2014-11-17T13:44:59-06:00 2013-12-31 161226221 FUST CHARLES CHAMBERS LLP 5784 WIDEWATERS PARKWAY SYRACUSE NY 13214 990 2013-01-01 141364513 ELIZABETHTOWN COMMUNITY HOSPITAL ELIZ 5188736377 75 PARK STREET ELIZABETHTOWN NY 12932 RODNEY BOULA CEO/PRESIDENT 5188736377 2014-11-15 1 JOSEPH J SCHLEGEL P00301329 3154463600 2013 2015-11-30 17:44:51Z RODNEY BOULA 75 PARK STREET ELIZABETHTOWN NY 12932 23372271 0 X ECH.ORG X 1926 NY MISSION: TO PROMOTE WELLNESS IN THE COMMUNITIES WE SERVE BY PROVIDING QUALITY HEALTHCARE WITH SKILL, COMPASSION AND DIGNITY. 11 11 261 30 143871 0 450608 1959533 19137204 19757896 104575 53617 1017799 1312627 20710186 23083673 0 0 0 0 11657683 13034863 0 0 0 7647417 7676902 19305100 20711765 1405086 2371908 22309385 23690754 11084821 10343854 11224564 13346900 X THE MISSION OF ECH IS TO PROMOTE HEALTH AND WELLNESS IN THE COMMUNITY AND TO PROVIDE QUALITY HEALTHCARE WITH SKILL, COMPASSION AND DIGNITY. IN CREATING OUR COMMUNITY BENEFITS PLAN WE KEEP THIS MISSION IN MIND, CONTINUALLY LOOKING FOR WAYS TO MEET COMMUNITY HEALTH NEEDS AND TO BE A GOOD NEIGHBOR. ECH IS DRIVEN BY PEOPLE WHO LIVE IN THE SERVICE AREA AND WHO WANT TO SEE THEIR FRIENDS AND NEIGHBORS GET THE CARE AND SERVICES THEY NEED. 0 0 4628614 5984631 INPATIENT ACUTE UNIT AND SUBACUTE REHABILITATIVE (SWING BED) INPATIENT PROGRAM:A 25-BED NURSING UNIT PROVIDING ACUTE AND SUB ACUTE (SWING BED)CARE. THE SMALLER ATMOSPHERE CREATES A CLOSER BOND BETWEEN THE PATIENT AND PROFESSIONALS ENCOURAGING OPTIMAL HEALING AND COMPASSIONATE CARE. THE SUB-ACUTE PROGRAM IS VITAL TO AREA RESIDENTS BECAUSE FOLLOWING A HIP-REPLACEMENT, KNEE-SURGERY OR CARDIAC OPERATION, RECUPERATION AND THERAPY CAN BE DONE AT ELIZABETHTOWN COMMUNITY HOSPITAL, SAVING THE FAMILY THE TIME AND EXPENSE OF TRAVEL. THE PROGRAM PROVIDES ONE-ON-ONE THERAPEUTIC CARE. 5419653 4439582 CLINIC SERVICES:ECH OPERATES THE ELIZABETHTOWN COMMUNITY HEALTH CENTER, WESTPORT HEALTH CENTER LOCATED IN WESTPORT , THE HIGH PEAKS HEALTH CENTER LOCATED IN WILMINGTON, NY AND THE SMITH HOUSE HEALTH CENTER LOCATED IN WILLSBORO, NY. ECH OPERATES AN OUTPATIENT CHEMOTHERAPY PROGRAM, WHICH INCLUDES UPDATED INFUSION EQUIPMENT MAKING IT POSSIBLE TO PROVIDE SAFE AND EFFICIENT METHODS FOR CHEMOTHERAPY AND BLOOD-RELATED INFUSIONS. IN ADDITION, THE NEW SPECIALIZED VENTILATING HOOD ENABLES THE PREPARATION OF CHEMOTHERAPY SOLUTIONS ON-SITE. THIS IS A GREAT CONVENIENCE FOR CANCER PATIENTS, SAVING THEM THE 90-MINUTE ROUND-TRIP DRIVE TO THE CLOSEST CHEMOTHERAPY FACILITY. 3001097 4314328 EMERGENCY ROOM SERVICES:ECH'S PRIOR YEARS EXPANSION OF THE EMERGENCY ROOM ADDED NEW STATE OF THE ART TRAUMA ROOMS, A TELEMENTRY SYSTEM FOR PATENT MONITORING, A REGISTRATION AREA DESIGNED FOR PATIENT PRIVACY AND CONFIDENTIALITY AND NEW WAITING AREAS FOR FAMILIES AND THEIR LOVED ONES.THE HOSPITAL OPERATES AN ALL-DIGITAL RADIOLOGY DEPARTMENT, ALLOWING TECHNOLOGISTS TO OBTAIN PATIENT IMAGES ANYWHERE IN THE HOSPITAL. IN THE EVENT OF A SIGNIFICANT EMERGENCY WITH MULTIPLE TRAUMAS, THE UNIT CAN BE USED ANYWHERE IN THE BUILDING. WHEN THE HOSPITAL IS FACED WITH AN UNUSUAL SURGE IN EMERGENCY ROOM TRAUMA CASES, HOSPITAL PROCEDURES ENABLE STAFF TO TRIAGE IN NONTRADITIONAL AREAS OF THE HOSPITAL. 4528552 6188111 4528552 6188111 17577916 1 1 0 0 0 0 0 0 0 1 1 1 0 0 1 1 1 1 0 0 0 0 0 0 1 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 21 0 1 261 1 0 0 0 0 0 0 0 0 0 0 X 11 11 0 0 0 0 1 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X ALAN CHARDAVOYNE CFO ECH 5188733136 75 PARK STREET ELIZABETHTOWN NY 12932 ALAN HIPPS BOARD TREASURER 0.80 X X 0 0 0 REV FRED SHAW BOARD MEMBER 0.80 X 0 0 0 PATTY BASHAW BOARD VICE PRESIDENT 0.80 X X 0 0 0 JAMES FORCIER BOARD PRESIDENT 2.00 X X 0 0 0 DOMINIC EISINGER PHD BOARD MEMBER 0.80 X 0 0 0 GEORGE SALG BOARD MEMBER 0.80 X 0 0 0 PATRICIA HICKEY BOARD SECRETARY 0.80 X X 0 0 0 MARTIN NEPHEW BOARD MEMBER 0.80 X 0 0 0 STEPHEN J VALLEY BOARD MEMBER 0.80 X 0 0 0 ROBERT A PERKINS BOARD MEMBER 0.80 X 0 0 0 H NICOLAS MULLER III PHD BOARD MEMBER 0.80 X 0 0 0 RODNEY BOULA CEO/PRESIDENT 40.00 X 249263 0 46450 MATT NOLAN COO 40.00 X 138724 0 8541 ALAN CHARDAVOYNE CFO 40.00 X 170396 0 10184 ROB DEMURO MD MEDICAL DIRECTOR 40.00 X 284636 0 36194 PASQUALINO CAPUTO PHYSICIAN 40.00 X 275693 0 35990 PATRICK JOHNSTON PHYSICIANS ASSISTANT 40.00 X 230389 0 11434 MARY GLICKMAN PHYSICIAN 40.00 X 246095 0 29387 HARRY DAVIS PHYSICIAN 40.00 X 136457 0 19867 JESSICA CRANE PHYSICIAN 40.00 X 134230 0 13962 1865883 0 212009 19 0 1 0 0 12682 1888326 58525 1959533 CRITICAL ACCESS HOSPITAL 900099 19757896 19757896 19757896 65478 65478 114000 114000 0 145000 156861 -11861 -11861 -11861 17737 12682 17737 0 340B REVENUE 900099 761081 761081 MEANINGFUL USE INCOME 900099 407675 407675 OTHER OPERATING REV. 900099 143871 143871 1312627 23083673 20926652 143871 53617 1531553 973170 558383 9210250 7643114 1567136 404418 315146 89272 1152115 950253 201862 736527 573925 162602 21049 21049 88382 88382 102317 102317 206602 127251 79351 103444 45979 57465 95362 50262 45100 1737156 1737156 477793 477793 CONTRACTED, LINEN & PUR 1661827 1479998 181829 BAD DEBT EXPENSE 893366 893366 MAINTENANCE AND UTILITI 890998 848251 42747 DRUGS SUPPLIES, GASES & 635804 635804 762802 635749 127053 20711765 17577916 3133849 0 3079232 3497759 1806051 1666697 84539 104380 3023225 2753565 256326 252590 306950 338316 14656769 1731928 11533585 12924841 1761381 2006306 458096 146300 22309385 23690754 1365646 1650737 552626 649726 5955000 5745000 1660544 1284854 1551005 1013537 11084821 10343854 X 10481490 12617829 728334 714331 14740 14740 11224564 13346900 22309385 23690754 X 2371908 206796 -456368 X 0 1 X 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 743074 1821094 11 1835108 729071 771785 423593 11 452315 743074 1075485 231296 256 535252 771785 982946 243135 181 150777 1075485 1777277 796072 -558 1589845 982946 0.97980 0.02020 0 0 970000 970000 9537308 643546 8893762 3918683 1054111 2864572 230778 34271 196507 12924841 U.S. GOVERNMENT AND AGENCY OBLIGATIONS 174499 F MUTUAL FUNDS 782184 F ASSETS BACKED SECURITIES 38487 F MARKETABLE EQUITY SECURITIES 1011136 F 2006306 DUE TO AFFILIATES 29354 INTEREST RATE SWAP LIABILITY 588957 WC/MALPRACTICE LIABILITY 71300 THIRD PARTY PAYOR SETTLEMENTS 323926 1013537 X 23101917 0 23101917 -18244 -18244 23083673 20825765 0 20825765 -114000 -114000 20711765 PART V, LINE 4: THE ENDOWMENT FUNDS (ASSETS WHOSE USE IS LIMITED) ARE TO BE USED FOR HOSPITAL EXPANSION AND RENOVATION AND PURCHASING HOSPITAL EQUIPMENT. PART X, LINE 2: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS GENERALLY EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE STANDARDS FOR ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES ESTABLISH A RECOGNITION THRESHOLD AND MEASUREMENT FOR INCOME TAX POSITIONS RECOGNIZED IN A HOSPITAL'S FINANCIAL STATEMENTS. THESE STANDARDS HAD NO IMPACT ON THE ACCOMPANYING FINANCIAL STATEMENTS. THE TAX YEARS OPEN TO EXAMINATION BY FEDERAL AND STATE TAXING AUTHORITIES ARE 2010 THROUGH 2013. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -114,000. GRANTS 95,756. PART XII, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -114,000. GOLF TOURNAMENT 30419 12682 17737 2163 14104 1470 30419 12682 17737 2163 14104 1470 17737 0 1 1 1 X 1 X 200.000000000000 1 1 1 0 1 1 196673 93457 103216 0.00500 2625885 1247800 1378085 0.06650 2822558 1341257 1481301 0.07150 2822558 1341257 1481301 0.07150 1 893366 47339 9276508 8862276 414232 X 1 1 1 1 ELIZABETHTOWN COMMUNITY HOSPITAL 75 PARK STREET PO BOX 277 ELIZABETHTOWN NY 12932 X X X 25 BEDS (ACUTE & SWING), 4 HEALTHCENTERS, CT, LAB, PHARM. PT. AMB SURG. ELIZABETHTOWN COMMUNITY HOSPITAL 1 1 X X X X X X X X 13 1 1 1 X WWW.AHRN.ORG, WWW.CO.ESSEX.NY.US X X X X X X X X X X 0 0 1 1 150.000000000000 1 1 X 1 1 X X X X 1 0 1 0 1 ELIZABETHTOWN COMMUNITY HOSPITAL PART V, SECTION B, LINE 3: EXECUTIVES FROM THE FOLLOWING INSTITUTIONS: ADIRONDACK HEALTH, INTER-LAKES HEALTH, MOSES-LUDINGTON HOSPITAL, ADIRONDACK RURAL HEALTH NETWORK AND ESSEX COUNTY PUBLIC HEALTH. ELIZABETHTOWN COMMUNITY HOSPITAL PART V, SECTION B, LINE 5D: ESSEX COUNTY PUBLIC HEALTH ELIZABETHTOWN COMMUNITY HOSPITAL PART V, SECTION B, LINE 7: PLEASE SEE ATTACHED IMPLEMENTATION PLAN AT PAGES 10 AND 11. ELIZABETHTOWN COMMUNITY HOSPITAL PART V, SECTION B, LINE 22: THE ORGANIZATION USES A GLOBAL FEE SCHEDULE. IF THE PATIENT APPLIED AND WAS DEEMED ELIGIBLE, THE APPROPRIATE DISCOUNTS WERE GRANTED. 4 ELIZABETHTOWN COMMUNITY HEALTH CENTER 66 PARK STREET ELIZABETHTOWN NY 12932 PRIMARY CARE HEALTH CENTER HIGH PEAKS HEALTH CENTER 7 COMMUNITY CIRCLE WILMINGTON NY 12997 PRIMARY CARE HEALTH CENTER SMITH HOUSE HEALTH CENTER 39 FARRELL ROAD WILLSBORO NY 12996 PRIMARY CARE HEALTH CENTER WESTPORT HEALTH CENTER 6097 NYS ROUTE 9N WESTPORT NY 12993 PRIMARY CARE HEALTH CENTER PART II, COMMUNITY BUILDING ACTIVITIES: THE HOSPITAL STAFF PARTICIPATES IN MANY LOCAL EVENTS THAT PROVIDE COMMUNITY MEMBERS THE OPPORTUNITY TO LEARN ABOUT THE HOSPITAL AND ABOUT IMPORTANT HEALTH SCREENINGS. IN ADDITION, THE HOSPITAL HOSTS EVENTS AND OFFERS TRAINING AND SUPPORT SERVICES TO OTHER HEALTH-ORIENTED ORGANIZATIONS. ECH PARTICIPATES IN THE FOLLOWING:(1)PROVIDES ADVANCED LIFE SUPPORT TRAINING FOR REGIONAL EMERGENCY MEDICAL TECHNICIANS. (2)PROVIDES MEDICAL DIRECTORSHIP TO SEVERAL LOCAL EMS AGENCIES, PROVIDES MONTHLY COURSES AND EDUCATION FOR CME CREDITS. (3)PROVIDES MEDICAL DIRECTORSHIP TO ST. JOSEPH'S ADDICTION TREATMENT & RECOVERY CENTER (4)SPONSORS AN ANNUAL DIABETES HEALTH FAIR AT THE HOSPITAL. (5)LENDS SPACE TO THE NORTH COUNTRY REGIONAL BLOOD DONOR CENTER FOR BLOOD DRIVES. (6)THE HOSPITAL AUXILIARY PROVIDES VOLUNTEERS FOR THE LAKE PLACID IRON MAN EVENT EACH JULY. (7)MEETING SPACE IS DONATED ON A MONTHLY BASIS TO EMS SQUADS. TECHNOLOGICAL CAPABILITIES ALLOW FOR DISTANCE TRAINING / EDUCATION. (8)WORKS WITH THE CANCER SCREENING PROGRAM TO PROVIDE INFORMATION ABOUT MAMMOGRAMS AND BONE DENSITY SCREENING AT THE ANNUAL BREAST CANCER AWARENESS EVENT. (9)FREE BLOOD PRESSURE CHECKS AND HEALTH INFORMATION ARE OFFERED AT THE ESSEX COUNTY FAIR. (10)HOSTS THE ESSEX COUNTY DIABETES SUPPORT GROUP MEETINGS IN THE HOSPITAL BOARDROOM. (11)EMPLOYEES FROM THROUGHOUT THE HOSPITAL USE HOSPITAL PAID TIME TO LEND THEIR EXPERTISE AND INCREASE THEIR INTERESTS IN SUCH AREAS AS THE ESSEX CO. HEALTHY LIVING PARTNERSHIP, WORKFORCE INVESTMENT BOARD, RETIRED SENIOR VOLUNTEER PROGRAM, TASK FORCE AGAINST DOMESTIC VIOLENCE, KIWANIS AND NORTH COUNTRY LIFE FLIGHT. (12)ECH'S CLINICAL STAFF COMPLETES ADDITIONAL TRAINING EACH YEAR (ACLS, PALS, BLS, VARIOUS RN / NURSING TRAINING PROGRAMS, CHEMOTHERAPY EDUCATION, PHYSICIAN EDUCATION, INFECTION CONTROL TRAINING, RADIOLOGY DEPARTMENT CONTINUING EDUCATION, LAB STAFF EDUCATION, ETC.) (13) MEETING SPACE FOR AA AND NA. EACH YEAR, THE HOSPITAL ALSO HOSTS THREE EVENTS THAT OFFER FREE HEALTH SCREENINGS TO LOCAL RESIDENTS. THE COMMUNITY HEALTH SCREENINGS ARE COORDINATED BY PUBLIC RELATIONS STAFF BUT ARE DEPENDENT UPON CLINICAL STAFF TO PERFORM EXAMS AND INTERPRET THE RESULTS. EACH EVENT IS STAFFED BY 5-8 CLINICAL STAFF MEMBERS FOR APPROXIMATELY 3-4 HOURS PER EVENT. (1)HUNTERS' HEALTH SCREENING (SEPTEMBER) IS A FREE, ANNUAL EVENT SPONSORED BY THE HOSPITAL. PARTICIPANTS RECEIVE A BASIC PHYSICAL / HEALTH SCREENING (EKG, BLOOD WORK, BLOOD PRESSURE, LAB TESTING, PHYSICIAN REVIEW AND REPORTING) AT NO COST. EVENT IS ARRANGED, COORDINATED AND PROMOTED BY ECH PUBLIC RELATIONS STAFF. IN 2013, THERE WERE APPROXIMATELY 44 PARTICIPANTS. (2)HEALTHY HEART DAY (FEBRUARY) IS ANOTHER FREE HEALTH SCREENING EVENT; AND IS CO-SPONSORED BY THE HOSPITAL AUXILIARY EACH YEAR. PARTICIPANTS RECEIVE HEART HEALTH EDUCATION, HEALTH SCREENINGS, LAB TESTING, PHYSICIAN REVIEW AND REPORTING. PARTICIPANTS CAN SPEAK TO EXPERTS DURING THE EVENT. IN 2013, THERE WERE 29 PARTICIPANTS. (3) IN MAY AND OCTOBER THE HOSPITAL HOSTS AN EVENT CO-SPONSORED BY THE CANCER SERVICES SCREENING PROGRAM OF ESSEX AND FRANKLIN COUNTIES AND THE HOSPITAL'S AUXILIARY. THE EVENING FEATURES A SPEAKER, ALONG WITH THE OPPORTUNITY TO TAKE PART IN A FREE HEALTH SCREENING. WOMEN WHO QUALIFIED (UN- OR UNDER-INSURED) WERE ABLE TO RECEIVE A CLINICAL BREAST EXAM AND MAMMOGRAM AT NO COST TO THEM, THROUGH THE CANCER SERVICES SCREENING PROGRAM OF ESSEX AND FRANKLIN COUNTIES. IN 2013, 22 FREE MAMMOGRAMS WERE OFFERED TO WOMEN AS PART OF THESE HEALTH FAIRS. PART III, LINE 4: THE BAD DEBT INCLUDED ON LINE 2 IS DETERMINED AT COST. FINANCIAL STATEMENT FOOTNOTE FOR BAD DEBT EXPENSE:THE HOSPITAL IS DESIGNATED AS A CRITICAL ACCESS HOSPITAL BY MEDICARE AND MEDICAID. THESE THIRD-PARTY PAYORS REIMBURSE THE HOSPITAL ON A COST BASIS. THE HOSPITAL ALSO HAS AGREEMENTS WITH OTHER THIRD-PARTY PAYORS. PAYMENT ARRANGEMENTS INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, COST-BASED REIMBURSEMENT, DISCOUNTED CHARGES AND PER DIEM PAYMENTS. NET PATIENT SERVICE REVENUE AND THE RELATED PATIENT ACCOUNTS RECEIVABLE ARE REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYORS AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS DUE TO FUTURE AUDITS, REVIEWS AND INVESTIGATIONS. RETROACTIVE ADJUSTMENTS ARE CONSIDERED IN THE RECOGNITION OF REVENUE ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ADJUSTED IN FUTURE PERIODS AS ADJUSTMENTS BECOME KNOWN OR AS YEARS ARE NO LONGER SUBJECT TO SUCH AUDITS, REVIEWS AND INVESTIGATIONS.AN ALLOWANCE FOR DOUBTFUL ACCOUNTS RECEIVABLE IS ESTIMATED BY MANAGEMENT BASED ON PERIODIC REVIEWS OF THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE CONSIDERING HISTORICAL EXPERIENCE AND PREVAILING ECONOMIC CONDITIONS. PART III, LINE 8: USED MEDICARE ONLY TOTAL CHARGES FROM REVENUE REPORT FOR 2013 AND APPLIED THE RATIO OF COST TO CHARGES FROM THE 2013 COST REPORT DATA. PART III, LINE 9B: THE ELIZABETHTOWN COMMUNITY HOSPITAL'S HELPING HANDS PROGRAM OFFERS FREE OR REDUCED CARE TO OUR PATIENTS WHO ARE UNINSURED OR UNDERINSURED AND MEET THE INCOME ELIGIBILITY CRITERIA SET BY THE FOLLOWING GUIDELINES. THE FREE OR REDUCED CARE APPLIES ONLY TO THE SERVICES PROVIDED BY THE ELIZABETHTOWN COMMUNITY HOSPITAL, WESTPORT HEALTH CENTER, ELIZABETHTOWN COMMUNITY HEALTH CENTER AND HIGH PEAKS HEALTH CENTER. PART VI, LINE 2: A NUMBER OF COMMUNITY PARTNERS ARE INVOLVED IN ASSESSING COMMUNITY HEALTH NEEDS WITHIN THE HOSPITAL'S SERVICE AREA.IN ADDITION TO ITS ESTABLISHED RELATIONSHIPS WITH OTHER HOSPITALS, COMMUNITY ORGANIZATIONS AND HEALTHCARE-BASED ORGANIZATIONS (EMS, PUBLIC HEALTH, MENTAL HEALTH, ETC.), ELIZABETHTOWN COMMUNITY HOSPITAL HAS PARTNERED WITH TWO REGIONAL GROUPS TO ASSESS THE REGION'S COMMUNITY HEALTH NEEDS - THE MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIPS COMMITTEE, AND THE ADIRONDACK RURAL HEALTH NETWORK.MOBILIZING FOR ACTION THROUGH PLANNING & PARTNERSHIP (MAPP): AGENCY REPRESENTATIVES FROM CLINTON, ESSEX, AND FRANKLIN COUNTIES MEET TO APPLY COMMUNITY BASED APPROACHES TO LOCAL HEALTH ISSUES. THE MAPP GROUP HAS WORKED TO CULL INFORMATION THROUGH ASSESSMENTS OF THE LOCAL PUBLIC HEALTH SYSTEMS, A CDC LOCAL PUBLIC HEALTH INDICATOR SURVEY, A QUALITY OF LIFE SURVEY OF SENIORS AND PARENTS WITH CHILDREN, AND FOCUS GROUPS. THE MAPP GROUP SHARES UPDATED INFORMATION ON A CONTINUAL BASIS TO REASSESS PRIORITIES AND GAUGE PROGRAM SUCCESS.ADIRONDACK RURAL HEALTH NETWORK (ARHN): THE ADIRONDACK RURAL HEALTH NETWORK IS A PARTNERSHIP OF PUBLIC, PRIVATE AND NON-PROFIT ORGANIZATIONS IN UPSTATE NEW YORK. ARHN MEMBERS COLLABORATE TO DEVELOP STRATEGIES ALONG WITH IMPLEMENTING, MONITORING AND EVALUATING VARIOUS INITIATIVES. THIS GROUP CONTINUES TO MEET ON A (ROUGHLY) MONTHLY BASIS IN ORDER TO SHARE INFORMATION, STATISTICS, SUCCESSES, CHALLENGES AND OUTCOMES. ELIZABETHTOWN COMMUNITY HOSPITAL (ECH): IN ADDITION TO PARTNERSHIPS WITH THE ARHN AND THE MAPP PROCESSES, ECH INDEPENDENTLY SEEKS THE VIEWS OF COMMUNITY MEMBERS TO GAIN THEIR THOUGHTS REGARDING HEALTH CARE IN THEIR COMMUNITY AND GAIN FEEDBACK REGARDING ECH SERVICES. THROUGHOUT 2010-2011 MANY DIFFERENT METHODS WERE USED TO COMMUNICATE WITH AREA RESIDENTS. EACH YEAR HOSPITAL ADMINISTRATOR ROD BOULA ATTENDS TOWN BOARD MEETINGS THROUGHOUT ESSEX COUNTY IN AN EFFORT TO UPDATE TOWN LEADERS AND COMMUNITY MEMBERS ABOUT THE HOSPITAL, ITS PLANS FOR THE FUTURE; AND TO ADDRESS ANY QUESTIONS. ANNUALLY, THE ADMINISTRATOR MEETS WITH EMS AND FIRE DEPARTMENTS WITHIN THE HOSPITAL SERVICE AREA TO ENCOURAGE OPEN COMMUNICATION AND FOSTER A GOOD WORKING RELATIONSHIP. THE ECH BOARD OF DIRECTORS IS COMPOSED OF 14 REPRESENTATIVES OF EITHER A SPECIFIC COMMUNITY AND/OR ORGANIZATION, INCLUDING THE ESSEX COUNTY OFFICE FOR THE AGING, TOWN OF ELIZABETHTOWN SUPERVISORS OFFICE, AND ESSEX COUNTY MENTAL HEALTH. A PLANNING COMMITTEE, COMPRISED OF BOARD MEMBERS, IDENTIFIES GAPS IN SERVICE AND DEVELOPS GOALS TO FILL THESE NEEDS. PATIENT SATISFACTION SURVEYS ARE CONDUCTED FOR EACH DEPARTMENT ON A CONTINUAL BASIS. PART VI, LINE 4: ELIZABETHTOWN COMMUNITY HOSPITAL'S PRIMARY SERVICE AREA HAS REMAINED UNCHANGED FOR 2013 PLANNING PURPOSES. IT IS COMPOSED OF TWENTY-TWO ZIP CODES IN NORTHEASTERN ESSEX COUNTY. THE HOSPITAL IS LOCATED 45-60 MINUTES AWAY FROM ANY OTHER HOSPITAL; THROUGH A MOUNTAINOUS REGION AND MOSTLY ALONG A SERIES OF SECONDARY ROADS.BASED ON U.S. CENSUS FOR 2010, 39,370 PEOPLE LIVE WITHIN ESSEX COUNTY OF WHICH 51.8% ARE MALE AND 48.2% ARE FEMALE. PEOPLE OVER THE AGE OF 65 CONSTITUTE 18.1% OF THE POPULATION AND CHILDREN UNDER THE AGE OF 18 MAKE UP 19.3% OF THE POPULATION.ETHNICALLY, 94.4% OF THE POPULATION IS WHITE, NON-HISPANIC. BY 2013 THE POPULATION OF THIS AREA IS EXPECTED TO DECLINE BY AN ESTIMATED 1.5%. PART VI, LINE 5: THE HOSPITAL STAFF PARTICIPATES IN MANY LOCAL EVENTS THAT PROVIDE COMMUNITY MEMBERS THE OPPORTUNITY TO LEARN ABOUT THE HOSPITAL AND ABOUT IMPORTANT HEALTH SCREENINGS. IN ADDITION, THE HOSPITAL HOSTS EVENTS AND OFFERS TRAINING AND SUPPORT SERVICES TO OTHER HEALTH-ORIENTED ORGANIZATIONS. ECH PARTICIPATES IN THE FOLLOWING:(1)PROVIDES ADVANCED LIFE SUPPORT TRAINING FOR REGIONAL EMERGENCY MEDICAL TECHNICIANS. (2)PROVIDES MEDICAL DIRECTORSHIP TO SEVERAL LOCAL EMS AGENCIES, PROVIDES MONTHLY COURSES AND EDUCATION FOR CME CREDITS. (3)PROVIDES MEDICAL DIRECTORSHIP TO ST. JOSEPH'S ADDICTION TREATMENT & RECOVERY CENTER (4)SPONSORS AN ANNUAL DIABETES HEALTH FAIR AT THE HOSPITAL. (5)LENDS SPACE TO THE NORTH COUNTRY REGIONAL BLOOD DONOR CENTER FOR BLOOD DRIVES. (6)THE HOSPITAL AUXILIARY PROVIDES VOLUNTEERS FOR THE LAKE PLACID IRON MAN EVENT EACH JULY. (7)MEETING SPACE IS DONATED ON A MONTHLY BASIS TO EMS SQUADS. TECHNOLOGICAL CAPABILITIES ALLOW FOR DISTANCE TRAINING / EDUCATION. (8)WORKS WITH THE CANCER SCREENING PROGRAM TO PROVIDE INFORMATION ABOUT MAMMOGRAMS AND BONE DENSITY SCREENING AT THE ANNUAL BREAST CANCER AWARENESS EVENT. (9)FREE BLOOD PRESSURE CHECKS AND HEALTH INFORMATION ARE OFFERED AT THE ESSEX COUNTY FAIR. (10)HOSTS THE ESSEX COUNTY DIABETES SUPPORT GROUP MEETINGS IN THE HOSPITAL BOARDROOM. (11)EMPLOYEES FROM THROUGHOUT THE HOSPITAL USE HOSPITAL PAID TIME TO LEND THEIR EXPERTISE AND INCREASE THEIR INTERESTS IN SUCH AREAS AS THE ESSEX CO. HEALTHY LIVING PARTNERSHIP, WORKFORCE INVESTMENT BOARD, RETIRED SENIOR VOLUNTEER PROGRAM, TASK FORCE AGAINST DOMESTIC VIOLENCE, KIWANIS AND NORTH COUNTRY LIFE FLIGHT. (12)ECH'S CLINICAL STAFF COMPLETES ADDITIONAL TRAINING EACH YEAR (ACLS, PALS, BLS, VARIOUS RN / NURSING TRAINING PROGRAMS, CHEMOTHERAPY EDUCATION, PHYSICIAN EDUCATION, INFECTION CONTROL TRAINING, RADIOLOGY DEPARTMENT CONTINUING EDUCATION, LAB STAFF EDUCATION, ETC.) (13) MEETING SPACE FOR AA AND NA. EACH YEAR, THE HOSPITAL ALSO HOSTS THREE EVENTS THAT OFFER FREE HEALTH SCREENINGS TO LOCAL RESIDENTS. THE COMMUNITY HEALTH SCREENINGS ARE COORDINATED BY PUBLIC RELATIONS STAFF BUT ARE DEPENDENT UPON CLINICAL STAFF TO PERFORM EXAMS AND INTERPRET THE RESULTS. EACH EVENT IS STAFFED BY 5-8 CLINICAL STAFF MEMBERS FOR APPROXIMATELY 3-4 HOURS PER EVENT. (1)HUNTERS' HEALTH SCREENING (SEPTEMBER) IS A FREE, ANNUAL EVENT SPONSORED BY THE HOSPITAL. PARTICIPANTS RECEIVE A BASIC PHYSICAL / HEALTH SCREENING (EKG, BLOOD WORK, BLOOD PRESSURE, LAB TESTING, PHYSICIAN REVIEW AND REPORTING) AT NO COST. EVENT IS ARRANGED, COORDINATED AND PROMOTED BY ECH PUBLIC RELATIONS STAFF. IN 2013, THERE WERE APPROXIMATELY 44 PARTICIPANTS. (2)HEALTHY HEART DAY (FEBRUARY) IS ANOTHER FREE HEALTH SCREENING EVENT; AND IS CO-SPONSORED BY THE HOSPITAL AUXILIARY EACH YEAR. PARTICIPANTS RECEIVE HEART HEALTH EDUCATION, HEALTH SCREENINGS, LAB TESTING, PHYSICIAN REVIEW AND REPORTING. PARTICIPANTS CAN SPEAK TO EXPERTS DURING THE EVENT. IN 2013, THERE WERE 29 PARTICIPANTS. (3) IN MAY AND OCTOBER THE HOSPITAL HOSTS AN EVENT CO-SPONSORED BY THE CANCER SERVICES SCREENING PROGRAM OF ESSEX AND FRANKLIN COUNTIES AND THE HOSPITAL'S AUXILIARY. THE EVENING FEATURES A SPEAKER, ALONG WITH THE OPPORTUNITY TO TAKE PART IN A FREE HEALTH SCREENING. WOMEN WHO QUALIFIED (UN- OR UNDER-INSURED) WERE ABLE TO RECEIVE A CLINICAL BREAST EXAM AND MAMMOGRAM AT NO COST TO THEM, THROUGH THE CANCER SERVICES SCREENING PROGRAM OF ESSEX AND FRANKLIN COUNTIES. IN 2013, 22 FREE MAMMOGRAMS WERE OFFERED TO WOMEN AS PART OF THESE HEALTH FAIRS. PART VI, LINE 6: COMMUNITY PROVIDERS, INC. (CPI), A NOT-FOR-PROFIT CORPORATION, IS THE SOLE MEMBER OF THE HOSPITAL AND CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER (CVPH), LOCATED IN PLATTSBURGH, NEW YORK. PART VI, LINE 7, REPORTS FILED WITH STATES NY X X X 0 0 0 0 0 0 0 0 0 RODNEY BOULA CEO/PRESIDENT 211263 0 38000 0 0 0 10469 0 35981 0 295713 0 0 0 ALAN CHARDAVOYNE CFO 160396 0 10000 0 0 0 7157 0 3027 0 180580 0 0 0 ROB DEMURO MD MEDICAL DIRECTOR 274636 0 10000 0 0 0 11955 0 24239 0 320830 0 0 0 PASQUALINO CAPUTO PHYSICIAN 275693 0 0 0 0 0 11579 0 24411 0 311683 0 0 0 PATRICK JOHNSTON PHYSICIANS ASSISTANT 230389 0 0 0 0 0 9676 0 1758 0 241823 0 0 0 MARY GLICKMAN PHYSICIAN 246095 0 0 0 0 0 5168 0 24219 0 275482 0 0 0 HARRY DAVIS PHYSICIAN 136457 0 0 0 0 0 5731 0 14136 0 156324 0 0 0 A ESSEX COUNTY INDUSTRIAL DEVELOPMENT AGENCY 141630643 2011-12-01 6160000 HOSPITAL RENOVATION AND EXPANSION 0 0 0 A 6160000 6160000 2009 1 0 1 1 A 0 0 0 0 0 0 1 A 0 0 0 0 0 0 0 0 0 A 0 SCHEDULE K, PART II ON MARCH 1, 2007, THE HOSPITAL ISSUED, THROUGH THE ESSEX COUNTY INDUSTRIAL DEVELOPMENT AGENCY, MULTI-MODE VARIABLE RATE DEMAND CIVIC FACILITY REVENUE BONDS, SERIES 2007A, IN THE AMOUNT OF $5,540,000 AND MULTI-MODE VARIABLE RATE DEMAND CIVIC FACILITY REVENUE REFUNDING BONDS, SERIES 2007B, IN THE AMOUNT OF $1,375,000. THE PROCEEDS FROM THE SERIES 2007A BONDS WERE USED FOR THE RENOVATION AND EXPANSION OF THE HOSPITAL. THE PROCEEDS FROM THE SERIES 2007B BONDS WERE USED TO REFINANCE THE MORTGAGE PAYABLE. ON DECEMBER 1, 2011, THE HOSPITAL REDEEMED THE SERIES 2007 BONDS IN THE AGGREGATE AMOUNT OF $6,160,000 (SERIES 2007A BONDS OF $5,330,000 AND SERIES 2007B BONDS OF $830,000) FUNDED BY THE PROCEEDS FROM THE ISSUANCE OF THE ESSEX COUNTY CAPITAL RESOURCE CORPORATION REVENUE BONDS, SERIES 2011 IN THE AMOUNT OF $6,160,000. THE SERIES 2011 BONDS WERE PURCHASED BY KEY BANK, N.A. UNDER A BOND PURCHASE AGREEMENT. AS PART OF THE AGREEMENT, THE SERIES 2011 BONDS ARE SUBJECT TO MANDATORY REDEMPTION IN SIMILAR AMOUNTS AS THE 2007 SERIES BONDS AND ARE SUBJECT TO OPTIONAL TENDER BY THE BANK FOR PURCHASE BY THE HOSPITAL AT A PRICE EQUAL TO THE PRINCIPAL PLUS ACCRUED AND UNPAID INTEREST BEGINNING ON JUNE 1, 2017. THE SERIES 2011 BONDS ARE SECURED BY A MORTGAGE THAT KEY BANK HOLDS WITH THE HOSPITAL. CERTAIN RESTRICTIVE COVENANTS INCLUDE REQUIREMENTS TO MAINTAIN CERTAIN FINANCIAL LEVELS AND RATIOS SUCH AS DAY'S CASH ON HAND AND FIXED CHARGE COVERAGE RATIOS. AT DECEMBER 31, 2013, THE HOSPITAL WAS IN COMPLIANCE WITH THE TERMS OF THE AGREEMENT. FORM 990, PART VI, SECTION A, LINE 6 COMMUNITY PROVIDERS, INC. (CPI) IS THE SOLE MEMBER OF ELIZABETHTOWN COMMUNITY HOSPITAL. FORM 990, PART VI, SECTION B, LINE 11 THE 990 WILL BE PROVIDED TO THE BOARD PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A WRITTEN CONFLICT OF INTEREST POLICY AND ALL MEMBERS ARE REQUIRED TO DISCLOSE ANY CONFLICTING INTERESTS OR STATE "NONE" ON THE ANNUAL CONFLICT OF INTEREST FORM. FORM 990, PART VI, SECTION B, LINE 15 THE GOVERNING BOARD IS PROVIDED AN INDEPENDENT REPORT OF COMPATIBLE HOSPITALS SALARY FOR THE CEO. THE GOVERNING BOARD ALSO REVIEWS VARIOUS PERFORMANCE MEASURES AND OTHER INFORMATION AND ARRIVES AT A SALARY AND BENEFIT PACKAGE FOR THE CEO. THE DIRECTOR OF HUMAN RESOURCES OBTAINS SALARY INFORMATION FROM AN INDEPENDENT SOURCE FOR LOCAL COMPATIBLE HOSPITALS FOR EACH HIGHER LEVEL POSITION AT THE HOSPITAL. THE INDEPENDENT INFORMATION CONTAINS SALARY LEVELS FOR EACH POSITION AT THE 25TH, 50TH AND 75TH PERCENTILE. THE CEO THEN CONSIDERS THIS INFORMATION AND THE PERFORMANCE FOR EACH OF THESE EMPLOYEES AND ARRIVES AT THE APPROPRIATE SALARY LEVEL. THE APPROACH AND METHODOLOGY IS ALSO PRESENTED TO THE GOVERNING BOARD. FORM 990, PART VI, SECTION C, LINE 19 THESE DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON WRITTEN REQUEST. FORM 990, PART XI, LINE 9: CHANGES IN FAIR VALUE OF INTEREST RATE SWAP 356,205. TRANSFER FROM FLETCHER ALLEN PARTNERS, INC 161,266. OVERSTATEMENT OF THIRD-PARTY SETTLEMENT FEES -878,083. GRANTS -95,756. CVPH MEDICAL CENTER 75 BECKMAN STREET PLATTSBURGH NY 12901 141338471 HOSPITAL PATIENT CARE NY 501(C)(3) 3 COMMUNITY PROVIDERS INC 0 COMMUNITY PROVIDERS INC 75 BECKMAN STREET PLATTSBURGH NY 12901 222544844 HEALTH CARE SERVICES NY 501(C)(3) 3 FLETCHER ALLEN PARTNERS 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0