEY PROVIDES A PRIMARY DATA SOURCE FOR IDENTIFYING THE HEALTH STATUS OF RESIDENTS IN A SEVEN-COUNTY AREA SERVED BY BASSETT HEALTHCARE NETWORK AND ITS AFFILIATE HOSPITALS AND OTHER PROVIDERS (CHENANGO, DELAWARE, HERKIMER, MADISON, MONTGOMERY, OTSEGO AND SCHOHARIE). THE UPSTATE HEALTH & WELLNESS SURVEY, CONDUCTED IN 2009 BY THE BASSETT'S RURAL RESEARCH INSTITUTE, CONSISTED OF SEPARATE SURVEYS COVERING THE TOPICS OF: (1) HOUSEHOLD HEALTH; (2) ACCESS TO HEALTH CARE; (3) CHILD LIFESTYLE AND BEHAVIOR CHOICES; (4) ADULT LIFESTYLE AND BEHAVIOR CHOICES; AND (5) HEALTH AND HEALTH NEEDS OF THE RURAL ELDERLY. THE SURVEY WAS DESIGNED TO PROVIDE BASELINE DATA TO: (1) ASSESS THE RURAL REGION IN TERMS OF 27 PRIORITY HEALTH INDICATORS ESTABLISHED IN 2008 BY THE COMMISSIONER OF THE NEW YORK STATE DEPARTMENT OF HEALTH; (2) IDENTIFY KEY GEOSPATIAL, SOCIAL AND DEMOGRAPHIC FACTORS RELATED TO LIVING IN RURAL AREAS THAT MAY EXPLAIN RURAL-URBAN HEALTH DIFFERENCES; AND (3) IDENTIFY THE NEED FOR EXISTING AND NEW COMMUNITY HEALTH PROMOTION PROGRAMS THROUGHOUT THE REGION. THE FIVE SEPARATE SURVEYS WERE EACH DESIGNED TO MEET ADDITIONAL AIMS. DIFFERENT SAMPLING FRAMES WERE USED FOR THE FIVE SURVEYS CONDUCTED IN 2009. THREE OF THE SURVEYS (HOUSEHOLD HEALTH; ACCESS TO HEALTH CARE; CHILD LIFESTYLE AND BEHAVIOR CHOICES) WERE ADMINISTERED TO RANDOM SAMPLES OF HOUSEHOLDS IN THE SEVEN-COUNTY STUDY REGION BASED ON A LIST OF HOUSEHOLD ADDRESSES. THE SAMPLING FRAMES FOR THE OTHER TWO SURVEYS (ADULT LIFESTYLE AND BEHAVIOR CHOICES; HEALTH AND HEALTH NEEDS OF THE RURAL ELDERLY) WERE DERIVED FROM A RANDOM SAMPLE OF THE ROSTER OF PARTICIPANTS IN A PREVIOUS HEALTH CENSUS CONDUCTED IN 1999. A RANDOM SAMPLE OF INDIVIDUALS WITH A BMI VALUE FROM THE 1999 HEALTH CENSUS WAS SELECTED FOR THE SURVEY ON ADULT LIFESTYLE AND BEHAVIOR CHOICES. THE SAMPLE FOR THE SURVEY ON THE RURAL ELDERLY INCLUDED ALL FARMERS FROM PRIOR HEALTH CENSUSES CONDUCTED IN 1989 AND 1999 WHO WOULD BE AT LEAST 50 YEARS OF AGE IN 2009 AND A RANDOM SAMPLE OF NON-FARMERS FROM THE 1989 OR 1999 HEALTH CENSUS WHO MET THE SAME AGE CRITERION. THE RANDOM HOUSEHOLD SURVEYS CONDUCTED IN EACH OF THE SEVEN COUNTIES OF BASSETT'S SERVICE AREA ARE SHOWN IN THE TABLE BELOW. THE SURVEYS CONDUCTED IN HERKIMER AND MONTGOMERY COUNTIES (WITHIN LITTLE FALLS HOSPITAL SERVICE AREA) INCLUDED 1,822, AND 1,692 RESPONDENTS RESPECTIVELY FOR THE HOUSEHOLD SURVEY, 92 AND 80 RESPONDENTS RESPECTIVELY FOR THE ACCESS SURVEY AND 153 AND 107 RESPONDENTS RESPECTIVELY FOR THE CHILD LIFESTYLE AND BEHAVIORAL CHOICES SURVEY. THE SURVEY WAS NOT CONDUCTED IN FULTON COUNTY WHICH ALSO INCLUDES SOME OF LITTLE FALLS SERVICE AREA. IN ADDITION, FOR THE PURPOSES OF THIS ASSESSMENT, THE SURVEY DATA WAS RE-AGGREGATED ALONG THE SERVICE AREA FOR LITTLE FALLS HOSPITAL AS DEFINED BY ZIP-CODES. A) - REGION, B) - HOUSEHOLD HEALTH (ALL RESPONDENTS/RESPONDENTS 18+), C) - ACCESS TO CARE (PRIMARY RESPONDENT), D) - CHILD LIFESTYLE (KIDS 2-18) A B C DALL REGIONS 13,226/11,009 1,784 979 SCOHARIE 1,847/1,542 95 144OTSEGO 2,663/2,235 80 163MONTGOMERY 1,692/1,386 80 107MADISON 1,840/1,478 412 138HERKIMER 1,822/1,548 92 153DELAWARE 1,373/1,153 545 125CHENANGO 1,989/1,667 480 149WHILE THE OVERALL GOAL OF DETERMINING THE GENERAL HEALTH STATUS OF BASSETT'S RURAL SERVICE REGION REMAINED CONSTANT, THE 2009 UPSTATE HEALTH & WELLNESS SURVEY EXPANDED ON PREVIOUS EFFORTS BY: 1) UNDERTAKING AN EXTENSIVE PRE-STUDY COLLABORATIVE PLANNING PROCESS WITH LOCAL HEALTH DEPARTMENTS AND THE PUBLIC; 2) COLLABORATING WITH PUBLIC HEALTH RESEARCHERS FROM AREA UNIVERSITIES; AND 3) INCLUDING PHYSICAL MEASUREMENTS ON SOME PARTICIPANTS TO CONFIRM THE VALIDITY OF SELF-REPORTS. IN ADDITION TO PROVIDING DESCRIPTIVE EPIDEMIOLOGIC DATA ON THE PREVALENCE OF HEALTH BEHAVIORS AND CONDITIONS, THE 2009 SURVEY WAS DESIGNED TO TEST A NUMBER OF HYPOTHESES IN THE AREAS OF OBESITY, AGING, HEALTH CARE ACCESS, CHRONIC DISEASE, MENTAL HEALTH, AND OTHER CONCERNS IDENTIFIED BY THE COMMUNITY.THIS INFORMATION IS FROM LITTLE FALLS HOSPITAL 2013 COMMUNITY HEALTH NEEDS ASSESSMENT PAGES 4-6. PART VI, LINE 3: LITTLE FALLS HOSPITAL PROVIDES ACCESS AND EDUCATION ON THE COMMUNITY SERVICE PROGRAM WITH CONTACT INFORMATION FOR PATIENTS TO CALL AND MAKE APPOINTMENTS FOR COMPLETING INFORMATION FOR CHARITY CARE. AT ALL PATIENT ACCESS POINTS WHERE SERVICES ARE PROVIDED, APPLICATIONS FOR ASSISTANCE ARE AVAILABLE. THE WWW.LFHNY.ORG WEBSITE INCLUDES A LINK ON INFORMATION FOR COMPLETING AN APPLICATION AND OTHER RESOURCES CALLED "FINANCIAL ASSISTANCE RESOURCE GUIDE". IN 2015 LITTLE FALLS HOSPITAL ASSISTED 35 PATIENTS FOR ENROLLMENT WITH THE NYS HEALTH MARKETPLACE PORTAL. PART VI, LINE 4: LITTLE FALLS HOSPITAL SERVES AN ESTIMATED POPULATION OF OVER 54,000 PEOPLE IN 10 COMMUNITIES THROUGHOUT HERKIMER COUNTY, AND SECTIONS OF FULTON AND MONTGOMERY COUNTIES. THE SERVICE AREA POPULATION IS COMPRISED OF INDIVIDUALS AND FAMILIES FROM ALL SOCIO-ECONOMIC AND EDUCATIONAL LEVELS. THE POPULATION IS 97 PERCENT WHITE, 51 PERCENT FEMALE AND 49 PERCENT MALE. THE AGE DISTRIBUTION OF THE POPULATION IS SIMILAR TO OTHER UPSTATE NEW YORK AREAS WITH 5.4 PERCENT OF THE POPULATION UNDER 5 YEARS OF AGE, 21 PERCENT UNDER THE AGE OF 18, AND 16.2 PERCENT AGED 65 AND OLDER. NEARLY 80 PERCENT OF THE POPULATION OVER 25 HAS GRADUATED FROM HIGH SCHOOL. PER CAPITA INCOME LEVELS ARE $16,141, LOWER THAN NEW YORK STATE'S AVERAGE OF $23,389 AND MEDIAN HOUSEHOLD INCOME OF $40,106 ARE ALSO BELOW THE STATE MEDIAN OF $55,980. IT'S ESTIMATED THAT 14 PERCENT OF THE POPULATION IS BELOW THE FEDERAL POVERTY LEVEL, HIGHER THAN BOTH THE STATE (13.7) AND U.S. (13.3) AVERAGES, AND AN ESTIMATED 14.4 PERCENT OF THE COUNTY'S POPULATION IS UNINSURED. IN ADDITION, THERE ARE NUMEROUS HEALTH STATUS INDICATORS THAT SHOW THAT MANY PRIMARY CARE NEEDS OF THE POPULATION RESIDING IN THE AREA REMAIN UNMET. THESE INCLUDE, COMPARATIVELY: LOWER PERCENTAGES OF PREGNANT WOMEN WITH EARLY PRENATAL CARE, ANEMIA AND OBESITY; HIGHER PERCENTAGES OF CHILDREN WITH ANEMIA; HIGHER PERCENTAGES OF ADULTS WHO ARE OVERWEIGHT, SMOKE AND DRINK EXCESSIVELY; HIGHER RATES OF DEATH AND HOSPITALIZATION FROM CARDIOVASCULAR AND HEART DISEASES; A HIGHER INCIDENCE OF CANCER OF THE LUNGS; HIGHER DEATH RATES DUE TO CIRRHOSIS AND DIABETES; HIGHER HOSPITALIZATIONS DUE TO PNEUMONIA AND FLU; AND HIGHER RATES OF DEATH AND HOSPITALIZATION FROM SUICIDE, SELF INFLICTED AND UNINTENTIONAL INJURIES. PART VI, LINE 5: LITTLE FALLS HOSPITAL IMPLEMENTS COORDINATED HEALTH CARE RESOURCES WITH BASSETT HEALTHCARE NETWORK. THIS COLLABORATION INCLUDED PLANNING AND IMPLEMENTING INITIATIVES UNDER A NEW YORK STATE DELIVERY SYSTEM REFORM INCENTIVE PAYMENT (DSRIP) PROJECT. THE GOALS OF THIS NYS STATEWIDE INITIATIVE IS TO REDUCE UNNECESSARY EMERGENCY DEPARTMENT AND INPATIENT ADMISSIONS BY 25% OVER THE NEXT FIVE YEARS. THE DOLGEVILLE AND NEWPORT HEALTH CENTERS ARE CRITICAL TO LITTLE FALLS HOSPITALS SUCCESS FOR MEETING THE GOALS OF DSRIP. THE SUCCESS OF LITTLE FALLS HOSPITAL ALSO BEGAN A CARE TRANSITION PROGRAM TO REDUCE THE NUMBER OF READMISSIONS. THE CARE TRANSITION PROGRAM PROTOCOL IS TO WORK IN COLLABORATION WITH PATIENT AND FAMILY ON FOLLOWING PATIENT DISCHARGE INSTRUCTIONS TO REDUCE RISK OF READMISSION. WE HAVE EXPERIENCED A REDUCTION IN OUR THIRTY-DAY READMISSION RATE FROM 9.5% TO 7% OVER FROM 2014 TO 2015. PART VI, LINE 6: LITTLE FALLS HOSPITAL IS A MEMBER OF THURSTON CORPORATION (DBA BASSETT HEALTHCARE NETWORK) THAT PROVIDES HEALTH SERVICES IN MORE THAN 20 COMMUNITIES SPANNING 5,600 SQUARE MILES AND SEVEN COUNTIES. THE NETWORK FOCUSES ITS COMMUNITY SERVICES PROGRAMS IN THE COUNTIES WHERE THE SIX AFFILIATED HOSPITALS AND GREATEST PATIENT POPULATIONS ARE LOCATED. OTSEGO COUNTY - POPULATION 61,709; DELAWARE COUNTY - POPULATION 47,276; HERKIMER COUNTY - POPULATION 64,508; SCHOHARIE COUNTY - POPULATION 32,099 (ACCORDING TO THE 2012 U.S. CENSUS ESTIMATES). THE MARY IMOGENE BASSETT HOSPITAL, AN ACUTE CARE INPATIENT TEACHING FACILITY IN COOPERSTOWN, OTSEGO COUNTY, O'CONNOR HOSPITAL, A CRITICAL ACCESS HOSPITAL IN DELHI, DELAWARE COUNTY, COBLESKILL REGIONAL HOSPITAL, AN ACUTE CARE FACILITY IN COBLESKILL, SCHOHARIE COUNTY, LITTLE FALLS HOSPITAL, A CRITICAL ACCESS HOSPITAL IN LITTLE FALLS, HERKIMER COUNTY, TRI TOWN REGIONAL HOSPITAL A 24/7 EMERGENCY CARE FACILITY IN SIDNEY, DELAWARE COUNTY, AUREILA OSBORN FOX MEMORIAL HOSPITAL, AN ACUTE CARE FACILITY IN ONEONTA, OTSEGO COUNTY, THE BASSETT CLINIC, AN OUTPATIENT PRIMARY AND SPECIALTY CARE CENTER IN COOPERSTOWN, A REGIONAL NETWORK OF OVER TWO DOZEN COMMUNITY BASED HEALTH CENTERS, 20 SCHOOL BASED HEALTH CENTERS, TWO AMBULATORY SURGERY CENTERS, VALLEY HEALTH SERVICES A RESIDENTIAL HEALTH CARE AND REHABILITATION FACILITY, AT HOME CARE, A CERTIFIED HOME CARE AGENCY AND FIRST COMMUNITY CARE OF BASSETT, AND A MEDICAL SUPPLY COMPANY, ALL OF WHICH MAKE UP THE BASSETT HEALTHCARE NETWORK AND PROVIDE HEALTH SERVICES TO THIS NINE COUNTY REGION IN CENTRAL NEW YORK. PART VI, LINE 7, REPORTS FILED WITH STATES NY X 0 0 X X X X 0 0 0 0 0 0 0 0 0 AUGUST LEINHART MD TRUSTEE 0 357450 0 2245 0 50 0 18550 0 3121 0 381416 0 0 AMY GRACE MD PRESIDENT OF MEDICAL STAFF 1500 191310 0 12815 0 0 0 9000 0 4919 1500 218044 0 0 LISA BETRUS THIRD VICE CHAIRMAN 0 171051 0 9500 0 0 0 9162 0 6120 0 195833 0 0 MICHAEL TENGERES TREASURER 0 316107 0 0 0 0 0 0 0 1538 0 317645 0 0 MICHAEL OGDEN PRESIDENT & CEO 0 178000 0 4000 0 256 0 7120 0 1438 0 190814 0 0 NICHOLAS NICOLETTA FORMER TREASURER 0 83046 0 0 0 0 0 0 0 1546 0 84592 0 0 PART I, LINE 3 THE COMPENSATION PROCESS FOR TOP OFFICIAL THE CHIEF EXECUTIVE OFFICER'S SALARY IS PAID BY A RELATED ORGANIZATION UNDER A MANAGEMENT SERVICES AGREEMENT. THE LITTLE FALLS HOSPITAL BOARD OF TRUSTEE'S REVIEWS THE FORMAL PROCESS THAT IS USED TO DETERMINE THE BASE COMPENSATION OF THE CEO. THE CEO WORK PLAN AND ACCOMPLISHMENTS FOR THE YEAR ARE REVIEWED. SALARY CHANGES ARE BASED ON MARKET, WORK PLAN, AND ACCOMPLISHMENTS. THE CEO'S SALARY IS SUBMITTED AS PART OF THE MANAGEMENT SERVICES AGREEMENT WHICH IS APPROVED BY THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE HOSPITAL IS BASSETT REGIONAL CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A BASSETT REGIONAL CORPORATION, AS THE SOLE MEMBER, HAS THE POWER TO ELECT OR APPOINT ONE OR MORE MEMBERS OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11 LITTLE FALLS HOSPITAL PRESENTS THE DRAFT 990 TO THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS PRIOR TO FILING. ANY QUESTIONS ARE RAISED AND ONCE APPROVED, THE 990 CAN BE FILED. A COMPLETE COPY OF THE ORGANIZATION'S FINAL FORM 990, INCLUDING ALL REQUIRED SCHEDULES, AS ULTIMATELY FILED WITH THE IRS, IS AVAILABLE TO EACH MEMBER OF THE BOARD BEFORE ITS FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST STATEMENTS ARE MADE ANNUALLY. NEW BOARD MEMBERS ARE REQUIRED TO DISCLOSE ON THEIR RESUME ALL AFFILIATED ORGANIZATIONS. FORM 990, PART VI, SECTION B, LINE 15 THE CHIEF EXECUTIVE OFFICER'S SALARY IS PAID BY A RELATED ORGANIZATION UNDER A MANAGEMENT SERVICES AGREEMENT. THE LITTLE FALLS HOSPITAL BOARD OF TRUSTEES REVIEWS THE FORMAL PROCESS THAT IS USED TO DETERMINE THE BASE COMPENSATION OF THE CEO. THE CEO'S WORK PLAN AND ACCOMPLISHMENTS FOR THE YEAR ARE REVIEWED. SALARY CHANGES ARE BASED ON MARKET, WORKPLAN, AND ACCOMPLISHMENTS. THE CEO'S SALARY IS SUBMITTED AS PART OF THE MANAGEMENT SERVICES AGREEMENT WHICH IS APPROVED BY THE BOARD. FORM 990, PART VI, SECTION C, LINE 19 LITTLE FALLS HOSPITAL MAKES AVAILABLE THE IRS FROM 990 UPON REQUEST ALONG WITH INFORMATION INCLUDED WITHIN THE 990 SUCH AS FINANCIAL REPORTS, CONFLICT OF INTEREST POLICY, AND CODE OF CONDUCT. THE HOSPITAL ALSO PROVIDES THE ANNUAL OPERATING PLAN AND CORPORATE VALUES IN PUBLIC AREAS OF THE FACILITY. FORM 990, PART XI, LINE 9: PENSION RELATED CHANGES OTHER THAN NET PERIODIC BENEFIT COST -286,586. CHANGE IN VALUE OF BENEFICIAL INTEREST IN CHARITABLE REMAINDER TRUST -104,871. CHANGE IN FRIENDS OF BASSETT 139,712. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. THURSTON CORPORATION ONE ROCKEFELLER PLAZA 31ST FLOOR NEW YORK NY 10020 133218680 SUPPORTING ORGANIZATION NY 501 (C) 3 11 C N/A 0 FRIENDS OF BASSETT ONE ATWELL ROAD COOPERSTOWN NY 13326 237041610 FUND RAISING ORGANIZATION NY 501 (C) 3 7 THURSTON CORPORATION 0 MARY IMOGENE BASSETT HOSPITAL ONE ATWELL ROAD COOPERSTOWN NY 13326 135596796 HEALTH CARE ORGANIZATION OFFERING INPATIENT AND OUTPATIENT SERVICES NY 501 (C) 3 3 THURSTON CORPORATION 0 AURELIA OSBORN FOX MEMORIAL HOSPITAL SOCIETY ONE NORTON AVENUE ONEONTA NY 13820 150539039 HEALTH CARE ORGANIZATION OFFERING INPATIENT AND OUTPATIENT SERVICES NY 501 (C) 3 3 THURSTON CORPORATION 0 TEMPLETON FOUNDATION ONE ATWELL ROAD COOPERSTOWN NY 13326 133317084 FACILITIES / OFFICE SPACE NY 501 (C) 3 9 THURSTON CORPORATION 0 BASSETT REGIONAL CORPORATION ONE ATWELL ROAD COOPERSTOWN NY 13326 133522783 PROVIDES EXCELLENCE IN THE COORDINATION PLANNING AND POLICY DIRECTION FOR NY 501 (C) 3 11 (B) THURSTON CORPORATION 0 COBLESKILL REGIONAL HOSPITAL 178 GRANDVIEW DRIVE COBLESKILL NY 12043 141772971 HEALTHCARE SERVICES OFFERING INPATEINT AND OUTPATIENT SERVICES NY 501 (C) 3 3 BASSETT REGIONAL CORPORATION 0 O'CONNOR HOSPITAL 460 ANDES ROAD DELHI NY 13753 161540394 HEALTH CARE ORGANIZATION OFFERING INPATIENT AND OUTPATIENT SERVICES NY 501 (C) 3 3 BASSETT REGIONAL CORPORATION 0 TRI TOWN REGIONAL HEALTHCARE 43 PEARL STREET SYNDEY NY 13838 260169584 HEALTHCARE SERVICES OFFERING OUTPATIENT SERVICES NY 501 (C) 3 3 BASSETT REGIONAL CORPORATION 0 VALLEY HEALTH SERVICES 690 GERMAN STREET HERKIMER NY 13350 222511614 NURSING HOME NY 501 (C) 3 3 BASSETT REGIONAL CORPORATION 0 0 0 1 0 0 0 0 0 0 1 0 1 1 0 1 0 1 0 0