2012-08-13T13:48:31-07:00 2011-12-31 990 2011-01-01 222807681 MEMORIAL HOSPITAL OF WILLIAM F AND GERTRUDE F JONES INC MEMO 5855931100 191 N Main Street Wellsville NY 14895 Tracy Gates 5855964002 2012-08-10 2011 2016-02-24 21:20:13Z GARY BALCOM 60 PARK LANE WELLSVILLE NY 14895 34591896 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 11 435 60 0 0 547651 1252897 29850196 30875356 291333 799473 2420701 1664170 33109881 34591896 0 0 0 0 21319914 19798355 0 0 0 13016412 13172460 34336326 32970815 -1226445 1621081 22471601 26317742 19058420 24232015 3413181 2085727 Provision of healthcare services 0 0 26651212 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 2118 PATIENTS PLUS 320 BIRTHS AND HAD 88583 PATIENT ENCOUNTERS ON AN OUTPATIENT BASIS. THE HOSPITAL HAS PROVIDED CHARITY CARE TO INDIGENT PATIENTS TOTALING $827,712. 0 0 0 26651212 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 0 1 49 0 1 435 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 Joseph Felsen MD 40 X 168554 0 0 ROBERT GILFERT 2 X 0 0 0 WILLIARD SIMONS 2 X 0 0 0 BARRY KULP 2 X 0 0 0 MICHAEL BERARDI 2 X 0 0 0 Mark Hunter 2 X 0 0 0 KIMBERLY TOOT 2 X 0 0 0 DANIEL GUINEY 2 X 0 0 0 WILLIAM COCH 2 X 0 0 0 Gary Balcom 2 X 0 0 0 Richard Shear 2 X 0 0 0 Rev Marian Schneider 2 X 0 0 0 Samantha Gilkey 2 X 0 0 0 Eva Benedict 40 X 200575 0 0 TRACY GATES 40 X 134200 0 0 HEATHER LANPHERE 40 X 369714 0 0 F Clifton Miller 40 X 328231 0 0 LU-ANNE KAYE 40 X 192115 0 0 Billy Carstens 40 X 186923 0 0 Mark Elliott 40 X 185221 0 0 1765533 0 0 15 0 1 0 DELPHI HOSPITALIST SERVICE 2701 CULVER ROAD ROCHESTER NY 14622 STAFFING 554271 Delphi Healthcare LLC 2701 CULVER ROAD ROCHESTER NY 14622 Staffing 356497 DR STEVEN COLLINS 6801 GLEASON HILL ROAD BELFAST NY 14711 MEDICAL PHYSICIAN 216000 CHARLES COLE MEMORIAL HOSPITAL 1001 E SECOND STREET COUDERSPORT PA 16915 ORTHOPEDIC SERVICES 150993 RESPITECH MEDICAL INC 250 RANCK AVENUE LANCASTER PA 17602 SLEEP STUDY SERVICES 102850 5 0 0 0 0 1118662 134235 0 1252897 PATIENT SERVICES 622000 30875356 30875356 0 0 0 0 0 0 30875356 779618 0 0 779618 0 0 0 0 0 0 0 0 19638 0 0 0 19638 0 19638 0 0 19638 0 19855 0 0 0 19855 19855 0 0 19855 0 PT & OT CONSULTING 900099 487915 0 0 487915 BAD DEBT CHARITY CARE 900099 827712 0 0 827712 CAFETERIA 900099 226499 0 0 226499 102406 0 0 102406 1644532 34591896 30875356 0 2463643 0 0 0 0 0 0 0 0 334775 0 334775 0 0 0 0 0 15323146 12507015 2816131 0 269477 215249 54228 0 2791739 2418985 372754 0 1079218 862043 217175 0 0 0 0 0 53608 26804 26804 0 82800 41400 41400 0 0 0 0 0 0 0 0 0 0 0 100000 50000 50000 0 25891 0 25891 0 5105937 4717903 388034 0 0 0 0 0 0 0 0 0 0 0 0 0 35871 21802 14069 0 0 0 0 0 45784 15991 29793 0 476897 0 476897 0 0 0 0 0 1375391 1100313 275078 0 319030 0 319030 0 PURCHASED SERVICES 3780039 3440386 339653 LICENSES & TAXES 221265 40309 180956 LEASES 708988 678182 30806 0 RECRUITMENT 100367 0 100367 0 740592 514830 225762 0 32970815 26651212 6319603 0 301214 1176678 0 0 0 0 4057514 6081898 0 0 0 0 0 0 698749 717986 210004 221010 24336299 16648433 6576788 7687866 0 0 10627332 10432304 0 0 0 0 0 0 22471601 26317742 11147652 15761488 0 0 0 0 7910768 8470527 0 0 0 0 0 0 0 0 19058420 24232015 X 1533897 362015 0 0 1879284 1723712 3413181 2085727 22471601 26317742 X 1621081 -2948535 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 145541 0 145541 12109450 0 8718477 3390973 690237 0 552668 137569 10701365 0 7377288 3324077 689706 0 0 689706 7687866 DEPRECIATION RESERVE FUND/KEY BANK 2806671 F CAPITAL IMPROVEMENTS/MORGAN STANLEY SMITH BARNEY 5858194 F TEMP RESTRICTED/STEUBEN TRUST 43727 F HELD IN TRUST/KEY BANK 1723712 F 10432304 34591896 32970815 1621081 -546197 0 0 0 -2790051 -3336248 -1715167 34591896 0 0 0 0 0 34591896 0 0 0 34591896 32970815 0 0 0 0 0 32970815 0 0 0 32970815 SchD_P11_S00_L08 Schedule D, Part XI, Line 8 PENSION LIABILITY ADJUSTMENT 1 1 1 X 1 X 1 1 1 0 1 1 0 0 215637 0 215637 0.0065 0 0 6524613 6123656 400957 0.0122 0 0 939649 0 939649 0.0285 0 0 7679899 6123656 1556243 0.0472 12 2565 17629 0 17629 0.00053 0 0 0 0 0 0 0 175 14642 0 14642 0.00044 0 0 0 0 0 0 2 41 65828 0 65828 0.00199 14 2781 98099 0 98099 0.00296 14 2781 7777998 6123656 1654342 0.05016 1 856152 856152 7732784 7432845 299939 X 1 1 6 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 JONES MEMORIAL HOSPITAL 1 JONES MEMORIAL HEALTH CARE CLINIC 2 JONES MEMORIAL HEALTH CARE CLINIC 3 JONES MEMORIAL HEALTH CARE CLINIC 4 JONES MEMORIAL HEALTH CARE CLINIC 5 JONES MEMORIAL HEALTH CARE CLINIC 6 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. It ended 2011 with an operating loss of (14642). 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 299939 is a surplus SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b The hospital's Charity Care/Financial Assistance Policy requires applicants to 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 Poverty Guidelines. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 The hospital uses several methods to assess 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 participate 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 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 200575 0 0 0 0 0 0 0 7686 0 208261 0 0 TRACY GATES 134200 0 0 0 0 0 0 0 22368 0 156568 0 0 0 HEATHER LANPHERE 369714 0 0 0 0 0 0 0 44662 0 414376 0 0 0 F Clifton Miller 328231 0 0 0 0 0 0 0 42302 0 370533 0 0 0 LU-ANNE KAYE 192115 0 0 0 0 0 0 0 32809 0 224924 0 0 0 Billy Carstens 186923 0 0 0 0 0 0 0 35172 0 222095 0 0 0 Mark Elliott 185221 0 0 0 0 0 0 0 18807 0 204028 0 0 0 F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b THE 990 WAS SENT TO THE EXECUTIVE COMMITTEE OF 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 CAMPARABLE DATA FOR THE MARKET AREA AND THE COMPLETE CONTRACT IS APPROVED BY THE 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_L05 Form 990, Part XI, Line 5 CHANGE IN UNREALIZED GAINS/LOSSES ON INVESTMENTS = -546,197, PENSION LIABILITY ADJUSTMENT = -2,790,051, NET APPRECIATION OF FUNDS IN TRUST = -155,572, NET ASSETS RELEASED FROM RESTRICTION = 585,920, DECREASE IN TEMP RESTRICTED = -42,635. TOTAL = -2,948,535. FORM 8868 WAS FILED AND APPROVED OF