Chenango Memorial Hospital Inc.

“United health services, inc. Is the sole member of chenango memorial hospital, inc.”

“The sole member, united health services, inc, shall elect trustees at the annual meeting of the organization.”

“The 990 preparation and filing is the responsibility of the hospitals board of directors who delegates the timely and accurate completion of the 990 to management. The finance division prepared the 990 forms which was reviewed by the organization's public accountants, controller, assistant vp of finance, corporate cfo and the cmh board of directors.”

“Directors, officers and key employees submit conflict of interest statements annually which are reviewed by the ceo, board chairman and the organization's audit committee.”

“It is the philosophy of the hospital that all staff including executive staff be compensated fairly for their work. Base salary levels, incentive/bonus programs and benefit plans shall take into account the local, regional and national markets to allow uhs hospitals to recruit, motivate, reward, recognize and retain highly talented executives with the skill sets required to fulfill its mission. The executive compensation program must focus executives' attention on uhs's strategic initiatives and mission critical performance objectives that will lead to the organization's and system's success. To carry out this compensation philosophy, the uhs hospitals (which includes chenango memorial hospital) board of directors' executive compensation committee reviews annually a comprehensive report prepared by an external executive compensation consulting firm, sullivan cotter associates to determine the appropriateness of the base and total compensation levels for the senior management staff. This annual report focuses on two key areas; 1) the competitiveness of the senior management staff's base and total compensation (including benefits) vs. National benchmark data for comparably sized health care systems and hospitals (based upon 'total revenue' metrics), and 2) a 'reasonableness assessment' consistent with u.s. Treasury department regulations governing executive compensation for not-for-profit organizations. The data from this report assists the executive compensation committee in determining the appropriateness of the senior managements' current base and total compensation levels and the need for any adjustments for that calendar year.”

“The organization provides form 1023, form 990 and other information required under internal revenue service regulations to the public, upon request.”

“Physician/provider fees: program service expenses 15,476,766. Management and general expenses 0. Fundraising expenses 0. Total expenses 15,476,766.”

“Cumulative effect of auxiliary income and expense 13,090. Change in interest in chenango memorial hospital foundation -18,939. Pension changes other than net periodic benefit costs -3,246,257. Change in value of funds held in trust by others -554,609.”

“Neither the process for the oversight of the audit or the process for the selection of the independent accountant has changed during the year.”

“*at the end of each class, participants are asked to complete a class survey. On a scale of 1 to 5 with 5 being the highest and 1 being the lowest, all classes and all segments of the classes scored over 4 in both 2014 and 2015. *the hospital also sends an e-mail to all new moms 2 weeks post-discharge with helpful links to the lhd, wic, breast feeding partners, chenango united way, baby and me tobacco free, and mothers and babies perinatal network. *we update the curriculum from time to time to improve the flow of information, respond to patient requests, and improve attendance. One of the improvements this year was to provide more education and assistance with breastfeeding. *a nurse from the maternity unit completed the national child passenger safety program to become an expert in car seat safety. She can now assist parents with car seat installation and other safety measures before mom and baby go home. *to improve breastfeeding rates, 4 nurses completed lactation counselor training. Breastfeeding assistance is now available in the women's health center, on the maternity unit, and in pediatrics. The hospital's (and county's) only lactation consultant passed her recertification. She works on maternity assisting moms with breastfeeding before discharge and then follows-up 3 days post-discharge. Breastfeeding rates have improved. In 2013, 71% of new moms breastfed at discharge; in 2014 74%, and in 2015 it increased to 75.5%. *the hospital has several representatives on the breastfeeding coalition initiated by the lhd in 2015. The coalition's main mission is to improve breastfeeding rates in the county, particularly among those that are socio-economically challenged. The coalition consists of numerous representatives from various community agencies, i.e. Wic, headstart, mothers & babies perinatal network, that have a vested interest in improving breastfeeding rates. The past year was spent organizing the committee and establishing goals and objectives. One of those objectives was to establish a weigh station called the "baby nook" within the county government building for use by employees and any nursing moms in the community. The "baby nook" is set for a grand opening january 28, 2016. *the hospital collaborated with the lhd on a billboard they are using to promote breastfeeding. This billboard was moved to various locations throughout chenango county during 2015 where the route has a high volume of traffic. *all expectant mothers (249) received a copy of "baby basics". The books are purchased from the mothers & babies perinatal network (mbpn). Nurses reviewed the books with first-time moms at each appointment. The books include chapters on smoking cessation and breastfeeding. *representatives from the mbpn have been in the waiting room every week between february 4, 2015 and november 4, 2015 to help patients with questions and services - including breastfeeding. Originally scheduled for 4 hours once a month in 2014, the representative's time has increased significantly since then. In fact, the women's health center tries to schedule pre-natal appointments when mbpn will be in the waiting room. *in total for 2015, the representative was on-site 32 days for a total of 102 hours. She visited 179 moms (some more than once) which resulted in 113 referrals to mbpn's resources. *in addition, the women's health center made 52 referrals directly to mbpn during the year for a variety of issues including smoking cessation and breastfeeding. Mbpn reports they made 32 connections. Lastly, the mothers & babies perinatal network hosts a meeting for various agencies to discuss projects, challenges, and developments regarding maternal and child health to see how mbpn can help. Attendees include representatives from catholic charities, doh, opportunities for chenango, and family planning of south central new york. -increase access to health insurance for county residents, adults and children the chenango health network plays an instrumental r”

“-improve breast cancer screening rates so that breast cancer is detected earlier. The chenango health network coordinates the "every woman counts" program in chenango county. The program advocates for cancer screenings for women. In 2013, cmh performed 320 mammograms and 360 clinical breast exams, pap smears and internal pelvic exams as a result of referrals from this program. 2014 progress report - breast cancer screenings *the above-mentioned program continued in 2014 and will continue indefinitely. In 2014, there were 361 patient referrals to cmh. 2015 progress report - breast cancer screenings *the above-mentioned program continued in 2015 and will continue indefinitely. In 2015, there were 294 patient referrals to cmh. -provide education and support to pregnant and post-partum women, particularly those women considered to be high risk (e.g. Medicaid, low income, teens) please see the paragraph "priority area: healthy women, infants, and children" earlier in this section. -address the increased rate of hepatitis c infection. Establish and promote a needle exchange program in the county cmh sponsors a sharps program in our emergency room where community members and businesses can deposit used needles. This program can help prevent the spread of hep c and hiv. In 2015, 63 lbs of needles were collected and disposed of as hazardous waste. We also disseminate education materials provided by public health and other agencies, particularly in our out-patient offices. 2015 progress report - hep c & needle exchange program in addition to continuing our sharps program and disseminating information, cmh has taken other steps in caring for patients: *all pre-natal moms are being tested for hep c in the women's health center. If positive, they are checked again during postpartum visits. In 2015, 7 cases were documented. Babies are checked at 18 mos. We currently have 2 referrals who are receiving treatment. These patients are receiving treatment with an affiliated gastroenterology service in binghamton where they have the infrastructure and support to help these patients. Treatment is provided after delivery. *our director of emergency services was participating in the lhd's forums focusing on hep c and drug use in chenango county. He left the hospital mid-year and his place on the forum was filled by a family nurse practitioner with psychiatric certification who practices in our sherburne, ny primary care office. She has been added to the governance committee of this group. These forums include representatives from all parts of the community, i.e. Law enforcement, court system, healthcare, and have been meeting since 2014 to address the growing problem of drug addiction in chenango county. *on november 24, 2015, dr. David wolf, md, of westchester medical center, provided a training session entitled "treatment for hepatitis c: new tests, new drugs, new recommendations". Several providers attended as well as some nurses from the lhd. *the population health improvement program (phip) has identified substance and alcohol abuse as one of their top 5 priorities. -increase awareness and utilization of local domestic/interpersonal violence services. Will be addressed by chenango catholic charities' crime victims program. The hospital's director of emergency services, er nurse manager, and social worker are members of the interdisciplinary team at catholic charities working on this program. 2015 progress report - domestic/interpersonal violence *chenango county catholic charities crime victims program & child advocacy center - their mission is to provide a safe haven for the most vulnerable, support to move victims from harm to healing and intervention in the cycle of violence to promote an individual's right to live without abuse. The program provides direct services to victims of domestic violence, sexual assault, child abuse, and other crimes. The hospital's er nurse manager and social worker attend monthly meetings of this group that includ”

“*to be addressed by the chenango county community mental hygiene services. Mental health is not a core business of uhs chenango memorial hospital. *the population health improvement program (phip) has identified mental health as one of their top 5 priorities. It is also a priority of the delivery system reform incentive program (dsrip). -support policy change such as tobacco-free worksite, parks, playgrounds and point-of-purchase advertising to be addressed by the chenango health network. -market and promote local parks and playgrounds to county residents to encourage use by more people not a core business of uhs chenango memorial hospital. -focus on healthy eating, acknowledge food insecurity issues, access to healthy foods and other stressors which may impede individuals and families' ability to eat healthy although this initiative indirectly relates to uhs chenango memorial hospital, we do not have the financial or human resources to focus on it. -support worksite wellness initiatives currently underway in the county, expand reach to smaller employer groups the hospital's president & ceo is a member of the southern tier regional healthcare quality and benefits management committee of excellus blue cross/blue shield. The committee consists of employers and healthcare organizations for excellus to explain their benefit programs and quality initiatives, utilization, control of utilization, i.e. Ct's and mri's, wellness programs, etc. Excellus reports the results of quality measures to understand the successes and challenges of their various programs. Delivery system reform incentive program (dsrip) the delivery system reform incentive program, essentially a program to reform medicaid, has developed since the original community health needs assessment was submitted 3 years ago. Representatives of uhs chenango memorial have spent numerous hours in collaboration with lourdes hospital (binghamton, ny), binghamton general & wilson hospitals (binghamton), cortland regional medical center (cortland), cayuga medical center (ithaca), delaware valley hospital (walton), guthrie corning hospital (corning), schuyler hospital (montour falls) to create a performing provider system (pps) consisting of these organizations. Ten (10) counties comprise this pps - broome, cayuga, chemung, chenango, cortland, delaware, schuyler, steuben, tioga, and tompkins. Dsrip promotes community-level partnerships in new york state and provides financial support to health care providers to implement programs to better meet the needs of their communities. The pps is a partnership of regional care providers who will collaborate to better transition from traditional fee-for-service payment for their services to the new, risk based, pay-for-performance approach.”

“A. Railing was installed on stairs leading to the emergency room to insure patient safety. B. The next phase of installing a security lockdown system was completed during the year. C. An emergency management drill was conducted with mercy flight out of syracuse, ny. Mercy flight is a larger chopper that is more accommodating for the family of a victim. Cmh normally uses lifenet out of sidney, ny. D. To accommodate patients with disabilities an assistance bell has been installed at the imaging center. Money has been budgeted for 2016 to install automatic doors. E. New parking lot signs were installed that are temperature activated to advise people of icy conditions. F. An energy assessment was completed to determine equipment that should be replaced to help save energy. G. Solidified the process for communicating the recall of any products or supplies. H. Improvements were made to the hospital's cooling tower. I. Assessment of all eye stations to determine addition, upgrade or removal/replacement. J. Added maternity to the camera security system. K. Replaced fire doors in the basement corridor. *system environment of care committee - this committee meets quarterly with representatives from each of the affiliated organizations to review networked bio-medical equipment concerns, system-wide policies that need revising, and environmental trends such as nuisance activity by the public, smoking violations, etc., all to ensure safety of the public, patients, and visitors. *workplace safety & safe patient handling - this group works on policies, security and safety for employees and patients. In october, a separate safe patient handling committee was established. It quickly merged with the existing workplace safety awareness team and the combined group has been meeting since november. During the year, the security lockdown system was expanded so all exterior doors can now be locked down to secure the building from a potentially violent situation outside the building. Surveillance was also installed in the back of the hospital to monitor suspicious activity and to report it to authorities as needed. Work began on the safe patient handling policy to reinvigorate the process for accident reporting and investigation of accidents. This team reports to the system nursing committee and the system eoc. The team also expanded the group to include staff with expertise in training, security, environmental services, maintenance and front line employees. A. Safe patient handling conference - sponsored by the new york state zero lift task force, the conference objectives were: a) learn how to build the business case for safe patient handling programs, b) understand what is required by the new legislation, c) learn how to utilize sph equipment for early mobilization success, d) hear about successful sph programs from those that have implemented them. *pharmaceutical waste and hazardous material waste program - the pharmaceutical waste program will keep drugs out of the hands of those who could potentially overdose or cause harm to themselves. The project began in march 2015. The goal was to improve the existing program by contracting with a vendor used system-wide for this purpose. Another priority was to repair the medical waste building on-site to be in compliance. The hospital invested over $12,000 in materials in 2015 to renovate the building and in fencing to secure the area. Additional time was spent in training, development of internal policies, working with the vendor, and completing inspections. The program went live march 2016. Coalition building *members of the hospital's management team serve on several boards or hold governance positions with organizations in the area. Hospital representation on some of the boards is discussed in part v, section c, line 11. *union (ny) volunteer emergency services - an ambulance company that serves the town of union, ny in broome county, it consists of 100 volunteer and 40 paid staff who run 4 ambulance”

“*iroquois health alliance (iha) - the hospital's ceo is an iha board member. The organization consists of ceo's of all the hospitals in central new york. It is the regional voice in albany and washington for upstate hospitals and healthcare systems members. The iha promotes a broader understanding of, and builds support for, the health care systems serving upstate new york. This forum has been used by the department of health and other government organizations to discuss changes in health care and new regulations directly with hospital ceo's. *future of healthcare policy advisory group - this committee was assembled by the health care association of new york state to examine and discuss activities involved with healthcare reform. The committee consists of hospital ceo's from all over new york state and they discuss dsrip (delivery system reform incentive program) or medicaid payment reform in new york state, ship (state health innovation plan) or payment reform in the commercial marketplace, the healthcare exchange as well as organization, financial and public impacts. Hanys then takes this feedback to draft policy statements and cautionary notes to the doh and the governor to provide informed guidance for policy makers. This committee started in the fall of 2014 and meets bi-monthly. *regional healthcare benefits & quality management committee - the committee consists of employers and healthcare organizations for excellus blue cross/blue shield to explain their benefit programs and quality initiatives, utilization, control of utilization, i.e. Use of ct scanners and mri's, wellness programs, etc. Excellus reports the results of quality measures to understand the successes and challenges of their various programs. *diabetes information fairs - the hospital hosted an annual fair in norwich on september 24th that 30 people attended. This free event was open to diabetics and their families and featured information that is important for anyone who has been diagnosed with diabetes. Participants learn about many aspects of diabetes care including complications of the disease particularly cardiovascular disease, nutrition, and preparation of a variety of diabetes-friendly food. Medical experts at the fair included primary care/internal medicine physicians and their nurses, a podiatrist and his nurse, a chef, registered dietitians, and a dentist. Numerous diabetic friendly businesses had booths at the event. *diabetes education committee - this group which consists of the hospital's diabetic educator, administrative assistant, and staff educator is chaired by a community physician. Other attendees include a registered dietitian, a podiatrist, and a community member. They meet quarterly and work primarily to increase physician referrals to the diabetic self management classes and plan education events like the diabetes health fairs. The hospital hosts these meetings in our basement conference room. *diabetes self management classes - this 4-series class includes instruction for diabetes patients and their caregivers on how to manage the disease. The first session is a pre-assessment, followed by three 3-hour classes, and then a followup. 30 people participated. *take a shot at diabetes - funds were raised to send a local child to camp aspire for children diagnosed with diabetes, to donate several gas cards to adults with diabetes for their medical trips and to support diabetes education programs at the local ymca. *transportation issues workshop - sponsored by the chenango county department of planning & development, various health and social service agencies attended for presentations by local transportation providers regarding their services and ability to transport people to services in chenango county and elsewhere, i.e. Syracuse, binghamton. Information on the nys 511 ride share program was distributed. *blood screening & health fair - the hospital's diabetic educator attends this annual event sponsored by the norwich rotary club”

“*pediatrics (norwich, ny) - yesu matta, md, was credentialed to join the medical staff on july 2, 2015. He has a growing pediatrics practice in our norwich office. *primary care (sherburne, ny) - marylou jorgensen, fnp, was credentialed on august 1, 2015 and joined other providers in our sherburne office. *ob/gyn (norwich, ny) - na young lee, fnp, a former graduate student who did her clinical rounds at the hospital, was credentialed on august 10, 2015 and joins 3 other ob/gyn's in our women's health center. *ent (norwich, ny) - rebecca tillotson, rpa-c, was credentialed november 10, 2015, and replaced a nurse practitioner who retired from our ent office. *orthopedics (norwich, ny) - rudolph buckley, md, an independent orthopedic surgeon, was contracted by the hospital and credentialed on november 2, 2015 to provide spinal orthopedic services in our norwich office. He brings with him two pa's who have also been credentialed by the hospital. Although he was credentialed in 2015, they did not start seeing patients until february 2016. *orthopedics (oneonta, ny) - tariq hussain, md, an orthopedic surgeon in the norwich, ny, office began seeing patients part-time in the uhs oneonta primary care office starting in march 2015 to help address a shortage of local orthopedic services in that area. *orthopedics (norwich, ny) - tariq hussain, md, was proctored and credentialed in early 2015 to do radio frequency ablation (rfa) procedures. Rfa procedures temporarily deaden nerve endings providing relief for patients suffering from severe pain usually in the back. He completed his first procedures on february 23rd. *child & adolescent psychiatry (sherburne, ny) - susan converse, np, completed her certification in child and adolescent psychiatry in may 2015. Chenango county has a severe shortage of mental health providers. Ms. Converse recognized the need in her pediatric practice and pursued the certification on her own time at her own expense. She began seeing patients on june 29th. *diabetic educator (norwich, ny) - cindy stratton, diabetic educator, came on board in the fall of 2015. Her role will be 2-fold: to continue the work of the retiring diabetic educator (see diabetes activities earlier in this section) and to provide 1-on-1 counseling with diabetic patients, especially the newly diagnosed, in the health center where they see their primary care provider. Workforce development as the only hospital in chenango county, uhs chenango memorial is the epicenter for training and mentoring of health care students. In 2015, nearly 200 students received hands-on, real-life experience on-site throughout the year. *morrisville state nursing program - representatives from cmh were invited to a meeting to support the college's relocation of their nursing program to their norwich campus. Uhs chenango memorial agreed to continue to support the program by providing a site for clinical experience. Furthermore, cmh offered information on what job opportunities graduate nurses could look forward to and areas of focus for the program's curriculum. Uhs hospitals was also represented and was open to expanding a clinical affiliation beyond just uhs chenango memorial. Cmh took the opportunity to write a letter of support for the program in order to advocate for the addition of a baccalaureate degree program, which was another initiative morrisville unveiled at the meeting. *cmh career days camp -this 2-day camp is sponsored by uhs chenango memorial hospital from funding provided by a local foundation. This is a 2-day event for area students going into 8th and 9th grade. During their camp experience, they are able to see various departments in the medical field and do hands-on activities, including laproscopic surgery, intubation, and patient transfers. Goal is to gain interest in the different fields so that the student can concentrate their high school studies on classes that would be needed for college enrollment. Participants included life-net, norwic”

“*high-reliability conference - the healthcare association of new york state (hanys) hosted this program designed specifically for hospital leadership teams and featured nationally-known faculty who discussed the critical role of leaders in implementing high-reliability strategies to drive performance across healthcare organizations. Speakers highlighted key elements for success, including the need for board and ceo commitment, "just culture," meaningful patient and family engagement, transparency and ongoing process improvement and learning. The overriding objective is to achieve consistently safe and effective clinical outcomes.”