2012-11-07T09:36:48-06:00 2011-12-31 990 2011-01-01 160762843 Kenmore Mercy Hospital KENM 7168282993 515 Abbott Road No 500 Buffalo NY 142202039 David P Macholz 7168282974 2012-11-07 2011 2016-02-24 21:20:13Z Joseph D McDonald 2121 Main Street Buffalo NY 14214 141316289 0 X www.chsbuffalo.org X 1957 NY The Catholic Health System (CHS) Mission is to provide quality healthcare Services in an acute care setting. Committed to a common mission, CHS providers continue the healing ministry of Jesus, seeking to improve the health of individuals and communities. We provide high quality service that has reverence, compassion, justice, and excellence. The 2011 Community Service Plan can be found at www.chsbuffalo.org 21 8 1055 376 0 0 673671 73162 140020393 137374537 159371 251069 1481465 3617521 142334900 141316289 0 0 0 0 73913119 77700114 0 0 0 69468565 61867564 143381684 139567678 -1046784 1748611 93746757 105666087 74848782 92045822 18897975 13620265 X The Catholic Health System (CHS) Mission is to provide quality healthcare services in an acute care setting. Committed to a common mission, CHS providers continue the healing ministry of Jesus, seeking to improve the health of individuals and communities. We provide high quality service that has reverence, compassion, justice, and excellence. The 2011 Community Service Plan can be found at www.chsbuffalo.org. 0 0 69544028 96065571 Inpatient services provided 2,607 Inpatient surgery visits, 517 visits for G.I. Lab, and 118 visits for urology. Inpatient services provided 32,390 acute care patient days and 5,139 medical rehab service days. The Skilled Nursing Facility provided 54,823 days of care. 28090070 38802595 Outpatient services provides 3,161 outpatient surgery vistits, 4,335 G.I. visits, 2,089 Interventional Radiology visits and 331 Transfusion visits. Outpatient services also provided 21,869 Emergency Department visits net of admissions and 88,105 Referred Ambulatory visits. 1814419 2506371 Primary Care Centers and Clinics provided 31,591 visits. 99448517 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 0 0 0 0 1 1 0 0 0 0 0 0 1 0 0 0 0 1 96 0 1055 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 21 8 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X David P Macholz VP FinanceCorporate Controller 7168282974 515 Abbott Road Buffalo NY 142202039 Joseph McDonald 37.50 X X 0 1071254 41897 Mark Sullivan 37.50 X X 0 499658 32323 James Millard 37.50 X X 296692 0 157819 David Macholz 37.50 X X 0 220214 31882 Dr Michael Albert 1.00 X 0 0 0 Dr Joseph Anain 1.00 X 0 117000 0 Brian Beitz 1.00 X 0 0 0 Peter Bergmann 37.50 X 0 558756 31685 Frances Crosby RN PhD 1.00 X 0 0 0 Richard Curran MD 1.00 X 0 0 0 Dennis Dombek 1.00 X 0 0 0 Dr Michael Edbauer 25.00 X 0 197492 43593 Christine Kluckhohn 37.50 X X 0 297068 116618 William Lawley Jr 1.00 X 0 0 0 James Manzella 1.00 X 0 0 0 Dr Paul Mason 1.00 X 0 25000 0 Michael Montante 1.00 X 0 0 0 Dr David Serra 1.00 X 0 0 0 Charles J Urlaub 37.50 X X 0 436009 32828 Cynthia ZaneEdD 1.00 X 0 0 0 Monsignor Robert E Zapfel 1.00 X 0 0 0 James A Dunlop Jr 37.50 X 0 443085 112103 Dr Brian D'Arcy 37.50 X 0 602143 48686 Walter Ludwig 37.50 X 197007 0 27687 Michael Moley 37.50 X 0 394218 39695 John Stavros 37.50 X 0 248323 39012 Maria Foti 37.50 X 0 230710 30394 Bartholomew Rodrigues 37.50 X 0 218184 33095 Dr Michael Galang 37.50 X 0 331760 25686 Nancy Sheehan 37.50 X 0 269768 27110 Dr James Fitzpatrick 37.50 X 156539 0 32208 Dr Sanford Pleskow 37.50 X 154919 0 858 Dr Qamrunnisa Rahman 37.50 X 149667 0 77936 Dr Suchitra Koneru 37.50 X 135718 0 31627 Dr Nadezhda Polataiko 37.50 X 136950 0 55339 1227492 6160642 1070081 32 0 1 0 Siemens Medical Solutions 51 Valley Stream Parkway Malverne PA 19355 Maintenance Services 661615 Kideney Architects 200 John James Audubon Pkwy W Amherst NY 14228 Architect Services 442722 Sodexho Operations LLC 60 Grider Street Buffalo NY 14215 Laundry Services 384194 Elder Medical Services PC 132 Cayuga Rd Suite 1C Cheektowaga NY 14225 Medical Services 383561 Seton Imaging 3730 Sheridan Dr Amherst NY 14226 Medical Services 314000 16 73162 73162 Patient Service Revenu 900099 93337693 93337693 Medicare/Medicaid 900099 44036844 44036844 137374537 198621 198621 260262 0 260262 260262 260262 52448 0 52448 52448 52448 Meaningful Use 900099 2657136 2657136 Cafeteria 900099 238407 238407 Shared Services 900099 114898 114898 346818 346818 3357259 141316289 137374537 0 3868590 60112319 41925521 18186798 2973820 2074100 899720 11098305 7740547 3357758 3515670 2452015 1063655 41708 41708 10000 10000 4591129 2181973 2409156 89900 70382 19518 171476 137599 33877 178105 27415 150690 2295911 6325 2289586 19946 15024 4922 24503 18015 6488 1287110 1287110 5877184 3255470 2621714 1134795 653685 481110 Medical Supplies 27473743 27707408 -233665 Purchased Services 9335340 4212436 5122904 Bad Debt 3593465 3593465 Shared Services & Dues 1404648 1404648 4338601 2038319 2300282 139567678 99448517 40119161 0 15738719 29570381 19476223 14589083 1454156 1641514 1385720 833296 93502661 49875114 43869685 43627547 11435671 15404268 93746757 105666087 20746095 18399995 13318952 12420239 11520986 10477175 29262749 50748413 74848782 92045822 X 18746304 12839819 151671 780446 18897975 13620265 93746757 105666087 X 1748611 -7026321 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 235852 235852 56688399 34534046 22154353 7051055 1524565 5526490 20886237 13423145 7463092 8641118 393358 8247760 43627547 Insurance Recoveries 9667929 Interest in net assets of KMH Foundation 3268942 Due from Affiliates 1481620 Other Receivables 808355 Workers Compensation Funding Surplus 165870 Interest in net assets of CCD Foundation 11552 15404268 Pension Obligation 28823065 Long Term portion of Insurance Liabilities 15063072 Due to Affiliates 4622179 Interest Rate Swap 1805747 Asset Retirement Obligation 141809 Other Long Term Liabilities 292541 50748413 141316289 139567678 1748611 -7026321 -7026321 -5277710 141243127 0 141243127 73162 73162 141316289 139567678 0 139567678 0 139567678 Part XI, Line 8 - Other Adjustments: Change in unrestricted interest in KMH Foundation, Inc. -889,413. Change in Pension Obligation -6,552,184. Distribution from parent 380,275. Change in unrealized loss on interest rate swap -593,774. Change in temporarily restricted interest in KMH Foundation,Inc. 628,775. Total to Schedule D, Part XI, Line 8: -7,026,321. Part XII, Line 4b - Other Adjustments: Contributions from Foundation 58,562. HEPP Grant 14,600. 1 1 1 X 110.000000000000 1 X 500.000000000000 1 1 1 0 1 1 1333566 115700 1217866 0.00870 9419136 6877133 2542003 0.01820 10752702 6992833 3759869 0.02690 466447 466447 0.00330 622473 622473 0.00450 152145 152145 0.00110 1241065 1241065 0.00890 11993767 6992833 5000934 0.03580 1006 1006 0.00000 77917 77917 0.00060 4100 4100 0.00000 1256 1256 0.00000 637 637 0.00000 62153 62153 0.00040 147069 147069 0.00100 1 1109340 502589 28366716 29720848 -1354132 X 1 0 1 1 Kenmore Mercy Hospital

2950 Elmwood Avenue Kenmore NY 14217

X X X Ambulatory Surgery, Dental O/P, Pediatric O/P, Audiology O/P Kenmore Mercy Hospital 1 1 1 110.000000000000 1 500.000000000000 1 X X X X X X 1 1 X X X X X X X 1 0 1 X 0 1 3 Ken-Ton Family Care

300 Two Mile Creek Road Tonawanda NY 14150

Extension Clinic: Pediatric O/P, Prenatal O/P, Primary Medical Care O/P Williamsville Diagnostic Center

400 International Drive Williamsville NY 14221

Extension Clinic: Primary Medical Care, PT O/P, Radiology O/P, CT Scan, MRI McAuley Residence

1503 Military Road Kenmore NY 14217

Long Term Care, Radiology O/P, Clinical Laboratory O/P Part I, Line 6a: The Kenmore Mercy Hospital Community Benefit Report is contained in a report prepared by the Catholic Health System. Part I, Line 7: Costing is a full step down methodology of cost from non-revenue producing departments to revenue producing departments', with assignment of cost to individual charge items based on volume and charge amount. All patient accounts are cost with the same methodology regardless of patient type (inpatient, outpatient, emergency room, etc.) or insurance coverage (Medicare, Medicaid, private insurance, uninsured, etc.). Part I, L7 Col(f): Bad debt expenses of $3,036,432 are included in Part IX, line 25, column (A) but subtracted when calculating the percentage in column (f). Part II: Kenmore Mercy Hospital provided Community Building in the form of Economic Development, Community Support, Environmental Improvements, Coalition Building, Community Health Improvement Advocacy, and Workforce Development which improved community leadership by promoting understanding of community healthcare needs and services at various events throughout the community as well as mentoring and education to students regarding healthcare careers. Part III, Line 4: The amount in Part III line 2 is the actual bad debt expenses of $3,036,432 written down to cost, utilizing the Uninsured Ratio of Cost to Charges (RCC) obtained from the full step down methodology of cost described in Part 1, line 7. The amount in Part III line 3 is the estimate of bad debt from uninsured balance which is developed as follows: as policy is to write accounts to bad debt 120 days after discharge, the discharge date period of 10/1/2010 to 9/30/2011 was used to determine the population of uninsured accounts. The balance of these accounts was determined and the RCC was applied to develop the estimate in H Part III Line 3.As our determination of eligibility for the Healthcare Assistance Program (HAP) (Charity Care) is based solely on the presentation for care without insurance, which is now for each account, and use of a sophisticated estimator (PARO) of each guarantor's ability to pay an estimate of "the amount that reasonably could be attributable to patients who likely would qualify for financial assistance under the hospital's charity care policy if sufficient information had been available to make a determination of their eligibility" is not relevant.The organization's financial statements do not include a footnote that describes bad debt expense, but the financial statements account for bad debt expenses in the statement of operations as actual expenses written off and an estimate of future write-offs less any recoveries. Part III, Line 8: The costing methodology used to determine the Medicare Allowable costs is Cost to Charge. The shortfall is not treated as a community benefit. Part V, Section A: Audiology O/P, Clinic Part Time Services, Clinical Laboratory Services, Coronary Care, CT Scanner, Emergency Department, Health Fairs O/P,Intensive Care, Medical Social Services, Medical/Surgical, Nuclear Medicine-Diagnostic, Nuclear Medicine-Therapeutic, Pharmaceutical Service, Physical Medical Rehabilitation, Physical Medicine and Rehabilitation O/P, Primary Medical Care O/P, Radiology - Diagnostic, Renal Dialysis - Acute, Respiratory Care, Therapy - Occupational O/P, Therapy - Physical O/P, Therapy - Speech Language, Pathology Kenmore Mercy Hospital Part V, Section B, Line 13g: Includes information in both English and Spanish on all signage and brochures for financial assistance. Kenmore Mercy Hospital Part V, Section B, Line 19d: Highest volume commercial payor rate Kenmore Mercy Hospital Part V, Section B, Line 21: There are instances where the full charges on the account are equal to or less than the highest volume commercial payor rate. Part VI, Line 2: Kenmore Mercy Hospital, as part of Catholic Health, involved many participants in assessing community health needs including: 1. New York State Department of Health Prevention Agenda for the Healthiest State Erie County Department of Health Catholic Health Kaleida Health Erie County Medical Center Sheehan Memorial Hospital 2. Health Consumers 3. Patients/residents/clients A. Hospital Inpatients and Outpatients B. Nursing Home Residents and Families C. Rehabilitation Patients D. Primary Care Center Patients E. Home Care Clients 4. Physicians 5. External Organizations, such as Academia, Community-based organizations, elected officials, employers and business, Faith based organizations, governmental organizations, media, philanthropists and schools.6. Statistical Resources1. New York State Department of Health Prevention Agenda for the Healthiest State Catholic Health worked in collaboration with the Erie County Department of Health, Kaleida Health, ECMC and Sheehan Memorial on the Erie Co. DOH Prevention Agenda for the Healthiest State. In February 2009, an Erie County Joint Planning Committee formed to identify prevention priorities and strategies to focus on collaboratively over the next 3 years, which included: Chronic Disease, Healthy Mothers, Healthy Babies, Healthy Children, Physical Activity and Nutrition and Tobacco Use.2. Health Consumers In creating the Catholic Health and Kenmore Mercy Hospital strategic plan, input was sought from a variety of constituents including consumers. In August 2008, eight (8) consumer focus groups were conducted asking consumers what they wanted from their patient care experience. These focus groups were created by reaching out to 8,000 area residents who were asked to contact friends/families/neighbors to participate. 3. Patients/residents/clients A. Hospital Inpatients and Outpatients Kenmore Mercy Hospital continues to participate in a regional patient satisfaction survey through a cooperative effort with the Buffalo Niagara Health Quality Coalition and area hospitals. Patient participation is voluntary. This survey takes place twice per year. Through hospital admission and outpatient ancillary sites, surveys were distributed to individuals to gain an understanding about their healthcare needs and how well their needs were being met. 4. Physicians Kenmore Mercy Hospital surveys its medical staff annually. Physicians are surveyed on issues relating to the quality and efficiency of services offered throughout Catholic Health including at Kenmore Mercy Hospital. 5. External OrganizationsCatholic Health and Kenmore Mercy Hospital also engaged in the P2 Collaborative (Pursuing Perfection) dedicated to improving the health of people across the region. There are more than 200 participant organizations including the provider community, payers, community based organizations, religious organizations, local business, colleges & universities, and governmental agencies. Areas of focus include working with physicians and organizations to enhance access to care and improve efficiency of care and empowering all of the Western New York community to take responsibility for and act on their own wellness.In an effort to engage health care needs at the grass roots level, Catholic Health and Kenmore Mercy Hospital work closely with the following organizations to assess community health need:Niagara Health Quality Coalition, Community Cancer Coalition, American Heart Association, Near East & West Side Task Force, Baker Victory Services, Community Health Center of BuffaloWNY Osteoporosis Resource Ctr., WNY Health Equity Work Group, Living Healthy Task Force of Erie Co., Minority Health Coalition, Buffalo Public Schools Worksite Wellness, Flu CoalitionEvery Parent Influences Children (EPIC), Tobacco Coalition, WNY Coalition for Diabetes, Community Health Foundation, Erie Co. Coalition for Diabetes, WNED Public Television, Catholic Charities, Niagara University6. Statistical ResourcesCatholic Health and Kenmore Mercy Hospital used PQI (Preventable Quality Indicators) to map specific areas by zip code to better understand needs and target for need. We mapped specifically for Congestive Heart Failure, Hypertension, Angina & Diabetes to identify target areas for community education & screening initiatives. Other statistical resources used to assess the needs of the communities served included: "Buffalo Public Schools: Student Body Mass Index", "Erie County Health Assessment Indicators", and "Erie County Health Indicators Profile". Goals/Objectives for the priorities identified for Catholic Health and Kenmore Mercy include: -Increase consumer knowledge and adoption of healthy lifestyle behaviors by encouraging frequent physical activity and healthy nutrition, leading to improved health status and reduced chronic disease prevalence for residents of Buffalo and Erie County. -Increase participants' ability to identify risk factors for cardiovascular disease. -Lower body mass index (BMI) in youth; early identification of adolescents and adults with high blood pressure, high blood cholesterol and high blood glucose through screening and prevention interventions. -Implement a social marketing campaign to positively influence voluntary behavior of target population to take action to maximize health. -Restrict the availability of less healthy foods and beverages in public service venues in Buffalo and Erie County, such as schools, community centers and hospitals.In addition, Catholic Health and Kenmore Mercy utilize resources to manage their public relations and social marketing initiatives (public facing website, Facebook and Twitter); exponentially increasing the effectiveness of its outreach and the success of its Community Service Plan. 2012 Community Education targets: 9,000 biometric screenings (5,610 in underserved areas); 240 community programs held; 4,328 people in attendance at community programs.Measures of Effectiveness: -Number of educational programs held (240) and number of participants (4,328). Number of visits to website (617,380) -Number of program attendees who attended cardiovascular presentations (1,084). -Social media metrics: Facebook pages (4), Facebook fans (4,571), Twitter followers (1,325), website visitors (617,380). -Local government facilities, hospitals and school districts adopt policies that limit the portion size of any entree by either reducing the standard portion size of entrees or offering smaller portion sizes in addition to standard portion sizes Part VI, Line 3: Kenmore Mercy Hospital 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 the Catholic Health System Healthcare Assistance Program (HAP) policy. For example, Kenmore Mercy Hospital has posters and brochures available which include contact information for the Financial Clearance staff in admissions areas, emergency rooms, primary care and outpatient rehabilitation clinics, Revenue Management Center (RMC) and other areas of the organization's facilities where eligible patients are likely to be present; provides information about financial assistance and HAP contact information to patients as part of the intake process; provides financial assistance and HAP contact information to inpatients either during or within 90 days of discharge of their hospital stay; patient bills include the following language: "The Catholic Health System has a Healthcare Assistance Program to assist those in need of financial assistance for qualified patients. If you would like to obtain additional information on the Healthcare Assistance Program, please call (716) 601-3600. Thank you. Our Customer Service area is our front end team to assist all patients in this process." Additionally, we discuss with the patient the availability of various government benefits, such as Medicaid or state programs, and assist the patient with qualification for such programs, where applicable, and there is information about financial aid posted on the Catholic Health System website. Part VI, Line 4: Kenmore Mercy Hospital serves a mostly suburban partially urban service area which is comprised of 88.5% white (non-Hispanic) and 3.9% African-American (non-Hispanic) households. The service area is more elderly than most with 18% of the population over the age of 65 compared to a national average of 13.3%. The community consists of fewer households than the national average with annual incomes below $15,000/year at 12.5% compared to a national average of 12.9%.Although Kenmore Mercy Hospital is not located in a designated Health Professional Shortage Area (HPSA), the hospital draws patients from other HPSAs in the region and one of its extension clinics is in a designated HPSA area. Part VI, Line 5: Catholic Health System's community service activities at the acute facilities include benefits to the broader community, which include non-billed services and provided services paid below costs. Charity care and benefits to the community are provided through long term care facilities, home care programs and Catholic Health system-wide community programs. These programs touch more than 40,000 Western New York residents through community health education programs, health screenings (including: glucose, blood pressure, and cholesterol screenings; and cardiac, stroke, vascular, diabetes, nutrition, stress management, and women's community programming) clinical and support services, clerkships, internships, scholarships, in-kind donations and community support activities. Additionally, thousands of people make unique visits to the Catholic Health website seeking information about an individual or family healthcare issue, and follow Catholic Health on Facebook and Twitter where daily posts talk to education and prevention of the priority areas.The governing Board of Directors of Kenmore Mercy Hospital is comprised of community representatives from universities, legal communities, & business leaders. Religious orders are represented, as well as active and retired medical staff members.The Kenmore Mercy Hospital medical staff can be considered an "open" medical staff, as any physician can apply for privileges. Each application is reviewed by a vigorous credentialing verification process. Part VI, Line 6: Kenmore Mercy Hospital is affiliated with the Catholic Health System, Inc., a New York State licensed corporation. Catholic Health System, located in Buffalo, New York exempt from taxation and a charitable organization described in Section 501(c) (3) of the Internal Revenue Code of 1986. Catholic Health is also the parent company of the following New York State corporations: Mercy Hospital of Buffalo, Sisters of Charity Hospital (Main Street Campus) , and Sisters of Charity Hospital (St. Joseph Campus). Its outpatient and post-acute facilities (and services) include Mercy Ambulatory Care Center, Mercy Diagnostic and Treatment Center, Mercy Diagnostic Center, Sheridan Health Care Center, Sisters Central Park Diagnostic Center, Williamsville Diagnostic Center, Kenmore Specialty Center, Ken-Ton Family Care Center, Lovejoy/St. Vincent Health Center, Mercy Comprehensive Care Center, Mercy OB/GYN Center, OLV Family Care Center, Sisters OB/GYN Center, Springville Primary Care Center, Williamsville Primary Care Center, Catholic Health Home Care, St. Elizabeth's Home, St. Vincent's Home, Father Baker Manor, McAuley Residence, Mercy Nursing Facility at OLV, St. Catherine Laboure Health Care Center, and St. Francis of Williamsville. Reports Filed With States Part VI, Line 7 NY 1 X X X X X X 0 1 0 0 0 1 1 0 0 Joseph McDonald 0 583131 0 208063 0 280060 0 26855 0 15042 0 1113151 0 0 Mark Sullivan 0 373986 0 92715 0 32957 0 17728 0 14595 0 531981 0 0 James Millard 214698 0 43291 0 38703 0 156544 0 1275 0 454511 0 0 0 David Macholz 0 171337 0 23650 0 25227 0 13750 0 18132 0 252096 0 0 Peter Bergmann 0 346695 0 167259 0 44802 0 13217 0 18468 0 590441 0 0 Dr Michael Edbauer 0 96362 0 59284 0 41846 0 16807 0 26786 0 241085 0 0 Christine Kluckhohn 0 186796 0 55065 0 55207 0 97902 0 18716 0 413686 0 0 Charles J Urlaub 0 324839 0 72463 0 38707 0 18124 0 14704 0 468837 0 0 James A Dunlop Jr 0 327293 0 82819 0 32973 0 94418 0 17685 0 555188 0 0 Dr Brian D'Arcy 0 253307 0 60760 0 288076 0 30581 0 18105 0 650829 0 0 Walter Ludwig 147400 0 18860 0 30747 0 11173 0 16514 0 224694 0 0 0 Michael Moley 0 259903 0 58553 0 75762 0 25222 0 14473 0 433913 0 0 John Stavros 0 169269 0 39644 0 39410 0 21022 0 17990 0 287335 0 0 Maria Foti 0 161084 0 36606 0 33020 0 23570 0 6824 0 261104 0 0 Bartholomew Rodrigues 0 145256 0 34317 0 38611 0 15377 0 17718 0 251279 0 0 Dr Michael Galang 0 265381 0 35389 0 30990 0 20485 0 5201 0 357446 0 0 Nancy Sheehan 0 187958 0 43103 0 38707 0 21899 0 5211 0 296878 0 0 Dr James Fitzpatrick 139650 0 16383 0 506 0 15521 0 16687 0 188747 0 0 0 Dr Sanford Pleskow 132315 0 0 0 22604 0 0 0 858 0 155777 0 0 0 Dr Qamrunnisa Rahman 135045 0 0 0 14622 0 71854 0 6082 0 227603 0 0 0 Dr Suchitra Koneru 121076 0 0 0 14642 0 7498 0 24129 0 167345 0 0 0 Dr Nadezhda Polataiko 136743 0 0 0 207 0 38559 0 16780 0 192289 0 0 0 Part I, Line 4b Certain Officers and Key employees participated in a supplemental nonqualified retirement plan per the terms and conditions of their employment arrangement. Pension Gap CHE SERP Joseph McDonald $26,000 $106,775 Dr.Brian D'Arcy $9,800 $142,750 Michael Moley $20,697 Peter Bergmann $7,334 Part I, Line 6 The 2011 Incentive payments were dependent upon achieving the Catholic Health System Operating Income target for Catholic Health System participants or the Ministry Operating Income target for Ministry participants. Joseph McDonald $208,063 Mark Sullivan $92,715 James A. Dunlop, Jr. $82,819 Dr. Brian D'Arcy $60,760 Nancy Sheehan $43,103 Michael Moley $58,553 John Stavros $39,644 Christine Kluckhohn $55,065 Maria Foti $36,606 Bartholomew Rodrigues $34,317 Dr. Michael Galang $35,389 Dr. Michael Edbauer $59,284 David Macholz $23,650 Peter Bergmann $76,258 James Millard $43,291 Walter Ludwig $18,860 Dr. James Fitzpatrick $16,383 Charles Urlaub $72,463 Dormitory Authority of State of New York 146000293 64983Q5t2 2006-11-29 16730000 Part V 0 0 0 16730000 657688 99008 15973304 1998 1 0 1 1 0 0 0 0 1 0 1 1 JP Morgan Chase NA 15.500000000000 0 0 0 0 0 Part I A (f) Description of Purpose To refund the New York State Medical Care Facilities Finance Agency FHA - insured mortgage Project Revenue Bonds, 1995 Series B, which were applied to finance the construction of a three floor patient tower and to refinance outstanding indebtedness. Susan Uralub Wife of Mercy CEO, C.J. Urlaub 76045 Corporate Nurse Educator 0 James Manzella Acute Care Board Member 326330 Key Employee of Manzella Marketing 0 David Zapfel Brother of BOD, Msgr. Robert Zapfel 62906 HR Employee of CHS 0 Kathleen Zapfel Sister-in-law of BOD, Msgr. Robert Zapfel 58749 HR Employee of CHS 0 Susan Gallagher-Stavros Wife of Key Employee, John Stavros 30035 Nurse, McAuley Seton Home Care 0 Marie Packard Daughter of BOD, Dennis Dombek 46301 Mercy Physical Therapist 0 Form 990, Part VI, Section A, line 6 CHS has three members: Ascension Health, Catholic Health East, and the Diocese of Buffalo, NY. Each member is able to participate equally in electing the governing body, approving significant decisions of the governing body, and in receiving a share of net assets upon dissolution, according to the CHS Bylaws. Form 990, Part VI, Section A, line 7a According to the CHS Bylaws, each member is equally allowed to appoint up to three individuals to act as its representatives on the Corporate Member Board, and in undertaking any action in its capacity as a Member. Form 990, Part VI, Section A, line 7b Each member is entitled to one vote on each matter properly submitted at any membership meeting, and the members also have reserve powers which allow approval for certain business events and ratification of certain business transactions. Form 990, Part VI, Section B, line 11 Yes, an electronic copy of the Form 990 was provided to the CHS Boards of Directors before it was filed. The CHS Board of Directors has delegated the responsibility to review the 990 to the Audit Committee. The CHS Audit Committee reviewed in detail selected information for all CHS entities. Reviewed with the Audit Committee: 1. Core Form Part IV: Checklist of required schedules 2. Core Form Part VI: Governance, Management and Disclosure 3. Core Form Part VII: Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees and Independent Contractors 4. Schedule H: Hospitals 5. Schedule K: Supplemental information on Tax Exempt Bonds 6. Schedule J: Compensation Information 7. Schedule L: Transactions with Interested Persons 8. Schedule R: Related Organizations and Unrelated Partnerships 9. Process for which remaining Core Form was completed, utilizing audited financial information Form 990, Part VI, Section B, line 12c All associates on the Merit program; all Physicians and Non Physician Practitioners as well as Physician groups who are independent contractors or employees of CHS; and all board members must complete a Conflict of Interest Disclosure Statement (COIDS) in order to fulfill the annual requirements. COIDS are distributed to all parties, as per applicable policy, and once complete are followed up with as follows: 1. Associate and Physician completed COIDS are reviewed and signed off by the manager. If a disclosure is noted, it is discussed with the manager, and the document is forwarded to the Compliance officer who reviews and follows up as appropriate. Once review/follow up is completed the Compliance Officer will sign the COIDS, maintain a copy in the compliance office and return the original to HR for filing in the Personnel file. 2. All board member COIDS are returned to Compliance Officer for review and follow up as warranted. The compliance officer will sign each COIDS and retain on file in the compliance office in a confidential manner. Form 990, Part VI, Section B, line 15 In 2011, the Catholic Health System utilized a Compensation Committee of the Board of Directors to monitor the Executive Compensation as per the Executive Compensation Philosophy and Strategy for the CHS CEO; COO; CFO; CEO's for each Ministry; and all Senior Vice Presidents. The Compensation Committee provides oversight to management decisions which are based on outlines approved by the committee, and performs a review of data. The outcome of these meetings is documented. Form 990, Part VI, Section C, line 19 We make our form 990 open for public inspection upon request. Our website includes an annual report which includes selected financial information. Our financial statements, governing documents and conflict of interest policy are provided upon request according to applicable federal and state laws. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Change in unrestricted interest in KMH Foundation, Inc. -889,413. Change in Pension Obligation -6,552,184. Distribution from parent 380,275. Change in unrealized loss on interest rate swap -593,774. Change in temporarily restricted interest in KMH Foundation,Inc. 628,775. Total to Form 990, Part XI, Line 5: -7,026,321. Catholic Health System Inc 515 Abbott Road Buffalo NY 14220 222565278 Health Care Delivery System NY 501c Schedule A line 9 0 Mercy Hospital of Buffalo 565 Abbott Road Buffalo NY 14220 160756336 Acute Care Hospital NY 501c Schedule A line 3 Catholic Health System Inc 0 Sisters of Charity Hospital 2157 Main Street Buffalo NY 14214 160743187 Acute Care Hospital NY 501c Schedule A line 3 Catholic Health System Inc 0 Nazareth Home of the Franciscan Sisters 291 North Street Buffalo NY 14201 160813142 Skilled Nursing Facility NY 501c Schedule A line 9 Catholic Health System Inc 0 St Clare Manor 543 Locust Street Lockport NY 14094 160782647 Skilled Nursing Facility NY 501c Schedule A line 9 Catholic Health System Inc 0 St Elizabeth Home for the Aged 5539 Broadway Lancaster NY 14086 160743154 Adult Home NY 501c Schedule A line 9 Catholic Health System Inc 0 St Francis Home of Williamsville 147 Reist St Williamsville NY 14221 160743153 Skilled Nursing Facility NY 501c Schedule A line 9 Catholic Health System Inc 0 St Francis of Buffalo Inc 34 Benwood Ave Buffalo NY 14214 161523535 Skilled Nursing Facility NY 501c Schedule A line 9 Catholic Health System Inc 0 St Joseph Manor 2211 West State Street Olean NY 14760 160796400 Skilled Nursing Facility NY 501c Schedule A line 9 Catholic Health System Inc 0 St Luke Manor for the Chronically Ill 17 Wiard St Batavia NY 14020 160794811 Skilled Nursing Facility NY 501c Schedule A line 9 Catholic Health System Inc 0 St Mary's Manor 515 6th Street Niagara Falls NY 14301 160924139 Skilled Nursing Facility NY 501c Schedule A line 9 Catholic Health System Inc 0 St Vincent Manor 319 Washington Avenue Dunkirk NY 14048 160743167 Adult Home NY 501c Schedule A line 9 Catholic Health System Inc 0 WNY Catholic Long Term Care Inc 6400 Powers Rd Orchard Park NY 14127 161434368 Skilled Nursing Facility NY 501c Schedule A line 9 Catholic Health System Inc 0 Niagara Homemaker Services (Mercy Home Care) 2875 Union Rd Suite 14 Cheektowaga NY 14227 161317960 Home Care Provider NY 501c Schedule A line 9 Catholic Health System Inc 0 McAuley Seton Home Care 2875 Union Rd Suite 14 Cheektowaga NY 14227 161310062 Home Care Provider NY 501c Schedule A line 9 Catholic Health System Inc 0 Catholic Health System Infusion Pharmacy Inc 2875 Union Road Suite 14 Cheektowaga NY 14227 200198518 Home Care Infusion Services NY 501c Schedule A line 9 Catholic Health System Inc 0 CHS Program of All-Inclusive Care for the Elderly Inc 55 Melroy Avenue Lackawanna NY 14218 261252884 All-inclusive Care for the Elderly NY 501c Schedule A line 3 Catholic Health System Inc 0 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1