2011-11-04T10:11:51-05:00 2010-12-31 FUST CHARLES CHAMBERS LLP 5784 WIDEWATERS PARKWAY SYRACUSE NY 13214 990 2010-01-01 150524324 DELAWARE VALLEY HOSPITAL INC DELA 6078652198 1 TITUS PLACE WALTON NY 138561457 DAVID POLGE 6078652160 2011-10-20 1 3154463600 2010 2016-03-07 17:11:31Z DAVID POLGE 1 TITUS PLACE WALTON NY 138561457 15727467 0 X WWW.UHS.NET/ X 1950 NY TO SERVE OUR PATIENTS IN AN EFFICIENT AND PATIENT-FOCUSED MANNER AND OFFER A RANGE OF ACUTE, OUTPATIENT, DIAGNOSTIC, RAHABILITATIVE, PRIMARY CARE AND WELLNESS SERVICES. 9 6 238 45 0 0 636420 443654 16261514 15178353 28440 26635 549832 78825 17476206 15727467 0 0 0 0 9483934 9878570 0 0 20711 5622945 5537932 15106879 15416502 2369327 310965 15856057 15422294 9567946 8830758 6288111 6591536 X TO PROVIDE HIGH QUALITY HEALTH AND MEDICAL CARE SERVICES TO THE RESIDENTS OF IT'S RURAL SERVICE AREA. THE PRINCIPAL GEOGPRAPHIC AREAS SERVED INCLUDES THE MIDDLE AND SOUTHWESTERN PORTIONS OF DELAWARE COUNTY. IN ADDITION, A SIGNIFICANT NUMBER OF RESIDENTS LIVING IN NORTHERN SULLIVAN COUNTY UTILIZE THESE SERVICES. THE MAIN HOSPITAL CAMPUS IS LOCATED IN WALTON, WITH HEALTH CENTERS OPERATED IN DOWNSVILLE AND ROSCOE. 0 0 4436644 6684684 INPATIENT AND ACUTE SERVICES: DELAWARE VALLEY HOSPITAL FULFILLS IT'S MISSION BY WORKING TOGETHER WITH THE COMMUNITY, PHYSICIANS, AND OTHER HEALTHCARE PROVIDERS TO CONTINUOUSLY IMPROVE THE AVAILABILITY AND QUALITY OF SERVICES. THIS INCLUDES THE ABILITY TO PROVIDE A COMPREHENSIVE RANGE OF SHORT-TERM (96 HRS. OR LESS) INPATIENT ACUTE, SWING BED, AND ADDICTION TREATMENT SERVICES VIA IT'S 25-BED HOSPITAL LOCATED ON THE MAIN CAMPUS IN WALTON IN DELAWARE COUNTY, NY. PATIENT DISCHARGES IN 2010 WERE COMPRISED OF 690 ACUTE, 136 SWING BED, AND 83 ADDICTION TREATMENT. ACUTE CARE REPRESENTED 2,202 PATIENT DAYS, IN ADDITION TO THE 1,324 PATIENT DAYS FOR SWING BED AND 1,527 PATIENT DAYS IN THE ADDICTION TREATMENT PROGRAM. INDICATIVE OF THE COMPREHENSIVE HEALTHCARE PROVIDED TO THESE PATIENTS, A TOTAL OF 10,787 LAB TESTS, 4,807 RESPIRATORY TREATMENTS, 670 X-RAYS, 720 PHYSICAL THERAPY SESSIONS, AND 615 EKG'S WERE ADMINISTERED. OTHER SERVICES INCLUDED OCCUPATIONAL THERAPY, ENDOSCOPIES, ECHO EXAMS, ULTRASOUNDS, CT EXAMS, AND MAMMOGRAPHIES. TO ENSURE OUR RURAL AREA RESIDENTS HAVE ACCESS TO HIGH QUALITY, EFFICIENT CARE IN A COMFORTABLE AND PRIVATE AREA, THE HOSPITALS NEW IMAGING CENTER IS EQUIPPED WITH A 16-SLICE CT SCANNER. 1696469 1529704 CLINICS: DELAWARE VALLEY HOSPITAL PROVIDES A WIDE RANGE OF PRIMARY AND PREVENTIVE CARE SERVICES THROUGH IT'S FAMILY HEALTH CENTERS LOCATED IN WALTON, DOWNSVILLE, AND ROSCOE. THESE HEALTH CENTERS FORM THE FOUNDATION NECESSARY TO SERVE OUR COMMUNITIES WITH A COORDINATED SYSTEM OF CARE WHILE PAYING SPECIAL ATTENTION TO UNDER-SERVED AREAS. IN 2010 OUR CLINICS PROVIDED CARE TO 9,762 PATIENTS IN WALTON, 2,408 IN ROSCOE, AND 1,240 IN DOWNSVILLE. WITH A FOCUS ON CONTINUOUS IMPROVEMENT, THE FAMILY HEALTH CENTERS OPERATE UNDER A NEW HEALTH INFORMATION MANAGEMENT SYSTEM AND CONTINUE TO BE SMOKE AND TOBACCO FREE. THEY HAVE ALSO BECOME A KEY TO THE IMPROVEMENT OF CHILDHOOD IMMUNIZATION LEVELS IN COORDINATION WITH DELAWARE COUNTY'S PUBLIC HEALTH NURSING SERVICES AND OTHER AREA HEALTHCARE PROVIDERS. 4622004 6963965 OUTPATIENT AND AMBULATORY SERVICES: DELAWARE VALLEY HOSPITAL PROVIDES A COMPREHENSIVE RANGE OF OUTPATIENT DIAGNOSTIC AND TREATMENT SERVICES AT IT'S WALTON CAMPUS. THESE INCLUDE A NEW 7-BED EMERGENCY DEPARTMENT WHICH SERVES THE COMMUNITY 24/7. OTHER TREATMENT SERVICES INCLUDE EMERGENCY CARE, REHABILITATIVE SERVICES, AMBULATORY PROCEDURES, AND ACCESS TO SPECIALTY SERVICES AND SURGERY. THE HOSPITAL ALSO CONDUCTS EXTENSIVE WELLNESS PROGRAMMING THAT INCLUDES CARDIOVASCULAR AWARENESS/CHOLESTEROL SCREENING, WEIGHT REDUCTION, CANCER EDUCATION AND SCREENING, AND DIABETES EDUCATION/GLUCOSE TESTING. THE PHYSCIAL THERAPY DEPARTMENT PROVIDES HOME VISITS IN COOPERATION WITH THE DELAWARE COUNTY PUBLIC HEALTH NURSING DEPARTMENT. A FREE PRESCRIPTION DELIVERY PROGRAM IS PROVIDED FOR ROSCOE AND DOWNSVILLE PATIENTS AS THESE COMMUNITIES LACK A PHARMACY. OCCUPATIONAL HEALTH PROGRAMMING MEETS THE NEEDS OF LOCAL BUSINESSES, FIRE DEPARTMENTS, AND EMERGENCY SQUADS BY PROVIDING PHYSICALS, DRUG TESTING, AND ERGONOMIC EDUCATION. IN 2010 THE EMERGENCY DEPARTMENT TREATED OR ADMITTED 5,397 RESIDENTS VIA ITS NEW 5,000+ SQ. FT. FACILITY, THE LAB PERFORMED 50,118 TESTS, AND 7,460 PHYSICAL/OCCUPATIONAL THERAPY SESSIONS WERE CONDUCTED. THE IMAGING CENTER PERFORMED 6,319 X-RAYS, CT SCANS, AND MAMMOGRAPHIES FOR OUTPATIENT SERVICES. EQUIPMENT UPGRADES FOR 2010 INCULDED A NEW HIGH PERFORMANCE BONE DENSITY MACHINE TO PROVIDE RELIABLE MEASUREMENTS TO AID IN DIAGNOSIS FOR PATIENTS. OTHER EQUIPMENT ADDITIONS INCLUDED A DEFIBRILLATOR UNIT AND PADDLES AND AN OLYMPUS PEDI-COLONSCOPE. BUILDING IMPROVEMENTS DURING 2010 INCLUDED NEW SECURE BADGE ACCESS TO THE HOSPITAL EMERGENCY AND ADDICTION TREATMENT FACILITIES AND SECURITY CAMERAS. 10755117 1 1 0 1 0 0 0 0 1 1 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 46 0 1 238 1 0 0 0 0 0 0 0 0 0 0 X 9 6 0 0 0 0 1 1 0 1 1 0 0 0 0 1 1 1 0 0 NY X JOHN SAVELLI 6078652198 DELAWARE VALLEY HOSPITAL 1 TITUS WALTON NY 138561457 DAVID POLGE 40.00 X X 183224 0 10280 DR MICHAEL FREEMAN 40.00 X X 227374 0 18039 DR RAJESH DAVE 1.00 X X 0 678610 52408 HELEN JOHNSTON 1.00 X X 0 0 0 EDWARD SNOW 1.00 X X 0 0 0 EDWARD SCHOTT 1.00 X X 0 0 0 PAUL CARLSTROM 1.00 X X 0 0 0 REV LARRY LIGHT 1.00 X 0 0 0 BRIDGET DEMOTT 1.00 X 0 0 0 DOTTIE KRUPPO 40.00 X 74765 0 6939 JOAN GUARNIERI 40.00 X 91195 0 7362 PAUL SUMMERS 40.00 X 104070 0 8673 DEBORAH HITT 40.00 X 77547 0 11133 VICTORIA CONKLING 40.00 X 93197 0 1907 DR VADIM DAVYDOV 40.00 X 170514 0 9093 DR VALENTINA DAVYDOV 40.00 X 170800 0 0 SUMAN CHOUDHURY 63.00 X 170097 0 14833 DEVELYN CORRIGAN 63.00 X 111867 0 0 1474650 678610 140667 7 0 1 0 MVP HEALTH PLAN INC PO BOX 26864 NEW YORK NY 10087 HEALTH CARE 314416 SECO PHYSICAL & OCCUPATIONAL THERAPY PO BOX 1046 NORWICH NY 13815 PHYSICAL AND OCCUPATIONAL THERAPY SERVIC 310102 HEALTHCARE MANAGEMENT SYSTEMS 2739 MOMENTUM PLACE CHICAGO IL 60689 INFORMATION TECHNOLOGY 269872 NATIONAL GOVERNMENT SERVICES PO BOX 13078 NEWARK NJ 07188 MEDICARE CONTRACTOR 265953 UNITED HEALTH SERVICES INC 20-40 MITCHELL AVE BINGHAMTON NY 13903 HEALTH CARE 213436 12 383234 60420 443654 NET PATIENT REVENUE 900099 15178353 15178353 15178353 25301 25301 1334 1334 1334 1334 VENDING MACHINE 722210 24364 24364 PHYSICIAN OTHER REVENU 621498 18949 18949 REBATES 900099 18426 18426 17086 17086 78825 15727467 15215728 0 68085 1266112 871186 394926 6736581 4811438 1911438 13705 196793 121764 74397 632 1112775 688521 420683 3571 566309 398446 166957 906 187014 187014 20993 20993 75665 75665 5429 5429 2000 2000 880276 768899 111377 942092 709622 230603 1867 191159 191159 226692 55268 171424 38390 26542 11818 30 34726 31322 3404 365366 365366 888824 877804 11020 181568 141153 40415 BAD DEBT EXPENSE 832370 832370 MISCELLANEOUS 611643 367057 244586 53725 53725 15416502 10755117 4640674 20711 2557358 1867280 642603 654900 101752 2721 1705146 1825175 113845 134131 464805 426743 18470672 10396019 8270314 8074653 492978 531930 1507256 1904761 15856057 15422294 953288 824833 5678593 5427574 1060279 963096 1326531 1134093 549255 481162 9567946 8830758 X 5863720 6248704 106181 24622 318210 318210 6288111 6591536 15856057 15422294 X 310965 -7540 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5429 5429 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: DELAWARE VALLEY HOSPITAL HAS LIMITED LOBBYING ACTIVITIES WHICH ARE CONDUCTED ON BEHALF OF THE ORGANIZATION THROUGH MEMBERSHIP IN IROQUOIS HEALTHCARE AND THE HEALTH CARE ASSOCIATION OF NEW YORK STATE (HANYS). THESE ACTIVITIES INCLUDE ADVERTISEMENTS AND CONTACTS WITH THE LEGISLATORS ON VARIOUS HEALTHCARE ISSUES. 424391 6550 88109 342832 361680 145420 82709 424391 765743 79512 299 483874 361680 0.07000 0.93000 1 0 51202 51202 8484554 3096669 5387885 9100042 6947409 2152633 834874 351941 482933 8074653 WELLS FARGO - PRINCIPAL PMTS. ON BOND 158020 F TEMPORARILY RESTRICTED DONATIONS 21520 F CAPITAL CONSTRUCTION (FUNDED DEPR.) 1725221 F 1904761 DUE UNITED MED. ASSOC. NET CHENANGO MEM. 3500 DUE UNITED HEALTH SERVICES HOSPITALS 462371 DUE UNITED HEALTH SERVICES, INC. 15291 481162 15727467 15416502 310965 36797 -44337 -7540 303425 15762930 36797 36797 15726133 1334 1334 15727467 15459505 44337 44337 15415168 1334 1334 15416502 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: PURCHASE OF CAPITAL EQUIPMENT (MEDICAL) AND IMPROVEMENT OF FACILITIES. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE. THE HOSPITAL IS SUBJECT TO FEDERAL INCOME TAXES ON UNRELATED BUSINESS INCOME UNDER SECTION 511 OF THE INTERNAL REVENUE CODE. PART XII, LINE 4B - OTHER ADJUSTMENTS: GAIN ON DISPOSAL OF ASSETS 1,334. PART XIII, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN FAIR VALUE OF INTEREST RATE SWAP 44,337. PART XIII, LINE 4B - OTHER ADJUSTMENTS: GAIN ON DISPOSAL OF ASSETS 1,334. PART XI, LINE 8 - CHANGE IN FAIR VALUE OF INTEREST RATE SWAP AGREEMENT. 1 1 X 1 X 1 X 1 1 0 1 1 126486 41235 85251 0.00550 4579962 3008705 1571257 0.10190 4706448 3049940 1656508 0.10740 182931 6940 175991 0.01140 42979 42979 0.00280 1300 0 1300 0.00010 227210 6940 220270 0.01430 4933658 3056880 1876778 0.12170 1 416185 35040 3445653 3647494 -201841 X 0 6 1 DELAWARE VALLEY HOSPITAL INC

1 TITUS PLACE WALTON NY 13856

X X X 2 ROSCOE FAMILY HEALTH CENTER

1982 OLD ROUTE 17 ROSCOE NY 12776

OUTPATIENT PHYSICIAN CLINIC 3 DOWNSVILLE FAMILY HEALTH CENTER

15212 MAIN STREET DOWNSVILLE NY 13755

OUTPATIENT PHYSICIAN CLINIC 4 WALTON FAMILY HEALTH CENTER

2 TITUS PLACE WALTON NY 13856

OUTPATIENT PHYSICIAN CLINIC 5 PHYSICAL AND OCCUPATIONAL THERAPY

123 STOCKTON AVENUE WALTON NY 13856

REHABILITATION CLINIC 6 SPECIALTY CLINIC

121 STOCKTON AVENUE WALTON NY 13856

OUTPATIENT PHYSICIAN CLINIC DELAWARE VALLEY HOSPITAL 1 PART I, LINE 7: DELAWARE VALLEY HOSPITAL IS A CRITICAL ACCESS HOSPITAL (CAH) AS DESIGNATED BY MEDICARE AND MEDICAID. UNLIKE NON-CAH'S THAT ARE REIMBURSED BASED ON A PROSPECTIVE REIMBURSEMENT METHODOLOGY, CAH'S ARE REIMBURSED THEIR ALLOWABLE COSTS FOR MEDICARE PURPOSES. THE MEDICARE COST REPORT (CMS 2552) AND THE MEDICAID INSTITUTIONAL COST REPORT (ICR) WAS UTILIZED FOR PURPOSES OF IDENTIFYING COSTS AND NET REVENUE. A. COSTS:I. FYE COSTS AS INDEPENDENTLY AUDITED. NON-ALLOWABLE COSTS (I.E.-PHYSICIANS, ETC.) ARE USED TO REDUCE COSTS TO ARRIVE AT ALLOWABLE COSTS.II. VARIOUS STATISTICAL BASIS ARE USED TO ALLOCATE GENERAL SERVICE COSTS (I.E.-ADMINISTRATION, PLANT OPERATIONS, HOUSEKEEPING, ETC.), VIA A "STEPDOWN" METHODOLOGY TO REVENUE PRODUCING COST CENTERS SUCH AS ANCILLARY COST CENTERS (I.E. - RADIOLOGY, LAB, PHYSICAL THERAPY, ETC.) ROUTINE COST CENTERS (MEDICAL SURGICAL, ETC.) AND OUTPATIENT COST CENTERS (EMERGENCY, CLINIC, ETC.). III. ROUTINE COSTS PER DAY ARE THEN CALCULATED BY DIVIDING DIRECT AND INDIRECT COSTS (STEPDOWN) BY TOTAL DAYS. THIS PER DAY COST CAN THEN BE MULTIPLIED BY PAYOR SPECIFIC DAYS TO ARRIVE AT ROUTINE PAYOR COSTS.IV. ANCILLARY AND OUTPATIENT COSTS RELATED TO SPECIFIC PAYORS CAN BE DETERMINED BASED ON THE RATIO OF COST TO CHARGES (RCC).1. THE RCC IS CALCULATED BY DIVIDING THE DIRECT AND INDIRECT COSTS (STEPDOWN COSTS)BY GROSS CHARGES. THE RCC CAN THEN BE MULTIPLIED BY PAYOR SPECIFIC GROSS CHARGES TO ARRIVE AT PAYOR SPECIFIC COSTS. B. REVENUE: I. MEDICARE: NET REVENUE IS BASED IN DVH'S ALLOWABLE COSTS (INPATIENT AND OUTPATIENT) ARE REIMBURSED WITH A 1% MARKUP. II. MEDICAID: NET REVENUE IS BASED ON THE FOLLOWING:A. INPATIENT - A BASE YEAR COST PER DAY TRENDED ANNUALLY FOR INFLATION.B. OUTPATIENT - MEDICAID PUBLISHED RATES.III. OTHER PAYORS: REVENUE IS BASED ON NEGOTIATED RATES OF PAYMENT. PART I, L7 COL(F): DELAWARE VALLEY HOSPITAL REPORTED BAD DEBT EXPENSE IN THE AMOUNT OF $832,370 IN PART IX, LINE 24A. THE AFOREMENTIONED BAD DEBT EXPENSE WAS NOT USED IN THE CALCULATIONS OF SCHEDULE H, PART 1, LINES 7A THRU 7K. PART II: ...THE CEO SERVES ON THE COUNTY RURAL HEALTH ALLIANCE WHICH BRINGS HEALTHCARE AND SERVICE AGENCIES TOGETHER TO RECOGNIZE AND ADDRESS HEALTHCARE NEEDS OF RESIDENTS. THE HOSPITALS DIETITIAN SERVES ON THE LOCAL SCHOOL COMMITTEE ON OBESITY TO HELP ADDRESS STUDENTS HEALTH. THE HUMAN RESOURCE COORDINATOR PARTICIPATES IN THE LOCAL SCHOOL CAREER DAY, MAKING STUDENTS AWARE OF HEALTHCARE CAREERS. THE HOSPITAL ALSO HOLDS A 2 DAY MASH CAMP FOR STUDENTS IN GRADES 7 - 12 TO OFFER THEM THE OPPORTUNITY TO HAVE HANDS ON EXPERIENCE IN VARIOUS HEALTHCARE CAREERS. NUMERIOUS JOB FARES ARE ATTENDED. FINALLY, THE CEO SERVES AS A BOARD MEMBER OF THE CATSKILL-HUDSON AREA HEALTH EDUCATION CENTER WHICH FOCUSES ON WORKFORCE DEVELOPMENT. COMMUNITY SUPPORT ACTIVITIES INCLUDE SERVICE ON A COMMITTEE TO ATTRACT AND RETAIN PROFESSIONALS TO OUR AREA IN THE FIELDS OF HEALTHCARE. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT SPECIFICALLY REFERENCE OR DESCRIBE BAD DEBT EXPENSE. AN ALLOWANCE FOR DOUBTFUL ACCOUNTS RECEIVABLE IS ESTIMATED BY MANAGEMENT BASED ON PERIODIC REVIEWS OF THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE CONSIDERING HISTORICAL EXPERIENCE AND PREVAILING ECONOMIC CONDITIONS. PART III, LINE 8: BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS NET PATIENT SERVICE REVENUE. THE HOSPITAL HAS A POLICY TO PROVIDE A COMMUNITY BENEFIT TO UNINSURED PATIENTS THAT CONSISTS OF FEE DISCOUNTS. CERTAIN PATIENTS THAT WERE PROVIDED FEE DISCOUNTS WOULD HAVE LIKELY QUALIFIED UNDER THE CHARITY CARE POLICY. PART VI, LINE 2: DELAWARE VALLEY HOSPITAL (DVH) WORKS CLOSELY WITH OTHER HEALTHCARE ORGANIZATIONS AND SERVICE AGENCIES TO ADDRESS THE NEEDS OF AREA RESIDENTS. THE DELAWARE COUNTY PUBLIC HEALTH DEPARTMENT CONDUCTED IT'S MANDATED NEEDS ASSESSMENT IN 2008. DVH PARTICIPATED IN THE PROCESS. THE HOSPITAL ALSO SERVES AS A MEMBER OF THE DELAWARE COUNTY RURAL HEALTHCARE ALLIANCE; A COALITION OF SERVICE AND HEALTHCARE AGENCIES. THE CEO OF THE HOSPITAL SERVES ON THE CATSKILL-HUDSON AREA HEALTH EDUCATION CENTER. THESE RELATIONSHIPS ALLOW THE HOSPITAL TO RECOGNIZE THE NEEDS OF THE COMMUNITY AND ADDRESS THEM AS APPROPRIATE IN CONJUNCTION WITH OTHER STAKEHOLDERS. PATIENT SATISFACTION SURVEYS ARE COMPLETED ON AN ONGOING BASIS. ADMINISTRATIVE REPRESENTATIVES ALSO ATTEND ALL DELAWARE VALLEY HOSPITAL VOLUNTEERS MEETINGS, WHOSE MEMBERS ARE ABLE TO OFFER INSIGHT INTO THE NEEDS OF THE COMMUNITY MEMBERS. PART VI, LINE 3: DELAWARE VALLEY HOSPITAL, INC. IS COMMITTED TO PROVIDING FINANCIAL ASSISTANCE TO ALL PATIENTS IN NEED AND TO COMMUNICATE THE AVAILABILITY OF ITS FINANCAIAL ASSISTANCE AND RELATED PROGRAMS TO ALL. PATIENT FINANCIAL ADVOCATES ARE AVAILABLE TO ASSIST PATIENTS AND PROVIDE ASSESSMENTS FOR ELIGIBILITY UNDER ANY STATE, FEDERAL, OR UHS SYSTEM HOSPITALS' FINANCIAL ASSISTANCE PROGRAM. BROCHURES AND SIGNAGE ARE POSTED IN MULTIPLE LANGUAGES IF REQUIRED BY NEW YORK STATE REGULATIONS AT EACH REGISTRATION/PATIENT ACCESS AREA. IF NEEDED, TRANSLATION SERVICES ARE AVAILABLE. DELAWARE VALLEY HOSPITAL, INC. ALSO MAINTAINS A FINANCIAL ASSISTANCE HELP LINE THAT IS ADVERTISED ON ALL (INPATIENT & OUTPATIENT) BILLS. PART VI, LINE 4: DELAWARE VALLEY HOSPITAL (DVH) IS A 25-BED CRITICAL ACCESS HOSPITAL (CAH) FACILITY LOCATED IN WALTON IN DELAWARE COUNTY, NY. DVH PROVIDES HIGH QUALITY HEALTH AND MEDICAL CARE SERVICES TO A RURAL POPULATION OF APPROXIMATELY 31,000 PEOPLE LIVING IN SOUTHWESTERN DELAWARE AND NORTHEASTERN SULLIVAN COUNTIES. AS A CAH FACILITY, THE HOSPITAL GENERALLY SERVES PATIENTS WHOSE ACUTE STAY WILL BE 96 HOURS OR LESS; HOWEVER, DVH ALSO PROMOTES LONGER-TERM INPATIENT REHABILITATIVE AND ADDICTION TREATMENT CARE FOR PATIENTS. A NEW 7-BED EMERGENCY DEPARTMENT WAS CONSTRUCTED IN 2008 AND SERVES THE COMMUNITY 24/7. THE HOSPITAL ALSO OFFERS DIAGNOSTIC AND TREATMENT SERVICES WHICH INCLUDE A FULL SERVICE LABORATORY ON SITE, AMBULATORY SURGERY, ENDOSCOPY AND BLOOD TRANSFUSIONS AND PHLEBOTOMY. IT'S NEW IMAGING CENTER IS EQUIPPED WITH CT SCAN, MAMMOGRAPHY, AND BONE DENSITOMETRY TO NAME A FEW. CARDIOPULMONARY SERVICES INCLUDE EKG, PFT'S, EVENT MONITORING AND A CARDIAC REHABILITATION PROGRAM. SPEECH, PHYSICAL AND OCCUPATIONAL THERAPY ARE OFFERED BOTH ON AN INPATIENT AND OUTPATIENT BASIS. PRIMARY AND PREVENTIVE CARE FOR ALL AGES, AND OCCUPATIONAL HEALTH SERVICES ARE PROVIDED THROUGH THE THREE FAMILY HEALTH CENTER SITES IN WALTON, DOWNSVILLE AND ROSCOE, NY. AREA SPECIALISTS COME TO DELAWARE VALLEY HOSPITAL'S VISITING SPECIALIST CENTER ON A REGULAR BASIS TO SEE PATIENTS. THE SERVICE AREA WAS DETERMINED BY EXAMINING INPATIENT ORIGIN BY ZIP CODE AND BY COUNTY. BECAUSE THE MAJORITY OF THE SERVICE AREA FALLS INTO A SINGLE COUNTY, COLLABORATION TO IDENTIFY PUBLIC HEALTH PRIORITIES TOOK PLACE AT THE COUNTY LEVEL. DVH'S SERVICE AREA IS CENTERED IN DELAWARE COUNTY, WITH 81% OF PATIENTS COMING FROM MIDDLE AND SOUTHWESTERN DELAWARE COUNTY COMMUNITIES, AND ANOTHER 15% FROM NORTHERN SULLIVAN, BROOME, OTSEGO, AND CHENANGO COUNTIES. DVH'S 85% ZIP CODE SERVICE AREA INCLUDES THE COMMUNITIES OF: WALTON, DOWNSVILLE, SIDNEY CENTER, ROSCOE, HANCOCK, HAMDEN, DELHI, EAST BRANCH, DELANCEY, SIDNEY, UNADILLA, BAINBRIDGE, FRANKLIN, AND LONG EDDY. PART VI, LINE 6: DURING 2010 THE DELAWARE VALLEY HOSPITAL PARTICIPATED IN SEVERAL PROGRAMS TO PROMOTE THE HEALTH AND WELLBEING OF THE LOCAL COMMUNITY WITHIN DELAWARE COUNTY. FOR EXAMPLE, THE HOSPITAL SUPPORTED THE DELAWARE COUNTY FAIR WITH A TOTAL OF 26 EMPLOYEES SPENDING 215 WORKING HOURS AT THE EVENT. THE HOSPITAL STAFF PROVIDED 373 BLOOD PRESSURE TESTS, 139 BLOOD SUGAR SCREENINGS AND OTHER HEALTH RELATED TESTS, FOR A TOTAL OF 656 SERVICES AT NO COST TO THE COMMUNITY. THE HOSPITAL ALSO PROVIDED VARIOUS SCREENING TESTS SUCH AS SERIES 2500, PSA, COLORECTAL, AND HGA1C TO A TOTAL OF 231 INDIVIDUALS WITHIN THE FIRE DEPARTENTS OF WALTON, STAMFORD, ANDES, HAMMOND, AND ROXBURY. OTHER EVENTS DURING THE YEAR INCLUDED A TEDDY BEAR CLINIC WHICH SERVED 96 CHILDREN IN THE LOCAL COMMUNITY AND PROVIDED THEM WITH AN INTRODUCTION AND BETTER UNDERSTANDING OF THE HOSPITAL'S EMERGENCY ROOM. THIS ALSO PROVIDED A CHANCE TO MEET THE STAFF THAT IS THERE TO TREAT THEM. OTHER COMMUNITY HEALTH IMPROVEMENT PROGRAMS INCLUDED DRUG SCREENS FOR THE DELAWARE VALLEY AND CHENANGO COUNTY DRUG COURT FOR CONVICTED (NON-VIOLENT) INDIVIDUALS. THIS PROGRAM PROVIDED DRUG TEST, COUNSELING, AND COMMUNITY SERVICE AS AN ALTERNATIVE TO INCARCERATION. THE HOSPITAL'S LIFESTEPS PROGRAM ADVOCATED WEIGHT LOSS AND HEALTHY EATING HABITS AND SOLUTIONS. THE HOSPITAL'S VICE-PRESIDENT OF COMMUNITY HEALTH SERVICES SERVES ON THE DELAWARE COUNTY RURAL HEALTH CARE ALLIANCE. THIS PROGRAM IS A COALITION OF HEALTH CARE PROVIDERS FROM DELAWARE COUNTY THAT STRESSES THE NEEDS OF VARIOUS ORGANIZATION IN THE COMMUNITY. ALSO TO NOTE, THE HOSPITAL'S BOARD OF DIRECTORS IS COMPRISED OF BOTH STAFF AND MEMBERS OF THE LOCAL COMMUNITY. PART VI, LINE 7: DELAWARE VALLEY HOSPITAL, INC. IS AN IMPORTANT PART OF A LARGER SYSTEM OF INTEGRATED DELIVERY OF CARE, WHICH PROVIDES ADDITIONAL BENEFITS TO THE COMMUNITY. AS A RESULT OF THE FORMATION OF UHS IN 1981 AND THE SUBSEQUENT TRANSFORMATION OF THE COMBINED ORGANIZATION INTO A HEALTH CARE SYSTEM, OUR REGION TODAY OFFERS MORE COMPLETE AND ADVANCED CARE THAN MANY COMMUNITIES FIVE TIMES OUR SIZE. IN 2007, THE UNITED HEALTH SERVICES SYSTEM ENGAGED IN A STRATEGIC PLANNING PROCESS FOR THE YEARS 2008-2011. CONSISTENT WITH THE MISSION AND VISION, THE PLAN FOCUSED ON CONTINUING TO STRENGTHEN THE HEALTH SYSTEM AND ITS SERVICES TO THE REGION. THE STRATEGIC PLAN IS ORGANIZED AROUND THREE GOALS: CLINICAL EXCELLENCE, GROWTH AND FINANCIAL STRENGTH. SPECIFIC DESTINATION METRICS OR MEASURES OF SUCCESS WERE DEVELOPED FOR EACH STRATEGIC GOAL. THE SPECIFIC INITIATIVES SUPPORTING ACHIEVEMENT OF THE GOALS ARE REVIEWED ON A REGULAR BASIS. EACH ENTITY CARRIES OUT INITIATIVES LOCALLY AND REGIONALLY. THE UHSH COMMUNITY SERVICE REPORT CAPTURES THE BENEFITS SPECIFIC TO UHSH, WITH THE OTHER AFFILIATES SUBMITTING SEPARATE REPORTS. -CLINICAL EXCELLENCE: UHS HAS FOCUSED ITS RESOURCES AND ENERGY AROUND ACHIEVING DISTINCTION AS A HEALTH SYSTEM IN CLINICAL QUALITY, PATIENT SAFETY AND SERVICE. UHS IS FOCUSED ON VIGOROUS ASSESSMENT AND IMPROVEMENT OF THE ORGANIZATION'S PERFORMANCE USING KEY PATIENT QUALITY, SAFETY AND SATISFACTION INDICATORS. THE PLAN PLACES A FOCUS IN PARTICULAR ON EMERGENCY ROOM PERFORMANCE, CLOSER INTEGRATION OF NON-ACUTE SERVICES WITH THE HOSPITALS, DEVELOPMENT AND IMPLEMENTATION OF STATE-OF-THE-ART INFORMATION TECHNOLOGY TO SUPPORT INITIATIVES IN PATIENT QUALITY AND SAFETY AND NEW INITATIVES IN THE RECRUITMENT AND RETENTION OF A QUALITY PHYSICIAN AND ALLIED HEALTH WORKFORCE. -SERVICE GROWTH: THIS GOAL AREA ADDRESSES THE KEY ASPECTS OF ALIGNING TECHNOLOGY, PHYSICIAN RESOURCES AND PROGRAMS AROUND THE CLINICAL NEEDS OF THE SERVICE AREA. THE PLAN FOCUSES ATTENTION ON KEY TERTIARY SERVICES AND THE ASSURANCE OF AN ADEQUATE SUPPLY OF PRIMARY CARE AND SPECIALIST PHYSICIANS FOR THE AREA. AT THE SAME TIME, UHS REMAINS COMMITTED TO MEETING THE COMMUNITY'S NEEDS IN BEHAVIORAL HEALTH SERVICES. -FINANCIAL STRENGTH: TO ENSURE UHS HAS THE FINANCIAL CAPACITY TO SUPPORT ITS SERVICE AND GROWTH GOALS, THE STRATEGIC PLAN CALLS THE ORGANIZATION TO DEMONSTRATE CONSISTENT PERFORMANCE WITH RESPECT TO BENCHMARKED OPERATING EFFICIENCIES. REPORTS FILED WITH STATES PART VI, LINE 7 NY X X X X 0 0 0 0 0 0 0 0 0 DAVID POLGE 177244 0 0 0 5980 0 5254 0 5026 0 193504 0 0 0 DR MICHAEL FREEMAN 222374 0 0 0 5000 0 3647 0 14392 0 245413 0 0 0 DR RAJESH DAVE 0 424228 0 135271 0 119111 0 18870 0 33538 0 731018 0 0 DR VADIM DAVYDOV 160514 0 0 0 10000 0 0 0 9093 0 179607 0 0 0 DR VALENTINA DAVYDOV 160800 0 0 0 10000 0 0 0 0 0 170800 0 0 0 SUMAN CHOUDHURY 170097 0 0 0 0 0 4250 0 10583 0 184930 0 0 0 COUNTY OF DELAWARE INDUSTRIAL DEVELOPMENT AGENCY 161137407 245867AA4 2007-06-29 5805000 CONSTRUCTION OF NEW ER/IMAGING CENTER; REFINANCE HOSPITAL MORTGAGE 0 0 0 5805000 250826 5805000 2008 0 0 1 1 0 0 0 0 1 0.00000 0.00000 0.00000 1 1 1 0 0 0 0 MARIANNE SCHOTT SPOUSE OF EDWARD SCHOTT, BOARD CHAIR 22086 EMPLOYEE WAGES 0 MICHAEL LAYTON BROTHER-IN-LAW OF DEBORAH HITT, V.P. QUALITY/SUPPORT SERVICES 45567 EMPLOYEE WAGES 0 BONNIE CRAIG SISTER OF DEBORAH HITT, V.P. QUALITY/SUPPORT SERVICES 30699 EMPLOYEE WAGES 0 NANCY VOLLKOMMER SISTER-IN-LAW OF VICKI CONKLING, V.P. NURSING ADMIN./CNO 27866 EMPLOYEE WAGES 0 DR DENISE FREEMAN SPOUSE OF MICHAEL FREEMAN, MEDICAL STAFF PRESIDENT 72491 EMPLOYEE WAGES 0 FORM 990, PART VI, SECTION A, LINE 6 THE MEMBER OF THE ORGANIZATION IS UNITED HEALTH SERVICES, INC. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBER OF THE ORGANIZATION IS UNITED HEALTH SERVICES, INC. FORM 990, PART VI, SECTION B, LINE 11 THE DELAWARE VALLEY HOSPITAL CONTROLLER PREPARES THE FORM 990 AND THEN PRESENTS IT TO OUR V.P. FINANCE/CFO FOR REVIEW. IT IS THEN FORWARDED TO OUR EXTERNAL AUDITORS, FUST CHARLES CHAMBERS FOR THEIR REVIEW. ONCE THEY DETERMINE IT TO BE COMPLETE, IT IS THEN PRESENTED TO THE PRESIDENT/CEO FOR APPROVAL PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 15A PERFORMANCE REVIEW OF PRESIDENT/CEO IS COMPLETED BY BOARD CHAIR AND 2ND VICE CHAIR/UHS, INC. LIAISON ANNUALLY. RESULTS PRESENTED TO EXECUTIVE COMPENSATION COMMITTEE, COMPRISED OF CHAIR, LIAISON, AND THREE OTHER BOARD MEMBERS. COMMITTEE USES SULLIVAN-CARTER, A PAID CONSULTING FIRM, TO OBTAIN NATIONAL CEO COMPENSATION DATA BY HOSPITAL TYPE, SIZE, ETC. AS BASIS FOR ESTABLISHING ACCEPTABLE RANGE OF COMPENSATION TO ENSURE COMPLIANCE WITH TREASURY REGULATION 53.4958-1(D)(4)(3). THE COMMITTEE THEN DETERMINES AND APPROVES THE PRESIDENT/CEO COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION PROVIDES FORM 990 AND OTHER INFORMATION REQUIRED UNDER INTERNAL REVENUE SERVICE REGULATIONS TO THE PUBLIC, UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CHANGE IN FAIR VALUE OF INTEREST RATE SWAP & UNREALIZED GAINS/LOSSES. FORM 990, LINE 2C, PART XII THE DELAWARE VALLEY HOSPITAL HAS AN AUDIT COMMITTEE IN PLACE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF ITS ANNUAL FINANCIAL STATEMENT AUDIT AND THE SELECTION OF INDEPENDENT ACCOUNTANTS. UNITED HEALTH SERVICES HOSPITAL INC 10-42 MITCHELL AVENUE BINGHAMTON NY 13903 161165049 HOSPITAL NY 501(C)(3) 3 UNITED HEALTH SERVICES INC 0 PROFESSIONAL HOME CARE 4401 VESTAL PARKWAY EAST VESTAL NY 13850 161261977 HOME HEALTH CARE NY 501(C)(3) 9 UNITED HEALTH SERVICES INC 0 IDEAL SENIOR LIVING CENTER 508 HIGH STREET ENDICOTT NY 13760 222902896 SENIOR LIVING CENTER NY 501(C)(3) 3 UNITED HEALTH SERVICES INC 0 IDEAL SENIOR LIVING CENTER HOUSING 508 HIGH STREET ENDICOTT NY 13760 222902899 SENIOR HOUSING NY 501(C)(3) 9 UNITED HEALTH SERVICES INC 0 CHENANGO MEMORIAL HOSPITAL 179 NORTH BROAD STREET NORWICH NY 13815 150532180 HOSPITAL NY 501(C)(3) 3 UNITED HEALTH SERVICES INC 0 UNITED MED MANAGEMENT 601 RIVERSIDE DRIVE JOHNSON CITY NY 13790 161396133 PHYSICIAN PRACTICE NY 501(C)(3) 11B UNITED HEALTH SERVICES INC 0 UNITED HEALTH SERVICES HOSPITAL INC 20-40 MITCHELL AVENUE BINGHAMTON NY 13903 PARENT COMPANY NY 501(C)(3) 9 UNITED HEALTH SERVICES INC BOARD OF DIRECTORS 0 0 0 0 0 1 0 0 0 0 0 0 1 0 1 1 1 0 0