2016-11-11T10:04:02-06:00 2015-12-31 160765486 LUMSDEN & MCCORMICK LLP 369 FRANKLIN STREET BUFFALO NY 14202 990 2015-01-01 160743310 ST JAMES MERCY HOSPITAL STJA 6073248000 411 CANISTEO STREET HORNELL NY 148432104 JENNIFER L SULLIVAN PRESIDENT & CEO 6073248000 2016-11-10 1 MICHAEL J GRIMALDI P01295846 7168563300 2015 2017-02-10 21:41:12Z JENNIFER L SULLIVAN 411 CANISTEO STREET HORNELL NY 148432104 46230245 0 X WWW.STJAMESMERCY.ORG X 1992 NY SEE SCHEDULE O.ST. JAMES MERCY HOSPITAL, GOVERNED BY A SELF-PERPETUATING COMMUNITY BASED BOARD, IS A COMMUNITY OF PERSONS COMMITTED TO BEING A TRANSFORMING, HEALING PRESENCE WITHIN THE RURAL COMMUNITIES WE SERVE, PARTICULARLY ADDRESSING THE NEEDS OF THE POOR, UNDERSERVED AND DISADVANTAGED. X 11 10 594 50 0 0 3641382 478689 38201913 35822731 26755 -128162 797806 10056987 42667856 46230245 0 0 0 0 26892751 24738233 0 0 0 20921806 24286419 47814557 49024652 -5146701 -2794407 21883237 13999388 23073281 10758517 -1190044 3240871 X SEE SCHEDULE O.ST. JAMES MERCY HOSPITAL, GOVERNED BY A SELF-PERPETUATING COMMUNITY BASED BOARD, IS A COMMUNITY OF PERSONS COMMITTED TO BEING A TRANSFORMING, HEALING PRESENCE WITHIN THE RURAL COMMUNITIES WE SERVE, PARTICULARLY ADDRESSING THE NEEDS OF THE POOR, UNDERSERVED AND DISADVANTAGED. 0 1 34201265 36682393 ST. JAMES MERCY HOSPITAL IS AN ACUTE HEALTHCARE FACILITY PROVIDING ROUTINE, AMBULATORY AND ANCILLARY SERVICES. MAJOR SERVICES INCLUDE MEDICAL, SURGICAL, X-RAY, LABORATORY AND MATERNITY (MATERNITY THROUGH 4/30/15). TOTAL ACUTE DISCHARGES FOR THE HOSPITAL WERE 791 (59 MATERNITY). OUTPATIENT REGISTRATIONS FOR THE HOSPITAL WERE 111,918 AND ADDICTION DAYS WERE 3,016 (THROUGH SEPTEMBER 2015). ST. JAMES MERCY HOSPITAL OPERATES A 112 BED LONG-TERM CARE SKILLED NURSING FACILITY. THE LONG-TERM CARE FACILITY SPECIALIZES IN SKILLED NURSING, ASSISTED LIVING AND REHABILITATION SERVICES. TOTAL PATIENT DAYS FOR THE LONG-TERM CARE FACILITY WERE 38,771. ST. JAMES MERCY HOSPITAL OPERATES SEVERAL PHYSICIAN PRACTICES. TOTAL OFFICE VISITS WERE 19,049, INCLUDING EXPRESS CARE. 271167 288551 LIFE LINE SERVICES - REVENUE GENERATED FROM RENTAL OF LIFE LINE UNITS TO THE ELDERY FOR MEDICAL ALERT. 34472432 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 1 0 0 0 0 0 1 0 1 0 0 0 1 108 0 1 594 1 0 0 0 0 0 0 0 0 0 0 X 11 10 0 1 1 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X STANLEY D KONOPKO 6073248110 411 CANISTEO STREET HORNELL NY 14843 JOHN WEYAND DC CHAIR 1.00 X X 0 0 0 SUSAN GRAY PHD VICE CHAIR 1.00 X X 0 0 0 PHILIP LOREE SECRETARY 1.00 X X 0 0 0 PETER D WALL TREASURER 1.00 X X 0 0 0 SHAWN HOGAN MAYOR, CITY OF HORNELL 1.00 X 0 0 0 ADRIAN ASHDOWN MD BOARD MEMBER 1.00 X 0 0 0 ROBERT DONIUS BOARD MEMBER 1.00 X 0 0 0 ISMAIL MEHR MD BOARD MEMBER 1.00 X 0 0 0 RHONDA PETERSON MD BOARD MEMBER 1.00 X 0 0 0 MANINDER VIRDEE BOARD MEMBER 1.00 X 0 0 0 MARY FRAN WEGMAN RSM BOARD MEMBER 1.00 X 0 0 0 JENNIFER L SULLIVAN PRESIDENT/CEO 39.00 1.00 X 691400 0 16810 STANLEY D KONOPKO CFO 40.00 X 0 0 0 KATHY J BRODBECK CHIEF NURSING OFFICER 40.00 X 161921 0 3622 NEVA BOSSARD INTERIM CHIEF NURSING OFFICER 40.00 X 109283 0 19222 PATRICIA DAGON VP CONTINUING CARE/CORPORATE COMPLIANCE OFFICER 40.00 X 236766 0 20060 SYLVIA BRYANT VP OF MISSION/DIRECTOR OF FOUNDATION 18.00 22.00 X 61403 71892 6100 TAMERA S SUZANNE PEDIATRIC NURSE PRACTITIONER 40.00 X 167887 0 2334 DR IFRAN A RIZVI PHYSICIAN 40.00 X 163773 0 7495 DR SCOTT S LEE PHYSICIAN 40.00 X 206889 0 8514 CHARLES M EDGECOMB PHARMACY DIRECTOR 40.00 X 165585 0 21117 DENISE BECHER MANAGER, DECISION SUPPORT/PLANNING 40.00 X 155627 0 10450 2120534 71892 115724 15 0 1 0 ELDERWOOD ADMINISTRATIVE SERVICES 7 LIMESTONE DRIVE WILLIAMSVILLE NY 14221 NURSING HOME STAFFING ASSISTANCE 3943309 EXIGENCE PO BOX 643850 CINCINNATI OH 45263 ER PHYSICIANS 1332147 EXIGENCE HOSPITAL MEDICINE PO BOX 643850 CINCINNATI OH 45263 HOSPITALISTS 855179 ROCHESTER GENERAL HOSPITAL 1425 PORTLAND AVENUE ROCHESTER NY 14621 ORTHOPEDIC PHYSICIAN SERVICES, BUSINESS 735107 ABADAN MEDICAL PLLC 325 CLEVELAND AVENUE HORNELL NY 14843 ANESTHESIOLOGY SERVICES 571011 14 294215 184474 478689 PATIENT SERVICE REVENUE 621990 35534180 35534180 LIFE LINE SERVICES 621610 288551 288551 35822731 -128162 -128162 109190 0 109190 109190 109190 NYS FUNDING - VAPAP 900099 3749436 3749436 NYS FUNDING - IAAF 900099 2753296 2753296 TRINITY REVENUE 900099 2227789 1148213 1079576 1217276 1217276 9947797 46230245 36970944 0 8780612 1323297 1103835 219462 17210056 12175996 5034060 85907 59552 26355 4792017 3420261 1371756 1326956 949940 377016 249445 152459 96986 80896 49443 31453 1164431 711693 452738 1619678 796804 822874 42118 25742 16376 13530 8269 5261 116075 57103 58972 638287 314007 324280 493186 242624 250562 PURCHASED SERVICES 7325813 4477490 2848323 PHYSICIAN FEES 4894446 4894446 SUPPLIES 4424195 2704040 1720155 ALL OTHER EXPENSES 1545598 944659 600939 1678721 1384069 294652 49024652 34472432 14552220 0 1071632 1700934 38291 4026659 6468357 1340889 555132 128994 212893 297596 4917 10663503 292679 4613269 4769393 21883237 13999388 5466361 6513345 2768922 17606920 1476250 23073281 10758517 X -1468270 2700146 278226 270451 270274 -1190044 3240871 21883237 13999388 X -2794407 16761 7208561 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 297596 4917 292679 292679 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS 6575 ASSETS WHOSE USE IS LIMITED 1333908 ASSETS HELD FOR SALE 3428910 4769393 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS 1273403 OTHER CURRENT LIABILITIES 202847 1476250 1 1 1 X 1 X 1 1 0 1 1 1803787 599632 1204155 0.02500 16560902 12145198 4415704 0.09180 18364689 12744830 5619859 0.11680 47491 47491 0.00100 102050 103077 -1027 0.00000 36719 36719 0.00080 186260 103077 83183 0.00180 18550949 12847907 5703042 0.11860 190 190 0.00000 190 190 0 524438 8045 7749920 6834440 915480 X 1 1 1 1 ST JAMES MERCY HOSPITAL 411 CANISTEO STREET HORNELL NY 14843 WWW.STJAMESMERCY.ORG 5002001H X X X ST JAMES MERCY HOSPITAL 0 0 1 X X X X X X X X X 13 1 1 1 1 X WWW.STJAMESMERCY.ORG/PDF/2012-COMMUNITY-HEALTH-NEEDS-ASSESSMENT.PDF X 1 15 1 WWW.STJAMESMERCY.ORG/PDF/SJMH-2013-2015-COMMUNITY-SERVICE-PLAN.PDF 0 0 1 X 200.000000000000 300.000000000000 X X X X X 1 1 X X X X 1 X WWW.STJAMESMERCY.ORG/FINANCIAL.SHTML X X X 1 0 X X X X 1 X 0 0 ST. JAMES MERCY HOSPITAL PART V, SECTION B, LINE 5: THE COMMUNITY NEEDS ASSESSMENT SURVEY WAS DISTRIBUTED TO COMMUNITY STAKEHOLDERS INCLUDING THE SJMH BOARD OF DIRECTORS, LOCAL GOVERNMENT LEADERS, AND SOCIAL SERVICE AGENCY DIRECTORS. THE INPUT WAS USED TO IDENTIFY HEALTH FACTORS AND DISPARITIES AND ALSO TO FURTHER IDENTIFY SURVEY PARTICIPANTS FROM ACROSS THE COMMUNITY. ST. JAMES MERCY HOSPITAL PART V, SECTION B, LINE 6A: IRA DAVENPORT MEMORIAL HOSPITAL, ARNOT HEALTH, CORNING HOSPITAL AND GUTHRIE HEALTH. ST. JAMES MERCY HOSPITAL PART V, SECTION B, LINE 6B: S2AY RURAL HEALTH NETWORK, STEUBEN COUNTY PUBLIC HEALTH DEPARTMENT, STEUBEN RURAL HEALTH NETWORK, HEALTH MINISTRY OF THE SOUTHERN TIER AND CANCER SERVICES PROGRAM OF STEUBEN COUNTY. ST. JAMES MERCY HOSPITAL PART V, SECTION B, LINE 11: NEEDS IDENTIFIED ARE ADDRESSED IN THE COMMUNITY SERVICE PLAN. ST. JAMES MERCY HOSPITAL PART V, SECTION B, LINE 22D: A PATIENT WHOSE HOUSEHOLD INCOME IS BETWEEN 201% AND 250% OF THE MOST RECENT FEDERAL POVERTY LEVEL QUALIFIED FOR A PARTIAL CHARITY CARE DISCOUNT. THE PATIENT LIABILITY IS 40% OF THE RATE OF REIMBURSEMENT SJMH WOULD HAVE RECEIVED FROM ITS "HIGHEST VOLUME PAYOR" (EXCELLUS BLUE CROSS) FOR LIKE SERVICES (INPATIENT, OUTPATIENT, ED). THE PATIENT IS ELIGIBLE FOR A CHARITY CARE DISCOUNT EQUAL TO THE DIFFERENCE BETWEEN CHARGES AND 40% OF THE EXCELLUS BLUE CROSS RATE. A PATIENT WHOSE HOUSEHOLD INCOME IS BETWEEN 251% AND 300% OF THE MOST RECENT FEDERAL POVERTY LEVEL QUALIFIES FOR A PARTIAL CHARITY CARE DISCOUNT. THE PATIENT IS RESPONSIBLE FOR PAYING THE EXCELLUS BLUE CROSS RATE. THE CHARITY CARE DISCOUNT WOULD EQUAL THE DIFFERENCE BETWEEN CHARGES AND THE EXCELLUS BLUE CROSS RATE.SJMH DETERMINED THAT EXCELLUS BLUE CROSS IS THE "HIGHEST VOLUME" PAYOR AS REFERENCED IN THE NYS STATUTE 2807-K. THEREFORE, FOR UNINSURED PATIENTS WITH HOUSEHOLD INCOMES BELOW 300% OF THE MOST RECENT FEDERAL POVERTY LEVEL, THE PATIENT RESPONSIBILITY WILL NOT EXCEED THE RATE OF REIMBURSEMENT SJMH WOULD HAVE RECEIVED FROM EXCELLUS BLUE CROSS. PART I, LINE 7: THE COST-TO-CHARGE RATIO IS USED FOR LINES 7A AND 7B, COMPUTED BY TAKING TOTAL EXPENSES LESS BAD DEBT DIVIDED BY TOTAL GROSS PATIENT REVENUE. 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 $ 920,884. PART II, COMMUNITY BUILDING ACTIVITIES: ST. JAMES MERCY HOSPITAL ACTIVELY RECRUITS PHYSICIANS AND OTHER HEALTH PROFESSIONALS TO PROVIDE SERVICES IN AREAS WITH A MEDICAL SHORTAGE OR ARE UNDERSERVED. PART III, LINE 2: THE HOSPITAL PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLES FOR ESTIMATED LOSSES RESULTING FROM THE INABILITY/UNWILLINGNESS OF PATIENTS TO MAKE PAYMENTS FOR SERVICES. THE ALLOWANCE IS DETERMINED BY ANALYZING HISTORICAL DATA AND TRENDS. ACCOUNTS RECEIVABLE ARE CHARGED OFF AGAINST THE ALLOWANCE FOR UNCOLLECTIBLES WHEN MANAGEMENT DETERMINES THAT RECOVERY IS UNLIKELY AND THE HOSPITAL CEASES COLLECTION EFFORTS. PART III, LINE 3: THE AMOUNT REPORTED IN PART III, SECTION A, LINE 3 IS DETERMINED BY ESTIMATING THE AMOUNT OF BAD DEBT EXPENSE THAT WOULD BE ATTRIBUTED TO PATIENTS WHO WOULD LIKELY QUALIFY FOR FINANCIAL ASSISTANCE BUT FOR WHOM SUFFICIENT INFORMATION WAS NOT OBTAINED TO MAKE THAT DETERMINATION. PART III, LINE 4: ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. TO EVALUATE THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS HISTORICAL DATA AND 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 TO EVALUATE THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS, THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF HISTORICAL DATA, 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 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: TO DETERMINE MEDICARE ALLOWABLE COSTS REPORTABLE IN THE MEDICARE COST REPORT, THE COST-TO-CHARGE RATIO IS APPLIED TO GROSS PATIENT REVENUE ASSOCIATED WITH SERVICES PERFORMED FOR PATIENTS WHO ARE ELIGIBLE FOR MEDICARE. PART III, LINE 9B: A BAD DEBT RESULTS FROM A PATIENT ACCOUNT BALANCE FROM WHICH PAYMENT WAS ANTICIPATED FROM THE PATIENT, CREDIT EXTENDED AND THE ACCOUNT LATER DEEMED TO BE UNCOLLECTIBLE. A BAD DEBT DOES NOT MEET THE CRITERIA FOR CHARITY CARE, THAT IS, BAD DEBT PATIENTS ARE CONSIDERED TO HAVE THE FINANCIAL CAPABILITY AND ABILITY TO PAY, BUT ARE UNWILLING TO PAY. COLLECTION ACTIVITIES ARE ONLY PURSUED WITH RESPECT TO AMOUNTS THAT PATIENTS ARE ABLE TO PAY AS DETERMINED BY THE HOSPITAL'S CHARITY CARE POLICY. NO COLLECTION ACTIVITIES TAKE PLACE WITH RESPECT TO AMOUNTS THAT PATIENTS ARE NOT EXPECTED TO PAY UNDER THIS POLICY.A SEPARATE CHARITY CARE POLICY IS IN PLACE AND WOULD BE EXHAUSTED BEFORE A PATIENT BALANCE WOULD BE DEEMED SELF-PAY. UNDER THE CHARITY CARE POLICY, CHARITY CARE/FINANCIAL ASSISTANCE IS PROVIDED TO A PATIENT WITH A DEMONSTRATED INABILITY TO PAY. A PATIENT IS ELIGIBLE FOR CHARITY CARE/FINANCIAL ASSISTANCE CONSIDERATION BASED UPON MEETING CERTAIN INCOME ELIGIBILITY CRITERIA AS ESTABLISHED BY THE FEDERAL POVERTY INCOME GUIDELINE SLIDING SCALE. PER NYS PHL 2807-K, THIS CONSIDERS PATIENTS WHOSE HOUSEHOLD INCOME IS UP TO 300% OF THE MOST RECENT FEDERAL POVERTY GUIDELINES.ALL UNINSURED, LOW-INCOME PATIENTS WITHIN ST. JAMES MERCY HOSPITAL'S PRIMARY SERVICE AREA WHO CAN DEMONSTRATE AN INABILITY TO PAY CHARGES MAY APPLY FOR CHARITY CARE/FINANCIAL ASSISTANCE FOR ADJUSTMENTS TO THEIR BALANCES FOR ALL MEDICALLY NECESSARY HEALTHCARE SERVICES, PROVIDED THAT A MEMBER, IN GOOD STANDING, OF ST. JAMES MERCY HOSPITAL'S MEDICAL STAFF DETERMINES THE NEED FOR SUCH MEDICAL CARE TREATMENT. PART VI, LINE 2: ST. JAMES MERCY HOSPITAL CONDUCTS A COMMUNITY NEEDS ASSESSMENT EVERY THREE YEARS IN CONJUNCTION WITH STEUBEN COUNTY PUBLIC HEALTH. BASED ON RESIDENTS' FEEDBACK, THE COUNTY'S HEALTH CARE PRIORITIES, STRATEGIES, AND PROGRAMS ARE DETERMINED. ST. JAMES MERCY HOSPITAL CREATES AN ANNUAL PLAN BASED ON THIS ASSESSMENT, AND THE PROGRESS OF THESE INITIATIVES IS REPORTED ANNUALLY TO THE NYS DEPARTMENT OF HEALTH. LOCAL HEALTH CARE PRIORITIES ARE ALSO IDENTIFIED THROUGH SURVEYING PARTICIPANTS AT PUBLIC HEALTH EDUCATION PROGRAMS. PART VI, LINE 3: AT THE TIME OF REGISTRATION, ALL SELF-PAY INDIVIDUALS RECEIVE AN INFORMATION SHEET DESCRIBING THE TYPES OF FEDERAL, STATE AND LOCAL GOVERNMENT PROGRAMS AVAILABLE, INCLUDING ST. JAMES MERCY HOSPITAL'S CHARITY CARE POLICY. THE ELIGIBILITY PROCESS IS COORDINATED BY A FINANCIAL COUNSELOR, WHO CONTACTS THE PATIENT OR PATIENT FAMILY MEMBER BY PHONE AND/OR LETTER. PATIENTS WHO QUALIFY FOR MEDICAID ARE ALSO DIRECTED TO AN IN-HOUSE FACILITATED ENROLLER, WHO COORDINATES THE MEDICAID APPLICATION PROCESS ON BEHALF OF THE PATIENT. PART VI, LINE 4: THE PRIMARY SERVICE AREA FOR ST. JAMES MERCY HOSPITAL IS THE 15-MILE RADIUS EXTENDING FROM HORNELL (STEUBEN COUNTY), NEW YORK, AND INCLUDES THE TOWNS OF WAYLAND TO THE NORTHEAST AND TROUPSBURG TO THE SOUTHEAST (JUST OUTSIDE OF THE 15-MILE RADIUS). THE SECONDARY SERVICE AREA IS THE 30-MILE RADIUS EXTENDING FROM HORNELL. PER THE 2010 CENSUS, THE POPULATION FOR THE PRIMARY SERVICE AREA (STEUBEN COUNTY) REMAINED RELATIVELY FLAT, INCREASING 0.3% FROM 2000 TO 2010 TO 98,990 AND IS PROJECTED TO REMAIN FLAT THROUGHOUT 2014. THE POPULATION AGED 65 AND OVER COMPRISES 16% OF THE PRIMARY SERVICE AREA COMPARED TO 13% FOR NEW YORK STATE. THE POPULATION IS RACIALLY AND ETHNICALLY HOMOGENOUS WITH 95.3% WHITE, 1.6% BLACK, 1.4% HISPANIC/LATINO, AND 1.2% ASIAN. PERSONS OVER THE AGE OF 65 REPRESENT 15.6% OF THE COUNTY, 2 PERCENTAGE POINTS HIGHER THAN THE STATE. MEDIAN HOUSEHOLD INCOME IS $42,764 COMPARED TO $54,554 FOR THE STATE. APPROXIMATELY 20% OF THE COUNTY POPULATION HAVE A BACHELOR'S DEGREE OR HIGHER COMPARED TO 32% OF STATE RESIDENTS. PART VI, LINE 5: ST. JAMES MERCY HOSPITAL IS THE LEAD AGENCY FOR THE CANCER SERVICES PROGRAM (CSP) OF STEUBEN COUNTY. A COMMUNITY-BASED, GRANT-FUNDED PROGRAM OF NEW YORK STATE DEPARTMENT OF HEALTH, THE CSP SERVES UNINSURED MEN AND WOMEN WITH COMPREHENSIVE, AGE-APPROPRIATE, NO-COST SCREENINGS FOR BREAST, CERVICAL AND COLORECTAL CANCER. ST. JAMES MERCY HOSPITAL PARTICIPATES IN COORDINATING THE PEDIATRIC HEALTH FAIR. THIS EVENT IS DIRECTED TO PARENTS AND COMMUNITY YOUTH AND IS HELD IN CONJUNCTION WITH A LONGSTANDING COMMUNITY KIDS "FUN RUN" TO PROMOTE EXERCISE AND HEALTHY LIFESTYLES. ST. JAMES MERCY HOSPITAL STAFF MEMBERS THROUGHOUT THE ORGANIZATION PARTICIPATE IN COMMUNTIY INITIATIVES AND HOLD SEATS ON BOARDS, INCLUDING THE STEUBEN RURAL HEALTH NETWORK, CATHOLIC CHARITIES, YMCA, UNITED WAY OF THE SOUTHERN TIER, STEUBEN CO. HEALTH PRIORITIES TEAM, AND OTHER NON-PROFIT ORGANIZATIONS WHOSE PRIMARY MISSION IS TO ASSESS AND ADDRESS COMMUNITY NEEDS. ST. JAMES MERCY HOSPITAL HAS ALSO COLLABORATED IN A PILOT PROGRAM IN COLLABORATION WITH THE HORNELL CITY SCHOOL DISTRICT AND IS DESIGNED TO ADDRESS THE ISSUE OF STUDENTS WITHOUT HEALTH INSURANCE IN PRE-K THROUGH GRADE 6, THROUGH EDUCATIONAL MATERIALS TO PARENTS AND MEDICAID ENROLLMENT ASSISTANCE. PART VI, LINE 7, REPORTS FILED WITH STATES NY X X X X 1 0 0 0 0 1 0 0 0 JENNIFER L SULLIVAN PRESIDENT/CEO 288156 0 65623 0 337621 0 2852 0 13958 0 708210 0 0 0 KATHY J BRODBECK CHIEF NURSING OFFICER 98492 0 15167 0 48262 0 525 0 3097 0 165543 0 0 0 PATRICIA DAGON VP CONTINUING CARE/CORPORATE COMPLIA 119182 0 28412 0 89172 0 6102 0 13958 0 256826 0 0 0 TAMERA S SUZANNE PEDIATRIC NURSE PRACTITIONER 78245 0 77642 0 12000 0 386 0 1948 0 170221 0 0 0 DR IFRAN A RIZVI PHYSICIAN 158616 0 5000 0 157 0 2288 0 5207 0 171268 0 0 0 DR SCOTT S LEE PHYSICIAN 205820 0 0 0 1069 0 2285 0 6229 0 215403 0 0 0 CHARLES M EDGECOMB PHARMACY DIRECTOR 151978 0 0 0 13607 0 7231 0 13886 0 186702 0 0 0 DENISE BECHER MANAGER, DECISION SUPPORT/PLANNING 101530 0 3958 0 50139 0 3334 0 7116 0 166077 0 0 0 PART I, LINE 6 THE PERFORMANCE MEASURES USED TO DETERMINE INCENTIVE COMPENSATION WERE BASED ON ACHIEVING A REDUCTION IN THE NET LOSS AS COMPARED TO THE FISCAL PRIOR YEAR. SCHEDULE J, PART I, LINE 4A PRIOR TO APRIL 30, 2015, ST. JAMES MERCY HOSPITAL WAS A MEMBER OF TRINITY HEALTH CORPORATION. TRINITY HEALTH CORPORATION OPERATES ON A FISCAL YEAR BASIS WHICH BEGAN ON JULY 1, 2014 AND ENDED ON JUNE 30, 2015. PRIOR TO TRINITY HEALTH CORPORATION'S YEAR END, ST. JAMES MERCY HOSPITAL WAS DIVESTED FROM TRINITY HEALTH CORPORATION AND BECAME AN INDEPENDENT COMMUNITY ORGANIZATION GOVERNED BY A SELF-PERPETUATING COMMUNITY BOARD. AS PART OF THAT DIVESTITURE, CERTAIN INDIVIDUALS RECEIVED INCENTIVE COMPENSATION BASED UPON CONTRACTUAL ARRANGEMENTS WITH TRINITY HEALTH CORPORATION WHEREBY A PORTION OF THEIR TOTAL COMPENSATION WAS CONSIDERED "AT RISK AND ONLY PAID IN THE EVENT THAT CERTAIN PERFORMANCE MEASURES WERE ACHIEVED RELATED TO QUALITY, FINANCE, GROWTH AND PEOPLE. THE FINANCE PERFORMANCE MEASURE WAS TIED TO REDUCING THE OVERALL NET LOSS OF THE ORGANIZATION. ALL INCENTIVE COMPENSATION AND SEVERANCE WAS PAID BY TRINITY HEALTH CORPORATION. THE FOLLOWING INDIVIDUALS RECEIVED INCENTIVE COMPENSATION (INCLUDED IN COLUMN B(II) OF SCHEDULE J AND SEVERANCE PAYMENTS (INCLUDED IN COLUMN B(III) OF SCHEDULE J): JENNIFER L. SULLIVAN, PRESIDENT AND CEO, RECEIVED $65,623 IN INCENTIVE COMPENSATION AND $337,500 IN SEVERANCE PAYMENTS IN 2015 WHICH WERE PAID BY TRINITY HEALTH CORPORATION IN 2015 RELATED TO HER SERVICE PROVIDED PRIOR TO MAY 1, 2015. KATHY J. BRODBECK, CHIEF NURSING OFFICER, RECEIVED $15,167 IN INCENTIVE COMPENSATION AND $48,000 IN SEVERANCE PAYMENTS IN 2015 WHICH WERE PAID BY TRINITY HEALTH CORPORATION IN 2015 RELATED TO HER SERVICE PROVIDED PRIOR TO MAY 1, 2015. PATRICIA DAGON, VP CONTINUING CARE, RECEIVED $28,412 IN INCENTIVE COMPENSATION AND $88,971 IN SEVERANCE PAYMENTS IN 2015 WHICH WERE PAID BY TRINITY HEALTH CORPORATION IN 2015 RELATED TO HER SERVICE PROVIDED PRIOR TO MAY 1, 2015. CHARLES M. EDGECOMB, PHARMACY DIRECTOR, RECEIVED $4,250 IN SEVERANCE PAYMENTS IN 2015 WHICH WERE PAID BY TRINITY HEALTH CORPORATION IN 2015 RELATED TO HIS SERVICE PROVIDED PRIOR TO MAY 1, 2015. DENISE BECHER, DIRECTOR REVENUE CYCLE AND DECISION SUPPORT RECEIVED $3,958 IN INCENTIVE COMPENSATION AND $49,997 IN SEVERANCE PAYMENTS IN 2015 WHICH WERE PAID BY TRINITY HEALTH CORPORATION IN 2015 RELATED TO HER SERVICE PROVIDED PRIOR TO MAY 1, 2015. STANLEY D KONOPKO CFO STANLEY D. KONOPKO, CFO, IS A PARTNER AT BONADIO & CO., LLP 308864 BONADIO & CO. LLP IS PAID SERVICES PERFORMED BY MR. KONOPKO. 0 ISMAIL MEHR MD DR. MEHR IS A BOARD MEMBER OF THE HOSPITAL 571011 DR. MEHR PROVIDES ANESTHESIOLOGY SERVICES TO THE HOSPITAL THROUGH HIS COMPANY ABADAN MEDICAL, PLLC. 0 CASH AND CASH EQUIVALENTS 2015-04-30 4326000 CASH VALUE 223127184 ST JAMES MERCY HEALTH SYSTEM INC 411 CANISTEO STREET HORNELL NY 14843 501(C)(3) PATIENT ACCOUNTS RECEIVABLE, NET 2015-04-30 2788000 NBV 223127184 ST JAMES MERCY HEALTH SYSTEM INC 411 CANISTEO STREET HORNELL NY 14843 501(C)(3) PREPAID EXPENSES AND INVENTORIES 2015-04-30 689000 CASH VALUE 223127184 ST JAMES MERCY HEALTH SYSTEM INC 411 CANISTEO STREET HORNELL NY 14843 501(C)(3) PROPERTY AND EQUIPMENT, NET 2015-04-30 7263000 NBV 223127184 ST JAMES MERCY HEALTH SYSTEM INC 411 CANISTEO STREET HORNELL NY 14843 501(C)(3) 0 0 0 1 SCHEDULE N, PART II, LINE 2D IN ADDITION TO THE DISPOSITION OF $15,066,000 ASSETS TO TRINITY HEALTH CORPORATION, TRINITY HEALTH CORPORATION ALSO ASSUMED APPROXIMATELY $22,568,000 OF LIABILITIES RESULTING IN A TRANSFER OF A NET LIABILITY OF $7,502,000.JENNIFER L. SULLIVAN, PRESIDENT AND CEO, RECEIVED $65,623 IN INCENTIVE COMPENSATION AND $337,500 IN SEVERANCE PAYMENTS IN 2015 WHICH WERE PAID BY TRINITY HEALTH CORPORATION IN 2015 RELATED TO HER SERVICE PROVIDED PRIOR TO MAY 1, 2015.KATHY J. BRODBECK, CHIEF NURSING OFFICER, RECEIVED $15,167 IN INCENTIVE COMPENSATION AND $48,000 IN SEVERANCE PAYMENTS IN 2015 WHICH WERE PAID BY TRINITY HEALTH CORPORATION IN 2015 RELATED TO HER SERVICE PROVIDED PRIOR TO MAY 1, 2015.PATRICIA DAGON, VP CONTINUING CARE, RECEIVED $28,412 IN INCENTIVE COMPENSATION AND $88,971 IN SEVERANCE PAYMENTS IN 2015 WHICH WERE PAID BY TRINITY HEALTH CORPORATION IN 2015 RELATED TO HER SERVICE PROVIDED PRIOR TO MAY 1, 2015.CHARLES M. EDGECOMB, PHARMACY DIRECTOR, RECEIVED $4,250 IN SEVERANCE PAYMENTS IN 2015 WHICH WERE PAID BY TRINITY HEALTH CORPORATION IN 2015 RELATED TO HIS SERVICE PROVIDED PRIOR TO MAY 1, 2015.DENISE BECHER, DIRECTOR REVENUE CYCLE AND DECISION SUPPORT RECEIVED $3,958 IN INCENTIVE COMPENSATION AND $49,997 IN SEVERANCE PAYMENTS IN 2015 WHICH WERE PAID BY TRINITY HEALTH CORPORATION IN 2015 RELATED TO HER SERVICE PROVIDED PRIOR TO MAY 1, 2015. FORM 990, PART III, LINE 3 IN 2014, THE HOSPITAL ANNOUNCED IT HAD ENTERED INTO AGREEMENTS FOR THE SALE OF BOTH ITS LONG-TERM CARE AND DIALYSIS SERVICES. THE COMPONENTS' OPERATING RESULTS FOR 2014 AND 2015 ARE REFLECTED AS DISCONTINUED OPERATIONS ON THE FINANCIAL STATEMENTS. ON APRIL 12, 2016, THE HOSPITAL COMPLETED THE SALE OF ITS LONG-TERM CARE SERVICE LINE. IN SEPTEMBER 2015, INPATIENT AND OUTPATIENT ADDICTION SERVICES WERE CLOSED AND ASSUMED BY LOYOLA RECOVERY FOUNDATION, INC. FORM 990, PART VI, SECTION A, LINE 3 STANLEY D. KONOPKO HAS SERVED AS THE ORGANIZATION'S CFO SINCE AUGUST 2013. MR. KONOPKO IS A PARTNER OF BONADIO & CO., LLP, AN ACCOUNTING FIRM, WHICH WAS PAID $308,864 FOR MR. KONOPKO'S SERVICES IN 2015. FORM 990, PART VI, SECTION A, LINE 4 THE BYLAWS WERE AMENDED AND RESTATED EFFECTIVE MAY 1, 2015 TO REMOVE ST. JAMES MERCY HEALTH SYSTEM AS THE SOLE CORPORATE MEMBER OF THE HOSPITAL. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE FORM 990 WAS MADE AVAILABLE TO EACH BOARD MEMBER BEFORE IT WAS FILED. ST. JAMES MERCY HOSPITAL HAS DESIGNED THE AUDIT AND COMPLIANCE COMMITTEE AS THE GROUP TO BE EDUCATED AND TO REVIEW THE RETURN. FORM 990, PART VI, SECTION B, LINE 12C A CALL FOR CONFLICTS IS PART OF EVERY BOARD MEETING. THE ANNUAL BOARD OF DIRECTORS EDUCATION SESSION WAS COMPLETED IN AUGUST 2015. FORM 990, PART VI, SECTION B, LINE 15 THROUGH APRIL 30, 2015, THE ORGANIZATION HAD ADOPTED TRINITY HEALTH CORPORATION'S PROCESS FOR DETERMINING COMPENSATION WHICH INCLUDED THE FOLLOWING: THE BOARD HAS AN INDEPENDENT COMMITTEE REVIEW AND APPROVE ALL ELEMENTS OF REMUNERATION FOR ALL DISQUALIFIED PARTIES, AS WELL AS OTHER KEY MANAGEMENT. THE BOARD/COMMITTEE HAS AN ESTABLISHED COMPENSATION PHILOSOPHY WHICH DETAILS THE OBJECTIVES OF MARKET POSITIONING AND PAY ELEMENTS. THE COMMITTEE ENGAGES WITH EXTERNAL CONSULTANTS TO PROVIDE MARKET DATA AND GUIDANCE COMPARING THE ORGANIZATION'S ROLES TO SIMILARLY SIZED HEALTH SYSTEMS UTILIZING BOTH TITLE AND JOB CONTENT COMPARISONS. THE COMMITTEE REVIEWS THE MARKET ANALYSIS, APPROVES ANY SALARY ADJUSTMENTS FOR THE EXECUTIVE POPULATION, CONSIDERS BOTH REASONABLENESS AND EFFECTIVENESS OF ALL REMUNERATIVE PROGRAMS AND ESTABLISHES THE DETAILED PERFORMANCE EXPECTATIONS WHICH ARE INCORPORATED INTO THE INCENTIVE PLAN. ALL OF THESE DISCUSSIONS AND DECISIONS ARE DOCUMENTED THROUGH THE PROVISION OF MEETING MINUTES. EFFECTIVE MAY 1, 2015, THE TRINITY HEALTH CORPORATION DIVESTED ITSELF OF ITS INTEREST IN THE ORGANIZATION AND THE ORGANIZATION BECAME AN INDEPENDENT HOSPITAL GOVERNED BY A SELF-PERPETUATING COMMUNITY BASED BOARD. THE ORGANIZATION CONTINUED TO FOLLOW THE PROCESS FOR DETERMINING COMPENSATION EXCEPT FOR THE ENGAGEMENT OF EXTERNAL CONSULTANTS. THE BOARD/COMMITTEE UTILIZED OTHER SOURCES OF MARKET DATA AND FOLLOWED THE SAME PROCEDURES AS OUTLINED ABOVE TO DETERMINE COMPENSATION. THERE WERE NO INCENTIVE COMPENSATION PLANS IN EFFECT FROM MAY 1, 2015 THROUGH DECEMBER 31, 2015. FORM 990, PART VI, SECTION C, LINE 19 ORGANIZATIONAL DOCUMENTS, SUCH AS THE ARTICLES OF INCORPORATION, CORPORATE BYALWS, GOVERNANCE POLICIES BELIEVED TO BE OF INTEREST TO THE PUBLIC, CONFLICT OF INTEREST POLICIES AND THE IRS FORM 990, ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: NET ASSETS CONTRIBUTION FROM TRINITY 7,502,000. TRANSFERS (TO) FROM AFFILIATES -226,000. OTHER CHANGES IN NET ASSETS -67,439. FORM 990, PART XII, LINE 2C: THE AUDIT AND COMPLIANCE COMMITTEE IS RESPONSIBLE FOR THE SELECTION OF THE INDEPENDENT AUDITOR AND OVERSIGHT OF THE AUDIT. THERE HAS NOT BEEN A CHANGE FROM THE PRIOR YEAR. ST JAMES MERCY FOUNDATION INC 411 CANISTEO STREET HORNELL NY 14843 161486437 FOUNDATION NY 501(C)(3) LINE 7 ST JAMES MERCY HOSPITAL 0 ST JAMES MERCY HEALTH SYSTEM INC 411 CANISTEO STREET HORNELL NY 14843 223127184 HEALTHCARE SYSTEM MANAGEMENT AND SUPPORT NY 501(C)(3) LINE 11B, II TRINITY HEALTH CORPORATION 0 SJM PROPERTIES INC 411 CANISTEO STREET HORNELL NY 14843 161294991 PROPERTY HOLDINGS NY ST JAMES MERCY HEALTH SYSTEM INC C 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1