2015-11-13T11:06:14-06:00 2014-12-31 161226221 FUST CHARLES CHAMBERS LLP 5784 WIDEWATERS PARKWAY SYRACUSE NY 13214 990 2014-01-01 150533577 SAMARITAN MEDICAL CENTER SAMA 3157855702 830 WASHINGTON STREET WATERTOWN NY 13601 SEAN MILLS CFO 3157855702 2015-11-10 1 JOSEPH J SCHLEGEL P00301329 3154463600 2014 2016-02-25 16:41:14Z SEAN MILLS 830 WASHINGTON STREET WATERTOWN NY 13601 208992989 0 X WWW.SAMARITANHEALTH.COM X 1881 NY SAMARITAN MEDICAL CENTER OPERATES AN ACUTE CARE HOSPITAL FACILITY IN WATERTOWN, NEW YORK, SERVING JEFFERSON, OSWEGO AND ST. LAWRENCE COUNTIES. THIS 294-BED FACILITY PROVIDES INPATIENT CARE, PSYCHIATRIC SERVICES, AMBULATORY SURGERY, PRIMARY AND EMERGENCY CARE AND OTHER OUTPATIENT SERVICES. 20 18 1861 135 0 0 2341867 3682489 199441080 201928287 264368 506011 2616398 2796024 204663713 208912811 0 0 0 0 111540486 110353204 0 0 302667 86332314 90125094 197872800 200478298 6790913 8434513 205390346 205193081 104734085 109525554 100656261 95667527 X SAMARITAN MEDICAL CENTER OPERATES AN ACUTE CARE HOSPITAL FACILITY IN WATERTOWN, NEW YORK, SERVING JEFFERSON, OSWEGO AND ST. LAWRENCE COUNTIES. THIS 294-BED FACILITY PROVIDES INPATIENT CARE, PSYCHIATRIC SERVICES, AMBULATORY SURGERY, PRIMARY AND EMERGENCY CARE AND OTHER OUTPATIENT SERVICES. 0 0 169680837 204592870 PROVIDE CARE FOR 10,730 INPATIENT DISCHARGES IN ADDITION, SAMARITAN MEDICAL CENTER PROVIDED FOR 156,096 OUTPATIENT VISITS, 53,986 EMERGENCY ROOM VISITS, AND 105,358 FAMILY HEALTH CLINIC VISITS. 169680837 1 1 0 0 0 0 0 0 0 1 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 150 0 1 1861 1 0 0 0 0 0 0 0 0 0 0 X 20 18 0 0 1 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X SEAN MILLS 3157796686 104 PADDOCK STREET WATERTOWN NY 13601 PAUL KRAEGER TREASURER, SR. VP OF FINANCE 17.50 2.50 X X 148823 0 10636 DAVID FLINT MD TRUSTEE 40.00 X 325122 0 39319 DAVID RECHLIN DO TRUSTEE 40.00 X 241697 0 7821 JACK RUSH MD TRUSTEE 40.00 X 192261 0 28682 ROBERT KIMBALL MD TRUSTEE 1.00 40.00 X 355257 0 39021 ALFRED CALLIGARIS CHAIRMAN OF FINANCE 1.00 X X 0 0 0 PAUL CARR TRUSTEE 1.00 X 0 0 0 BRUCE DINES DMD TRUSTEE 1.00 X 0 0 0 REV FRED GARRY VICE CHAIR 1.00 X X 0 0 0 KATHLEEN GEBO TRUSTEE 1.00 X 0 0 0 COL MATTHEW MATTNER TRUSTEE 1.00 X 0 0 0 MELANIE PARKER-GUERTSEN SECRETARY 1.00 X X 0 0 0 RONALD PERCIACCANTE MD TRUSTEE 1.00 X 0 0 0 MARY PERRINE TRUSTEE 1.00 X 0 0 0 CATHERINE BURNS QUENCER TRUSTEE 1.00 X 0 0 0 DANIEL SAMANN TRUSTEE 1.00 X 0 0 0 ROBERT SEAMAN TRUSTEE 1.00 X 0 0 0 WALTER TODD TRUSTEE 1.00 X 0 0 0 JOAN TREADWELL-WOODS TRUSTEE 1.00 X 0 0 0 JAN TURCOTTE MD TRUSTEE 1.00 X 0 0 0 DANIEL VILLA TRUSTEE 1.00 X 0 0 0 KERRY ROBERGE TRUSTEE 1.00 X 0 0 0 RENEE WATERBURY TRUSTEE 1.00 X 0 0 0 LISA WEBER CHAIR 1.00 X X 0 0 0 MARTIN YENAWINE TRUSTEE 1.00 X 0 0 0 THOMAS H CARMAN PRESIDENT & CEO 40.00 4.00 X 527267 0 112492 SEAN MILLS CFO 40.00 3.50 X 174990 0 20258 MICHAEL SHORT CIO 40.00 1.00 X 199505 0 25525 MARIO VICTORIA CMO 40.00 1.00 X 415486 0 39315 BRIAN O'HEARN VP PATIENT CARE/CNO 40.00 X 228792 0 33241 ANTHONY JOSEPH VP LONG TERM CARE 40.00 1.00 X 180531 0 30892 ALEJANDRO RODRIGUEZ MD UROLOGIST 40.00 X 697447 0 39320 JOSEPH WETTERHAHN MD FAMILY PRACTICE MD 40.00 X 495327 0 38898 MOONJOHN KIM MD INTERVENTIONAL RADIOLOGIST 40.00 X 566412 0 39474 SHAHANDEH HAGHIR MD PATHOLOGIST 40.00 X 440602 0 34530 BRADFORD BILICKI SURGEON 1.00 40.00 X 410328 0 39327 5599847 0 578751 111 0 1 0 JEFFERSON ANESTHESIOLOGIST SERVICES 826 WASHINGTON ST WATERTOWN NY 13601 ANESTHESIA SERVICES 2579946 NORTH COUNTRY ORTHOPAEDIC GROUP 1571 WASHINGTON ST WATERTOWN NY 13601 PURCHASED SERVICES 1063829 LOCUMTENENSCOM PO BOX 405547 ATLANTA GA 30384 PURCHASED SERVICES 814936 NORTH COUNTRY EMERGENCY MEDICAL CONSULTA 830 WASHINGTON ST WATERTOWN NY 13601 PURCHASED SERVICES 597780 NEUROSURGICAL ASSOCIATES OF CNY 750 EAST ADAMS ST SYRACUSE NY 13211 PURCHASED SERVICES 512333 30 112959 2065979 1503551 3682489 PATIENT SERVICE REVENUE 623000 201928287 201928287 201928287 354763 354763 131441 0 131441 131441 131441 1594 229832 0 80178 1594 149654 151248 151248 SOLD SERVICES 541900 1892532 1892532 CAFETERIA 722210 715760 715760 56291 56291 2664583 208912811 204592870 0 637452 2982715 834902 2147813 84070269 73174633 10848514 47122 6066622 5180109 886513 11164672 9481279 1622606 60787 6068926 5182076 886850 827424 11495 815929 154223 137412 16811 355765 354648 1117 1987389 398451 1553154 35784 2922350 2062803 824345 35202 3967382 3194478 772904 185085 71274 109272 4539 186100 34213 144086 7801 595204 542707 52497 239993 239993 11659450 10631659 1027791 1681913 1081224 600689 SUPPLIES 27222811 26828805 370213 23793 OTHER EXPENSES 21100577 15252467 5779089 69021 PROVISION FOR BAD DEBT 10259973 10259973 EQUIP REPAIR & MAINT 5196692 3520878 1675124 690 1582763 1582763 200478298 169680837 30494794 302667 5684 5832 31370909 36708575 28806482 25183338 2081965 2224336 2587049 2911051 262289625 154467110 112962017 107822515 2341360 2502930 18162004 20200130 7072876 7634374 205390346 205193081 29223310 31068692 50164974 48624891 25345801 29831971 104734085 109525554 X 98604838 93141304 1176952 1651752 874471 874471 100656261 95667527 205390346 205193081 X 8434513 4676 -13427922 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2051423 1474414 999614 2526223 2910899 657922 1517398 2051423 9761548 147073 6997722 2910899 9720908 1183545 1142905 9761548 1686419 8606970 572481 9720908 0.34620 0.65380 0 0 1099952 1099952 123805625 41250098 82555527 3363765 2331842 1031923 133213140 110885170 22327970 807143 807143 107822515 CSV OF OFFICERS LIFE INSURANCE 424882 F INVESTMENT IN NEWELL ST., LLC 90000 C DUE FROM AFFILIATES 16227982 C ED PHYSICIAN CALL 326185 C FINANCING COSTS -SERIES B 632020 C INTEREST RATE SWAP -1025695 F MEDICAL MALPRACTICE LT INS RECOVERY 3524756 C 20200130 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 5049174 RETIREMENT PLAN OBLIGATIONS 24782797 29831971 X PART V, LINE 4: THE INTENDED USE OF THE ENDOWMENT FUNDS IS TO SUPPORT SAMARITAN MEDICAL CENTER AND RELATED FACILITIES IN PROVIDING HEALTH CARE SERVICES TO THE PUBLIC. PART X, LINE 2: SAMARITAN QUALIFIES AS A TAX-EXEMPT, NOT-FOR-PROFIT ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AS OF DECEMBER 31, 2014 AND 2013, SAMARITAN DID NOT HAVE ANY UNRECOGNIZED TAX BENEFITS. THE TAX YEARS OPEN TO EXAMINATION BY FEDERAL AND NEW YORK STATE TAXING AUTHORITIES ARE 2011 THROUGH 2014. THE HOSPITAL DOES NOT ANTICIPATE THAT THE TOTAL UNRECOGNIZED TAX BENEFITS WILL CHANGE IN THE NEXT TWELVE MONTHS. 1 1 1 X 1 X 1 1 0 1 1 1378090 413775 964315 0.00480 31002312 21221532 9780780 0.04880 32380402 21635307 10745095 0.05360 164280 164280 0.00080 1020531 24050 996481 0.00500 8353690 6024184 2329506 0.01160 9538501 6048234 3490267 0.01740 41918903 27683541 14235362 0.07100 1 3917466 50112646 57655649 -7543003 X 1 1 1 1 SAMARITAN MEDICAL CENTER 830 WASHINGTON STREET WATERTOWN NY 13601 X X SAMARITAN MEDICAL CENTER 1 0 0 1 X X X X X X X X 13 1 1 1 1 X SAMARITANHEALTH.COM X NCNYHEALTHCOMPASS.ORG X 1 14 1 SAMARITANHEALTH.COM 0 0 1 X 200.000000000000 300.000000000000 X 1 1 X X X 1 X X X X X 1 0 X X X 1 X 0 0 SAMARITAN MEDICAL CENTER PART V, SECTION B, LINE 5: THE GOAL OF THE COMMUNITY HEALTH SURVEY WAS TO ENGAGE RESIDENTS OF THE THREE-COUNTY REGION (JEFFERSON, LEWIS, ST. LAWRENCE COUNTIES) AND GAUGE THEIR PERCEPTIONS OF HEALTH NEEDS IN THE COMMUNITY. ULTIMATELY, THE SURVEY WAS DESIGNED TO INFORM THE REGIONAL CHA/CHIP PROCESS UNDERTAKEN THROUGH A COLLABORATION BETWEEN PUBLIC HEALTH AGENCIES, HOSPITALS AND COMMUNITY-BASED ORGANIZATIONS. THE INSTRUMENT WAS MODELED AFTER A SURVEY DISTRIBUTED WITHIN ST. LAWRENCE COUNTY FOR THE PURPOSE OF ASSESSING HEALTH NEEDS WITHIN THAT REGION. A VAST RANGE OF HEALTH RELATED TOPICS WERE COVERED, INCLUDING SPECIFIC DISEASES AND CONDITIONS, HEALTH RISKS, ACCESS TO CARE, PREVENTION, AND COMMUNITY HEALTH NEEDS. THE SURVEY WAS OPEN TO COMMUNITY RESIDENTS FROM JUNE 1ST THROUGH JULY 1ST, 2013. THE INSTRUMENT WAS DISTRIBUTED USING AN ONLINE SURVEY TOOL (SURVEY MONKEY). RESPONDENTS ACCESSED THE SURVEY BY FOLLOWING A WEB LINK. INFORMATION ABOUT THE SURVEY WAS SENT TO REGIONAL HEALTH ORGANIZATIONS/AGENCIES AND THEIR AFFILIATES, VARIOUS NEWS OUTLETS, SOCIAL MEDIA OUTLETS, AND PRIVATE MEDICAL PRACTICES (ALONG WITH RESPECTIVE PATIENT PORTALS). FLYERS WERE ALSO CREATED AND POSTED AT VARIOUS COMMUNITY SITES (E.G. CLINICS AND HOSPITALS). THE PRELIMINARY FINDINGS OF THIS REPORT WERE SHARED WITH THE NORTH COUNTRY HEALTH COMPASS PARTNERS DURING MONTHLY MEETINGS HELD SINCE APRIL 2013. PRELIMINARY DATA WAS ALSO SHARED AS FOLLOWS: IN AN ONLINE SURVEY TOOL TO ENGAGE STAKEHOLDERS IN THE SELECTION OF PREVENTION AGENDA PRIORITIES AND GOALS, WHICH WAS OPEN FROM JULY 29, 2013 TO AUGUST 15, 2013; AT THE "PROMOTE MENTAL HEALTH AND PREVENT SUBSTANCE ABUSE" AD HOC WORK GROUP SESSION WHICH WAS HELD ON SEPTEMBER 9, 2013; AT THE "PREVENT CHRONIC DISEASES" AD HOC WORK GROUP SESSION WHICH WAS HELD ON SEPTEMBER 9, 2013; IN A MEETING WITH THE SOLE REGIONAL PEDIATRIC DENTIST TO BRAINSTORM STRATEGIES TO ADDRESS ORAL HEALTH ISSUES AFFECTING CHILDREN ON SEPTEMBER 13, 2013; AT THE "PROMOTE HEALTHY WOMEN, INFANTS AND CHILDREN" AD HOC WORK GROUP SESSION WHICH WAS HELD ON SEPTEMBER 16, 2013; AND IN A MEETING WITH THE FDRHPO PROVIDER EXECUTIVE COMMITTEE (PEC), COMPRISED OF PHYSICIANS WITHIN THE REGION, ON SEPTEMBER 25, 2013 SAMARITAN MEDICAL CENTER PART V, SECTION B, LINE 6A: SAMARITAN MEDICAL CENTER AS WELL AS CANTON-POTSDAM HOSPITAL, CARTHAGE AREA HOSPITAL, CLAXTON-HEPBURN MEDICAL CENTER, CLIFTON-FINE HOSPITAL, GOUVERNEUR HOSPITAL, LEWIS COUNTY GENERAL HOSPITAL, MASSENA MEMORIAL HOSPITAL, RIVER HOSPITAL SAMARITAN MEDICAL CENTER PART V, SECTION B, LINE 11: THE REGIONAL PRIORITIES WERE SELECTED AFTER CAREFULLY EVALUATING COMMUNITY HEALTH NEEDS, POPULATION HEALTH DATA, REGIONAL ASSETS, AND REGIONAL BARRIERS. THE PROCESS OF IDENTIFYING THE REGIONAL PRIORITIES INVOLVED INPUT FROM 28 STAKEHOLDERS INCLUDING HOSPITAL CEOS, HOSPITAL ADMINISTRATORS, PUBLIC HEALTH EMPLOYEES (DIRECTORS, HEALTH PLANNERS, NURSES AND EDUCATORS), AND REPRESENTATIVES FROM COMMUNITY-BASED ORGANIZATIONS ACROSS THE THREE COUNTIES. THE SELECTION OF PRIORITIES AND GOALS FOR REGIONAL HEALTH IMPROVEMENT WAS BASED ON EXPRESSED COMMUNITY HEALTH NEEDS AND POPULATION HEALTH DATA INDICATING THE HEALTH ISSUES THAT WERE OF GREATEST CONCERN. FACTORS THAT WERE CONSIDERED WHEN PRIORITIZING WHICH NEEDS WERE TO BE ADDRESSED INCLUDE: HEALTH OUTCOMES THAT DID NOT MEET STATE BENCHMARKS; HEALTH OUTCOMES THAT WERE REGIONAL (NOT COUNTY-SPECIFIC) PRIORITIES; AND AT LEAST ONE HEALTH DISPARITY. STAKEHOLDERS WERE ALSO ENCOURAGED TO CONSIDER THE FOLLOWING WHEN MAKING AN INFORMED DECISION ABOUT WHICH PRIORITIES SHOULD BE SELECTED: IMPACT ON OTHER HEALTH OUTCOMES; RESOURCES AVAILABLE; EASE OF IMPLEMENTING SOLUTIONS; LEADERSHIP SUPPORT AVAILABLE; AND IMPORTANCE TO THE PUBLIC HEALTH SYSTEM. ULTIMATELY, THOSE NEEDS THAT SAMARITAN'S COMMUNITY SERVICE PLAN DID NOT ADDRESS WERE SIMPLY A LOWER PRIORITY, WERE NOT ACHIEVABLE IN A REASONABLE TIMEFRAME OR DID NOT HAVE ADEQUATE RESOURCES TO MEET THE NEEDS.SAMARITAN MEDICAL CENTER IS AN ACTIVE MEMBER OF NORTH COUNTRY HEALTH COMPASS PARTNERS WHICH HAS GROWN TO A COALITION OF APPROXIMATELY 30 MEMBERS CONSISTING OF MEMBERS FROM A WIDE CROSS SECTION OF STAKEHOLDERS: PUBLIC HEALTH DEPARTMENTS, HEALTHCARE FACILITIES, HEALTHCARE AGENCIES, COMMUNITY BASED ORGANIZATIONS AND MOST RECENTLY FAITH-BASED ORGANIZATIONS AND PATIENT AND FAMILY ADVOCATE REPRESENTATION. THE FOCUS OF THE COALITION IS TO BROADLY IMPROVE POPULATION HEALTH FOR OUR REGION BY SUPPORTING THE NUMEROUS POPULATION HEALTH IMPROVEMENT STATE INITIATIVES. THROUGH INVOLVEMENT IN THESE INITIATIVES WE SEEK TO: ASSESS AND IMPROVE POPULATION HEALTH FOR THE 260,000 PEOPLE THAT LIVE WITHIN OUR TRI-COUNTY REGION; STRENGTHEN THE POPULATION HEALTH INFRASTRUCTURE; IMPROVE ACCESS TO PRIMARY AND PREVENTION CARE; AND FOCUS ON ELIMINATING HEALTH DISPARITIES. THE INITIATIVES THAT SAMARITAN MEDICAL CENTER IS ACTIVELY ENGAGED IN INCLUDE:RURAL HEALTH DEVELOPMENT PROGRAM - AWARDED IN 2013 THIS PROGRAM FUNDED THE DEVELOPMENT OF THE NORTH COUNTRY HEALTH COMPASS WEBSITE. IT HELPED DEVELOP A REGIONAL HEALTH ASSESSMENT AND REGIONAL HEALTH IMPROVEMENT PLAN WHICH HELPS GUIDE THE WORK BEING DONE BY THE COLLABORATIVE AND HELPED DETERMINE WHAT DSRIP INITIATIVES IT WOULD FOCUS ON FOR THE REGION. NY STATE'S DELIVERY SYSTEM REFORM INCENTIVE PROGRAM (DSRIP), FOR WHICH SAMARITAN MEDICAL CENTER IS THE LEAD REGIONAL APPLICANT, IS A 5 YEAR INITIATIVE TO REORGANIZE HEALTH CARE PROGRAMS TO MEET THE NEEDS OF NOT ONLY THE MEDICAID POPULATION BUT EVERYONE WHO WILL EVENTUALLY BECOME A PATIENT. THE GOALS OF DSRIP ARE TO PROVIDE A BETTER QUALITY EXPERIENCE, LOWER COST OF CARE AND IMPROVE OUTCOMES OVERALL. IT SEEKS TO ACCOMPLISH THIS BY: ENGAGING THE UNINSURED AND MEDICAID LOW-UTILIZERS, AND NON-UTILIZERS; STRENGTHEN THE MENTAL HEALTH AND SUBSTANCE ABUSE INFRASTRUCTURE AND INCREASE ACCESS TO HIGH-QUALITY CHRONIC DISEASE PREVENTION AND MANAGEMENT (SPECIFICALLY COLORECTAL CANCER AND COPD). POPULATION HEALTH IMPROVEMENT PROGRAM (PHIP) - WHILE NOT THE PROGRAM ADMINISTRATOR, SAMARITAN MEDICAL CENTER PLAYED AN ACTIVE ROLE IN THIS PROGRAM FOR THE TUG HILL SEAWAY REGION. THE ROLE OF THE PHIP IS TO: CONVENE STAKEHOLDERS; SERVE AS POPULATION HEALTH DATA RESOURCE; AND ADDRESS THE NEEDS OF THE POPULATION. STATE HEALTH INNOVATION PLAN (SHIP) - THE GOALS ARE TO: IMPROVE ACCESS TO QUALITY CARE FOR ALL REGIONAL RESIDENTS, PROMOTE POPULATION HEALTH, DEVELOP WORKFORCE STRATEGY, MAXIMIZE HEALTH INFORMATION TECHNOLOGY, AND ESTABLISH A PERFORMANCE MEASURE AND EVALUATION.REGIONAL PRIORITIES -THE DATA THAT HAS BEEN GATHERED HAS BEEN CONDENSED TO 192 INDICATORS. OF THESE, NINE HEALTH ISSUES BECAME REGIONAL PRIORITIES:COLORECTAL CANCER - RATES ARE HIGHER THAN THE STATE AVERAGETOBACCO USE - RATES ARE HIGHER THAN THE STATE AVERAGEHEART DISEASE - RATES ARE HIGHER THAN THE STATE AVERAGEDIABETES - RATES ARE HIGHER THAT THE STATE AVERAGECOMPREHENSIVE WELL CHILD CARE - APPROXIMATELY 50% RECEIVE WELL CHILD CARE; THE STATE GOAL IS 90%PEDIATRIC ORAL HEALTH - 40% OF OUR 3RD GRADERS HAVE UNTREATED TOOTH DECAYBINGE DRINKING - HIGHER THAT THE STATE AVERAGESELF-INFLICTED INJURY SUICIDES - DOUBLE THE STATEWIDE AVERAGE SAMARITAN MEDICAL CENTER PART V, SECTION B, LINE 22D: WE USED A PERCENTAGE OF GROSS CHARGES. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY SAMARITAN MEDICAL CENTER PART V, SECTION B, LINE 16A WEBSITE: SAMARITANHEALTH.COM SAMARITAN MEDICAL CENTER PART V, SECTION B, LINE 16B WEBSITE: SAMARITANHEALTH.COM 8 SAMARITAN FAMILY HEALTH - CLAYTON 909 STRAWBERRY LANE CLAYTON NY 13624 PRIMARY CARE CLINIC SAMARITAN FAMILY HEALTH - PLAZA 1575 WASHINGTON STREET WATERTOWN NY 13601 PRIMARY CARE CLINIC SAMARITAN FAMILY HEALTH - UROLOGY 19324 US ROUTE 11 WATERTOWN NY 13601 OUTPATIENT UROLOGY CLINIC SAMARITAN FAMILY HEALTH - LACONA 3 DEMOTT STREET LACONA NY 13083 PRIMARY CARE CLINIC SAMARITAN FAMILY HEALTH - WBI 428 WASHINGTON STREET WATERTOWN NY 13601 OUTPATIENT IMAGING CLINIC SAMARITAN OUTPATIENT BEHAVIOR HEALTH 165 COLEMAN STREET WATERTOWN NY 13601 OUTPATIENT PSYCHIATRIC CLINIC SAMARITAN FAMILY HEALTH - LERAY 26908 INDEPENDENCE WAY EVAN MILLS NY 13637 PRIMARY CARE CLINIC/URGENT CARE CAPE VINCENT CLINIC 782 E BROADWAY CAPE VINCENT NY 13618 PRIMARY CARE CLINIC PART I, LINE 6A: SAMARITAN COMPLETES AND FILES THE COMMUNITY SERVICE PLAN ANNUALLY. A FULL REPORT IS COMPLETED AND SUBMITTED EVERY THREE YEARS, WITH UPDATES SUBMITTED EACH OF THE OTHER TWO YEARS. THE REPORTS ARE AVAILABLE TO THE PUBLIC VIA SAMARITAN'S WEBSITE (WWW.SAMARITANHEALTH.COM) OR BY CONTACTING THE SAMARITAN MARKETING OFFICE. PART I, LINE 7: THE RATIO OF COST TO CHARGES METHODOLOGY WAS UTILIZED IN COMPUTING ALL EXPENSES REPORTED ON LINES 7A. THROUGH 7G. THE WORKSHEET (#1 THROUGH #6) TEMPLATES IN THE INSTRUCTIONS FOR SCHEDULE H WERE FOLLOWED TO COMPUTE COSTS REPORTED. PART I, LINE 7G: THE COSTS REPORTED ON THIS LINE REPRESENT THE NET EXPENSE FOR THE OUTPATIENT PRIMARY CARE CLINICS OPERATED BY SAMARITAN MEDICAL CENTER. THE "NET" EXPENSE WAS COMPUTED UTILIZING WORKSHEET 6 OF THE SCHEDULE H FORM. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF PATIENT ACCOUNTS RECEIVABLE, SAMARITAN MEDICAL CENTER (SMC), SAMARITAN MEDICAL PRACTICE, P.C. (SMP) AND SAMARITAN KEEP NURSING HOME, INC. (SKH) ANALYZE PAST PAYMENT HISTORY AND IDENTIFY TRENDS FOR EACH MAJOR PAYOR SOURCE OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. FOR RECEIVABLES ASSOCIATED WITH PATIENTS WHO HAVE THIRD-PARTY COVERAGE, SMC, SMP AND SKH ANALYZE CONTRACTUALLY DUE AMOUNTS AND PROVIDE AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS AND FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS, SMC, SMP AND SKH ALSO ANALYZE AMOUNTS DUE AND PROVIDE AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE BASED ON PAST EXPERIENCE, INCLUDING CONSIDERATION OF CURRENT BUSINESS AND ECONOMIC CONDITIONS. WHEN SMC, SMP AND SKH ESTABLISH THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BOTH TAKE INTO CONSIDERATION THE FACT THAT MANY SELF-PAY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE AMOUNT OF BAD DEBT AT COST REPORTED ON LINE #2 WAS CALCULATED BY APPLYING THE OVERALL HOSPITAL RCC (COMPUTED USING WORKSHEET #2) TO THE PROVISION FOR BAD DEBT EXPENSE AS REPORTED IN OUR 2014 AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: MEDICARE ALLOWABLE COSTS REPORTED WERE TAKEN DIRECTLY FROM THE 2014 MEDICARE COST REPORT FILED WITH NATIONAL GOVERNMENT SERVICES. THE METHODOLOGY IS BASED ON APPLYING FACILITY RATIO OF COST TO CHARGES TO THE MEDICARE (PROGRAM) CHARGES, AS PROVIDED BY NATIONAL GOVERNMENT SERVICES IN THE PS&R REPORT.THE MEDICARE SHORTFALL REPORTED SHOULD BE TREATED AS COMMUNITY BENEFIT EXPENSE. SAMARITAN MEDICAL CENTER PROVIDES MEDICAL SERVICES TO ALL PATIENTS REGARDLESS OF INSURANCE COVERAGE. THE OVERALL (INPATIENT AND OUTPATIENT) MEDICARE PAYOR MIX FOR 2014 WAS APPROXIMATELY 38%. PART III, LINE 9B: IF CHARITY CARE ASSISTANCE IS GRANTED, PATIENT ACCOUNTS THAT HAVE BEEN REFERRED TO A COLLECTION AGENCY WITHIN 60 DAYS OF APPLICATION DATE ARE ELIGIBLE FOR CHARITY CARE DISCOUNT. ANY BILL AMOUNT REMAINING AFTER APPLICATION OF THE CHARITY CARE DISCOUNT IS THE RESPONSIBILITY OF THE PATIENT. THE PATIENT WILL BE ASSISTED BY THE HOSPITAL IN MAKING SHORT TERM ARRANGEMENT TO SATISFY ANY REMAINING BALANCE ON THE ACCOUNT. PART VI, LINE 2: SAMARITAN MEDICAL CENTER PARTICIPATED WITH COMMUNITY PARTNERS FROM JEFFERSON AND LEWIS COUNTY TO ASSESS THE COMMUNITY HEALTH NEEDS, IDENTIFY PREVENTION AGENDA PRIORITIES, DEFINE GOALS, OBJECTIVES AND WORK PLANS TO MEET THESE COMMUNITY HEALTH NEEDS. THESE PARTNERS INCLUDE FORT DRUM, JEFFERSON COUNTY PUBLIC HEALTH, LEWIS COUNTY PUBLIC HEALTH, CARTHAGE AREA HOSPITAL, LEWIS COUNTY GENERAL HOSPITAL, RIVER HOSPITAL, NORTH COUNTRY CHILDREN'S CLINIC, NORTHERN NEW YORK RURAL HEALTHCARE ALLIANCE, INC., FORT DRUM REGIONAL HEALTH PLANNING ORGANIZATION.SAMARITAN CONTINUES TO WORK WITH ITS PARTNERS, MEETING REGULARLY (AT MINIMUM, QUARTERLY AND AS FREQUENTLY AS MONTHLY) TO ASSESS THE EFFECTIVENESS OF OUR COLLABORATIVE ACTIVITIES.FINALLY, IN TERMS OF PRIORITIZING HEALTH ISSUES, THE RECOMMENDATIONS OF LOCAL, REGIONAL, STATE, AND NATIONAL HEALTH EXPERTS WERE REVIEWED AND CONSIDERED IN THE PROCESS OF IDENTIFYING PRIORITY ISSUES. THE PLANNING COMMITTEE SELECTED THE FINAL HEALTH PRIORITIES AS THEY RELATED TO THE NYS DOH PREVENTION AGENDA AND BY USING COMMUNITIES WORKING TOGETHER FOR A HEALTHIER NEW YORK. PART VI, LINE 3: THE CHARITY CARE PROGRAM CAN BE COMMUNICATED TO PATIENTS BY ANY SAMARITAN STAFF MEMBER; AS OUR CHARITY CARE PROGRAM IS AN EDUCATION TOPIC IN NEW EMPLOYEE ORIENTATION AND IS PART OF OUR ANNUAL MANDATORY EDUCATION REQUIREMENT. ADDITIONALLY, EACH PATIENT IS PROVIDED WITH A FINANCIAL ASSISTANCE APPLICATION AND RETURN ENVELOPE INCLUDED IN THE SAMARITAN PATIENT HANDBOOK. OUR GOVERNMENT INSURANCE LIAISON RECEIVES REFERRALS FROM PATIENT & FAMILY SERVICES REGARDING PATIENTS THAT MIGHT NEED ASSISTANCE OR EDUCATION REGARDING FEDERAL, STATE OR OTHER GOVERNMENT PROGRAMS. ADDITIONALLY, SHE ATTEMPTS TO CONTACT ALL SELF PAY ADMISSIONS. SAMARITAN PROVIDES SPACE FOR A NYS FACILITATED ENROLLER TO MEET WITH INDIVIDUALS INTERESTED IN APPLYING FOR NYS PROGRAMS. PART VI, LINE 4: SAMARITAN MEDICAL CENTER IS A 294 BED ACUTE CARE HOSPITAL SERVING SEVERAL COMMUNITIES IN UPSTATE NEW YORK. THE HOSPITAL IS LOCATED IN WATERTOWN, NEW YORK IN JEFFERSON COUNTY, WHICH LIES WITHIN A FEDERALLY DESIGNATED HPSA. THE POPULATION SERVED BY SAMARITAN MEDICAL CENTER PRIMARILY INCLUDES JEFFERSON COUNTY AND PORTIONS OF LEWIS, NORTHERN OSWEGO AND ST. LAWRENCE COUNTIES.SAMARITAN PROVIDES A FULL ARRAY OF INPATIENT AND OUTPATIENT HOSPITAL SERVICES, INCLUDING INPATIENT MEDICAL/SURGICAL, CRITICAL CARE, PEDIATRIC, MATERNITY, AND MENTAL HEALTH SERVICES AND AN EMERGENCY SERVICES DEPARTMENT.THE U.S. CENSUS REPORT LISTS THE 2009 ESTIMATED TOTAL POPULATION OF JEFFERSON COUNTY AT 118,719. THIS REPRESENTS A 6.2% GROWTH FROM THE 2000 CENSUS OF 111,738. THE INCREASE IN TOTAL POPULATION IS LARGELY DUE TO THE EXPANSION OF MILITARY PERSONNEL AT FORT DRUM. FORT DRUM DOES NOT OPERATE A HOSPITAL ON THE ARMY BASE, NOR DO THEY STAFF MEDICAL SPECIALISTS IN THEIR OUTPATIENT HEALTH CENTER.THE PERCENTAGE OF JEFFERSON COUNTY TOTAL POPULATION BELOW THE POVERTY LEVEL HAS GRADUALLY INCREASED FROM 11% IN 1990 TO 13.5% IN 2002 TO 14.6% IN 2008. MEDIAN HOUSEHOLD INCOME FOR 2008 FALLS SHORT OF STATEWIDE MEDIAN HOUSEHOLD INCOME BY APPROXIMATELY 20%. UNEMPLOYMENT IN JEFFERSON COUNTY IS APPROXIMATELY 8% - 9%. THE JEFFERSON COUNTY POPULATION CONTINUES TO BE PREDOMINANTLY CAUCASIAN, ALTHOUGH THERE ARE AN INCREASING NUMBER OF PERSONS OF OTHER RACE AND, IN PARTICULAR, HISPANIC, OR AFRICAN AMERICAN IN ORIGIN.THE CURRENT OVERALL (INPATIENT AND OUTPATIENT) PAYOR MIX EXPERIENCED AT SAMARITAN MEDICAL CENTER IS AS FOLLOWS:MEDICARE 38%, MEDICAID 17%, BLUE CROSS 13%, COMMERCIAL 10%, TRICARE 17%, NO FAULT 1%, WORKMEN'S COMPENSATION 1%, AND SELF PAY 3%. PART VI, LINE 5: SINCE 2006, SAMARITAN HAS RECRUITED AND RETAINED MORE THAN 80 PHYSICIANS TO THE AREA. PHASE III OF THE FACILITY MASTER PLAN BEGAN IN 2011 WHICH PROVIDES FOR RENOVATION OF THE EXISTING MAIN BUILDING. THIS RENOVATION AND RECONFIGURATION PROJECT WILL CONTRIBUTE DIRECTLY TO PROMOTING INCREASED OUTPATIENT SERVICES BY CONSOLIDATING HEALTHCARE SERVICES AND ENHANCE OUTPATIENT AND AMBULATORY CARE AT LEVELS THAT ARE BOTH EFFICIENT AND ACCESSIBLE.SAMARITAN MEDICAL CENTER EXPANDED SERVICES IN 2012 TO INCLUDE A ROBOTICALLY ASSISTED SURGICAL PROGRAM, SPINE CENTER OF EXCELLENCE AND NEUROSURGERY. PREVIOUSLY, THESE SERVICES WERE ONLY ACCESSIBLE TO COMMUNITY MEMBERS AT OUTSIDE REFERRAL CENTERS IN SYRACUSE AND BEYOND. PART VI, LINE 7, REPORTS FILED WITH STATES NY X X X X X 0 1 0 0 0 0 0 0 0 PAUL KRAEGER TREASURER, SR. VP OF FINANCE 135294 0 0 0 13529 0 10615 0 21 0 159459 0 0 0 DAVID FLINT MD TRUSTEE 292206 0 809 0 32107 0 22695 0 16624 0 364441 0 0 0 DAVID RECHLIN DO TRUSTEE 130000 0 86697 0 25000 0 7800 0 21 0 249518 0 0 0 JACK RUSH MD TRUSTEE 140543 0 6313 0 45405 0 12058 0 16624 0 220943 0 0 0 ROBERT KIMBALL MD TRUSTEE 353257 0 2000 0 0 0 22615 0 16406 0 394278 0 0 0 THOMAS H CARMAN PRESIDENT & CEO 485960 0 19042 0 22265 0 90900 0 21592 0 639759 0 0 0 SEAN MILLS CFO 174990 0 0 0 0 0 3634 0 16624 0 195248 0 0 0 MICHAEL SHORT CIO 190005 0 0 0 9500 0 13300 0 12225 0 225030 0 0 0 MARIO VICTORIA CMO 323647 0 75339 0 16500 0 22691 0 16624 0 454801 0 0 0 BRIAN O'HEARN VP PATIENT CARE/CNO 211946 0 6346 0 10500 0 16617 0 16624 0 262033 0 0 0 ANTHONY JOSEPH VP LONG TERM CARE 172238 0 0 0 8293 0 15023 0 15869 0 211423 0 0 0 ALEJANDRO RODRIGUEZ MD UROLOGIST 586147 0 100000 0 11300 0 22696 0 16624 0 736767 0 0 0 JOSEPH WETTERHAHN MD FAMILY PRACTICE MD 284502 0 11801 0 199024 0 22274 0 16624 0 534225 0 0 0 MOONJOHN KIM MD INTERVENTIONAL RADIOLOGIST 544568 0 11844 0 10000 0 22850 0 16624 0 605886 0 0 0 SHAHANDEH HAGHIR MD PATHOLOGIST 430702 0 0 0 9900 0 22698 0 11832 0 475132 0 0 0 BRADFORD BILICKI SURGEON 349755 0 35373 0 25200 0 22703 0 16624 0 449655 0 0 0 PART I, LINE 4B PART I, LINE 4B: THOMAS H. CARMAN RECEIVED CONTRIBUTIONS TO AN IRC 457(F) PLAN OF $73,400 DURING 2014. A DORMITORY AUTHORITY OF THE STATE OF NEW YORK 146000293 649905DD5 2009-04-09 31660000 CONSTRUCTION OF NEW PATIENT PAVILION AND PARKING GARAGE 0 0 0 B DORMITORY AUTHORITY OF THE STATE OF NEW YORK 146000293 649905DE3 2009-04-09 23945000 CONSTRUCTION OF NEW PATIENT PAVILION AND PARKING GARAGE, REFUND 1998 SERIESA 0 0 0 A 31660000 883291 1623236 27750175 3169880 2010 0 0 0 1 B 23945000 737831 1388843 18830508 4463480 2010 1 0 0 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 A 0 0 0 0 1 0 0 0 0 B 0 0 0 0 1 0 0 0 0 A 0 B 0 FORM 990, PART VI, SECTION A, LINE 4 SAMARITAN MEDICAL CENTER ADOPTED THE PROVISIONS OF THE NEW YORK STATE NON PROFIT REVITALIZATION ACT. FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION'S FORM 990 AND ACCOMPANYING SCHEDULES WERE REVIEWED BY THE EXECUTIVE COMMITTEE OF THE BOARD PRIOR TO FILING. FORM 990 WAS PROVIDED TO EACH BOARD MEMBER PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ANNUAL DISCLOSURE STATEMENTS ARE REQUIRED BY ALL BOARD MEMBERS AND KEY PERSONS. WE HAVE BEEN AT 100% COMPLIANCE WITH THIS REQUIREMENT EACH YEAR. RESPONSES ARE REVIEWED INITIALLY BY THE CEO AND CHIEF COMPLIANCE OFFICER FOR ACCURACY AND COMPLETENESS. THIS INFORMATION IS THEN PUT INTO A FULL REPORT TO THE BOARD OF TRUSTEES FOR REVIEW AND CONSIDERATION IN UPCOMING DECISION MAKING. BOARD MEMBERS AND KEY PERSONS AFFIRM THEIR UNDERSTANDING OF THEIR DUTY TO REPORT ANY ADDITIONAL OR NEW POTENTIAL CONFLICTS THROUGHOUT THE YEAR. BOARD MEMBERS WITH A CONFLICT ARE PROHIBITED FROM PARTICIPATION IN VOTING AND DECISION MAKING IN RELATED TRANSACTIONS. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION USES AN EXTERNAL CONSULTANT TO ANALYZE AND ESTABLISH COMPENSATION AND BENEFITS FOR ALL EXECUTIVE POSITIONS. AN EVALUATION IS PERFORMED ANNUALLY. THE ANALYSIS INCLUDES A REVIEW OF MARKET DATA BASED ON REGION, FACILITY SIZE, AND RESPECTIVE RESPONSIBILITIES. THIS INFORMATION IS PRESENTED TO THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES FOR REVIEW AND SUBSEQUENTLY PRESENTED TO THE FULL BOARD OF TRUSTEES FOR APPROVAL. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC. THE FINANCIAL STATEMENTS ARE FILED AS PART OF THE ANNUAL FORM 990 AND ANNUAL NYS DEPARTMENT OF HEALTH INSTITUTIONAL COST REPORT, AND ARE AVAILABLE UPON REQUEST. FORM 990, PART XI, LINE 9: PENSION AND POSTRETIREMENT LIABILITY -6,508,058. VALUE OF INTEREST RATE SWAP 79,846. EQUITY TRANSFERS TO AFFILIATE -6,999,710. FORM 990 PART XII LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. SAMARITAN KEEP NURSING HOME 133 PRATT STREET WATERTOWN NY 13601 160969838 SKILLED NURSING FACILITY NY 501(C)3 LINE 3 SCH A SAMARITAN MEDICAL CENTER 0 THE SAMARITAN MEDICAL CENTER FDN OF NORTHERN NEW YORK INC 830 WASHINGTON STREET WATERTOWN NY 13601 161490523 PROVIDES FUND FOR SAMARITAN MEDICAL CENTER AND AFFLIATES NY 501(C)3 LINE 7 SCH A SAMARITAN MEDICAL CENTER 0 EDWARD J NOBLE HOSPITAL- SAMARITAN 104 PADDOCK STREET SUITE 104 WATERTOWN NY 13601 237227989 HOSPITAL NY 501(C)3 LINE 3 SCH A SAMARITAN MEDICAL CENTER 0 SAMARITAN MEDICAL PRACTICE PC 830 WASHINGTON STREET WATERTOWN NY 13601 261528342 PHYSICIAN MEDICAL PRACTICE NY 501(C)3 LINE 3 SCH A SAMARITAN MEDICAL CENTER 0 SAMARITAN SENIOR VILLAGE INC 22691 CAMPUS DRIVE WATERTOWN NY 13601 454913668 SENIOR CITIZEN COMMUNITY NY 501(C)3 LINE 3 SCH A SAMARITAN MEDICAL CENTER 0 0 1 1 0 0 0 0 0 0 1 0 1 1 0 0 0 0 0 0