2013-11-12T14:16:21-06:00 2012-12-31 161226221 FUST CHARLES CHAMBERS LLP 5784 WIDEWATERS PARKWAY SYRACUSE NY 13214 990 2012-01-01 150532180 CHENANGO MEMORIAL HOSPITAL INC CHEN 6073374111 179 NORTH BROAD STREET NORWICH NY 13815 DRAKE LAMEN MD 6073374111 2013-11-12 1 ANGELA M FRANCO P00589741 3154463600 2012 2016-02-24 21:20:13Z DRAKE LAMEN MD 179 NORTH BROAD STREET NORWICH NY 13815 69862113 0 X WWW.UHS.NET/CMH X 1910 NY CHENANGO MEMORIAL HOSPITAL, INC. (THE HOSPITAL) IS A NOT-FOR-PROFIT CORPORATION ORGANIZED TO OPERATE ACUTE AND SKILLED NURSING FACILITIES IN NORWICH, NEW YORK. THE HOSPITAL PROVIDES INPATIENT, OUTPATIENT, AND EMERGENCY CARE SERVICES FOR RESIDENTS OF CHENANGO COUNTY. 15 10 635 102 51000 -49591 1117338 905361 63938784 67702540 308094 334261 406955 918747 65771171 69860909 55362 54180 0 0 33932059 34655854 0 0 0 29950985 32874534 63938406 67584568 1832765 2276341 33030740 34995961 35146459 32005060 -2115719 2990901 X CHENANGO MEMORIAL HOSPITAL, INC. (THE HOSPITAL) IS A NOT-FOR-PROFIT CORPORATION ORGANIZED TO OPERATE ACUTE AND SKILLED NURSING FACILITIES IN NORWICH, NEW YORK. THE HOSPITAL PROVIDES INPATIENT, OUTPATIENT, AND EMERGENCY CARE SERVICES FOR RESIDENTS OF CHENANGO COUNTY. 0 0 22050193 21090815 INPATIENT, ACUTE AND LONG TERM SKILLED NURSING SERVICES- CHENANGO MEMORIAL HOSPITAL FULFILLS ITS MISSION BY WORKING TOGETHER WITH THE COMMUNITY, PHYSICIANS AND OTHER HEALTH CARE PROVIDERS TO CONTINUOUSLY IMPROVE THE AVAILABILITY AND QUALITY OF SERVICES AND THE ABILITY TO PROVIDE A COMPREHENSIVE RANGE OF SHORT-TERM INPATIENT ACUTE SERVICES AND LONG-TERM SKILLED NURSING CARE. CHENANGO MEMORIAL HOSPITAL PROVIDES A WIDE RANGE OF MEDICAL-SURGICAL SERVICES, INCLUDING: OPHTHALMOLOGY, EMERGENCY MEDICINE, MATERNITY CARE, PULMONARY MEDICINE, AND PEDIATRICS. TOTAL INPATIENT DAYS FOR THE YEAR ENDED DECEMBER 31, 2012 TOTALED 7,781. DISCHARGES WERE 2,085, AND AVERAGE LENGTH OF STAY WAS 3.73 DAYS. LONG TERM SKILLED NURSING DAYS WERE 26,674. THERE WERE 310 BIRTHS AND 369 INPATIENT SURGERIES PERFORMED AT CHENANGO MEMORIAL HOSPITAL IN 2012. IN 2012, CHENANGO MEMORIAL HOSPITAL GAVE FINANCIAL ASSISTANCE TO 54 INDIVIDUALS FOR WHICH $593,727 OF INPATIENT CARE (AT CHARGES) WAS PROVIDED. 22477899 37954641 OUTPATIENT AND AMBULATORY SERVICES- CHENANGO MEMORIAL HOSPITAL ALSO PROVIDES A WIDE RANGE OF OUTPATIENT DIAGNOSTIC AND TREATMENT SERVICES, INCLUDING EMERGENCY DEPARTMENT, AMBULATORY SURGERY, FULL-SERVICE LABORATORY, COMPREHENSIVE IMAGING AND OTHER PROCEDURAL OUTPATIENT SERVICES. TOTAL PATIENT VISITS FOR OUTPATIENT SERVICES FOR YEAR-ENDED 2012 TOTALED 158,979. INCLUDED IN THE 158,979 VISITS WERE 14,957 EMERGENCY ROOM VISITS, 1,226 EMERGENCY ROOM TREATED AND ADMITTED AS ACUTE CARE PATIENTS, 2,543 VARIOUS OUTPATIENT SURGICAL CASES, AND 140,253 OTHER OUTPATIENT DEPARTMENT VISITS. IN 2012 CHENANGO MEMORIAL HOSPITAL GAVE FINANCIAL ASSISTANCE TO 542 INDIVIDUALS FOR WHICH $1,218,775 OF OUTPATIENT CARE (AT CHARGES) WAS PROVIDED. 17326335 8657084 CLINICS- CHENANGO MEMORIAL HOSPITAL PROVIDES A WIDE RANGE OF PRIMARY CARE AND SPECIALTY CARE CLINICS. PRIMARY CARE SERVICES ARE THE FOUNDATION FOR SERVING THE COMMUNITY WITH A COORDINATED SYSTEM OF CARE, WITH SPECIAL ATTENTION TO UNDER-SERVED AREAS. CMH OFFERS SIX FAMILY HEALTH CENTERS LOCATED THROUGHOUT A MULTI-COUNTY SERVICE AREA: 1) NORWICH FAMILY HEALTH CENTER 2) INTERNAL MEDICINE 3) OXFORD FAMILY HEALTH CENTER 4) SHERBURNE FAMILY HEALTH CENTER 5) SIDNEY FAMILY HEALTH CENTER AND 6) WALK-IN CENTER. OTHER OUTPATIENT SERVICES INCLUDE: DENTAL CLINIC, GERIATRICS, WOMEN'S HEALTH CENTER AND GENERAL SURGERY, ENT AND HEART CENTER. TOTAL PATIENT VISITS FOR THE CMH CLINICS AT YEAR-ENDED 2012 TOTALED 80,453. 54180 867747 54180 867747 61854427 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 78 0 1 635 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 15 10 0 0 0 0 1 1 0 1 1 0 0 0 1 1 1 1 1 1 1 0 NY X DRAKE LAMEN MD 6073374111 179 NORTH BROAD ST NORWICH NY 13815 DRAKE LAMEN MD 55.00 X X 287257 0 44593 HOWARD L ATKINSON 1.00 X 0 0 0 THOMAS C EMERSON 1.00 X 0 0 0 ROBERT W NASSAR 1.00 X X 0 0 0 MATTHEW J SALANGER 1.00 X X 0 1284770 38034 ERIC G LARSEN 1.00 X X 0 0 0 RAJESH DAVE MD 1.00 X 0 573938 33045 JOHN M KWASNIK 1.00 X 0 0 0 MARILYN M QUINNEY 1.00 X X 0 0 0 AARON J VALENTINE 1.00 X X 0 0 0 KEVIN B DECKER DDS 55.00 X X 190008 0 40569 JOANNE RACE BORFITZ 1.00 X 0 0 0 ROBERT G GOMULKA 1.00 X 0 460103 32888 CATHERINE M SCARLETT 1.00 X X 0 0 0 RIC FESTARINI 1.00 X 0 0 0 CYNTHIA BRIGLIN-MAVADY MD 1.00 X X 0 0 0 MARGARET SWARTWOOD 55.00 X 121843 0 27035 RON CEROW 55.00 X 115413 0 30928 ANNE ENGLISH 55.00 X 105318 0 20961 DRU CAVANAGH 33.00 22.00 X 88718 66621 31657 WENDY SURDOVAL 55.00 X 104688 0 25258 MICHAEL TREVISANI 55.00 X 276173 0 49238 CHRISTINA KISACKY 55.00 X 144532 0 35209 ROBERT MCCARTHY 27.50 27.50 X 82970 82970 20244 CHUNJIE YANG MD 55.00 X 300019 0 49076 EMMANUEL M GUIZANO MD 55.00 X 283736 0 32448 TIMOTHY COREY MD 55.00 X 299998 0 49778 FRANK C COLE III MD 55.00 X 293180 0 44033 JAMES O'BRIEN MD 55.00 X 350002 0 49843 3043855 2468402 654837 37 0 1 0 DELF KING MD PC PO BOX 819 NORWICH NY 13815 ANESTHESIA SVCS 1637999 MORRISON MANAGEMENT PO BOX 102289 ATLANTA GA 30368 THERAPY SVCS 1560663 CROTHALL BANC OF AMERICA LOCKBOX SVCS CHICAGO IL 60693 HOUSEKEEPING SVCS 1074826 VJC MEDICAL PO BOX 568 FRISCO TX 75034 PHYSICIAN TEMPORARY SERVICES 681044 SECO PHYSICAL AND OCCUPATIONAL THERAPY PO BOX 1046 NORWICH NY 13815 THERAPY SVCS 610041 14 2890 6647 284549 611275 905361 OUTPATIENT AND AMBULATORY SERVICE 623000 37954641 37954641 INPATIENT, ACUTE AND LONG TERM SK 623000 21090815 21090815 CLINICS 623000 8657084 8657084 67702540 334261 334261 1204 6647 1204 0 MEANINGFUL USE FUNDS 623000 413511 413511 OTHER OPERATING REVENUE 623000 233269 233269 CAFETERIA REVENUE 623000 220967 220967 51000 51000 918747 69860909 68570287 51000 334261 54000 54000 180 180 1806020 1806020 24382724 21964251 2418473 2845777 2561199 284578 3816132 3434519 381613 1805201 1624681 180520 824552 824552 16618 16618 97045 97045 12676 12676 4374130 4374130 8777 8777 580913 453750 127163 205541 198591 6950 1106451 998743 107708 89537 45955 43582 269881 269881 2193705 2193705 864381 864381 SUPPLIES 13975370 13014852 960518 BAD DEBTS 4932514 4932514 NEW YORK STATE CASH REC 612857 612857 MISCELLANEOUS AUXILLARY 15517 15517 2694069 2434701 259368 67584568 61854427 5730141 0 2071741 2880354 6550427 6688137 9125402 9338480 383401 393220 513496 554482 52567627 41179538 11355636 11388089 94312 95697 2936325 3657502 33030740 34995961 6135094 6024456 4057531 3659706 24953834 22320898 35146459 32005060 X -8953715 -4191967 386275 741074 6451721 6441794 -2115719 2990901 33030740 34995961 X 2276341 1385 2828894 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 12676 12676 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: DUES PAID TO HEALTHCARE ASSOCIATION OF NYS AND IROQUOIS HEALTHCARE 6837996 894949 2755 552832 7182868 6912990 1097217 -24876 1147335 6837996 6555026 885911 177728 705675 6912990 5781660 1128222 646828 1001684 6555026 7180804 1315814 -1251758 1463200 5781660 0.89680 0.10320 0 1 1 167753 167753 23089070 17030091 6058979 1349570 1052482 297088 25391576 22163630 3227946 2569658 933335 1636323 11388089 INTEREST IN CMH FOUNDATION 2563328 ASSETS LIMITED TO USE- RESTRICTED CASH FOR EQUIPMENT 687242 OTHER ASSETS 406932 3657502 DUE TO THIRD-PARTY PAYORS 4931661 DUE TO AFFILIATES 715873 LONG TERM PENSION LIABILITY 14429420 CAPITAL LEASE OBLIGATIONS 561389 OTHER LIABILITIES 1682555 22320898 X 69818661 0 69818661 42248 42248 69860909 67513924 0 67513924 70644 70644 67584568 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE INTENDED USE OF ENDOWMENT FUNDS IS A COMBINATION OF DESIGNATED SPECIAL PURPOSES AND GENERAL USE BY THE HOSPITAL. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: 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 EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE. THE HOSPITAL IS SUBJECT TO FEDERAL INCOME TAXES ON UNRELATED BUSINESS INCOME UNDER SECTION 511 OF THE INTERNAL REVENUE CODE. AS OF DECEMBER 31, 2012 AND 2011, THE HOSPITAL DID NOT HAVE ANY UNRECOGNIZED TAX BENEFITS OR ANY RELATED ACCRUED INTEREST OR PENALTIES. THE TAX YEARS OPEN FOR EXAMINATION BY FEDERAL AND STATE TAXING AUTHORITIES ARE 2009 THROUGH 2012. PART XI, LINE 4B - OTHER ADJUSTMENTS: AUXILIARY INCOME 42,248. PART XII, LINE 4B - OTHER ADJUSTMENTS: AUXILIARY EXPENSES 70,644. 1 1 X 1 X 1 X 1 1 0 1 1 681655 269289 412366 0.00660 11069705 8557930 2511775 0.04010 365090 323464 41626 0.00070 12116450 9150683 2965767 0.04740 12116450 9150683 2965767 0.04740 8375 8375 0.00010 17378 17378 0.00030 2987 2987 0.00000 5100 5100 0.00010 33840 33840 0.00050 0 1874355 935974 14053609 17428946 -3375337 X 1 0 1 1 CHENANGO MEMORIAL HOSPITAL INC

179 NORTH BROAD STREET NORWICH NY 13815

X X X CHENANGO MEMORIAL HOSPITAL 1 1 1 100.000000000000 1 0 1 1 X X X X X 1 0 X X X X 1 X 0 1 8 CMH FAMILY HEALTH CENTER IN NORWICH

4 NEWTON AVENUE NORWICH NY 13815

FAMILY HEALTH CENTER CMH FAMILY HEALTH CENTER IN SHERBURNE

38A CLASSIC STREET SHERBURNE NY 13460

FAMILY HEALTH CENTER CMH DENTAL CENTER

32 CONKEY AVENUE NORWICH NY 13815

DENTAL HEALTH CETNER CV STRATTON CENTER FOR THERAPIES

NORWICH SHOPPING PLAZA- ROUTE 12 NORTH NORWICH NY 13815

CENTER FOR THERAPIES CMH FAMILY HEALTH CENTER IN OXFORD

40 NORTH CANAL STREET OXFORD NY 13830

FAMILY HEALTH CENTER CMH FAMILY HEALTH CENTER IN SIDNEY

44 PEARL STREET SIDNEY NY 13838

FAMILY HEALTH CENTER CMH WALK-IN CENTER

4 NEWTON AVENUE NORWICH NY 13815

WALK IN CLINIC CMH ENT CENTER

32 CONKEY AVENUE NORWICH NY 13815

ENT CENTER PART I, LINE 3C: PATIENTS WHO HAVE NO INSURANCE, OR HAVE A PATIENT BALANCE ON A SINGLE ACCOUNT GREATER THAN $2,000, HAVE COMPLETED THE APPLICATION PROCESS, INCLUDING APPLYING FOR GOVERNMENT ASSISTANCE (IF DEEMED ELIGIBLE), AND ARE DENIED FOR THE SLIDING FEE FOR EXCESS INCOME, WILL BE AWARDED THE 15% "PARTICIPATION" DISCOUNT. NO FURTHER PAPERWORK IS REQUIRED. UNDER NO CIRCUMSTANCES CAN A PERSON RECEIVE BOTH A SLIDING FEE AND A 15% PARTICIPATION DISCOUNT. PART I, LINE 7: A COMBINATION OF IRS PROVIDED WORKSHEETS AND THE RATIO OF PATIENT CARE COST TO CHARGES WAS USED. PART I, L7 COL(F): 100% OF THE ANNUAL BAD DEBT EXPENSE OF $4,932,513 WAS NOT INCLUDED IN THE CALCULATION OF NET BENEFIT EXPENSE. PART II: THE HOSPITAL'S COMMUNITY BUILDING ACTIVITIES SUPPORT THE HOSPITAL'S MISSION TO DELIVER LOCAL, HIGH QUALITY HEALTHCARE, AND SERVE AS A GATEWAY TO CLINICALLY INTEGRATED SERVICES PROVIDED IN COLLABORATION WITH OTHER LOCAL, REGIONAL, AND NATIONAL CAREGIVERS. SEVERAL MID-LEVEL AND SENIOR-LEVEL MANAGERS SERVE ON COMMUNITY BOARDS THAT INCLUDE: CHENANGO COUNTY HOSPICE AND PALLIATIVE CARE, CHENANGO COUNTY DOH PAC, CHENANGO HEALTH NETWORK, CHENANGO MEMORIAL HOSPITAL FOUNDATION, AND THE CHENANAGO COUNTY EMS BOARD. ADDITIONALLY, THE HOSPITAL HOSTS AN ANNUAL MASH PROGRAM FOR TEENS INTERESTED IN PURSUING A CAREER IN HEALTHCARE AND STUDENTS IN THE NEW VISIONS PROGRAM HELD BY DCMO BOCES. CMH IS A PARTICIPANT IN THE ANNUAL HEALTH SCREENINGS AND WELLNESS EVENT HOSTED BY THE CHENANGO COUNTY ROTARY CLUB AND HOSTS 2 BLOOD DRIVES EACH YEAR FOR THE RED CROSS. LASTLY, THE HOSPITAL PARTICIPATES IN EMERGENCY PREPAREDNESS DRILLS THAT FREQUENTLY INCLUDE LOCAL AND STATE EMERGENCY PERSONNEL. CMH HOLDS DIABETES INFORMATION PROGRAMS IN THE COMMUNITY AND HOSTS SEVERAL SUPPORT GROUPS. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT SPECIFICALLY REFERENCE OR DESCRIBE BAD DEBT EXPENSE. THE ORGANIZATION'S COSTING METHODOLOGY USED IN DETERMINING THE AMOUNTS REPORTED ON PART III, SECTION A. LINES 2 AND 3 IS THE RATIO OF PATIENT CARE COSTS TO CHARGES. PART III, LINE 8: CMH FEELS THAT ANY SERVICES PROVIDED TO MEDICARE BENEFICIARIES THAT RESULT IN A SHORTFALL TO THE ORGANIZATION BASED ON A LESS THAN ADEQUATE MEDICARE REIMBURSEMENT SHOULD BE TREATED AS A COMMUNITY BENEFIT. CMH TREATS ANY AND ALL COMMUNITY MEMBERS REGARDLESS OF ABILITY TO PAY. CMH'S SERVICE REGION HAS A HIGHER PROPORTION OF ELDERLY THAT THE U.S. AVERAGE. THEREFORE, CMH IS SERVICING AT RISK MEDICARE BENEFICIARIES WITH ALL ITS PROGRAMS AND SERVICES. PART III, LINE 9B: THE ORGANIZATION'S COLLECTION POLICY PROVISIONS ON THE COLLECTION PRACTICES TO BE FOLLOWED FOR PATIENTS WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE ARE AS FOLLOWS:CHARITY CARE IS GIVEN FIRST, THE REMAINING BALANCE, IS THEN SUBJECT TO AN INTEREST FREE PAY PLAN. IF THE PATIENT/ GUARANTOR CHOOSES TO IGNORE ALL FURTHER ATTEMPTS TO MAKE ARRANGEMENTS FOR PAYMENTS, AFTER 180 DAYS THE ACCOUNT IS SENT TO A COLLECTION AGENCY AT THE DISCOUNTED LEVEL. PART III SECTION A #2 THE COST OF BAD DEBTS IS COMPUTED BY APPLYING THE OVERALL RATIO OF PATIENT COST TO CHARGES TO THE TOTAL BAD DEBT EXPENSE. PART III SECTION B #3 THE CHARITY CARE BAD DEBT IS DERIVED BY COMPUTING THE CHARGES SUBJECT TO COLLECTION WHICH IS THE DIFFERENCE BETWEEN THE TOTAL CHARGES AND SELF PAY AMOUNTS. THE OVERALL RATIO OF PATIENT COST TO CHARGES IS APPLIED TO CHARITY CARE BAD DEBT. CHENANGO MEMORIAL HOSPITAL PART V, SECTION B, LINE 20D: GROSS CHARGES TO ALL PATIENTS WHETHER INSURED OR NOT. CHENANGO MEMORIAL HOSPITAL PART V, SECTION B, LINE 22: ALL PATIENTS NO MATTER WHAT PAYMENT METHOD ARE CHARGED GROSS CHARGES, THE PATIENTS BALANCE CAN THEN BE REDUCED BY INSURANCE PAYMENTS AND CONTRACTUAL ADJUSTMENTS, AS WELL AS FINANCIAL ASSISTANCE ADJUSTMENTS/DISCOUNTS, SO THAT THE PATIENT ULTIMATELY MAY END UP PAYING MUCH LESS THAN GROSS CHARGES. PART VI, LINE 2: CHENANGO MEMORIAL HOSPITAL USES COMMUNITY SPECIFIC DATA FROM MULTIPLE SOURCES TO UNDERSTAND THE HEALTH CARE NEEDS OF OUR AREA RESIDENTS. DURING 2012, WE CONTINUED TO FOCUS ON IMPROVING COMMUNITY HEALTH CARE BY LISTENING TO INPUT FROM CUSTOMERS AND RESPONDING TO THOSE NEEDS. CHENANGO MEMORIAL HOSPITAL CONTINUALLY INVITES THE PUBLIC TO PARTICIPATE IN ITS SELF-ASSESSMENT PROCESS BY MEANS OF SURVEYS, PRIMARY MARKET STUDIES, FOCUS GROUPS, AND E-MAIL COMMENTS SUBMITTED THROUGH OUR COMPREHENSIVE INTERNET SITE. THROUGHOUT THE YEAR, INPUT FROM STAFF, THE PUBLIC AND BOARD MEMBERS IS UTILIZED IN DETERMINING AND SHAPING THE HOSPITAL'S RESPONSE TO THE COMMUNITY'S HEALTH CARE NEEDS. RECENT STUDIES USED BY OUR ORGANIZATION FOR THE PURPOSE OF ASSESSING OUR MARKET'S HEALTH STATUS INCLUDE:- PRESS GANEY PATIENT SATISFACTION SURVEY SCORES AND COMMENTS (ONGOING)- UHS-SPONSORED PRIMARY MARKET RESEARCH STUDIES, INCLUDING AN ONGOING CONSUMER PERCEPTION SURVEY CONDUCTED BY NRC.- MARKET EXPERT SOFTWARE FROM THE HOSPITAL ASSOCIATION OF NEW YORK STATE (HANYS) WHICH CONTAINS A HEALTH STATUS PROFILER MODULE.- ADMINISTRATIVE AND BOARD STRATEGIC PLANNING COMMITTEES.- FEEDBACK FROM PHYSICIANS- PHYSICIAN AND EMPLOYEE SATISFACTION SURVEYS.- QUALITATIVE SURVEYS AND FOCUS GROUPS TO CAPTURE CONSUMER FEEDBACK- LOCAL AND NATIONAL HEALTH-RELATED NEWS REPORTS.- REPORTS FROM INDUSTRY PUBLICATIONS AND ORGANIZATIONS.CHENANGO MEMORIAL HOSPITAL'S COMMUNITY SERVICE PLANNING IS SHAPED BY ANNUAL STRATEGIC PLANNING WHICH INCLUDES A REVIEW OF ALL AVAILABLE HEALTH/COMMUNITY ASSESSMENT DOCUMENTS, INCLUDING:- COMMUNITY HEALTH ASSESSMENT 2010-2013, CHENANGO COUNTY HEALTH DEPARTMENT- HEALTHY PEOPLE 2020- ANNUAL ENVIRONMENTAL ASSESSMENT PREPARED BY UHS MARKET RESEARCH- UHS, INC. 2012 STRATEGIC PLAN IN 2012, THE CHENANGO MEMORIAL HOSPITAL COMMUNITY SERVICE PLAN CONTINUED TO ADDRESS THE PREVENTION AGENDA OBJECTIVES CHOSEN IN COLLABORATION WITH THE CHENANGO COUNTY HEALTH DEPARTMENT AND OTHER COMMUNITY PARTNERS.CMH CONTINUALLY INVITES THE PUBLIC TO PARTICIPANT IN ITS SELF-ASSESSMENT PROCESS BY MEANS OF SURVEYS, PRIMARY MARKET STUDIES, FOCUS GROUPS, AND E-MAIL COMMENTS SUBMITTED THROUGH OUR COMPREHENSIVE INTERNET SITE. THROUGHOUT THE YEAR, INPUT FROM STAFF, THE PUBLIC AND BOARD MEMBERS IS UTILIZED IN DETERMINING AND SHAPING THE HOSPITAL'S RESPONSE TO THE COMMUNITY'S HEALTH CARE NEEDS. THE UHS INC. 2012 STRATEGIC PLAN WAS ALSO INTEGRAL TO ASSESSING COMMUNITY HEALTH NEEDS.CHENANGO MEMORIAL HOSPITAL (CMH) HAS BEEN AN ACTIVE MEMBER OF OUR COUNTY'S RURAL HEALTH NETWORK, CHENANGO HEALTH NETWORK (CHN), SINCE ITS INCEPTION TWENTY YEARS AGO, AND A CMH REPRESENTATIVE SITS ON THE CHN BOARD. THE NETWORK'S MEMBERSHIP INCLUDES BROAD-BASED REPRESENTATIVE OF LOCAL HEALTH AND HUMAN SERVICE PROVIDERS AND BUSINESSES. THE NETWORK'S QUARTERLY BOARD MEETINGS FOCUS ON HEALTH PRIORITY AREAS IN CHENANGO COUNTY, AND THEIR WORK PROVIDED PRELIMINARY INPUT INTO THE COMMUNITY SERVICE PLAN PRIORITIES. IN ADDITION, HOSPITAL STAFF, REPRESENTATIVES OF PUBLIC HEALTH, AND CHENANGO HEALTH NETWORK FORMED A PLANNING GROUP TO GUIDE THE PRIORITY SELECTION FOR THIS PLAN. IN ADDITION, CHENANGO COUNTY COMPLETED A 2 YEAR MAPP. THIS PROCESS ELICITED CONSUMER INPUT FROM OVER 20 FOCUS GROUPS CONDUCTED THROUGHOUT THE COUNTY DURING THE SPRING AND SUMMER OF 2009 AND INCLUDES A WIDE VARIETY OF DEMOGRAPHICS. INPUT FROM THIS PROCESS HAS BEEN FACTORED INTO THE PLANNING PROCESS OF CHENANGO MEMORIAL'S COMMUNITY SERVICE PLAN. PART VI, LINE 3: OUR ORGANIZATION INFORMS AND EDUCATES PATIENTS AND PERSONS WHO MAY BE BILLED FOR PATIENT CARE ABOUT THEIR ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE, OR LOCAL GOVERNMENT PROGRAMS OR UNDER OUR CHARITY CARE POLICY AS FOLLOWS:* EVERY CLINIC AND AREA OF PATIENT REGISTRATION HAS A NOTICE POSTED INFORMING THE PATIENT/S/PUBLIC OF THE AVAILABILITY OF FINANCIAL ASSISTANCE* BROCHURES DESCRIBING THE POLICY ARE AVAILABLE AT CLINICS, POINTS OF REGISTRATION, AND ARE MAILED TO SELF PAY PATIENTS ALONG WITH APPLICATIONS* INPATIENTS ARE VISITED BY THE PATIENT FINANCIAL ADVOCATE. THEY ARE MADE AWARE OF GOVERNMENT PROGRAMS AND IF NECESSARY, ARRANGEMENTS ARE MADE WITH THE DEPARTMENT OF SOCIAL SERVICES TO HAVE A WORKER COME IN AND TAKE THE APPLICATION FROM THE PATIENT. THE PATIENT IS GIVEN INFORMATION AND APPLICATION FOR FINANCIAL ASSISTANCE, AND APPLICATION CAN BE TAKEN RIGHT AT PATIENT BEDSIDE* THE WOMAN'S HEALTH CENTER INFORMS ALL SELF PAY PREGNANT WOMEN OF THE "PRESUMPTIVE ELIGIBILITY" PROCESS AND PATIENTS ARE DIRECTED TO PATIENT FINANCIAL SERVICES FOR COMPLETION OF THE APPLICATION AND COMPLETION OF A WIC APPLICATION IF PATIENT SO DESIRES* EVERY CMH EMPLOYEE IS MADE AWARE OF THE CHARITY CARE PROGRAM AT ORIENTATION AND ENCOURAGED TO MAKE PATIENTS AND THE PUBLIC AWARE OF THE PROGRAM. PERSONNEL WHO HAVE PATIENT CONTACT ARE ANNUALLY IN-SERVICED ON CHARITY CARE PROGRAM* EVERY BILL THAT IS SENT OUT IS MARKED "FOR INFORMATION REGARDING OUR "PATIENT FINANCIAL ASSISTANCE" PROGRAM" PLEASE CONTACT 607-337-4295 PART VI, LINE 4: CHENANGO MEMORIAL HOSPITAL'S SERVICE AREA IS CENTERED IN CHENANGO COUNTY BUT ALSO SERVES PATIENTS FROM OTSEGO, DELAWARE, AND MADISON COUNTIES. PATIENTS FROM CHENANGO COUNTY REPRESENT 68.5% OF THE HOSPITAL'S TOTAL SERVICE AREA WITH THE REMAINING 31.4% COMING FROM THE SURROUNDING COUNTIES. THE HOSPITAL'S PRIMARY SERVICE AREA CONSISTS OF NORTH PITCHER, SOUTH OTSELIC, NEW BERLIN, SHERBURNE, SMYRNA, GUILFORD, MCDONOUGH, MT UPTON, NORWICH, OXFORD, PLYMOUTH, SOUTH NEW BERLIN, AND SOUTH PLYMOUTH. IN THE SECONDARY SERVICE AREA, PATIENTS COME FROM PITCHER, EARLVILLE, AFTON, BAINBRIDGE, GILBERTSVILLE, SIDNEY, AND SMITHVILLE FLATS.PER CAPITAL INCOME, AS REPORTED BY THE US CENSUS BUREAU (2007-2011), IN CHENANAGO COUNTY WAS $22,786 VERSUS $31,796 FOR NEW YORK STATE. MEDIAN HOUSEHOLD INCOME FOR THE SAME PERIOD IN CHENANGO COUNTY WAS $44,662 VERSUS $56,951 FOR THE STATE. 13.9% OF RESIDENTS LIVE BELOW THE POVERTY LINE VS 14.5% STATEWIDE. IN 2012, CHENANGO COUNTY HAD A DISPROPORTIONATE SHARE OF RESIDENTS AGED 65+ AT 17.8% COMPARED TO THE NYS AVERAGE OF 14.1%. ONLY 17.5% OF RESIDENTS HAVE AT LEAST A BACHELOR'S DEGREE VERSUS 32.5% STATEWIDE. PART VI, LINE 5: THE UHS SYSTEMS MISSION IS TO SERVE THE PEOPLE OF OUR REGION, TO IMPROVE OR MAINTAIN THEIR HEALTH, AND TO PROVIDE THE PATIENT-CENTERED, CONTEMPORARY HEALTH SERVICES IN A CARING, COMPETENT, AND CONVENIENT MANNER. SERVICE WILL BE AFFORDABLE AND WELL ORGANIZED TO MEET THE NEEDS OF OUR PATIENTS AND THEIR FAMILIES. CMH SERVES THE COMMUNITY WITH AN OPEN MEDICAL STAFF AND A DIVERSE COMMUNITY BOARD OF DIRECTORS. ANY SURPLUS FUNDS GENERATED THROUGH OPERATIONS ARE USED SOLELY TO PURCHASE MEDICAL EQUIPMENT AND TECHNOLOGY, UPGRADE FACILITIES AND PROVIDE FOR PROGRAM SERVICE ENHANCEMENTS. PART VI, LINE 6: CMH IS AN IMPORTANT PART OF A LARGER SYSTEM OF INTEGRATED DELIVERY OF CARE, WHICH PROVIDES ADDITIONAL BENEFITS TO THE COMMUNITY. AS A RESULT OF THE FORMATION OF CMH IN 1910 AND THE SUBSEQUENT TRANSFORMATION OF THE COMBINED ORGANIZATION INTO A HEALTH CARE SYSTEM, OUR REGION TODAY OFFERS MORE COMPLETE AND ADVANCED CARE THAN MANY COMMUNITIES FIVE TIMES OUR SIZE. IN 2012, CHENANGO MEMORIAL HOSPITAL'S SYSTEM ENGAGED IN A STRATEGIC PLANNING PROCESS FOR THE YEARS 2013-2016. CONSISTENT WITH THE MISSION AND VISION, THE PLAN IS FOCUSED ON CONTINUING TO STRENGTHEN THE HEALTH SYSTEM AND ITS SERVICES TO COMMUNITY. THE STRATEGIC PLAN IS ORGANIZED AROUND FOUR GOALS: CLINICAL EXCELLENCE,SERVICE EXCELLENCE, MARKET GROWTH AND FINANCIAL STRENGTH. SPECIFIC DESTINATION METRICS OR MEASURES OF SUCCESS WERE DEVELOPED FOR EACH STRATEGIC GOAL. THE SPECIFIC INITIATIVES SUPPORTING ACHIEVEMENT OF THE GOALS ARE REVIEWED ON A REGULAR BASIS. EACH ENTITY CARRIES OUT INITIATIVES LOCALLY AND REGIONALLY. THE CMH COMMUNITY SERVICE REPORT CAPTURES THE BENEFITS SPECIFIC TO CMH. THE OTHER HOSPITAL MEMBERS OF THE UHS SYSTEM, UHS WILSON MEDICAL CENTER, UHS BINGHAMTON GENERAL HOSPITAL, AND DELAWARE VALLEY HOSPITAL SUBMIT SEPARATE REPORTS.- CLINICAL EXCELLENCE: CMH HAS FOCUSED ITS RESOURCES AND ENERGY AROUND ACHIEVING DISTINCTION AS A HEALTH SYSTEM IN CLINICAL QUALITY, PATIENT SAFETY AND SERVICE. CMH IS FOCUSED ON VIGOROUS ASSESSMENT AND IMPROVEMENT OF THE ORGANIZATION'S PERFORMANCE USING KEY PATIENT QUALITY, SAFETY AND SATISFACTION INDICATORS. THE PLAN PLACES A FOCUS IN PARTICULAR ON EMERGENCY ROOM PERFORMANCE, CLOSER INTEGRATION OF NON-ACUTE SERVICES WITH THE HOSPITALS, DEVELOPMENT AND IMPLEMENTATION OF STATE-OF-THE-ART INFORMATION TECHNOLOGY TO SUPPORT INITIATIVES IN PATIENT QUALITY AND SAFETY AND NEW INITIATIVES IN THE RECRUITMENT AND RETENTION OF A QUALITY PHYSICIAN AND ALLIED HEALTH WORKFORCE.- SERVICE EXCELLENCE: ADDRESS DELIVERING ON THE CMH BRAND PROMISE OF A MEANINGFULLY BETTER PATIENT EXPERIENCE. THE PLAN FOCUSES ON PATIENT-CENTERED CARE AND THE BRAND PROMISE OF RESPECT AND ACCOUNTABILITY. THIS GOAL ALIGNS TECHNOLOGY WITH PERFORMANCE STANDARDS TO IMPROVE ACCESS TO BETTER MEET PATIENT NEEDS.- MARKET GROWTH: THIS GOAL AREA ADDRESSES THE KEY ASPECTS OF ALIGNING TECHNOLOGY, PHYSICIAN RESOURCES AND PROGRAMS AROUND THE CLINICAL NEEDS OF THE SERVICE AREA. THE PLAN FOCUSES ATTENTION ON KEY TERTIARY SERVICES AND THE ASSURANCE OF AN ADEQUATE SUPPLY OF PRIMARY CARE AND SPECIALIST PHYSICIANS FOR THE AREA. AT THE SAME TIME, CMH REMAINS COMMITTED TO MEETING THE COMMUNITY'S BEHAVIORAL HEALTH SERVICES NEEDS.- FINANCIAL STRENGTH: TO ENSURE CMH HAS THE FINANCIAL CAPACITY TO SUPPORT ITS CLINICAL SERVICE AND GROWTH GOALS, THE STRATEGIC PLAN CALLS THE ORGANIZATION TO DEMONSTRATE CONSISTENT PERFORMANCE WITH RESPECT TO BENCHMARKED OPERATING EFFICIENCIES. THIS INCLUDES PARTICIPATING IN 340B INDIGENT CARE PHARMACY PRICING IN ORDER TO SERVE MORE ELIGIBLE PATIENTS AND PROVIDE MORE COMPREHENSIVE SERVICE.CHENANGO MEMORIAL HOSPITAL FILES THE COMMUNITY BENEFIT REPORT WITH NEW YORK STATE. 1 CMH AUXILIARY TO CMH HOSPITAL 179 NORTH BROAD STREET NORWICH NY 13815 150532180 501 (C) (3) 54000 0 CASH ESD ULTRASOUND AND MED/SURG BEDS X X 1 1 X X X X 0 0 0 0 0 0 0 0 0 DRAKE LAMEN MD 287257 0 0 0 0 0 30000 0 14593 0 331850 0 0 0 MATTHEW J SALANGER 0 805904 0 157106 0 321760 0 16750 0 21284 0 1322804 0 0 RAJESH DAVE MD 0 480788 0 78696 0 14454 0 16750 0 16295 0 606983 0 0 KEVIN B DECKER DDS 190008 0 0 0 0 0 22801 0 17768 0 230577 0 0 0 ROBERT G GOMULKA 0 388087 0 64036 0 7980 0 16750 0 16138 0 492991 0 0 DRU CAVANAGH 88718 66621 0 0 0 0 18641 0 13016 0 120375 66621 0 0 MICHAEL TREVISANI 276173 0 0 0 0 0 30000 0 19238 0 325411 0 0 0 CHRISTINA KISACKY 144532 0 0 0 0 0 17344 0 17865 0 179741 0 0 0 ROBERT MCCARTHY 82970 82970 0 0 0 0 5559 5559 4563 4563 93092 93092 0 0 CHUNJIE YANG MD 300019 0 0 0 0 0 30000 0 19076 0 349095 0 0 0 EMMANUEL M GUIZANO MD 283736 0 0 0 0 0 30000 0 2448 0 316184 0 0 0 TIMOTHY COREY MD 299998 0 0 0 0 0 30000 0 19778 0 349776 0 0 0 FRANK C COLE III MD 293180 0 0 0 0 0 30000 0 14033 0 337213 0 0 0 JAMES O'BRIEN MD 350002 0 0 0 0 0 30000 0 19843 0 399845 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 UNITED HEALTH SERVICES, INC. IS THE SOLE MEMBER OF CHENANGO MEMORIAL HOSPITAL, INC. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE MEMBER, UNITED HEALTH SERVICES, INC, SHALL ELECT TRUSTEES AT THE ANNUAL MEETING OF THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11 THE 990 PREPARATION AND FILING IS THE RESPONSIBILITY OF THE HOSPITALS BOARD OF DIRECTORS WHO DELEGATES THE TIMELY AND ACCURATE COMPLETION OF THE 990 TO MANAGEMENT. THE FINANCE DIVISION PREPARED THE 990 FORMS WHICH WAS REVIEWED BY THE ORGANIZATION'S PUBLIC ACCOUNTANTS, CONTROLLER AND VP OF FINANCE. FORM 990, PART VI, SECTION B, LINE 12C DIRECTORS, OFFICERS AND KEY EMPLOYEES SUBMIT CONFLICT OF INTEREST STATEMENTS ANNUALLY WHICH ARE REVIEWED BY THE CEO, BOARD CHAIRMAN AND THE ORGANIZATION'S AUDIT COMMITTEE. FORM 990, PART VI, SECTION B, LINE 15 IT IS THE PHILOSOPHY OF THE HOSPITAL THAT THE EXECUTIVE STAFF BE COMPENSATED FAIRLY FOR THEIR WORK. BASE SALARY LEVELS, INCENTIVE/BONUS PROGRAMS AND BENEFIT PLANS SHALL TAKE INTO ACCOUNT THE LOCAL, REGIONAL AND NATIONAL MARKETS TO ALLOW UHS HOSPITALS TO RECRUIT, MOTIVATE, REWARD, RECOGNIZE AND RETAIN HIGHLY TALENTED EXECUTIVES WITH THE SKILL SETS REQUIRED TO FULFILL ITS MISSION. THE EXECUTIVE COMPENSATION PROGRAM MUST FOCUS EXECUTIVES' ATTENTION ON UHS'S STRATEGIC INITIATIVES AND MISSION CRITICAL PERFORMANCE OBJECTIVES THAT WILL LEAD TO THE ORGANIZATION'S AND SYSTEM'S SUCCESS. TO CARRY OUT THIS COMPENSATION PHILOSOPHY, THE UHS HOSPITALS (WHICH INCLUDES CHENANGO MEMORIAL HOSPITAL) BOARD OF DIRECTORS' EXECUTIVE COMPENSATION COMMITTEE REVIEWS ANNUALLY A COMPREHENSIVE REPORT PREPARED BY AN EXTERNAL EXECUTIVE COMPENSATION CONSULTING FIRM, SULLIVAN COTTER ASSOCIATES TO DETERMINE THE APPROPRIATENESS OF THE BASE AND TOTAL COMPENSATION LEVELS FOR THE SENIOR MANAGEMENT STAFF. THIS ANNUAL REPORT FOCUSES ON TWO KEY AREAS; 1) THE COMPETITIVENESS OF THE SENIOR MANAGEMENT STAFF'S BASE AND TOTAL COMPENSATION (INCLUDING BENEFITS) VS. NATIONAL BENCHMARK DATA FOR COMPARABLY SIZED HEALTH CARE SYSTEMS AND HOSPITAL (BASED UPON 'TOTAL REVENUE' METRICS), AND 2) A 'REASONABLENESS ASSESSMENT' CONSISTENT WITH U.S. TREASURY DEPARTMENT REGULATIONS GOVERNING EXECUTIVE COMPENSATION FOR NOT-FOR-PROFIT ORGANIZATIONS. THE DATA FROM THIS REPORT ASSISTS THE EXECUTIVE COMPENSATION COMMITTEE IN DETERMINING THE APPROPRIATENESS OF THE SENIOR MANAGEMENTS' CURRENT BASE AND TOTAL COMPENSATION LEVELS AND THE NEED FOR ANY ADJUSTMENTS FOR THAT CALENDAR YEAR. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION PROVIDES FORM 1023, FORM 990 AND OTHER INFORMATION REQUIRED UNDER INTERNAL REVENUE SERVICE REGULATIONS TO THE PUBLIC, UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CUMULATIVE EFFECT OF AUXILIARY INCOME AND EXPENSE 28,401. CHANGE IN INTEREST IN CHENANGO MEMORIAL HOSPITAL FOUNDATION 415,623. PENSION CHANGES OTHER THAN NET PERIODIC BENEFIT COSTS -1,592,496. CHANGE IN VALUE OF FUNDS HELD IN TRUST BY OTHERS -9,927. FORGIVENESS OF DEBT BY AFFILIATE 3,987,293. UNITED HEALTH SERVICES HOSPITALS INC 33-57 HARRISON STREET JOHNSON CITY NY 13790 161165049 HOSPITAL NY 501 (C) (3) 3 UNITED HEALTH SERVICES INC 0 IDEAL SENIOR LIVING CENTER INC 508 HIGH AVENUE ENDICOTT NY 13760 222902896 SENIOR LIVING CENTER NY 501 (C) (3) 3 UNITED HEALTH SERVICES INC 0 IDEAL SENIOR LIVING CENTER HOUSING CO 508 HIGH AVENUE ENDICOTT NY 13760 222902899 SENIOR HOUSING NY 501 (C) (3) 9 UNITED HEALTH SERVICES INC 0 TWIN TIER HOME HEALTH INC 4401 VESTAL PARKWAY EAST VESTAL NY 13850 222348211 HOME HEALTH CARE NY 501 (C) (3) 3 UNITED HEALTH SERVICES INC 0 UNITED HEALTH SERVICES INC 20-42 MITCHELL AVENUE BINGHAMTON NY 13903 222682421 PARENT COMPANY NY 501 (C) (3) 9 BOARD OF DIRECTORS UHS INC 0 UNITED MEDMANAGEMENT 601 RIVERSIDE DRIVE JOHNSON CITY NY 13790 161396133 PHYSICIAN PRACTICES NY 501 (C) (3) 11B UNITED HEALTH SERVICES INC 0 PROFESSIONAL HOME CARE INC 4401 VESTAL PARKWAY EAST VESTAL NY 138503556 161261977 HOME HEALTH CARE NY 501 (C) (3) 3 UNITED HEALTH SERVICES INC 0 DELAWARE VALLEY HOSPITAL INC ONE TITUS PLACE WALTON NY 13856 150524324 HOSPITAL NY 501 (C) (3) 3 UNITED HEALTH SERVICES INC 0 ECKELBERGER TOWER INC 156 CORLISS AVENUE JOHNSON CITY NY 13790 237171440 MEDICAL STUDENT HOUSING NY 501 (C) (3) 9 UNITED HEALTH SERVICES INC 0 CMH FUND 179 NORTH BROAD STREET NORWICH NY 13815 222985550 INACTIVE NY 501 (C) (3) 11B CHENANGO MEMORIAL HOSPITAL INC 0 PROJECT HEAR INC 4401 VESTAL PARKWAY EAST VESTAL NY 13850 161462675 HOME EMERGENCY ALARM SYSTEM NY 501 (C) (3) 3 TWIN TIER HOME HEALTH INC 0 PATHWAY HEALTH MANAGEMENT INC 20 MITCHELL AVENUE BINGHAMTON NY 13903 161228654 WINDING DOWN OF MANAGEMENT SERVICES TO SUSQUENHANA MEDICAL ASSOCIATES NY UNITED HEALTH SERVICES INC C 0 CHENANGO MADA INC 179 N BROAD STREET NORWICH NY 13915 161290726 INACTIVE NY CMH FUND INC C 1.00000 0 1 1 1 0 1 0 0 0 0 0 0 1 1 0 1 0 0 0 0