Clifton Springs Hospital & Clinic

“Each board has an executive committee. The executive committee consists of the officers of the board plus the chief executive officer of the corporation and such other directors as the chair may nominate from time to time for appointment by a majority vote of the entire board. Between meetings of the board, and to the extent permitted by law, the executive committee shall possess the powers of the board with respect to managing and conducting the affairs of the corporation, except as otherwise provided by law or within certain by-laws.”

“The organization is a membership (not a stock) corporation under new york state law. The organization's sole corporate member is rochester regional health, a related not-for-profit organization.”

“Rochester regional health, as the sole corporate member, also has the right to approve or ratify significant decisions of the organization's governing body, including amendment of bylaws and charters, removal of members of the governing body, and the decision to dissolve the organization.”

“Prior to filing, a copy of the form 990 is provided to, and reviewed with, all members of the audit and compliance committee. This review is performed in consultation with the organization's tax advisors, and is based on the organization's audited financial statements and other relevant information for the appropriate time period.levant information for the appropriate time period.”

“Upon employment, all employees receive the ethical standard of conduct booklet for which they sign a receipt of acknowledgement. Conflict of interest education is conducted annually for all employees. Conflict of interest is defined, as is management of a conflict of interest. Employees are required to disclose and seek resolution to any actual or potential conflict of interest before taking a potentially improper action. Annually, each key employee, director and officer of the organization is required to complete a conflict of interest and disclosure form, providing management with sufficient information about his/her personal interests and relationships so that management can: (1) determine whether any actual or perceived conflict of interest exists, and (2) monitor work assignments to avoid placing the key employee or officer in a position where there may be a question as to his/her objectivity as well as to avoid any appearance of impropriety. Throughout the year, key employees, officers and directors of the organization are also required to notify management promptly if any change to their disclosures occurs. In addition, each member of the board of directors must also complete a conflict of interest and disclosure form, which must be submitted to the general counsel. Board members leave the room during discussions and abstain from voting when they have a conflict of interest.”

“The organization's officer and key employee compensation arrangements are reviewed and approved by the compensation committee. Information reviewed for the officer/key employee includes comparable data from similar size tax-exempt organizations in the western/central ny community as well as compensation for these positions (as disclosed on form 990) with other organizations in the healthcare industry that are of similar size, demographics and geography. Review and approval of the compensation arrangement by the compensation committee is documented.”

“The organization makes its governing documents, conflict of interest policy and financial statements available to the public upon request at the administrative offices of the affiliated health system at 100 kings highway south, rochester, ny 14617. A nominal fee is charged if copies are requested.”

“Estimated amount of other compensation from the organization and related organizations - this column is reflective of (1) the actuarial change in defined benefit pension plan and post-retirement benefits for the tax year and (2) non-taxable benefits.”

“The process has not changed from the prior year.”