STATE OF NEW YORK
PUBLIC HEALTH AND HEALTH PLANNING COUNCIL
STANDING COMMITTEES
May 23, 2012
10:00 a.m.
90 Church Street
4th Floor, Room 4A & 4B
New York City
I. COMMITTEE ON ESTABLISHMENT AND PROJECT REVIEW
Jeffrey Kraut, Chair
A. Applications for Construction of Health Care Facilities
Acute Care Services - Construction
Exhibit #1
Number
Applicant/Facility
1.
111444 C
Lincoln Medical and Mental Health Center
(Bronx County)
2.
112323 C
New York Presbyterian Hospital – Columbia Presbyterian Center
(New York County)
3.
121088 C
Millard Fillmore Suburban Hospital
(Erie County)
Long Term Home Health Care Program - Construction
1.
Number
Applicant/Facility
121093 C
St. Cabrini Nursing Home
(Westchester County)
Exhibit #2
B. Applications for Establishment and Construction of Health Care
Facilities/Agencies
Acute Care Services – Establish/Construct
1.
Number
Applicant/Facility
121169 E
NYHB, Inc.
(Kings County)
Exhibit #3
Ambulatory Surgery Center - Establish/Construct
Exhibit #4
Number
Applicant/Facility
1.
112179 B
Amsterdam REC, LLC d/b/a Amsterdam Regional Eye Center
(Montgomery County)
2.
112379 B
The Surgery Center at Orthopedic Associates, LLC
(Dutchess County)
Diagnostic and Treatment Centers - Establish/Construct
Number
Applicant/Facility
1.
101101 B
Street Corner Clinic, Inc.
(Kings County)
2.
112042 B
The Chautauqua Center
(Chautauqua County)
Dialysis Services - Establish/Construct
1.
Exhibit #6
Number
Applicant/Facility
092158 B
DV Corp. d/b/a Riverside Dialysis
(Westchester County)
Hospice – Establish/Construct
1.
Exhibit #5
Exhibit #7
Number
Applicant/Facility
121049 E
Lewis County Hospice
(Lewis County)
Residential Health Care Facilities - Establish/Construct
Number
Applicant/Facility
1.
082143 E
OMOP, LLC d/b/a Orchard Manor, Inc.
(Orleans County)
2.
112156 E
Parkview Operating Co., d/b/a Westchester Center for
Rehabilitation & Nursing
(Westchester County)
2
Exhibit #8
Certified Home Health Agencies – Establish/Construct
Exhibit #9
Number
Applicant/Facility
1.
121018 E
Lewis County General Hospital d/b/a Lewis County General Hospital Certified
Home Healthcare Agency
(Lewis County)
2.
121219 E
L. Woerner, Inc. d/b/a HCR
(Clinton County)
C. Certificates
Restated Certificate of Incorporation
Exhibit #10
Applicant
1.
The Elizabeth Church Manor Nursing Home Corporation
2.
The James G. Johnston Memorial Nursing Home Corporation
Certificate of Amendment of the Certificate of Incorporation
Exhibit #11
Applicant
1.
NYU Downtown Hospital Chinese Community Partnership for Health Foundation, Inc.
D. Home Health Agency Licensures
Home Health Agency Licensures
Exhibit #12
Number
Applicant/Facility
1633-L
320 MacDougal Street, Inc.
(Bronx, Richamond, Kings, Queens, Nassau and
New York Counties)
1712-L
Aide and Comfort, Inc.
(Nassau, Suffolk, Westchester, Rockland, Queens,
New York, Bronx, Kings, and Richmond
Counties)
3
1688-L
Alissa Home Care, Inc.
(Kings, Bronx, Queens, Richmond, New York,
and Nassau Counties)
1944-L
Always Best Care of NY, LLC
(Nassau and Suffolk Counties)
1667-L
B & M School of Health Careers, Inc.
(New York, Kings, Bronx, Richmond, Queens,
and Westchester Counties)
1623-L
Best Help Home Care Corp.
(Kings and Bronx Counties)
1844-L
CareGivers by Design, Inc.
(Westchester and Richmond Counties)
1765-L
Care Providers, Inc. d/b/a Home Helpers #58319
(Queens, Bronx, Kings, Richmond, New York,
and Nassau Counties)
1919-L
Caring Moments Homecare, Inc.
(New York, Nassau, Kings, Bronx, Queens, and
Richmond Counties)
1587-L
CHDFS, Inc.
(Bronx, Rockland, Kings, New York, and Queens
Counties)
1689-L
Everyday Care, Inc.
(New York, Bronx, Kings, Richmond, Queens and
Nassau Counties)
1986-L
Good Samaritan CareGivers, Inc., d/b/a
Good Samaritan Home Health Agency
(Allegany, Erie, Niagara, Cattaraugus, Genesee,
Orleans, Chautauqua, Monroe, and Wyoming
Counties)
1971-L
Ideal Home Care Services, Inc.
(Suffolk, Nassau, New York, Bronx, Queens,
Richmond and Kings Counties)
4
1969-L
J & A Hurley, Inc. d/b/a Home Instead
Senior Care
(Schenectady, Schoharie, Albany and
Montgomery Counties)
1856-L
Life’s Changing Seasons Eldercare, LLC
(Onondaga, Oswego, Seneca, Cayuga, Cortland,
Oneida, Madison and Tompkins Counties)
1706-L
K & D Home Care, Inc.
(New York, Bronx, Kings, Richmond, Queens and
Nassau Counties)
1923-L
Marks Homecare Agency of NY, Inc.
(New York, Bronx, Kings, Richmond, Queens,
and Westchester Counties)
1798-L
NurseCore Management Services –
New York, LLC
(Livingston, Monroe, Ontario and Wayne
Counties)
1889-L
PCDI Healthcare and Consultants of Texas, LLC
(New York, Kings, Bronx, Queens, Richmond and
Nassau Counties)
1965-L
Regina G. Yankey d/b/a Orange Homecare and
Staffing Agency
(Orange, Sullivan, Rockland, Dutchess,
Westchester, Bronx, and Putnam Counties)
1800-L
Safe Haven Home Care, Inc.
(Bronx, Richmond, Kings, New York and Queens
Counties)
1937-L
Queens Homecare Agency, Inc.
(Bronx, Kings, New York, Queens, and Richmond
Counties)
1939-L
Funzalo & Canteet, Inc. d/b/a Right at Home
North Shore LI
(Nassau, Suffolk, and Queens Counties)
5
1789-L
Senior Comfort Solutions, LLC
d/b/a Comfort Keepers
(Nassau and Suffolk Counties)
1977-L
Sephardic Home Care Services, Inc.
(New York, Nassau, Kings, Queens, Bronx, and
Richmond Counties)
1973-L
T.A. Daniels Holdings, Inc.
d/b/a Senior Helpers
(Westchester County)
1975-L
Tayler Ashley Group, Inc. d/b/a Senior Helpers
(Dutchess, Westchester, Orange, Putnam, Sullivan,
and Ulster Counties)
1961-L
TriMed Home Care Services, Inc.
(Nassau and Suffolk Counties)
1922-L
Your Choice Homecare Agency, Inc.
(New York, Westchester, Kings, Queens, Bronx
and Richmond Counties)
2113-L
Steuben County Public Health & Nursing Services
(Steuben County)
1976-L
Parent Care, LLC
(Kings, Richmond, Queens, New York, Bronx,
and Nassau Counties)
2099-L
SeniorBridge Family Companies (NY), Inc.
(See exhibit for counties listed)
2033-L
Heritage Ransomville Management, LLC d/b/a
Heritage Manor of Ransomville Home Care
(Niagara County)
6
STATE OF NEW YORK
PUBLIC HEALTH AND HEALTH PLANNING COUNCIL
STANDING COMMITTEES
May 24, 2012
10:00 a.m.
90 Church Street
4 Floor, Room 4A & 4B
New York City
th
I. COMMITTEE ON CODES, REGULATIONS AND LEGISLATION
Angel Gutiérrrez, M.D., Chair
Exhibit #13
For Emergency Adoption
Subpart 86-2 of Title 10 NYCRR – Sprinkler Systems
TO BE DISTRIBUTED UNDER SEPARATE COVER
For Discussion
Subpart 86-2 of Title 10 NYCRR – Sprinkler Systems
TO BE DISTRIBUTED UNDER SEPARATE COVER
10-15 Amendment of Section 400.18 of Title 10 NYCRR
(Statewide Planning and Research Cooperative System (SPARCS))
II. JOINT MEETING OF THE COMMITTEE ON PUBLIC HEALTH AND
COMMITTEE ON HEALTH PLANNING
Dr. Jo Ivey Boufford, Chair, Committee on Public Health
Dr. John Rugge, Chair, Committee on Health Planning
III. COMMITTEE ON HEALTH PLANNING
Dr. John Rugge, Chair, Committee on Health Planning
IV. COMMITTEE ON PUBLIC HEALTH
Dr. Jo Ivey Boufford, Chair, Committee on Public Health
7
New York State Department of Health
Public Health and Health Planning Council
May 23, 2012
ATTACHMENTS
Acute Care Services - Construction
Exhibit #1
Number
Applicant/Facility
1.
111444 C
Lincoln Medical and Mental Health Center
(Bronx County)
2.
112323 C
New York Presbyterian Hospital – Columbia Presbyterian Center
(New York County)
3.
121088 C
Millard Fillmore Suburban Hospital
(Erie County)
BFA ATTACHMENT A
NEW YORK CITY HEALTH AND HOSPITALS CORPORATION
(A Component Unit of the City of New York)
Balance Sheets
June 30, 2011 and 2010
(In thousands)
Assets
Current assets:
Cash and cash equivalents
U.S. government securities and other investment~
Patient accounts receivable, net {
Premiums receivable
Estimated third~party payor settlements, net,
Estimated pools receivable, net
Grants receivable
Supplies
Assets restricted as to use and required for current liabilities
Other current assets
$
Total current assets
Assets restricted as to use, net of current portion'
U.S. government securities and other investments
Capital assets, net (
Deferred financing costs, net
Total assets
Liabilities and Net Assets (Deficit)
Current liabilities:
Current installments oflong·tenn debt,
Accrued salaries, fringe benefits, and payroll taxes
Accounts payable and accrued expenses (
Estimated pools payable, net
Due to City of New York, net
Current portion of Dostemployment benefits obligation, other than
pension
$
56,996
751,026
426,757
207,374
61,607
656,306
400,231
191,500
161,857
94,400
93,000
1,536,553 _
Total current liabilities
Long-tenn debt, net of current installments,
Postemployment benefits obligation, other than pension, net of current
portion
Total liabilities
1,564,501
1,039,664
901,352
4,218,416
3,688,635
6,794,633
6,154,488
1,975,015
1,871,925
156,332
8,719
928
60,448
(3,051,322)
146,430
9,765
928
52,835
(2,611,257)
Commitments and contingencies
Net assets (deficit):
Invested in capital assets, net ofrelated debt
Restricted:
For debt service
Expendable for specific operating activities
Nonexpendable pennanent endowments
For statutory reserve requirements
Unrestricted
Total net assets (deficit)
(849,880)
$
5,944,753
(529,374)
5,625,114
BFA ATTACHMENT A CONT.
NEW YORK CITY HEALTH AND HOSPITALS CORPORATION
(A Component Unit of the City nfNew York)
Statements of Revenues, Expenses, and Changes in Net Assets (Deficit)
Years ended June 30, 2011 and 2010
(In thousands)
2011
2010
Operating revenues:
Net patient service revenue
$
1,279,390
213,226
47,519
4,778,845
287,048
1,107,197
220,152
47,323
6,883,()88
6,440,565
2,583,078
1,964,049
1,044,293
620,601
857,467
256,134
2,611,423
1,837,224
960.706
602,623
825,375
253,419
7,325;622
7,090,770
(442,534)
(650,205)
14,069
(92,868)
557
5,593
(97,573)
58
(78,242)
(91,922)
(520,776)
(742,127)
198,192
2,078
258,507
3,981
200,270
262,488
(320,506)
(479,639)
Net assets (deficit) at beginning of year
(529,374)
(49,735)
Net assets (deficit) at end of year
(849,880)
(529,374)
Appropriations from City of New York, net (
Premium revenue
Grants revenue
Other revenue
Tot,j) dpcratingfcvcnues
Operating expenses:
Personal services
Other than personal services
Fringe benefits and employer payroll taxes
Postemployment benefits, other than pension
Affiliation contracted services
Depreciation
Total operating expenses
Operating loss
Nonoperating revenues (expenses):
Investment income
Interest expense
Contributions restricted for specific operating activities
Total nonoperating expenses, net
Loss beloTe other changes in net assets (deficit)
Other changes in net assets:
Capital contributions Ii-mded by City of New York
Capital contributions Ii-mded by grantors and donors
Total other changes in net assets
Decrease in net assets
5,3] 5,360
27,593
BFA Attachment B
Project 111444
Current Year
Lincoln Medical and Mental Health
Inpatient
Total Expense
Average Cost
Discharge
Operating Expenses - Current Year
Operating
Capital
Total
656
656
656
$7,109,001
Q
7,109,001
$10,836.89
$0.00
$10,836.89
1,193
1.193
1,193
$12,522,305
340,290
$12,862,595
$10,496.48
$285.24
$10,781.72
1,193
1,193
1,193
$12,522,305
340,290
$12,862,595
$10,496.48
$285.24
$10,781.72
Operating Expenses ~ First Year
Operating
Capital
Total
Operating Expenses - Third Year
Operating
Capital
Total
BFA Attachment A
The New Y o~k and Presbyterian Hospital
Statements of Financial Position
December 31
2011
2010
(In Thousands)
Assets
Current assets:
Cash, cash equivalents and short-term investments·.
Cash and cash equivalents
Short-term investments
Total cash, cash equivalents and short-term investments
Patient accounts receivable, less allowance for
uncollectibles (2011 - $215,668; 2010 - $189,417)
Other current assets
Assets limited as to use - current portion.
Due from related organizations - net \
Professional liabilities insurance recoveries receivable - current
portion,
Beneficial interest in net assets held by related
organizations - current portionj
Total current assets
Assets limited as to use - non-current
Funded depreciation
Capital acquisition under lease agreements
Mortgage reserve funds under loan agreements
Total assets limited as to use - non-current
Property, buildings and equipment - net·
Other non-current assets ~ net
Professional liabilities insurance recoveries receivable non-current
Beneficial interest net assets held by related
organizations - non-current
Total assets
$
226,882
517,666
744,548
$
195,947
287,348
483,295
394,840
57,003
22,07'5
394,553
54,041
22,522
1,696
48,393
47,296
59,089
1,325,948
54,340
1,057,743
597,012
624,686
138,892
736,342
152,643
777,399
1,794,501
81,444
1,761,111
85,227
70
153,171
~FA
Attachment A (cant )
December 31
2011
2010
(In Thousands).
Liabilities and net assets
Current liabilities:
Long-term debt - current portion
Accounts payable and accrued expenses
Accrued salaries and related liabilities
Due to related organizations - net:
Pension and postretirement benefit
liabilities - current portion!
Professional liabilities - current portion.
Other current liabilities :
Total current liabilities
Long-term debt
Professional liabilities
Pension liability :.
Postretirement benefit liability
Deferred revenue :
Other noncurrent liabilities
Total liabilities
$
84,113
. 2'53,636
186,439
2,247
$
77,792
230,779
169,018
11,822
48,393
119,641
706,291
10,000
47,296
111,774
646,659
696,303.
282,847
253,459
30,963
6,094
155,190
2,131,147
751,26'2
296,388
141,113
30,062
7,767
111,946
1,985,197
1,898,132
1,794,091
1,116,955
1,116,955
212,692
3,227,779
$ 5,358,926 $
1,023
1,123,309
1,124,332
214,628
3,133,051
5,118,248
Commitments and contingencies .
Net assets:
Unrestricted
Temporarily restricted:
Temporarily restricted - held by Hospital
Temporarily restricted - held by related organization
Total temporarily restricted
Permanently restricted - held by related organizations
Total net assets
Total liabilities and net assets
BFA Attachment A (cont.)
The New York and Presbyterian Hospital
Statements 0'[ Operations
Year Ended December 31
2011
2010
(In Thousands)
Operating revenues
$ 3,452,618
$ 3,266,191
226,202
3,678,820
194,314
3,460,505
1,668,635
448,031
1,104,495
227,510
3,498,770
1,585,323
413,772
1,085,361
51,416
209,800
3,345,672
Operating income
180,050
114,833
Investment return '
Excess of revenues over expenses before accrual
of net medical resident tax refund
(11,850)
83,211
168,200
198,044
Accrual of net medical resident tax refund
Excess of revenues over expenses
540
168,740
212,323
53,582
92,610
Net patient service revenue
Other revenue
Total operating revenues
Operating expenses
Salaries and wages
Employee benefits
Supplies and other expenses
Interest and amortization of deferred financing fees
Depreciation and amortization
Total operating expenses
Other changes in unrestricted net assets:
Distributions from New York.. Presbyterian Fund,
the purchase of fixed assets
Change in pension and postretirement benefit liabilities to
be recognized in future periods
Change unrestricted net assets
~0,099
BHFP Attachment: Map
CON # 112323 New York Presbyterian Hospital·
Columbia Presbyterian Center.
New York County Hospitals
BFA Attachment A
KALEIDA HEALTH
Consolidated Balance Sheets
December'31, 2011 and 2010
(Dollars in thousands)
2011
Assets
Current assets:
Cash and cash equivalents
Investments'
'Accounts receivable:
Patient, less estimated allowance for doubtful accounts of
$32,161 in 2011 and $35,494 in 2010"
Other
Inventories
Prepaid e.xpenses and other current as~ets
Total
curr~nt ,.~<:ptc.:
Assets limited as to use :
Designated under debt agreements
Designated under self-insurance programs
Board designated and donor restricted
Other
Property and equipment, less a.ccumulated depreciation and
amortization
Receivable for insur~nce recoy,al.ties
Grants receivable ~
Deferred financing costs, 11(,;"
Other
Total assets
$
2010
41,267
139,260
60,122
148,795
152,348
10,030
20,563
11,752
151,456
8,291
375,220
402,751
42,476
123,920
85,974
1,187
50,831
138,592
85,741
"1,3,80
253,557
276,544
477,556
9,078
19,307
12,209
86
351,188
7,809
47,143
12,933
6,321
113
1,104,689
23~419
10,668
BFA Attachment A (cant.)
2011
Liabilities and Net Assets
Current liabilities:
Accounts payable and other accrued expenses
Accrued payroll and related expenses
Line of credit.
Estimated thira~party payol settlements
Current portion of long-term debt
Other current liabilities
$
Total current liabilities
Long-term debt, less current portion
Construction costs payable.·~.
Estimatea~self-insurance reserves ~
Asset retirement obligations
Pension and postretirement obligations:'
Other long-term liabilities
Total liabilities
~S,273
2010
54,888
10,000
23,288
18,223
9,122
91,615
54,216
10,000
27,499
18,889
4,427
210,794
206,646
276,245
13,290
168,328
13,030
264,767
.13,235
~26,544
748,895
589,217
959,689
795,863
91,356
87,668
15,400.
180,453
112,973
15,400
11,696
160,516
10,685
176,507
3,269
Commitments and contingencies:
Net assets:
Unrestricted
Temporarily restricted ·
Permanently restricted·
308,826
Total net assets
Total liabilities and net assetS
$
1,104,689
BFA Attachment A (cont.)
KALEIDA HEALTH
Consolidated Statements of Operations and Changes in Net Assets
.Years ended December 31, 2011 and 2010
(Dollars in thousands)
2011
Operating revenue:
Net patient service revenue"
Other operating revenue
Net assets released from restrictIons
S
101
operations
Total operating revenue
Operating expenses:
Salaries and benefits
Purchased services and other"
Medical and non-medical supplies
Depreciation and amortization
Provision for bad debts .
Interest
Total operating expenses
(Loss) income from operations
Other income (losses):"
Investment income.
Net realized gains (losses) on sales of investments
Net change in unrealized gains and losses on investments
Restructuring charges, loss on impairment and disposal of assets
Total other (los,ses) income; net
(Deficiency) excess of revenue over expenses
$
2010
1,178,419
18,944
5,747
1,180,088
17,982
7,703
1,203,110
1,205,773
689,218
223,007
222,993
58,664
18,739
10,551
668,426
211,344
222,096
52,718
19,759
12,662
1,223,172
1,187,005
(20,062)
18,768 "
1,707
12,469
(13,629)
(7,453)
12,339
(189) -14,917
(3,409)
(6,906)
23,658
(26,968)
42,426
New York State Department of Health
Public Health and Health Planning Council
May 23, 2012
ATTACHMENTS
Long Term Home Health Care Program - Construction
1.
Number
Applicant/Facility
121093 C
St. Cabrini Nursing Home
(Westchester County)
Exhibit #2
of Westchester
Balance Sheet
December 31, 2011
Ouudlted
Audited
ASSETS
Current usetI
, Cub·~ cash equiYlleDts
Cub .. residem t\mdI
$ S,061.gss
432,01S
4,090,2!1
InvatmeDII
ResideatllcCOUDtI receinbJe
Less: aI10waDce fot doubttbllCCOWl13
Due trom CabriDi Cater fbr Nuniq "Bmlt)Wtl.tioo
Due froorCabrini 'em It Homo'. ..... ..
Due from Third Party reimbursemaJt lpoei.
Inventories .. It ~t
Prepaid ~J depoaib md other receivables
S 7.884,227'
• 8.316.010
128,109
1,888',211 '
2,183.000
64.179
290.281
85.181
· 1,183,359
8.Gee.38S
(2,888,000)
.
84.179
Total'current UIetI
Limited use UH8
Cah·EacroW
InvafmeDta held
Investment ... EIcrow
Toml other lISets
G7p11.467
Toml Uleta
LIABILITIES AND NIT ASSETS
Current liabilities
Account! payable ........ ~I'~I ~I~"""
• U47JM8
2,tl8,180
Accrued 'alaries,Wlra IUd ldlnillr iltems
Accrued ooutnaetioD 00I1I
Fundi held in tnut for residca..
r .,,'11_.......~Iftft ofpremium 011 bcmdI payable
of mortpp 10IDI
887.218
315A08
_,788
828.ao1
·1
Total current
...--"936;000"--'
1.621,841
Total
201)
BFA Attachment A (C'ontinued)
CIlbrini o/WutchGW
,Statement " Rey.ue ud ~un
Y.r~Dte"r31,21U
, UuWldl£ld
V.rlldM
Curnu Mo.
Adu!l
I","
vpdwp
OPIRATiNG UVIM1I
I 3,181,1'10 I. 3,204.,712 I
233,110
13UU
194.163
Ilafdenl rev.-," '
AAeummt R ~ _rwtA-
Raidul rweoue-prior,. muue adj~
Looa lInD home health em·
MWtdayan
Adultdayan .. ~oa
Pbytklau bWmI
Oth- (mdudu IIft·Dp ~ ad oda_)
238;53
321,121
114.163
(12,121)
1Ca....
10U00
'p.m)
M.7S
2,380
8G,432
AID)
1_
7.
S 4,00'. I 3.a7.,03t I
Tow Opentiq Rncue
OPUATlNG·EXPINSa
'SiJiriN' ,
""
(4U82)
101'-
~,~~
• 1)71.104 "
"
(1")
1U2
1OO.GO
(28.71)
(U1)
(1.2t)
211'» ,
'leuR
4"
(41,"'1)'''
ra:a>
Eanp~,BlDdb
....
I~I
1'"
(·.em
Ul7e012
.......
,
'.0'11
710,_
4_ '
41'-
I .,2C)7'-
...
':"111
e 44,2'17Ml,'
" fl_- " 'U13.18'"
.AI
...
UI"'t.
301.77'
1._,142
~
,~
U2U1t
'107
23'32O,«K
NYS 'NuniDl Home Cub IUafpb ~
327,864
224,420
_.147
~.7'21
12.04
2U62
~)
341.721
110.713
(1n.111)
21.317
~,t)
U4
(127.12)
_JOt
''''
14'.
.,....
2,71GM2
'--'18
2JU.8
'Prorilion b kd uhf ~
~1
S~Noa"Ub«
1.aM.-
emsn)
(It.31)
11.. . .
.,. _171
~
(17'-.
lUM
?a.M
....
1._
~
tl.46t.t17
P~tM4
11.
3.07I,I'IJ
4.MO~
tot. .
(4.IIJ
(1.117.111)
om-n
"'8M
(1~
£nm~
" ~doD ofRUD 201 Houlina hoi_
TOIII HGo-OpIndDI Ell,..
I2MO
itO
(t.tll)
(tM)
'IUIt
If.:"
100..
It.
112,111
107.710
8,-
(tMI2)
(too.GO)
1U13
NIT GAIN OR (LOSS)
..
4O.TI
184'-
3A.~
...M.
(I.Ie)
71114
*.21.
S).GW
.a.1U7I
34.1'-
87,738
1,.
~I'
(MUID)
400
,.
(ItU4)
2._717
8.114
3..
23,-
30. . . .
(1,1111.18)
NON-OPIRATlNG UPIlfSIS
IfON-oPIRAnNO CAlHlLOSS
.....
,.,
5!,!!,8
'QAlN/(LOSS) FROM OPDATJONS
~ JDomDC (lDclud8I unnaIWd pfu
o-nlnatiOlH
Specill Swat R ~
0Ib«
Total Nc:m.()pendq RewmM
..........
1uu'4,
8M,m
TOTAL OPERATING UPENDS
NON-OPIIlATINO RIVBNtII
".,..
1U1n.m·
DUB
1.-"
ua
'.'
41".
'
(21..10)
(38U3)
UOO
I
tu4
(101.m')
fAM4)
-.
'(ftt,III)' , (U7)
',410
118,1.
..
4Ja,18O
3.101
_-I)
'It.M
142,.
CUll
881.717
1.017
13.110
(10.11)
(&II)
f2.!!D
~
SoppUn 4 othc ex,.,.
Adult day CIn .. anmpcn1a1kM
lDeerut
Mortpp lDM'UU PrlmiID
Dspreciatiea '
.....
3'--
CIA)
C!'"'
CODttlaed Sen1cu .. ~
(1 A)
(131M)
t,en,IID
I!lp)
..M.IM
~)
~
34.7lU77
U8
(1OQ.OO)
(t&OG)
1,012M
27'-'711
,.,
(4,InJ
...
HP
a._m
ruM)
1• •
44.438
(-..
(1t1,4tJ)
q.p
,(G2.Itl)
Semen .. L11IHC
Coub'8C8ed Semen .. 1"benpbbl
(4IOM7)
(M,Itt)
aDA!7
C~
'
~
~
Sable'" IaII«
•
Dteembtr 31,1010
1O,lt3
mu,
_021
4.100
--...
~
(Uh.lt3)
...
Am
".n.,"
..-
'
till1\. 1\.r:r:acnmenr: ti
Center for Nursing and Ket18Dllllta'tlon
542 East 5th Street
New York, New York 10009
Balance Sheet
December 31 r 2011
Unaudited
Current assets:
Cash and
equtvalent~
Cash held In trust
Investments
........ ,-
.
$
res'dents
.
Resident accounts receivable
allowance for doubtful accounlts
from ·Cabrlnl Housing De"eloIJ·me,nt
fromCabrfnl
Inventories
Prepaid expenses
at
other current assets
Total current. assets
6.323.498
Pm,[}entv. plant and eOUllomlent net
Intangible asset
&It
as~ets
$
Net Assets
Current Ifabllities:
Accoun'ts paYable
Ac.r.~rufl~·(J' salaries
Due to Cabrlnl of We:stenl8st4er
to third party reimbursement aaeOOlt9S
Funds.held In trust for residents
$
$
1,254~4S1
85,181 .
128;608
2,602,000
6,128.858
term liabll~les
Due to
'liabilities
2,~28.366
GG
Net Assets - beginning
$
BFA Attachment B '(Continued)
Cabrinl Center for Nursing and R.h8bBtatJon
542 East 5th S1reet
New YOlk. New YOlk 10009
~ofR. . . . IlIIIfId~
Year Ended Decemb« 31.2011
Unaudited
V..- Ended December 31, 2011
V-iP=P.
CumInt MDnII
""'..
S 2.1Ap20
~
fill.
.... IJ_I.at~Rdn4llinUe
Raldent nwenue· Pfb"ywgr
•
8dI~
LOng tIInn horne ...NIh c:IK'a
• :
Mu1\ day care
Mult day ~ .. nnsooa11llSon
I .
Adutt day care • prior yu.r nate ad!ustrr*lts·:
~nIDI~
I .
01h. Opwating
TCbI OpeqUng Revenue
a.7-4'
32.018
22a.S72
3&.351
24.214
(74)
...
--
2.510,112
..
VIlriIrwa
SuppU.llllnd m h . ~
~~NF~~1km
~ f....s~.RNaandt.PNi
"
I
S 2.220.424
71.M3
...
202..973
U.W
.
~~~ThGnilpv
'.
Con~~Ln+tC
Adult Day e.te .. TmNllPOd1abl
DePradaOOn and ~
N't8 Nut3ilQ Home Carl ~ l ~
$ . (JlA04l
22.015
: 32.078
25.899
(25.631)
"
Iudqt!
""'"
(3)
31
I
$ 21.104.123
S 21.CM8.483
835.381
141.785
100
1.104.G15
13
(40)
(42)
2,,7a.8S2
544,963
345.994
(8e.638)
388.121
(178,,742,)
411.m .
1125.783)
26'
2,802.231
(21.326)
(1)
33..411.,.431
3Q,508.891
5
13.,101.101
e2.152
:
371.523
2,948
3.515
~
2.909.545
10
2;.150.800
13.738.711
AlO§l4§
131.864
'MUS
1.985.811
1,852.581
(133;122»
<1)
1&.041,50Z
18.645.511
804.014
565.119
3I1.aG
l1UA58)
(44)
4.1OU0I
219.220
29.113
(72)
(32)
'128.344
4.108.105 .
. ...
350.000 :
54.350
C21.5e3)
(2CUl7l)
(11.B06)
(1~)
50.031
SCn.4Q7
152.200 .
121.8G
106.3G1
22.071
1,447.612
315,805
.,M
n.832
C1~~1)
(16)
37.840
15.761
42
4Ie.3Q2
126,401
1~
140.4~
12.192(41,516)
('3.904)
~
40g
f$2QQ5S)
22
(61)
(3)
(1116)
lch.a55
1.2fi..991
430.991
110.184
1.064.416
,l29.anl
1•••402
1.~NO
..
.2...oa.eg1
(21)
(100)
(100)
'91
(18..000)
(21)
11~ .
25.495.144
925.428
$
636.946
nt5 fl41
...
1
10
100
15
(25)
(86.838)
"000 .
3.2QO
5.2~p
243
1.104.915
..
..
1.75&3eO
81.604
.
723.695
UOO)
(100)
1.500
I
2.391.811
(11'.193)
(14)
(1.500)
640
41,401
--..::i
:
"5945
-.sa
Y."Ended
Qfc4mblf31 Z01Q
1..171.111
SubtobJ Ubcr
~
FtwcntJW~..)
fa~~)
Q1,050l
-
12.419.799
~
(1)
11.111.758
4.512.022
1S1.ISQ
(2K063)
~)
899.800
172.113
1.368.282'
368,035
715.050
1.01&.029
(319.30")
1241.291)
un.57e)
115.188
8.309
(134.89)
(13.522)
1.222.20+
5Si 100
(lfI2.5Qi)
"
1.881.302
~
SubtlgtBl Non-l..abot
1.1:n;104
a;.11&
(n1,QaO)
(84)
13.,214,,242
11.191.3Q
(2,,011.680)
C18}
12.19,295
Total Ope.nIIting f..1q)enH8
3.,116.982
2.191.&14
(illS.308)
(33)
~,144
_842,.868
(1.412,.811)
(5)
30,()3g.053
(946,e34)
(500)
1.112.182
Gadn/(LoA)from ~
~1k:lM.. Spedlll
. (1.136.070)
...
1.,200
355
(3.410)
10.101
(10.,200)
(2.738)
4.a06
(100)
(95)
331
ev..-
Grants
5W
1.055
OSher
TObll Hon..Qp• •tlng R_aue
(1.~)
:un
1.260
m..1§..
10124
15.438·
25,,156
(10,311)
1.754
10.144
,.no
7.
, T o t a lN ~ ~
H~al\gG., (lOlM~
H.GlIIIJn/(~)
370
15.OU
(1.121,002)
11.G48
(11.m)
1~.801
$ (175.82»)
1.103
1,211
S
(945.313)
4.100
1.491.11&
441
3.003
13
15USI
200..506 .
(44.850)
(12)
Mal
11.2-43
128.385 .
40.000
(38.1!)8)
(22.151)
3&4
~1
15,,000 :
1??5"
25
---
«US.8m
M
100
410.610
t50Q.481 :
31..M1
ao.5Q9 •
11.'"
-"01'
5OJ5OI •
34.11'
...
331 .3Q
(81)
456.111
(31;101)
I
(538)
121.
S
1.123.585
(181.~53)
19.162
113.$25
147.463
Sl,411
10.541
23,231
1.P5Q
(12..111)
.1.2J.I.U
40.953
..eas
1.143
15..832
461.411
.
51
13.574
31
18.462
M.,151
18.,256
'"
Q313§1D
«100)
-
1"031 :
210.746
146
111.449
324.450
$
---
(9.621)
(3a.561l
(112)
$ 1.133.112
11.ml4
285.962
$
97.5OQ
New York State Department of Health
Public Health and Health Planning Council
May 23, 2012
ATTACHMENTS
Acute Care Services – Establish/Construct
1.
Number
Applicant/Facility
121169 E
NYHB, Inc.
(Kings County)
Exhibit #3
NYHB, Inc. is a proposed not-for-profit health care organization. NYHB. Inc. is submitting this Establishment-Only Certificate of Need Application to seek approval to become the active parent
and co-operator of New York Methodist Hospital f'NYMH-) and New York Community Hospital of Brooklyn, Inc. ("NYCH"). NYMH and NYCH are both existing Article 28 facilities.
NYHB Inc. win be the sole member of the Hospitals upon completion of the project.
I
NYHB,lnc.
New York
Hospital
=
~
>-
~
~
~
~
=e
~
=
~
>-
BFA Attachment B
NEW YORK METHODIST HOSPITAL
COMBINED STATEMENTS OF FINANCIAL POSITiON
AT DECEMBER 31 2011
t
{DOLLARS IN
December
THIOU:SAI\tD~Sl
December
2010
December
December
2011
Assets
Current Assets:
Cash and cash equivalents
$
Short-term investrnents
75,122 $
76.487
51 t 773
76,479
Accounts receivable:
Receivabie for patient care': net
Insurance recovery receivable
Other - net
Inventories
Other current assets
Assets limited as to use ~ current portion
56 791
20A40
16,010
9 587
2,329
2,069
65,430
Total Current Assets
Debt service reserve - 2004 bonds
Debt service .. 1999 & 2004 bonds
Donor restricted
Investments held by captive insurance cos.
Deferred employee compensation pian
25,445
10,503
9,693
2,493
1,975
1
243~791
258,835
1,097
3 761
1.975
6,587
75.505
1.098
3}61
2.069
6.587
93,040
t
Hrnited as to use - noncurrent
Accrued salaries and related
HabHities
Due to related
Professional Jnsurance
Other current liabilities
3t 734 $
3,942
33,148
33,491
36 560
38,772
t
Total Current LiabHities
Long.. tenn debt, less current
portion
Accrued pension liabilities
Professional tnsurance Habmtles,
less current portion
Deferred employee compensation
plan
763
1,389
3,936
4A60
7;155
4A50
85~296
86,504
45,655
40,228
49,389
18,907
162,453
159,325.
Tota! UabiliUes
382 094
1
175,241
2 162
Unrestricted
Other non-current assets
2~615
2,420
Temporarny restricted
Permanentty restricted
Total Non-Current Assets
280,564
273,103
$
6,330
61 1639
295.590
1,807
J
6,050
Other non-current liabilities
Tctal Non-Current Liabilities
165~606
Tota I Assets
$
Non-Current Liabilities:
Less assets limited as to use - current
PropertYt buUdings & equipment - net
investments in real estate .. net
debt
accrued
Accounts payable
expenses
t
Non..Current Assets:
Assets Hmited as to use:
Project Fund - 2004 bonds
Liabilities and Net Assets
Current liabHfties:
Current portion of
Net Assets:
109,888
18,325
109,305
17,505
Total Net Assets
Total Liabilities
Net
$
$
BFA Attachment B (cont.)
NEW YORK METHODiST HOSPiTAL
COMBINED STATEMENTS
OPERATIONS
(DOLLARS IN THOUSANDS)
ACTUAL
$
Outpatient
Emergency room
Ambulatory surgery
Referred ambulatory
875 810
40,733
113,028
1
92,964
82 740
301,037
1,506,312
1
Professional services
Totaf Charges
All ambu latory
Professional services
Provlsion for Bad Debts
BUDGET
$
871.036
30,990
91,243
91,147
74,959
ACTUAL
$
864,364
33,377
88A47
87.404
71,576
442,440
216,297
447,682
218,354
190,095
437,873
190,347
193,968
588,638
585,526
8.199
8,791
196.000
Total Allowances
Net Patient Service Revenue
10,085
on marketable securities
CCC Captive reaHzed gains
cee Captive unreaHzed gains (losses)
Investment Income
Rentaj income
Contributions
Total Supplemental Revenue
Total Revenue
(2.940)
1,684
1A06
3,225
2,144
191
2,313
4,968
2,577
240
5,609
11,972
(3,134)
7,887
3,071
622,745
655,358
and
Employee "fringe
254,827
72.980
246,181
expenses
Prc)fe~isicmalliabjlity
insurance
Interest expense
Depreciation & amortization
30 540
1
2,701
239
246,677
72,307
232.483
33,000
2,858
243 140
68.751
228,112
1
33~618
2 813
1
23,328
Total Expenses
610,653
1.878
Medical Resident FICA Refunds
23.365
4,294
1,878
27.659
(608)
3A97
659
(26,251)
8A23
on marketable
Net assets released from restrictions used
for purchase of property and equipment
Change in mlnirnum pension liability
Net assets of Brooklyn Radiology Services, PC
Change in Unrestricted Net Assets Before
Net Assets Reclassification
1,878
973
Reclassification of accumulated endowment earnings
Change in Unrestricted Net
-2-
39.902
BFA Attachment C
2,356
2
5,509
assets
2
BFA Attachment C (cont.)
$
3
$
935
BFA Attachment C (cont.)
(In Thousands)
revenue
$
26,615
$
2;7,577
$
23,886
26,615
4
YORK COMMUNITY HOSPITAL OF BROOKLYN. INC.
AS OF DECEMBER 3 t, 2011 AND DECEMBER 31,
AlldUN
LIABILITIES AND NET ASSETS
CURRENT ASSETS
Cash and Cash Equivalents
Accrued Interest Receivable
Patient Accounts Receivable - Gross
Patient Accounts Receivable .. Allowance
Inventories
Prepaid Expenses and Other Current Assets
Assets Umited As To Use
TOTAL CURRENT ASSETS
NONCURRENT ASSETS
Assets Limited As To Use
Property, Plant, and Equipment .. Net
CURRENT LIABILITIES
$
34,020,000
17,000
24,%3,000
(12,161,000)
1.133,000
1.034,000
$
25)S8t OOO
13,,000
23,054,000
( 13,284,000)
l,4SS.000
926,000
828,.000
703tK)O
50.428,000
38,225,000
Accounts Payable and Acenred Expenses
Accrued Salaries and Related Liabilities
Due to Related Organizations
Due to Third Party Reimbursement Payers
Cum:nt Portion of Est Self·Insured Professional Liability
II~086.000
2,86831000
IS8.0oo
9,000
828,000
10.478\'000
2,894,000
172.000
9,000
703,000
CO
TOTAL CURRENT LIABILITIES
14,949,000
14,,256,000
f"II"I'.
~
NONCURRENT LIABILITIES
8,016,000
17.977.000
7.748,000
18~4S6.000
~
>
Other Noncurrent Liabilities
Accrued Pension Liability
Long Tenn Portion of&t Sclf·lnsured Professional Liability
17 t OO7.000
5,411,000
7t4SS.000
12,554,000
3,718.000
6,324,,000
TOTAL NONCURRENT LIABILITIES
29,873,000
22,596.000
31,599.000
27,577.000
~
~
=a
~
=
~
TOTAL NONCURRENT ASSETS
25.993.000
26,204.000
NET ASSETS
ASSETS
TOTAL
NETASSErS
0
BFA Attachment D (cont.)
Inc..
York
Ineome Statement & Selected Statistics
December 2011
YurtoDate
$000
MORth
5000
Prior
Prior
Vear
Actual
Year
Actual
..
•
..
••
. ' 11 ~ ,." ...
$
6,730
98S
$
Revenues
6.376
925
1.115
68
Total
Aetual
... • ... ,".11 ........................ '.".
7t 301
28
'783
I
4,483
1,303
(366)
172
33
192
5.811
S
354
60
414
40
$ 6.614 : $
79.134
703
11668
7,317 .
24 ~
90,802
78,775
11428
90,203
351
335
93,64'
3,361
1135
39,413
14671
4t 496
2.162
218
S4~084
192
7,394
25,324
2,127
2,856
1 091
2,305
87187
199
76 ~
166 ~
2,614
487
2,291
2.918
12
2,389
996
1994
85169
986
1
6,927
1577
9O~38
359
240
599
16
2496
3111
S
2496
7,329
244
82
$
2305
88619
832
$
10
87,096
329
87425
1
$
.......
S
• . . •• .. t··"'·
....
636
31'708
5.83
Average
CSM,
"'l'
..
..
620
3t H37
6.19
414 : S
...... "' .. , ........... ,
16
(129)
0.36
......
591
3,755
6.35
-
......
5862
"" .... • ... ) .. "" . . . ,
7;387
44,615
6.05
$
... , . . . . . . . "' .. 111.11 • • '"
••• ) ....
·.t"
"' ... ,
......
'\
......... " .
7,650
(263)
47,218
6,.17
(2,543)
1.250
0.067
0.12
"".' .
.........
.....
7:l16S
44,,255
6.18
Mix Index
Medicare
Medicaid
Bhre Cross
1.349
0.099
1.229
0.759
1.265
1.148
1.204
755
796
344
545
1.. 188
1..180
Other Parol'S
Room Visits
Visits
1.250
1,,095
(0.033)
(0.151)
0.032
0.061
1..062
3.410
LIS7
L211
1.317
0.985
1.250
1.043
1.198
1.204
(0.105)
(0.006)
1.153
1.223
(41)
S47
11,168
10.456
712
9,521
401
(57)
397
4,,215
4,789
(574)
4,836
S6S
20
556
557
565
7
5SS
1..339
1.095
1.265
1.132
1.523
New York State Department of Health
Public Health and Health Planning Council
May 23, 2012
ATTACHMENT
Ambulatory Surgery Center - Establish/Construct
Exhibit #4
Number
Applicant/Facility
1.
112179 B
Amsterdam REC, LLC d/b/a Amsterdam Regional Eye Center
(Montgomery County)
2.
112379 B
The Surgery Center at Orthopedic Associates, LLC
(Dutchess County)
l11"A Attachment B
AMSTERDAM REC, LLC
OPENING DAY PROFORMA BALANCE SHEET
ASSETS
CURRENT ASSETS .
Cash Balances
Accounts Receivable - Net
Total Current Assets
$ 71,837
$ $ 71,837
PROPERTY
Facility Improvements
Equipment (net pf depreciation)
Total Property
$506,000
$206,300
$712,300 .
INTANGIBLE ASSETS
Project Start-Up Costs and Application Fees
TOTAL ASSETS
$101,038
$885,175
LIABILITIES AND NET ASSETS
CURRENT LIABILITIES
$
LONG·TERM LIABILITES
Facility Improvement Loan
Equipment Loan
Working Capital Loan
$420,000
$206,300
$ 35,000
Total Long..Term Liabilities
$661,300
TOTAL LIABILITIES
$661,300
LLC· CAPITAL
$223,875*
TOTAL LIABILITIES AND LLC CAPITAL
$885,175
* $36,837 working capital contribution; $187,038, project cost capital contribution.
BFA Attachment C
ESTABLISHMENT CHECKLIST FOR AMBULATORY CARE SITE
APPLICATION: CON 112179 Amsterdam REC, LLC d/b/a Amsterdam Regional Eye
Center
NATURE OF APPLICATION:
PRIMARY CARE
SPECIALTY
Ophthalmology
xx
AUSPICE:
AFFILIATIONS:
NON PROFIT
PROPRIETARY
PUBLIC
.. Limited Liability Company
xx
None
YEAR ONE
UNIT COST:
OPERATING
CAPITAL
TOTAL
PAYOR SOURCE:
$ 335.76
.$ 177.46
$ 513.22
YEAR ONE
MEDICAID..FFS
MEDICAID..MC
MEDICA·RE..FFS
COMMERCIAL-MC
PRIVATE PAY'
CHARITY
10.0%
1-2.0%
39.0%
35.0%
2.0%
2.0%
YEAR THREE
$
.$
$
333.12
158.36
491.48
BFA Attachment B
Pro Forma Balance Sheet
ASSETS
Cash
Moveable Equipment
Leasehold Improvements
TOTAL ASSETS
$894,686
803,855
3,781,075
$5,479,616
LIABILITIES
Bank Loan
Working Capital Loan
TOTAL LIABILITIES
NET ASSETS
$4,126,437
447,343
$4,573,780
$905,836
BFA Attachment C
Detailed Budget
YEAR ONE
-----------------Operating
Capital
TOTAL EXPENSES
Expenses
$2,970,264
1,110,296
$4,080,560
Procedures
5,528
5,528
Cost Per Procedure
$537.31
200.85
$738.16
Expenses
$4,253,677'
1,114,438
$5,368,115
Procedures
6,080
6,080
Cost Per Procedure
$699.62
183.29
$882.91
YEAR THREE
--------------------Operating
Capital
TOTAL EXPENSES
BFA Attachment D
ESTABLISHMENT CHECKLIST FOR AMBULATORY CARE SITES
APPLICATION: CON#'112379-B The Surgery Center at Orthopedic Associates, LLC
NATURE OF APPLICATION:
PRIMARY CARE
X
SPECIALTY
IF SPECIALTY - TYPE:
AUSPICE:
X
NON PROFIT
PROPRIETARY
PUBLIC
AFFILIATIONS: NA
UNIT COST:
OPERATING
CAPITAL
TOTAL
PAYOR SOURCE:
YEAR ONE
YEAR THREE
$537.31
200.85
$738.16
$699.62
183.29
$882.91
YEAR ONE
YEAR THREE
10.00 %
MEDICAID-M/C
5.46%
MEDICAID-FFS
MEDICARE-MC
NA
39.09%
MEDICARE-FFS
COMMERCIAL FFS 20.00%
COMMERCIAL MC 20.00%
3.27%
SELF-PAY
2.18%
CHARITY CARE
10.00 %
5.46%
NA
39.09%
20.00%
20.00%
3.27%
2.18%
New York State Department of Health
Public Health and Health Planning Council
May 23, 2012
ATTACHMENT
Diagnostic and Treatment Centers - Establish/Construct
Number
Applicant/Facility
1.
101101 B
Street Corner Clinic, Inc.
(Kings County)
2.
112042 B
The Chautauqua Center
(Chautauqua County)
Exhibit #5
BFA Attachment A
BROOIQ,YN AIDS TASK FORCE INC~
Statement of'Financial Positi~n
.
June 30~ 2010 and· 2009
Assets
2010
,2009
Current Assets:
Cash
InveSUl1ent
Due from Funding Agencies
ivledicaid receivable;: net
Security deposit
Prepaid expenses
S
4,629
. 25,000
957,542
123,270
$
44,934
940,986
131,035
123,860
52:556
163,953
52,328
85,156
1,4J 1~S78
1)406,858
70~31 0
99~828
1~482, 188
=--:::t..-==:
Liabilities and Net .4.ssets
~A.ccounts Payable and accrued expenses
Notes Payable
Due to Funding Agencies
638:562
721,697
100)000
) 25~OOO
127,621
5)378
Total Liabilities
866:183
852~O75
Un restri cted Net Assets
Operating
616,005
654,61 I
'T'otaJ Net f\.ssets
616,005
Other receivable
Total Current Assets
Property and Equipment;: Net
1"'otal Assets
Total Liabilities and Net Assets
113~487
1)506~686
BFA Attachment A (cont.)
BROOIQYN AIDS TASI( F,'ORC:E INC
Statement of . 4 ctivit.ies .
For the years ended June 30, 2010 and 2009
2009
2010
Revenue andSuJ;2.12QJ".h;.
C;rants and Contracts
lvre'dicaid
Fee for Service
COD tri.butions
Interest
Total Revenue
aJld
S 5,442,503
S
4,978,504
866,697
836,725
170:856
34)054
100)309
3,385
127,6.24
546
Support
_
..?...?..98~12_~
Q.p~rati!lg Ex~tlSes:
Program Services:
Co.rom.u.nity Service P.rogram
Com.illunity follow..up
Substan.ce .Abuse Treatment Program
J\J.coholisrn Services
}Jousing Opport1.1nltie~5'for Persons with
A.lDS
Oi\Sl\S Scatter Sil:e Iiousine-.;>
I'argeted Capacity Expansion Progran1 for
Public HeaJ.th SoIul.ion
H.ASA Scatter Site I-Iousing
Sl1bst~lnces
1,144,09.3
498,803
299,987
1 226)375
344;867
33.), 799
573 ,572
496]114
904,162
1:) 1(7)604
~)44.l499
Other Programs
_.~.
"[otal Progr<ul1 Services
___:2: 58?, 4J0.
.s...l.±;j2.p-9 r t blg.-'s erv ices:
.General and Administration
306,579
103,360
367:283
490)893
1,088,314
165~2~~
1,030,830
._..__60Q
1,166)574
___ 2~72Q.
. -_.hQ~}.J~~~Q
__lJ.§9)29l~
FUlJd Raising
T Ot8J Si.lpportlD.g Servi.ces
.
'Total Operating Expenses
~~16~~
Changes in Net AsseT:s
1
~=::-i~?~6q~)
6)062)207
.:-
R\
(79' '15 8
2:.~-z:::::....:.~~J:.~
BFA Attachment B
BROOKLYr~
AIDS TASKFORCE, INC.
Statemnt of Financial Position
As of October 31, 2011
Assets
Current Assets :
Cash
Investment
Due from Funding Partners
Medicaid Receivable, Net
Security deposit
Prepaid expenses
Other receivable
10/31/11
$
Total Current Assets
234,099
45,531
521,016
85,691
187,553
14,278
85,156
1,173,324
Fixed Assets :
Property, Equipment and
Leasehold Improvements, Net
70,310
1,243,634
Total Assets
Liabilities and Net Assets
Accounts Payable and Accrued Expenses
Notes Payable
Deferred Revenue
397,068
75,000
153",110
Total Liabilities
625,178
Unrestricted Net Assets
618,456
Total Liabilities and Net Assets
$
1,243,634
BFA Attachment B (cont.)
BROOKLYN AIDS TASK FORCE, INC.
Statemnt of Activities
For the four Dlonthsended October 31, 2011
10/31/11
Revenues and Support:
Medicaid
Grants and Contracts
Fee for Services
Contributions
Interest
Total Revenue and Support
Operating Expenses:
Community Service Program
Community Follow-up Program
Substance Abuse Treatment Program
Housing Opportunities for Persons with AIDS
Targeted Capacity Expansion J?rogralll for susbstances
Public Health Solutions
OASAS Scatter Site Housing
Other Programs
Indirect Cost recovery
Total Program Services
$
353,218
1,878,679
18,725
893
326
$
2,251,841
$
$
Supporting Services:
General and Administration
Fund Raising
452,660
195,992
105,285
673,447
123,559
255,640
144,140
206,403
(159,617)
1,997,509
240,871
o
Total Supporting Services
$
240,871
Total Operating Expenses
$
2,238,380
Chang~s
$
13,461
in Net Assets
BFA Attachment C
PROJECT HOSPITALITY, INC. AND SUBSIDIARY
Consolidated Statement of Financial Position
June 30t 2010 and 2009
2009"'
2010
Assets
Cash and cash equivalents
Due from funding sources -net of advanoes of ·
$98,912 in 2010 and. $175,338 in 2009
Contributions receivable
.
ACCOWlts receivable
· Prepaid expenses
One from related parties,
Security deposits .
Fixed assets at'cost, net ofaocumulated
depreciation and aID()rtization
Total assets
Liabilitie§ and net assets
Liabilities
Accounts payable and Rcomed expenses
Due to funding sources
Due to others
Loans payable
Mortgage payable·
.
Total liabjlities
$ 5,084)742
$ 4,188,797
~,243.664
2,165.063
553 t 849
57,181
4,121
314 J277
17.649
7,426.
22~?39
752,870
36,324
21973 1845
2,669,476
534,805
$ '11,229,147
$
10r427~681
$ 1,409J 633
119
$
It486~862
1~S88
25,000
83,380
25,000
340r9~7
363>342
1,777.257
It9581584
4,961,631
4J290~825
I~37St284
1,268,965
. Gonuninnents and contingencies·
Net assets
Umestricted
Unrestricted board designated endowmont
Unrestricted fixed assets
Total unrestricted net assets
Temporarily restricted
9,310,760
141,130
8~229,266
Total net assets
9,451,890
8t469tO~Z.
$ 11)229)147
g
$ 10,427,681
Total liabilities and net assets
2~~7~!845 .
22669~476
239,831
BFA Attachment C (cant.)
·"'·~"PRomCT0~HOSPIT:A1JITY;1NC~·":AN:p:-·SUBSlJ)IARY~·-~'·"··.~_.
'co' ......... \ •...;;.;;.. •. ""-,, .... ;;,_~••:.•._
,:.... <,.....:.;.. :,~~ ...... ~:,., __••,•.,_..:__ ~ .:.-..
·._.... tc· ."~ r<*;'•.
;'•• ~~"
,>__ ~, :.'-.... :.•'~~ ...,.::,.._.; . :~" . '. ,-J.. ,._~~~ •.; •.,.;."..
!:"._.~.;,.. ~_.'.
Consolidated Statement ofActivities and Change·in Net Assets
Fiscal year ended June, 30, 2010
Temporarily
Unrestricted
restricted
Total
Revenue
Government grants
Medicaid reimbursements
Conmllutions·
Special events
Direct expenses on speoial events
$ 15,844,070
$ 15,844,070
1)695~581
(
Rental income
Interest income
Other income
Contributions..:.. In-kind
1,69S~581
593)669
271,740
32,786 )
419,375
·25.484 .
.117)522
58)681
$
903,976
(
1.497,645
271,740
32,786 )
419~375
25,484
117,522
58,681
Total revenue
Net assets released from restriction
18,993.336
1,002,677
(
Total revenue
19t996,013
(
19~897,312
903,976
1,002,677 )
98~701
19,897,312
)
Expenses
Program servJces
Support and treatment services
Re..housing services
Homeless oare and prevention services
4 t 634,609
6,073)195
5,870,442
4,634,609
6~O13,195
5,870,411
16~578~246
Total program servioes
16)578,246
Supporting services
Management and general
Fund raising
2,041,414
294,859
·2,041,414
294t 8S9 .
Total supporting services
2,33 {),273
22336,273
18,914,519
18~914,519
Total expenses
Changes in net assets
Net assets at beginning ofyear
Net assets at end of year
1)OBlt 494
(
$
9)310,760
982)793
8,469,097
98,701 )
239,831
8,229t266
$
141,130
$
9c451,89~
BFA Attachment C (cant.)
1
BFA Attachment D
Project Hospitality (PH)
Balance Sheet - BN Balance Sheet w/detail
As of 12/31120) t
Current Year
Assets
Cash and Casb equivalents
'Assets held for board designated endownment
Investments .
Due From Funding Sources
Contributions Receivable
Accounts Receivables
Prepaid
Due From Related Parties
Security Deposits
Fixed AS$ets (Net)
D~e (fo)/From Other Funds
Total Assets
4,892,348.25
110)332.51
I; 187~378.87~
1,267;t364.00
100,000.00
15,788.15
0.00
637,433.80
43)378.75
962,479.35
(474,412.48)
B,742,091.20
Liabilities
Account,s Payable and Accrued Expenses
Other Liabilities
741,828.98
0.00
Advances due to Funding sources
Unearned Income
Loans Payable
Mortgage Payable
Total Liabilities
lOl~026.33
0.00
842,855.31
Net Assets
Net Assets Beginning of Year
Current Year Change in Net Assets
Total Net Assets
7,822.953.22
76,282.67
7,899,235.89
Lh~bilities
8,742,091.20
and Net Assets
0.00
0.00
BFA Attachment D (cont.)
Project Hospitality (PH)
St3tcment of Reve2,ues and Expendit~res.. JH ConsHdated R&E audit
FrOfn 7/1/2011 Through 1213112011
Current Year Actual
Support & Revenue
Govern ment Income
7,251,544.26
Medicaid Reimbursements
Contributions
Special ~vents Income
Direc~ expenses on special events
Overhead Reimbursement
R~ntal Income
Realize~ G,ain ( Loss) on Investments
Interest Income
Dividend Income
Other Income
Unrealized Gain (Loss) on Investments
Contributions .. In kind
Total Support & Revenue
Expenditures
Personnel Related
588)072.31
825,130.05
171,305.52
(11,434.20)
459,191.82
213.875.97
2.94
4,968.19
303.25
38..380.95
(5,440.4 I)
0.00
9,535 t900.65
5,993,736.00
741,897.19
Occupancy
Office Related
Fondraising
Special Events expense
Insurances
Professional Fees
Contracted Services
Staff Related
Equipment Purchases, Rental/Lease & Maintenance
Vehicle .Related
Client Related
Non Reimbursable Program Expense
152,852.44
2,590.30
21,568.48
148,207.47
185,&'51.83
132,239.36
44,375.03
50,876.90
165,,9.16.48
1,350,913.25
1,452.2~
0.00
7,949.15
459,191.82
Grant Expense
Other Financial Expense
lnd treet Overhead
Depreciation
Tolai Expend itures
Net Jncome (Deficiency) Revenu~ Less Expenses
_____,~9~
_ _~~~17.9t
BFA Attachment,E
Community Health Action of Staten Island, Inc.
St.at.enlent of Financial Position
June 30, 2010
(vvith cOlnparative amounts at ]tme 30, 2009)
2009
2010
ASSETS
Current Assets
Cash ~d cash equivalents
$
115,543
Govemm.ent contracts receivable
748,054
Third.party reimbursement receivable
Other receivables, net
276,106
$
145,502
128,127
883,547
226,751
64,866
1,267,830
1,320,666
1,337,668
35,208
1,400,128
32,666
$ 2,640,706
$ 2,753)460
$
$
Toml Current Assets
I.oIand, building, equipn1ent and leasehold in1provenlents, net
Other assets
LIABILITIES AND NET ASSETS
Current I...iabilities
Accounts payable and accrued expenses
I)eferred revenue
Current portion of
M,ortgages payable
N'ote payable
Total Current I...tiabilities
Accrued vacation
Mortgages payable, net of current portion
Note payable, net of current portion.
Total Liabilities
Net Assets
Umestricted
'remporarily restricted
'fotal Net Assets
40,409
43,397
66,396
90,851
40,419
6,012
37,883
130)237
205~278
181,286
413,939
188{646
455,004
4,823
1.0,894
730,285_
859,822
1,887,921
22,500
1,768,638
1,910,421
1,893,638
$ 2,640,706
$ 2,753,460
10,148
·125,000
BFA Attachment E (cont.)
Cornruunity H.ealth Action of Staten Island,
rnc~
Statelnent of Activities
Year Ended June 30,2010
(vY'ith summarized totals for the year ended June 30, 2009)
2009
2010
T'crnporarily
Unrestricted
Total
Restricted
Total
R.EVENUEANDsurpORT
(]overnn1ent contract services
J:.'oundat.ion and corporate contributions
Individual and other contributions
l.Jnited Way
rrhird party reimburselnent
Special events, net of direct expenses of
$47,741 and $59,508
Rent.al income
Interest incon1e
Net assets released from restrictions
1~otal
$
3,683,337
276,996
71,147
$
$
22,500
16,026
1,419,417
136,138
30,450
2,032
125,000
3,683,337
299,496
71,147
3,863,338
16,026
398,955
57,068
9,088
1,4]9,417
1,376,977
136,138
30,450
1.47,680
2,032
6,061
18,350
__.-Jl25 ,OOO)
5,877,517
_ _( 102,500)
R.evenue and Support
$
EXPENSES
Progranl services
Management and general
Fundraising
.'Total
NET ASSE1"'S
'Beginning of year
End of year
782~588
165,569
___1~~.269
~_L~.5,744
5,641,260
6,081., 872_
I~xpenses
Change in Net Assets
5,180,461
4,693,103
782,588
4,693,103
735,674
119,283
(102,500)
1,768)638
__..l?_~., OOQ
~3,63~
_~8,00C2.
L1l1.~
£~~ 222Q.~
L2~2I~42~
L]J.93,638
16,783
BFA Attachment F
COMMUNITY HEALTH ACTION OF STATEN ISLAND, INC.
STATEMENT OF FINANCIAL POSITION
AS OF OCTOBER 31,2011
Current Year
As of 10/11
Assets
Current Assets
Cash and Cash Equivalents
Contracts Receivable
Medicaid Receivable- COB
Medicaid Receivable- COO
Medicaid Receivable- COO ~Trans.
COO Program Trans. Receivable
Other Receivable
Pr~paid Expenses
Total Current Assets
$
102,640
730,112
116,033
83,924
7,786
207
27,431
$
1,068,134
$
$
1,277,450
1,277,450
$
$
44,343
44,343
$
2,389,927
Current Liabilities
Accounts Payable & Accrued Expenses
Accrued Vacation Payable
Deferred Revenue
Total Current liabilities
$
$
$
$
43,797
174,698
236,479
454,975
Long Term Liabilities
Mortgage Payable - Building
Line of Credit
Car Loan Payable
Total Long Term Liabilities
$
$
$
$
398,908
100,000
2,025
500,933
Total Liabilities
$
955,908
Unrestricted
Total Net Assets
$
$
1,434,019
1,434,019
$
2,389,927
Fixed Assets
Property, Equipment, and
Leasehold Improvements
Total Fixed Assets
Other Assets
Other Assets
Total Other Assets
Total Assets
liabilities and Net Assets
Net Assets
Total Liabilities & Net Assets
BFA Attachment F (cont.)
BFA Attachment G
STREET CORNER CLINIC
CERTIFICATION OF D&TC AND EXTENSION CLINICS
PRO FORMA BALANCE SHEET
ASSETS
Cash
Other Assets (Non-Equipment)
Equipment
TOTAL ASSETS
$329,580
$540,778
$552,927
$1,423,285
LIABILITIES AND NET ASSETS
LIABILITIES
Capital Loan - Mobile Van
Capital Loan - Capital Financing
Working Capital Loan
TOTAL LIABILITIES
NET ASSETS
TOTAL LIABILITIES AND
NET ASSETS
$462,822
$466,827
$164,790
$1,094,439
$328,846
$1,423,285
BFA Attachment H
ESTABLISHMENT CHECKLIST FOR AMBULATORY CARE SITES
APPLICATION: 101101-8 Street Corner Clinic, Inc. (Kings)
NATURE OF APPLICATION:
x
PRIMARY CARE
SPECIALTY
IF SPECIALTY - TYPE
AUSPICE:
x
NON PROFIT
PROPRIETARY
PUBLIC
AFFILIATIONS: Lutheran Medical Center and Richmond University Medical
Center
UNIT COST:
OPERATING
CAPITAL
TOTAL
YEAR ONE
YEAR THREE
$82.14
10.21
$81.78
$92.35
YEAR ONE
PAYOR SOURCE:
MEDICARE-FFS
MEDICAID-FFS
MEDICAID-MC
CHARITY CARE
22.1 %
56.7%
15.7%
5.5%
8.55
$90.33
YEAR THREE
22.0%
56.7%
15.7%
5.6%
BFA Attachment A
THE CHAUTAUQUA CENTER
CERTIFY AND CONSTRUCT A DIAGNOSTIC AND TREATMENT CENTER
PRO FORMA BALANCE SHEET .
Proposed
.QUQ
ASSETS
Cash
EquIpment
Other Assets
$288,919
$122,660
~
TOTAL ASSETS
$483,606
LIABIUTIES AND
NET ASSETS
LIABILmeS
Capita/Loan
.. Working Capital Loan
lQ
TOTAL LIABILmeS
$0
$0
NET ASSETS
$483,806
TOTAL LIABILITIES AND
NET ASSETS
$483,806
Note: The applicant is a recently formed entity that has no assets and liabilities.
BFA Attachment B
ESTABLISHMENT CHECKLIST FOR AMBULATORY CARE SITES
APPLICATION: CON 112042-B The Chautaugua Center (Chautauqua County)
NATURE OF APPLICATION:
AUSPICE:
xx
PRIMARY CARE
xx
NON PROFIT
PROPRIETARY
PUBLIC
- limited liability
AFFILIATIONS: Brooks Memorial Hospital and Lakeshore Hospital
UNIT COST:
OPERATING
CAPITAL
TOTAL
PAYOR SOURCE:
Commercial Managed Care
MEDICARE Fee-For-Service
MEDICARE Managed Care
MEDICAID-Fee-For-Service
MEDICAID Managed Care
Self Pay·
Charity Care
YEAR ONE
$146.30
$ 19.31
$165.61
YEAR THREE
$106.90
.$ . 7.21
$114.11
YEAR ONE AND YEAR THREE
15.0%
.7.0%
3.0%
7.0%
38.0%
20.0%
10.0%
New York State Department of Health
Public Health and Health Planning Council
May 23, 2012
ATTACHMENT
Dialysis Services - Establish/Construct
1.
Number
Applicant/Facility
092158 B
DV Corp. d/b/a Riverside Dialysis
(Westchester County)
Exhibit #6
092158 B
DV Corp. d/b/a Riverside Dialysis
(Westchester County)
There are no attachments for this project
New York State Department of Health
Public Health and Health Planning Council
May 23, 2012
ATTACHMENT
Hospice – Establish/Construct
1.
Number
Applicant/Facility
121049 E
Lewis County Hospice
(Lewis County)
Exhibit #7
LEWIS COUNTY GENERAL HOSPITAL
Lowville, New York
"BEFORE TRANSFER"
~------------------------------------------------------:
I
.
BOARD OF MANAGERS
I
I
I
I
1
I
I
I
I
I
I
Chief Executive Officer
Eric Burch
MEDICAL DIRECTOR
Catherine Williams, M.D.
I
I
I
I
I
I
I
I
t
PI/RISK
MGMT.
Jean Dryja, R.N.
NURSING HOME
ADMINISTRATOR
Joseph Todora
1
I
*Performance
Improvement
*LTC Nursing
SerVices
*Corporate
Compliance
*Adult Day Carel
Transportation/
Lifenet
*Risk
Management
FINANCE
. Terry Lang
I
*Jnfection
Control
FACILITIES
MANAGEMENT
Tom Ferguson
HUMAN
RESOURCES
Tim Ryan
*Patient Accounts
*Construction!
Renovation
. *Patient Review
Coordinator
*Nutritional Services
*Environmental
Services
*Unen
*Health
Management
PATIENT CARE
SERVICES
David Wood, R.N.
CLINIC
MANAG.EMENT
VACANT
1
*Emergency
Dept..
*Volunteers
*ICU
*Staff Education!
Development
*Med Surgl
Maternity
*Benefit
Administration
*ORJAmbuJatoryl
*Salary
*Pharmacy
*Radiology
*Supervisors
*Laboratory
Anesthesia
II
t----
*Employee
Relations
*Activities
*Social Service/
Discharge Planning
I
1
I
*Plant Operations
*Materials
Management
-Bio Med Equipment
1
1
*Accounting
*1 nformationSystems
*UR
I
I
I
ANCILLARY
MANAGEMENT
Michele Prince
Jl
-1---
*Beaver River
Health Center
*South Lewis
Health Center
*Copenhagen
Health Center
*Surgical Practice
Administration
*08 Practice
*Recruitment and
Retention
*Respiratory
*Employee Health
*Rehabilitation
*Payroll
*Occupational
Medicine
*Orthopedics
*Fam i1y Practice
t:d
I-:rj
*Emergency
Preparedness
Coordinator
*Registrationll
Communications
D>
D>
rt
rt
~
()
§
CD
~
rt
D>
LEWIS COUNTY GENERAL HOSPITAL
Lowville, New York
,-------------------------------------------------------------
I
MEDICAL DIRECTOR
Catherine Williams, M.D.
PI/RISK
MGMT.
Jean Dryja, R.N.
I
NURSING HOME
ADMINISTRATOR
Joseph Todora
1
I
*Performance
Improvement
*LTC Nursing
Services
*Corporate
Compliance
*Adult Day Carel
Transportation/
Lifenet
*Risk
Management
*Activities
*UR
*Social Service/
Discharge Planning
·Infection
Control
At\.I~~I=R
Chief Executive Officer
Eric Burch
1
r
II
BOARD OF MANAGERS
1
FINANCE
Terry Lang
I
*Nutritional Services
*Environmental
Services
FACILITIES
MANAGEMENT
Tom Ferguson
1
·Accounting
*Plant Operations
"Patient Accounts
·Construction!
Renovation
·Materials
Management
-Bio Med Equipment
*Information Systems
*Patient Review
Coordinator
I
*Health
Management
-,
HUMAN
RESOURCES
Tim Ryan
*Emergency
Preparedness
Coordinator
PATIENT CARE
SERVICES
David Wood, R.N.
*Emergency
Dept.
*Volunteers
*ICU
·Staff Education!
Development
I---
CLINIC
MANAGEMENT
VACANT
1
1
*Employee
Relations
*Med Surgl
. Matemity
I
r--:--v_--_-----L~I
ANCILLARY
MANAGEMENT
OUTREACH
MANAGER
VACANT
Michele Prince
--1----"
L.
.,.~.
*Benefit
Administration
*0R/Ambulatory!
Anesthesia
*Salary
Administration
*Pharmacy
*Radiology
*CHHA
*Supervisors
*Laboratory
*Hospice
_ ____.
*Beaver River
Health Center
...__l
*South Lewis
Health Center
*Copenhagen
Health Center
*Surgical Practice
*OB Practice
*Recruitment and
Retention
*Respiratory
*Employee Health
*Rehabilitation
*Orthopedics
*Family Practice
·Payroll
*Linen
I
*Occupational
Medicine
*Registration!
Communications
to
t-rj
::t>
::t>
rt
rt
PJ
()
§
ro
~
rt
::t>
()
o
~
rt
BFA Attachment B
LE\\'IS COUNTY GI~NERAtJ'IIOSPITALJAND
IlESII)I~N"rlAI..J lII~ALTI-I C:AI~.I~ I~ACltJlrrY
(/\ C0111pOncnt Unit of the County
or Lcvvis', Nc\v York)
Balance Sheets
I)CCCI11bcr
31,2010 and 2009
Current assets:
Cash and ~ash equivalents
$
Patient accolints receivable, net of'allq\vancc for doubtrul
nccqunts .of approxinlately $1,049,000 in 2010 and
$1,233,000 in 2009
InVClllolties
Prepaid expenses and other current assets
Intcrgovcrnlncntal transfer revenue receivable
l'ot~l
2010
2009
2,273,351
3,276,894
4,912,569
5~ 143,407
693,990
7,463,957
671,,930
124,419
3,651,810
)6,285,330
13,468,460
322,215
1,469
941.,463
current assets
Noncurrent c'lsh and cash eqt.livalcnts:
Internally qesignatcd for capitnl.ncquisitions
Restricted by contributors for scholarships
Pri nei pal of pcrnlancnt CndO\Vlncnts
Cash held in trust for patients
106,665
120,~21
26,706
89,852
26,706
79,811
545,438
228,207
240,534
279,955
188,939
25,533,416
856,865
'fotal capital asset~, net of aCCUIllulatcd depreciation
27,341,413
26,579,220
Grants and pledges receivable restricted for capital acquisitions
9~,296
5,172
312,723
7,t190
44,275,649
40,596,100
'Total noncurrent cash and cash equivalents
Capi~al
assets:
I..Jand
Depreciable capital assets, l1Ct
or aCCtHllulatcd'dcprcciation
26,820,924
COI1s'trtlctiol1-iI1-11rogress
Othci' nsscts
Total assets
$
BFA Attachment B cont.
BFA Attachment B cont.
LI~"!IS COUNTY GI~N)~RAL l-IOSPI'''AL
ANI)
IlE'SIDEN'rIAL lII~AI./rl·l CAI{"~ FACfLI(]'\'
(A COll1poncnt Unit of the County ofl.. c\vis, Ne\v '{ark)
Statcll1cnts of rZcvcnues, I~xpcnscs and Changes in Net Assets
Years ended Dcccinbcr 31 , 2010 and 2009
()pcrating revenues:
Net patient scrvi~e rcv911ue (net of provision for bad
debts ofapproxinlatcly $1,101,00'0 in2010 and
$1,018)000 in '2009)
Intergovcrnll1clltal transfer revenue
Other
$ 44,475,239
7,005,854
974,672
43,087,91 Lt
3,692,485
965,565
52,455,765
47,745,964
23,169,693
3,516,254
21,153,3,35
13,316,898
7,117,547
7,764,471
3,070,021
T'otal operating. expenses
57,658,389
52,422,272
Operating loss
(5,202,624)
(4,676,308)
(454,576)
12,141
25,211
(472,823)
11,029
29,698
(417,224)
(432,096)
(5,619,848)
(5,108,404 )
(2,832,263)
352,353
39,9,890
(8,099,758)
(4,708,514)
17,396,857
22,105,371
9,297,099
17,396,857
~rotal
operating revenues
()pcratil!g cxpcn~es:
Salaries and \vages
I~lnploycc bC'tlCf.i'ts
Supplies and oUJer
Purchased services
l)cprecia~iot1 arid anl0rtization
14)866,~~4
7,650,880
8,455,228
Nonoperating revenues (expenses):
Intcre,st expense
Illtcresl i nC0t11C
Other
'T'otal nonoperating expenses, net
I)cflciency of revenues over expenses
~rransrer
to l..Jc\vis County
Capital grants nn,d contributions
])ccreasc in net assets
Nel assets at beginning of year
Net ,assets at end of year
$
C1JRRL~
MONTH
PRIOR
YEAREf'.;"D
INCREASE!
(DECREASE)
%
VAR
ASSETS:
LlA8lLITIES:
Current Assets
Current Liabilities
Cash
$1,165,067
$1,698,309
($533,242)
-31.4%
12,357,152
!5,955,308)
2,421,501
24.4%
4,884,596
1,179,329
719,533
1.489,373
9,935,651
(4.988,630)
4,947,021
7,743,409
730,712
693,990
859,735
(2.858,813)
629.638
3.7%
73.2%
15,839,742
16,673,176
(833,434)
-5.0%
Receivables:
Patient and Third Party Payors
less: Estimated Uncollectibles
Net Accounts Receivable
Other Receivables
Pre-Paid Expenses
Inventories
Due from Third Party Payors
Total Current Assets
6,401 1844
(966,678)
1,454,823
448,617
25,543
19.4%
29.4%
-36.9%
61.4%
Limited Use and Other Assets:
InvestlTIents Whose Use is Limited
Property, Plant &
Equipmen~
893,368
1,091,198
(197.830)
-18.10/0
at Cost
Land and land Improvements
Building and Building Improvements
Equipment
Construction In Progress
Gross Plant Assets
Less: Accumulated Depreciation
279,955
0
0
1,984
2,612,321
60,535,343
2,614,305
(33,193.929)
(3,420.004)
0.0%
0.0%
0.0%
933.1%
4.3%
10.3%
27,341,414
(805,699)
-2.9%
45.105,788
(1,836,963)
-4.1%
1,884,069
1,884,069
36,643 1 182
36,643,182
21J28,137
21,730.121
2.892,276
63,149,64S
(36,613,933)
Net Property & Equipment
26,535,715
TOTAL ASSETS:
43,268.825
Accounts Payable
Accrued Payrol[
Accrued Benefits
Accrued Expenses
Due to Third Pa.rty Payors
Current Portion Of Long Tenn Debt
Current Portion Of Post Retirement Obligation
Total Current Liabilities
Long Term Liabilities
Notes Payable - Other
Notes Payable - Leases
Other
Bonds Payable
Net Post Retirment Obligation
Total Long Term Liab.
TOTAL LIABILITIES
CURRENT
PRIOR
110NTH
YEARE~1)
4,100,873
1,610,868
1,886,582
6,524
271,095
6.647,969
1,210,889
15,734,800
3,175,707
1,397,784
1,639?13
INCREASE!
(DECREASE)
925,166
213,084
246,869
6,267
947.448
6,891,179
1.210,889
(676,353)
{243,210)
0
15,268,987
465,813
2,218,951
908,984
373,067
(1.380,446)
266,382
257
%
VAR
29.1%
15.20/0
15.1%
4.1%
-71.4%
-3.5%
0.0%
3.1%
838,505
1,175,366
305,789
5,486,530
15,628,850
23,435,040
11,328,850
20,564,626
4,300,000
38.00/0
2,870,414
14.0%
39,169.840
_ ~5}833,613
3,336,227
9.3%
5,734,774
(67,278)
(248,244)
-62.2%
29.3%
-18.0%
-4.3%
NET ASSETS:
Beginning Net Assets
Change in Fund Balance
Current Year Surplus/(Deficit)
TOTAL NET ASSETS
TOTAL LIABILITIES
& NET ASSETS:
9,272,175
341,658
(5,514,848)
17,336.715
113,246
(8.177,786)
(8,064,540)
-46.5%
228,412
201.7%
2.662.938
32.6c~
4,098,985
9,272,17 5
(5)173) 190)
-55.8%
$43.268,825
$45,105,788
{$1.836.963)
-4.1%
to
~
~
rt
rt
~
n
::r'
S
(D
:::1
rt
0
--LEW·I-S---COUNTYGEN-ERAL' :BO-'SPITAL..
. . LO~LE;'~W yORK- . .
S·TA-TEMENT OP:OPERATIONSFOR THE PERIoi}:E1\rnlNG . ···December -31,2011
CURRENT
MONTH
inpatient Revenue
Skilled Nursing Facility Revenue
Outpatient Revenue
Clinic Revenue
Physician Office Revenue
Gross Patient Care Revenue
LESS: Contractual Allowances
Charity Care
Net Patient Care Revenue
Intergovernmental Transfer
Other Operating Revenue
TOTAL OPERATING REVENUE
Sa'aries and Wages
Employee Benefits
Professional Fees
Supplies
Utilities
Purchased Services
Insurance Expense
Other Expenses
Leases and Rentals
Provision for Bad Debt
Depreciation Expense
Nevv York State Assessment
C1JRRE~T'f
VARLlliCE
A.CTvs BtJD
ACTUAL
MONTH
BUDGET
PRIOR
)'EAR
MONTH
$1,231,023
1,290 318
3\827,005
203,787
1,051,173
7,603,306
S1,B62,175
1,422,743
3 743,235
225,336
1,079,413
8,032,902
$1,341,008
1,298,022
3,203,804
197,577
872,405
6,912,816
(3,279,006)
(99,508)
(3 671,844)
4,224,792
(UNFAVOR)
VARlAJ.'iCE
VARIANCE
0/0
TO DATE
YEAR
TO DATE
V..U t.
ACTUAL
BUDGET
TO DATE
$19,393,400
16,752,231
45,998,491
2,725,834
13,328,253
98,198,209
$16,429,315
15,778,333
40,870 937
2,319,410
9,392,079
84,790,074
YE.AR
($33'1,152)
(132,425)
83,770
(21,549)
(28,240)
(429,596)
-21.2%
-5.3%
$16,576.200
16.098,175
44,688,072
2,457,440
12,647,520
92,467,407
(3;709,107)
(115,395)
392,838
(14,085)
10.7%
-16.5%
(40,671,220)
(1,506,378)
(45,005,098)
(1,025,077)
4,275,635
3,088,314
(50,843)
-1.2%
50,289,809
265,509
244,911
265 508
339,881
1,123,726
(116,257)
1
(94.970t
0.0%
-27.9%
4,735 1212
4,881 ,024
4,095,783
(145,812)
2,151,877
5,344,057
670,608
433,334
54,060
420,441
60,117
2,160,123
1,970,058
5,325,966
513,306
458,165
81,306
392,771
62,314
87 598
21 ,190
140,149
1
73,786
1
1
(85,423)
1
937,639
492,238
453,517
74,204
378,647
63,344
58,062
15,902
20,224
119,248
286,667
16.114
87,500
266,667
9,687
TOTAL EXPENSES
9,650,533
4,997,539
OPERATING INCOMEJ(LOSS}
(4,~J5,:?~J
1
8,246
(4,406,418)
(178,370)
20,183
2"0,144
(41,794)
ACTvsBtJD
(UNFAVOR)
VARIAt't"CE
0/0
VAR.
($2 817,200)
(654,056)
(1,310,419)
(268,394)
(680,733)
(5)730,802)
-14.5%
-3.9%
-2.8%
-9.8%
--5.1%)
-5.8%
(37,978,065)
(1,125,022)
4,333,878
(481,301)
9.6%
-47.0%
52,168,034
45,686,987
(1.878,225)
-3.6%
5,581,972
2,976,384
3,186,102
4,078,570
7,005,854
883,246
2,395,870
(1 ,102, 186)
752%
-27.0%)
-3.0%
58,848,165
59,432,706
53,576 1087
(584,541)
-1.0%
0.4%
24.256,064
15,780,334
6,923,818
5,215,561
799,562
4,785,697
716,105
754,275
222,834
1,177,916
3,420,004
25,109,800
11,186,058
5,848,444
5,442,320
890,464
4,543,750
760,139
721,370
190,821
1,050,000
3,200,000
22,366,663
14,866,335
4 901\349
5,162,302
856,891
4,355,821
653,991
679,073
208,285
1,100,684
3,516,254
111,061__
853,736
(4,594,276)
(1,075,374)
226,759
90,902
(241,947)
44,034
(32,905)
(32,013)
(127,916)
(220,004)
(32,750)
-41.1%
-18.4%
4.2%
10.2%
-5.3%
5.8%
-4.6%)
..16.8%
-12.2%
-6.9%
-28.2%
-9.30/0
2.2%
-9.6%
-2.6%
-469.9%
-36.2%
4.5%
27.1%
-11.0%
3,227
5.1%
(15,724)
-27.1%
(4,322)
~27.2%
-36.3%
11,391
(31,748)
(20,000)
(6,427)
__ ~9,fi?~O.468
(4,653,003)
-93.1%
__~~~?98,815)
-4118.9%
2,254
0
2254.0°,10
566,254
PRIOR
YEAR
-7.5%
-66.3%
14?,991
1~16,~4t _
1
1
1
59,059,407
~778,709
_~,141,I§~4)_
(5,352,996)
373,299
(5,202,622)
(5,72~!~~_§t
77,096
0
1,200
17,678
0
64,201,161
3.4%
-sg%
to
Non-Operating Revenue
County Capital Contribution
Grant Revenue
Non-Operating Expense
Net Non-Operating Revenue (Expense)
ITOTAL NET SURPLUS/(DEFICIT}
2,354
0
(6,595)
(37 962)
(42,203)
1
($4,957,524)
_~~_~(116.§~~§1.
~ (!3,534,6~85)~
100
0
22,917
(38,306)
2 ,085
(54,943)
(29,512)
344
(15,289)
(28,324)
(26,914)
($131,795)
($5,563,009)
($4,825,729)
0
24,534
0.0%
-128.8%
0.9%
-176.0%
-3661.5%
0
75,896
0
232,094
275,000
294,003
(42,906)
(471.042)
(161,852)
(426,901)
(454,57?)
(150,701)
(142,896)
(44,141)
(11,151)
I I ($5,514,848)
$222,598
($5,345,518)
($5,737,446)
-1534.0% ;;
6324.7% ~
0.0% ~
-15.6% n
-10.3%
-7.4% CD
g
~
rt
-2577.5
%
'
(J
n
0
~
rt
New York State Department of Health
Public Health and Health Planning Council
May 23, 2012
ATTACHMENTS
Residential Health Care Facilities - Establish/Construct
Exhibit #8
Number
Applicant/Facility
1.
082143 E
Orchard Manor, Inc.
(Orleans County)
2.
112156 E
Parkview Operating Co., LLC d/b/a Westchester Center for
Rehabilitation & Nursing
(Westchester County)
ASSETS
ASSETS ...
LIABILITIES ...
ED
EQUITY
EXPENSE
NET INCOME
MEDICAID
73.89%
7.25°k
18.86%
73.890/0
7.25°k
18.860/0
74.490/0
5.30%
20.210/0
79.51%
3.30%
17.19%
Assets
Inventories
Total
Assets
Patient
Total Assets
Liabilities
$750,000
Other Liabilities Pat Funds
Equity
Total Liabilities &
$918,558
8,558
ASSETS ASSETS - FIXED
LIABILITIES EQUITY
EXPENSE
NET INCOME
96.00%
96.000k
89.37%
88.16°k
25.30%
19.370/0
51 ,,23°k
28.37%
20.40%
54.61 ok
23.43%
21.96%
55.34%
MEDICARE
PRIVATE/OTHER
11
2010 Patient data
19.37%
for 201
ASSETS ...
AND
LIABILITIES CURRENT
LIABILITIES ...
EQUITY
NUMBER OF BEDS
OF
MEDICAID
PRIVATE/OTHER
*2010
data used for 2011
160
96.13%
160
96.13%
160
92.590/0
156
96.11°k
69.75%
69.750/0
22.80%
7.. 45%
73.310/0
19.620/0
7.07%
71.86%
18.290/0
9.. 85%
7.. 45°k
ASSETS ... FIXED
LIABILITIES ...
LIABILITIES "-.. .
H ........... -
EXPENSE
NET INCOME
NUMBER OF BEDS
PERCENT OF
100
95.41%
100
95,,410/0
100
93.910/0
100
95.990/0
MEDICAID
MEDICARE
PRIVATE/OTHER
83.180/0
13.08%
3.740/0
83.18%
13.080/0
3.74%
85.560/0
11
3.18°k
81.29%
16.30%
2.410/0
* 2010
used for 201
12131/2011
ASSETS ASSETS AND
LIABILITIES - CURRENT
1,720,315
10,583,130
EQUITY
EXPENSE
NET INCOME
44
.'lIUI"• ...., ...... l OF BEDS
PERCENT OF OCCUPANCY
97.280/0
0.000/0
2.720/0
MEDICAID
PRIVATE/OTHER
* 2010
30.820/0
used for 2011
97.280/0
0.00%
2.72%
99.07%
0.00%
0.93%
Attachment H
Lease Rental vs. Capital Reimbursement
Orchard Manor d/b/a OMOP LLC
Year
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
Total Shortfall
Average ShortFall
(Shortfall) Medicaid (Shortfall)
Return Of Equity Return On Equity Total Reimbursement Lease rental
39,386
(442,109)
(340,424)
700,000
218,505
2~7,891
218,505
28,133
246,638
700,000
(453,362)
(349,089)
218,505
16,880
235,385
700,000
(464,615) .
(351,754)'
218,505
5,627
224,132
700,000
112,066
700,000
(452,709)
(587,934)
112,066
700,000
(587,934)
(452,709)
700,000
12,066
(452,709)
(587,934)
112,066
700,000
(452,709)
(587,934)
112,066
700,000
(452,709)
(587,934)
12,066
(452,709)
(587,934)
700,000
(4,129,942)
as
BFA Attachment B
PARKVI:EW OPERATING CO., LLC
OPERATING PROJECTION
January 1, 2012
PROFORMA BALANCE SHEET
ASSETS
PARKVIEW
OPERATING CO"
Westchester
Gardens Realty,
LLC
LLC
Elimination
CURRENT ASSETS
TOT)~L
$
$
$
Cash
Total
__t __
3,327,000
3,327,000
CURRENT ASSETS
.18,393,790
17,165,000
PROPERTY AND EQUIPMENT
$
TOTAL ASSETS
4,555,790
$
17,165,,000
$
$
21 ,720,790
LIABILITIES AND MEMBERS' EQUITY
CURRENT LIABILITIES
Current Portion of long - term debt
$
$
60,000
~_._.___
60,000__
60,000
60,000
14,333,790
14,333,790
14,393 ,790
14,393,790
4 ,555,790
2,771,210
7,327 000
TOTAL MEMBERS' EQUITY
4 t 555,790
2,771,210
7,327,000
TOTJ\L LIABILITIES AND MEMBEF $
4,555,790
TOTAL CURRENT LIABILITIES
LONG - TERM DEBT
,TOTAL LIABILITIES
MEM'BERS' EQUITY
Members' Equity
$
17 165 000
1
1
1
$
21,720,790
BFA Attachment C
Financial Summary
Westchester Center for Rehabilitation & Nursing
FISCAL PERIOD ENDED
ASSETS - CURRENT
ASSETS - FIXED AND OTHER
LIABILITIES - CURRENT
LIABILITIES - LONG-TERM
EQUITY
INCOME
EXPENSE
NET INCOME
OPERATOR/RELATIVE SALARIES
12/31/11
12/31/10
12/31/09
$6,946,435
3,842,489
6,090,100
5,548,353
(849,529)
$5,328,930
3,699,373
7,517,398
3,509,621
(1,998,716)
$3,890,709
3,920,692
$6,634,469
2,941,494
(1 ,764,562)
$17,371,592
17,065,619
305,973
$17,506,744
18,080,891
(574,147)
$18,143,170
18,233,001
(89,831)
$0
$1,998
$41,600
NUMBER OF BEDS
PERCENT OF OCCUPANCY (DAYS)
240
81.6%
240
80.9%
240
81.2%
PERCENT OCCUPANCY (DAYS):
MEDICAID
MEDICARE
PRIVATE/OTHER
77.2%
9.1%
13.7%
83.8%
8.4%
7.8%
83.9%
9.1%
7.0%
MEDICAID RATE BREAKDOWN:
OPERATING
CAPITAL
TOTAL
2011
2010
2009
$172.69
18.37
$191.06
$169.76
18.37
$188.13
198.35
14.37
212.72
BFA Attachment D
Financial Summary
Highfield Gardens Care Center of Great Neck
FISCAL PERIOD ENDED
ASSETS - CURRENT
ASSETS - FIXED AND OTHER
LIABILITIES - CURRENT
LIABILITIES - LONG-TERM
EQUITY
INCOME
EXPENSE
NET INCOME
OPERATOR/RELATIVE SALARIES
12/31/2011
12/31/10
12/31/09
$5,457,640
3,558,298
5,100,926
835,568
3,079,444
$4,380,839
4,233,923
5,243,235
1,397,651
1,973,876
$3,328,622
4,775,185
$4,168,743
1,159,093
2,775,971
$23,720,457
22,737,800
982,657
$21,922,034
21,816,705
105,329
$23,805,616
21,860,878
1,944,738
$0
$0
$0
NUMBER OF BEDS
PERCENT OF OCCUPANCY (DAYS)
200
90.00/0
200
91.4%
200
93.30/0
PERCENT OCCUPANCY (DAYS):
MEDICAID
MEDICARE
PRIVATE/OTHER
68.90/0
16.2°k
14.90/0
74.20/0
15.8%
10.0%
74.9%
20.5%
4.60/0
MEDICAID RATE BREAKDOWN:
2011
2010
2009
$221.00
27.14
$248.14
$219.20
27.14
$246.34
223.83
30.68
254.51
OPERATING
CAPITAL
TOTAL
BFA Attachment E
ESTABLISHMENT CHECKLIST FOR NURSING HOMES
APPLICATION: 112156-E Westchester Center for Rehabilitation & Nursing
NATURE OF PROPOSAL: Change in operational ownership
EFFECT ON OPERATIONAL OWNERSHIP: Change from a proprietary limited liability corporation to a,
limited liability corporation with 100 % new members.
EFFECT ON REAL ESTATE OWNERSHIP: N/A
FIXED ASSET PURCHASE PRICE:
N/A
FIXED ASSET MEDICAID VALUE:
N/A
CAPITAL REIMBURSEMENT:
_ _ Arms Length Lease
X
Historic Cost Method
_ _Shortfall; Average Annual Amount
BUSINESS PURCHASE PRICE: $1,228,790
New York State Department of Health
Public Health and Health Planning Council
May 23, 2012
ATTACHMENTS
Certified Home Health Agencies – Establish/Construct
Exhibit #9
Number
Applicant/Facility
1.
121018 E
Lewis County General Hospital d/b/a Lewis County General Hospital
Certified Home Healthcare Agency
(Lewis County)
2.
121219 E
L. Woerner, Inc. d/b/a HCR
(Clinton County)
LEWIS COUNTY GENERAL HOSPITAL
Lowville, New York
II
I~-----------------------------------------------------
BOARD OF MANAGERS
I
I
I
I
I
I
I
I
I
I
I
I
I
I
Chief Executive Officer
Eric Burch
MEDICAL DIRECTOR
Catherine Williams, M.D.
I
I
I
I
I
I
PI/RISK
MGMT.
Jean Dryja, R.N.
I
I
NURSING HOME
ADMINISTRATOR
Joseph Todora
~I
f1TC Nursing
*Performance
Improvement
*Corporate
Compliance
I
*Risk
Management
II
*UR
I I
*Jnfection
Control
I
I
Services
I
FINANCE
. Terry Lang
I
FACILITIES
MANAGEMENT
Tom Ferguson
I
HUMAN
RESOURCES
Tim Ryan
I
'Adult Day Carel
*Materials
Management
-Bio Med Equipment
*Construction/
Renovation
*1 nformationSystems
I, 'Patient Review
*Health
Management
*Environmental
Services
*Linen
*Emergency
Preparedness
Coordinator
CLINIC
MANAGEMENT
VACANT
I
*Emergency
Dept. .
*Volunteers
*ICU
*Staff Education/
Development
*Med Surg/
Maternity
*Benefit
Administration
*ORlAmbulatoryl
Anesthesia
*Salary
Administration
*Pharmacy
*Radiology
*Supervisors
*Laboratory
Coordinator
*Nutritional Services
r--------,
*Employee
Relations
'Activities
*Social Service/
Discharge Planning
PATIENT CARE
SERVICES
David Wood, R.N.
I
*Plant Operations
*Patient Accounts
Transportation/
Lifenet
I
I
~-~-l
ANCILLARY
MANAGEMENT
Michele Prince
I
~
*Beaver River
HeaIth Center
*South Lewis
Health Center
*Copenhagen
Health Center
*Surgical Practice
*OB Practice
*Recruitment and
Retention
*Respiratory
*Employee Health
*Rehabilitation
*Payroll
*Occupational
Medicine
*Orthopedics
*Family Practice
*Registrationl/
Communications
Cd
~
>
>
it
it
\l)
(J
g
(l)
~
it
>
LEWIS COUNTY GENERAL HOSPITAL
Lowville, New York
,------------------------------------------------------------MEDICAL DIRECTOR
Catherine Williams, M.D.
Chief Executive Officer
Eric Burch
1
r
PI/RISK
MGMT.
Jean Dryja, R.N.
I
*Performance
Improvement
-,
r
NURSING HOME
ADMINISTRATOR
Joseph Todora
I
*LTC Nursing
Services
*Corporate
Compliance
*Adult Day Care!
Transportation!
Lifenet
*Risk
Management
*Activities
*UR
*Social Service!
Discharge Planning
*lnfection
Control
BOARD OF MANAGERS
FINANCE
Terry Lang
I
*Nutritional Services
*Environmental
Services
*Linen
*Emergency
Preparedness
Coordinator
FACILITIES
MANAGEMENT
Tom Ferguson
*Plant Operations
*Patient Accounts
*Constructionl
Renovation
*Materials
Management
-8io Med Equipment
*Health
Management
,
,
HUMAN
RESOURCES
Tim Ryan
I
*Accounting
*Information Systems
*Patient Review
Coordinator
I
PATIENT CARE
SERVICES
David Wood, R.N.
*Emergency
Dept.
*Volunteers
*ICU
*8enefit
Administration
*Salary
Administration
*Recruitment and
Retention
CLINIC
MANAGEMENT
VACANT
I
I
*Employee
Relations
*Staff Education!
Development
t----
*Med Surg!
. Maternity
*OR!Ambulatory!
Anesthesia
I
~~~'~-~'-~I
ANCILLARY
MANAGEMENT
Michele Prince
OUTREACH
MANAGER
VACANT
i
*Beaver River
Health Center
*South Lewis
Health Center
I
*Copenhagen
Health Center
*Pharmacy
*Radiology
*CHHA
*Supervisors
*Laboratory
*Hospice
*Surgical Practice
*OB Practice
*Respiratory
*Orthopedics
*Employee Health
*Rehabilitation
*Payroll
*Occupational
Medicine
*Family Practice
*Registrationl
Communications
td
I-:tj
>
>
rt
rt
~
(')
::J
S
(D
~
rt
>
(')
o
~
rt
BFA Attachment B
LE\\'IS COUNTY GI~NERAL (·IOSPITAI-J AND
IlESII)I~Nl'I.AtJ lIEALTJ-I. C:AltE FAC·ltJlrrV
(A COll1poncnt Unit of the County of Lc\vis', Nc\v York)
Balance Sheets
l)cccJl,bcr 31 , 2010 and 2009
Current assets;
Cash and cash equivalepts
$
Patient accounts receivable, net orilllq\vancc for doubtful
accqunts ,of approxinlately $1,049,000 in 2010 and
$1,233,000 iIi 2009
In\/ciltories
Prepaid expenses and other current assets
Illtcrgovcrnrncntallransfer revenue receivable
l'otal current assets
2010
2009
2,273,351
3',276,894
4)912,569
693,990
941,,463
7,463,957
5,143,407
671,,930
124,419
3,651,810
16,285,330
13,468,460
322,215
106,695
26,706
120,~21
NonG~llTcnt
cush and cash eql.livalcnts:
Internally qesignatcd for capitnl,ncquisitions
Restricted by <;o11tribqtors f9r scholarships
Principal 9fpernlancnt e,ndO\Vll1cnts
1,469
89,852
26,706
79,811
545,438
228,207
240,534
26,820,,924
279,955
188,939
25;5~3,416
rrotal capital assel$, net of accU111ulatcd depreciation
27,341,413
26,579,220
Gi"ants and pledges receivable restricted for capital acquisitions
9~;296
312,723
7;490
C,lsh held in trust for patients
l'otal noncurrent cash and cash equivalents
CapHa1 assets:
[.l~\nd
Depn~qiable capi~al ass9ts, net of accunlulntcd'dcpreciation
Constrtlction-in-11r()gress
Othci" nssets
Total assets
5,172
$
44,275,649
856,865
40,596, J 00 .
BFA Attachment B cant.
L,iabilitics and Net Assets
2009
2010
ClltTcnt liabilities:
Short-tenn bo,rro\vings
Current lnaturities 6C long-ilcrn) debt
ACCOlints phyabl~ and aq'9r:u¢d cxi)ensc~
Due·to l.4c\vis County
Net· Pos.l}~ctirenlcllt obI igatiOli
J~stinlalcd third-party payor scHlclncnts, net
$
14,395,639
8;735,220
~,643,758
7,247,116
2,21 S,951
11,328,850
391,352
6,835,596
381,31 t
34,978,550
23,199,243
17,497,03 t
18,402,711
106,665
28,666
120,221
16,732
258
4~G87,823
l.Jong-tenn debt, net or currellt tnaturitics
I)uc to Lc\vis County
LJong-terln net poslrcti.rclllcn,t obligation
Other long-tern) liabilities
;rotalliabililics
Invested in capital assets, net
1,210,889
87,714
929,393
5,35Q,120
784,911
1,322,042
348,154
6,205,856
-rotal current liabij Ii tics
Net assets:
1,600,000
603,357
or related debt
I<.estrictcd :.
l~Xl)e'nclable for scholarslli ps
~xi)endablc
[pr cancer supporl
Expendable for capital acqtlisitions
~xpe~idable fOl~ diab~tes
258
4,815
,edu.cation
Nonexpcndablc pcrnlanent cndO\Vnlcnt
26,706
Unrestricted
-rola} net nsscts
(~olnnliln)ents
26,706
(8,367, I02)
(1,169,771)
9,297,099
17,396,857
44,275,649
40,596,100
and contingencies I,
'rotaI liabilities and net assets
$
BFA Attachment B cont.
LJ~\"IS GOlJNTY GI~,NJ~R,AL
tIQSPIT A~ ANI)
IlltsIDEN'rIAL lII~AL,rrJ-l CAJ{I~ FACILrl'\'
(A COlllponcnt Unit orihe County ofl....c\vis, Ne\v '{ark)
Statenlcnts off{cvcnues,
I~xpcnscs
and Changes in Net Assets
Years ended DCcclllbcr 31, 2010 and 2009
()pcrating revenues:
Net patient scrvi~e rc\'~nue (net of provision for bad
debt's of approxinlatc)y $1,101 ,ociO in 20'1 () and
$1,(18)000 in '2009)
IntergovCrllJ11Clltal transfer revenue
Other
l~otal
$ 44,475,239
7,005,854
974,672
43,087,914
3;692,485
965;565
52,455,765
47,745,964
23,169 s693
8,455,228
21,153,3.35
13,316,898
7,117,547
7,764,471
3,516,254
3~O70,O21
operating revenues
()pCt~ritil~g expcn~~~:
Salar,ies and ~vag~'s
I~nlployee bC'ncflts
Supplies ,und ot1jcr
PUl"chasedscrvi ces
l)cprecia~ioh arid anl0rtizution
14,866,3J4
7~65q,880
l'otal operating. expenses
57,658,389
52~422,272
Operating loss
(5,202,624)
(4,676,308)
(454,576)
12,141
25,211
(472,823)
11,029
29,698
(417,224)
(432,096)
(5,619,848)
(5,108,404)
(2,832,263)
352,353
399,89,0
(8,099,758)
(4,708,514)
17,396,857
22,105,371
9,297,099
17,396,857
Nonoperati,ng revenues (expenses):
Intcre,st ~xpcnse
hltcrest inc'o111e
Other
rrotal nonoperating expenses, net
Deficiency of revenues over expenses
'T'ransCer to L,c\vis County
Capital grants an,d contributions
))ccreasc in net assets
Net assets at beginning of year
Net assets at end of year
$
CURRENT
MONTH
PRIOR
YEAREND
lNCREASE/
%
(])ECREASE2..
VAR.
CURRENT
MONTH
PRIOR
YEAREND
4,100,873
1,610,868
1,886,582
6,524
271,095
6,647,969
1,210,889
3,175,707
1,397,784
1,639,713
6,267
IN"CREASEI
%
(DECREASE)
VAR.
LlABILITIES:
ASSETS:
Current Liabilities
Current Assets
Cash
Receivables:
Patient and Third Party Payors
Less: Estimated Uncollectibles
Net Accounts Receivable
Other Receivables
Pre-Paid Expenses
Inventories
Due from Third Party Payors
Total Current Assets
$1,165,067
$1,698,309
($533,242)
-31.4%
2,421,501
24.4%
19.4%
1,454t 823
29.4°~
(2,858,813)
-36.90/0
61.40/0
25,543
3.7%
1.489,373
9,935,651
(4.988.630)
4,947,021
7 t 743,409
730,712
693,990
859,735
629.638
73.2%
15,839,742
16,673,176
(833A34)
-5.0%
12 357,152
(5,955.308)
6,401 1844
4,884,596
1,179,329
719,533
1
(966,678)
448,617
Limited Use and Other Assets:
Investments Whose Use is Limited
893,368
1,091,198
(197,830)
-18.1%
Property, Plant & Equipmen~ at Cost
Land and Land improvements
Building and Building rmprovements
(33,193,929)
0
1,984
2.612,321
2,614,305
(3,420. 0042
Net Property & Equipment
26,535,715
27,341,,414
(80S,699)
-2.9%
TOTAL ASSETS:
43,268.825
45.105.788
___ (1,836,$6.~t
-4.1%
Construction 1n Progress
Gross Plant Assets
Less: Accumulated Depreciation
1,884,069
36,643,182
21,728,137
279,955
60,535,343
0.0%
0.0%
0.0%
1,884,069
36,643,182
21,730,121
2.892,276
S3,149,648
(36,613,933)
°
933.1%
4..3%
10.3%
Accounts Payable
Accrued Payroll
Accrued Benefits
Accrued Expenses
Due to Third Party Payors
Current Portion Of long Tenn Debt
Current Portion Of Post Retirement Obligation
Total Current Liabilities
15,734t 8oo
6,891,179
1.210,869
15,2687987
925,166
213,084
246,869
257
(676,353)
{243,210)
0
465)813
{1,380A46)
266,382
(67,278)
(248,244)
4,300.000
2 r 870A14
947A48
29.10/0
15.2%
15.1%
4.1%
-71.4%
-3.5%
0.0%
3.1o/G
Long Term Liabilities
Notes Payable - Other
Notes Payable - Leases
Other
Bonds Payable
Net Post Retirment Obligation
15.628.850
Total Long Term Liab.
23,435,040
2,218,951
908,984373,067
5,734,774
11,328.850
20 7564,626
TOTAL LIABILITIES
39,169.840
351 833,613
3 336.227
9,272,175
341.658
(5.514,848)
17,336,715
113,246
(8.177,786)
(8,064,540)
228,412
2.662,938
201.7%
32.6%
4,098,985
9,272,175
(5,113,190)
-55.8%
$43.268,825
$45.105,788
($1.836.963)
-4.1%
838,505
1,175,366
305,789
5,486,530
t
-62.2%
29.3%
-18.00/0
-4.30/0
38.00/0
14.0%
9.3%
NET ASSETS:
Beginning Net Assets
Change in Fund Balance
Current Year Surplus/(DefJcit)
TOTAL NET ASSETS
TOTAL LIABILITIES
& NET ASSETS:
--46.50/0
Cd
~
tJ>
rt
rt
~
()
::J
S
ro
::i
rt
(J
··LEW·I·S"··.COUNTY· GENERAL':flO·SPITAL·
..
.
LO~LE~"NF;W Y:0~' -.:
.
S·TA··TEMENT OF·:OPERATIONS·
FOR THE PERIOj):E:NDING . ··.DeceIriber31,2011
VARIANCE
Inpatient Revenue
Skilled Nursing Faciltty Revenue
Outpatient Revenue
Clinic Revenue
Physician Office Revenue
CURRENT
CURRENT
PRIOR
ACTvsBUD
MONTH
ACTUAL
MONTH
BUDGET
YEAR
MONTH
(UNFAVOR)
VARIANCE
$1,231,023
1,290,318
3,827,005
203,787
1)051,173
7,603,306
$1,562,175
1,422,743
3,743,235
225,336
1,079,413
8,032,902
$1,341,008
1,298.022
3,203,804
($331,152)
(132)425)
197,Sn
(21,549)
(2S' 240)
(3,279,006)
(99,508)
VARIANCE
%
VAlt.
YEAR
TO DATE
ACTIJAL
YEAR
PRIOR
ACTvsBUD
TO DATE
BUDGET
YEAR
(UNFAVOR)
%
TO DATE
VARIA.t~CE
VAR.
$191393,400
16,752:231
45,998,491
2,725,834
13,328,253
98,198,209
$16,429,315
15,778,333
40,870,937
2,319,410
9,392,079
84,790,074
872,405
6,912,816
(429,596)
-21.2%
-9.30/0
2.2%
-9.6%
-2.6%
-5.3%
(3,671,844)
(85,423)
(3,709,107)
(115,395)
392,838
(14,085)
10.7%
-16.5%
(40,671,220)
(1,506,378)
(45,005,098)
(1,025,077)
4,224,792
4,275,635
3,088,314
(50,843)
-1.2%)
50,289,809
265,509
244,911
265,508
339,881
1,123,726
(116,257)
1
(94,970)
0.0%
-27.9%
4,735,212
4 881,024
4,095,783
(145,812)
2,151,877
5,344,057
670,608
433,334
54,060
420,441
60,117
73,786
20,224
119,248
286,667
16.114
2,160,123
937,639
492,238
453,517
15,902
87,500
266,667
9,687
1,970,058
5,325,966
513,306
458,165
81 ,306
392,n1
62,314
87,598
21,190
140,149
566,254
11,391
8,246
(4,406,418)
(178,370)
20,183
20,144
(41,794)
3,227
(15,724)
(4,322)
TOTAL EXPENSES
9,650,533
4,997,530
9,630,468
OPERATING INCOME/(LOSS)
(4,915,321)
~(1t§.~Q?J
2,354
0
(6,595)
(37,962)
100
0
22,917
(38,306)
(15,289)
Gross Patient Care Revenue
LESS: Contractual Allowances
Charity Care
Net Patient Care Revenue
Intergovernmenta[ Transfer
Other Operating Revenue
TOTAL OPERATING REVENUE
Salaries and Wages
Employee Benefits
Professional Fees
Supplies
Utilities
Purchased Services
Insu ranee Expense
Other Expenses
Leases and Rentals
Provision for Bad Debt
Depreciation Expense
Nevt/ York State Assessment
T
74,204
378,647
63,344
58 t 062
83,nO
$16,576,200
16,098.175
44,688,072
2,457,440
12,647,520
($2~817,200)
(654,056)
(1,310,419)
(268,394)
-14.5%
-3.9%
-2.8%
-9.8%
(680,733)
(5,730,802)
~.1°,10
(37,978,065)
(1,125,022)
4,333,878
(481,301)
9.6%
-47.0%
52,168,034
45,686,987
(1.878,225)
-3.6%
5,581,972
2,976,384
3,186,102
4,078,570
7,005,854
883,246
2,395,870
(1,102,186)
-27.0%
-3.0%
58,843,165
59,432,706
53,576~O87
(584,541)
-1 . 0%
24,256,064
15,780,334
6,923,818
5,215,561
799,562
4,785,697
716,105
754,275
1 t 177,916
3,420,004
148,991
25,109,800
11,186,058
5,848,444
5,442,320
890,464
4,543,750
760,139
721,370
190,821
1,050,000
3,200,000
116,241
22,366,663
14,866,335
4,901,349
5,162,302
856,891
4,355,821
653,991
679,073
208,285
1,100,684
3,516,254
111,061
853,736
(4,594,276)
(1,075,374)
226,759
90,902
(241,947)
(6.427)
0.4%
-469.9%
-36.2%
4.5%
27.1%
-11.0%
5.1%
-27.1%
...27.2%
-36.3%
-7.5%
-66.3%
44,034
(32,905)
(32.013)
(127,916)
(220,004)
(32,750)
-18.4%
4.2%
10.2%
-5.3%
5.8%
-4.6%
..16.8%
-12.2%
-6.9%
-28.2%
(4,653,003)
-93.1%
64,201,j61
__~9,O59,107
_~?,?18, 7(J~
{5,141,754}
.8g%
t
(31,748)
(20,000)
92,467~407
222,834
-5.8%
752%
3.4%
-41.1%
t;d
Non-Operating Revenue
County Capital Contribution
Grant Reven ue
Non-Operating Expense
Net Non-Operating Revenue (Expense)
ITOTAL NET SURPLUSf(DEFICIT}
(42,203)
($4,957,524)
($131,795)
(5,534,685)
(4,798,815) _
2,085
2,254
0
24,534
0
(29,512)
(54,943)
(28,324)
(26,914)
($5,563,009)
344
($4,825,729)
-4118.9%
2254.0%
0.0%
-128.8%
0.9%
-176.0%
-3661.50/0
~~§~~~_~t
77,096
0
232,094
(471,042)
(161,852)
I I ($5,514,848)
~73,29~_
1,200
~~a9.~t~~~)
0
275,000
(426,901)
17,678
0
294,003
(454,577)
(150,701)
(142,896)
$222,598
($5,345,518)
_(§,?~~,2_9!)}
-1534.0% ::
75,896
6324.7%
0
o.a°tlo
(42,906)
(44,141)
(11,151)
($5,737,446)
?;
~
... 15~6% ()
..10.3% §
ro
-7.4%
~
I
rt
-2577..50/0 C1
()
0
~
rt
...... . -' ' -. t-··
~~
I.........
•-
t·.··• ....:.:.. _..,.._.. ~..:"
'..,.,.::
.~:.·
~l#.:.~·.~_
..·"·""":.•._·:,,,,,-:,,,:.·":..,,,,:,:,,,:r"':"'·,,
~••••
_
:"""
_ ••:
., •.&:_
•••••:
_
_
•• _"".
L. WOERNER, INC.
DIBIA'HeR
.BFA Attachment A
, BALANCE SHEETS
December 31,
i
.I
"
;·1
-,
I
:~
2009
2010
ASSETS
Current assets:
. C~sh and-cash equivalents
Accounts receivable, less allowance for
doubtful accounts of $115,000 ($137,000 - 2009)
Prepaid expenses and other current assets
Tmaleurrentassem
$
4,393~124
$
467,648
5,476,548
497,855
10,367,527
6,539,949
622,243
7,629,840
Property and eqUipment, net
1,417,008
1,442,080
Intangible asset
1,400,000
Total assets
$
13,184,535
$
9,071,920
$
1,821,429
997,720
2,272,014
362,101
160,000
$
5,535,09~
1,821,429
150,340
2,128,931
339,714
160,000
1,675,667
11,148,3~2
6,276,0~1
27,084
785;000
812,084
42,131
2,606,429
2,648,560
11,960,446
8,924,641
J-IABILITIES AND STOCKHOLDERS' EQUITY
Current liabilities:
r;;a
f';;j
~:
Note payable - current portion
Accounts payable
Accrued expenses
Unearned revenue
Refundable advance
Due to third-party payors
Total current liabilities
Long-term liabilities:
Security deposits
Note payable ... net of current'portion
Total long-term liabilities
Total liabilities
:;~
j
I
p!
Stockholders' equity:
Common Stoc~ ... no par, 2,.000,000 shares authorized
and issued, 1,981,832 and 1,994,402 shares
outstanding (inclUdes 543,208' and 708,978 unallocated
ESOP shares, respectively)
Treasury stock (18~168 and 5,598 shares at cost)
Additional paid-in capital
Retained earnings
Unearned ESOP shares
Total stockholders' equity
Total liabilities and equity
93,500
(289,382)
604,371
1,499,104
(683,504)
1,224,089
93,500
(76,875)
858,354
4,193,210
(4,920,910)
147,279
$
9,071,920
.................. ;.
BFA Attachment A (cont.)
L. WOERNER, INC.
D/B/A HeR
STATEMENTS OF OPERATIONS
Years Ended Dece~ber 31,
2009
2010
Revenues:
I
.·1
: .~
i
Operating expenses:
Payroll
Payroll taxes and employee benefits
ESOP contributions
Outside services
Travel
Bad debt expense
Depreciation
Utilities
Medical expenses
Office expense
Rent
Equipment rental. repairs and maintenance
Legal and accounting
Training and recruitment
Miscellaneous
Cash receipt assessment
·'nsurance
Interest
Dues and subscriptions
Real estate taxes
Total operating expenses '
Operating (loss) income
Provision for taxes
Net (loss) income
..- -;-:...
'-::~~-
$
43,216,205'
$
43,368.491
28,749;789
5,080,421
4,000,000
2,578,368
945,380
600,590
542,827
502,953
502,911
406,064
405,972
382,607
289,855
190,948
187,668
'165,237
124,397
110,378
. -69;916
69,485
45,905,766
25,619,916
4,275,974
4,000.000
2,535,705
761.042
313,334
392.806
361,281
440,648
356,196
364.510
338,551
216,116
122.728
89.226
108.909
117.938
221,711
59.661
67,904
40,764,156
(2,689,561 )
2,604,335
~.:--.-:':":-.-'
~
.
BFA Attachment B
L.Woerner, In.c. dba HeR
Preliminary Balance Sheet
December 31, 2011
ASSETS:
Current Assets
Cash
Accounts Receivable
Prepaid Expenses
114,355
8,002;395
796,359
Total Current Assets
8,913,108
Total Property, Plant & Equipment
2,124,334
Other Assets
Intangibles and Security Deposits
TOTAL ASSETS
1,400,000
12,437,443
Liabilities:
Current Liabilities
~Demaod Notes Payable .
Libor Term Note/Current
Accounts Payable
Accrued Expense.
Unearned Revenue
Reserve for Payor Settlements
Total Current Llabilitle.
2,990,000
785,000
. 1,810,080
2,555,993
402,872
7,623,725
16,167,670
Other Liabilities
Llbor Term Note/Long Term
Security Deposlts- Patients
TOTAL LIABILITIES
STOCKHOLDERS· EQUITY:
Common Stock
. Unearned ESOP Shares ·
Additional Paid In Capital
Treasury Stock
Retained E8r~lng8
TOTAL STOCKHOLDERS·
LIABILITIES & STOCKHOLDERS'
o
41
16,209,108
93,500
318,498
604,371
(392,193)
(4,393,837)
BFA Attachment B (cont.)
.L. Woerner, Inc. d/b/a HeR
Preliminary Profitl(Loss) Statement
YTD December 2011
Revenues
$42, 163,763
Direct Costs
29,268,053
Gross Margin
$12,895~710
Indirect Costs
Payroll and Related Expenses
Other Indirect. Expenses
$11,166,489
Tota/lndlrect Expenses
$18,788,711
Net P~ofJtI.fLoss)
($5,893;QQ1}
7,622,2~2
L.Woerner, Inc. dba HeR
Year One· Opening Balance Sheet
ASSETS:
Current Assets
Cash
Accounts Receivable
Prepaid Expenses
. Total Current Assets
Total Property, Plant & Equipment
Other Assets
Intangibles and Security Deposits
TOTAL ASSETS
BFA Attachment D
$1,382,549
8,990,510
300,000
10,673,059
2,092,915
2,061,000
$14.826,974
Liabilities:
Current Liabilities
Line of Credit Payable
. - -_
Llbor Term"'Note/Current
Accounts Payable
Accrued Expenses
Accrued Payroll & Fringes
Unearned Revenue
Reserve for Payor Settl,ments
Total Current Liabilities
Other Liabilities
.Long Term Note
Security Deposits- Patients
$4,880,000
":····-'·-329;643'
1,231,843
425,000
1,726,521
360,000
7,183,200
16,126,207
. 37,423
TOT~L LIABIL~TIES
16,163,629
STOCKHOLDERS· EQUITY:
Common Stock
Unearned ESOP sn~lrAA
Additional Paid In Capital
Treasury Stock
Owner Contributions
Retained Earnings
93,600
(683,604)
604,371
(392,193)
1,050,000
(2,008,829)
TOTAL STOCKHOLDERS· EQUITY
(1 ,336,656)
$14,826,974
BFA Attachment E
Woern~r,
d/b/a HCR Corporate Structure (Post-Transaction)
'* CON for purchase of Delaware County CHAA and LTHHCP also is currently in process.