2013-11-15T13:42:55-06:00 2012-12-31 161226221 FUST CHARLES CHAMBERS LLP 5784 WIDEWATERS PARKWAY SYRACUSE NY 13214 990 2012-01-01 150533578 LITTLE FALLS HOSPITAL LITT 3158231000 140 BURWELL STREET LITTLE FALLS NY 13365 JAMES VIELKIND 3158231000 2013-11-14 1 JOSEPH J SCHLEGEL P00301329 3154463600 2012 2016-03-07 17:11:31Z JAMES VIELKIND 140 BURWELL STREET LITTLE FALLS NY 13365 33524695 0 X LFHNY.ORG X 1893 NY LITTLE FALLS HOSPITAL IS A CRITICAL ACCESS HOSPITAL PROVIDING ACCESS TO HEALTH CARE SERVCIES TO RESIDENTS OF HERKIMER COUNTY, AND WESTERN PORTIONS OF MONTGOMERY AND FULTON COUNTIES. LITTLE FALLS HOSPITAL EMERGENCY DEPARTMENT IS STAFFED WITH PHYSICIANS ON A 24/7 BASIS. TWENTY FIVE BEDS ARE USED FOR INPATIENT AND SKILLED NURSING CARE. AMBULATORY SURGERY SERVCIES ARE PROVIDED FOR A VARIETY OF SPECIALTIES, PERFORMANCE IMPROVEMENT AND HIGH QUALITY OF CARE IS DEMOSTRATED WITHIN THE HOSPITAL CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS (HCAHPS) AS REPORTED IN HOSPITAL COMPARE. 16 13 347 17 0 0 856607 589094 26972536 28142900 196800 61421 0 0 28025943 28793415 0 0 0 0 13528783 14326208 9250 9250 76723 13425422 14047264 26963455 28382722 1062488 410693 30895128 34802499 13134431 15228007 17760697 19574492 X LITTLE FALLS HOSPITAL IS A VOLUNTARY, NOT-FOR-PROFIT COMMUNITY HEALTHCARE SYSTEM WHOSE MISSION IS TO OFFER QUALITY CARE WITH COMPASSION, TO ALL WHO NEED OUR SERVICES. 0 0 7634171 8546300 INPATIENT SERVICESLITTLE FALLS HOSPITAL INPATIENT SERVICES WERE ACTIVE IN PLANNING FOR THE FEBRAURY 2013 "GO LIVE" OF PROVIDER ORDER ENTRY ALONG WITH A COMPLETE INTEGRATED ELECTRONIC MEDICAL RECORD. A NEW PHARMACY DISPENSING PROCEDURE WAS IMPLEMENTED TO REDUCE POTENTIAL FOR MEDICATION ERRORS. THE HOSPITAL IMPROVED ITS PATIENT HOSPITAL CONSUMER ASSESSMENT RATING TO 75 FROM 62 FOR A PEER GROUP PERCENTILE RANKING OF 95. 7066656 8254568 LITTLE FALLS HOSPITAL OPERATES AN EMERGENCY DEPARTMENT WITH TWENTY FOUR HOURS OF PHYSICIAN COVERAGE SEVEN DAYS PER WEEK. THE EMERGENCY DEPARTMENT PROVIDED ACCESS TO CARE FOR APPROXIMATELY 16,000 PATIENTS IN 2012. THESE SERVCIES ARE PROVIDED TO ALL PATIENTS REGARDLESS OF ABILITY TO PAY. PLANNING FOR THE ELECTRONIC MEDICAL RECORD AND PROVIDER ELECTRONIC ORDER ENTRY WAS A LARGE PROJECT AHEAD OF THE FEBRUARY 2013 SYSTEM "GO LIVE" DATE. 8707080 10776927 TOTAL AMBULATORY OUTPATIENT VISITS WERE APPROXIMATELY 34,000 VISITS IN 2012. AN AMBULATORY FACILITY PROJECT WAS INITIATED TO IMPROVE PATIENT PRIVACY, UPDATE INFRASTRUCTURE, AND LOCATE SERVICES IN MORE EFFICIENT AREAS OF THE HOSPITAL. THIS PROJECT WILL BE COMPLETED IN 2013 WITH A TOTAL COST OF APPROXIMATELY $12M. 736780 1215620 THE HOSPITAL RECEIVED NYS MEDICAID "MEANINGFUL USE" FUNDS OF $186,000. THESE FUNDS WERE USED TO ASSIST IN FUNDING FOR THE IMPLEMENTATION OF THE ELECTRONIC MEDICAL REORD. 736780 1215620 24144687 1 1 0 0 0 0 0 0 0 1 1 1 1 0 1 1 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 1 0 0 0 1 33 0 1 347 1 0 0 0 0 0 0 0 0 0 0 X 16 13 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X JAMES G VIELKIND 3158235281 140 BURWELL STREET LITTLE FALLS NY 13365 JOHN BULLIS 2.00 1.50 X 0 0 0 JOAN S CONBOY 2.00 X 0 0 0 TIMOTHY DALY 2.00 X 0 0 0 ANTHONY DELUCA 2.00 X X 0 0 0 JOY MALONE 2.00 X 0 0 0 MARSHA MASON 2.00 X 0 0 0 GERARD J SNYDER 2.00 X X 0 0 0 JENNIFER VANWAGONER 2.00 X X 0 0 0 RANBIR SODHI MD 2.00 X 0 0 0 AUGUST LEINHART MD 2.00 40.00 X 0 473320 24803 NICHOLAS J NICOLETTA 2.00 51.50 X X 0 483575 26532 JEFFREY WOEPPEL 2.00 48.00 X X 0 197600 22077 KEVIN CROSLEY 2.00 X 0 0 0 JUSTIN HUMMEL 2.00 X 0 0 0 DALE ADAMSON MD 2.00 40.00 X 0 168059 14060 ROBERT CASULLO 2.00 X 0 0 0 MICHAEL OGDEN 40.00 X 0 153288 8331 JAMES G VIELKIND 40.00 X 130598 0 4136 RICHARD NOCELLA 40.00 X 157236 0 13968 287834 1475842 113907 6 0 1 0 BIVENS & ASSOCIATES ARCHITECTS 528 PLUM STREET SUITE 200 SYRACUSE NY 132041473 ARCHITECT SERVICES 385731 TWO BROTHERS CONTRACTING 185 MOHAWK STREET WHITESBORO NY 13501 CONTRACTOR SERVICES 225092 MEDSPAR LLC PO BOX 830 BINGHAMTON NY 139020830 BILLING SERVICES 136533 FUST CHARLES CHAMBERS 5784 WIDEWATER PARKWAY SYRACUSE NY 13214 AUDITING, TAX AND CONSULTING SERVICES 133892 DM CONSULTING PO BOX 4715 UTICA NY 13504 INFORMATION TECHNOLOGY 114400 5 342293 246801 589094 OUTPATIENT SERVICES 623000 19031495 19031495 INPATIENT HOSPITAL 621930 8546300 8546300 PROGRAM SERVICE LEASE 532000 433377 433377 HOSPITAL CAFETERIA 900099 124344 124344 OTHER OPERATING REVENUE 900099 7384 7384 28142900 66754 66754 4725947 4731280 -5333 -5333 -5333 28793415 28204321 0 0 305938 171204 134734 10873332 9336805 1488718 47809 805378 688104 113799 3475 1521774 1292625 222571 6578 819786 697143 119126 3517 70798 70798 43250 12145 31105 56272 56272 9250 9250 687329 459988 227341 2229070 2174173 53178 1719 795538 638333 157205 648192 563576 83988 628 31072 20333 10173 566 32678 15756 16189 733 152296 133426 18850 20 1374845 1204502 170161 182 240104 197290 42814 PURCHASED MEDICAL SERVI 3730570 3730570 PROVISION FOR BAD DEBT 2277927 2277927 ADMINISTRATIVE SERVICES 915028 915028 NEW YORK STATE ASSESSME 76843 76843 685452 453944 229262 2246 28382722 24144687 4161312 76723 348968 1265667 1039532 1146049 5437347 4009271 3484074 3044932 382900 394976 1215888 1607890 30562757 17302903 8962981 13259854 1915088 4883639 5478882 2429906 2455626 2299567 173842 460748 30895128 34802499 3217283 4192044 39912 31431 3937377 5119529 5939859 5885003 13134431 15228007 X 5007384 9475082 12028938 9327867 724375 771543 17760697 19574492 30895128 34802499 X 410693 268663 1134439 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 12753313 12870 1085526 3752299 10099410 12156996 623347 -27030 12753313 5547082 5230555 1782439 403080 12156996 2664349 174329 3874661 1166257 5547082 4951188 327877 -202282 2412434 2664349 0.07640 0.92360 0 1 1 339702 339702 20429734 10075440 10354294 9793321 7227463 2565858 13259854 MARY LEARY CHARITABLE REMAINDER TR 1003779 F ELSA O'BRIEN CHARITABLE REMAINER TR 1426127 F 2429906 DIRECT FINANCE LEASE 2299567 C 2299567 ACCRUED PENSION LIABILITY 4906176 ACCRUED SALARIES, PAYROLL TAXES AND FRINGE BENEFITS 903827 OTHER LIABILITIES 75000 5885003 X 30196517 268663 1134439 1403102 28793415 0 28793415 26104795 0 26104795 2277927 2277927 28382722 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ENDOWMENT FUNDS DISTRIBUTE INCOME FOR PURPOSES OF CAPITAL INVESTMENT. TEMPORARY ENDOWMENTS ARE USED BASED ON THE INTENT OF THE DONATION. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL QUALIFIES AS AN ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES PURSUANT TO SECTION 501(A) 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 TO EXAMINATION BY FEDERAL AND NEW YORK STATE TAXING AUTHORITIES ARE 2009 THROUGH 2012. THE HOSPITAL DOES NOT ANTICIPATE THAT THE TOTAL UNRECOGNIZED TAX BENEFITS WILL CHANGE IN THE NEXT TWELVE MONTHS. PART XI, LINE 2D - OTHER ADJUSTMENTS: PENSION RELATED CHANGES OTHER THAN NET PERIODIC BENEFIT COST 111,805. CHANGES IN VALUE OF BENEFICIAL REMAINDER TRUST 464,163. CHANGE IN INTEREST IN NET ASSETS OF FRIENDS OF BASSETT 558,471. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBTS 2,277,927. BUILDINGS INCLUDES CONSTRUCTION IN PROGRESS OF $5,696,846 FOR 2012 AND $1,115,093 FOR 2011 1 1 1 X 300.000000000000 0 1 1 0 1 1 252 149983 121248 28735 0.00110 1622 888572 850535 38037 0.00150 10990 3994820 3018815 976005 0.03740 12864 5033375 3990598 1042777 0.04000 2 78284 2883 75401 0.00290 2 78284 2883 75401 0.00290 2 12864 5111659 3993481 1118178 0.04290 1 838868 35883 9288741 9196773 91968 X 1 1 1 1 LITTLE FALLS HOSPITAL

140 BURWELL STREET LITTLE FALLS NY 13365

X X INCLUDES 25 INPATIENT BEDS, LITTLE FALLS HOSPITAL 1 0 1 1 300.000000000000 0 1 X 0 1 X X X X X X 1 0 X X X X 1 X 0 0 PART I, LINE 3C: LITTLE FALLS HOSPITAL DID NOT PROVIDE CHARITY CARE OR DISCOUNTED CARE TO PATIENTS WITH INSURANCE BENEFITS. PART I, LINE 7: COST FOR CHARITY CARE PATIENTS WAS CALCULATED USING RATIO OF COST TO CHARGES. COST ASSOCIATED WITH MEDICAID AND MEDICAID HMO PROGRAMS REPRESENTS AGGREGATE ALLOWABLE COST AND TOTAL GROSS CHARGES USED TO CALCULATE A FACILITY LEVEL COST TO CHARGE RATIO. THIS FACILITY LEVEL COST TO CHARGE RATIO WAS APPLIED TO TOTAL MEDICAID AND MEDICAID HMO CHARGES TO ARRIVE AT TOTAL MEDICAID COST. COST OF OTHER MEANS TESTED PROGRAMS IS COMPRISED OF MEDICAID HMO AND NYS FAMILY HEALTH PLUS INSURANCE PROGRAMS. PART I, LINE 7G: LITTLE FALLS HOSPITAL DOES NOT PROVIDE DISCOUNTED CARE FOR PATIENTS WITH INSURANCE. HARDSHIP CASES ARE REVIEWED ON AN INDIVIDUAL BASIS. PART I, L7 COL(F): LITTLE FALLS HOSPITAL REMOVED $2,277,927 OF BAD DEBT EXPENSE TO CALCULATE COST OF PATIENT CARE. PART III, LINE 4: 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 THAT PROVIDE FOR PAYMENTS AT AMOUNTS DIFFERENT FROM THEIR ESTABLISHED RATES. PAYMENT ARRANGEMENTS INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, COST-BASED REIMBURSEMENT, DISCOUNTED CHARGES AND PER DIEM PAYMENTS. THE HOSPITAL RECOGNIZES PATIENT SERVICE REVENUE ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY PAYOR COVERAGE ON THE BASIS OF CONTRACTUAL RATES FOR THE 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.FOR UNINSURED PATIENTS THAT DO NOT QUALIFY FOR CHARITY CARE, THE HOSPITAL RECOGNIZES REVENUE ON THE BASIS OF ITS STANDARD RATES FOR SERVICES PROVIDED OR ON THE BASIS OF NEGOTIATED DISCOUNTED RATES. ON A BASIS OF HISTORICAL EXPERIENCE, A SIGNIFICANT PORTION OF THE HOSPITAL'S UNINSURED PATIENTS WILL BE UNABLE OR UNWILLING TO PAY FOR THE SERVICES PROVIDED. THUS, THE HOSPITAL RECORDS A PROVISION FOR BAD DEBTS RELATED TO UNINSURED PATIENTS IN THE PERIOD THE SERVICES ARE PROVIDED. REVENUE FROM THE MEDICARE AND MEDICAID PROGRAMS, INCLUDING THE HMO PROGRAMS OFFERED BY THESE PAYORS, ACCOUNTED FOR APPROXIMATELY 55% AND 59% OF THE HOSPITAL'S NET PATIENT SERVICE REVENUE FOR THE YEARS 2012 AND 2011, RESPECTIVELY. LAWS AND REGULATIONS GOVERNING THE MEDICARE AND MEDICAID PROGRAMS ARE EXTREMELY COMPLEX AND SUBJECT TO INTERPRETATION. AS A RESULT, THERE IS AT LEAST A REASONABLE POSSIBILITY THAT RECORDED ESTIMATES WILL CHANGE BY A MATERIAL AMOUNT IN THE NEAR TERM. IN 2012 AND 2011, NET PATIENT SERVICE REVENUE INCREASED (DECREASED) BY APPROXIMATELY $101,000 AND $(150,000), RESPECTIVELY, RELATED TO EITHER SETTLEMENT OF PRIOR YEAR ISSUES OR CHANGES IN ESTIMATES ASSOCIATED WITH THIRD-PARTY ISSUES. THE HOSPITAL GRANTS UNSECURED CREDIT TO ITS PATIENTS, MOST OF WHOM ARE LOCAL RESIDENTS AND ARE INSURED UNDER THIRD-PARTY PAYOR AGREEMENTS. THE MIX OF RECEIVABLES FROM PATIENTS AND THIRD-PARTY PAYORS AT DECEMBER 31 WAS AS FOLLOWS: 2012 2011MEDICARE 45% 43%MEDICAID 10% 13%PRIVATE PAYORS 16% 11%INSURANCE AND ALL OTHERS 29% 33% 100% 100%PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS.THE HOSPITAL'S ALLOWANCE FOR DOUBTFUL ACCOUNTS WAS 31% AND 25% OF THE RELATED PATIENT ACCOUNTS RECEIVABLE, NET OF CONTRACTUAL ALLOWANCES AT DECEMBER 31, 2012 AND 2011, RESPECTIVELY. THIS INCREASE PRIMARILY RELATES TO NEGATIVE TRENDS EXPERIENCED IN THE COLLECTION OF AMOUNTS FROM SELF-PAY RESIDENTS IN RECENT YEARS AS A RESULT OF UNSTABLE ECONOMIC CONDITIONS.LITTLE FALLS HOSPITAL INCURRED BAD DEBT EXPENSE OF $2,277,927 IN 2012 CONSISTING OF SERVICES UNPAID BY UNISURED AND UNDERINSURED PATIENTS. THE COSTING OF BAD DEBT EXPENSE REPRESENTS USING RCC PERCENTAGES BY PATIENT SERVICE TYPE AGAINST THE SAME SERVICE TYPES INCURRING BAD DEBTS. IN 2012 THE RCC PERCENTAGE WAS 37.57%. PART III, LINE 8: LITTLE FALLS HOSPITAL COSTING METHODOLOGY CONSISTS OF INFORMATION FROM MEDICARE COST REPORT. AS A CRITICAL ACCESS HOSPITAL PAYMENT IS BASED ON 101 % OF MEDICARE ALLOWABLE COST. PART III, LINE 9B: COLLECTION AND CHARITY CARE POLICY SPECIFY ACCOUNTS WITH ACTIVE CARE APPLICATIONS WILL NOT GO TO COLLECTION AGENCIES WHILE IN REVIEW. PART V, SECTION A: LITTLE FALLS HOSPITAL HAS PRIMARY CARE CLINICS IN DOLGEVILLE, NY AND NEWPORT,NY. EXTENDED EVENING HOURS ARE PROVIDED ONE NIGHT PER WEEK IN THE DOLGEVILLE, NY PRIMARY CARE CENTER. LITTLE FALLS HOSPITAL PART V, SECTION B, LINE 12H: LITTLE FALLS HOSPITAL CHARGES FOR SERVICES BASED ON RELATIONSHIPS OF COST OF SERVICES, AND AGGREGATE MARGINS REQUIRED FOR HEALTHCARE SERVICES. LITTLE FALLS HOSPITAL PART V, SECTION B, LINE 14G: LITTLE FALLS HOSPITAL BILLING FORMS INCLUDE A STATEMENT TO INQUIRE ABOUT FINANCIAL ASSISTANCE WITH A PHONE NUMBER TO CALL. UNINSURED PATIENTS ARE MAILED AN APPLICATION FOR THEIR COMPLETION. LITTLE FALLS HOSPITAL PART V, SECTION B, LINE 20D: LITTLE FALLS HOSPITAL CHARGES UNIFORM CHARGES TO ALL PAYERS REGARDLESS OF RESPONSIBLE PARTY FOR THE BILL. PART VI, LINE 2: HEALTH CARE SERVICE NEEDS ARE ASSESSED ON A COLLABORATIVE BASIS BY BASSETT HEALTHCARE NETWORK AND LITTLE FALLS HOSPITAL TO ENSURE ACCESS TO SERVICES IN AN EFFICIENT DELIVERY OF CARE MODEL. IN 2012 BASSETT HEALTHCARE NETWORK UNDERTOOK A LOCALIZED DATA ANALYSIS OF SERVICE DEMAND MEASURED AGAINST THE RESOURCES AVAILABLE TO MEET THE DEMAND. THIS STUDY WILL SERVE AS ONE OF THE REPORTS FOR DEVELOPMENT OF THE COMMUNITY HEALTH NEEDS ASSESSMENT IN 2013, AND CONTINUAL REGIONAL PLANNING. WITH THIS COLLABORATIVE PROCESS, STAKEHOLDERS HAVE BEEN IDENTIFIED TO PROVIDE INTO FOR THE COMMUNITY HEALTH ASSESSMENT, AND RELATED PLANS FOR IMPLEMENTATION. PARTICIPANTS INCLUDED REPRESENTATIVES OF LOCAL HOSPITALS, HEALTH DEPARTMENTS, HUMAN SERVICE AGENCIES AND COMMUNITY ORGANIZATIONS. PART VI, LINE 3: LITTLE FALLS HOSPITAL PROVIDES ACCESS AND EDUCATION ON THE COMMUNITY SERVICE PROGRAM WITH CONTACT INFORMATION FOR PATIENTS TO CALL TO HAVE ASSISTANCE IN COMPLETING THE APPLICATIONS. AT ALL PATIENT ACCESS POINTS WHERE SERVICES ARE PROVIDED APPLICATIONS ARE PROVIDED. IN ADDITION THE WEBSITE FOR LITTLE FALLS HOSPITAL INCLUDES INFORMATION ON THE COMMUNITY ASSISTANCE PROGRAM. IN 2012 THE NUMBER OF APPROVED VISITS FROM THE COMMUNITY SERVICE PROGRAM INCREASED BY 82 OR APPROXIMATELY A 50% INCREASE. PART VI, LINE 4: LITTLE FALLS HOSPITAL SERVES AN ESTIMATED POPULATION OF OVER 54,000 PEOPLE IN 10 COMMUNITIES THROUGHOUT HERKIMER COUNTY AND SECTIONS OF FULTON AND MONTGOMERY COUNTIES. THE SERVICE AREA POPULATION IS COMPRISED OF INDIVIDUALS AND FAMILIES FROM ALL SOCIO-ECONOMIC AND EDUCATIONAL LEVELS. THE POPULATION IS 97 PERCENT WHITE, 51 PERCENT FEMALE AND 49 PERCENT MALE. THE AGE DISTRIBUTION OF THE POPULATION IS SIMILAR TO OTHER UPSTATE NEW YORK AREAS WITH 5.4 PERCENT OF THE POPULATION UNDER 5 YEARS OF AGE, 21 PERCENT UNDER THE AGE OF 18 AND 16.2PERCENT AGED 65 AND OLDER. NEARLY 80 PERCENT OF THE POPULATION OVER 25 HAS GRADUATED FROM HIGH SCHOOL. PER CAPITA INCOME LEVELS ARE $16,141, LOWER THAN NEW YORK STATE'S AVERAGE OF $23,389 AND MEDIAN HOUSEHOLD INCOME AT $40,106 ARE ALSO BELOW THE STATE MEDIAN OF $55,980. IT ESTIMATED THAT 14 PERCENT OF THE POPULATION IS BELOW THE FEDERAL POVERTY LEVEL, HIGHER THAN BOTH THE STATE (13.7) AND U.S. (13.3) AVERAGES AND AN ESTIMATED 14.4 PERCENT OF THE COUNTY'S POPULATION IS UNINSURED. IN ADDITION, THERE ARE NUMEROUS HEALTH STATUS INDICATORS THAT SHOW THAT MANY PRIMARY CARE NEEDS OF THE POPULATION RESIDING IN AREA REMAIN UNMET. THESE INCLUDE COMPARATIVELY: LOWER PERCENTAGES OF PREGNANT WOMEN WITH EARLY PRENATAL CARE, ANEMIA AND OBESITY; HIGHER PERCENTAGES OF CHILDREN WITH ANEMIA; HIGHER PERCENTAGES OF ADULTS WHO ARE OVERWEIGHT, SMOKE AND DRINK EXCESSIVELY; HIGHER RATES OF DEATH AND HOSPITALIZATION FROM CARDIOVASCULAR AND HEART DISEASES; A HIGHER INCIDENCE OF CANCER OF THE LUNGS; HIGHER DEATH RATES DUE TO CIRRHOSIS AND DIABETES; HIGHER HOSPITALIZATIONS DUE TO PNEUMONIA AND FLU; AND HIGHER RATES OF DEATH AND HOSPITALIZATION FROM SUICIDE, SELF INFLICTED AND UNINTENTIONAL INJURIES. PART VI, LINE 5: LITTLE FALLS HOSPITAL ACTIVELY PLANS AND IMPLEMENTS COORDINATED HEALTH CARE RESOURCES WITH BASSETT HEALTHCARE NETWORK. THIS SYNERGY ALLOWS FOR GREATER ACCESS, MINIMIZES DUPLICATION OF SERVICES, AND RESULTS WITH HIGH QUALITY CARE. LITTLE FALLS HOSPITAL SERVES ALL PATIENTS WITHOUT CONSIDERATION OF PAYMENT SOURCES. IN 2012 THE AGGREGATE OUTPATIENT GOVERNMENT AND UNINSURED SPONSORED PAYMENT PERCENTAGE WAS 72%. THIS MEANS 72% OF PATIENTS ARE COVERED BY MEDICAID, MEDICARE, GOVERNMENT SPONSORED HMO PROGRAMS OR ARE UNINSURED (NOTE PERCENTAGE IS BASED UPON GOVERNMENT PROGRAMS TO TOTAL FACILITY CHARGES). TO MANAGE CARE MORE APPROPRIATELY EMPHASIS HAS BEEN PREVALENT IN QUALITY OF CARE MEASUREMENTS. THIS HAS RESULTED IN IMPROVING FEWER PATIENTS REQUIRING RE-ADMISSION TO THE HOSPITAL AFTER 30 DAYS. IN ADDITION THE NUMBER OF PATIENTS CONNECTED WITH FOLLOW-UP COMMUNICATIONS HAS SHOWN IMPROVED SHORT AND LONG-TERM HEALTH STATUS BENEFITS. CONTINUED EFFORTS TO EXPAND THE PRIMARY CARE PROVIDER BASE WILL FURTHER IMPROVE ACCESS TO PRIMARY CARE RESULTING IN A MORE PATIENT CENTERED DELIVERY OF CARE MODEL.IN 2013 THE IMPLEMENTATION OF THE "ELECTRONIC HEALTH RECORD" WILL RESULT IN A MORE SIGNIFICANT ADOPTION OF CARE DOCUMENTATION PROTOCOLS TO FURTHER IMPROVE THE HEALTH STATUS OF OUR PATIENTS. PART VI, LINE 6: LITTLE FALLS HOSPITAL IS A MEMBER OF THURSTON CORPORATION (DBA BASSETT HEALTHCARE NETWORK) THAT PROVIDES HEALTH SERVICES IN MORE THAN 20 COMMUNITIES SPANNING 5,600 SQUARE MILES AND SEVEN COUNTIES. THE NETWORK FOCUSES ITS COMMUNITY SERVICES PROGRAMS IN THE COUNTIES WHERE THE SIX AFFILIATED HOSPITALS AND GREATEST PATIENT POPULATIONS ARE LOCATED. OTSEGO COUNTY - POPULATION 61,709; DELAWARE COUNTY - POPULATION 47,276; HERKIMER COUNTY - POPULATION 64,508; SCHOHARIE COUNTY - POPULATION 32,099 (ACCORDING TO THE 2012 U.S. CENSUS ESTIMATES). THE MARY IMOGENE BASSETT HOSPITAL, AN ACUTE CARE INPATIENT TEACHING FACILITY IN COOPERSTOWN, OTSEGO COUNTY, O'CONNOR HOSPITAL, A CRITICAL ACCESS HOSPITAL IN DELHI, DELAWARE COUNTY, COBLESKILL REGIONAL HOSPITAL, AN ACUTE CARE FACILITY IN COBLESKILL, SCHOHARIE COUNTY, LITTLE FALLS HOSPITAL, A CRITICAL ACCESS HOSPITAL IN LITTLE FALLS, HERKIMER COUNTY, TRI TOWN REGIONAL HOSPITAL A 24/7 EMERGENCY CARE FACILITY IN SIDNEY, DELAWARE COUNTY, AUREILA OSBORN FOX MEMORIAL HOSPITAL, AN ACUTE CARE FACILITY IN ONEONTA, OTSEGO COUNTY, THE BASSETT CLINIC, AN OUTPATIENT PRIMARY AND SPECIALTY CARE CENTER IN COOPERSTOWN, A REGIONAL NETWORK OF 26 COMMUNITY BASED HEALTH CENTERS, 19 SCHOOL BASED HEALTH CENTERS, TWO AMBULATORY SURGERY CENTERS, VALLEY HEALTH SERVICES A RESIDENTIAL HEALTH CARE AND REHABILITATION FACILITY, AT HOME CARE, A CERTIFIED HOME CARE AGENCY AND FIRST COMMUNITY CARE OF BASSETT, A MEDICAL SUPPLY COMPANY, ALL OF WHICH MAKE UP THE BASSETT HEALTHCARE NETWORK AND PROVIDE HEALTH SERVICES TO THIS NINE COUNTY REGION IN CENTRAL NEW YORK. REPORTS FILED WITH STATES PART VI, LINE 7 NY X X X X 0 0 0 0 0 0 0 0 0 AUGUST LEINHART MD 0 472027 0 0 0 1293 0 23096 0 1707 0 498123 0 0 NICHOLAS J NICOLETTA 0 376575 0 107000 0 0 0 23096 0 3436 0 510107 0 0 JEFFREY WOEPPEL 0 197600 0 0 0 0 0 17596 0 4481 0 219677 0 0 DALE ADAMSON MD 0 167000 0 0 0 1059 0 10626 0 3434 0 182119 0 0 MICHAEL OGDEN 0 152440 0 0 0 848 0 7436 0 895 0 161619 0 0 RICHARD NOCELLA 157236 0 0 0 0 0 0 0 13968 0 171204 0 0 0 PART I, LINE 3 THE COMPENSATION PROCESS FOR TOP OFFICIAL THE CHIEF EXECUTIVE OFFICER'S SALARY IS PAID BY A RELATED ORGANIZATION UNDER A MANAGEMENT SERVICES AGREEMENT. THE LITTLE FALLS HOSPITAL BOARD OF TRUSTEE'S REVIEWS THE FORMAL PROCESS THAT IS USED TO DETERMINE THE BASE COMPENSATION OF THE CEO. THE CEO WORK PLAN AND ACCOMPLISHMENTS FOR THE YEAR ARE REVIEWED. SALARY CHANGES ARE BASED ON MARKET, WORK PLAN, AND ACCOMPLISHMENTS. THE CEO'S SALARY IS SUBMITTED AS PART OF THE MANAGEMENT SERVICES AGREEMENT WHICH IS APPROVED BY THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION B, LINE 11 LITTLE FALLS HOSPITAL PRESENTS THE DRAFT 990 TO THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS PRIOR TO FILING. ANY QUESTIONS ARE RAISED AND ONCE APPROVED, THE 990 CAN BE FILED. A COMPLETE COPY OF THE ORGANIZATION'S FINAL FORM 990, INCLUDING ALL REQUIRED SCHEDULES, AS ULTIMATELY FILED WITH THE IRS, IS AVAILABLE TO EACH MEMBER OF THE BOARD BEFORE ITS FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST STATEMENTS ARE MADE ANNUALLY. NEW BOARD MEMEBERS ARE REQUIRED TO DISCLOSE ON THEIR RESUME ALL AFFILIATED ORGANIZATIONS. FORM 990, PART VI, SECTION B, LINE 15 THE CHIEF EXECUTIVE OFFICER'S SALARY IS PAID BY A RELATED ORGANIZATION UNDER A MANAGEMENT SERVICES AGREEMENT. THE LITTLE FALLS HOSPITAL BOARD OF TRUSTEES REVIEWS THE FORMAL PROCESS THAT IS USED TO DETERMINE THE BASE COMPENSATION OF THE CEO. THE CEO'S WORK PLAN AND ACCOMPLISHMENTS FOR THE YEAR ARE REVIEWED. SALARY CHANGES ARE BASED ON MARKET, WORKPLAN, AND ACCOMPLISHMENTS. THE CEO'S SALARY IS SUBMITTED AS PART OF THE MANAGEMENT SERVICES AGREEMENT WHICH IS APPROVED BY THE BOARD. FORM 990, PART VI, SECTION C, LINE 19 LITTLE FALLS HOSPITAL MAKES AVAILABLE THE IRS FROM 990 UPON REQUEST ALONG WITH INFORMATION INCLUDED WITHIN THE 990 SUCH AS FINANCIAL REPORTS, CONFLICT OF INTEREST POLICY,AND CODE OF CONDUCT. THE HOSPITAL ALSO PROVIDES THE ANNUAL OPERATING PLAN, CORPORATE VLAUES, IN PUBLIC AREAS OF THE FACILITY. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: PENSION RELATED CHANGES OTHER THAN NET PERIODIC BENEFIT COST 111,805. CHANGE IN VALUE OF BENEFICIAL INTEREST IN CHARITABLE REMAINDER TRUST 464,163. CHANGE IN INTEREST IN NET ASSETS OF FRIENDS OF BASSETT, INC. 558,471. THURSTON CORPORATION ONE ROCKEFELLER PLAZA 31ST FLOOR NEW YORK NY 10020 133218680 SUPPORTING ORGANIZATION NY 501 (C) 3 11 C N/A 0 FRIENDS OF BASSETT ONE ATWELL ROAD COOPERSTOWN NY 13326 237041610 FUND RAISING ORGANIZATION NY 501 (C) 3 7 THURSTON CORPORATION 0 MARY IMOGENE BASSETT HOSPITAL ONE ATWELL ROAD COOPERSTOWN NY 13326 135596796 HEALTH CARE ORGANIZATION OFFERING INPATIENT AND OUTPATIENT SERVICES NY 501 (C) 3 3 THURSTON CORPORATION 0 AURELIA OSBORN FOX MEMORIAL HOSPITAL SOCIETY ONE NORTON AVENUE ONEONTA NY 13820 150539039 HEALTH CARE ORGANIZATION OFFERING INPATIENT AND OUTPATIENT SERVICES NY 501 (C) 3 3 THURSTON CORPORATION 0 TEMPLETON FOUNDATION ONE ATWELL ROAD COOPERSTOWN NY 13326 133317084 FACILITIES / OFFICE SPACE NY 501 (C) 3 9 THURSTON CORPORATION 0 BASSETT REGIONAL CORPORATION ONE ATWELL ROAD COOPERSTOWN NY 13326 133522783 PROVIDES EXCELLENCE IN THE COORDINATION PLANNING AND POLICY DIRECTION FOR NY 501 (C) 3 11 (B) THURSTON CORPORATION 0 COBLESKILL REGIONAL HOSPITAL 178 GRANDVIEW DRIVE COBLESKILL NY 12043 141772971 HEALTHCARE SERVICES OFFERING INPATEINT AND OUTPATIENT SERVICES NY 501 (C) 3 3 BASSETT REGIONAL CORPORATION 0 O'CONNOR HOSPITAL 460 ANDES ROAD DELHI NY 13753 161540394 HEALTH CARE ORGANIZATION OFFERING INPATIENT AND OUTPATIENT SERVICES NY 501 (C) 3 3 BASSETT REGIONAL CORPORATION 0 TRI TOWN REGIONAL HEALTHCARE 43 PEARL STREET SYNDEY NY 13838 260169584 HEALTHCARE SERVICES OFFERING OUTPATIENT SERVICES NY 501 (C) 3 3 BASSETT REGIONAL CORPORATION 0 VALLEY HEALTH SERVICES 690 GERMAN STREET HERKIMER NY 13350 222511614 NURSING HOME NY 501 (C) 3 3 BASSETT REGIONAL CORPORATION 0 0 0 1 0 0 0 0 0 0 1 0 1 1 0 1 0 1 0 0