2016-11-14T08:07:28-06:00 2015-12-31 160765486 LUMSDEN & MCCORMICK LLP 369 FRANKLIN STREET BUFFALO NY 14202 990 2015-01-01 141372647 MOSES-LUDINGTON HOSPITAL MOSE 5185853864 1019 WICKER STREET TICONDEROGA NY 12883 JOHN REMILLARD PRESIDENT 5185853864 2016-11-10 1 MICHAEL J GRIMALDI P01295846 7168563300 2015 2017-02-10 21:41:12Z JOHN REMILLARD 1019 WICKER STREET TICONDEROGA NY 12883 12088807 0 X WWW.INTERLAKESHEALTH.COM X 1908 NY A CARING, COMMUNITY RESPONSIVE HEALTHCARE PARTNER THAT PROMOTES WELLNESS, INDIVIDUAL DIGNITY, QUALITY, AND VALUE. 9 9 174 15 0 0 230012 275379 11930802 11384980 116756 113405 157558 315043 12435128 12088807 0 0 0 0 6585361 6203942 0 0 0 6342678 5623617 12928039 11827559 -492911 261248 8220402 8542770 13701241 13762361 -5480839 -5219591 A CARING, COMMUNITY RESPONSIVE HEALTHCARE PARTNER THAT PROMOTES WELLNESS, INDIVIDUAL DIGNITY, QUALITY AND VALUE. 0 0 9556994 11384980 MOSES-LUDINGTON HOSPITAL BEGAN PROVIDING HEALTH CARE SERVICES IN JUNE 1908. TODAY THE HOSPITAL IS A 15 BED CRITICAL ACCESS HOSPITAL WITH A 24-HOUR EMERGENCY ROOM AND HELICOPTER TRANSPORT CAPABILITY, OUTPATIENT CLINIC, PHYSICAL AND OCCUPATIONAL THERAPY CENTERS, CARDIAC REHABILITATION CENTER, OUTPATIENT SURGICAL SERVICES, AND EARLY PREVENTION CENTER. 9556994 1 1 0 0 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 0 0 0 0 0 0 0 1 0 0 0 1 17 0 1 174 1 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X JENNIFER OLCOTT 5185852831 1019 WICKER STREET TICONDEROGA NY 12883 X ROLAND ALLEN CHAIRPERSON 2.00 2.00 X X 0 0 0 ROBERT DEDRICK VICE-CHAIRPERSON 2.00 2.00 X X 0 0 0 ROSS KELLEY TREASURER 2.00 2.00 X X 0 0 0 CHATTIE VAN WERT SECRETARY 2.00 2.00 X X 0 0 0 DR GLEN CHAPMAN PRESIDENT MEDICAL STAFF 2.00 2.00 X 0 0 0 MICHAEL DISKIN TRUSTEE 2.00 2.00 X 0 0 0 WALTER LENDER TRUSTEE 2.00 2.00 X 0 0 0 DAVID SHELMIDINE TRUSTEE 2.00 2.00 X 0 0 0 DAWN STODDARD TRUSTEE 2.00 2.00 X 0 0 0 RODNEY C BOULA INTERIM CHIEF EXECUTIVE OF 20.00 20.00 X 0 0 0 ALAN CHARDAVOYNE INTERIM CHIEF FINANCIAL OF 20.00 20.00 X 0 0 0 NANCY CAFFREY PHYSICIAN ASSISTANT 40.00 X 168305 0 16282 MATTHEW HINGE PHYSICIAN ASSISTANT 40.00 X 115461 0 0 JAMES HOGAN PHYSICIAN ASSISTANT 40.00 X 133777 0 16281 JAMES L'EPISCOPO PHYSICIAN ASSISTANT 40.00 X 133197 0 5711 550740 0 38274 4 0 1 0 UNIDINE CORPORATION 1000 WASHINGTON STREET SUITE 510 BOSTON MA 02118 DIETARY SERVICES 625426 CARDINAL HEALTH - PHARMACY MANAGEMENT 1330 ENCLAVE PARKWAY HOUSTON TX 77077 PHARMACY SERVICES 256624 COMMUNITY PROVIDERS 75 BEEKMAN STREET PLATTSBURGH NY 12901 CEO CHARGES 222000 NIXON PEABODY 677 BROADWAY 10TH FLOOR ALBANY NY 12207 LEGAL SERVICES 131166 4 273220 2159 275379 PATIENT SERVICE REVENUE 621990 11384980 11384980 11384980 113405 113405 MEANINGFUL USE INCENTIVE PAYMENTS 621990 236901 236901 CAFETERIA 722210 56017 56017 REBATES AND REFUNDS 900099 13092 13092 9033 9033 315043 12088807 11384980 0 428448 X 4859329 3999228 860101 994546 818511 176035 350067 288105 61962 184881 184881 53606 53606 1695492 1181558 513934 1347783 1181846 165937 716587 409675 306912 9783 5510 4273 4063 4063 357276 321548 35728 96293 17044 79249 PROVISION FOR BAD DEBTS 972186 972186 EQUIPMENT RENTAL & MAIN 738855 307157 431698 SHARED SERVICES 100532 28893 71639 PROFESSIONAL DEVELOPMEN 43742 25733 18009 -697462 -697462 11827559 9556994 2270565 0 652376 232565 316228 1113797 1156679 268297 247149 80380 53796 6360115 4811093 1394090 1549022 4395234 5303559 8220402 8542770 1361769 1835085 377045 11168472 11429231 1171000 121000 13701241 13762361 X -5812271 -5551867 2366 3210 329066 329066 -5480839 -5219591 8220402 8542770 261248 0 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 331432 844 332276 330674 758 331432 329823 851 330674 329231 592 329823 329066 165 329231 0.99030 0.00970 0 0 318586 158888 159698 5540099 4652205 887894 501430 501430 1549022 INTER-COMPANY A/R 4739273 ASSETS LIMITED AS TO USE 332276 OTHER RECEIVABLES 232010 5303559 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 121000 121000 X PART X, LINE 2: THE HOSPITAL IS A 501(C)(3) ORGANIZATION EXEMPT FROM INCOME TAXES UNDER SECTION 501(A) OF THE INTERNAL REVENUE CODE. THE HOSPITAL BELIEVES IT IS NO LONGER SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAXING AUTHORITIES FOR YEARS PRIOR TO 2012. 1 1 0 1 X 300.000000000000 1 0 1 1 51925 51925 0.00480 2391313 862298 1529015 0.14090 51925 51925 0.00480 2495163 862298 1632865 0.15050 9686640 7776240 1910400 0.17600 9686640 7776240 1910400 0.17600 12181803 8638538 3543265 0.32650 0 550484 244063 4460126 4471018 -10892 X 1 1 1 1 MOSES-LUDINGTON HOSPITAL 1019 WICKER STREET TICONDEROGA NY 12883 HTTP://WWW.INTERLAKESHEALTH.COM/ X MOSES-LUDINGTON HOSPITAL 1 0 0 1 X X X X X X X X X 13 1 1 0 1 X WWW.INTERLAKESHEALTH.COM X 1 13 0 1 0 1 X 300.000000000000 X X X X 1 1 X X X 1 X HTTP://WWW.INTERLAKESHEALTH.COM/ X 1 X X 0 X X X 1 X 0 0 MOSES-LUDINGTON HOSPITAL PART V, SECTION B, LINE 5: THE 81 QUESTION SURVEY WAS DEVELOPED THROUGH A COLLABORATIVE EFFORT BY A SEVEN-MEMBER SURVEY ARHN SUBCOMITTEE DURING THE AUTUMN OF 2012. THE SEVEN VOLUNTEER MEMBERS ARE REPRESENTATIVES OF THE COUNTY PUBLIC HEALTH DEPARTMENTS AND HOSPITALS IN THE REGION THAT ARE INVOLVED IN THE ADIRONDACK RURAL HEALTH NETWORK (ARHN). SUBCOMITTEE MEMBERS IDENTIFIED THE BROAD RESEARCH QUESTIONS TO BE ADDRESSED BY THE SURVEY, DRAFTED THE INDIVIDUAL SURVEY QUESTIONS, AND DEVELOPED THE LIST OF RELEVANT HEALTH CARE STAKEHOLDERS THAT RECEIVED THE SURVEY. A MORE DETAILED DESCRIPTION OF THE PROCESS IS INCLUDED IN THE FULL REGIONAL REPORT.THE SURVEY WAS ADMINISTERED ELECTRONICALLY USING A WEB-BASED SURVEY PROGRAM AND DISTRIBUTED TO AN EMAIL CONTACT LIST OF 624. ULTIMATELY, 285 SURVEYS WERE COMPLETED DURING THE SIX-WEEK SURVEY PERIOD, A RESPONSE RATE OF 45.7%. OF ALL 285 RESPONSES, 86 INDICATED THAT ESSEX COUNTY WAS PART OF THEIR SERVICE AREA; HOWEVER IT SHOULD BE NOTED THAT MANY OF THE RESPONDING HEALTHCARE STAKEHOLDERS SERVICE MULTIPLE COUNTIES WITHIN THE LARGER ARHN REGION.IN ADDITION TO THE COMMUNITY SURVEY, MOSES-LUDINGTON, IN COLLABORATION WITH ESSEX COUNTY PUBLIC HEALTH AND ARHN, HELD MEETINGS FOR BOTH INTERNAL AND EXTERNAL STAKEHOLDERS ENTITLED "ESSEX COUNTY: THE HEALTH OF OUR COMMUNITIES" ON MAY 2, 2013. THE MEETINGS PROVIDED AN OVERVIEW OF HOSPITAL AND PUBLIC HEALTH REPORTING REQUIREMENTS, A BRIEFING WITH RESPECT TO THE PREVENTION AGENCY 2013-2017, ESSEX COUNTY'S QUALITATIVE DATA (COMMUNITY SURVEY RESULTS), ESSEX COUNTY'S QUANTITATIVE DATA AND GENERAL DISCUSSION. AREAS OF DISCUSSION INVOLVED PRIORITIZATION AS IT RELATED TO FACTORS SUCH AS:- ALIGNMENT WITH OTHER PRORITIES - WHAT IS THE COMMUNITY ALREADY DOING- PUBLIC HEALTH LAW - MANDATORY SERVICES- STRATEGIC PLANS- MEDICAL HOME- ACCOUNTABLE CARE ORGANIZATIONS- ACCREDITATION- AVAILABLE RESOURCES - SUSTAINABILITY- CAPACITY TO IMPLEMENT INTERVENTIONS- PRECEPTION VERSUS REALITY - ALIGNMENTPARTICIPANTS INCLUDED:MOSES-LUDINGTON INTERNAL ATTENDEES:- VICKI WHEATON-SARACINI, DIRECTOR OF CORPORATE PLANNING AND SERVICE - ADIRONDACK HEALTH INSTITUTE- ROBERT MARTINIANO, PROJECT DIRECTOR - CENTER FOR HEALTH WORKFORCE STUDIES- CHIP HOLMES, CHIEF EXECUTIVE OFFICER - INTER-LAKES HEALTH- TRISTAN GLANVILLE, CHIEF FINANCIAL OFFICER - INTER-LAKES HEALTH- LISA BUSBY, CHIEF INFORMATION OFFICER - INTER-LAKES HEALTH- LAURA TIRADO, NH ADMINISTRATOR - INTER-LAKES HEALTH- TARA JOUBERT, DIRECTOR OF SUPPORT SERVICES - INTER-LAKES HEALTH- SUE HUNTINGTON, DIRECTOR OF HIM / COMPLIANCE OFFICER - INTER-LAKES HEALTH- TAMARA EVENS, DIRECTOR OF HUMAN RESOURCES - INTER-LAKES HEALTH- KRISTEN THOMPSON, DIRECTOR OF CLINICAL SERVICES - INTER-LAKES HEALTH- TAMMY J. SMITH, REVENUE CYCLE DIRECTOR - INTER-LAKES HEALTH- HEIDI SCHEMPP, DIRECTOR OF SOCIAL SERVICES - INTER-LAKES HEALTH- KATE SHMULSKY, DIRECTOR OF PHARMACY - INTER-LAKES HEALTH- MERRIBETH ELLING, DIRECTOR OF THERAPY SERVICES - INTER-LAKES HEALTH- ELIZABETH BARRETT, DIRECTOR OF RADIOLOGY - INTER-LAKES HEALTH- BRENDA DUSHANE, NH DIRECTOR OF NURSING - INTER-LAKES HEALTH- BONNIE MAIOLO, DIRECTOR OF MATERIALS MANAGEMENT - INTER-LAKES HEALTH- MARIA WATERS, ACTIVITIES DIRECTOR - INTER-LAKES HEALTH- MARY ELLEN LARSON, NURSE MANAGER / STAFF EDUCATOR - INTER-LAKES HEALTH- GORDONNA BLODGETT, DENTAL PRACTICE MANAGER - INTER-LAKES HEALTH- CHRIS SHAFFER, REGISTRATION MANAGER - INTER-LAKES HEALTH- BARB WRIGHT, COMPLIANCE SPECIALIST - INTER-LAKES HEALTHEXTERNAL ATTENDEES:- BILL OWENS - CONGRESSMAN NEW YORK'S 21ST DISTRICT- VICKI WHEATON-SARACINI - ADIRONDACK HEALTH INSTITUTE- ROBERT MARTINIANO - CENTER FOR HEALTH WORKFORCE STUDIES- JESSICA DARNEY BUEHLER - ESSEX COUNTY PUBLIC HEALTH- CHERI MARTELL - PLANNED PARENTHOOD MOHAWK HUDSON- DONNA GORTON - HUDSON HEADWATERS HEALTH NETWORK- MARK JOHNS - TICONDEROGA POLICE DEPARTMENT CHIEF OF POLICE- PETER M SAYERS - MOUNTAIN FAMILY CARE PHYSICIAN AND OWNER- SHARON REYNOLDS - PRIDE OF TICONDEROGA EXECUTIVE DIRECTOR- CHRIS MALLON - INTERNATIONAL PAPER TICONDEROGA MILL MANAGER- MATTHEW COURTRIGHT - TICONDEROGA AREA CHAMBER OF COMMERCE- DOUG TERBEEK - PREVENTION TEAM- DEBRA MALANEY - TOWN OF TICONDEROGA - SUPERVISOR- HEIDI PALMER - ESSEX COUNTY OFFICE OF THE AGING- KRISTINA CHARBONEAU-WELLS - ST JOSEPH'S ADDICTION, TREATMENT & RECOVERY CENTERS- CHATTIE VAN WERT - INTER-LAKES HEALTH BOARD OF DIRECTORS- ROSS KELLY - INTER-LAKES HEALTH BOARD OF DIRECTORS- ROLLY ALLEN - INTER-LAKES HEALTH BOARD OF DIRECTORS VICE CHAIR- SANDRA BOLTON - INTER-LAKES HEALTH BOARD OF DIRECTORS BOARD CHAIR- TAMMY J. SMITH - INTER-LAKES HEALTH MOSES-LUDINGTON HOSPITAL PART V, SECTION B, LINE 6A: OTHER HOSPITALS INCLUDE ELIZABETHTOWN COMMUNITY HOSPITAL AND ADIRONDACK MEDICAL CENTER.DATA WAS GATHERED AND ANALYZED BY ARHN - A REGIONAL MULTI-STAKEHOLDER COALITION THAT CONDUCTS COMMUNITY HEALTH PLANNING ACTIVITIES BY PROVIDING THE FORUM FOR LOCAL PUBLIC HEALTH SERVICES, COMMUNITY HEALTH CENTERS, HOSPITALS, COMMUNITY MENTAL HEALTH PROGRAMS, EMERGENCY MEDICAL SERVICES, AND OTHER COMMUNITY-BASED ORGANIZATIONS TO ASSESS REGIONAL NEEDS AND THE EFFECTIVENESS OF THE RURAL HEALTH CARE DELIVERY SYSTEM. MOSES-LUDINGTON HOSPITAL PART V, SECTION B, LINE 11: OTHER HIGH RANKING ISSUES IDENTIFIED IN OUR COMMUNITY HEALTH NEEDS ASSESSMENT WHICH WE WILL NOT BE DIRECTLY ADDRESSING INCLUDE:- MATERNAL AND INFANT HEALTH: AS A SMALL, CRITICAL ACCESS HOSPITAL WITHOUT ONSITE SPECIALTY SERVICES, WE FEEL ILL-EQUIPPED TO ADDRESS THIS IDENTIFIED NEED.- BUILT ENVIRONMENT: WE FEEL THIS ISSUE BETTER ALIGNS WITH THE MISSION OF OTHER ORGANIZATIONS IN THE DEVELOPMENT OF COMMUNITY WALKING PATHS AND COMMUNAL GARDENS.- SUBSTANCE ABUSE AND MENTAL, EMOTIONAL AND BEHAVORIAL HEALTH: ESSEX COUNTY HAS VERY LIMITED MENTAL HEALTH RESOURCES TO HANDLE THE NEEDS OF THE POPULATION. ALTHOUGH IDENTIFIED AS A SIGNIFICANT NEED IN OUR COMMUNITY, MOSES-LUDINGTON CANNOT DEVELOP AND MAINTAIN INTERVENTIONS TO ADDRESS IT. SUBSTANCE ABUSE AND MENTAL HEALTH ARE NOT IN MLH'S CORE MISSION OR SKILL SET.- TOBACCO USE AND SECOND HAND SMOKE EXPOSURE: MOSES-LUDINGTON HAS IMPLEMENTED POLICY CHANGES TO PROHIBIT TOBACCO USED ON ITS CAMPUS. WE ASSESS EACH PATIENT FOR SMOKING STATUS AND PROVIDE EDUCATIONAL INSTRUCTION UPON DISCHARGE. FOR PATIENTS OVER THE AGE OF 13, SMOKING STATUS IS CAPTURED AND REPORTED AS PART OF MEANINGFUL USE STAGE 1. ONE OF THE BIGGEST CONTRIBUTORS TO THE PROBLEM IN OUR COUNTY IS THE NUMBER OF REGISTERED TOBACCO VENDORS WHICH IS 31% OVER THE UPSTATE BENCHMARK. MOSES-LUDINGTON DID NOT FEEL IT COULD MAKE A SIGNIFICANT IMPACT ON THIS AREA OF NEED. MOSES-LUDINGTON HOSPITAL PART V, SECTION B, LINE 22D: IN ACCORDANCE WITH HFAL SECTION 2807-K(9-A) OF THE NEW YORK PUBLIC HEALTH LAW, THE PATIENT'S LIABILITY WILL BE BASED ON A DISCOUNT FROM THE FACILITY'S INTERIM RATES FOR ITS HIGHEST VOLUME PAYOR, MEDICARE. FOR PATIENTS WHOSE INCOME IS AT OR BELOW 100% OF THE FEDERAL POVERTY LEVEL (FPL) THEIR LIABILITY WILL BE 0% OF FACILITY'S INTERIM MEDICARE RATE. FOR PATIENTS WHOSE INCOME IS BETWEEN 100.1% AND 150% OF FLP THEIR LIABILITY WILL BE 20% OF THE FACILITY'S INTERIM MEDICARE RATE. FOR PATIENTS WHOSE INCOME IS BETWEEN 150.1% AND 200% OF FLP THEIR LIABILITY WILL BE 50% OF THE FACILITY'S INTERIM MEDICARE RATE. FOR PATIENTS WHOSE INCOME IS BETWEEN 200.1% AND 250% OF FPL THEIR LIABILITY WILL BE 75% OF THE FACILITY'S INTERIM MEDICARE RATE. FOR PATIENTS WHOSE INCOME IS BETWEEN 250.1% AND 300% OF FPL THEIR LIABILITY WILL BE 100% OF THE FACILITY'S INTERIM MEDICARE RATE. PATIENTS WHOSE INCOME IS GREATER THAN 300% OF FPL WILL NOT QUALIFY FOR FINANCIAL ASSISTANCE. MOSES-LUDINGTON HOSPITAL PART V, SECTION B, LINE 24: SELF-PAY PATIENTS ARE CHARGED GROSS CHARGES UNTIL THEY CONTACT THE HOSPITAL FOR A PROMPT PAYMENT DISCOUNT OR FINANCIAL ASSISTANCE. THE HOSPITAL DOES NOT ROUTINELY DISCOUNT SELF-PAY BILLS. PART I, LINE 3C: MOSES-LUDINGTON HOSPITAL DOES NOT PROVIDE COMPLETELY FREE CARE TO LOW INCOME INDIVIDUALS. THE HOSPITAL CHARGES AT LEAST $1 FOR SERVICES. PART I, LINE 7: IN CALCULATING LINE 7, COLUMN E, WE USED THE WORKSHEETS PROVIDED IN THE INSTRUCTIONS FOR THIS SCHEDULE. THE CHARGES AND COSTS THAT WE USED WERE FROM THE COST REPORT AND INCLUDED ALL SERVICES PROVIDED BY THE HOSPITAL. WHERE A COST TO CHARGE RATIO WAS NEEDED, WE USED THE COST TO CHARGE RATIO FROM WORKSHEET C ON THE FILED 2015 MEDICARE COST REPORT. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 972,186. PART III, LINE 4: ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, INTER-LAKES HEALTH ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, INTER-LAKES HEALTH ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO HAVE FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), INTER-LAKES HEALTH RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 8: SINCE MOSES-LUDINGTON IS A CRITICAL ACCESS HOSPITAL, WE TOOK THE MEDICARE ALLOWABLE COSTS CALCULATED ON THE COST REPORT AND REPORTED THEM ABOVE ON LINE 6. PART III, LINE 9B: PER THE MOSES-LUDINGTON FINANCIAL ASSISTANCE POLICY:1. WHEN A PATIENT HAS COMPLETED AND RETURNED AN APPLICATION FOR FINANCIAL ASSISTANCE, THE CLAIM WILL NOT BE FORWARDED TO A COLLECTION AGENCY, PENDING DETERMINATION OF ELIGIBILITY.2. THE HOSPITAL WILL NOT FORECLOSE, REQUIRE A FORCED SALE OR PLACE A LIEN ON THE APPLICANT'S PRIMARY RESIDENCE.3. PATIENTS WILL BE NOTIFIED AT LEAST 30 DAYS PRIOR TO FORWARDING AN ACCOUNT TO THE COLLECTION AGENCY.4. MOSES-LUDINGTON HOSPITAL WILL PROVIDE WRITTEN CONSENT TO A COLLECTION AGENCY PRIOR TO COMMENCING LEGAL ACTION ON AN ACCOUNT.5. COLLECTION AGENCIES CONTRACTED BY MOSES-LUDINGTON HOSPITAL WILL FOLLOW THE HOSPITAL'S FINANCIAL AID POLICIES AND PROCEDURES, INCLUDING THE MEANS OF APPLYING FOR AID.6. COLLECTIONS ARE PROHIBITED FROM PATIENTS ELIGIBLE FOR MEDICAID AT THE TIME OF SERVICE.7. A FAVORABLE DETERMINATION STILL ENABLES THE PATIENT TO MAKE INSTALLMENT PAYMENTS AT NO GREATER THAN 10% OF GROSS MONTHLY INCOME. THE PATIENT WILL BE REQUIRED TO SIGN A PAYMENT AGREEMENT IN THIS INSTANCE.PATIENTS KNOWN TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE ARE MAINTAINED IN A SPREADSHEET ACCESSIBLE BY REGISTRATION AND PATIENT ACCOUNTING. ACCOUNTS ARE PROACTIVELY ADJUSTED TO THE DISCOUNTED RATES. PART VI, LINE 2: MOSES-LUDINGTON HOSPITAL (MLH) REGULARLY SOLICITS FEEDBACK AND INPUT FROM THE RESIDENTS OF OUR COMMUNITIES REGARDING THEIR HEALTH CARE NEEDS AND PREFERENCES. THIS ALLOWS MLH TO ENSURE THAT ESSENTIAL HEALTH CARE SERVICES ARE PRESERVED AND DEVELOPED AS NEEDED. TO THIS END, MLH SERVES ON THE ADIRONDACK RURAL HEALTH NETWORK (ARHN), COMMUNITY HEALTH PLANNING COMMITTEE (CHPC) AND COMMUNITY HEALTH ASSESSMENT (CHA) TASKFORCE.THE ARHN IS A COMMUNITY PARTNERSHIP OF PUBLIC, PRIVATE AND NON-PROFIT ORGANIZATIONS IN UPSTATE NEW YORK. THE ARHN FACILITATES A COLLABORATIVE PROCESS FOR DEVELOPING STRATEGIES AND FOR IMPLEMENTING, MONITORING AND EVALUATING THE REGIONAL HEALTH CARE SYSTEM. AS A LONG TIME MEMBER OF THE ARHN, MLH ACTIVELY SUPPORTS AND PARTICIPATES IN THIS GATHERING OF INFORMATION FROM A VARIETY OF STAKEHOLDERS. THIS PROCESS IS CONDUCTED REGIONALLY AND IS REPEATED EVERY THREE TO FIVE YEARS.MLH ALSO SOLICITS INDIVIDUAL PATIENT FEEDBACK REGULARLY THROUGH MULTIPLE PATIENT SATISFACTION SURVEYS. THESE SURVEYS ARE DEPARTMENT SPECIFIC AND ARE A VALUABLE METHOD OF MEASURING PUBLIC PERCEPTION OF PATIENT CARE. BOTH IN-PATIENT AND OUT-PATIENT DEPARTMENT DISCHARGES ARE SURVEYED, IN WRITTEN FORM AND BY TELEPHONE. PART VI, LINE 3: BY VIRTUE OF ITS EXEMPTION FROM FEDERAL AND STATE TAXES, AND AS PART OF THE HOSPITAL'S MISSION TO SERVE THE HEALTHCARE NEEDS OF THE COMMUNITY, MLH PROVIDES CHARITY CARE TO PATIENTS WITHOUT HEALTH INSURANCE OR THE FINANCIAL MEANS TO PAY FOR HOSPITAL SERVICES. CHARITY CARE IS PROVIDED TO ALL PATIENTS IN NEED IN FULL COMPLIANCE WITH TITLE VI OF THE CIVIL RIGHTS ACT, WITHOUT REGARD TO RACE, CREED, COLOR OR NATIONAL ORIGIN. CHARITY CARE SERVICES INCLUDE THOSE WHO ARE CLASSIFIED AS FINANCIALLY OR MEDICALLY INDIGENT ACCORDING TO THE HOSPITAL'S ELIGIBILITY SYSTEM.MLH PUBLISHES A FINANCIAL ASSISTANCE SUMMARY, UPDATED ANNUALLY, THAT ANSWERS ELIGIBILITY QUESTIONS AND DESCRIBES THE APPLICATION PROCESS. MLH EMPLOYS PATIENT ACCOUNTING REPRESENTATIVES FOR THIS PURPOSE. REGISTRATION STAFF IS TRAINED TO EDUCATE PATIENTS WHO NEED FINANCIAL ASSISTANCE WHEN THEY PRESENT FOR SERVICES. UNINSURED PATIENTS ARE PROVIDED A PACKET OF INFORMATIONAL MATERIAL, INCLUDING A FINANCIAL ASSISTANCE APPLICATION. SERVICES OF A TRANSLATOR ARE AVAILABLE FOR NON-ENGLISH SPEAKING OR HEARING IMPAIRED PATIENTS.IN THE EVENT THAT IT IS DETERMINED THAT A PATIENT DOES NOT QUALIFY FOR FREE OR LOW-COST INSURANCE, MLH'S FINANCIAL COUNSELOR OR PATIENT ACCOUNTING REPRESENTATIVE WILL ASSIST THEM IN APPLYING FOR A DISCOUNT. PART VI, LINE 4: MLH'S SERVICE AREA IS DEFINED BY ZIP CODE, AND IS COMPOSED PRIMARILY OF SIX ZIP CODES IN SOUTHEASTERN ESSEX COUNTY AND NORTHEASTERN WARREN AND WASHINGTON COUNTIES. HISTORICALLY, ABOUT 90% OF MLH'S PATIENTS RESIDE WITHIN THIS GEOGRAPHY, WITH THE REMAINING 10% BEING SEASONAL RESIDENTS. MLH SERVES AN INDEFINABLE TOURIST POPULATION AS WELL, SINCE THIS REGION IS A POPULAR NATIONAL VACATION SPOT. MLH IS LOCATED IN CONGRESSIONAL DISTRICT 23, 57 MILES FROM THE NEAREST ACUTE CARE NEW YORK STATE HOSPITAL, AND IS GEOGRAPHICALLY REMOTE FROM THREE COUNTY SEATS. THE TOWN OF TICONDEROGA IS LOCATED WITHIN THE 6 MILLION ACRE ADIRONDACK PARK. THE AREA'S SMALL VILLAGES AND HAMLETS ARE AT RISK FOR COMPLETE ISOLATION DURING ALL SEASONS BECAUSE OF THE SEVERE WEATHER CONDITIONS, FREQUENT POWER OUTAGES, ROAD IMPASSABILITY, AND MOUNTAINOUS TOPOGRAPHY. FOR THESE REASONS, AREA RESIDENTS TEND TO BE PLACE-BOUND AND ISOLATED. PUBLIC TRANSPORTATION IS VIRTUALLY NON-EXISTENT, AND THERE ARE FEW SECONDARY ROADS. MLH OPERATES A GRANT FUNDED BUS FOR PATIENT TRANSPORT TO AND FROM THE HOSPITAL AND PHYSICIAN'S OFFICES FOR THOSE WHO NEED TRANSPORTATION. THE TOWN OF TICONDEROGA ALSO OWNS AND OPERATES A SENIOR BUS AS LOW COST TRANSPORTATION FOR THE OTHERWISE HOME-BOUND ELDERLY.THE ECONOMY IS PRIMARILY GOVERNMENTAL OR SEASONAL, AND INCLUDES LAW ENFORCEMENT, PRISONS, EDUCATION, AND HEALTHCARE. MLH/ILH IS ONE OF THE TOP THREE EMPLOYERS IN THE TICONDEROGA AREA, FOLLOWED BY THE SCHOOL SYSTEM AND INTERNATIONAL PAPER'S TICONDEROGA MILL. MUCH OF THE AREA'S EMPLOYMENT OPPORTUNITIES FOCUS ON SEASONAL TOURISM, ALTHOUGH THIS HAS BEEN THINNING OVER THE YEARS. IT REACHED AN ALL-TIME LOW AFTER RISING GAS PRICES MET THE DWINDLING ECONOMIC CLIMATE NATIONWIDE. SEASONAL EMPLOYMENT USUALLY COMES WITHOUT HEALTHCARE BENEFITS, AND SO EXPANDS THE NUMBER OF WORKING COMMUNITY MEMBERS WITHOUT MEDICAL INSURANCE. LACKING SUBSTANTIAL EMPLOYMENT WITHOUT COMPREHENSIVE BENEFIT PLANS CONTRIBUTES TO THE POVERTY OF THE AREA'S RESIDENTS. IN THIS REGION, CHILDREN BETWEEN THE AGES OF 5 AND 17 LIVE IN POVERTY AT A RATE ALMOST 25% HIGHER THAN THE NATIONAL AVERAGE.BASED ON THE U.S. CENSUS ESTIMATES FOR 2008, APPROXIMATELY 14,000 PEOPLE LIVE YEAR-ROUND WITHIN MLH'S SERVICE AREA, OF WHICH 50.4% ARE MALE AND 49.6% ARE FEMALE. OF THE TOTAL FEMALE POPULATION, APPROXIMATELY 38% ARE OF CHILDBEARING AGE. PEOPLE OVER THE AGE OF 65 CONSTITUTE 17.3% OF THE POPULATION. ETHNICALLY, NEARLY 100% OF THE POPULATION IS WHITE AND/OR NON-HISPANIC. THE GREATEST POPULATION GROWTH TREND IN OUR SERVICE AREA WILL BE FOR PEOPLE BETWEEN THE AGES 45 AND 75. PART VI, LINE 5: MOSES-LUDINGTON HOSPITAL (MLH) AND ITS PARENT INTER-LAKES HEALTH (ILH) ARE GOVERNED BY A VOLUNTEER BOARD MADE UP OF COMMUNITY MEMBERS. MANY MEMBERS OF OUR BOARD SERVE IN A PUBLIC CAPACITY, EITHER AS A MEMBER OR OFFICER ON ANOTHER NOT-FOR-PROFIT BOARD OR COMMITTEE, OR IN A POSITION WITHIN PUBLIC HEALTH, OR AS A MEMBER OF A NON-FOR-PROFIT SERVICE ORGANIZATION WITHIN THE SAME SERVICE AREA.MLH PARTICIPATES IN THE HRSA BIOTERRORISM GRANT PROGRAM, A FEDERAL PROGRAM ADMINISTERED THROUGH THE NYS DEPARTMENT OF HEALTH'S GRANT ADMINISTRATION OFFICES. THIS PROGRAM PROVIDES ONGOING INDIVIDUAL AND GROUP TRAINING IN MANY ASPECTS OF EMERGENCY PREPAREDNESS. MLH'S ENVIRONMENT OF CARE (EOC) MANAGER FACILITATES THE GRANT AND OVERSEES THE HOSPITAL SAFETY PROGRAM AND DECONTAMINATION TEAM. SHE PARTICIPATES IN REGULAR DRILLS IN COOPERATION WITH AREA ORGANIZATIONS, INCLUDING BUT NOT LIMITED TO LOCAL EMS SQUADS, THE VOLUNTEER FIRE DEPARTMENT, LOCAL POLICE AND COUNTY AUTHORITIES.FOR 15 YEARS, MLH HAS BEEN OFFERING AN OSTEOPOROSIS PREVENTION CLASS DESIGNED AROUND WEIGHT-BEARING EXERCISES AND HOSTED BY THE ESSEX COUNTY OFFICE OF THE AGING. THIS CLASS IS FREE, OPEN TO THE PUBLIC, HELD WEEKLY AND GENERALLY HAS BETWEEN 9 AND 15 PARTICIPANTS. MLH ALSO HOSTS WEIGHT WATCHERS WEEKLY MEETING FOR THE TICONDEROGA AREA. A NUMBER OF NOT-FOR-PROFIT COMMUNITY-BASED ORGANIZATIONS USE SPACE AT MLH TO HOST COMMUNITY SERVICE-ORIENTED MEETINGS, FREE AND OPEN TO THE PUBLIC, INCLUDING BUT NOT LIMITED TO ALCOHOLICS ANONYMOUS AND CELEBRATE RECOVERY.MLH DONATES PRIVATE CONSULTATION SPACE ON CAMPUS FOR THE ESSEX COUNTY MENTAL HEALTH ASSOCIATION TO UTILIZE AS A CLINIC OFFICE TO COUNSEL PATIENTS FROM OUR SERVICE AREA THAT MAY NOT HAVE RELIABLE TRANSPORTATION TO TRAVEL THE 50-MILE TRIP TO THE ASSOCIATION'S ELIZABETHTOWN HEADQUARTERS. PART VI, LINE 6: IN JUNE OF 2010, INTER-LAKES HEALTH SIGNED AN AFFILIATION AGREEMENT WITH FLETCHER ALLEN HEALTH CARE (FAHC). THE INTENT BEHIND THIS AGREEMENT WAS TO "RAISE THE BAR" OF CLINICAL AND MANAGERIAL EXPERTISE AT MOSES-LUDINGTON HOSPITAL. THE AFFILIATION AGREEMENT WILL ENABLE BOTH ORGANIZATIONS TO WORK MORE CLOSELY TOGETHER TO MEET THE HEALTH CENTER NEEDS OF THE SOUTHERN ADIRONDACKS AND GREATER TICONDEROGA AREA. FAHC BRINGS A WEALTH OF RESOURCES TO THE TABLE WITH THEIR PARTNERS AT THE UNIVERSITY OF VERMONT COLLEGE OF MEDICINE AND THE COLLEGE OF NURSING AND HEALTH SCIENCES. A MANAGEMENT AGREEMENT IS IN PLACE BETWEEN THE TWO FACILITIES. FAHC HAS BEEN INSTRUMENTAL IN THE SEARCH AND ACQUISITION OF A PERMANENT CEO FOR MLH. THIS INDIVIDUAL SERVES AS PRESIDENT AND CEO OF ALL OF INTER-LAKES HEALTH, INC. PART VI, LINE 7, REPORTS FILED WITH STATES NY X X 0 0 0 0 0 0 0 0 0 NANCY CAFFREY PHYSICIAN ASSISTANT 168305 0 0 0 0 0 0 0 16282 0 184587 0 0 0 JAMES HOGAN PHYSICIAN ASSISTANT 133777 0 0 0 0 0 0 0 16281 0 150058 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 INTER-LAKES HEALTH, INC. IS THE SOLE CORPORATE MEMBER OF MOSES-LUDINGTON HOSPITAL. FORM 990, PART VI, SECTION B, LINE 11 THE PRESIDENT AND INTERIM CFO REVIEW PRIOR TO THE FILING OF FORM 990. A FINAL COPY IS SHARED WITH THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 12C THE POLICY IS MONITORED AND ENFORCED THROUGH REGULAR EDUCATION AND INVOLVEMENT BY THE CORPORATE COMPLIANCE COMMITTEE. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION IS DETERMINED BY BOARD AND HUMAN RESOURCES REVIEW AS WELL AS SALARY SURVEYS. FORM 990, PART VI, SECTION C, LINE 19 THE POLICIES ARE MADE AVAILABLE VIA THE WEBSITE AND BY REQUEST. FORM 990, PART IX, LINE 11G OTHER FEES FOR SERVICES: PROGRAM SERVICE EXPENSES 709,775. MANAGEMENT AND GENERAL EXPENSES 486,542. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,196,317. OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 471,783. MANAGEMENT AND GENERAL EXPENSES 27,392. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 499,175. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. INTER-LAKES HEALTH INC 1019 WICKER STREET TICONDEROGA NY 12883 141746088 SOLE CORPORATE MEMBER OF THE HOSPITAL, NURSING HOME, FOUNDATION, LORD HOWE NY 501(C)(3) 11 N/A 0 MOSES-LUDINGTON NURSING HOME 1019 WICKER STREET TICONDEROGA NY 12883 237304957 PROVIDER OF LONG TERM HEALTH CARE SERVICES OF PATIENTS NY 501(C)(3) 9 INTER-LAKES HEALTH INC 0 INTER-LAKES FOUNDATION INC 1019 WICKER STREET TICONDEROGA NY 12883 810566557 PROMOTE AND SUPPORT COMMUNITY HEALTHCARE SERVICES NY 501(C)(3) 7 INTER-LAKES HEALTH INC 0 LORD HOWE ESTATES HOUSING DEVELOPMENT FUND CORPORATION 1019 WICKER STREET TICONDEROGA NY 12883 242434840 PROVIDING SUBSIDIZED HOUSING FOR THE ELDERLY AND HANDICAPPED NY 501(C)(3) 9 INTER-LAKES HEALTH INC 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0