2011-11-01T08:42:19-07:00 2010-12-31 990 2010-01-01 222807681 MEMORIAL HOSPITAL OF WILLIAM F AND GERTRUDE F JONES INC MEMO 5855931100 191 N Main Street Wellsville NY 14895 Tracy Gates 5855964002 2011-11-01 2010 2016-03-07 17:11:31Z GARY BALCOM 60 PARK LANE WELLSVILLE NY 14895 33109881 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 11 442 60 0 0 820131 547651 30010945 29850196 -313547 291333 2335702 2420701 32853231 33109881 0 0 0 0 21305668 21319914 0 0 0 12963860 13016412 34269528 34336326 -1416297 -1226445 22982035 22471601 17726075 19058420 5255960 3413181 Provision of healthcare services 0 0 27556930 0 0 QUALITY OF HEALTH CARE: THE MEMRIAL 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 1971 PATIENTS PLUS 338 BIRTHS AND HAD 84007 PATIENT ENCOUNTERS ON AN OUTPATIENT BASIS. THE HOSPITAL HAS PROVIDED CHARITY CARE TO INDIGENT PATIENTS TOTALING $1,073,362. 0 0 0 27556930 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 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 48 0 1 442 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 Laura Greyson 2 X 0 0 0 Sharon Ash 2 X 0 0 0 Joseph Felsen MD 40 X 160000 0 0 Charles Joyce 2 X 0 0 0 Rev Marian Schneider 2 X 0 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 Gary Balcom 2 X 0 0 0 Richard Shear 2 X 0 0 0 Mark Hunter 2 X 0 0 0 Samantha Gilkey 2 X 0 0 0 Eva Benedict 40 X 193281 0 0 TRACY GATES 40 X 79519 0 0 F Clifton Miller 40 X 380844 0 0 HEATHER LANPHERE 40 X 257920 0 0 Billy Carstens 40 X 219056 0 0 LU-ANNE KAYE 40 X 192538 0 0 Mark Elliott 40 X 181589 0 0 Robert Bruckner 40 X 78513 0 0 1743260 0 0 14 1 1 0 DELPHI HOSPITALIST SERVICE 2701 CULVER ROAD ROCHESTER NY 14622 STAFFING 326471 Delphi Healthcare LLC 2701 CULVER ROAD ROCHESTER NY 14622 Staffing 220833 FAMILY MEDICAL HEALTH OF ALFRED 28 CHURCH STREET ALFRED NY 14802 STAFFING 163081 RESPITECH MEDICAL INC 250 RANCK AVENUE LANCASTER PA 17602 SLEEP STUDY SERVICES 109900 KIRK HERIOT MD 290 EDGEWOOD AVENUE ROCHESTER NY 14618 PATHOLOGY SERVICES 106808 5 0 0 0 0 277594 270057 0 547651 PATIENT SERVICES 622000 29850196 29850196 0 0 0 0 0 0 29850196 281121 0 0 281121 0 0 0 0 0 0 0 0 24592 0 0 0 24592 0 24592 0 0 24592 0 10212 0 0 0 10212 10212 0 0 10212 0 PT & OT CONSULTING 900099 614246 0 0 614246 BAD DEBT CHARITY CARE 900099 1073362 0 0 1073362 CAFETERIA 900099 212954 0 0 212954 495547 0 0 495547 2396109 33109881 29850196 0 2712034 0 0 0 0 0 0 0 0 351313 0 351313 0 0 0 0 0 15283480 12626662 2656818 0 1496113 1266226 229887 0 3117386 2757203 360183 0 1071622 865442 206180 0 0 0 0 0 54549 0 54549 0 26100 0 26100 0 0 0 0 0 0 0 0 0 0 0 50000 0 50000 0 44445 100 44345 0 5001582 4647581 354001 0 0 0 0 0 0 0 0 0 0 0 0 0 35170 24987 10183 0 0 0 0 0 42144 13119 29025 0 501691 0 501691 0 0 0 0 0 1323265 1058612 264653 0 374276 0 374276 0 PURCHASED SERVICES 3565954 3188790 377164 0 LICENSES & TAXES 225962 39352 186610 0 LEASES 748561 723362 25199 0 RECRUITMENT 45743 157 45586 0 MISCELLANEOUS 976970 345337 631633 0 34336326 27556930 6779396 0 718588 301214 0 0 0 0 4084197 4057514 0 0 0 0 0 0 680245 698749 200198 210004 23496818 16920030 7328257 6576788 0 0 9970550 10627332 0 0 0 0 22982035 22471601 9049915 11147652 0 0 0 0 8676160 7910768 0 0 0 0 0 0 0 0 17726075 19058420 X 3434209 1533897 0 0 1821751 1879284 5255960 3413181 22982035 22471601 X -1226445 -616334 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 145541 0 145541 686514 0 530932 155582 12424003 0 8581240 3842763 10240760 0 7807858 2432902 0 0 0 0 6576788 DEPRECIATION RESERVE FUND/KEY BANK 2655278 F CAPITAL IMPROVEMENTS/CLOVER 6007903 F TEMP RESTRICTED/STEUBEN TRUST 84867 F HELD IN TRUST/KEY BANK 1879284 F 10627332 33109881 34336326 -1226445 298338 0 0 0 -972205 -673867 -1900312 33109881 0 0 0 0 0 33109881 0 0 0 33109881 34336326 0 0 0 0 0 34336326 0 0 0 34336326 SchD_P11_S00_L08 Schedule D, Part XI, Line 8 THIS IS AN ADJUSTMENT MADE TO RECORD OUR PENSION LIABILITY. 1 1 1 X 1 X 1 1 1 0 1 1 0 0 168029 0 168029 0.0049 0 0 6211816 5078704 1133112 0.033 0 0 1021956 0 1021956 0.0298 0 0 7401801 5078704 2323097 0.0677 9 1907 19908 0 19908 0.0006 2 33 74257 0 74257 0.0022 0 163 17239 0 17239 0.0005 0 0 0 0 0 0 1 60 20895 0 20895 0.0006 12 2163 132299 0 132299 0.0039 12 2163 7534100 5078704 2455396 0.0716 1 1169831 1021956 7439963 7664951 -224988 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

EXTENSION CLINIC 3 JONES MEMORIAL HEALTH CARE CLINIC

15 LODER STREET WELLSVILLE NY 14895

EXTENSION CLINIC 4 JONES MEMORIAL HEALTH CARE CLINIC

13 LODER STREET WELLSVILLE NY 14895

EXTENSION CLINIC 5 JONES MEMORIAL HEALTH CARE CLINIC

20 MAIN STREET ANDOVER NY 14806

EXTENSION CLINIC 6 JONES MEMORIAL HEALTH CARE CLINIC

28 CHURCH STREET ALFRED NY 14802

EXTENSION CLINIC 7 JONES MEMORIAL HEALTH CARE CLINIC

5877 OLD STATE ROUTE 19 BELMONT NY 14813

EXTENSION CLINIC 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 JONES MEMORIAL HEALTH CARE CLINIC 7 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_L072f Schedule H, Part I, Line 7, Column f N/A 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 2010 with an operating loss of (17239). 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 (224988) on Line 7 should be treated as a community benefit since the amount is written off by the hospital. 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 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 (six in total throughout Allegany County) and through email distribution of the survey to agency list serves in the region. The survey was also distrubuted 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. SchH_P06_S00_L07 Schedule H, Part VI, Line 7 New York X X X 0 0 0 0 0 0 0 0 0 Eva Benedict 193281 0 0 0 0 0 0 0 7410 0 200691 0 0 TRACY GATES 79519 0 0 0 0 0 0 0 12590 0 92109 0 0 0 F Clifton Miller 380844 0 0 0 0 0 0 0 48919 0 429763 0 0 0 Billy Carstens 219056 0 0 0 0 0 0 0 39020 0 258076 0 0 0 LU-ANNE KAYE 192538 0 0 0 0 0 0 0 35616 0 228154 0 0 0 Mark Elliott 181589 0 0 0 0 0 0 0 18313 0 199902 0 0 0 HEATHER LANPHERE 257920 0 0 0 0 0 0 0 39945 0 297865 0 0 0 Joseph Felsen MD 160000 0 0 0 0 0 0 0 31220 0 191220 0 0 0 Robert Bruckner 78513 0 0 0 0 0 0 0 11196 0 89709 0 0 0 F990_P06_S0B_L11a Form 990, Part VI, Section B, Line 11a 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 COMPARABLE 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 = 298,338 PENSION LIABILITY ADJUSTMENT = - 972,205 NET APPRECIATION OF FUNDS IN TRUST = 57,533 TOTAL - 616,334 FORM 8868 WAS FILED AND APPROVED OF.