2013-09-15T08:59:57-05:00 2012-12-31 160765486 LUMSDEN & MCCORMICK LLP 369 FRANKLIN STREET BUFFALO NY 14202 990 2012-01-01 160743301 BROOKS MEMORIAL HOSPITAL BROO 7163661111 529 CENTRAL AVENUE DUNKIRK NY 14048 J GARY RHODES 7163661111 2013-09-05 1 MICHAEL J GRIMALDI P01295846 7168563300 2012 2016-02-24 21:20:13Z J GARY RHODES 529 CENTRAL AVENUE DUNKIRK NY 14048 44592594 0 X WWW.LAKEERIEHEALTH.ORG X 1898 NY AN ACUTE CARE HOSPITAL SERVING PRIMARILY RESIDENTS OF NORTHERN CHAUTAUQUA COUNTY 16 13 556 36 -2102 -2352 176790 211447 41748396 41280676 314115 316523 664112 1264094 42903413 43072740 0 0 0 0 23653429 25527393 0 0 0 19380384 19879795 43033813 45407188 -130400 -2334448 34147820 33294269 10664602 11084059 23483218 22210210 SEE SCHEDULE O BELOW FOR FULL MISSION STATEMENT. 0 0 17587786 16369278 NURSING SERVICES - PROVISION OF DAILY CARE INCLUDING INPATIENT AND OUTPATIENT SERVICES WITHIN THE INSTITUTION 18075908 24911398 OTHER PROFESSIONAL SERVICES - ANCILLARY SERVICES PROVIDED WITHIN THE FACILITY INCLUDING LABORATORY, RADIOLOGY, INHALATION THERAPY, ETC. 35663694 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 56 0 1 556 1 1 1 0 0 0 0 0 0 0 0 0 X 16 13 0 0 0 0 1 0 1 1 1 0 0 0 1 1 1 1 1 1 1 1 0 NY X J GARY RHODES 7163661111 529 CENTRAL AVENUE DUNKIRK NY 14048 CHRISTOPHER LANSKI 2.00 X X 0 0 0 TIMOTHY COOPER 2.00 X X 0 0 0 BRIAN FENZL 2.00 X X 0 0 0 LOUIS DIPALMA 2.00 X X 0 0 0 EUGENE BAILEN 2.00 X 0 0 0 WALTER GOTOWKA 2.00 X 0 0 0 RICHARD MILAZZO MD 2.00 X 0 0 13622 DR VIRGINIA S HORVATH 2.00 X 0 0 0 ANDREW BURR 2.00 X 0 0 0 THOMAS POSTLE 2.00 X 0 0 0 THOMAS SYROCZYNSKI 2.00 X 0 0 0 JAMES WILD MD 2.00 30.00 X 0 0 60000 VIRGINIA COOPER 2.00 X 0 0 0 G JAY BISHOP MD 2.00 X 4600 0 15086 KEVIN OUWELEEN MD 2.00 X 0 0 0 SUSAN MCNAMARA PHD 2.00 X 0 0 0 JONATHAN I LAWRENCE 20.00 20.00 X 189643 189643 40180 RALPH T WEBDALE 40.00 X 132306 0 20773 KENNETH D CRONE 20.00 20.00 X 81544 81545 21861 JARROD JOHNSON 40.00 X 182652 0 21867 TERESA LARSON 40.00 X 92635 0 25791 SALLIE PIAZZA 40.00 X 91539 0 19330 JOAN VANDETTE 40.00 X 66441 0 8849 MARY STAPLES 20.00 20.00 X 4272 4272 1040 THOMAS EAST 20.00 20.00 X 6055 6055 3233 851687 281515 251632 3 0 1 0 DR JOHN OROSZ 3425 WEBSTER ROAD FREDONIA NY 14063 PATHOLOGIST/LAB MED DIRECTOR 230000 DR RAJIV PARIKH 1134 CENTRAL AVENUE DUNKIRK NY 14048 INPATIENT PEDIATRICIAN 110000 2 164883 46564 211447 PATIENT SERVICE REVENU 621990 41280676 41280676 41280676 207992 207992 17400 0 17400 17400 17400 1623456 4929 1501695 18159 121761 -13230 108531 108531 LAB SERVICES 900099 562614 562614 MEALS ON WHEELS 900099 239513 239513 CAFETERIA 722210 176785 176785 267782 -2102 269884 1246694 43072740 41280676 -2102 1582719 976853 976853 18971727 15962463 3009264 1475196 1016965 458231 2679047 1838930 840117 1424570 946305 478265 67914 67914 794058 794058 50244 50244 10064264 9090191 974073 731783 731783 501311 375983 125328 25006 25006 117715 91740 25975 12773 12773 2592136 2067814 524322 486733 373599 113134 PROVISION FOR BAD DEBTS 1638856 1638856 PURCHASED SERVICES 1217440 906492 310948 MEDICAL SPECIALIST FEES 700548 700548 CONTRACT LABOR 640312 603782 36530 238702 37253 201449 45407188 35663694 9743494 0 2468381 896432 4901948 4590694 3919741 4167073 1262049 1271967 505877 366631 50291879 38432832 13021732 11859047 5623591 6675341 1414171 1427234 1030330 2039850 34147820 33294269 4121588 4321521 470131 312684 6072883 6449854 10664602 11084059 X 22069047 20782976 656962 670025 757209 757209 23483218 22210210 34147820 33294269 X -2334448 410743 650697 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1414171 13063 1427234 1412273 1898 1414171 1280118 132155 1412273 1066646 213472 1280118 1387081 -320435 1066646 0.47000 0.53000 1 0 401330 401330 10464705 8177449 2287256 989532 748083 241449 38390541 29507300 8883241 45771 45771 11859047 ADVANCES TO RELATED PARTIES 2039850 2039850 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 1765282 ACCRUED PENSION LIABILITY 4684572 6449854 41447114 -1638856 -1638856 43085970 -13230 -13230 43072740 43781562 13230 13230 43768332 1638856 1638856 45407188 PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS -1,638,856. PART XI, LINE 4B - OTHER ADJUSTMENTS: LOSS ON DISPOSAL OF PROPERTY AND EQUIPMENT -13,230. PART XII, LINE 2D - OTHER ADJUSTMENTS: LOSS ON DISPOSAL OF PROPERTY AND EQUIPMENT 13,230. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 1,638,856. 1 1 1 X 1 X 1 1 0 1 1 420221 20614 399607 0.00880 7578985 7110041 468944 0.01030 7999206 7130655 868551 0.01910 31490 31490 0.00070 26695 26695 0.00060 2022 2022 0.00000 60207 60207 0.00130 8059413 7130655 928758 0.02040 849 849 0.00000 49180 49180 0.00110 50029 50029 0.00110 0 782765 5764127 4563738 1200389 X 1 1 1 1 BROOKS MEMORIAL HOSPITAL

529 CENTRAL AVENUE DUNKIRK NY 14048

X X X RENAL DIALYSIS BROOKS MEMORIAL HOSPITAL 1 1 1 100.000000000000 1 300.000000000000 1 X X X X X X X 1 1 X X X X X X 1 X X 1 X X X X X 1 X X 0 1 PART I, LINE 3C: THE USE OF SIGNIFICANT ASSETS TO BE TAKEN INTO ACCOUNT IN DETERMINING THE AMOUNT A PATIENT WILL PAY FOR MEDICAL SERVICES WILL APPLY ONLY TO THOSE PATIENTS WHOSE INCOME EXCEEDS 150% OF THE FEDERAL POVERTY GUIDELINES. THE NEXT STEP WILL BE TO DETERMINE IF A PATIENT HAS ANY AVAILABLE ASSETS, WHICH CAN BE USED TO SATISFY OUTSTANDING MEDICAL EXPENSES. THOSE TOTAL AVAILABLE ASSETS WILL INCLUDE, BUT NOT BE LIMITED TO, ASSETS IDENTIFIED AS CASH AND THOSE CONVERTIBLE TO CASH AND UNNECESSARY FOR THE PATIENT'S NORMAL LIVING EXPENSES. THE PATIENT'S TOTAL ASSETS TO BE CONSIDERED FOR PAYMENT WILL BE EXPECTED TO BE APPLIED TO THE MEDICAL SERVICES BASED ON THE TABLE THAT FOLLOWS THIS PARAGRAPH. THE REMAINING MEDICAL EXPENSE BALANCE WILL BE DISCOUNTED ACCORDING TO THE PATIENTS ELIGIBILITY DETERMINATION IN SECTION (II). IF THE % OF THE FEDERAL POVERTY INCOME GUIDELINES IS 300% OR LESS THE MAXIMUM AMOUNT OF ASSETS TO BE USED FOR THE PAYMENT OF AN INDIVIDUAL ACCOUNT WILL NOT EXCEED THE "HIGHEST VOLUME PAYOR", AS DEFINED BY NEW YORK STATE NYS PUBLIC HEALTH LAW LAWS OF 2006 CHAPTER 57 SECTION 2807-K SUBDIVISION 9-A, AMOUNT FOR THAT ACCOUNT. ASSETS NOT INCLUDED IN THIS DETERMINATION WILL BE THE: "PATIENT'S" RESIDENCE, ASSETS HELD IN A TAX-DEFERRED OR COMPARABLE RETIREMENT SAVINGS ACCOUNT, COLLEGE SAVINGS ACCOUNTS, OR VEHICLES USED REGULARLY BY A PATIENT OR IMMEDIATE FAMILY MEMBERS. ASSETS NOT UNDER CONSIDERATION AS A SOURCE OF AVAILABLE ASSETS, SUCH AS, THE PRIMARY RESIDENCE ARE SUBJECT TO ANY LEGAL ACTION THAT DOES NOT FORCE THE SALE OR FORECLOSURE OF SUCH PROPERTIES. THE PATIENT'S TOTAL AVAILABLE ASSETS WILL BE REDUCED ACCORDING TO THE NEW YORK STATE ASSET LEVELS TO ARRIVE AT THE TOTAL ASSETS TO BE CONSIDERED.NEW YORK STATE GUIDELINES (THESE LEVELS WILL BE PUBLISHED BY NYS ANNUALLY)HOUSEHOLD SIDE ASSET LEVELS1 $ 9,5002 $13,9003 $15,9854 $18,0705 $20,1556 $22,2407 $24,3258 $26,410EACH ADDITIONAL PERSON $ 2,085BROOKS MEMORIAL HOSPITALTOTAL ASSETS CONSIDERED EXPECTED % OF ASSETS TO BE USED FOR PAYMENT < $ 1,000 10%$ 1,000 - $ 2,000 15%$ 2,001 - $ 3,000 20%$ 3,000 - $ 5,000 25%$ 5,001 - $ 7,500 30%$ 7,501 - $10,000 40%$10,001 - $25,000 50%$25,001 - NO LIMIT 60%THE MAXIMUM CHARGE AMOUNT AS DESCRIBED ABOVE WILL BE ADJUSTED ACCORDING TO THE FEDERAL POVERTY GUIDELINES INCOME LEVELS AS FOLLOWS:- 0% TO 100% OF THE FPL WILL BE REDUCED TO THE LESSER OF THE "NOMINAL PAYMENT AMOUNT" OR THE MAXIMUM CHARGE AMOUNT.- 101% TO 150% OF THE FPL WILL BE REDUCED ON A SLIDING SCALE NOT TO EXCEED 20% OF THE MAXIMUM CHARGE AMOUNT, BUT NOT LESS THAN THE "NOMINAL PAYMENT AMOUNT" UNLESS THE MAXIMUM CHARGE AMOUNT IS LOWER.- 151% TO 250% OF THE FPL WILL BE REDUCED ON A SLIDING SCALE INCREASING FROM THE 20% TO 100% OF THE MAXIMUM CHARGE AMOUNT, BUT NOT LESS THAN THE "NOMINAL PAYMENT AMOUNT" UNLESS THE MAXIMUM CHARGE AMOUNT IS LOWER.- 251% TO 300% OF THE FPL THE CHARGE WILL BE EQUAL TO THE MAXIMUM CHARGE AMOUNT.- 301% TO UNLIMITED % WILL RESULT IN THE BROOKS MEMORIAL HOSPITAL STANDARD CHARGE AMOUNT FOR THAT SERVICE REDUCED BY 25%, BUT NOT LESS THAN THE MAXIMUM CHARGE AMOUNT FOR THAT TYPE OF SERVICE. PART I, LINE 6A: N/A PART I, LINE 7: RCC USED AS CALCULATED IN WORKSHEET 2. PART I, LINE 7G: PHYSICIAN CLINIC NOT INCLUDED IN SUBSIDIED SERVICES - N/A. PART II: BROOKS MEMORIAL HOSPITAL IS IN A MEDICALLY UNDERSERVED AREA. SIGNIFICANT ONGOING EFFORTS AT PHYSICIAN RECRUITMENT CONSTITUTE THE BULK OF THE EXPENSE IN COMMUNITY BUILDING ACTIVITIES FOR WORKFORCE DEVELOPMENT. CURRENT PHYSICIAN SHORTAGES INCLUDE PRIMARY CARE, PEDIATRICS, OBSTETRICS, SURGERY, ORTHOPEDIC, UROLOGY, RADIATION ONCOLOGIST, NEUROLOGIST, MEDICAL ONCOLOGIST AND PULMONOLOGIST.OUR MEDICAL EXPLORERS POST AND HEALTH CAMP CAREERS EXPOSE LOCAL YOUTH TO THE EXCITING POSSIBILITIES AND OPPORTUNITIES AVAILABLE IN HEALTHCARE. THEY FOSTER LONG TERM RELATIONSHIPS BETWEEN THE HOSPITAL AND THESE FUTURE HEALTH CARE PROVIDERS, OFTEN ENCOURAGING THEM TO RETURN TO THEIR HOME COMMUNITIES. PART III, LINE 4: FOOTNOTE TO AUDITED FINANCIAL STATEMENTS: PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF PATIENT 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 EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO HAVE FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). 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 A SIGNIFICANT 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.WHY BAD DEBT SHOULD BE INCLUDED AS A COMMUNITY BENEFIT COST: A HIGH PROPERTION OF BAD DEBT DERIVES FROM PATIENTS WHO ARE NOT ABLE TO PAY FOR SERVICES AND THAT THE PROVISION OF SUCH SERVICES AT A LOSS CONSISTITUTES A FORM OF COMMUNITY BENEFIT. IT IS DIFFICULT FOR A HOSPITAL TO DISTINGUISH THESE PATIENTS WHO FAIL TO RESPOND TO ANY COMMUNICATION AND/OR EFFFORT TO DETERMINE ELIGIBILITY FOR COMMUNITY CARE. PART III, LINE 8: THE ALLOWABLE MEDICARE COST WERE TAKEN DIRECTLY FROM COST REPORT WORKSHEET D. PART III, LINE 9B: A PATIENT WHO IS APPROVED FOR FINANCIAL ASSISTANCE IS ELIGIBLE FOR A PERIOD OF 6 MONTHS FROM THE DATE OF NOTIFICATION. ALL ACCOUNTS FOR THE PATIENT, COVERED BY THE APPLICATION AND DURING THE ELIGIBILITY PERIOD, WILL BE ADJUSTED BASED ON THE LEVEL OF FINANCIAL ASSISTANCE AWARDED. ANY PAYMENTS RECEIVED FROM THE PATIENT ON ACCOUNTS COVERED BY THE APPLICATION OR DURING THE ELIGIBILITY PERIOD WILL BE REFUNDED BASED ON THE LEVEL OF FINANCIAL ASSISTANCE AWARDED. DETERMINNG COST OF BAD DEBT, ACCOUNTING FOR DISCOUNTS/PAYMENTS RELATED TO B PART III, LINE 2 RCC USED AS CALCLUATED IN WORKSHEET 2 FOR PART III, LINE 2 TO CALCULATE BAD DEBT COST. PATIENT PAYMENTS AND DISCOUNTS ARE NOT COUNTED TOWARD BAD DEBT IF POSTED PRIOR TO AN ACCOUNT BEING TRANSFERRED TO BAD DEBT. ONCE IN BAD DEBT, PATIENT PAYMENTS AND DISCOUNTS ARE USED OT REDUCE BAD DEBT. PART III, LINE 3 THERE WERE NO PATIENTS TURNED OVER TO BAD DEBT WHO QUALIFIED FOR CHARITY CARE. PATIENTS ELIGIBLE FOR CHARITY CARE WHO OWED BALANCES WERE NOT TURNED OVER TO BAD DEBT EVEN THOUGH THEY DID NOT PAY THEIR BALANCES. BROOKS MEMORIAL HOSPITAL PART V, SECTION B, LINE 17E: USE AN EARLY OUT THIRD PARTY TO CONTACT PATIENTS BY TELEPHONE AFTER ACCOUNTS ARE OVER 60 DAYS. ACCOUNTS ARE RETURNED TO THE HOSPITAL FOR DISPOSITION. BROOKS MEMORIAL HOSPITAL PART V, SECTION B, LINE 20D: THE MAXIMUM AMOUNT A PATIENT WILL BE CHARGED IS DETERMINED BASED ON THE HIGHER OF: MEDICARE RATES, MEDICAID RATES, OR RATES PAID BY THE HIGHEST VOLUME COMMERCIAL PAYOR BASED ON THE TYPE OF SERVICE PROVIDED. BROOKS MEMORIAL HOSPITAL PART V, SECTION B, LINE 22: PATIENTS WHO DO NOT APPLY FOR FINANCIAL ASSISTANCE OR REQUEST A REDUCTION TO THEIR BILL WILL BE CHARGED THE GROSS CHARGE FOR SERVICSE PROVIDED. PART VI, LINE 2: THE HOSPITAL PARTICIPATES WITH OTHER HEALTHCARE PROVIDERS AND INTERESTED PARTIES IN THE CHAUTAUQUA COUNTY COMMUNITY HEALTH PLANNING TEAM (CCCHPT), THE CHAUTAUQUA COUNTY HEALTH NETWORK AND THE CHAUTAUQUA HEALTH ACTION TEAM TO ASSESS THE NEED REGIONALLY. THE HOSPITAL ALSO UTILIZES PATIENT SATISFACTION SURVEY TOOLS AND LOCAL PUBLIC INFORMATION PERTAINING TO POPULATION CHARACTERISTICS AND HEALTH STATUS. AT MONTHLY PUBLIC PRESENTATIONS OF HEALTH TOPICS, PROGRAM EVALUATION FORMS REQUEST INPUT FROM TEH ATTENDEES FOR NEEDED SERVICES AND TOPICS. PART VI, LINE 3: 1. INFORMATION ABOUT THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY IS PROVIDED UPON ADMISSION, IS POSTED ON THE HOSPITAL WEBSITE, THROUGHOUT THE HOSPITAL, AND PROVIDED THROUGH THE CHAUTAUQUA COUNTY HEALTH NETWORK. STAFF IN THE HOSPITAL HAVE ALSO BEEN IN-SERVICED ABOUT THE FINANCIAL ASSISTANCE PROGRAM SO THAT THEY CAN PROVIDE INFORMATION TO PATIENTS AS WELL.2. BROOKS MEMORIAL HOSPITAL HAS A FACILITATED ENROLLER FROM FIDELIS IN THE HOSPITAL EVERY THURSDAY FROM 1-4 PM, OFFERING ASSISTANCE TO THE PUBLIC.3. BROOKS MEMORIAL HOSPITAL HAS ARRANGED WITH AN AGENCY TO FACILITATE ENROLLING IN THE MEDICAID PROGRAM. THE AGENCY WILL PROVIDE EDUCATION, ASSISTANCE IN COMPLETING THE APPLICATION, AND REPRESENT THE PATIENT AT THE MEDICAID AGENCY.4. BROOKS MEMORIAL HOSPITAL CONTINUES TO MAKE REFERRALS TO THE GET COVERED HELPLINE.5. FINANCIAL ASSISTANCE PROGRAM - CONTINUE TO EDUCATE AND PROVIDE FINANCIAL ASSISTANCE OPTIONS FOR THOSE THAT ARE UNINSURED OR UNABLE TO PAY. IN ADDITION TO THE HOSPITAL'S OWN FINANCIAL ASSISTANCE POLICY BROCHURE, BUSINESS OFFICE PERSONNEL WILL CONTINUE TO DISTRIBUTE BROCHURES DEVELOPED BY CCHN TO ASSIST THE UNINSURED OR UNDERINSURED TO FIND AFFORDABLE HEALTHCARE. PATIENT FINANCIAL SERVICES STAFF WILL CONTINUE TO BE EDUCATED REGARDING ALL AVAILABLE ASSISTANCE IN OBTAINING HEALTH INSURANCE. PART VI, LINE 4: THE HOSPITAL'S PRIMARY SERVICE AREA IS NORTHERN CHAUTAUQUA COUNTY IN NEW YORK AND INCLUDES THE CITY & TOWN OF DUNKIRK, VILLAGES OF FREDONIA, BROCTON, CASSADAGA, FORESTVILLE, AND THE TOWNS OF POMFRET, PORTLAND, STOCKTON, SHERIDAN, AND ARKWRIGHT. THE SECONDARY SERVICE AREA INCLUDES THE TOWNS OF HANOVER, CHERRY CREEK, VILLENOVA AND WESTFIELD. IN THE HOSPITAL'S IMMEDIATE MUNICIPALITY 15.3% OF THE POPULATION IS 65 OR OLDER, 25.9% IS UNDER 20 YEARS OLD. 6.1% IS AFRICAN AMERICAN AND 26.4% IS HISPANIC. PART VI, LINE 5: THE BOARD OF TRUSTEES IS A COMMUNITY BOARD, MADE UP ENTIRELY OF CIVIC AND COMMUNITY LEADERS, WHO SERVE VOLUNTARILY. THE BOARD APPOINTS THE CEO, APPROVES BUDGETS, DEVELOPS STRATEGIC PLANS AND PROVIDES OVERSIGHT FOR THE HOSPITAL IN GENERAL. POTENTIAL CONFLICT OF INTEREST BETWEEN BOARD MEMBERS AND THE HOSPITAL ARE REVIEWED ANNUALLY.THE HOSPITAL'S MEDICAL STAFF IS COMPRISED OF QUALIFIED PHYSICIANS FROM WITHIN THE COMMUNITY. THE HOSPITAL CONTRACTS DIRECTLY ONLY FOR EMERGENCY ROOM PHYSICIANS AND A PATHOLOGIST BUT DOES NOT EMPLOY ANY PHYSICIANS.THE HOSPITAL OPERATES A FULL-TIME EMERGENCY ROOM OPEN TO ALL PATIENTS, REGARDLESS OF THEIR ABILITY TO PAY. PATIENTS COME TO THE EMERGENCY ROOM BY THEIR OWN TRANSPORTATION OR BY AMBULANCE FROM EITHER A LOCAL FIRE DEPARTMENT OR AN INDEPENDENT AMBULANCE BUSINESS THAT SERVES THE ENTIRE COUNTY. IN ORDER TO ENSURE 24 HOUR PHYSICIAN COVERAGE IN THE ER, THE HOSPITAL PROVIDES A SUBSIDY TO THE ER PHYSICIAN GROUP. NON EMERGENCY CARE IS PROVIDED BASED UPON PHYSICIAN ORDERS TO ALL PATIENTS, REGARDLESS OF THEIR ABILITY TO PAY.SURPLUS FUNDS ARE INVESTED IN MEDICAL EQUIPMENT UPGRADES AND NEW TECHNOLOGIES THROUGH A CAPITAL BUDGET PROCESS. THERE ARE NO "OWNERS" OR STOCKHOLDERS SO NO SURPLUS FUNDS ARE PAID OUT TO OWNERS OR STOCKHOLDERS.BROOKS MEMORIAL HOSPITAL IS IN A MEDICALLY UNDERSERVED AREA. SIGNIFICANT ONGOING EFFORTS AT PHYSICIAN RECRUITMENT ARE EXPENDED. CURRENT PHYSICIAN SHORTAGES INCLUDE PRIMARY CARE, PEDIATRICS, OBSTETRICS, SURGERY, ORTHOPEDIC, UROLOGY, RADIATION ONCOLOGIST, NEUROLOGIST, MEDICAL ONCOLOGIST AND PULMONOLOGIST.THE HOSPITAL IS AN ACTIVE MEMBER OF THE COUNTY WIDE DIABETES TASK FORCE. THE GOALS OF THIS ORGANIZAION ARE TO IDENTIFY PROBLEMS, PROPOSE AND IMPLEMENT CHANGES THAT AFFECT THE SYSTEM, PROMOTE GOOD HEALTH, ENCOURAGE PREVENTION, IMPROVE MANAGEMENT AND CREATE AWARENESS.THE HOSPITAL WORKS TO ENSURE AN ADEQUATE BLOOD SUPPLY IN THE COMMUNITY AND SURROUNDING AREAS BY HOSTING MONTHLY BLOOD DRIVES IN COOPERATION IWTH THE COMMUNITY BLOOD BANK.SOME YEARS AGO THE HOSPITAL IDENTIFIED THE NEED FOR DIALYSIS IN THE COMMUNITY. IN 2009 THE HOSPITAL REPLACED THE EXISTING 10 STATIONS AND ADDED 4 ADDITIONAL STATIONS AS THE TARGETED POPULATION CONTINUES TO GROW. THIS SERVICE OPERATES AT A LOSS, YET THE HOSPITAL CONTINUES TO INVEST IN IT.THE HOSPITAL STRIVES TO IMPROVE THE QUALITY OF PATIENT CARE BY A VARIETY OF ACCREDITATIONS, SURVEYS AND BENCHMARKS INCLUDING:THE HOSPITAL IS ACCREDITED THROUGH DNV, THE AMERICAN COLLEGE OF RADIOLOGY FOR MAMMOGRAPHY, MRI, CT SCAN, NUCLEAR MEDICINE AND ULTRASOUND, THE AMERICAN COLLEGE OF RADIATION ONCOLOGY, AND THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION FOR THE CARDIAC REHABILITATION DEPARTMENT. THE HOSPITAL TAKES A PROACTIVE APPROACH TO THE PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS, INCLUDING:- INSTITUTION WIDE PROGRAM TO PROMOTE EFFECTIVE HAND WASHING- INSTITUTION WIDE PROGRAM TO REDUCE URINARY TRACT INFECTIONS- INSTITUTION WIDE PROGRAM TO REDUCE CENTRAL LINE INFECTIONS- INSTITUTION WIDE PROGRAM TO REDUCE VENTILATOR-ASSOCIATED INFECTIONS. THE HOSPITAL MEETS OR EXCEEDS NATIONAL AND STATE BENCHMARKS FOR THE USE OF ANTIBIOTICS RELATED TO SURGERY. THE HOSPITAL EXCEEDS NATIONAL AND STATE BENCHMARKS FOR THE PREVENTION OF BLOOD CLOTS AFTER SURGERY. THE HOSPITAL IMPLEMENTED BAR CODE MEDICATION ADMINISTRATION TO REDUCE/ELIMINATE MEDICATION ERRORS. THE HOSPITAL USES PATIENT SURVEYS THROUGH BOTH PRESS GANEY AND HCAPHS. AREAS THAT MEASURED BELOW AVERAGE ARE REVIEWED WEEKLY AND BEING ADDRESSED THROUGH:- HOURLY ROUNDING- PRE-OPERATIVE JOINT EDUCATION CLASSES- SURGICAL AMBASSADOR PROGRAM- POST DISCHARGE CALLS TO ASSURE PATIENTS UNDERSTAND THEIR MEDICATION INSTRUCTIONS- CUSTOMER SERVICE TRAINING PART VI, LINE 6: ALL OF THE HOSPITALS AND FACILITIES WITHIN LAKE ERIE REGIONAL HEALTH SYSTEM WORK CLOSELY TOGETHER BOTH IN DETERMINING THE HEALTH NEEDS OF THE COMMUNITIES SERVED AND DECIDED HOW BEST TO MEET THOSE NEEDS. OFFICIALS FROM BOTH HOSPITALS HAVE BEEN SELECTED TO WORK TOGETHER ON VARIOUS PROJECTS TO FURTHER THIS CAUSE, INCLUDING RESEARCHING COMMUNITY HEALTH NEEDS, WORKING WITH LOCAL HEALTH ORGANIZATIONS THROUGHOUT THE COUNTY AND BEYOND, DELEVELOPING A FREE COMMUNITY WELLNESS PROGRAM CALLED HEALTHQUEST WNY, PROMOTING HEALTHQUEST WNY AND OTHER HEALTH RELATED EVENTS, DEVELOPING AND PROMOTING HEALTHY LIFESTYLE CLASSES AT EACH OF OUR FACILITIES, REACHING OUT TO IDENTIFIED POPULATIONS OF NEED AND MORE. THIS ALLOWAS THE FACILITIES WITHIN THE SYSTEM TO MORE EVENLY SHARE THE BURDEN OF PROVIDING SUCH INFORMATION AND SERVICES WHILE ALSO ALLOWING US TO EXTEND OUR REACH FURTHER OUT INTO THE COMMUNITY THAN WE WOULD BE ABLE TO DO INDIVIDUALLY AND WITH FEWER UNNECESSARY REDUNDANCIES. REPORTS FILED WITH STATES PART VI, LINE 7 NY X X 0 0 0 0 0 0 0 0 0 JONATHAN I LAWRENCE 162618 162618 23843 23843 3182 3182 8500 8500 11590 11590 209733 209733 0 0 RALPH T WEBDALE 131492 0 0 0 814 0 5974 0 14799 0 153079 0 0 0 KENNETH D CRONE 81544 81545 0 0 0 0 6082 6082 4848 4849 92474 92476 0 0 JARROD JOHNSON 157564 0 25000 0 88 0 0 0 21867 0 204519 0 0 0 KEVIN WILD ADMIN. FELLOW AND SON OF BOARD MEMBER 21656 KEVIN WILD IS AN ADMINISTRATIVE FELLOW AND A SON OF BOARD MEMBER DR. JAMES WILD. 0 FORM 990, PART VI, SECTION A, LINE 6 SOLE CORPORATE MEMBER FORM 990, PART VI, SECTION A, LINE 7B THE DECISIONS OF THE GOVERNING BODY ARE SUBJECT TO APPROVAL OF BOARD MEMBERS. FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS PREPARED AND REVIEWED BY VARIOUS INDIVIDUALS WITHIN MANAGEMENT AND PROVIDED TO THE GOVERNING BODY PREGIOUS TO ITS FILING WHEN TIME ALLOWS OR AT ITS NEXT MEETING WHEN TIME DOES NOT PERMIT REVIEW PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C DEPARTMENT MANAGERS, ADMINISTRATION, BOARD MEMBERS, AND MATERIAL MANAGEMENT EMPLOYEES SIGN A CONFLICT OF INTEREST STATEMENT ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION B, LINE 15 THE PRESIDENT/CEO'S COMPENSATION IS REVIEWED AND APPROVED BY THE EXECUTIVE COMMITTEE OF THE BOARD. WAGES AND INCREASES ARE COMPARED TO INDUSTRY STANDARDS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC ON THE HOSPITAL WEBSITE (WWW.BROOKSHOSPITAL.ORG) AND CERTAIN DOCUMENTS ARE AVAILABLE AT THE HOSPITAL AND AT PHYSICIANS' OFFICES. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: NET CHANGE IN FUNDS HELD IN TRUST 13,063. PENSION LIABILITY ADJUSTMENT 637,634. FORM 990, PART XII, LINE 2C THE BOARD OF TRUSTEES ASSUME RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND THE SELECTION OF AN INDEPENDENT ACCOUNTANT. FULL MISSION STATEMENT PART III, LINE I BROOKS MEMORIAL HOSPITAL IS A PRIMARY ACUTE CARE HOSPITAL DEDICATED TO PROVIDING QUALITY HEALTH CARE SERVICES TO CONTINUOUSLY IMPROVE THE HEALTH OF PEOPLE IN WESTERN NEW YORK. TO ACCOMPLISH THIS MISSION: S.E.R.V.E. WE WILL CONTINUE TO SUPPORT THE COMMUNITY/PATIENT BY PROVIDING A BROAD ARRAY OF SERVICES TO MEET THEIR PRIMARY HEALTH CARE AND WELLNESS NEEDS, WHILE SHARING OUR SPECIAL SERVICE CAPABILITIES TO BENEFIT OUR REGION. WE WILL CONTINUE TO PROVIDE NEEDED EDUCATION ON WELLNESS AND HEALTH TO OUR PATIENTS AND COMMUNITY. WE WILL FOSTER THIS THROUGH THE DEVELOPMENT AND PROFESSIONAL GROWTH OF ALL EMPLOYEES. WE WILL REMAIN DEDICATED TO PROVIDING QUALITY HEALTH CARE THROUGH QUALITY PEOPLE. WE WILL TREAT EACH PERSON (PATIENT, FAMILY, PHYSICIAN, EMPLOYEE, AND VISITOR) WITH REVERENCE AND RESPECT, WITHOUT DISCRIMINATION ON THE BASIS OF RACE, CREED, RELIGION, NATIONALITY, SEX, AGE, FINANCIAL CLASS OR ANY OTHER BASIS. WE WILL ACTIVELY WORK WITH THE PHYSICIANS TO FULFILL OUR COMMON GOAL OF PROVIDING QUALITY PATIENT CARE. WE WILL VALUE ALL MEMBERS OF THE HEALTH CARE SYSTEM. WE WILL CONTINUE TO WORK WITH PATIENTS, FAMILIES, PHYSICIANS, HOSPITAL STAFF AND CLERGY AS A TEAM. WE WILL STRIVE TO CONTINUOUSLY IMPROVE THE QUALITY OF SERVICE TO THE COMMUNITY BY MEETING AND EXCEEDING THE NEEDS OF THE WHOLE PERSON IN A COMPASSIONATE, SAFE, MODERN, AND EFFICIENT MANNER. WE WILL SEEK LONG-TERM, MUTUALLY BENEFICIAL RELATIONSHIPS TO DELIVER QUALITY HEALTH CARE. WE WILL MONITOR, EVALUATE AND UPDATE SERVICES AND SYSTEMS AS NEEDS CHANGE, SO AS TO CONTINUE TO PROVIDE QUALITY HEALTH CARE, WHILE BEING FISCALLY RESPONSIBLE TO ENABLE US TO ACCOMPLISH THIS MISSION. TLC HEALTH NETWORK 12644 SENECA ROAD IRVING NY 140819716 160772474 HOSPITAL NY 501(C)(3) LINE 3 N/A 0 LAKE ERIE REGIONAL HEALTH SYSTEM OF NEW YORK 529 CENTRAL AVENUE DUNKIRK NY 14048 262778107 SOLE MEMBER OF HOSPITAL NY 501(C)(3) LINE 11C, III-FI N/A 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0