2016-11-15T09:25:29-06:00 2015-12-31 201767403 HOFFMAN EELLS & GRAY CPAS PC 1 MAIN STREET SUITE 101 CANTON NY 136171277 990 2015-01-01 161012691 CANTON-POTSDAM HOSPITAL CANT 3152615103 50 LEROY STREET POTSDAM NY 13676 RICHARD JACOBS VP FOR FINANCE/CFO 3152615103 2016-11-15 true JOHN J GRAY JR CPA P00076464 3153862925 2016-11-11 2015 2017-02-10 21:41:12Z RICHARD JACOBS CANTON-POTSDAM HOSPITAL POTSDAM NY 13676 151794256 false X WWW.CPHOSPITAL.ORG X 1920 NY CANTON-POTSDAM HOSPITAL'S MISSION IS TO PROVIDE SKILLED, COMPASSIONATE, COST-EFFECTIVE CARE THAT PROMOTES WELLNESS AND MEETS COMMUNITY NEEDS. 18 7 1301 285 0 1111375 305653 129916602 138023147 300198 184872 9665762 12589913 140993937 151103585 0 0 81509663 92672878 0 0 47865294 53261097 129374957 145933975 11618980 5169610 100388006 101388202 47393323 47177035 52994683 54211167 X CANTON-POTSDAM HOSPITAL'S MISSION IS TO PROVIDE SKILLED, COMPASSIONATE COST-EFFECTIVE CARE THAT PROMOTES WELLNESS AND MEETS COMMUNITY NEEDS. false false 75127719 196138649 ACUTE CARE: CANTON-POTSDAM HOSPITAL HAS A TOTAL OF 94 LICENSED BEDS, COMPRISED OF 17 FOR CHEMICAL DEPENDENCY-REHABILITATION, 7 FOR CHEMICAL DEPENDENCY- DETOXIFICATION, 4 FOR CORONARY CARE, 2 FOR INTENSIVE CARE, 8 FOR MATERNITY AND 56 FOR MEDICAL/SURGICAL. PROFESSIONAL STAFF COVERAGE FOR OUR IN- PATIENT CENSUS IS PROVIDED BY A HOSPITALIST PROGRAM. TOTAL PATIENT DAYS INCREASED BY APPROXIMATELY 13.7% FROM 2014 TO 2015. TOTAL DISCHARGES INCREASED BY APPROXIMATELY 4% FROM 2014 TO 2015. OBSERVATION CASES INCREASED BY APPROXIMATELY 10% FROM 2014 TO 2015. EMERGENCY ROOM VISITS INCREASED BY 6% FROM 2014 TO 2015. 22870391 43645811 HOSPITAL BASED CLINICS: THERE WAS SIGNIFICANT GROWTH OF THE HOSPITAL BASED CLINICS. THERE WERE OVER 129,000 VISITS IN 2015, COMPARED TO OVER 109,000 IN 2014; ROUGHLY AN 18% INCREASE. EIGHT NEW OUT PATIENT CLINIC LOCATIONS WERE ESTABLISHED, TO INCLUDE OUTPATIENT SERVICES FOR OB, ORTHOPEDICS, PAIN MANAGEMENT, ENDOCRINOLOGY, INTERNAL MEDICINE, RHEUMATOLOGY AND GENERAL SURGERY. 9158853 15591062 OPERATING ROOM: IN 2015, THE OPERATING ROOM NUMBER OF CASES INCREASED BY APPROXIMATELY 10.5%, COMPARED TO 2014. SIGNIFICANT INCREASES WERE DUE TO THE CARDIOLOGY, GYNECOLOGY, PAIN MANAGEMENT, PODIATRY AND PULMONARY SERVICE LINES. THE HOSPITAL ALSO EXPERIENCED A 5% INCREASE IN AMBULATORY SURGERY UNIT VISITS FROM 2014. 6380525 7514845 ONCOLOGY SERVICES: IN 2015, THE ONCOLOGY VISITS DECREASED APPROXIMATELY 6.7% FROM 2014. THIS DECREASE IS ATTRIBUTABLE TO A TURNOVER OF PHYSICIANS. AUGUST 2016 YTD STATISTICS INDICATE AN 8% INCREASE OVER BUDGETED 2016 VISITS AND AN APPROXIMATE 18% INCREASE IN VISITS YEAR TO DATE COMPARED WITH 2015. 6380525 7514845 113537488 true false false true false false false false false true true false false true true true true true false false false false false false false false true true false false true true false false true false false false false false false true false false false false false true true true false false true 297 0 true 1301 true false false false false false false false false false false false false X 18 7 false false false false false false false true true false true true true true true true true true true true false NY X RICHARD JACOBS CANTON-POTSDAM HOSP 3152615100 50 LEROY STREET POTSDAM NY 13676 MICHAEL TULLOCH MD DIRECTOR 2.00 X 120809 0 0 RONALD BERRY DIRECTOR 2.00 X 0 0 0 DONALD DANGREMOND DIRECTOR 2.00 X 0 0 0 KATHRYN MULLANEY TREASURER 4.00 X X 0 0 0 JUDY CHASE SECRETARY 4.00 X X 0 0 0 MICHAEL GRIFFIN DIRECTOR 2.00 X 0 0 0 BRIAN GARDAM DIRECTOR 2.00 X 0 0 0 JUNE PEOPLES DIRECTOR 2.00 X 0 0 0 LAURIE MAKI DIRECTOR 2.00 X 0 0 0 PAUL MCGRATH DIRECTOR 2.00 X 0 0 0 JOANNE SCOTT DIRECTOR 2.00 X 0 0 0 JUDY CHITTENDEN VICE CHAIRPE 4.00 X X 0 0 0 EDWARD MUCENSKI DIRECTOR 2.00 X 0 0 0 PAUL COLE DVM DIRECTOR 2.00 X 0 0 0 JAMES THEODORE DIRECTOR 2.00 X 0 0 0 MARK CORNETT BOARD CHAIR 4.00 X X 0 0 0 FLORENCE BERO DIRECTOR 2.00 X 0 0 0 RICHARD VANLEUVEN DIRECTOR 2.00 X 0 0 0 DAVID ACKER PRESIDENT & 50.00 X 508974 0 100650 RICHARD JACOBS VP FOR FINAN 50.00 X 278876 0 28264 JEFFREY HAASBEEK MD PHYSICIAN 50.00 X 806965 0 44450 XIAOSONG SONG MD PHYSICIAN 50.00 X 778955 0 31812 KRIS VANWAGNER MD PHYSICIAN 50.00 X 755513 0 22214 JOHN SAVAGE MD PHYSICIAN 50.00 X 682509 0 30690 MARCO BERARD MD PHYSICIAN 50.00 X 679359 0 29956 4611960 288036 153 false true false INSIGHT HEALTH CORPORATION PO BOX 847689 DALLAS TX 752847689 MRI/IMAGING 1422094 LAVALLEEBRENSINGER ARCHITECTS 155 DOW STREET SUITE 400 MANCHESTER NH 03101 ARCHITECTURAL 927071 MAYO MEDICAL LABORATORIES PO BOX 9146 MINNEAPOLIS MN 554809146 LAB SERVICES 844140 MORRISON MANAGEMENT SPECIALISTS PO BOX 102289 ATLANTA GA 303682289 FOOD SERVICE 676660 UNIVERSITY OF VERMONT MEDICAL CENTE PO BOX 1902 BURLINGTON VT 054021902 LAB SERVICES 672130 35 242000 63653 305653 NET PATIENT SERVICE REVENUE 900099 138023147 138023147 138023147 179797 179797 588952 519583 69369 69369 69369 176163 165671 5417 10492 -5417 5075 10492 -5417 OTHER 6691390 6691390 340B RETAIL PROGRAM 3944583 3944583 OTHER 1697349 1697349 187222 187222 12520544 151103585 138033639 12764293 2242156 1771303 470853 72708404 57434264 15274140 2874236 2270646 603590 10123957 7997926 2126031 4724125 3732059 992066 259875 259875 222304 222304 98708 98708 271586 271586 684683 540900 143783 1821019 1439457 381562 668263 527926 140337 252787 199702 53085 845564 666098 179466 7164285 5659785 1504500 1223184 966315 256869 SUPPLIES 19785757 15629959 4155798 PURCHASED/CONTRACTED SERV 9916464 7834006 2082458 EQUIPMENT RENTAL & MAINT 4386629 3477187 909442 OTHER 3249979 2612425 637554 2410010 505944 1904066 145933975 113537488 32396487 0 3537041 3795141 4797657 1168899 14127336 17524276 1554596 1558006 2180554 2461824 117878004 76512304 41991957 41365700 909653 894097 31289212 32620259 100388006 101388202 15212296 16488860 14819212 13474152 3768468 4058275 13593347 13155748 47393323 47177035 X 51896132 53106211 378793 385198 719758 719758 52994683 54211167 100388006 101388202 X 5169610 -20682 -3932444 X false true X true false X false false false false false false false false true 98707 98707 false SCHEDULE C, PART II-B, LINE 1 IROQUOIS HEALTHCARE ALLIANCE: 5,270: FEDERAL AND STATE ADVOCACY HANYS ANNUAL MEMBERSHIP DUES: 10,859: FEDERAL AND STATE ADVOCACY AMERICAN HOSPITAL ASSOCIATION ANNUAL MEMBERSHIP DUES: 4,569: FEDERAL AND STATE ADVOCACY WILSON, ELSER, MOSKOWITZ: 78,009: FEDERAL AND STATE LOBBYING AND REPRESENTATION 909653 -15556 894097 899859 9794 909653 845727 54132 899859 820749 24978 845727 831307 -10558 820749 0.81000 0.19000 false false 766771 766771 56931758 22445835 34485923 2704664 1434860 1269804 56084966 52631609 3453357 1389845 1389845 41365700 INTEREST IN CANTON HOSP FOUNDATION 19044328 DUE FROM ST. LAWRENCE HEALTH SYSTEM 5352231 OTHER NOTES & LOANS RECEIVABLE (NET) 2713222 ASSETS WHOSE USEFUL LIFE IS LIMITED 2384576 DUE FROM AFFILIATES 1615482 OTHER ASSETS 1439575 PHYSICIAN LOANS/NOTES RECEIV. (NET) 70845 32620259 ACCRUED RETIREMENT OBLIGATION 5262183 ESTIMATED THIRD PARTY SETTLEMENTS 4302421 457 & ASSET RETIREMENT OBLIGATION 2119590 INTEREST RATE SWAP 1376210 DUE TO AFFILIATES 95344 13155748 X 151383618 519582 519582 150864036 239549 239549 151103585 146453557 519582 519582 145933975 145933975 SCHEDULE D, PAGE 3, PART X THE HOSPITAL AND CPMP ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE CODE) AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501 (A) OF THE CODE. THE HOSPITAL AND CPMP RECOGNIZE THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. RECOGNIZED INCOME TAX POSITIONS ARE MEASURED AT THE LARGEST AMOUNT THAT IS GREATER THAN FIFTY PERCENT LIKELY OF BEING REALIZED UPON SETTLEMENT. CHANGES IN RECOGNITION IN MEASUREMENT ARE REFLECTED IN THE PERIOD IN WHICH THE CHANGE IN JUDGEMENT OCCURS. THE HOSPITAL AND CPMP DID NOT RECOGNIZE THE EFFECT OF ANY UNCERTAIN INCOME TAX POSITIONS IN EITHER 2015 OR 2014. SCHEDULE D, PAGE 4, PART XI, LINE 2D RENTAL EXPENSES 519,582 SCHEDULE D, PAGE 4, PART XI, LINE 4B GIFT AND BEQUESTS: 51,823 CHANGE OF FAIR MARKET VALUE OF INTEREST RATE SWAP 134,584 UNRESTRICTED ENDOWMENT INCOME: 20,372 REALIZED LOSS ON INVESTMENTS: -2,127 OTHER: 34,897 SCHEDULE D, PAGE 4, PART XII, LINE 2D RENTAL EXPENSES 519,582 true true true X true X true true false true true 621476 14287 607189 0.00420 15577499 718295 14859204 0.10180 16198975 732582 15466393 0.10600 207893 207893 0.00140 212718 212718 0.00150 36878 36878 0.00030 834 834 458323 458323 0.00310 16657298 732582 15924716 0.10910 749476 749476 0.00510 749476 749476 0.00510 true 1527636 466121 28840967 29439890 -598923 true true 1 1 CANTON-POTSDAM HOSPITAL 50 LEROY STREET POTSDAM NY 13676 WWW.CPHOSPITAL.ORG X X X CANTON-POTSDAM HOSPITAL 1 false false true X X X X X X X X X X 16 true true true true X WWW.CPHOSPITAL.ORG X true 14 false false false true X 100.000000000000 300.000000000000 true true X X X X true X WWWCPHOSPITALORG X WWWCPHOSPITALORG X WWWCPHOSPITALORG X X X X true X X true X X X X X X true X false true FACILITY 1, CANTON-POTSDAM HOSPITAL - PART V, LINE 3J SEE PART VI FACILITY 1, CANTON-POTSDAM HOSPITAL - PART V, LINE 5 SEE PART VI FACILITY 1, CANTON-POTSDAM HOSPITAL - PART V, LINE 6A SEE PART VI FACILITY 1, CANTON-POTSDAM HOSPITAL - PART V, LINE 6B SEE PART VI FACILITY 1, CANTON-POTSDAM HOSPITAL - PART V, LINE 15E SEE PART VI FACILITY 1, CANTON-POTSDAM HOSPITAL - PART V, LINE 22D SEE PART VI FACILITY 1, CANTON-POTSDAM HOSPITAL - PART V, LINE 24 SEE PART VI ADDITIONAL INFORMATION CANTON-POTSDAM HOSPITAL 2015-FORM 990, SCHEDULE H, SUPPLEMENTAL INFORMATION PART V, 20D: THE HOSPITAL USES THE HIGHEST VOLUME COMMERCIAL COVERAGE RATE, FROM BLUE CROSS/BLUE SHIELD, WHICH IS ALSO GENERALLY THE LOWEST RATE CHARGED. 1.REQUIRED DESCRIPTIONS: PART II -COMMUNITY BUILDING ACTIVITIES - THE AMOUNT REPORTED ON PART II LINE 8 REPRESENTS THE INVESTMENT MADE IN RECRUITING NEW HEALTHCARE PRACTITIONERS TO OUR SERVICE AREA DURING 2015. DUE TO ITS INDIGENT POPULATION AND RURAL NATURE, MUCH OF THE REGION SURROUNDING THE HOSPITAL IS DESIGNATED AS A MANPOWER SHORTAGE AREA. PART III, SECTION A, LINES 2 & 3 THE COSTS ON LINE 2 ARE BASED UPON THE MEDICARE ICR FOR 2015 APPLIED TO THE GROSS CHARGES WRITTEN OFF. THE COSTS ON LINE 3 WERE CALCULATED IN ACCORDANCE WITH THE COSTING METHODOLOGY EMPLOYED BY THE NYS DOH BAD DEBT COSTING PROCESS. PART III SECTION A, LINE 4 - PAGE 15 OF THE AUDITED FINANCIAL STATEMENTS (FN3-PATIENT ACCOUNTS RECEIVABLE AND RELATED ALLOWANCE FOR ESTIMATED UNCOLLECTIBLE ACCOUNTS). PART III SECTION B, LINE 8 - THE SHORTFALL CALCULATED ON LINE 7 OF 598,923 IS THE RECOGNIZED SHORTFALL BETWEEN MEDICARE COSTS AND MEDICARE REIMBURSEMENTS UTILIZING THE COST TO CHARGE RATIO AND INFORMATION PROVIDED ON THE ORGANIZATION'S 2015 MEDICARE COST REPORT. PART III SECTION C, LINE 9B - THE ORGANIZATION APPLIES THE SAME COLLECTION PRINCIPLES TO AMOUNTS DUE FROM PATIENTS WHO HAVE QUALIFIED FOR PERCENTAGE DISCOUNTS BUT STILL HAVE A RESPONSIBILITY FOR A PORTION OF THEIR BILL BASED UPON THE SLIDING FEE SCHEDULE. NO SEPARATE DISTINCTION IS MADE FOR THE APPLICATION OF OUR COLLECTION PROCESSES IN THOSE CASES. 2.NEEDS ASSESSMENT: PLEASE REFERENCE THE ABOVE REQUIRED DESCRIPTIONS, PART V SECTION B, LINES 5 AND 11B. 3.PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE: THE ORGANIZATION CONSPICUOUSLY POSTS ITS FINANCIAL ASSISTANCE POLICY IN EACH REGISTRATION/RECEPTION AREA. PATIENTS ARE ENCOURAGED TO APPLY FOR ASSISTANCE AND GIVEN CONTACT INFORMATION AT THESE AREAS. IN ADDITION, ANY PATIENT THAT IS UNINSURED AND ADMITTED TO THE HOSPITAL FOR CARE IS PHYSICALLY VISITED BY A FINANCIAL COUNSELOR, AND AN EXPLANATION OF OUR PROGRAM IS MADE ALONG WITH AN APPLICATION. PATIENTS REQUESTING ASSISTANCE IN THE COMPLETION OF THE APPLICATION ARE GIVEN SUCH. ANY INFORMATION REQUIRED FOR APPLICATION FOR THE NYS MEDICAID APPLICATION PROCESS IS COLLECTED BY OUR FINANCIAL CASE MANAGERS AND COMMUNICATED TO THE APPROPRIATE CASE MANAGERS AT OUR COUNTY DEPARTMENT OF SOCIAL SERVICES FOR DETERMINATION OF MEDICAID ELIGIBILITY. 4.COMMUNITY INFORMATION: CANTON-POTSDAM HOSPITAL IS LOCATED IN ST. LAWRENCE COUNTY IN UPSTATE NEW YORK. ST. LAWRENCE COUNTY, THE LARGEST COUNTY IN NEW YORK, IS LOCATED IN THE NORTHERNMOST REACHES OF THE STATE BORDERING ON THE ST. LAWRENCE RIVER AND CANADA. IT IS A RURAL ENVIRONMENT CONSISTING OF 2,685 SQUARE MILES WITH A POPULATION OF APPROXIMATELY 112,000 RESIDENTS. CANTON-POTSDAM HOSPITAL'S PRIMARY SERVICE AREA INCLUDES APPROXIMATELY 55,000 PEOPLE LIVING IN THE COMMUNITIES OF POTSDAM, CANTON AND NEARBY SMALLER COMMUNITIES AND INCLUDES THE STUDENT POPULATION OF FOUR COLLEGES IN CANTON AND POTSDAM. THE SECONDARY SERVICE AREA FOR THE HOSPITAL IS PREDOMINANTLY THE REMAINING COMMUNITIES WITHIN ST. LAWRENCE COUNTY WITH SOME RESIDENTS OF THE WESTERN FRANKLIN COUNTY AREA BEING SERVED. 5.PROMOTION OF COMMUNITY HEALTH: AT THE 2015 HEALTH FAIRS, THE IMAGING DEPARTMENT PROVIDED FREE HEEL BONE DENSITY SCREENING EXAMS TO THE COMMUNITY. THE APPROXIMATE COST FOR THIS SERVICE WAS 21,115. IN ADDITION TO THESE SCREENINGS, THE HOSPITAL HOSTS AND ATTENDS NUMEROUS HEALTH FAIRS THROUGHOUT THE YEAR, ALONG WITH HOSTING EVENTS SUCH AS "ASK THE PHYSICIAN", "PARTNERING IN YOUR CARE" LUNCHEONS AND WOMEN'S WELLNESS DAY EVENTS. THE APPROXIMATE VALUE OF THESE EFFORTS WAS 18,509. THE CHEMICAL DEPENDENCY DEPARTMENT OF THE HOSPITAL DONATED TIME AS COUNSELORS TO THE COUNTY JAIL, SPOKE ABOUT CHEMICAL DEPENDENCY AT THE LOCAL COLLEGES, ATTENDS DRUG COURT TO ASSIST WITH CASES AND TREATMENT OPTIONS AND HOSTS OTHER SPEAKING/EDUCATIONAL ENGAGEMENTS. THE TOTAL ESTIMATED COST OF THIS TIME IS 41,872. THE HOSPITAL'S LIFELINE DEPARTMENT HAS PROVIDED THE COMMUNITY WITH 136 FREE LIFELINE INSTALLS. THE TOTAL COST OF THESE INSTALLS FOR 2015 WAS 4,352. THE HOSPITAL'S BIRTHPLACE PROVIDES CHILDBIRTH CLASSES, BREASTFEEDING CLASSES, EARLY PREGNANCY CLASSES AND INFANT CPR CLASSES. THE APPROXIMATE 2015 COST ASSOCIATED WITH THESE BENEFITS WAS 20,000. THE HOSPITAL CONDUCTS A BREAST CANCER SUPPORT GROUP ONCE A MONTH, AS WELL AS SPONSORS A CANCER SURVIVOR'S DAY AND BREAST CANCER SURVIVOR DINNER. THE HOSPITAL CONDUCTS PERIODIC FREE CANCER SCREENINGS AND PROVIDES THE COMMUNITY INFORMATION AT A VARIETY OF EVENTS. THE TOTAL APPROXIMATE COST OF THESE BREAST CANCER EDUCATION AND AWARENESS ACTIVITIES FOR 2015 WAS 7,156. ADDITIONALLY 18 FREE MAMMOGRAMS WERE CONDUCTED, FOR AN APPROXIMATE VALUE OF 7,776. 6.AFFILIATED HEALTH CARE SYSTEM: ST. LAWRENCE HEALTH SYSTEM, FORMED DECEMBER 5, 2013, IS OPERATED EXCLUSIVELY FOR THE SOLE CHARITABLE PURPOSE OF BENEFITING AND SUPPORTING CANTON-POTSDAM HOSPITAL AND OTHER CORPORATIONS. AMONG OTHER BENEFITS, THE HEALTH SYSTEM MAY PROVIDE ADVICE AND ASSISTANCE CONCERNING LONG AND SHORT- RANGE PLANNING FOR, AND MONITOR AND PROVIDE ADVICE AND ASSISTANCE TO HELP COORDINATE THE ACTIVITIES OF THE SUPPORTED ORGANIZATION IN ELIMINATING DUPLICATIVE FUNCTIONS; PROVIDE MANAGEMENT CONSULTING ASSISTANCE TO THE SUPPORTED ORGANIZATION TO FURTHER IMPROVE AND ADVANCE HEALTH SERVICES TO THE RESIDENTS OF NEW YORK STATE AND COOPERATE WITH THE SUPPORTING ORGANIZATIONS IN CARRYING OUT THEIR CHARITABLE PURPOSES. 7.STATE FILING OF COMMUNITY BENEFIT REPORT: OUR COMMUNITY BENEFIT REPORT IS FILED ANNUALLY WITH NEW YORK STATE. PART V, SECTION B, LINE 24 - IT IS THE HOSPITAL'S POLICY TO CHARGE ITS GROSS CHARGE TO ALL PATIENTS AND/OR THEIR INSURANCE. TO THE EXTENT THE PATIENT QUALIFIES FOR DISCOUNT, IT IS APPLIED ACCORDINGLY. PART V SECTION B, LINE 5 - (IN CONDUCTING ITS MOST RECENT CHNA, DESCRIBE HOW THE HOSPITAL TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE COMMUNITY, AND IDENTIFY THE PERSONS THE HOSPITAL FACILITY CONSULTED) CANTON-POTSDAM HOSPITAL'S (CPH'S) MOST RECENT CHNA WAS CONDUCTED BY ITS NEW YORK STATE DSRIP PPS, ADIRONDACK HEALTH INSTITUTE, AS WELL AS ITS LOCAL PARTNERS, THE ST. LAWRENCE COUNTY PUBLIC HEALTH DEPARTMENT AND THE ST. LAWRENCE HEALTH INSTITUTE. CPH PARTICIPATES AT THE BOARD LEVEL ON THE ST. LAWRENCE HEALTH INITIATIVE, A NOT-FOR-PROFIT ORGANIZATION COORDINATING HEALTH ASSESSMENT AMONG ALL AREA HEALTH FACILITIES. THIS ORGANIZATION AND OUR DSRIP PPS PROVIDE FORMAL ONGOING COORDINATION OF NEEDS ASSESSMENT AND PROGRAMMING. THE CHNA WAS COMPLETED IN 2016 AND TAKES INTO ACCOUNT INPUT FROM PERSONS REPRESENTING THE COMMUNITY PRIMARILY THROUGH A TELEPHONE AND WEB SURVEY CONDUCTED IN THE SUMMER OF 2016 WITH 679 RESPONDENT RESIDENTS OF THE THREE-COUNTY REGION OF ST. LAWRENCE, LEWIS, AND JEFFERSON. CPH ALSO SEEKS INPUT FORMALLY THROUGH AN ANNUAL FORUM WITH COMMUNITY LEADERS FROM ALL ACROSS OUR PRIMARY AND SECONDARY SERVICE AREAS, FREQUENT MEETINGS WITH PUBLIC HEALTH OFFICIALS, LOCAL COLLEGE PRESIDENTS, THE LEADERS OF OTHER AREA HEALTH FACILITIES, AND LOCAL GOVERNMENT OFFICIALS. ADDITIONAL INPUT WAS GATHERED FROM HOSPITAL AND HOSPITAL SYSTEM BOARD MEMBERS REPRESENTING PUBLIC HEALTH, DENTISTRY, HOSPICE AND PALLIATIVE CARE, VETERINARY HEALTH, AREA COLLEGES, AND AREA BUSINESSES. CPH PARTNERED IN LATE 2015 WITH THE ST. LAWRENCE COUNTY COMMUNITY DEVELOPMENT PROGRAM, WHICH OPERATES FOOD BANKS IN OUR SERVICE AREA, TO OFFER HEALTH SERVICES AND TO SEEK INPUT FROM THOSE SERVED BY THE FOOD BANKS. INPUT IS ALSO SOUGHT THROUGH THE HOSPITAL'S AND SYSTEM'S AUXILIARY GROUPS, AND FORUMS WITH ITS VOLUNTEERS, COMPRISING STUDENTS, THE ELDERLY, AND THOSE LIVING WITH DISABILITIES. IN 2013, A PATIENT ADVISORY GROUP WAS FORMED. THIS GROUP PROVIDES INVALUABLE FEEDBACK ON THE PATIENT EXPERIENCE AND COMMUNITY NEEDS. PART V, SECTION B, LINE 6A&B - CANTON-POTSDAM HOSPITAL'S CHNA WAS AUTHORED BY THE HOSPITAL USING DATA GATHERED BY THE ADIRONDACK HEALTH INSTITUTE (REPRESENTING A NINE-COUNTY NORTHERN NY REGION WHICH INCLUDES ST. LAWRENCE COUNTY) AND DATA GATHERED FOR ST. LAWRENCE, LEWIS, AND JEFFERSON COUNTIES ON BEHALF OF THE ST. LAWRENCE HEALTH INSTITUTE. PART V SECTION B, LINE 11 - (DESCRIBE HOW THE FACILITY IS ADDRESSING THE SIGNIFICANT NEEDS IDENTIFIED IN ITS MOST RECENTLY CONDUCTED CHNA AND ANY SUCH NEEDS THAT ARE NOT BEING ADDRESSED TOGETHER WITH THE REASONS WHY SUCH NEEDS ARE NOT BEING ADDRESSED.) CANTON-POTSDAM HOSPITAL'S CHNA IDENTIFIED CHRONIC DISEASE PREVENTION AND MANAGEMENT AND MENTAL, EMOTIONAL, AND BEHAVIORAL (MEB) HEALTH AS THE TWO HIGHEST PRIORITY AREAS NEEDING TO BE ADDRESSED. WITHIN THESE AREAS, CHILD AND ADOLESCENT OBESITY, HEART FAILURE, DIABETES, AND COPD WERE IDENTIFIED AS THE MOST PRESSING NEEDS IN CHRONIC DISEASE MANAGEMENT; SUBSTANCE ABUSE AND SUICIDE PREVENTION WERE IDENTIFIED AS TOP NEEDS IN THE MEB HEAL X X X X X false false false false false false false false false DAVID ACKER PRESIDENT & CEO 506380 2594 86050 14600 609624 RICHARD JACOBS VP FOR FINANCE/CFO 278876 18442 9822 307140 JEFFREY HAASBEEK MD PHYSICIAN 806965 13250 31200 851415 XIAOSONG SONG MD PHYSICIAN 778955 13250 18562 810767 KRIS VANWAGNER MD PHYSICIAN 755513 13250 8964 777727 JOHN SAVAGE MD PHYSICIAN 682509 13250 17440 713199 MARCO BERARD MD PHYSICIAN 679359 4844 25112 709315 SCHEDULE J, PART III THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS SEEKS THE INPUT OF A CONSULTING FIRM WITH NATIONAL EXPERIENCE TO REVIEW THE COMPENSATION PACKAGES OFFERED TO TOP MANAGEMENT AND THE REGULATORY COMPLIANCE ISSUES OF NOT-FOR-PROFITS. UPON THE FINDINGS OF THE CONSULTANT AND DELIBERATIONS OF THE COMPENSATION COMMITTEE, THE COMMITTEE WILL THEN MAKE A RECOMMENDATION TO THE FULL BOARD. THE FULL BOARD WILL THEN VOTE ON THE TOP OFFICIAL'S COMPENSATION PACKAGE. THE COMPENSATION OF OTHER KEY EMPLOYEES IS DETERMINED PRIMARILY BY THE WORK OF THE HUMAN RESOURCE DEPARTMENT, THE RECOMMENDATION OF THE VICE PRESIDENT OF HUMAN RESOURCES (HR), AND BY INFORMATION GATHERED FROM INDEPENDENT SURVEY DATA OF NATIONAL AND SURROUNDING MARKETS. THE VICE PRESIDENT OF HUMAN RESOURCES WILL REVIEW THE SURVEY DATA TO ESTIMATE SALARY RANGES AND COMPENSATION PACKAGES. THE VP OF HR MAKES THE RECOMMENDATION TO THE CEO. THE CEO WILL BRING THE INFORMATION TO THE COMPENSATION COMMITTEE. AFTER DELIBERATIONS AND CONSIDERATIONS, THE COMPENSATION COMMITTEE WITH THEN BRING THEIR RECOMMENDATION TO THE FULL BOARD FOR THEIR FINAL APPROVAL. A ST LAWRENCE COUNTY IDC 272614310 2010-08-30 21305500 SEE PART VI false true false A 5535000 20921703 11168176 9590000 2011 true false false true A false false false false false false true A false true false false true false false false true A true SCHEDULE K - ADDITIONAL INFORMATION ST. LAWRENCE COUNTY IDC CANTON-POTSDAM HOSPITAL FOUNDATION, INC. EIN: 16-1279472 ATTACHMENT TO FORM 990, SCHEDULE K PART VI - SUPPLEMENTAL INFORMATION PART I, LINE A THIS FINANCING CONSISTS OF TWO SERIES OF BONDS - THE 17,720,000 ST. LAWRENCE COUNTY INDUSTRIAL DEVELOPMENT AGENCY CIVIC DEVELOPMENT CORPORATION REVENUE BONDS (CANTON-POTSDAM HOSPITAL), SERIES 2010 (THE "HOSPITAL BONDS") AND 3,585,000 ST. LAWRENCE COUNTY INDUSTRIAL DEVELOPMENT AGENCY CIVIC DEVELOPMENT CORPORATION REVENUE BONDS (CANTON-POTSDAM HOSPITAL FOUNDATION, INC.), SERIES 2010 (THE "FOUNDATION BONDS-; THE FOUNDATION BONDS AND THE HOSPITAL BONDS ARE HEREINAFTER JOINTLY REFERRED TO AS THE "BONDS"). PROCEEDS OF THE HOSPITAL BONDS WERE USED TO FINANCE THE CONSTRUCTION AND EQUIPPING OF HEALTH CARE FACILITIES OWNED BY CANTON-POTSDAM HOSPITAL (THE "HOSPITAL"), AND TO REFUND OUTSTANDING TAX-EXEMPT OBLIGATIONS ISSUED AUGUST 20, 2002 TO FINANCE HOSPITAL FACILITIES. PROCEEDS OF THE FOUNDATION BONDS WERE ISSUED TO FINANCE THE ACQUISITION, CONSTRUCTION AND EQUIPPING OF MEDICAL FACILITIES OWNED BY CANTON-POTSDAM HOSPITAL FOUNDATION, INC. (THE "FOUNDATION") WHICH ARE LEASED TO THE HOSPITAL. THE HOSPITAL BONDS AND FOUNDATION BONDS WERE SOLD AT THE SAME TIME PURSUANT TO A COMMON PLAN OF FINANCING AND WILL BE PAID OUT OF SUBSTANTIALLY THE SAME SOURCE OF FUNDS. THEREFORE, PURSUANT TO TREASURY REGULATION SECTION 1.150-1(C), THE HOSPITAL BONDS AND THE FOUNDATION BONDS ARE TREATED AS A SINGLE ISSUE OF BONDS FOR TAX PURPOSES, IN THE AGGREGATE PRINCIPAL AMOUNT OF 21,305,000. CONSISTENT WITH THE CHARACTERIZATION OF THE BONDS AS A SINGLE ISSUE FOR TAX PURPOSES, THE HOSPITAL BONDS AND FOUNDATION BONDS ARE REPORTED AS A SINGLE ISSUE ON SCHEDULE K TO THE HOSPITAL'S FORM 990. PART II, LINE 3 - TOTAL PROCEEDS OF ISSUE THE BONDS WERE ORIGINALLY ISSUED AS "DRAW-DOWN BONDS" IN THE MAXIMUM PRINCIPAL AMOUNT OF 21,305,000, WHICH REPRESENTS THE ORIGINAL ISSUE PRICE OF THE BONDS REPORTED ON IRS FORM 8038. ULTIMATELY, ONLY 20,921,703 OF BOND PROCEEDS WERE ACTUALLY DRAWN. PART II, LINE 11 - OTHER SPENT PROCEEDS PROCEEDS OF THE BONDS IN THE PRINCIPAL AMOUNT OF 9,590,000 WERE SPENT ON SEPTEMBER 27, 2010 TO REDEEM CERTAIN OUTSTANDING TAX-EXEMPT BONDS ISSUED AUGUST 20, 2002 TO FINANCE HOSPITAL FACILITIES. SEE PART V false SCHEDULE L, PART V 2015 FORM 990, SCHEDULE L PART IV, SUPPLEMENTAL RESPONSE OUR ORGANIZATION HAS BUSINESS TRANSACTIONS INVOLVING CERTAIN MEMBERS OF OUR BOARD OF DIRECTORS, WHICH ARE DETAILED BELOW: 1.KATHRYN MULLANEY, OUR BOARD TREASURER, RETIRED AS THE VICE PRESIDENT FOR FINANCE AT ST. LAWRENCE UNIVERSITY (SLU)IN 2014. OUR ORGANIZATION PROVIDES HEALTHCARE SERVICES AND STAFFS A CLINIC ON THE SLU CAMPUS. THE OPERATION COSTS OF THAT CLINIC IN 2015 WERE APPROXIMATELY 614,361 WHICH WERE REIMBURSED BY SLU ON A PASS THROUGH BASIS. 2.MICHAEL GRIFFIN AND PAUL MCGRATH, BOARD MEMBERS, ARE EMPLOYEES OF CLARKSON UNIVERSITY (CU). DONALD DANGREMOND RETIRED FROM CLARKSON UNIVERSITY AS OF JUNE 30, 2015. OUR ORGANIZATION PROVIDES HEALTHCARE SERVICES AND STAFFS A CLINIC ON THE CU CAMPUS. THE OPERATION COSTS OF THAT CLINIC IN 2015 WERE APPROXIMATELY 331,760 WHICH WERE REIMBURSED BY CU ON A PASS THROUGH BASIS. 3.DR. MICHAEL TULLOCH, BOARD MEMBER, IS CONTRACTED TO PERFORM INTERPRETATIONS OF CARDIOLOGY SERVICES PROVIDED AT OUR FACILITY. HE WAS COMPENSATED 120,809 FOR THIS SERVICE IN 2015. HIS PAYMENT FOR PROFESSIONAL SERVICES IS BASED ON A PER PROCEDURE FEE STRUCTURE. 4.BRIAN GARDAM, BOARD MEMBER, IS ALSO THE EXECUTIVE DIRECTOR OF HOSPICE OF PALLIATIVE CARE OF ST. LAWRENCE VALLEY (HOSPICE). CANTON-POTSDAM HOSPITAL CONTRACTS WITH HOSPICE FOR INPATIENT HOSPICE SERVICES FOR SYMPTOM MANAGEMENT AND PAIN CONTROL. IN 2015, 5,690 WAS REMITTED TO HOSPICE FOR THESE SERVICES. CANTON-POTSDAM HOSPITAL ALSO REMITTED TO HOSPICE 2,000 TO SUPPORT THE TASTE OF SPRING AND TASTE OF AUTUMN ANNUAL HOSPICE FUNDRAISERS. 5.JAMES THEODORE, BOARD MEMBER, IS ALSO THE MORGAN STANLEY SMITH BARNEY LLC FINANCIAL ADVISOR FOR AN ACCOUNT HELD IN THE NAME OF CANTON-POTSDAM HOSPITAL FOUNDATION, INC. (A RELATED TAX-EXEMPT ORGANIZATION). THIS FOUNDATION ACCOUNT IS USED AS A PASS-THROUGH FOR DONATIONS OF STOCK. THE BALANCE IN THIS ACCOUNT AS OF DECEMBER 31, 2015 WAS 0. 6.DURING 2010, BOND ISSUES WERE OBTAINED FOR CANTON-POTSDAM HOSPITAL FROM COMMUNITY BANK, NA AND KEY BANK, AS DISCLOSED IN SCHEDULE K. THE COMMUNITY BANK, NA PORTION OF THESE BOND ISSUES WERE IN THE AMOUNT OF 3,585,000. IN 2011, THE HOSPITAL WAS ISSUED A MORTGAGE BY COMMUNITY BANK, NA FOR CONSTRUCTION OF THE E.J. NOBEL ANNEX BUILDING, IN THE AMOUNT OF 2,200,000. EDWARD MUCENSKI, BOARD MEMBER, IS A BOARD MEMBER OF COMMUNITY BANK, NA. AS OF DECEMBER 31, 2015 THE HOSPITAL WAS CURRENT ON ANY OBLIGATIONS DUE TO THE BANK. 7.BOARD MEMBER JUNE PEOPLES IS EMPLOYED BY NORTH COUNTRY PUBLIC RADIO (NCPR) AS DIRECTOR OF GIVING AND FINANCE. NCPR HAS A LIFETIME LEASE AT THE HOSPITAL'S MEDICAL OFFICE BUILDING IN CANTON, NEW YORK. 8.BOARD MEMBER MARK CORNETT IS A CONSULTANT EMPLOYED BY SLIC NETWORK SOLUTIONS. SLIC RENTS OFFICE SPACE AT THE HOSPITAL'S MEDICAL OFFICE BUILDING IN CANTON, NEW YORK. CANTON-POTSDAM HOSPITAL REMITTED APPROXIMATELY 161,577 TO SLIC IN 2015 FOR TELECOMMUNICATION SERVICES. 9. DR. FLORENCE BERO, BOARD MEMBER, IS IN PRACTICE WITH CANTON FAMILY PHYSICIANS WHICH LEASES SPACE FROM CANTON-POTSDAM HOSPITAL AT THE E.J. NOBLE BUILDING IN CANTON, NY. IN 2015, 47,898 WAS REMITTED TO CANTON- POTSDAM HOSPITAL FOR LEASED SPACE. FORM 990, PAGE 2, PART III, LINE 4D ONCOLOGY SERVICES: IN 2015, THE ONCOLOGY VISITS DECREASED APPROXIMATELY 6.7% FROM 2014. THIS DECREASE IS ATTRIBUTABLE TO A TURNOVER OF PHYSICIANS. AUGUST 2016 YTD STATISTICS INDICATE AN 8% INCREASE OVER BUDGETED 2016 VISITS AND AN APPROXIMATE 18% INCREASE IN VISITS YEAR TO DATE COMPARED WITH 2015. FORM 990, PAGE 6, PART VI, LINE 11B THE FORM 990 IS PREPARED BY THE FINANCE DEPARTMENT STAFF MEMBERS. UPON COMPLETION, A COPY WITH SUPPORTING DOCUMENTATION IS REVIEWED BY THE VICE PRESIDENT FOR FINANCE AND THE CONTROLLER. AFTER REVIEW, ANY CHANGES ARE MADE AND A COPY IS PRESENTED TO THE FINANCE COMMITTEE. THE FINANCE COMMITTEE WILL THEN REVIEW AND MAY REQUEST CHANGES TO THE FORM. ONCE THE CHANGES ARE IMPLEMENTED, THE FORM 990 IS SUBMITTED TO THE FULL BOARD OF DIRECTORS FOR THEIR REVIEW, COMMENTS AND APPROVAL. FORM 990, PAGE 6, PART VI, LINE 12C BOARD MEMBER CONFLICT OF INTEREST DISCLOSURE FORMS ARE COMPLETED AND REVIEWED BY THE BOARD ANNUALLY. FORM 990, PAGE 6, PART VI, LINE 15A LINE 15A: THE AUDIT, COMPLIANCE, AND COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS UTILIZES THE INPUT OF A NATIONAL CONSULTING FIRM WITH EXPERTISE IN EXECUTIVE COMPENSATION TO REVIEW THE COMPENSATION PACKAGES OFFERED TO TOP MANAGEMENT AS WELL AS OUR COMPLIANCE WITH REGULATORY REQUIREMENTS FOR EXECUTIVE COMPENSATION FOR NOT-FOR-PROFIT HOSPITALS. UPON THE FINDINGS OF THE CONSULTANT AND DELIBERATIONS OF THE AUDIT, COMPLIANCE, AND COMPENSATION COMMITTEE, THE COMMITTEE WILL THEN MAKE A RECOMMENDATION TO THE FULL BOARD. THE FULL BOARD WILL THEN VOTE ON THE TOP OFFICIAL'S COMPENSATION PACKAGE. FORM 990, PAGE 6, PART VI, LINE 15B LINE 15B: THE COMPENSATION OF OTHER KEY EMPLOYEES IS DETERMINED PRIMARILY BY INFORMATION GATHERED FROM INDEPENDENT SURVEY DATA FROM NATIONAL AND SURROUNDING MARKETS COORDINATED BY THE HUMAN RESOURCE DEPARTMENT. THE CEO AND VICE PRESIDENT OF HUMAN RESOURCES REVIEW THE SURVEY DATA TO DETERMINE SALARY RANGES AND COMPENSATION PACKAGES. THE CEO BRINGS THE INFORMATION AND FINDINGS TO THE AUDIT, COMPLIANCE, AND COMPENSATION COMMITTEE OF THE BOARD FOR THEIR DELIBERATION AND CONSIDERATION. THE AUDIT, COMPLIANCE, AND COMPENSATION COMMITTEE WITH THEN BRING THEIR RECOMMENDATION TO THE FULL BOARD FOR THEIR FINAL APPROVAL. FORM 990, PAGE 6, PART VI, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9 CONTRIBUTIONS FOR CAPITAL 334,125 TEMPORARILY RESTRICTED CONTRIBUTIONS FOR CAPITAL 197,114 CHANGE IN INTEREST IN NET ASSETS OF CPH FOUNDATION -389,342 CHANGE IN FUNDED STATUS OF EMPLOYEE BEN PLAN 93,268 CAPITAL CAMPAIGN GIFTS -190,709 TRANSFER TO GOUVERNEUR HOSPITAL -1,000,000 TRANSFER TO ST. LAWRENCE HEALTH SYSTEM -1,326,465 TRANSFER TO AFFILIATE (CANTON POTSDAM MEDICAL PRAC -1,650,435 TOTAL -3,932,444 CANTON-POTSDAM HOSPITAL FOUNDATION 29 GROVE STREET POTSDAM NY 13676 161279472 PART VII NY 501C3 11A SLHS false CANTON-POTSDAM MEDICAL PRACTICEPLLC PLLC 50 LEROY STREET POTSDAM NY 13676 460714367 PART VII NY 501C3 SLHS true ST LAWRENCE HEALTH SYSTEM 50 LEROY STREET POTSDAM NY 13676 464259168 PART VII NY 501C3 11A N/A false NORTHERN LIGHTS HEALTHCARE PARTNERS 732 FORD STREET OGDENSBURG NY 13669 462500951 PART VII NY 501C3 N/A false GOUVERNEUR HOSPITAL INC 77 W BARNEY STREET GOUVERNEUR NY 13642 464249555 HOSPITAL NY 501C3 SLHS false false true false false false false false false false true true false true false false true true true false CANTON-POTSDAM MEDICAL PRACTICE PLLC J 4206155 FMV ST LAWRENCE HEALTH SYSTEM INC B 3172616 CASH EXCHANGED CANTON-POTSDAM HOSPITAL FOUNDATION J 8923 CASH EXCHANGED CANTON-POTSDAM MEDICAL PRACTICE PLLC J 133750 FMV GOUVERNEUR HOSPITAL INC J 1411728 FMV GOUVERNEUR HOSPITAL INC K 527132 FMV CANTON-POTSDAM HOSPITAL FOUNDATION K 554270 CASH EXCHANGED CANTON-POTSDAM HOSPITAL FOUNDATION M 104272 CASH EXCHANGED CANTON-POTSDAM HOSPITAL FOUNDATION P 111716 CASH EXCHANGED CANTON-POTSDAM HOSPITAL FOUNDATION Q 198504 CASH EXCHANGED ST LAWRENCE HEALTH SYSTEM INC Q 1846151 CASH EXCHANGED CANTON-POTSDAM HOSPITAL FOUNDATION R 80066 CASH EXCHANGED SCHEDULE R CANTON-POTSDAM HOSPITAL FOUNDATION IS RESPONSIBLE FOR RAISING, INVESTING AND MANAGING FUNDS FOR THE HOSPITAL. CANTON-POTSDAM MEDICAL PRACTICE, PLLC PROVIDES PHYSICIAN SERVICES IN AN OUTPATIENT CLINIC SETTING AS BENEFIT TO THE COMMUNITY AND HOSPITAL. ST. LAWRENCE HEALTH SYSTEM, FORMED DECEMBER 5, 2013, IS OPERATED EXCLUSIVELY FOR THE SOLE CHARITABLE PURPOSE OF BENEFITING AND SUPPORTING CANTON-POTSDAM HOSPITAL AND OTHER AFFILIATED CORPORATIONS. NORTHERN LIGHTS HEALTH CARE PARTNERSHIP, INC. OPERATES A CERTIFIED HOME HEALTH AGENCY. GOUVERNEUR HOSPITAL, INC., A NOT-FOR-PROFIT ORGANIZATION, IS THE AFFILIATE OF CANTON-POTSDAM HOSPITAL, AND SUPPORTED BY THE PARENT ORGANIZATION OF ST. LAWRENCE HEALTH SYSTEM.