2015-08-05T08:51:27-07:00 2014-12-31 990 2014-01-01 222807681 MEMORIAL HOSPITAL OF WILLIAM F AND GERTRUDE F JONES INC MEMO 5855931100 191 N Main Street Wellsville NY 14895 Tracy Gates CFO 5855964002 2015-08-03 2014 2016-02-25 16:41:14Z Rich Shear 191 N Main Street Wellsville NY 14895 36107691 0 X www.jmhny.org X 1921 NY JONES MEMORIAL HOSPITAL IS COMMITTED TO ENSURING ACCESS TO THE HIGHEST QUALITY HEALTHCARE FOR OUR COMMUNITY IN A CARING MANNER. 12 11 453 60 0 0 2002211 1280865 30958432 32021828 380337 464043 1614251 2340955 34955231 36107691 0 0 0 0 21013281 21841266 0 0 0 14070783 14745612 35084064 36586878 -128833 -479187 31235553 30469933 20310446 25652889 10925107 4817044 Provision of healthcare services 0 0 29894781 0 0 QUALITY OF HEALTH CARE: THE MEMORIAL HOSPITAL OF WILLIAM F. & GERTRUDE F. JONES, INC. A/K/A JONES MEMORIAL HOSPITAL IS A SOLE COMMUNITY PROVIDER WITH 70 ACUTE CARE BEDS, NOT FOR PROFIT, LOCATED IN RURAL WELLSVILLE NY IN A PROFESSIONALLY UNDERSERVED AREA. WE PROVIDE PRIMARY CARE, AMBULATORY CARE, EMERGENCY CARE AND ACUTE (MEDICAL, SURGICAL, PEDIATRIC, OB AND GYN) AND INTENSIVE CARE PLUS COMMUNITY OUTREACH PROGRAMS. WE ADMITTED 1678 PATIENTS PLUS 350 BIRTHS AND HAD 79364 PATIENT ENCOUNTERS ON AN OUTPATIENT BASIS. THE HOSPITAL HAS PROVIDED CHARITY CARE TO INDIGENT PATIENTS TOTALING $948,776.93. 0 0 0 29894781 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 36 0 1 453 1 0 0 0 0 0 0 X 12 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X TRACY GATES CFO 5855964002 191 N Main Street Wellsville NY 14895 ROBERT GILFERT BOARD MEMBER 2 0 X 0 0 0 MICHAEL BERARDI BOARD MEMBER 2 0 X 0 0 0 KIMBERLY TOOT BOARD MEMBER 2 0 X 0 0 0 WILLIAM COCH BOARD MEMBER 2 0 X 0 0 0 GARY BALCOM BOARD MEMBER 2 0 X 0 0 0 KATHY WOUGHTER BOARD MEMBER 2 0 X 0 0 0 MARY KATE COLE BOARD MEMBER 2 0 X 0 0 0 RICHARD SHEAR CHAIRMAN 2 0 X 0 0 0 SAMANTHA GILKEY VICE CHAIRPERSON 2 0 X 0 0 0 BARRY KULP SECRETARY 2 0 X 0 0 0 DANIEL GUINEY TREASURER 2 0 X 0 0 0 EVA BENEDICT Exec Director/CEO 40 0 X 236987 0 7880 TRACY GATES CFO 40 0 X 156348 0 22970 HEATHER LANPHERE OB/GYN 40 0 X 345206 0 49820 F CLIFTON MILLER OB/GYN 40 0 X 354599 0 47403 MARK ELLIOTT CRNA 40 0 X 194411 0 20205 KEITH GEMBUSIA MD 40 0 X 195194 0 40020 LU-ANNE KAYE MD 40 0 X 180206 0 37829 1662951 0 226127 17 0 1 0 DELPHI HOSPITALIST SERVICE 2701 CULVER ROAD ROCHESTER NY 14622 STAFFING 576639 PICCO PULMONARY & INTERNAL MEDICINE 11 MAIN STREET HORNELL NY 14843 STAFFING 410000 DELPHI HEALTHCARE LLC 2701 CULVER ROAD ROCHESTER NY 14622 Staffing 279712 DR STEVEN COLLINS 6801 GLEASON HILL ROAD BELFAST NY 14711 MEDICAL PHYSICIAN 216000 CHARLES COLE MEMORIAL HOSPITAL 1001 E SECOND STREET COUDERSPORT PA 16915 STAFFING 211767 5 0 0 0 0 1111503 169362 0 1280865 PATIENT SERVICES 622000 32021828 32021828 0 0 0 0 0 0 32021828 457545 0 0 457545 0 0 0 0 0 0 0 0 78662 0 0 0 78662 0 78662 0 0 78662 0 6498 0 0 0 6498 6498 0 0 6498 0 PT & OT CONSULTING INCOME 900099 345987 0 0 345987 BAD DEBT CHARITY CARE POOL 900099 948777 0 0 948777 CAFETERIA 900099 255050 0 0 255050 712479 0 0 712479 2262293 36107691 32021828 0 2804998 0 0 0 0 0 0 0 0 379574 0 379574 0 0 0 0 0 16728997 13290574 3438423 0 204677 159001 45676 0 3331469 3331469 0 0 1196549 929524 267025 0 0 0 0 0 0 0 0 0 77812 0 77812 0 0 0 0 0 0 0 0 0 0 0 85134 0 85134 0 28406 0 28406 0 5541112 5089058 452054 0 0 0 0 0 0 0 0 0 0 0 0 0 31252 20772 10480 0 0 0 0 0 31925 8051 23874 0 178914 0 178914 0 0 0 0 0 1848693 1478954 369739 0 349455 0 349455 0 PURCHASED SERVICES 4674128 4235229 438899 0 LICENSES AND TAXES 214596 40864 173732 0 LEASES 578475 528838 49637 0 RECRUITMENT 66130 0 66130 0 1039580 782447 257133 0 36586878 29894781 6692097 0 2371798 1240536 0 0 0 0 7078866 8260699 0 0 0 0 0 0 796301 866688 290771 286778 28892037 21171813 8896497 7720224 0 0 11801320 12095008 0 0 0 0 0 0 31235553 30469933 13950957 20518030 0 0 0 0 6359489 5134859 0 0 0 0 0 0 0 0 20310446 25652889 X 9060656 2988389 0 0 1864451 1828655 10925107 4817044 31235553 30469933 X -479187 0 0 0 0 -5628876 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 145541 0 145541 790029 0 630865 159164 12645216 0 9857228 2787988 14926077 0 10683720 4242357 385174 0 0 385174 7720224 0 0 MORTGAGE RESERVE FUND 2236226 F CAPITAL IMPROVEMENTS 7742124 F TEMP RESTRICTED/STEUBEN TRUST 288003 F HELD IN TRUST/KEY BANK 1828655 F 12095008 36107691 0 0 0 0 0 36107691 0 0 0 36107691 36586878 0 0 0 0 0 36586878 0 0 0 36586878 1 1 X 1 X 1 X 1 1 1 0 1 1 0 0 381673 0 381673 0.0106 0 0 6597422 5445168 1152254 0.0321 0 0 1150620 0 1150620 0.032 0 0 8129715 5445168 2684547 0.0747 16 1177 188401 42973 145428 0.004 3 133 158960 0 158960 0.0044 0 0 7205 500 6705 0.0002 0 0 0 0 0 0 12 231 7559 0 7559 0.0002 31 1541 362125 43473 318652 0.0088 31 1541 8491840 5488641 3003199 0.0835 0 0 0 0 0 0 0 0 0 0 0 0 5 17030 7152 0 7152 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 800 0 800 0 1 300 21211 8864 12347 0 1 0 5519 0 5519 0 0 0 0 0 0 0 8 17330 34682 8864 25818 0 1 663201 663201 4514105 6882354 -2368249 X 1 1 7 1 JONES MEMORIAL HOSPITAL 191 NORTH MAIN STREET WELLSVILLE NY 14895 www.jmhny.org X X A 2 JONES MEMORIAL HEALTH CARE CLINIC 127 NORTH MAIN STREET WELLSVILLE NY 14895 EXTENSION CLINIC A 3 JONES MEMORIAL HEALTH CARE CLINIC 15 LODER STREET WELLSVILLE NY 14895 EXTENSION CLINIC A 4 JONES MEMORIAL HEALTH CARE CLINIC 13 LODER STREET WELLSVILLE NY 14895 EXTENSION CLINIC A 6 JONES MEMORIAL HEALTH CARE CLINIC 5877 OLD STATE ROUTE 19 BELMONT NY 14813 EXTENSION CLINIC A 7 JONES MEMORIAL HEALTH CARE CLINIC 120 FIRST STREET BOLIVAR NY 14715 EXTENSION CLINIC A A 0 0 1 X X X X X X X 13 1 1 1 1 X X 1 14 1 www.jmhny.org 0 0 1 X 300 1 1 X X X 1 X X X X X X X X 1 X 0 X X X X 1 X 0 0 Schedule H, Part V, Section B, Line 3-Group A PLEASE SEE SCHEDULE H, PART VI, LINE 2 SUPPLEMENTAL INFORMATION. Schedule H, Part V, Section B, Line 4-Group A PLEASE SEE SCHEDULE H, PART VI, LINE 2 SUPPLEMENTAL INFORMATION. Schedule H, Part V, Section B, Line 5-Group A PLEASE SEE SCHEDULE H, PART VI, LINE 2 SUPPLEMENTAL INFORMATION. Schedule H, Part V, Section B, Line 6a-Group A CUBA MEMORIAL HOSPITAL Schedule H, Part V, Section B, Line 6b-Group A ALLEGANY COUNTY DEPARTMENT OF HEALTH AND AALEGANY WESTERN STEUBEN RURAL HEALTH NETWORK Schedule H, Part V, Section B, Line 7d-Group A PLEASE SEE SCHEDULE H, PART VI, LINE 2 SUPPLEMENTAL INFORMATION Schedule H, Part V, Section B, Line 10-Group A THE HOSPITAL PROVIDES DISCOUNTED CARE NOT FREE CARE. Schedule H, Part V, Section B, Line 11-Group A OBJECTIVE 1.IMPROVE GIRLS ON THE RUN PARTICIPANTS WHO DEMONSTRATE FAVORABLE SELF ESTEEM, EATING ATTITUDES AND BEHAVIORS, PHYSICAL ACTIVITY ATTITUDE, AND BODY SIZE SATISFACTION AS MEASURED IN THE PRE POST TEST SURVEYS RESULTS. OBJECTIVE 2.INDIVIDUALS LIVING WITH CHRONIC ILLNESS WHO PARTICIPATE IN THE CHRONIC DISEASE SELF MANAGEMT PROGRAM WILL DEMONSTRATE SIGNIFICANT IMPROVEMEMENTS IN EXERCISE, COGNITIVE SYMPTOM MANAGEMENT, COMMUNICATION WITH PHYSICIANS, SELF REPORTED GENERAL HEALTH, HEALTH DISTRESS, FATIGUE, DISABILITY AND SOCIAL ROLE ACTIVITIES LIMITATIONS. GRADUATES WILL SPEND FEWER DAYS IN THE HOSPITAL AND DECREASE OUTPATIENT VISITS AND HOSPITALIZATIONS. OBJECTIVE 3. INDIVIDUALS DIAGNOSED AS PRE DIABETIC WILL INCREASE AWARENESS AND KNOWLEDGE OF THE SERIOUSNESS OF DIABETES, ITS RISK FACTORS, AND EFFECTIVE STRATEGIES FOR PREVENTING COMPLICATIONS ASSOCIATED WITH DIABETES AND PREVENTING TYPE 2 DIABETES. A MINIMUM OF 50 PERCENT OF DPP PARTICIPANTS WILL INCREASE AND SUSTAIN EFFECTIVE LIFESTYLE CHANGES TO PREVENT DIABETES INCLUDING LOSING 7 PERCENT OF BODY WEIGHT THROUGH HEALTHY EATING AND PHYSICAL ACTIVITY. Schedule H, Part V, Section B, Line 16a-Group A WWW.JMHNY.ORG Schedule H, Part V, Section B, Line 16b-Group A WWW.JMHNY.ORG Schedule H, Part V, Section B, Line 16c-Group A WWW.JMHNY.ORG Schedule H, Part I, Line 7 WORKSHEET 2 RATIO OF PATIENT CARE COST TO CHARGES CALCULATION WAS USED. Schedule H, Part I, Line 7g JONES MEMORIAL HOSPITAL OPERATES A DIABETIC CLINIC AS A SERVICE TO THE PUBLIC DUE TO THE HIGH NEED FOR IT IN ALLEGANY COUNTY. Schedule H, Part II AS A COMMUNITY HOSPITAL, JONES MEMORIAL TAKES AN ACTIVE PART IN PROMOTING THE HEALTH OF THOSE WE SERVE THROUGH A WIDE VARIETY OF ACTIVITIES. IN ADDITION TO COMMUNITY HEALTH FAIRS AND SCREENINGS, JMH IS COMMITTED TO MEETING THE NEEDS OF THIS COMMUNITY FOR GENERATIONS TO COME. WE PROVIDE HANDS ON EXPERIENCE FOR FUTURE HEALTHCARE PROVIDERS AND SHADOWING EXPERIENCES FOR STUDENTS EXPLORING THEIR CAREER OPTIONS. BY WORKING WITH ORGANIZATIONS LIKE THE WELLSVILLE AREA CHAMBER OF COMMERCE, THE ALLEGANY WESTERN STEUBEN RURAL HEALTH NETWORK AND SEVERAL ALLEGANY COUNTY DEPARTMENTS, WE ARE PARTNERS HELPING THIS COMMUNITY GROW TOWARDS A HEALTHY FUTURE. Schedule H, Part III, Section A, Line 4 PATIENT ACCOUNTS RECEIVABLE ARE DUE 30 DAYS AFTER THE DATE OF DISCHARGE. RECEIVABLES PAST DUE MORE THAN 120 DAYS ARE CONSIDERED DELINQUENT. DELINQUENT RECEIVABLES ARE GENERALLY WRITTEN OFF BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE PATIENT AND OTHER THIRD PARTY PAYORS. Schedule H, Part III, Section B, Line 8 THE AMOUNT ON LINE 6 IS CALCULATED FROM WORKSHEET E PARTS A AND B ON THE COST REPORT. THE FULL LOSS SHOULD BE CONSIDERED A COMMUNITY BENEFIT. Schedule H, Part III, Section C, Line 9b PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE RECEIVE A DISCOUNT FROM A SLIDING FEE SCHEDULE BASED ON THE FEDERAL POVERTY GUIDELINES. FLEXIBLE PAYMENT PLANS ARE INCORPORATED AS APPROPRIATE. Schedule H, Part VI, Line 2 THE HOSPITAL USES SEVERAL METHODS TO ASESS THE HEALTHCARE NEEDS OF THOSE IN THE SERVICE AREA. PUBLIC SURVEY INCLUDES SOME DEMOGRAPHIC INFORMATION AND A RATINGS SYSTEM FOR 48 ITEMS IDENTIFIED AS HEALTH NEEDS. THE PUBLIC WAS NOTIFIED OF THE SURVEY PROCESS AND ENCOURAGED TO PARTICIPATE THROUGH PAID ADVERTISING IN THE WELLSVILLE DAILY REPORTER AND HORNELL EVENING TRIBUNE, PRESS RELEASES TO LOCAL NEWS AGENCIES, INVITATIONS ON THE HOSPITAL WEBSITE HOME PAGE, DISTRIBUTION OF PAPER SURVEYS THROUGH THE JMH MEDICAL PRACTICE SITES (SIX IN TOTAL THROUGHOUT ALLEGANY COUNTY) AND THROUGH EMAIL DISTRIBUTION OF THE SURVEY TO AGENCY LIST SERVES IN THE REGION. THE SURVEY WAS ALSO DISTRIBUTED VIA SURVEY MONKEY, AN ONLINE SURVEY SERVICE TO ALLOW RECIPIENTS TO RECEIVE AND RESPOND VIA EMAIL. Schedule H, Part VI, Line 3 OUR PATIENT STATEMENTS PROVIDE A NOTICE INFORMING PATIENTS ABOUT OUR FINANCIAL ASSISTANCE PROGRAM. WE HAVE FINANCIAL COUNSELORS THAT CONTACT OUR SELF PAY POPULATION AND INFORM THEM OF OUR PROGRAM. THEY SEND LETTERS FOR THOSE THEY ARE UNABLE TO REACH BY TELEPHONE. WE HAVE SIGNAGE THROUGHOUT OUR CAMPUS INDICATING WE HAVE A FINANCIAL ASSISTANCE PROGRAM WITH THE CONTACT INFORMATION. EACH SELF PAY INPATIENT IS SEEN AND EDUCATED ABOUT OUR PROCESS FOR APPLYING FOR FINANCIAL ASSISTANCE. Schedule H, Part VI, Line 4 THE HOSPITAL SERVICE AREA IS PRIMARILY ALLEGANY COUNTY. WHILE 80 PERCENT OF THE INPATIENT AND OUTPATIENT VISITS ORIGINATE FROM WELLSVILLE, BOLIVAR, ANDOVER, BELOMONT, SCIO, FRIENDSHIP, BELFAST, ANGELICA AND WHITESVILLE, FOR THE PURPOSES OF COMMUNITY HEALTH NEED AND COLLABORATIVE EFFORTS, JONES MEMORIAL HOSPITAL VIEWS THE GREATER ALLEGANY COUNTY REGION AS THE SERVICE AREA. JONES MEMORIAL HOSPITAL IS THE ONLY ACUTE CARE HOSPITAL IN ALLEGANY COUNTY HPSA DEISGNATION. X X X 0 0 0 0 0 0 0 0 0 HEATHER LANPHERE OB/GYN 345206 0 0 0 0 0 0 0 49820 0 395026 0 0 0 F CLIFTON MILLER OB/GYN 354599 0 0 0 0 0 0 0 47403 0 402002 0 0 0 KEITH GEMBUSIA MD 195194 0 0 0 0 0 0 0 40020 0 235214 0 0 0 EVA BENEDICT Exec Director/CEO 236987 0 0 0 0 0 0 0 7880 0 244867 0 0 LU-ANNE KAYE MD 180206 0 0 0 0 0 0 0 37829 0 218035 0 0 0 MARK ELLIOTT CRNA 194411 0 0 0 0 0 0 0 20205 0 214616 0 0 0 TRACY GATES CFO 156348 0 0 0 0 0 0 0 22970 0 179318 0 0 0 Form 990, Part VI, Section B, Line 11b THE 990 WAS PRESENTED TO THE BOARD OF DIRECTORS PRIOR TO FILING. THE 990 IS PREPARED BY THE ACCOUNTING DEPARTMENT AND REVIEWED BY THE CHIEF FINANCIAL OFFICER. Form 990, Part VI, Section B, Line 12c ANNUALLY, THE HOSPITAL REQUIRES ALL BOARD MEMBERS, SENIOR MANAGERS AND DEPARTMENT MANAGERS TO COMPLETE THE CONFLICT OF INTEREST STATEMENT. THE STATEMENTS ARE REVIEWED BY THE HOSPITAL'S COMPLIANCE OFFICER FOR ANY POTENTIAL CONFLICTS. Form 990, Part VI, Section B, Line 15 THE CEO'S SALARY IS SET FOR A SPECIFIC CONTRACT PERIOD BY THE BOARD OF DIRECTORS AND INCLUDES AN ESCALATION CLAUSE FOR INCREASES DURING THE CONTRACT PERIOD. THE PROCESS INCLUDES A REVIEW OF COMPARABLE DATA FOR THE MARKET AREA AND THE COMPLETE CONTRACT IS APPROVED BY THE BOARD OF DIRECTORS. Form 990, Part VI, Section C, Line 19 THE ORGANIZATION DOES MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. THE HOSPITAL PUBLISHES AN ANNUAL FINANCIAL AND STATISTICAL REPORT IN THE LOCAL NEWSPAPER EACH SPRING. IT ALSO HAS THESE DOCUMENTS AVAILABLE FOR IN PERSON REVIEW OR WITHIN 30 DAYS OF A WRITTEN REQUEST FROM THE GENERAL PUBLIC. COPIES OF THESE DOCUMENTS ARE STORED IN THE ADMINISTRATIVE OFFICE OF THE HOSPITAL FOR THIS PURPOSE. Form 990, Part XI, Line 9 CHANGE IN UNREALIZED GAIN/LOSSES ON INVESTMENTS = -29151, PENSION LIABILITY ADJUSTMENT = -5,977,051, TEMP RESTRICTED CONTRIBUTIONS = 413,122 AND CHANGE IN VALUE OF PERPETUAL TRUST = -35,796. TOTAL = -5,628,876. SUBMITTED FORM 8868