2013-11-05T14:09:12-07:00 2012-12-31 990 2012-01-01 222807681 MEMORIAL HOSPITAL OF WILLIAM F AND GERTRUDE F JONES INC MEMO 5855931100 191 N Main Street Wellsville NY 14895 Tracy Gates 5855964002 2013-11-05 2012 2016-03-07 17:11:31Z Rich Shear 191 North Main Street Wellsville NY 14895 36540652 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 11 448 60 0 0 1252897 2804442 30875356 31310728 799473 344442 1664170 2081040 34591896 36540652 0 0 0 0 19798355 20633841 0 0 0 13172460 13939210 32970815 34573051 1621081 1967601 26317742 29677209 24232015 24532390 2085727 5144819 Provision of healthcare services 0 0 27814656 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 1729 PATIENTS PLUS 278 BIRTHS AND HAD 89408 PATIENT ENCOUNTERS ON AN OUTPATIENT BASIS. THE HOSPITAL HAS PROVIDED CHARITY CARE TO INDIGENT PATIENTS TOTALING $994,824. 0 0 0 27814656 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 61 0 1 448 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 2 0 X 0 0 0 MICHAEL BERARDI 2 0 X 0 0 0 KIMBERLY TOOT 2 0 X 0 0 0 WILLIAM COCH 2 0 X 0 0 0 GARY BALCOM 2 0 X 0 0 0 REV MARIAN SCHNEIDER 2 0 X 0 0 0 MARK HUNTER 2 0 X 0 0 0 RICHARD SHEAR 2 0 X 0 0 0 SAMANTHA GILKEY 2 0 X 0 0 0 BARRY KULP 2 0 X 0 0 0 DANIEL GUINEY 2 0 X 0 0 0 EVA BENEDICT 40 0 X 207568 0 7951 TRACY GATES 40 0 X 147884 0 23025 HEATHER LANPHERE 40 0 X 305769 0 43397 F CLIFTON MILLER 40 0 X 292000 0 40425 LU-ANNE KAYE 40 0 X 185000 0 31692 MARK ELLIOTT 40 0 X 185000 0 18722 BILLY CARSTENS 40 0 X 180000 0 31332 1503221 0 196544 16 0 1 0 DELPHI HOSPITALIST SERVICE 2701 CULVER ROAD ROCHESTER NY 14622 STAFFING 501278 DELPHI HEALTHCARE LLC 2701 CULVER ROAD ROCHESTER NY 14622 Staffing 318503 DR STEVEN COLLINS 6801 GLEASON HILL ROAD BELFAST NY 14711 MEDICAL PHYSICIAN 217050 JAMES R RUMMEL JR 153 WEST STATE STREET WELLSVILLE NY 14895 STAFFING 214000 AMN HEALTHCARE 2735 COLLECTION CTR DRIVE CHICAGO IL 60693 STAFFING 158008 7 0 0 0 0 2719617 84825 0 2804442 31310728 31310728 0 0 31310728 341942 0 0 341942 0 0 0 0 0 0 0 0 18968 0 0 0 18968 0 18968 0 0 18968 0 2500 0 0 0 2500 2500 0 0 2500 0 PT & OT CONSULTING INCOME 900099 448218 0 0 448218 BAD DEBT CHARITY CARE POOL 900099 994824 0 0 994824 CAFETERIA 900099 230309 0 0 230309 388721 0 0 388721 2062072 36540652 31310728 0 2425482 0 0 0 0 0 0 0 0 355452 0 355452 0 0 0 0 0 15874971 12980834 2894137 0 745756 596444 149312 0 2542871 2175144 367727 0 1114791 891592 223199 0 0 0 0 0 137079 0 137079 0 85627 0 85627 0 0 0 0 0 0 0 0 0 0 0 50000 0 50000 0 30153 0 30153 0 5155454 4745641 409813 0 0 0 0 0 0 0 0 0 0 0 0 0 36996 28605 8391 0 0 0 0 0 45137 13050 32087 0 452561 0 452561 0 0 0 0 0 1390988 1112790 278198 0 367818 0 367818 0 PURCHASED SERVICES 4336574 3954406 382168 0 LICENSES AND TAXES 230225 35567 194658 0 LEASES 620102 585598 34504 0 RECRUITMENT 88070 0 88070 0 912426 694985 217441 0 34573051 27814656 6758395 0 1176678 2507055 0 0 0 0 6081898 6948617 0 0 0 0 0 0 717986 786993 221010 368891 25754731 18020041 7687866 7734690 0 0 10432304 11330963 0 0 0 0 0 0 26317742 29677209 15761488 17114675 0 0 0 0 8470527 7417715 0 0 0 0 0 0 0 0 24232015 24532390 X 362015 3295106 0 0 1723712 1849713 2085727 5144819 26317742 29677209 X 1967601 0 0 0 0 1091491 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 145541 0 145541 12319192 0 9117289 3201903 754868 0 576497 178371 12137141 0 8326255 3810886 397989 0 0 397989 7734690 DEPRECIATION RESERVE FUND/KEY BANK 2829707 F CAPITAL IMPROVEMENTS/MORGAN STANLEY 6502376 F TEMP RESTRICTED/STEUBEN TRUST 149167 F HELD IN TRUST/KEY BANK 1849713 F 11330963 36540652 0 0 0 0 0 36540652 0 0 0 36540652 34573051 0 0 0 0 0 34573051 0 0 0 34573051 1 1 1 X 1 X 1 1 1 0 1 1 0 0 650662 0 650662 0.0193 0 0 5272087 2835249 2436838 0.0724 0 0 1185993 0 1185993 0.0352 0 0 7108742 2835249 4273493 0.1269 11 2648 18270 0 18270 0.0005 0 0 0 0 0 0 0 0 4910 0 4910 0.0001 0 0 0 0 0 0 1 28 61877 0 61877 0.0018 12 2676 85057 0 85057 0.0024 12 2676 7193799 2835249 4358550 0.1293 1 910624 910624 6038119 6851385 -813266 X 1 1 7 1 JONES MEMORIAL HOSPITAL

191 NORTH MAIN STREET WELLSVILLE NY 14895

X X 2 JONES MEMORIAL HEALTH CARE CLINIC

127 NORTH MAIN STREET WELLSVILLE NY 14895

X EXTENSION CLINIC 3 JONES MEMORIAL HEALTH CARE CLINIC

15 LODER STREET WELLSVILLE NY 14895

X EXTENSION CLINIC 4 JONES MEMORIAL HEALTH CARE CLINIC

13 LODER STREET WELLSVILLE NY 14895

X 5 JONES MEMORIAL HEALTH CARE CLINIC

20 MAIN STREET ANDOVER NY 14806

X EXTENSION CLINIC 6 JONES MEMORIAL HEALTH CARE CLINIC

5877 OLD STATE ROUTE 19 BELMONT NY 14813

X EXTENSION CLINIC 7 JONES MEMORIAL HEALTH CARE CLINIC

120 FIRST STREET BOLIVAR NY 14715

X EXTENSION CLINIC JONES MEMORIAL HOSPITAL 1 1 X X X X X X X 10 1 1 1 X X X X X X X X X 1 0 1 0 1 300 1 X 1 1 X X 1 X X 1 X X X X X X X 1 X 0 0 JONES MEMORIAL HEALTH CARE CLINIC 2 1 X X X X X X X 10 1 1 1 X X X X X X X X X 1 0 1 0 1 300 1 X 1 1 X X 1 X X 1 X X X X X X X 1 X 0 0 JONES MEMORIAL HEALTH CARE CLINIC 3 1 X X X X X X X 10 1 1 1 X X X X X X X X X 1 0 1 0 1 300 1 X 1 1 X X 1 X X 1 X X X X X X X 1 X 0 0 JONES MEMORIAL HEALTH CARE CLINIC 4 1 X X X X X X X 10 1 1 1 X X X X X X X X X 1 0 1 0 1 300 1 X 1 1 X X 1 X X 1 X X X X X X X 1 X 0 0 JONES MEMORIAL HEALTH CARE CLINIC 5 1 X X X X X X X 10 1 1 1 X X X X X X X X X 1 0 1 0 1 300 1 X 1 1 X X 1 X X 1 X X X X X X X 1 X 0 0 JONES MEMORIAL HEALTH CARE CLINIC 6 1 X X X X X X X 10 1 1 1 X X X X X X X X X 1 0 1 0 1 300 1 X 1 1 X X 1 X X 1 X X X X X X X 1 X 0 0 JONES MEMORIAL HEALTH CARE CLINIC 7 1 X X X X X X X 10 1 1 1 X X X X X X X X X 1 0 1 0 1 300 1 X 1 1 X X 1 X X 1 X X X X X X X 1 X 0 0 SchH_P01_S00_L07 Schedule H, Part I, Line 7 WORKSHEET 2 RATIO OF PATIENT CARE COST TO CHARGES CALCULATION WAS USED FOR LINE 7. SchH_P01_S00_L07g 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. SchH_P03_S0A_L04 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. SchH_P03_S0B_L08 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. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b THE HOSPITALS CHARITY CARE FINANCIAL ASSISTANCE POLICY REQUIRES APPLICANTSTO APPLY FOR MEDICAID. THE CRITERIA USED BY THE HOSPITAL FOR THOSE PATIENTS WHO APPLY FOR MEDICAID WILL BE A SLIDING FEE SCHEDULE BASED ON THE FEDERAL POVERY GUIDELINES. SchH_P05_S0B_L04 Schedule H, Part V, Section B, Line 4 SAME AS FACILITY 1 SchH_P05_S0B_L05 Schedule H, Part V, Section B, Line 5 SAME AS FACILITY 1 SchH_P06_S00_L02 Schedule H, Part VI, Line 2 THE HOSPITAL USES SEVERAL METHODS TO ASSES 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 PARTCIPATE 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 PRACTICES SITES (FIVE 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. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 OUR PATIENT STATEMENTS PROVIDE A NOTICE INFORMING OUR 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. SchH_P06_S00_L04 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, BELMONT, 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 DESIGNATION. X X X 0 0 0 0 0 0 0 0 0 EVA BENEDICT 207568 0 0 0 0 0 0 0 7951 0 215519 0 0 0 TRACY GATES 147884 0 0 0 0 0 0 0 23025 0 170909 0 0 0 HEATHER LANPHERE 305769 0 0 0 0 0 0 0 43397 0 349166 0 0 0 F CLIFTON MILLER 292000 0 0 0 0 0 0 0 40425 0 332425 0 0 0 LU-ANNE KAYE 185000 0 0 0 0 0 0 0 31692 0 216692 0 0 0 BILLY CARSTENS 180000 0 0 0 0 0 0 0 31332 0 211332 0 0 0 MARK ELLIOTT 185000 0 0 0 0 0 0 0 18722 0 203722 0 0 0 F990_P06_S0B_L11b 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. F990_P06_S0B_L12c 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. F990_P06_S0B_L15 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 THR BOARD OF DIRECTORS. A GENERAL INCREASE IS APPROVED BY THE BOARD OF DIRECTORS FOR ALL EMPLOYEES, INCLUDING KEY EMPLOYEES OF THE ORGANIZATION AS PART OF THEIR APPROVAL OF THE ANNUAL OPERATING BUDGET. THE BASIS FOR THE INCREASE IS BASED ON COMPARABLE DATA FOR THE ORGANIZATION'S MARKET AREA. F990_P06_S0C_L19 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. F990_P11_S00_L09 Form 990, Part XI, Line 9 CHANGE IN UNREALIZED GAINS/LOSSES ON INVESTMENTS = 326,589, PENSION LIABILITY ADJUSTMENT = -777,686, NET APPRECIATION OF FUNDS IN TRUST = 126,001, NET ASSETS RELEASED FROM RESTRICTION = 562,241, INCREASE IN TEMP RESTRICTED = 854,346. TOTAL = 1,091,491. FORM 8868 WAS FILED AND APPROVED OF