2023-11-15T07:33:00-06:00 2022-12-31 135565207 KPMG LLP 515 BROADWAY 4TH FLOOR ALBANY NY 122072974 990 2022-01-01 160743102 OLEAN GENERAL HOSPITAL OLEA 7163756104 515 MAIN STREET OLEAN NY 14760 DR JILL OWENS PRESIDENT & CEO 7163756104 2023-11-14 1 DR JILL OWENS 999009999 0 STEPHANIE LONCZAK P01880207 5184274600 0 AAL1 IAL1 2022 2023-04-26 12:10:37Z DR JILL OWENS 515 MAIN STREET OLEAN NY 14760 175027214 0 X WWW.BRMC-OGH.ORG/ X 1898 NY THE MISSION OF OLEAN GENERAL HOSPITAL IS TO PROVIDE EXCELLENT CARE IN RESPONSE TO THE HEALTH CARE NEEDS OF THE OLEAN, NY AND BRADFORD, PA COMMUNITIES. IN SUPPORT OF THIS MISSION, OLEAN GENERAL HOSPITAL IS COMMITTED TO THE FOLLOWING: - COMPASSION: OUR SYMPATHETIC AWARENESS OF EACH PERSON'S NEEDS- INTEGRITY: OUR DEDICATION TO HONESTY- INNOVATION: OUR PURSUIT OF CREATIVITY- RESPECT: OUR COMMITMENT TO TREAT EVERYONE WITH DIGNITY- COMMUNITY: OUR UNDERSTANDING THAT WE EXIST TO SERVE THOSE AMONG US- EDUCATION: OUR BELIEF THAT KNOWLEDGE FOSTERS EXCELLENCE 15 12 1972 206 0 0 15231954 14587682 166278955 153143036 825949 2521281 8047153 4775215 190384011 175027214 0 0 0 0 90012005 106889136 0 0 0 98977466 93556198 188989471 200445334 1394540 -25418120 199325482 148563553 103301051 75606692 96024431 72956861 X THE MISSION OF OLEAN GENERAL HOSPITAL IS TO PROVIDE EXCELLENT CARE IN RESPONSE TO THE HEALTH CARE NEEDS OF THE OLEAN, NY AND BRADFORD, PA COMMUNITIES. IN SUPPORT OF THIS MISSION, OLEAN GENERAL HOSPITAL IS COMMITTED TO THE FOLLOWING:- COMPASSION: OUR SYMPATHETIC AWARENESS OF EACH PERSON'S NEEDS- INTEGRITY: OUR DEDICATION TO HONESTY- INNOVATION: OUR PURSUIT OF CREATIVITY- RESPECT: OUR COMMITMENT TO TREAT EVERYONE WITH DIGNITY- COMMUNITY: OUR UNDERSTANDING THAT WE EXIST TO SERVE THOSE AMONG US- EDUCATION: OUR BELIEF THAT KNOWLEDGE FOSTERS EXCELLENCE 0 0 159721317 153143036 SEE SCHEDULE O.IN 2022, OLEAN GENERAL HOSPTAL DISCHARGED APPROXIMATELY 7,000 PATIENTS AND PROVIDED SERVICES TO APPROXIMATELY 275,000 OUTPATIENT VISITORS.THE OGH CAMPUS IN OLEAN, NY INCLUDES 186 PATIENT ROOMS, TOGETHER WITH COMPREHENSIVE PATIENT, ADMINISTRATIVE AND PHYSICIAN SERVICES AND ACCOMONDATIONS TO MEET THE DIAGNOSTIC, TREATMENT, ADMINISTRATIVE AND EDUCATIONAL NEEDS OF ITS PATIENTS AND MEDICAL STAFF. THE BRMC CAMPUS IN BRADFORD, PA INCLUDES 50 PATIENT ROOMS AND 95 SKILLED NURSING BEDS. OGH OFFERS PATIENTS AND THEIR FAMILIES A FULL RANGE OF DIAGNOSTIC AND MEDICAL SERVICES, AS WELL AS MANY SPECIALTY SERVICES. A WIDE ARRAY OF MULTI-SPECIALTY PHYSICIANS AND CLINICIANS OFFER SERVICES RANGING FROM ORTHOPEDIC, VASCULAR, NEUROLOGY TO GENERAL MEDICINE. THE HOSPITAL PROVIDES CANCER, CARDIAC AND VASCULAR CARE, OB/GYN, GENERAL SURGERY, UROLOGY, WOMEN'S HEALTH, INTERNAL MEDICINE, PEDIATRICS, SLEEP MEDICINE, AND PSYCHIATRIC CARE.2022 WAS A DIFFICULT YEAR TO ACCOMPLISH "NORMAL" IMPROVEMENTS AND PROGRAM ACCOMPLISHMENTS AS A RESULT OF THE CONTINUED COVID 19 PANDEMIC. THERE ARE COUNTLESS STORIES OF HEROIC DEEDS BY MANY OF OUR HEALTHCARE WORKERS WHICH MADE A DIFFERENCE IN OUR PATIENTS' LIVES AS WELL AS SIMPLY SAVING LIVES. OUR GREATEST ACCOMPLISHMENT IN 2022 WAS THE CONTINUED EFFORTS AROUND THE PANDEMIC. BELOW WE ALSO HIGHLIGHT A FEW TRADITIONAL AREAS OF FOCUS AT OGH AND BRMC RELATIVE TO ACCOMPLISHMENTS IN 2022.HIGHLIGHTED BELOW ARE SOME OF THE INITIATIVES THAT WERE REALIZED IN 2022 AT OGH AND BRMC:- PROVIDER RECRUITMENT IS CRITICAL TO OFFER EXISTING AND EXPANDED SERVICES AT A HEALTH SYSTEM. DURING 2022, OGH WAS SUCCESSFUL IN RECRUITING AND PROGRAM DEVELOPMENT IN THE FOLLOWING AREAS:- PRIMARY CARE - HIRED 2 MID-LEVELS- ORTHOPEDICS - HIRED 2 MID-LEVELS2022 FINANCIAL PERFORMANCE -OLEAN GENERAL HOSPITAL (OGH) REPORTED A NET LOSS OF ($25,674,000) FOR 2022 WHICH RESULTS WERE VERY NEGATIVELY IMPACTED BY THE COVID 19 PANDEMIC. REVENUE WAS UNDER BUDGET ($20,723,000) AND EXPENSES WERE OVER BUDGET BY ($7,864,000).DURING 2022 THE ORGANIZATION IMPLEMENTED 22 INITIATIVES THAT HAD AN ESTIMATED VALUE OF $8,500,000. DURING 2022 QUALITY MATTERS, OLEAN GENERAL HOSPITAL (OGH) DEVELOPS A QUALITY IMPROVEMENT PLAN ANNUALLY. WHILE 2022 WAS NO DIFFERENT THAN ANY OTHER PLANNING YEAR, THE COVID 19 PANDEMIC FORCED OGH TO FOCUS INTERNALLY ON PLANNING OF POTENTIAL DISASTERS AND ULTIMATELY TAKING CARE OF LARGE NUMBERS OF COVID 19 INFECTED PATIENTS. THIS PUT A DAMPER ON A NUMBER OF QUALITY IMPROVEMENT INITIATIVES. DESPITE THAT IMPACT, SEVERAL PROJECTS WERE PURSUED DURING 2022 INCLUDING:- DEVELOPED PLANS TO IMPROVE HCAHPS SCORES THROUGH: ORGANIZING THE PATIENT EXPERIENCE COMMITTEE; LEADERSHIP ROUNDING ON FLOORS; INCREASED AWARENESS OF ALL LEVELS OF STAFF ON IMPORTANCE OF CUSTOMER SATISFACTION; FOCUS ON "COMMIT TO SIT" PROGRAM AS WELL AS ANSWERING PATIENT CALL BELLS ON A MORE TIMELY BASIS; IMPROVE DISCHARGE INSTRUCTIONS AND PATIENT UNDERSTANDING; IMPROVE BAR CODE MEDICATION SCANNING; IMPROVE PATIENT MED RECONCILIATIONS TO 95% OF ALL PATIENTS; REDUCE OR EVEN ELIMINATE STAGE I, II, AND III PRESSURE ULCERS.DURING 2022 INFORMATION TECHNOLOGY MATTERS:1. BLUE ORANGE RISK ASSESSMENT -TT- COMPLETED THE 2022 RISK ASSESSMENT WITH BLUE ORANGE COMPLIANCE- COMPLETED THE PEN TESTS AND VULNERABILITY SCANS- COMPLETED THE VIRTUAL WALKTHROUGHS OF EACH FACILITY AND LOCATION- CONDUCTED INTERVIEWS WITH EACH ORGANIZATION.2. CHECKPOINT FIREWALL UPGRADES- UPGRADED THE CHECKPOINT FIREWALLS TO THE LATEST STABLE VERSION OF R81.10. COMPLETED THIS ACROSS BOTH DATA CENTERS AND ALL FIREWALL SERVICES. ALSO UPGRADED THE SMALLER CHECKPOINT APPLIANCES AT KEY LOCATIONS WITH A SITE-TO-SITE VPN.3. CISCO DNA AND ISE- CONFIGURED THE CISCO APPLIANCES FOR DNA AND ISE USE. WILL BE DOING MORE IN 2023 WITH THESE SERVICES AND THE NETWORK UPGRADES THAT ARE EXPECTED.4. CHEMISTRY ANALYZER UPGRADE- UPGRADED TO A NEW CHEMISTRY ANALYZER IN OGH. INCLUDED THE BACK-END SERVERS NEEDED FOR THE SYSTEM5. CATH LAB / SENSIS UPGRADE- OGH CATH LAB WAS REPLACED. THE SYSTEM WAS 10+ YEARS OLD AND RUNNING ON UNSUPPORTED SYSTEMS AND SOFTWARE. THIS WAS UPGRADED TO THE NEW SENSIS AND INTERNAL SYSTEMS FOR THE CATH LAB. SIEMENS IS STILL WORKING ON THE INTERFACE ISSUES AND IS CURRENTLY IN A MANUAL PROCESS (AS HAD BEEN SINCE INCEPTION). HOPEFULLY, IN 2023, SIEMENS CAN PATCH THE SYSTEM TO ENABLE THE INTERFACE TO CONTINUE TO WORK, ENGINEERS HAVE BEEN ONSITE TO TAKE LOGS AND IDENTIFY THE ISSUE.6. CLOUDMED IMPLEMENTATION- WORKED WITH KALEIDA, FINANCE, AND REVENUE CYCLE TO GIVE UTILIZE CLOUDMED FOR REV CYCLE.- DOZENS OF CLOUDMED USERS WERE SETUP FOR MEDITECH ACCESS.- EACH AREA WAS DIVIDED INTO THEIR SPECIALTY AND PROFILES WERE CREATED TO GIVE ONLY ACCESS THAT WAS NEEDED.- 99% IMPLEMENTED. ONE FINAL REQUEST TO HAVE ACCESS TO THE CANCER CENTER SYSTEM FOR REVIEW OF THESE REV CYCLE PATIENT NEEDS.7. CMS SAFER ASSESSMENT- COMPLETED THE CMS SAFER ASSESSMENTS FOR ALL SITES. ONE OF THE PROMOTING INTEROPERABILITY REQUIREMENTS IS TO UTILIZE THEIR FORMS AND COMPLETE THEM. MET WITH THE APPS AND TECH GROUPS, AS WELL AS THE CHANGE CONTROL GROUPS TO FILL THESE OUT AS ACCURATELY AS POSSIBLE. SUBMITTED ALL TO THE SECURITY OFFICER IN DECEMBER 2022.8. MEDENT CONSOLIDATION PHASE 1- COMPLETED PHASE 1 OF THE MEDENT CONSOLIDATION. ALL INSTANCES OF MEDENT IN OGH/BRMC/HSP/FMG ARE NOW RUNNING ON A SINGLE MEDENT DATABASE. ALL CONVERSIONS WERE COMPLETE. MULTI-SITE BILLING WAS ALSO IMPLEMENTED TO BE ABLE TO SEGREGATE THE TAX ID BILLING PER ENTITY.9. MEDITECH -TT PRIORITY PACK UPGRADE- HUGE UPGRADE TO THE ENTIRE MEDITECH PLATFORM. MOVED TO THE LATEST PRIORITY PACK.- TESTED ALL OF THE PP UPDATES IN TEST. MET WITH THE TEAMS TO REVIEW AND TEST.- WORKED WITH MEDITECH TO SCHEDULE AND IMPLEMENT THE CHANGE.- ONLY A FEW MINOR ISSUES AFTER THE UPGRADE, WHICH MEDITECH WAS ABLE TO FIX, QUICKLY.- THIS PUTS US AT A VERSION THAT IS SUPPORTED BY CMS FOR THE LATEST PROMOTING INTEROPERABILITY10. NYS HCDA (SURGE) PROJECT.- WORKED WITH NYS DOH TO BUILD OUT THE SURGE NEEDS AND NEDOC NEEDS FOR THE NYS DOH REQUIREMENT.- SETUP THE DR, SQL, AND SHAREPOINT FOR INTERNAL REPORTING OF STAFFING AND THE SUBMISSION OF DATA TO THE STATE.- MET THE STATE TIMELINE AND BEGAN SUBMITTING TO TEST EVERY 2 HOURS FOR OGH.- AWAITING THE STATE TO BE READY FOR SENDING TO A LIVE ENVIRONMENT.- ASSISTED OTHER MEDITECH HOSPITALS IN THE STATE ON HOW WE ARE GATHERING AND CAPTURING AND SUBMITTING THE DATA.11. NYS HANYS EQIC REPORTING- WORKED WITH THE STATE AS A BETA SITE TO SEND THE LAB AND PHARMACY DATA TO HANYS.- WE ARE NOW SENDING LIVE DATA FOR THIS REQUIREMENT FOR OGH, BRMC.- MET WITH SEVERAL HOSPITALS, HANYS, AND NYS TO SHOW HOW WE DEVELOPED THIS. AS WELL AS SHARED OUR SCRIPTS FOR THE MEDITECH HOSPITALS IN NYS.12. WINSURGE UPGRADE- COMPLETED THE WINSURGE UPGRADE FOR OGH PATHOLOGY. THE SYSTEM WAS ON A VERY OLD VERSION AND UNSUPPORTED OS. THEY ARE NOW ON THE LATEST VERSIONS AND FULLY SUPPORTED.13. XCELERA UPGRADE TO ISCV- PHILLIPS HAS CHANGED FROM THE XCELERA PLATFORM FOR CARDIO TO ISCV. THE OLD SYSTEM WAS EOS/EOL AND NEEDED UPGRADED. ALL DATA WAS MIGRATED FROM OLD TO NEW, AND OGH/BRMC WENT LIVE WITH THE NEW ISCV. 159721317 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 153 0 1 1972 1 0 0 0 0 0 0 0 0 0 0 0 0 X 15 12 0 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X X TANNYAH CHAPMAN 7163757426 515 MAIN STREET OLEAN NY 14760 JEFF BELT BOARD CHAIRMAN 5.50 1.00 X X 0 0 0 MUHAMMED JAVED MD BOARD VICE CHAIRMAN 5.50 1.00 X X 147167 0 0 LISA FIORENTINO PHD RN BOARD SECRETARY 5.50 1.00 X X 0 0 0 PAUL RIDLEY BOARD TREASURER 5.50 1.00 X X 0 0 0 SHABIR BHAYANI MD DIRECTOR 5.50 40.00 X 0 63975 0 MARC BOUTILLETTE DIRECTOR 5.50 1.00 X 0 0 0 DANIEL DEROSE DIRECTOR 5.50 1.00 X 0 0 0 LISELLE ESPOSITO DIRECTOR (AS OF 4/22) 5.50 1.00 X 0 0 0 DAVID FERGUSON DIRECTOR 5.50 1.00 X 0 0 0 JULIE MARASCO DIRECTOR 5.50 1.00 X 0 0 0 ZAFAR MIRZA MD DIRECTOR AND PHYSICIAN 40.00 1.00 X 1926246 0 0 DOUGLAS PISANO PHD DIRECTOR 5.50 1.00 X 0 0 0 ANIL PRADHAN MD DIRECTOR 5.50 1.00 X 0 0 0 DAVID PRINCE DIRECTOR 5.50 1.00 X 0 0 0 GILBERT WITTE MD DIRECTOR 5.50 1.00 X 0 0 0 MARY LAROWE INTERIM PRES AND CEO (THRU 04/22) 1.00 40.00 X X 0 0 0 MELISSA SCHOLL OSF DIRECTOR (THRU 04/22) 5.50 1.00 X 0 0 0 JEANNINE SCHOENECKER SECRETARY (THRU 04/22) 5.50 1.00 X 0 0 0 JILL OWENS PRESIDENT (AS OF 5/22) 40.00 5.50 X 220499 107489 3229 LUIS GONZALEZ MD PRESIDENT & CEO (AS OF 1/22) 40.00 5.50 X 0 763809 119594 GAIL A BAGAZZOLI VP - QUALITY & CNO (THRU 8/22) 40.00 1.00 X 126764 0 39375 RICHARD G BRAUN JR CHIEF OPERATING OFFICER (THRU 5/22) 40.00 1.00 X 287440 0 30975 LAURIE DUNN CNO (AS OF 7/22) 40.00 1.00 X 70232 0 7078 WILLIAM F MILLS VP - MEDICAL AFFAIRS (THRU 1/22) 23.50 15.00 X 139233 0 26949 HENRI P LAMOTHE VP - MEDICAL AFFAIRS (AS OF 5/22) 23.50 15.00 X 154349 0 13280 MELISSA SULLIVAN VP - CLINICAL & SUPPORT (THRU 1/22) 40.00 1.00 X 14142 0 10666 DAVID MONROE CHIEF ADMIN OFFICER (AS OF 6/22) 40.00 1.00 X 151435 0 40595 MOHANED AL-HUMADI PHYSICIAN 40.00 0.00 X 1394558 0 104827 AUBREY ASHIE PHYSICIAN 40.00 0.00 X 632896 0 80620 STEVEN PANCIO PHYSICIAN 40.00 0.00 X 554547 0 72153 SHANCHIYA RAVINDRADAS PHYSICIAN 40.00 0.00 X 477674 0 56907 GARY CARL PHYSICIAN 40.00 0.00 X 498177 0 102511 JEFFREY S ZEWE FORMER PRESIDENT & CEO 0.00 0.00 X 184025 0 20799 6979384 935273 729558 110 1 1 0 PROLINK HEALTHCARE LLC 4600 MONTGOMERY ROAD CINCINNATI OH 45212 AGENCY/TRAVEL NURSES 7623947 KEYSTONE MEDICAL SERVICES OF OLEAN 6075 POPLAR AVENUE SUITE 401 MEMPHIS TN 38119 EMERGENCY ROOM PHYSICIAN FEES 6984765 TRUSTED NURSE STAFFING LLC BUFFALO STATION 1200 WILLIAM STREE BUFFALO NY 14240 AGENCY/TRAVEL NURSES 3858343 ZAFAR K MIRZA 1741 DAVID DR OLEAN NY 14760 ENDOSCOPIC SERVICES/ON CALL 1926246 GREAT LAKES ANESTHESIOLOGY 1001 MAIN STREET SUITE K-3502 BUFFALO NY 14203 ANESTHESIA SERVICES 1821058 26 3450738 7821624 3315320 14587682 NET PATIENT SERVICE REVENUE 621990 153143036 153143036 153143036 2345854 2345854 354718 0 354718 354718 354718 175427 0 175427 175427 175427 OTHER 900099 2667820 2667820 PHARMACY 340B 622110 1376057 1376057 CAFETERIA/VENDING 722210 376620 376620 4420497 175027214 153143036 0 7296496 X 3237507 2073413 1164094 85142996 70066668 15076328 4938365 2867413 2070952 9221612 5090078 4131534 4348656 3280852 1067804 -151874 -151874 46476171 35892720 10583451 476057 1489 474568 1051906 301115 750791 3568000 3568000 152368 50983 101385 667215 667215 6348896 4444227 1904669 5094409 4812077 282332 SUPPLIES 28418309 26275904 2142405 EQUIPMENT RENTALS 1370385 912022 458363 PROPERTY TAXES 75206 75206 PATIENT/RESIDENT ACTIVI 9150 9150 200445334 159721317 40724017 0 15011109 3664299 18582794 14803573 5477799 5425745 2063634 1625958 147940058 92709078 56324312 55230980 23282110 7107596 4015015 2591768 74568709 58113634 199325482 148563553 29025340 40540468 15670235 15923396 58605476 19142828 103301051 75606692 X 37513733 14443289 58510698 58513572 96024431 72956861 199325482 148563553 X -25418120 -7366163 9716713 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 20860011 -2922223 17937788 20243726 616285 20860011 18796034 1447692 20243726 16811783 1984251 18796034 18039649 -1227866 16811783 0.64030 0.35970 1 0 2042126 2042126 82982701 48912428 34070273 5982444 4228952 1753492 54767801 39567698 15200103 2164986 2164986 55230980 ASSETS LIMITED AS TO USE 53428873 OTHER ASSETS 3734061 DUE FROM AFFILIATES 950700 58113634 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 13702748 ACCRUED PENSION LIABILITY 11344525 DUE TO/FROM AFFILIATES -6719830 ACCRUED SICK TIME 815385 19142828 X PART X, LINE 2: FIN 48 FOOTNOTE FORM 990 KALEIDA AND SUBSTANTIALLY ALL OF ITS AFFILIATES HAVE BEEN DETERMINED BY THE INTERNAL REVENUE SERVICE TO BE ORGANIZATIONS DESCRIBED IN INTERNAL REVENUE CODE (THE CODE) SECTION 501(C)(3) AND, THEREFORE, ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. KALEIDA RECOGNIZES INCOME TAX POSITIONS WHEN IT IS MORE-LIKELY THAN-NOT THAT THE POSITION WILL BE SUSTAINABLE BASED ON THE MERITS OF THE POSITION. MANAGEMENT HAS CONCLUDED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS THAT NEED TO BE RECORDED. PART V, LINE 4: TO PROVIDE SUPPORT AND RENEW PLANT AND EQUIPMENT BASED ON HOSPITAL NEED. 1 1 X 1 X 400.000000000000 1 X 1 1 0 0 4802994 2019530 2783464 0.01390 38278402 28658721 9619681 0.04800 43081396 30678251 12403145 0.06190 5 127 318456 44709 273747 0.00140 5 127 318456 44709 273747 0.00140 5 127 43399852 30722960 12676892 0.06330 1 25907103 36039766 -10132663 X 1 1 2 1 OLEAN GENERAL HOSPITAL 515 MAIN STREET OLEAN NY 14760 X X X X DENTAL CLINIC, RADIATION ONCOLOGY, DIALYSIS 2 OLEAN GENERAL HOSPITAL DBA BRADFORD REGIONAL MEDICAL CENTER 116 INTERSTATE PARKWAY BRADFORD PA 16701 X X X OLEAN GENERAL HOSPITAL 1 0 0 1 X X X X X X X X X X 22 1 0 1 1 X HTTPS://WWW.BRMC-OGH.ORG/ABOUT/CHNA/ X 1 22 1 HTTPS://WWW.BRMC-OGH.ORG/ABOUT/CHNA/ 0 1 X 400.000000000000 400.000000000000 X X X X X 1 1 X X X 1 X HTTPS://WWW.BRMC-OGH.ORG/VISITORS/FINANCIAL-ASSISTANCE/ X HTTPS://WWW.BRMC-OGH.ORG/VISITORS/FINANCIAL-ASSISTANCE/ X HTTPS://WWW.BRMC-OGH.ORG/VISITORS/FINANCIAL-ASSISTANCE/ X X X X X X 1 X 0 X X X 1 X 0 0 OLEAN GENERAL HOSPITAL PART V, SECTION B, LINE 5: OLEAN GENERAL HOSPITAL:OLEAN GENERAL HOSPITAL AND BRADFORD REGIONAL MEDICAL CENTER ARE A MERGED ORGANIZATION. IN 2022 THE TWO CAMPUS HOSPITAL CONDUCTED AN INDEPENDENT COMMUNITY HEALTH NEEDS ASSESSMENTS AND COMMUNITY HEALTH IMPROVEMENT PLAN THAT REPRESENT THE NEED OF BOTH FACILITIES. CHNAS FOR BOTH HOSPITALS APPEAR ON THE WEBSITE FOR OLEAN GENERAL HOSPITAL AND BRADFORD REGIONAL MEDICAL CENTER (WWW.BRMC-OGH.ORG). THE 2022-2024 CATTARAUGUS COUNTY COMMUNITY SERVICE PLAN (CSP), COMMUNITY HEALTH ASSESSMENT AND COMMUNITY HEALTH IMPROVEMENT PLAN (CHA-CHIP) WERE DEVELOPED BY OLEAN GENERAL HOSPITAL D/B/A BRADFORD REGIONAL MEDICAL CENTER (OGH/BRMC)1 AND THE CATTARAUGUS COUNTY HEALTH DEPARTMENT (CCHD). STRATEGY SOLUTIONS, INC. (SSI) WAS ENGAGED BY THE CCHD, OGH/BRMC TO ASSIST WITH THE CSP AND THE CHA-CHIP. REPRESENTATIVES FROM OGH/BRMC AND THE CCHD WORKED COLLABORATIVELY TO GUIDE AND CONDUCT COMPLETION OF THE CSP AND THE CHA-CHIP. A STEERING COMMITTEE MADE UP OF SENIOR LEADERS OF UPPER ALLEGHENY HEALTH SYSTEM (UAHS), OGH/BRMC, THE CCHD, AS WELL AS REPRESENTATIVES FROM COMMUNITY ORGANIZATIONS, WHICH INCLUDES LEADING HEALTH AND SOCIAL SERVICE ORGANIZATIONS AND MUNICIPALITIES, PROVIDED ADDITIONAL INPUT. THE COMBINED EXPERTISE, INPUT AND KNOWLEDGE OF THE MEMBERS OF THE STEERING COMMITTEE WAS VITAL TO THE PROJECT. THIS GROUP DESERVES SPECIAL RECOGNITION FOR THEIR TIRELESS OVERSIGHT AND SUPPORT OF THE CSP/CHA-CHIP PROCESS. DURING THE CSP/CHA-CHIP PROJECT, 23 STAKEHOLDERS WERE INTERVIEWED BY STRATEGY SOLUTIONS, INC. (SSI). SSI ADMINISTRATED A COMMUNITY HEALTH SURVEY WITH 1,656 SURVEYS COMPLETED. OGH/BRMC AND THE CCHD CONDUCTED A COMMUNITY HEALTH INTERCEPT SURVEY WITH 241 SURVEYS COMPLETED. FINALLY, INFORMATION WAS GATHERED BY THE PROJECT TEAM THROUGH A SERIES OF 12 FOCUS GROUPS, INCLUDING A CROSS SECTION OF COMMUNITY GROUPS. INFORMATION-GATHERING EFFORTS ALLOWED THE PROJECT TEAM AND STEERING COMMITTEE TO GAIN A BETTER UNDERSTANDING OF THE HEALTH STATUS, HEALTH CARE NEEDS, SERVICE GAPS, AND BARRIERS TO CARE FOR THOSE LIVING IN MCKEAN AND CATTARAUGUS COUNTIES.UPON COMPLETION OF COMMUNITY HEALTH ASSESSMENT (CHA), A PLANNING PROCESS WAS INITIATED TO CREATE THE 2022-2024 COMMUNITY HEALTH IMPROVEMENT PLAN (CHIP). THE LEADERSHIP AT THE CCHD REVIEWED THE PAST PLAN AND DETERMINED THAT GIVEN THE IMPACT COVID-19 HAD ON IMPLEMENTATION OF THE 2019-2021 CHA AND THE CONTINUED PRIORITIZED FOCUS ON CHRONIC DISEASE AND BEHAVIORAL HEALTH, EXISTING STRATEGIES CURRENTLY UNDERWAY SHOULD BE CONTINUED. LEADERSHIP REACHED OUT TO COMMUNITY PARTNERS TO AFFIRM THEIR WILLINGNESS TO CONTINUE.THE 2022-2024 OGH/BRMC COMMUNITY SERVICE PLAN (CSP) AND THE CCHD'S COMMUNITY HEALTH ASSESSMENT AND COMMUNITY HEALTH IMPROVEMENT PLAN (CHA-CHIP) WERE CONDUCTED TO IDENTIFY SIGNIFICANT HEALTH NEEDS AS OUTLINED BY THE NEW YORK STATE DEPARTMENT OF HEALTH'S 2019-2024 PREVENTION AGENDA, WHERE APPLICABLE. IT ALSO PROVIDES CRITICAL INFORMATION OGH/BRMC, THE CCHD, AND OTHERS IN A POSITION TO MAKE A POSITIVE IMPACT ON THE HEALTH OF THE REGION'S RESIDENTS. THE CSP/CHA-CHIP ENABLES THE HEALTH DEPARTMENT, HOSPITAL AND OTHER COMMUNITY PARTNERS TO STRATEGICALLY ESTABLISH PRIORITIES, DEVELOP INTERVENTIONS, AND DIRECT RESOURCES TO IMPROVE THE HEALTH OF RESIDENTS LIVING IN THE SERVICE AREA.TO CONDUCT THE COLLABORATIVE STUDY, OGH/BRMC AND THE CCHD RETAINED STRATEGY SOLUTIONS, INC. (SSI), AN ERIE, PENNSYLVANIA PLANNING AND RESEARCH FIRM WHOSE MISSION IS TO CREATE HEALTHY COMMUNITIES. THE CSP/CHA-CHIP FOLLOWED BEST PRACTICES AS OUTLINED BY THE ASSOCIATION OF COMMUNITY HEALTH IMPROVEMENT (ACHI)3. THE CSP/CHA-CHIP AS ALSO DESIGNED TO ENSURE OGH/BRMC COMPLIANCE WITH CURRENT INTERNAL REVENUE SERVICE (IRS) GUIDELINES FOR CHARITABLE 501(C)(3) TAX-EXEMPT HOSPITALS PUBLISHED IN DECEMBER 2014.THE CSP/CHA-CHIP INCLUDES A DETAILED EXAMINATION OF PRIORITY AREAS IDENTIFIED IN THE NYS PREVENTION AGENDA: (1) PREVENT CHRONIC DISEASES; (2) PROMOTE A HEALTHY AND SAFE ENVIRONMENT; (3) PROMOTE HEALTHY WOMEN, INFANTS AND CHILDREN; (4) PROMOTE WELL-BEING AND PREVENT MENTAL HEALTH AND SUBSTANCE USE DISORDERS; AND (5) PREVENT COMMUNICABLE DISEASES.THE PREVENTION AGENDA IS A SIX-YEAR EFFORT TO MAKE NEW YORK THE HEALTHIEST STATE. DEVELOPED IN COLLABORATION WITH 140 ORGANIZATIONS, THE PLAN IDENTIFIES NEW YORK'S MOST URGENT HEALTH CONCERNS, AND SUGGESTS WAYS LOCAL HEALTH DEPARTMENTS, HOSPITALS, AND PARTNERS FROM HEALTH, BUSINESS, EDUCATION, AND COMMUNITY ORGANIZATIONS CAN WORK TOGETHER TO SOLVE THEM.TO MEET THE DECEMBER 2014 IRS REQUIREMENTS FOR A NON-PROFIT HOSPITAL, THE CSP/CHA-CHIP INCLUDES EVALUATION OF THE 2019-2021 CSP/CHA-CHIP, DEMOGRAPHICS AND SOCIO-ECONOMIC INDICATORS, PRIORITIZATION OF NEEDS, AND A CHIP/IMPLEMENTATION STRATEGY FOR THE NEXT THREE YEARS.PRIMARY AND SECONDARY DATA REVIEWED: SECONDARY PUBLIC HEALTH DATA ON DISEASE INCIDENCE AND MORTALITY AND BEHAVIORAL RISK FACTORS WERE GATHERED FROM NUMEROUS SOURCES INCLUDING THE PENNSYLVANIA DEPARTMENT OF HEALTH, NEW YORK STATE DEPARTMENT OF HEALTH'S PREVENTION AGENDA DASHBOARD, CENTERS FOR DISEASE CONTROL AND PREVENTION, HEALTHY PEOPLE 2030, COUNTY HEALTH RANKINGS, AND A NUMBER OF OTHER REPORTS AND PUBLICATIONS. PRIMARY QUALITATIVE DATA COLLECTED SPECIFICALLY FOR THIS ASSESSMENT INCLUDED 23 IN-DEPTH INTERVIEWS WITH STAKEHOLDERS REPRESENTING THE NEEDS OF THE SERVICE AREA, AS WELL AS 12 FOCUS GROUPS. FOUR COMMUNITY HEALTH SURVEYS WERE ALSO CONDUCTED DURING THIS PROCESS:(I) A CATTARAUGUS COUNTY CSP/CHA-CHIP COMMUNITY HEALTH SURVEY WITH 899 RESPONSES,(II) A CATTARAUGUS COUNTY HEALTH DEPARTMENT'S COMMUNITY INTERCEPT SURVEY WITH 223 RESPONSES,(III) A MCKEAN COUNTY CSP/CHA-CHIP COMMUNITY HEALTH SURVEY WITH 757 RESPONSES,(IV) A BRADFORD REGIONAL MEDICAL CENTER COMMUNITY INTERCEPT SURVEY WITH 18 RESPONSES, ANDIN ADDITION TO GATHERING INPUT FROM STAKEHOLDER INTERVIEWS, INPUT AND GUIDANCE ALSO CAME FROM 72 COMMUNITY REPRESENTATIVES (36 REPRESENTING MCKEAN COUNTY AND 36 REPRESENTING CATTARAUGUS COUNTY) WHO SERVED ON THE CSP/CHA-CHIP STEERING COMMITTEE. MANY MEMBERS OF THE STEERING COMMITTEE ARE AFFILIATED WITH THE HEALTHY LIVABLE COMMUNITIES CONSORTIUM OF CATTARAUGUS COUNTY.2019-2024 PREVENTION AGENDA PRIORITIES AND DISPARITIES: AFTER ALL PRIMARY AND SECONDARY DATA WERE REVIEWED AND ANALYZED BY THE STEERING COMMITTEE, THE DATA SUGGESTED A TOTAL OF 32 DISTINCT POSSIBLE PRIORITIES FOR POTENTIAL INTERVENTION TO BE CONSIDERED FOR THE CATTARAUGUS COUNTY CSP/CHA-CHIP AND 13 FOR MCKEAN COUNTY. MEMBERS OF THE STEERING COMMITTEE AND CSP/CHA-CHIP PROJECT COORDINATION TEAM MET ON MARCH 9, 2022 TO REVIEW THE DATA AND PRIORITIZE THE POSSIBLE PRIORITY AREAS. THE METHODOLOGY USED INCLUDED RATING EACH POSSIBLE PRIORITY AREA BY THREE DIFFERENT CRITERIA: (I) MAGNITUDE OF THE PROBLEM, (II) IMPACT ON OTHER HEALTH OUTCOMES AND (III) CAPACITY (SYSTEMS AND RESOURCES) TO ADDRESS THE ISSUE/NEED. BASED ON THIS PRIORITIZATION AND LOOKING AT EVIDENCED-BASED SOLUTIONS, THE FOLLOWING TOP TWO PRIORITIES, AS ALIGNED WITH THE NYS PREVENTION AGENDA (NYS PA), ARE THE AREAS THAT OGH/BRMC AND THE CCHD WILL BE WORKING ON FOR 2022-2024: (I) PREVENT CHRONIC DISEASES WITH A DISPARITY CONCENTRATION ON POVERTY; AND (II) PROMOTE WELL-BEING AND PREVENT MENTAL HEALTH AND SUBSTANCE USE DISORDERS WITH A DISPARITY CONCENTRATION ON POVERTY.A DETAILED PLAN OF IMPLEMENTATION IS DESCRIBED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT AND COMMUNITY HEALTH IMPLEMENTATION PLAN ON PAGES 192-209. OLEAN GENERAL HOSPITAL PART V, SECTION B, LINE 6B: OLEAN GENERAL HOSPITAL:IN DEVELOPING THE COMMUNITY HEALTH NEEDS ASSESSMENT FOR CATTARAUGUS COUNTY AND MCKEAN COUNTY, OTHER MEMBERS CONSULTED INCLUDED UNITED WAY, CATTARAUGUS COUNTY DEPARTMENT OF COMMUNITY SERVICES, NURSE PRACTITIONER/AMISH CONNECTION, ST. BONAVENTURE UNIVERSITY, CASA-TRINITY INC., CUTCO, UNIVERSAL PRIMARY CARE, YMCA TWIN TIERS, DEPARTMENT OF SOCIAL SERVICES, CATTARAUGUS COUNTY HEALTH DEPARTMENT, DIRECTORS IN INDEPENDENT LIVING, AND CONNECTING COMUNITIES IN ACTION. OLEAN GENERAL HOSPITAL PART V, SECTION B, LINE 11: OLEAN GENERAL HOSPITAL:THE HOSPITAL FACILITIES CHNA HAS IDENTIFIED THE NEEDED AREAS OF FOCUS TO BE THE PREVENTION OF CHRONIC DISEASES WITH A DISPARITY CONCENTRATION ON POVERTY; AND PROMOTE WELL-BEING AND PREVENT MENTAL HEALTH AND SUBSTANCE USE DISORDERS WITH A DISPARITY CONCENTRATION ON POVERTY. THE HOSPITALS WILL BE IN PARTNERSHIP WITH COUNCIL ON ALCOHOL AND SUBSTANCE ABUSE - TRINITY, CONNECTING COMMUNITIES IN ACTION, CATTARAUGUS COUNTY HEALTH DEPARTMENT, CATTARAUGUS COUNTY SCHOOLS, CORNELL COOPERATIVE EXTENSION, DEPARTMENT OF AGING, DEPARTMENT OF SOCIAL SERVICES, GENESIS HOUSE, HEALTH COMMUNITY ALLIANCE, OLEAN MEDICAL GROUP, REALITY CHECK AND UNIVERSAL PRIMARY CARE. 1. INCREASE FOOD SECURITY THROUGH: NUMBER OF PARTNERS THAT SCREEN FOR FOOD INSECURITY AND FACILITATE REFERRALS TO SUPPORTIVE SERVICES.2. PREVENT INITIATION OF TOBACCO USE, INCLUDING COMBUSTIBLE TOBACCO AND VAPING PRODUCTS (DEFINED AS E-CIGARETTES AND SIMILAR DEVICES) BY NYS YOUTH AND YOUNG ADULTS THROUGH: (I) USE MEDIA AND HEALTH COMMUNICATIONS TO HIGHLIGHT THE DANGERS (II) USE EVIDENCE-BASED PROGRAMMING (CATCH MY BREATH) SPECIFIC TO MIDDLE AND HIGH SCHOOL STUDENTS; AND (III) USE HEALTH COMMUNICATIONS TARGETING HEALTH CARE PROVIDERS: # OF SCHOOLS AND STUDENTS REACHED RECEIVING DANGERS OF TOBACCO PRESENTATIONS, WORK WITH DEPARTMENTAL HEALTH SYSTEM GRANTEES TO PROMOTE THE DELIVERY OF EVIDENCED-BASED CESSATION SERVICES BY HEALTH CARE PROVIDERS, NUMBER OF INDIVIDUALS REFERRED.3. INCREASE CANCER SCREENING RATES FOR BREAST, CERVICAL AND COLORECTAL CANCERS THROUGH: NUMBER OF HEALTH SYSTEMS THAT IMPLEMENT/IMPROVE PROVIDER/PATIENT REMINDERS, NUMBER OF PATIENTS SCREENED AND REACHED THROUGH PATIENT REMINDER SYSTEMS.4. PROMOTE EVIDENCE-BASED CARE TO PREVENT AND MANAGE CHRONIC DISEASES IN THE CLINICAL SETTING INCLUDING ASTHMA, ARTHRITIS, CARDIOVASCULAR DISEASE, DIABETES AND PREDIABETES, AND OBESITY: NUMBER OF PATIENTS TESTED FOR PREDIABETES. PART I, LINE 3C: OLEAN GENERAL HOSPITAL HAS IMPLEMENTED AND COMMUNICATES ITS FINANCIAL ASSISTANCE (CHARITY CARE) POLICY, WHICH ASSISTS LOW INCOME, UNINSURED OR UNDERINSURED INDIVIDUALS WHO LACK THE FINANCIAL RESOURCES TO PAY FOR MEDICAL SERVICES RENDERED. THE AMOUNT OF THE DISCOUNT VARIES BASED ON THE PATIENT'S INCOME AND SIZE OF FAMILY. THE FINANCIAL ASSISTANCE POLICY PROVIDES THE FOLLOWING INFORMATION:- FINANCIAL ASSISTANCE IS AVAILABLE FOR PATIENTS WITH LIMITED INCOMES AND HEALTH INSURANCE.- ANYONE WHO NEEDS EMERGENCY SERVICES CAN RECEIVE CARE AND GET A DISCOUNT IF THEY MEET THE INCOME LIMITS.- EVERYONE WHO LIVES IN THE SERVICE AREAS CAN GET A DISCOUNT ON NON-EMERGENCY MEDICALLY NECESSARY SERVICES IF THEY MEET THE INCOME LIMITS. MEDICAL TREATMENT CANNOT BE DENIED BECAUSE OF YOUR FINANCIAL STATUS.- FINANCE ASSISTANCE IS CONTINGENT UPON A PATIENT'S COOPERATION IN FOLLOWING THE ENTITIES APPLICATION REQURIEMENTS.- THE DISCOUNT IS DEPENDENT ON INCOME AND FAMILY SIZE.- THE ENTITY HAS THE ABILITY TO WORK ON PAYMENT PLANS, DEPENDENT ON INCOME IF NOT ELIGIBLE FOR FINANCIAL ASSISTANCE. PART I, LINE 7: THE COSTING METHODOLOGY ADDRESSES ALL PATIENT SEGMENTS THROUGHOUT THE SERVICES OFFERED AT THE ORGANIZATION. AS REPORTED ON THE COST REPORT, COSTS WERE MULTIPLIED BY THE RATIO OF COSTS TO CHARGES TO DETERMINE THE MEDICARE COST. THE TOTAL COST FROM DIRECT GME ALLOWABLE COSTS WERE SUBTRACTED FROM THE MEDICARE COST TO CALCULATE THE TOTAL MEDICARE ALLOWABLE COST. PART I, LINE 7G: SUBSIDIZED PROGRAMS ARE NOT RECORDED AT THIS LEVEL OF DETAIL. ALL COSTS ASSOCIATED WITH THESE PROGRAMS, INCLUDING IP PSYCHIATRIC DEPARTMENT, EMERGENCY DEPARTMENT AND SALAMANCA CLINIC ARE INCLUDED IN THE AMOUNTS PROVIDED. PART II, COMMUNITY BUILDING ACTIVITIES: OVER THE LAST 10 YEARS, THE OLEAN AND BRADFORD AREAS HAD SIGNIFICANT PRIMARY CARE AND SPECIALIST CARE SHORTFALLS. AFTER A FEW YEARS OF SUCCESSFUL RECRUITING, NUMEROUS MID-LEVEL PRIMARY CARE PROVIDERS HAVE BEEN RECRUITED, HOWEVER THERE ARE STILL PHYSICIAN SHORTAGES IN THE PRIMARY CARE SPACE. SPECIALIST PHYSICIANS ARE STILL IN GREAT DEMAND IN THE AREA. THE MOST PRESSING NEEDS CURRENTLY ARE IN: CARDIOLOGY, UROLOGY, ENT, OBSTETRICS, PSYCHIARTY AND GASTROENTEROLOGY.THE HOSPITAL ALSO PROVIDES CLINICIAL ROTATIONS FOR MEDICAL STUDENTS IN INTERNAL AND EMERGENCY MEDICINE THROUGH AN AFFILIATION AGREEMENT WITH LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE. IN ADDITION, ST BONAVENTURE UNIVERSITY PRE-MEDICAL STUDENTS PARTICIPATE IN A 14 WEEK ROTATION PROVIDING EXPOSURE TO VARIOUS CLINICAL SPECIALTIES AND DIAGNOSTIC MODALITIES, FOR AN IN-DEPTH EXPOSURE TO THE REALITIES OF A CAREER IN MEDICINE. THE UNIVERSITY OF PITTSBURGH AT BRADFORD NURSING STUDENTS PARTICIPATE IN CLINICAL ROTATIONS THROUGH THE BRADFORD CAMPUS. PART III, LINE 2: DUE TO THE ADOPTION OF ASU NO. 2014-09 - REVENUE FROM CONTRACTS WITH CUSTOMERS (TOPIC 606) BAD DEBT EXPENSE IS NO LONGER REPORTED ON THE AUDITED FINANCIAL STATEMENT. RATHER IT IS TREATED AS A PRICE CONCESSION. PLEASE SEE THE FOLLOWING 2022 AUDITED FINANCIAL STATEMENT FOOTNOTE WHICH DESCRIBES THIS.OLEAN GENERAL HOSPITAL DETERMINES PATIENT SERVICE REVENUE BY REDUCING THE STANDARD CHARGE TO THIRD-PARTY PAYORS BY ANY CONTRACTUAL AMOUNTS OR DISCOUNTS (EXPLICIT CONCESSIONS) AND ESTIMATES ROUTINE UNCOLLECTIBLE AMOUNTS ASSOCIATED WITH THE SERVICE, INCLUDING DEDUCTIBLES, CO-PAYS AND AMOUNTS DUE FROM UNINSURED PATIENTS (COLLECTIVELY, IMPLICIT PRICE CONCESSIONS). OLEAN GENERAL HOSPITAL DETERMINES ITS ESTIMATES OF EXPLICIT CONCESSIONS BASED ON CONTRACTUAL AGREEMENTS, ITS DISCOUNT POLICIES, AND HISTORICAL EXPERIENCE. OLEAN GENERAL HOSPITAL DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSIONS BASED ON ITS HISTORICAL COLLECTION EXPERIENCE. SUBSEQUENT CHANGES TO THE ESTIMATE OF THE TRANSACTION PRICE ARE GENERALLY RECORDED AS ADJUSTMENTS TO PATIENT SERVICE REVENUE IN THE PERIOD OF THE CHANGE. ADJUSTMENTS ARISING FROM A CHANGE IN TRANSACTION PRICE WERE NOT SIGNIFICANT IN 2022 AND 2021. PART III, LINE 8: THE ALLOWABLE COSTS REPORTED ON LINE 6 ARE DIRECTLY FROM THE HOSPITAL'S 2022 MEDICARE COST REPORT, WHICH IS PREPARED USING A RATIO OF COST TO CHARGES BASIS (RCC) AS REQUIRED BY MEDICARE. THE MEDICARE SHORTFALL SHOULD BE CONSIDERED A COMMUNITY BENEFIT BECAUSE THE ORGANIZATION PROVIDES CARE TO LOW INCOME, UNINSURED OR UNDERINSURED INDIVIDUALS WHO LACK THE FINANCIAL RESOURCES TO PAY FOR MEDICAL SERVICES RENDERED, INCLUDING THOSE WHO ARE COVERED BY MEDICARE. FOR MANY OF THE MEDICAL SERVICES PROVIDED BY THE HOSPITAL, MEDICARE DOES NOT PROVIDE SUFFICIENT REIMBURSEMENT TO COVER THE COST OF PROVIDING CARE TO OUR PATIENTS, WHICH FORCES THE ORGANIZATION TO USE OTHER FUNDS TO COVER THE DEFICIT. PART III, LINE 9B: COLLECTION PRACTICES:I) OGH WILL NOT CAUSE THE FORCED SALE OR FORECLOSURE OF A PATIENT'S PRIMARY RESIDENCE.II) OGH WILL NOT SEND ACCOUNT TO COLLECTION IF THE PATIENT HAS SUBMITTED A COMPLETED APPLICATION FOR FINANCIAL ASSISTANCE, INCLUDING THE REQUIRED DOCUMENTATION, WHILE AN APPLICATION IS PENDING.III) OGH WILL PROVIDE WRITTEN NOTIFICATION TO A PATIENT AT LEAST 30-DAYS BEFORE AN ACCOUNT IS SENT TO COLLECTION. THIS WRITTEN NOTICE MAY BE INCLUDED ON A BILL.IV) OGH REQUIRES THAT A COLLECTION AGENCY HAVE ITS WRITTEN CONSENT PRIOR TO STARTING LEGAL ACTION FOR COLLECTION.V) OGH WILL TRAIN ALL GENERAL HOSPITAL STAFF WHO INTERACT WITH PATIENTS OR HAVE RESPONSIBILITY FOR BILLING AND COLLECTION.VI) OGH WILL MEASURE OUR COMPLIANCE WITH THESE POLICIES.VII) OGH REQUIRES ANY COLLECTION AGENCY UNDER CONTRACT TO FOLLOW OUR FINANCIAL ASSISTANCE POLICY AND PROVIDES INFORMATION TO PATIENT'S ON HOW TO APPLY, WHERE APPROPRIATE.VIII) OGH DOES NOT ALLOW COLLECTION ACTIVITY IF THE PATIENT IS DETERMINED ELIGIBLE FOR MEDICAID FOR THE SERVICES THAT WERE RENDERED AND OGH IS ABLE TO COLLECT MEDICAID PAYMENT. PART VI, LINE 2: THE STRATEGIC PLANNING COMMITTEE OF OLEAN GENERAL HOSPITAL IS CHARGED WITH DEVELOPING A STRATEGIC DIRECTION FOR THE HOSPITAL OVER THE LAST FEW YEARS THAT COMMITTEE ASSISTED IN THE DEVELOPMENT OF SUSTAINABILITY STRATEGIES FOR THE HOSPITAL INCLUDING THE AFFILIATION WITH A TERTIARY CARE PROVIDER IN 2017 AND THE MERGER OF THE TWO PREVIOUS HOSPITALS (OLEAN GENERAL HOSPITAL AND BRADFORD REGIONAL MEDICAL CENTER INTO THE ONE LEGAL ENTITY OLEAN GENERAL HOSPITAL) IN 2018. IN 2019 THE COMMITTEE BEGAN DEVELOPING ADDITIONAL SUSTAINABILITY STRATEGIES FOR THE SYSTEM INCLUDING LOOKING AT TAKING ADVANTAGE OF THE HOSPITALS VARIOUS STRENGTHS IN DIFFERENT GEOGRAPHIC AREAS. THESE DELIBERATIONS WERE CONCLUDED IN 2020 AND A 17 POINT TRANSFORMATION PLAN WAS IMPLEMENTED INCLUDING CONSOLIDATION OF SURGERY AND HIGHER-END INPATIENT SERVICES TO THE OLEAN CAMPUS. THE PLAN IS ESTIMATED TO HAVE A FINANCIAL IMPACT OF $10M TO OGH FINANCIAL RESULTS ANNUALLY, AFTER 2023. THE ORGANZATION CONTINUES TO IDENTIFY ADDITIONAL OPPORTUNITIES AS THE COVID-19 PANDEMIC CHANGED HOW SERVICES ARE PROVIDED.ESSENTIAL TO THE SUCCESS OF ANY STRATEGIC PLAN IS THE HOSPITAL'S ABILITY TO BOTH IMPLEMENT RECOMMENDATIONS MADE WITHIN THE PLAN AND TO RECOGNIZE THE DOCUMENT AS A DYNAMIC AND FLEXIBLE TOOL TO BE USED AS A GUIDGE FOR THE FUTURE. SPECIFIC GOALS AND STRATEGIES MAY OR MAY NOT BE OBTAINED AND, UPON EVALUATION AND THE AVAILABILITY OF NEW INFORMATION AND DEVELOPMENTS, MAY NEED TO BE MODIFIED. A SUCCESSFUL STRATEGIC PLAN RECONGIZES THIS POTENTIAL FOR CHANGE AND IS FLEXIBLE ENOUGH TO ACCOMMODATE NEW OR DIFFERENT OPPORTUNITIES AND CHALLENGES.CRITICAL HEALTH CARE ISSUES:THE HEALTH CARE INDUSTRY IS UNDER CONSTANT SCRUTINY TO PROVIDE AFFORDABLE HEALTH CARE SERVICES THAT ARE ALSO OF THE HIGHEST QUALITY. A HOSPITAL'S ABILITY TO ACCOMPLISH THIS GOAL IS INFLUENCED BY SEVERAL FACTORS. FOLLOWING IS A LISTING OF CRITICAL ISSUES THAT WILL CONTINUE TO AFFECT HOSPITAL'S ABILITY TO PERFORM.1. IMPACT OF COVID 19: THE SINGLE LARGEST EXTERNAL FACTOR AFFECTING HEALTHCARE TODAY IS THE IMPACT OF THE COVID 19 PANDEMIC ON HOSPITALS. ALTHOUGH THE PANDEMIC HIT U.S. HOSPITALS IN EARLY 2020, THE LONG-LASTING EFFECTS WILL BE FELT FOR YEARS TO COME, SEVERAL PHENOMENA CAUSED BY THE PANDEMIC INCLUDE:A. LARGE FINANCIAL LOSSES, DESPITE FEDERAL STIMULUS FUNDING. OGH LOST ($25,674,000) IN 2022. PATIENT VOLUMES CONTINUE TO BE DEPRESSED AS A RESULT OF RESOURCE CONSTRAINTS AS WELL AS PATIENT FEARS OVER CONTRACTING COVID.B. STAFFING HAS BEEN IMPACTED GREATLY BY THE PANDEMIC. HIGH ACUITY PATIENTS AND WAVES OF THEM IN A SHORT PERIOD OF TIME COUPLED WITH THE STRESSES OF TAKING CARE OF HIGHLY INFECTIOUS PATIENTS HAS LED TO SIGNIFICANT PROVIDER BURN-OUT. IN FACT, A NATIONAL MOVEMENT OF NURSES LEAVING THEIR POSITIONS AND TAKING "TRAVELER" ASSIGHMENTS HAS PUT A HUGE HOLE IN THE STAFFING AT HOSPITALS. REPLACEMENT STAFF, IF AVAILABLE, ARE AT A 200 TO 300 PERCENT INCREASE OVER FORMER COSTS.C. EMERGENCY ROOM WAIT TIMES HAVE SOARED AS A RESULT OF THE PANDEMIC. THIS ALSO IMPACTS PATIENT SATISFACTION NEGATIVELY.2. QUALITY: HEALTH CARE QUALITY AND SAFETY HAVE BEEN STRATEGICALLY IMPORTANT FOR SEVERAL YEARS. WIDESPREAD PUBLIC REPORTING OF HOSPITAL QUALITY RESULTS AND VALUE BASED PAYMENT MODELS HAVE POSITIONED QUALITY AT THE FOREFRONT OF HEALTHCARE DELIVERY. RECRUITMENT AND RETENTION OF HIGHLY SKILLED DOCTORS AND NURSES, COMBINED WITH CAPABLE INFORMATION SYSTEMS ARE CRITICAL TO MEET THE HIGH STANDARDS SET TODAY IN HEALTHCARE. CONCEPTS SUCH AS: "RE-ADMISSIONS", HOSPITAL ACQUIRED INFECTIONS, FALL FREQUENCY AND PREVENTABLE MEDICATION ERRORS ARE HOUSEHOLD WORDS WHEN IT COMES TO EVALUATING A HOSPITAL'S QUALITY TODAY. HOSPITALS MUST MARSHAL THE KNOWN RESOURCES AND PROVIDE HIGH-END CARE AS COMPARED TO OTHERS. THE VALUE BASED PAYMENT METHODOLOGIES ALSO HAVE SIGNIFICANT FINANCIAL IMPLICATIONS FOR HOSPITALS TODAY. CONSUMERS WILL CONTINUE TO SEEK OUT MORE AND MORE QUALITY DATA UPON WHICH TO BASE CARE DECISIONS ON.3. INFORMATION TECHNOLOGY: HEALTH INFORMATION TECHNOLOGY INCLUDES COMPUTER BASED TOOLS DEVELOPED SPECIFICALLY FOR HEALTH CARE DELIVERY. THESE TOOLS CAN PROVIDE UP-TO-DATE INFORMATION ON THEIR PATIENTS, ACCESS TO THE LATEST MEDICAL KNOWLEDGE AND BEST PRACTICES THROUGH DECISION SUPPORT SYSTEMS. IT IS UNDERSTOOD THAT INVESTMENTS IN NEW CLINICAL AND INFORMATION TECHNOLOGY CAN SIGNIFICANTLY ENHANCE PATIENT SAFETY AND CLINICAL OUTCOMES. COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE), BAR CODING AND ITS POTENTIAL TO REDUCE MEDICATION ERRORS, AND ELECTRONIC MEDICAL RECRODS (EMRS) AND THEIR POSITIVE IMPACT ON MEDICAL ERRORS ARE ALL EXAMPLES OF HEALTH CARE'S USE OF IT SOLUTIONS TO IMPROVE QUALITY. THE FEDERAL GOVERNMENT HAS HIGHLIGHTED THE ROLE OF HEALTH INFORMATION TECHNOLOGY AS A MEANS TO IMPROVE HEALTH CARE QUALITY, SAFETY PROVIDED STIMULUS AND INCENTIVE PAYMENTS TO PROVIDERS TO FACILITATE AND HASTEN THEIR ADOPTION INTO THE CARE DELIVERY PROCESS. EMR'S HAVE BECOME A PREREQUISITE OF ANY DELIVERY SYSTEM THAT INTENDS TO PROVIDE COORDIANTED COST EFFECTIVE CARE.4. PHYSICIANS: PHYSICIANS HAVE EMERGED AS CRITICAL OPERATIONAL AND STRATEGIC PARTNERS TO HOSPITALS. THOSE THAT ARE SUCCESSFUL IN ENGAGING AND COLLABORATING WITH THEIR MEDICAL STAFF WILL BE BEST ABLE TO DEMONSTRATE HIGH QUALITY MANDATES. THE ABILITY TO SUCCESSFULLY RECRUIT PHYSICIAN WILL BE CRITICAL. AT A TIME WHEN HEALTHCARE EMPHASIZES THE ROLE OF PRIMARY CARE, THERE IS A SPECIAL NEED TO INTENSIFY EFFORTS RECRUIT, RETAIN AND AGGREGATE PRIMARY CARE PROVIDERS. BECAUSE THE VAST MAJORITY OF NEW PHYSICIANS PREFER EMPLOYMENT AS THEIR PRACTICE PREFERENCE, THE ABILITY OF HOSPITALS TO BE ABLE TO OFFER PHYSICIANS A CONTEMPORARY AND COMPETITIVE "EMPLOYMENT PLATFORM" IS ESSENTIAL. PART VI, LINE 3: INSURANCE INFORMATION IS GATHERED DURING THE SCHEDULING AND/OR REGISTRATION PROCESS. IF THE PATIENT INDICATES THAT THEY HAVE NO INSURANCE, REGISTRATION STAFF WILL ASK THE PATIENT FOR PERMISSION TO TRANSFER THEM TO SOUTHERN TIER HEALTHCARE SYSTEMS FOR ASSISTANCE WITH SCREENING FOR ELIGIBILITY FOR GOVERNMENT PROGRAMS (I.E. MEDICAID, CHILD HEALTH PLUS, FAMILY HEALTH PLUS). SOUTHERN TIER HEALTHCARE SYSTEMS' PERSONNEL WILL CONTACT THE PATIENT AND DISCUSS OPTIONS, INCLUDING THE HOSPITAL'S FINANCIAL ASSISTANCE PROGRAM AND CAN DISCUSS AND SHARE INFORMATION WITH PATIENTS AT ANY TIME BEFORE, DURING OR AFTER THE EPISODE OF CARE. BILLING STATEMENTS CONTAIN THE FOLLOWING MESSAGE: "IF YOU HAVE ANY QUESTIONS OR WOULD LIKE TO APPLY FOR OUR FINANCIAL ASSISTANCE PROGRAM, PLEASE CALL OUR OFFICE AT...", THE FINANCIAL ASSISTANCE POLICY IS POSTED ON THE HOSPITAL WEBSITE TO HELP EDUCATE THE PUBLIC. PART VI, LINE 4: OLEAN GENERAL HOSPITAL IS LOCATED IN OLEAN, NEW YORK, THE LARGEST CITY IN CATTARAUGUS COUNTY. THE HOSPITAL SERVES APPROXIMATELY 86,000 RESDIENTS OF CATTARAUGUS COUNTY AND THE SURROUNDING AREA. THE POPULATION OF THE AREA IS DISTRIBUTED AS FOLLOWS: 22% UNDER THE AGE OF 18, 60% AGE 18 TO 64, AND 18% 65 AND OLDER. APPROXIMATELY ONE IN TEN FAMILIES (10.50% ARE LIVING IN POVERTY, WHICH IS SLIGHTLY HIGHER THAN THE STATE (9.9%). IT IS ESTIMATED THAT 55.0% OF THE POPULATION AGE 16 AND OLDER IS CIVILIAN EMPLOYED, WHILE 2.5% ARE UNEMPLOYED. OF THOSE AGE 16 AND OLDER, 42.5% ARE NOT IN THE WORKFORCE. AVERAGE HOUSEHOLD INCOME $71,678, MEDIAN HOUSEHOLD INCOME $54,151. THE BRADFORD CAMPUS IS LOCATED IN BRADFORD, PA. THE HOSPITAL SERVES APPROXIMATELY 40,500 RESIDENTS OF MCKEAN COUNTY AND THE SURROUNDING AREA. THE MEDIAN HOUSEHOLD INCOME IS $56,117. PART VI, LINE 5: THE MEDICAL CENTER(S) ACTIVITIES FOCUS AROUND PROVIDING ACCESS QUALITY CARE TO CATTARAUGUS COUNTY IN NEW YORK, MCKEAN COUNTY IN PENNSYLVANIA, AND SURROUNDING RURAL AREAS. THE MEDICAL CENTER FURTHERS ITS EXEMPT PURPOSE BY PROMOTING THE HEALTH OF THE COMMUNITY BY THE ELECTION OF A COMMUNITY BASED BOARD OF DIRECTORS. THE BOARD OF DIRECTORS IS REPRESENTED BY A DEDICATED AND DIVERSE GROUP OF COMMUNITY LEADERS WHOSE PURPOSE IS TO REMAIN FAITHFUL TO THE MISSION OF THE MEDICAL CENTER(S) - TO PROVIDE QUALITY, COMPASSIONATE, ACCESSIBLE CARE. THE MEDICAL CENTER(S) PARTNER WITH LOCAL COMMUNITY PROVIDERS TO EXTEND THE AVAILABILITY OF SERVICES PROVIDED WITHIN THE CAMPUS. THE BROADER USE OF THE MEDICAL FACILITY BY LOCAL PROVIDERS ALLOWS FOR THE GROWTH OF THE MEDICAL CENTER AND ITS SERVICES. ALL EFFORTS ARE MADE BY THE MEDICAL CENTER MANAGEMENT AND BOARD OF DIRECTORS TO MODERNIZE THE CAPITAL NEEDS OF THE CENTER AND IMPROVE THE QUALITY OF CARE. PART VI, LINE 6: OLEAN GENERAL HOSPITAL IS PART OF THE UPPER ALLEGHENY HEALTH SYSTEM (UAHS), ORIGINALLY AN INTEGRATION OF TWO REGIONAL HOSPITALS UNDER A COMMON PARENT ORGANIZATION. UAHS HAS A MISSION OF COLLABORATIVE HEALTH CARE IN THE TWO COMMUNITIES SERVED BY THE INTEGRATED HOSPITALS TO MEET THE HEALTH CARE NEEDS OF THE RESIDENTS AND SURROUNDING AREAS. TO FURTHER THIS INTEGRATION, BRMC WAS MERGED INTO OGH ON JANUARY 12, 2018 AND IS NOW PART OF A 2 CAMPUS HOSPITAL. UAHS, WHICH INCLUDES OLEAN GENERAL HOSPITAL, IS FURTHER INCLUDED AS PART OF THE KALEIDA HEALTH AFFILIATED HEALTH CARE SYSTEM. THE FOLLOWING MEMBERS ARE INCLUDED IN THIS GROUP: THE UPPER ALLEGHENY HEALTH SYSTEM, KALEIDA HEALTH FOUNDATION, VISITING NURSING ASSOCIATION OF WNY, INC., VNA HOMECARE SERVICE, INC., AND OISHEI CHILDREN'S HOSPITAL OF BUFFALO FOUNDATION. PART VI, LINE 7, REPORTS FILED WITH STATES NY,PA PART VI, LINE 2 (CONTINUED): 5. FINANCE AND CAPITAL: FINANCIAL PERFORMANCE AND ACCESS TO CAPITAL WILL CONTINUE TO BE AMONG THE MOST CRITICAL ISSUES CONFRONTING HOSPITALS. EVEN WITH HEALTHCARE REFORM EFFORTS, HEALTHCARE COSTS WILL CONTINUE TO OUTPAGE INFLATION. INCREASING WAGE AND SALARY COSTS, AND RISING HEALTH CARE COSTS IN GENERAL WILL CONTINUE TO OUTPACE INFLATION. INCREASING WAGE AND SALARY COSTS, AND RISING HEALTH CARE COSTS IN GENERAL WILL CONTINUE TO IMPACT OPERATING PERFORMANCE AND PRESS HOSPITALS TO CONTINUE A RELENTLESS FOCUS ON COST MANAGEMENT. ADDITIONALLY, REVENUE STRATEGIES WILL NEED TO BE DEVELOPED TO GENERATE PROFITABLE GROWTH IN PATIENT VOLUME, AS WILL THE NEED TO ENSURE OPTIMAL MANAGEMENT OF ALL REVENUE ACTIVITIES. HOSPITALS ARE FACING SIGNIFICANT ANNUAL PAYMENT REDUCTIONS IN TERMS OF DECREASES IN MEDICARE UPDATES, DISPROPORTIONATE SHARE, SNF AND HOMECARE PAYMENTS, AND MEDICAID PAYMENT LEVELS. AS HOSPITALS CONTINUE TO POST LOW OR NO PROFIT MARGINS, INVESTMENT INCOME WILL BE MORE IMPORTANT THAN EVER. HOWEVER, GIVEN THE FACT THAT INVSTMENT INCOME IS A HIGHLY UNCERTAIN COMPONENT OF A HOSPITAL'S OVERALL FINANCIAL HEALTH, HOSPITALS WILL BE DRIVEN TO PURSUE MORE PHILANTHROPY. HOSPITAL CAPITAL SPENDING WILL BE DRIVEN BY GROWING DEMANDS FOR ADVANCED TECHNOLOGY NEEDED TO ENSURE PATIENT QUALITY AND SAFETY, THE NEED TO REPLACE AND UPDATE AGING FACILITIES, AND THE DESIRE AND NEED TO IMPROVE TECHNOLOGY BASED SERVICES.6. RISK MANAGEMENT AND COMPLIANCE: HEALTHCARE'S TECHNOLOGY HAS NEVER BEEN MORE COMPLICATED, PATIENTS' DEMANDS HIGHER, AND THE BUSINESS CHALLENGES GREATER. ACCORDINGLY, COMPREHENSIVE RISK MANAGEMENT PROGRAM ARE ESSENTIAL IN ASSURING CARE DELIVERY SYSTEMS THAT ARE HIGHLY EFFECTIVE IN TERMS OF ASSURING APPROPRIATE LEVELS OF PATIENT SAFETY AND QUALITY. THE DEPARTMENT OF JUSTICE ESTIMATES THAT THE FEDERAL GOVERNMENT LOSSES BILLIONS OF DOLLARS ANNUALLY IN HEALTH CARE FRAUD.CONSEQUENTLY, THE GOVERNMENT'S HEALTHCARE FRAUD ENFORCEMENT ACTIVITITES WITH RESPECT TO ALL HEALTHCARE PROVIDERS CONTINUE TO GROW AND EXPAND. WELL ESTABLISHED CORPORATE COMPLIANCE PROGRAMS ARE ESSENTIAL IN TERMS OF ALLOWING HOSPITALS TO IDENTIFY POTENTIAL AREAS OF LIABIILTY AND TO CORRECT PROBLEMS.7. NURSING:NURSES AND NURSING CARE ARE CENTRAL TO THE DELIVERY OF SAFE AND EFFECTIVE PATIENT CARE. ACCORDINGLY, ENSURING AN ADEQUATE NURSING WORKFORCE AND CREATING A WORK ENVIRONMENT THAT SUPPORTS NURSING PRACTICE AND INTER-DISCIPLINARY COLLABORATIOIN ARE IMPORTANT PRIORITIES FOR HOSPITALS TODAY. X X X X X 1 0 0 0 0 0 0 0 0 ZAFAR MIRZA MD DIRECTOR AND PHYSICIAN 1926246 0 0 0 0 0 0 0 0 0 1926246 0 0 0 MOHANED AL-HUMADI PHYSICIAN 1394558 0 0 0 0 0 17019 0 87808 0 1499385 0 0 0 LUIS GONZALEZ MD PRESIDENT & CEO (AS OF 1/22) 0 763809 0 0 0 0 0 20500 0 99094 0 883403 0 0 AUBREY ASHIE PHYSICIAN 632896 0 0 0 0 0 0 0 80620 0 713516 0 0 0 STEVEN PANCIO PHYSICIAN 554547 0 0 0 0 0 1046 0 71107 0 626700 0 0 0 GARY CARL PHYSICIAN 498177 0 0 0 0 0 18469 0 84042 0 600688 0 0 0 SHANCHIYA RAVINDRADAS PHYSICIAN 477674 0 0 0 0 0 12921 0 43986 0 534581 0 0 0 JILL OWENS PRESIDENT (AS OF 5/22) 220499 104275 0 0 0 3214 0 0 3229 0 223728 107489 0 0 RICHARD G BRAUN JR CHIEF OPERATING OFFICER (THRU 5/22) 108979 0 0 0 178461 0 11493 0 19482 0 318415 0 0 0 JEFFREY S ZEWE FORMER PRESIDENT & CEO 0 0 0 0 184025 0 9017 0 11782 0 204824 0 0 0 DAVID MONROE CHIEF ADMIN OFFICER (AS OF 6/22) 151435 0 0 0 0 0 5356 0 35239 0 192030 0 0 0 HENRI P LAMOTHE VP - MEDICAL AFFAIRS (AS OF 5/22) 154349 0 0 0 0 0 0 0 13280 0 167629 0 0 0 WILLIAM F MILLS VP - MEDICAL AFFAIRS (THRU 1/22) 56996 0 0 0 82237 0 13010 0 13939 0 166182 0 0 0 GAIL A BAGAZZOLI VP - QUALITY & CNO (THRU 8/22) 126764 0 0 0 0 0 14045 0 25330 0 166139 0 0 0 PART I, LINE 4A THE FOLLOWING INDIVIDUALS RECEIVED SEVERANCE PAYMENTS. THESE AMOUNTS ARE REPORTED IN SCHEDULE J, PART II, COLUMN (III). - RICHARD G. BRAUN, JR. - $178,461 - WILLIAM F. MILLS - $82,237 - JEFFREY ZEWE - $184,025 A CATTARAUGUS COUNTY CAPITAL RESOURCES CORPORATION 273458026 999999999 2010-10-06 21585000 REFUNDING OF BONDS, FINANCE AND NEW AMBULATORY SURGERY CENTER & HIS 0 0 0 A 21585000 431700 2012 1 0 1 1 A 0 0 0 0 0 0 0 A 0 0 0 0 1 0 0 0 0 A 1 FORM 990, PART I & III, LINE 1, DESCRIPTION OF ORGANIZATION MISSION (CONT.) THE HOSPITAL IS GOVERNED BY A 17 MEMBER BOARD OF DIRECTORS COMPRISED OF 16 VOLUNTARY INDIVIDUALS WHO RESIDE THROUGHTOUT THE OLEAN GENERAL HOSPITAL AND BRADFORD REGIONAL MEDICAL CENTER SERVICE AREAS AND THE CEO OF UPPER ALLEGHENY HEALTH SYSTEM. WITH A LICENSED CAPACITY OF 186 BEDS ON THE OLEAN CAMPUS, 50 BEDS AT THE BRADFORD CAMPUS AND 95 BEDS AT THE BRADFORD NURSING HOME, THE HOSPITAL PROVIDES THE COMMUNITY WITH VITAL HEALTH CARE SERVICES INCLUDING MEDICAL/SURGICAL, PEDIATRIC, OBSTETRICAL CARE, BEHAVIORAL HEALTH, AND LONG-TERM CARE. THE HOSPITAL ALSO PROVIDES INTENSIVE AND CORONARY CARE, CHRONIC DIALYSIS, AND 24 HOURS EMERGENCY SERVICES WITH ACCESS TO HELICOPTERS FOR EMERGENCY TRANSFER OF PATIENTS REQUIRING TERTIARY CARE. ADDITIONAL SERVICES INCLUDE DIAGNOSTIC IMAGING, LABORATORY, CARDIOPULMONARY, OCCUPATIONAL WELLNESS, DIABETES EDUCATION, PATIENT EDUCATION, RADIATION ONCOLOGY SPECIFICALLY ON THE OGH CAMPUS, A SLEEP DISORDERS CENTER AT BRMC CAMPUS, OUTPATIENT PRIMARY CARE, AND A DENTAL CENTER AT OGH CAMPUS, IN CONJUNCTION WITH THE STATE UNIVERSITY OF NEW YORK AT BUFFALO, SPONSORS NEW YORK STATE'S ONLY RURAL TRACK POST GRADUATE MEDICAL EDUCATION/RESIDENCY TRAINING PROGRAM. FORM 990, PART VI, SECTION A, LINE 6 UPPER ALLEGHENY HEALTH SYSTEM, INC. IS THE SOLE CORPORATE MEMBER OF THE HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7B GOVERNANCE DECISIONS ARE SUBMITTED FOR APPROVAL BY KALEIDA HEALTH. FORM 990, PART VI, SECTION B, LINE 11B A DRAFT COPY OF THE FORM 990 IS REVIEWED FOR ACCURACY AND COMPLETENESS BY THE HOSPITAL'S CHIEF OPERATING OFFICER AND SENIOR MANAGEMENT OF UPPER ALLEGHENY HEALTH SYSTEM. IN ADDITION, A FINAL DRAFT COPY OF THE 990 IS PROVIDED TO MEMBERS OF THE BOARD OF DIRECTORS TO REVIEW AND COMMENT. FORM 990, PART VI, SECTION B, LINE 12C THE HOSPITAL'S CONFLICT OF INTEREST POLICY IS PRESENTED AND REVIEWED ANNUALLY. EACH MEMBER OF THE BOARD COMPLETES A DISCLOSURE FORM. SEE THE FORMAL POLICY, AS OUTLINED IN THE ORGANIZATION'S BYLAWS, BELOW. THIS POLICY IS ALSO APPLICABLE TO OFFICERS OF THE ORGANIZATION. CONFLICTS OF INTEREST: EACH DIRECTOR, PRIOR TO TAKING HIS/HER POSITION ON THE BOARD, AND ALL PRESENT DIRECTORS AS SOON AS PRACTICABLE AFTER THE ADOPTION ON THESE BYLAWS, SHALL SUBMIT IN WRITING OF THE CHAIRMAN OF THE BOARD AND THE CHIEF EXECUTIVE OFFICER A LIST OF ALL BUSINESS OR OTHER ORGANIZATIONS OF WHICH HE/SHE IS AN OFFICER, DIRECTOR, TRUSTEE, MEMBER, HOWEVER (EITHER AS SOLE PROPRIETOR OR PARTNER), SHAREHOLDER WITH 5% OR GREATER INTEREST IN ALL OUTSTANDING VOTING SHARE, EMPLOYEE OR AGENT, WITH WHICH THE CORPORATE HAS, OR MIGHT BE REASONABLY IN THE FUTURE ENTER INTO, A RELATIONSHIP OR A TRANSACTION IN WHICH THE DIRECTOR WOULD HAVE CONFLICTING INTERESTS. EACH WRITTEN STATEMENT WILL BE RESUBMITTED WITH ANY NECESSARY CHANGES EACH YEAR. THE CHAIRMAN OF THE BOARD SHALL BECOME FAMILIAR WITH THE STATEMENTS OF ALL DIRECTORS IN ORDER TO GUIDE HIS/HER CONDUCT SHALL A CONFLICT ARISE. THE CHAIRMAN-ELECT OF THE BOARD SHALL BE FAMILIAR WITH THE STATEMENT FILED BY THE CHAIRMAN. SHOULD THE CHAIRMAN-ELECT POSITION BE VACANT, THE MOST SENIOR MEMBER OF THE EXECUTIVE COMMITTEE WILL ASSUME THIS RESPONSIBILITY. AS SUCH TIME AS ANY MATTER COMES BEFORE THE BOARD IN SUCH A WAY AS TO GIVE RISE TO A CONFLICT OF INTEREST, THE AFFECTED DIRECTOR SHALL MAKE KNOWN THE POTENTIAL CONFLICT WHETHER DISCLOSED BY HIS WRITTEN STATEMENT OR NOT, AND AFTER ANSWERING ANY QUESTIONS THAT MIGHT BE ASKED OF HIM/HER, SHALL WITHDRAW FROM THE MEETING FOR SO LONG AS THE MATTER SHALL CONTINUE UNDER DISCUSSION. SHOULD THE MATTER BE BROUGHT TO A VOTE, THE AFFECTED DIRECTOR SHALL NOT VOTE ON IT. IN THE EVENT THE CONFLICT OF INTEREST AFFECTS THE CHAIRMAN, THE CHAIRMAN-ELECT IN EMPOWERED AND SHALL REQUIRE THAT THE CHAIRMAN REMOVE HIM/HERSELF IN THE SAME MANNER, AND FOR THE DURATION OF DISCUSSION AND ACTION ON THE MATTER THE CHAIRMAN-ELECT SHALL PRESIDE. SHOULD THE CHAIRMAN-ELECT POSITION BE VACANT, THE MOST SENIOR MEMBER OF THE EXECUTIVE COMMITTEE WILL ASSUME THIS RESPONSIBILITY. IF THE MATTER IS THE ITEM OF BUSINESS FOR WHICH A SPECIAL MEETING OF THE BOARD WAS CALLED, THE AFFECTED DIRECTOR SHALL NOT BE COUNTED TO ESTABLISH A QUORUM, NOR SHALL HE/SHE PARTICIPATE IN THE DELIVERATIONS OR VOTE ON IT. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE COMMITTEE OF THE HOSPITAL D/B/A THE EXECUTIVE COMPENSATION COMMITTEE (THE COMMITTEE) IS APPOINTED BY THE BOARD OF DIRECTORS TO ASSIST THE BOARD IN ESTABLISHING AND OVERSEEING THE EXECUTIVE COMPENSATION PROGRAM OF THE HOSPITAL. THE COMMITTEE IS RESPONSIBLE FOR ADHERING TO THE OVERALL COMPENSATION PHILOSOPHY OF THE HOSPITAL. THE COMPENSATION PHILOSOPHY IS A TOTAL COMPENSATION CONCEPT THAT WILL EMPLOY A COMBINATION OF BASE SALARY, VARIABLE OPPORTUNITY, FLEXIBLE BENEFITS, DEFERED COMPENSATION AND OTHER PREREQUISITES AS MAY BE NEEDED FROM TIME TO TIME TO MAINTAIN A COMPETITIVE POSITION WITH PEER INSTITUTIONS IN THE REGION. FORM 990, PART VI, SECTION C, LINE 19 THE HOSPITAL HAS AVAILABLE, UPON REQUEST TO ADMINISTRATION, ITS MOST RECENTLY FILED FORM 990, GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS. THE HOSPITAL ALSO REPORTS ANNUALLY ITS COMMUNITY BENEFIT EFFORTS AND ISSUES ANNUAL REPORT THAT INCLUDES FINANCIAL AND OTHER INFORMATION OF INTEREST TO THE PUBLIC. FORM 990, PART IX, LINE 11G PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 12,449,404. MANAGEMENT AND GENERAL EXPENSES 436,655. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 12,886,059. CONSULTING: PROGRAM SERVICE EXPENSES 2,600. MANAGEMENT AND GENERAL EXPENSES 807,602. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 810,202. MEDICAL EQUIPMENT SERVICE CONTRACTS: PROGRAM SERVICE EXPENSES 1,257,512. MANAGEMENT AND GENERAL EXPENSES 2,823,874. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,081,386. BUILDING AND EQUIPMENT MAINTENANCE AND REPAIRS: PROGRAM SERVICE EXPENSES 529,458. MANAGEMENT AND GENERAL EXPENSES 554,265. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,083,723. COLLECTION FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 559,197. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 559,197. OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 15,831,902. MANAGEMENT AND GENERAL EXPENSES 3,520,622. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 19,352,524. NON-HEALTHCARE PROVIDER FEES: PROGRAM SERVICE EXPENSES 5,821,844. MANAGEMENT AND GENERAL EXPENSES 1,881,236. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 7,703,080. FORM 990, PART XI, LINE 9: MINIMUM PENSION LIABILITY ADJUSTMENT 15,921,635. NET ASSET CONTRIBUTIONS -238,060. CHANGE IN FOUNDATION NET ASSETS -5,966,862. FORM 990, PART XII, LINE 2C: THE AUDIT AND COMPLIANCE COMMITTEE ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT, AS WELL AS THE CHOICE OF AN INDEPENDENT ACCOUNTANT. THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. AS PART OF KALEIDA HEALTH, THE FINANCIAL STATEMENTS OF OLEAN GENERAL HOSPITAL ARE PART OF THE CONSOLIDATED STATEMENTS ISSUED BY KALEIDA HEALTH. ADDITIONAL INFORMATION IS CONTAINED WITHIN THE KALEIDA HEALTH LONG-FORM REPORT. ANY AUDIT ISSUES RAISED BY THE KALEIDA HEALTH AUDITORS ARE REVIEWED BY THE OGH AUDIT AND COMPLIANCE COMMITTEE. KALEIDA HEALTH HAS AN AUDIT AND COMPLIANCE COMMITTEE THAT OVERSEES THE PROCESS AND SELECTED THE INDEPENDENT ACCOUNTANT. OLEAN GENERAL HOSPITAL FOUNDATION 515 MAIN STREET OLEAN NY 14670 161497087 FUNDRAISING NY 501(C)(3) PF N/A 0 KALEIDA HEALTH 726 EXCHANGE STREET SUITE 200 BUFFALO NY 14210 161533232 HOSPITAL NY 501(C)(3) LINE 12B, II N/A 0 BRADFORD HOSPITAL FOUNDATION 116 INTERSTATE PARKWAY BRADFORD PA 16701 251612399 FUNDRAISING PA 501(C)(3) LINE 12B, II N/A 0 MILLARD FILLMORE AMBULATORY SURGER CTR 726 EXCHANGE STREET SUITE 200 BUFFALO NY 14210 161307129 SUPPORT ORG NY 501(C)(3) 12A KH 1 VNA HOME CARE SERVICES 726 EXCHANGE STREET SUITE 200 BUFFALO NY 14210 161491203 HOME HLTH CAR NY 501(C)(3) 10 KH 1 VNA OF WESTERN NEW YORK 726 EXCHANGE STREET SUITE 200 BUFFALO NY 14210 160743214 HOME HLTH CAR NY 501(C)(3) 10 KH 1 VISK 726 EXCHANGE STREET SUITE 200 BUFFALO NY 14210 222738425 SUPPORT ORG NY 501(C)(3) 10 KH 1 KALEIDA HEALTH FOUNDATION 726 EXCHANGE STREET SUITE 200 BUFFALO NY 14210 161579143 FUNDRAISING NY 501(C)(3) 7 KH 1 THE CHILDREN'S HOSPITAL OF BUFFALO FOUNDATION 726 EXCHANGE STREET SUITE 200 BUFFALO NY 14210 161332044 FUNDRAISING NY 501(C)(3) 7 KH 1 CHILDREN'S HEALTH HOME OF WNY INC 726 EXCHANGE STREET SUITE 200 BUFFALO NY 14210 814086046 PED HOME HLTH NY 501(C)(3) 10 KH 1 UPPER ALLEGHENY HEALTH SYSTEM INC 515 MAIN STREET OLEAN NY 14760 271255425 SUPPORT ORG NY 501(C)(3) 12A KH 1 BRADFORD REGIONAL MED SERVICES 116 INTERSTATE PARKWAY BRADFORD PA 16701 232875157 PHYS. GROUP NY 501(C)(3) 3 BRMC 1 HEALTH SYSTEM PHYSICIAN PC 130 SOUTH UNION STREET OLEAN NY 14760 464304317 PHYS. GROUP NY 501(C)(3) 10 OGH 1 OLEAN GENERAL HEALTHCARE SYSTEMS LLC 85 WOODRIDGE DRIVE AMHERST NY 14228 161544460 PROVIDER OF DURABLE MEDICAL EQUIPMENT, HOME CARE PRODUCTS NY OGH RELATED 166586 604680 0 0 0.50000 HARLEM ROAD LEASING LLC 3435 MAIN STREET BUFFALO NY 14214 205588135 EQUIPMENT LEASING NY N/A 0 0 AMTON IMAGING LLC 199 PARK CLUB LANE SUITE 300 WILLIAMSVILLE NY 14221 262925470 HEALTH CARE NY N/A 0 0 SITE E LLC 726 EXCHANGE STREET SUITE 200 REAL ESTATE MGMNT NY 14210 272124795 REAL ESTATE MGMT NY N/A 0 0 SOUTHTOWNS IMAGING LLC 5959 BIG TREE RD SUITE 105 ORCHARD PARK NY 14127 471123230 EQUIPMENT LEASING NY N/A 0 0 COLLABORATIVE CARE VENTURES LLC 726 EXCHANGE STREET SUITE 200 BUFFALO NY 14210 472365690 HEALTH CARE NY N/A 0 0 GREAT LAKES MED BILLING SERVICES LLC 199 PARK CLUB LANE SUITE 300 WILLIAMSVILLE NY 14221 461668448 MEDICAL BILLING NY N/A 0 0 ALTUS MANAGEMENT LLC 840 AERO DRIVE SUITE 150 CHEEKTOWAGA NY 14225 900149133 GROUP PURCH ORG NY N/A 0 0 SOUTHTOWNS SURGERY CENTER LLC 726 EXCHANGE STREET SUITE 200 BUFFALO NY 14210 464742028 HEALTH CARE NY N/A 0 0 OLEAN GENERAL SERVICES CORP 515 MAIN STREET OLEAN NY 14760 161447054 JOINT VENTURE HOLDING COMPANY NY OLEAN GENERAL HOSPITAL C 166439 4617409 1.00000 0 KALEIDA PROPERTIES INC 726 EXCHANGE STREET SUITE 200 BUFFALO NY 14210 222738483 PROP MGMT SERV NY N/A C 0 WESTLINK CORPORATION 726 EXCHANGE STREET SUITE 200 BUFFALO NY 14210 161354421 MED & DIAG SE NY N/A C 0 KHBC INC 726 EXCHANGE STREET SUITE 200 BUFFALO NY 14210 462164089 HEALTH CARE NY N/A C 0 GREAT LAKES INTEGRATED NETWORK INC 726 EXCHANGE STREET SUITE 200 BUFFALO NY 14210 823184375 HEALTH CARE NY N/A C 0 OLEAN MEDICAL PRACTICE PLLC 726 EXCHANGE STREET SUITE 515 BUFFALO NY 14210 881324896 HEALTH CARE NY N/A C 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 PART III, IDENTIFICATION OF RELATED ORGANIZATIONS TAXABLE AS PARTNERSHIP: NAME OF RELATED ORGANIZATION: OLEAN GENERAL HEALTHCARE SYSTEMS LLC PRIMARY ACTIVITY: PROVIDER OF DURABLE MEDICAL EQUIPMENT, HOME CARE PRODUCTS, AND SERVICES