2011-08-08T09:42:05-05:00 2010-09-30 MARCUM LLP CITY PLACE II 185 ASYLUM STREET HARTFORD CT 06103 990 2009-10-01 061422973 Mount Sinai Rehabilitation Hospital Inc MOUN 8607143500 114 woodland street No 4312 hartford CT 06105 john n giamalis 8607143500 2011-07-29 1 Douglas Farrington 8605498500 2009 2016-02-24 21:20:13Z John N Giamalis 114 woodland street No 4312 hartford CT 06105 19502763 0 X www.stfranciscare.org X 1995 CT Rehabilitation services 11 9 211 52 0 0 597696 705148 15252472 16459401 81680 172612 52404 54723 15984252 17391884 0 0 12461704 13470874 0 0 3118075 2980627 15579779 16451501 404473 940383 16937841 18411350 1043300 1536085 15894541 16875265 To operate a rehabilitation hospital in Hartford, Connecticut, and provide inpatient and outpatient rehabilitation services to persons who are disabled with physical or mental handicap. 0 0 16390807 16509522 To provide comprehensive inpatient and outpatient medical rehabilitation services in the greater hartford connecticut community as part of the saint francis care health system. 16390807 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 1 7 0 1 211 1 0 0 0 0 0 0 0 0 0 11 9 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 X X X Donna Gilbert 8607149632 114 woodland street suite 4312 hartford CT 06105 X howard w orr 2.00 X X 0 0 0 christopher m dadlez 2.00 X X 0 1594976 290008 delores graham 2.00 X X 0 0 0 p anthony giorgio phd 2.00 X X 0 0 0 edward s johnson dds 2.00 X X 0 292914 14839 brad davis 2.00 X 0 0 0 jeannine mara 2.00 X X 0 0 0 rolf knoll md 2.00 X 0 491043 28134 john suisman 2.00 X 0 0 0 michael e cummings 2.00 X 0 0 0 wendy e elberth 2.00 X 0 0 0 Diane M Bernier 55.00 X 139781 0 12981 Anne-Marie Alcide 55.00 X 132229 0 10663 Maura A Murray 55.00 X 122967 0 7095 margaret c vansteenburgh 55.00 X 117498 0 11364 JOAN R PAGE 55.00 X 120554 0 3177 633029 2378933 378261 11 0 1 0 Cross Country Staffing PO Box 404674 Atlanta GA 303844674 Nursing Fees 101507 1 666750 38398 705148 Patient Care Services 621400 16459401 16459401 16459401 167610 167610 24130 24130 24130 24130 2115881 2110879 5002 5002 5002 Wellness Revenue 900099 25921 25921 Coffee shop revenue 900099 3102 3102 Miscellaneous Revenue 900099 1500 1500 70 70 30593 17391884 16509522 0 177214 8945742 8945742 460824 460824 3152032 3152032 912276 912276 19200 19200 1350318 1350318 51225 51225 292058 280812 11246 455354 455354 34278 9373 24905 544177 544177 5343 5343 Licenses & Fees 62107 62107 Miscellaneous 57868 57868 Bad Debts 43258 43258 Repairs & Maintenance 28073 28073 Dues & Subscriptions 21278 21278 16090 16090 16451501 16390807 60694 0 2278826 1240998 2045178 6519568 3436337 3292109 6460 9210 12120907 7374496 4894200 4746411 203069 186689 4073771 2416365 16937841 18411350 908742 1264233 134558 271852 1043300 1536085 X 15136507 15809467 758034 1065798 15894541 16875265 16937841 18411350 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 8500517 5160256 3340261 361098 93325 267773 2166183 1243185 922998 1093109 877730 215379 4746411 DUE FROM AFFILIATES 2416365 2416365 due to third parties reimbursement agencies 271852 271852 17391884 16451501 940383 40341 40341 980724 1 1 X 1 X 1 X 0 1 0 1 1 31 72296 0 72296 0.00440 675 887390 0 887390 0.05390 706 959686 959686 0.05830 15 41981 0 41981 0.00260 3550 28842 0 28842 0.00180 3565 70823 70823 0.00440 4271 1030509 1030509 0.06270 1536 0 1536 0.00010 34513 0 34513 0.00210 36049 36049 0.00220 0 17338 6316364 5361744 954620 X 1 1 MOUNT SINAI REHABILITATION HOSPITAL

490 BLUE HILLS AVENUE HARTFORD CT 06112

X Part I, Line 3c: n/aPart I, Line 4: The Hospital accepts all patients regardless of their ability to pay. A patient is classified as a charity patient by reference to the established policies of the Hospital. Essentially, these policies define charity services as those services for which no payment is anticipated. In assessing a patient's inability to pay, the Hospital utilizes the generally recognized poverty income levels for the State of Connecticut, but also includes certain cases where incurred charges are significant when compared to incomes. In addition, all self-pay patients receive a 35% discount from charges which is not included in net patient service revenue for financial reporting purposes. Part I, Line 6a: Mount Sinai Rehabilitation Hospital, Inc. prepares an annual community benefit report jointly with Saint Francis Hospital & Medical Center, Inc. a related entity. This report is available on the Saint Francis Hospital website. Part I, Line 7: MSR uses a cost accounting system within the Decision Support System product. It is a fully absorbed costing system using remaps of expense and revenues where needed. Indirect, or Overhead, costs are allocated using statistics in order to allocate the costs to the revenue producing departments. The method of allocating dollars to the charge items is currently primarily based on a RCC method using our charge item price as the driver. We have interspersed some National RVU's from the CMS Fee schedule to many departments as well as using costs to help allocate our Pharmacy and Supply expenses. All charge items obtain a cost and all patient segments are fully costed. Part I, Line 7g: n/a Part I, Line 7f: n/a Part III, Line 4: The Hospital accepts all patients regardless of their ability to pay. A patient is classified as a charity patient by reference to the established policies of the Hospital. Essentially, these policies define charity services as those services for which no payment is anticipated. In assessing a patient's inability to pay, the Hospital utilizes the generally recognized poverty income levels for the State of Connecticut, but also includes certain cases where incurred charges are significant when compared to incomes. In addition, all self-pay patients receive a 35% discount from charges which is not included in net patient service revenue for financial reporting purposes. Part III, Line 8: n/a for shortfall reported in line 7.Medicare allowable costs of care on line 6 were determined from the Medicare cost reports. Part III, Line 9b: See Part III, line 4 Part VI, Line 2: Mount Sinai Rehabilitation Hospital participated in a community health assessment with the three other hospitals located in Hartford, Saint Francis Hospital and Medical Center, Connecticut Children's Medical Center, and Hartford Hospital and the city of Hartford Health and Human Services Department to conduct a community health needs assessment. Meetings of the "Community Needs Assessment Workgroup" took place over a 6 month period every two weeks to discuss the design and implementation of the needs assessment. An inventory of local resources was conducted to determine how best utilize resources at the local colleges and universities, local community organization, city government and the hospitals themselves. An outside consultant was engaged to complete the needs assessment once the work plan was agreed upon. The assessment methodology included a number of data gathering processes: review of the available secondary data, inclusion of data from a local Health Equity Index and telephone interviews of local key informants. Secondary Data Profile Findings:Hartford is a very diverse (42% Hispanic and 37% African American), young (49% between the ages of 15-45), poor (32% of all people below the poverty level) and under educated (32% of 25 year olds did not graduate from high school) city. The unemployment rate is 18% and safety is a major concern for residents with rates of larceny, drug abuse, assault and murder all higher than state levels. Health issues of the cities residents include high rates of diabetes, obesity, asthma, drug abuse and mental illness. Rates of heart disease and cancer are on average lower than the rest of the state which is likely due to the age of the city's residents. Key Informant Interview Findings:Results from the key informant interviews served to clarify the issues that those working in the community see as key community needs. Interestingly, the information on the most important health issues was right on target with diabetes, obesity, mental illness and drug abuse all included in the top 5 key health issues. Additionally, key informants felt that neighborhood safety was a major concern as is the quality of housing and the limited number of job opportunities. Information collected from key informants on the quality of health care indicate a problem with access to primary care, transportation challenges, limited insurance coverage, and limited knowledge about where to go for help. Part VI, Line 3: Patients' ability to pay for health care is assessed during the intake process. If it becomes clear that the patient does not have coverage or has minimal coverage they are referred to a financial counselor who reviews their current income to determine eligibility for either state assistance or help from Mount Sinai Charity Care dollars. In areas of the hospital where new patients arrive: the rehabilitation clinic, the Mandell Center, and the admissions area, signage is posted about the financial assistance available to all patients who qualify. This information outlines, in both English and Spanish, the availability of financial counseling and assistance for medical bills. Additionally, a "Patient and Family Information Notebook" which includes a chapter on the availability of financial assistance for patients who either do not have coverage or are not covered fully by their health insurance is located in each patient room. Information about the financial assistance policy is also included in discharge materials. Mount Sinai does not turn patients away due to their inability to pay. Finally, patients who have not been forthcoming in their need for financial assistance prior to the delivery of health care services are provided with information about our charity care policy when they receive a bill for the services rendered. They are encouraged to talk to a financial counselor to discuss a payment plan and to determine if they are eligible for state assistance or if a portion of their bill can be "written off" to charity care. Part VI, Line 4: Mount Sinai Rehabilitation Hospital serves patients from all over Connecticut, and on occasion nationally due to the strong reputation of the rehabilitation program and the Multiple Sclerosis Mandell Center. The majority of patients, however, come from Hartford County, which includes the state capital, Hartford, and thirty-five surrounding urban and suburban communities. Hartford, CT is the second most impoverished city of its size 850,000 in the United States, second only to Brownsville, TX. According to U.S. Census Bureau 2009 estimates, 38% of families with children in Hartford live below the federally established poverty level. The median household income is $28,300 per year and only 26% of households are owner occupied. Over 70% of children in the Hartford Public schools received free or reduced price lunch. The rate of infants born low-birth weight (less than 2500 g) is 9.4%, well over the national average of 6.8%. Hartford is an urban community, the majority of Hartford residents are minorities with 42% Latino, 37% African American, 17% White and 4% other races. Acute rehabilitation service are available in Hartford at Nursing Home facilities but Mount Sinai is the only licensed rehabilitation hospital in the area. Part VI, Line 5: The hospital is involved in a variety of community building activities which address the root causes of health problems. Some are specific to the community served and others are more global in approach, such as advocacy work and board membership in local organizations that provide critical services to those in need. Economic DevelopmentThe Mount Sinai Foundation makes contributions on an annual basis to support patients with multiple sclerosis and stroke related compilations so that they may have access to expertise and technology not often covered by insurance. The staff at Mount Sinai advocate on behalf of MS patients so that their lives can be improved both physically and economically when they are able to get back to work. Community Support Mount Sinai Rehabilitation Hospital is involved in a wide array of Community Support programs and initiatives. They range from advocating for increased levels of treatment for rehabilitation, partnering with business to develop adapted golf carts and rowing shells, and organizing and sponsoring the MS walk on an annual basis. The services offered by Mount Sinai include an array of outpatient sites designed to increase access to care and to provide specialized treatment as needed. They include a Sports Medicine clinic at 95 Woodland Street, the main hospital Blue Hills site, and the Mandell Jewish Community Center in West Hartford. Each of these sites offers state of the art facilities that provide much needed services to the community of rehabilitation patients treated by the hospital. Additionally physical therapy services are provided via partnerships in numerous communities throughout the state including: Avon, East Hartford, Enfield, Glastonbury, Granby and Winsted.Leadership DevelopmentOn a regular basis grand rounds are offered to nursing staff within the Hartford community to educate them about rehabilitation treatment and encourage connections for patients to the specialized services available.Community activities such as student training, participation in research projects, and educational session are encouraged. Coalition BuildingAdaptive Rowing Program includes collaboration with a variety of agencies including Riverfront Recapture, Jaycees Foundation and the Christopher Reeves foundation. Staff play a role in developing coalitions to provide unique services to the disabled population.Executive staff at Mount Sinai is expected to participate in community improvement activities such as serving on boards, assisting small non-profits with fundraising activities, providing expertise and in-kind support and providing meeting space free of charge. In the area of workforce development Mount Sinai offers training of nursing staff in the area of rehabilitation. Internship opportunities for college students as well as high school students during the summer months to expose them to careers in rehabilitation are on-going. Masters and PhD level student are also recruited to participate in a variety of projects so that they better understand the opportunities available in the workplace. Advocacy for Health ImprovementsAdvocacy work at Mount Sinai is done by those with high level expertise in an area of health care to which they can speak with both knowledge and conviction. Some examples of staff who have been engaged in advocacy work in the past include:Dr. Wade is a board member of the CT MS Society and also serves as a diplomat for the American Board of Psychiatry and Neurology. Dr. Lo conducts a number of research projects focused on improvement of services to MS patients including a cooperative study with VA hospitals, brain injury rehabilitation, the use of robotics for rehabilitation and epidemiological studies of MS patients. Part VI, Line 6: The hospital is involved in a variety of initiatives that focus on the improving the health of the community overall. Collaborative efforts with a variety of local community foundations and non-profit organizations are numerous. The Mt. Sinai Rehabilitation - Rowing disabled persons including Veterans is very well known in the Hartford region and has enabled numerous patients to regain physical and social confidence. Numerous resources are donated by the hospital and partnering organizations including Riverfront Recapture, the Jaycees Foundation, the Christopher Reeves foundation and others. The Golfers in Motion program is designed to re-introduce golf into the lives of those who have suffered an injury or illness resulting in disability. The program had developed adaptive equipment and specialized rehabilitation services to enable golfers to return to the course and begin to normalize their lives. Part VI, Line 7: The organization is not a part of an affiliated health care system.Part VI, Line 8: Community Benefits are reported to the state's office of the Health Care Advocate in Connecticut. A Community Benefit report is published and widely distributed in the local community and it is posted on the website for full viewing. 0 1 0 0 0 0 0 0 0 christopher m dadlez 0 784033 0 526000 0 284943 0 258500 0 31508 0 1884984 0 0 edward s johnson dds 0 265914 0 27000 0 0 0 0 0 14839 0 307753 0 0 rolf knoll md 0 341947 0 82539 0 66557 0 0 0 28134 0 519177 0 0 Diane M Bernier 139781 0 0 0 0 0 0 0 12981 0 152762 0 0 0 Part I, Line 4b: Christopher Dadlez participated in a supplemental nonqualified retirement plan. AMOUNT: $258,500 Part I, Line 3: Mount Sinai Rehabilitation Hospital relied on Saint Francis Hospital to establish the compensation of its CEO using the following: - compensation committee - independent compensation consultant - written employment contract - compensation survey or study - approval by the board or compensation committee P Anthony Giorgio Director P. Anthony Giorgio is a Director of Connecticut Bank & Trust. Mt. Sinai Rehabilitation Hospital maintains a banking relationsip with Connecticut Bank & Trust. One Thousand Corporation, a related entity, leases space to a CBT branch location. 0 Form 990, Part VI, Section B, line 11 THE SAINT FRANCIS HOSPITAL & MEDICAL CENTER AUDIT AND CORPORATE COMPLIANCE COMMITTEE HAS RESPONSIBILITY FOR REVIEWING THE FORM 990 AND REPORTS BACK TO THE FULL BOARD REGARDING THEIR REVIEW OF THE FORM 990. THE FORM 990 IS AVAILABLE ON THE BOARD'S INTERNAL SECURE WEB PORTAL. Form 990, Part VI, Section B, line 12c The policy includes an obligation of each board member to annually disclose all material facts and relationships and refrain from voting on any matter when there is a conflict of interest. The governance and nominations committee reviews the results of these submissions annually for compliance with governance policies. Form 990, Part VI, Section B, line 15 REFER TO PART III OF SCHEDULE J FOR PROCESS. Form 990, Part VI, Section C, line 19 A LINK ON THE SAINT FRANCIS WEBSITE HAS BEEN ESTABLISHED FOR INDIVIDUALS TO REQUEST GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, FORM 990 AND FINANCIAL STATEMENTS. form 990, part xi, line 2c: the board of directors has delegated its oversight responsibility of the audit of the organization's financial statements to saint francis hospital and medical center audit & corporate compliance committee. 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