TY 2010 Form 990

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)	(C) Position (check all that apply)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(1) CHESTER PATRICK MD CHAIRMAN	2.00	X	X			0	0
(2) DAVID NOLAN VICE CHAIRMAN/TREASURER	2.00	X	X			0	0
(3) LYNN REESE SECRETARY	2.00	X	X			0	0
(4) MARY DAVIS DIRECTOR	2.00	X				0	0
(5) W ROBERT HERMANN DIRECTOR	2.00	X				0	0
(6) MICHAEL KRAMER DIRECTOR	2.00	X				0	0
(7) KIM COOK DIRECTOR	2.00	X				0	0
(8) RONALD CANTOR DIRECTOR	2.00	X				0	0
(9) DR ANKUR DESAI DIRECTOR	2.00	X				0	0
(10) SALLY HINMAN DIRECTOR	2.00	X				0	0
(11) DARLENE BURNS CEO	55.00		X			319,787	9,513
(12) WALEED ALBERT MD CMO	55.00			X		258,673	14,874
(13) BASIL ARIGLIO COO	55.00			X		248,376	14,874
(14) NICHOLAS MAYHEW CFO	55.00			X		204,052	14,803
(15) RAYMOND CARNEVALE VP	55.00				X	165,054	5,871
(16) BRUCE PETERSON AVP/CIO	55.00				X	148,182	14,712
(17) SCOTT BURNS PHARMACY DIRECTOR	55.00				X	129,443	11,226

(A) Name and business address	(B) Description of services	(C) Compensation
CENTREX LABS 28 CAMPION RD NEW HARTFORD,NY13413	LAB SERVICES	4,152,631
CARDINAL HEALTH 6012 EAST MOLLOY ROAD SYRACUSE,NY13211	PHARMECEUTICALS	2,194,251
ROME EMERGENCY SERVICES 484 TEMPLE HILL ROAD NEW WINDSOR,NY12553	ER SERVICES	424,583
HUEBER BREUER PO BOX 515 SYRACUSE,NY13205	ARCHITECT	362,073
CHUL JO YANG MD 115 GENESEE STREET NEW HARTFORD,NY13413	PSYCHIATRY SERVICES	112,667
2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization 5

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.	(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses
1	Grants and other assistance to governments and organizations in the U.S. See Part IV, line 21
2	Grants and other assistance to individuals in the U.S. See Part IV, line 22
3	Grants and other assistance to governments, organizations, and individuals outside the U.S. See Part IV, lines 15 and 16
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....	1,084,971		1,084,971
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....
7	Other salaries and wages	37,364,917	32,527,641	4,837,276
8	Pension plan contributions (include section 401(k) and section 403(b) employer contributions) ....	1,523,167	1,343,311	179,856
9	Other employee benefits .......	5,705,139	5,705,129	10
10	Payroll taxes ...........	2,815,978	2,458,269	357,709
11	Fees for services (non-employees):
a	Management ......
b	Legal .........	120,286		120,286
c	Accounting ...........	80,316		80,316
d	Lobbying ...........
e	Professional fundraising. See Part IV, line 17..
f	Investment management fees ......	11,238		11,238
g	Other ..........
12	Advertising and promotion ....
13	Office expenses .......	491,448	201,798	289,650
14	Information technology ......	798,994	101,197	697,797
15	Royalties ..
16	Occupancy ...........	892,877	840,172	52,705
17	Travel ............	104,220	52,847	51,373
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......
19	Conferences, conventions, and meetings ....	66,991	43,466	23,525
20	Interest ...........	626,370	586,975	39,395
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization .....	4,198,041	3,696,369	501,672
23	Insurance ..............	1,259,288	58,791	1,200,497
24	Other expenses. Itemize expenses not covered above. (Expenses grouped together and labeled miscellaneous may not exceed 5% of total expenses shown on line 25 below.)
a	PURCHASE SERVICES	6,820,414	6,367,825	452,589	0
b	SUPPLIES	6,180,701	6,157,102	23,599	0
c	BAD DEBT EXPENSE	6,147,555	6,147,555	0	0
d	PHARMACY	2,621,499	2,614,773	6,726	0
e	OTHER	2,472,998	796,473	1,676,525	0
f	All other expenses	4,987,759	4,595,591	392,168
25	Total functional expenses. Add lines 1 through 24f	86,375,167	74,295,284	12,079,883	0
26	Joint costs. Check here if following SOP 98-2 (ASC 958-720). Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation

Part X Balance Sheet
	1	Cashnon-interest-bearing ..........	24,396	1	3,031,569
2	Savings and temporary cash investments .......	2,456,924	2	2,274,926
3	Pledges and grants receivable, net .........		3
4	Accounts receivable, net .........	11,270,550	4	11,374,729
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........		5
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........		6
7	Notes and loans receivable, net .............	2,509,492	7	1,388,348
8	Inventories for sale or use ..............	1,592,849	8	1,959,094
9	Prepaid expenses and deferred charges ............	738,790	9	806,060
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	80,041,751
b	Less: accumulated depreciation. .....	10b	41,082,506	37,096,532	10c	38,959,245
11	Investments—publicly traded securities ..........		11
12	Investments—other securities. See Part IV, line 11 ......		12
13	Investments—program-related. See Part IV, line 11 ..		13
14	Intangible assets .........		14
15	Other assets. See Part IV, line 11 ...........	1,301,948	15	1,640,006
16	Total assets. Add lines 1 through 15 (must equal line 34)...	56,991,481	16	61,433,977
	17	Accounts payable and accrued expenses .	10,769,280	17	11,529,039
18	Grants payable ..........		18
19	Deferred revenue ..........		19
20	Tax-exempt bond liabilities ..........		20
21	Escrow or custodial account liability. Complete Part IV of Schedule D..		21
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........		22
23	Secured mortgages and notes payable to unrelated third parties ..	13,625,864	23	13,736,568
24	Unsecured notes and loans payable to unrelated third parties ....	5,712,593	24	6,575,000
25	Other liabilities. Complete Part X of Schedule D.....	2,839,427	25	5,196,586
26	Total liabilities. Add lines 17 through 25.....	32,947,164	26	37,037,193
		Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....	23,585,306	27	23,772,243
28	Temporarily restricted net assets .....	12,024	28	40,494
29	Permanently restricted net assets .....	446,987	29	584,051
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances .....	24,044,317	33	24,396,784
34	Total liabilities and net assets/fund balances .....	56,991,481	34	61,433,977

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.

Attach to Form 990 or Form 990-EZ. right arrow

See separate instructions.

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization

ROME MEMORIAL HOSPITAL

Employer identification number

16-1471634

Part I

Reason for Public Charity Status (All organizations must complete this part.) See instructions

The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)

A church, convention of churches, or association of churches. section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in

section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in

section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross

receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of

its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses

acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)

An organization organized and operated exclusively to test for public safety. Seesection 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.

Type I

Type II

Type III - Functionally integrated

Type III - Other

By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).

If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box ..................................................

Since August 17, 2006, has the organization accepted any gift or contribution from any of the
following persons?

(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)

Yes

and (iii) below, the governing body of the the supported organization? ................

11g(i)

(ii) a family member of a person described in (i) above? ......................

11g(ii)

(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................

11g(iii)

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(iv) Is the organization in col. (i) listed in your governing document?		(v) Did you notify the organization in col. (i) of your support?		(vi) Is the organization in col. (i) organized in the U.S.?		(vii) Amount of support?
(i) Name of supported organization	(ii) EIN	Yes	No	Yes	No	Yes	No	(vii) Amount of support?


Total

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2010

Page 2

Part II

Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year(or fiscal year beginning in)		(a) 2006	(b) 2007	(c) 2008	(d) 2009	(e) 2010	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3	The value of services or facilities furnished by a governmental unit to the organization without charge..
4	Total. Add lines 1 through 3..
5	The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6	Public Support. Subtract line 5 from line 4.

Section B. Total Support

Calendar year(or fiscal year beginning in)		(a) 2006	(b) 2007	(c) 2008	(d) 2009	(e) 2010	(f) Total
7	Amounts from line 4..
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9	Net income from unrelated business activities, whether or not the business is regularly carried on..
10	Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11	Total support (Add lines 7 through 10).

Gross receipts from related activities, etc. (See instructions.) ..................

First Five Years If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.......................................... right arrow

Section C. Computation of Public Support Percentage

Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f)) .........

Public Support Percentage for 2009 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2010. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ...................... right arrow

33 1/3% support test—2009. If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2010. If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization .................................................. right arrow

10%-facts-and-circumstances test—2009. If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly
supported organization .............................................. right arrow

Private Foundation If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions ................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2010

Page 3

Part III

Support Schedule for Organizations Described in IRC 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)

Section A. Public Support

Calendar year(or fiscal year beginning in)		(a) 2006	(b) 2007	(c) 2008	(d) 2009	(e) 2010	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2	Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3	Gross receipts from activities that are not an unrelated trade or business under section 513..
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5	The value of services or facilities furnished by a governmental unit to the organization without charge..
6	Total. Add lines 1 through 5.
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons...
b	Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c	Add lines 7a and 7b..
8	Public Support (Subtract line 7c from line 6.)

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2006	(b) 2007	(c) 2008	(d) 2009	(e) 2010	(f) Total
9	Amounts from line 6...
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.
11	Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13	Total support (Add lines 9, 10c, 11 and 12.).

Section C. Computation of Public Support Percentage

Public Support Percentage for 2010 (line 8 column (f) divided by line 13 column (f)) .........

Public support percentage from 2009 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f)) ......

Investment income percentage from 2009 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2010. If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .......... right arrow

33 1/3% support tests—2009. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .... right arrow

Private Foundation If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions ..... right arrow

Schedule A (Form 990 or 990-EZ) 2010

Page 4

Part IV

Supplemental Information. Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2010

Additional Data

Software ID:
Software Version:

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

OMB No. 1545-0047

2010

Name of organization

ROME MEMORIAL HOSPITAL

Employer identification number

16-1471634

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

Check if your organization is covered by the General Rule or a Special Rule.
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.

General Rule

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or
property) from any one contributor. Complete Parts I and II.

Special Rules

For a section 501(c)(3) organization filing Form 990 or 990-EZ, that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), and received from any one contributor, during the year, a contribution of the
greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For a section 501(c)(7), (8), or (10) organization filing Form 990, or 990-EZ, that received from any one contributor,
during the year, aggregate contributions of more than $1,000 for use exclusively for religious, charitable,
scientific, literary, or educational purposes, or the prevention of cruelty to children or animals. Complete Parts I, II, and
III.

For a section 501(c)(7), (8), or (10) organization filing Form 990, or 990-EZ, that received from any one contributor,
during the year, contributions for use exclusively for religious, charitable, etc., purposes, but these contributions did
not aggregate to more than $1,000. If this box is checked, enter here the total contributions that were received during
the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule
applies to this organization because it received nonexclusively religious, charitable, etc., contributions of $5,000 or more
during the year. ......................... Arrow Bullet

Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990, or check the box in the heading of its
Form 990-EZ, or on line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).

For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2010)

Name of organization ROME MEMORIAL HOSPITAL
Schedule B (Form 990, 990-EZ, or 990-PF) (2010) Page 1 of 1 of Part I
Part I	Contributors (see Instructions)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
RESTRICTED	RESTRICTED RESTRICTED RESTRICTED RESTRICTED, RESTRICTED RESTRICTED	$RESTRICTED	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Name of organization ROME MEMORIAL HOSPITAL
Schedule B (Form 990, 990-EZ, or 990-PF) (2010) Page 1 of 1 of Part II
Part II	Noncash Property (see Instructions)
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Page 1 of 1 of Part III

Name of organization
ROME MEMORIAL HOSPITAL

Employer identification number

16-1471634

Part III

Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
aggregating more than $1,000 for the year. (Complete columns (a) through (e) and the following line entry.)
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet

Complete if the organization is described below.
SchCMd Bullet

Attach to Form 990 or Form 990-EZ. SchCMd Bullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public
Inspection

If the organization answered “Yes,” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet

Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet

Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes,” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet

Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)) Complete Part II-A. Do not complete Part II-B.
Round Bullet

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes,” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35a (Proxy Tax), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

ROME MEMORIAL HOSPITAL

Employer identification number

16-1471634

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization's direct and indirect political campaign activities on behalf of or in opposition to candidates for public office in Part IV.

Political expenditures .................................... SchCMd Bullet

Volunteer hours ........................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ......... SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ...... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............

Yes No

Was a correction made? .........................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c) except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt funtion activities .................................... SchCMd Bullet

Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b.. SchCMd Bullet

Did the filing organization file Form 1120-POL for this year? ..........................

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.

For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2010

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check if the filing organization belongs to an affiliated group.
B Check if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(b) Affiliated Group Totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......
b	Total lobbying expenditures to influence a legislative body (direct lobbying) .......
c	Total lobbying expenditures (add lines 1a and 1b) ...................
d	Other exempt purpose expenditures ........................
e	Total exempt purpose expenditures (add lines 1c and 1d) ...............
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) .................
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ................
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ................
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ......................................	Yes No

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2007	(b) 2008	(c) 2009	(d) 2010	(e) Total

2a	Lobbying non-taxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots non-taxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2010

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

(a)

Yes

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

Volunteers? .........................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....

Media advertisements? ....................................

Mailings to members, legislators, or the public? .........................

Publications, or published or broadcast statements? .......................

Grants to other organizations for lobbying purposes? .......................

Direct contact with legislators, their staffs, government officials, or a legislative body? ........

Yes

20,844

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......

Other activities? If "Yes," describe in Part IV ..........................

Total. lines 1c through 1i ...................................

20,844

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 .................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ................

Did the organization agree to carryover lobbying and political expenditures from the prior year? ..........

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) if BOTH Part III-A, lines 1 and 2 are answered “No” OR if Part III-A, line 3 is answered “Yes”.

Dues, assessments and similar amounts from members .....................

Section 162(e) non-deductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).

Current year .........................................

Carryover from last year ....................................

Total ...........................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................

Taxable amount of lobbying and political expenditures (see instructions) ..............

Part IV

Supplemental Information

Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; and Part ll-B, line 1i.
Also, complete this part for any additional information.

Identifier	Return Reference	Explanation
EXPLANATION OF OTHER LOBBYING ACTIVITIES:	PART II-B, LINE 1I:	$20,844 REPRESENTS THE PORTION OF THE 2010 MEMBERSHIP DUES OF HANYS, AHA, AND IROQUOIS HEALTHCARE ALLIANCE, THAT RMH IS A MEMBER OF, THAT HAS BEEN DEEMED TO BE RELATED TO LOBBYING EXPENSES. THESE EXPENDITURES ARE DEFINED AS DIRECT COMMUNICATIONS WITH CERTAIN MEMBERS OF FEDERAL, STATE, OR LOCAL GOVERNMENTS TO INFLUENCE LEGISLATION.

Schedule C (Form 990 or 990EZ) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11, or 12.
SchDMd Bullet

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

ROME MEMORIAL HOSPITAL

Employer identification number

16-1471634

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .......
2	Aggregate contributions to (during year) ...
3	Aggregate grants from (during year) ...
4	Aggregate value at end of year .......

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds may be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit. ...................................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or pleasure) Preservation of an historically importantly land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a–2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements .......................	2a
b	Total acreage restricted by conservation easements ..................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 8/17/06 ........	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the taxable year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................

Yes No

Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................

Yes No

In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.

If the organization elected, as permitted under SFAS 116, not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under SFAS 116, to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:

(i)

Revenues included in Form 990, Part VIII, line 1 ........................ SchDMd Bullet

(ii)

Assets included in Form 990, Part X .............................. SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 relating to these items:

Revenues included in Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990

Cat. No. 52283D

Schedule D (Form 990) 2010

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.

During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No

If "Yes," explain the arrangement in Part XIV and complete the following table:


c	Beginning balance .................................	1c
d	Additions during the year ..............................	1d
e	Distributions during the year .............................	1e
f	Ending balance ...................................	1f

Did the organization include an amount on Form 990, Part X, line 21? .....................

Yes No

If “Yes,” explain the arrangement in Part XIV.

Part V

Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.

		(a)Current Year	(b)Prior Year	(c)Two Years Back
1a	Beginning of year balance ....	591,605	338,312	33,374
b	Contributions ........	4,471	120,609	304,938
c	Investment earnings or losses ...	28,465	132,684
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........
f	Administrative expenses ....
g	End of year balance ......	624,541	591,605	338,312

Provide the estimated percentage of the year end balance held as:

Board designated or quasi-endowment: SchDMd Bullet

6.000 %

Permanent endowment: SchDMd Bullet

94.000 %

Term endowment: SchDMd Bullet

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) unrelated organizations ........................

3a(i)

(ii) related organizations ........................

3a(ii)

If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIV the intended uses of the organization's endowment funds.

Part VI

InvestmentsLand, Buildings, and Equipment. See Form 990, Part X, line 10.

Description of investment		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................
b	Buildings ................	41,294,593	15,588,624	25,705,969
c	Leasehold improvements ............	2,197,063	2,051,405	145,658
d	Equipment ................	30,467,079	21,584,470	8,882,609
e	Other .................	6,083,016	1,858,007	4,225,009
Total. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)........				38,959,245

Schedule D (Form 990) 2010

Page 3

Part VII

InvestmentsOther Securities. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)		(b)Book value	(c) Method of valuation: Cost or end-of-year market value
(1)Financial derivatives
(2)Closely-held equity interests
Other








Total. (Column (b) should equal Form 990, Part X, col.(B) line 12.)

Part VIII

InvestmentsProgram Related. See Form 990, Part X, line 13.

(a) Description of investment type		(b) Book value	(c) Method of valuation: Cost or end-of-year market value









Total. (Column (b) should equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. See Form 990, Part X, line 15.

(a) Description				(b) Book value









Total. (Column (b) should equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities. See Form 990, Part X, line 25.

1.(a) Description of Liability		(b) Amount
Federal Income Taxes
LINE OF CREDIT		4,000,000
ASSET RETIREMENT		556,928
ADVANCE FROM THIRD PARTIES		441,000
THIRD PARTY PAYABLES		198,658





Total. (Column (b) should equal Form 990, Part X, col.(B) line 25.)		5,196,586
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).

Schedule D (Form 990) 2010

Page 4

Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1	Total revenue (Form 990, Part VIII, column (A), line 12) ....................	1	86,430,807
2	Total expenses (Form 990, Part IX, column (A), line 25) .....................	2	86,375,167
3	Excess or (deficit) for the year. Subtract line 2 from line 1 .............	3	55,640
4	Net unrealized gains (losses) on investments ..........................	4	231,197
5	Donated services and use of facilities .............................	5
6	Investment expenses ...................................	6
7	Prior period adjustments ..................................	7
8	Other (Describe in Part XIV) .................................	8	65,630
9	Total adjustments (net). Add lines 4 - 8 .............................	9	296,827
10	Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 .........	10	352,467

Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1	Total revenue, gains, and other support per audited financial statements .......			1	95,986,569
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains on investments ..........	2a	231,197
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIV): ............	2d	9,335,803
e	Add lines 2a through 2d .....................			2e	9,567,000
3	Subtract line 2e from line 1.....................			3	86,419,569
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part XIV): ...........	4b	11,238
c	Add lines 4a and 4b.......................			4c	11,238
5	Total Revenue. Add lines 3 and 4c. (This should equal Form 990, Part I, line 12.) ......			5	86,430,807

Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1	Total expenses and losses per audited financial statements .............			1	95,880,402
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities ..........	2a
b	Prior year adjustments ..............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIV): ............	2d	9,516,473
e	Add lines 2a through 2d......................			2e	9,516,473
3	Subtract line 2e from line 1.....................			3	86,363,929
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a
b	Other (Describe in Part XIV): ............	4b	11,238
c	Add lines 4a and 4b.......................			4c	11,238
5	Total expenses. Add lines 3 and 4c. (This should equal Form 990, Part I, line 18.) ......			5	86,375,167

Part XIV

Supplemental Information

Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.

Identifier	Return Reference	Explanation
DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS:	PART V, LINE 4:	INTENDED USE OF ENDOWMENT FUND IS THAT THE PRINCIPLE CAN BE INVESTED, WHILE KEPT IN TACT IN PERPETUITY; ONLY THE INCOME GENERATED CAN BE USED BY THE ORGANIZATION.
		PART X - LIABILITY UNDER FIN 48 FOOTNOTE RMH IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501 (C) (3) OF THE INTERNAL REVENUE CODE, AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501 (A) OF THE INTERNAL REVENUE CODE. THE STANDARDS FOR ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES ESTABLISH A RECOGNITION THRESHOLD AND MEASUREMENT FOR INCOME TAX POSITIONS RECOGNIZED IN THE HOSPITAL'S CONSOLIDATED FINANCIAL STATEMENTS. THESE STANDARDS HAD NO IMPACT ON THE ACCOMPANYING FINANCIAL STATEMENTS. AS OF DECEMBER 31, 2010, THE HOSPITAL DID NOT HAVE ANY UNRECOGINIZED TAX BENEFITS OR ANY RELATED ACCRUED INTEREST OR PENALTIES. THE TAX YEARS OPEN TO EXAMINATION BY FEDERAL AND STATE TAXING AUTHORITIES ARE 2007 THROUGH 2010. PART XI, LINE 8 - RECONCILIATION OF CHANGES - OTHER AFFILIATE INCOME-CONSOLIDATED FINANCIAL STATEMENTS $ 9,555,768 AFFILIATE EXPENSES-CONSOLIDATED FINANCIAL STATEMENTS $-9,505,233 BOOK TO TAX DEPRECIATION DIFFERENCE $-4,198,041 BOOK/TAX DEPRECIATION DIFFERENCE $ 4,198,041 PART XII, LINE 2D - REVENUE AMOUNTS INCLUDED IN FINANCIALS - OTHER AFFILIATE INCOME - CONSOLIDATED FINANCIAL STATEMENTS $9,555,768 PART XIII, LINE 2D - EXPENSE AMOUNTS INCLUDED IN FINANCIALS - OTHER AFFILIATE EXPENSES-CONSOLIDATED FINANCIAL STATEMENTS $ 9,505,233 PART XIII, LINE 4B - EXPENSE AMOUNTS INCLUDED ON RETURN - OTHER BOOK TO TAX DEPRECIATION DIFFERENBCE $-4,198,041 BOOK /TAX DEPRECIATION DIFFERENCE $ 4,198,041

Schedule D (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

ROME MEMORIAL HOSPITAL

Employer identification number

16-1471634

Part I

Charity Care and Certain Other Community Benefits at Cost

Yes

Does the organization have a charity care policy? If "No," skip to question 6a...........

Yes

If "Yes," is it a written policy? .......................

Yes

If the organization has multiple hospitals, indicate which of the following best describes application of the charity care policy to the various hospitals.

Applied uniformly to all hospitals Applied uniformly to most hospitals Generally tailored to individual hospitals

Answer the following based on the charity care eligibility criteria that applies to the largest number of the organization's patients.

Does the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care to low

income individuals? If "Yes," indicate which of the following is the FPG family income limit for eligibility for free care:

Yes

100% 150% 200% Other

Does the organization use FPG to determine eligibility for providing discounted care to low income individuals? If

"Yes," indicate which of the following is the family income limit for eligibility for discounted care: .....

Yes

200% 250% 300% 350% 400% Other

If the organization does not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization uses an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.

Does the organization's policy provide free or discounted care to the "medically indigent"? ......

Does the organization budget amounts for free or discounted care provided under its charity care policy? ...

If "Yes," did the organization's charity care expenses exceed the budgeted amount?.........

If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discounted
care to a patient who was eligibile for free or discounted care?...............

Does the organization prepare an annual community benefit report?.............

Yes

If "Yes," does the organization make it available to the public? ..............

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Charity Care and Certain Other Community Benefits at Cost

	(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a Charity care at cost (from Worksheets 1 and 2) ..	736,642	297,188	439,454	0.550 %
b Unreimbursed Medicaid (from Worksheet 3, column a) .	18,353,138	14,685,209	3,667,929	4.570 %
c Unreimbursed costs—other means-tested government programs (from Worksheet 3, column b) ....	562,273	384,532	177,741	0.220 %
dTotal Charity Care and Means-Tested Government Programs .....	19,652,053	15,366,929	4,285,124	5.340 %
Other Benefits e Community health improvement services and community benefit operations (from (Worksheet 4) ....	76,946	31,591	45,355	0.060 %
f Health professions education (from Worksheet 5) ..	30,920	29,302	1,618	0 %
g Subsidized health services (from Worksheet 6) ..
h Research (from Worksheet 7)
i Cash and in-kind contributions to community groups (from Worksheet 8) ..
jTotal Other Benefits ...	107,866	60,893	46,973	0.060 %
kTotal. Add lines 7d and 7j. ..	19,759,919	15,427,822	4,332,097	5.400 %

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2010

Schedule H (Form 990) 2010

Page 2

Part II

Community Building Activities Complete this table if the organization conducted any community building activities.

		(c) Total community building expense	(d) Direct offsetting revenue	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building	789	494	295	0 %
7	Community health improvement advocacy	1,979	0	1,979	0 %
8	Workforce development	75,305	0	75,305	0.090 %
9	Other
10	Total	78,073	494	77,579	0.090 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Does the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................

Enter the amount of the organization's bad debt expense (at cost).....

2,095,202

Enter the estimated amount of the organization's bad debt expense (at cost) attributable to patients eligible under the organization's charity care policy ..

166,065

Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense. In addition, describe the costing methodology used in determining the amounts reported on lines 2 and 3, and rationale for including a portion of bad debt amounts as community benefit.

Section B. Medicare

Enter total revenue received from Medicare (including DSH and IME).....

23,850,824

Enter Medicare allowable costs of care relating to payments on line 5.....

27,906,493

Subtract line 6 from line 5. This is the surplus or (shortfall)........

-4,055,669

Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.
Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.
Check the box that describes the method used:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Does the organization have a written debt collection policy? ...............

Yes

If "Yes," does the organization's collection policy contain provisions on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance? Describe in Part VI......

Part IV

Management Companies and Joint Ventures

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership%	(e) Physicians' profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2010

Page 3

Part VFacility Information

Section A. Hospital Facilities (list in order of size, measured by total revenue per facility, from largest to smallest) How many hospital facilities did the organization operate during the tax year?12 Name and address		Other (Describe)
1	ROME MEMORIAL HOSPITAL 1500 NORTH JAMES STREET ROME,NY13440	X	X	X
2	COMMUNITY RECOVERY CENTER 264 W DOMINICK STREET ROME,NY13440				SUBSTANCE ABUSE COUNSELING
3	MOHAWK VALLEY RADIATION MEDICINE 107 E CHESTNUT STREET ROME,NY13440				RADIATION ONCOLOGY
4	PHYSICAL THERAPY 107 E CHESTNUT STREET ROME,NY13440				OFFSITE PHYSICAL THERAPY SERVICES
5	BOONVILLE FAMILY CARE 13407 ROUTE 12 BOONVILE,NY13309				PRIMARY CARE SERVICES
7	LABORATORY COLLECTION SITE 1801 BLACK RIVER BLVD ROME,NY13440				OFFSITE LAB COLLECTION SITE
8	LABORATORY COLLECTION SITE 1617 N JAMES STREET ROME,NY13440				OFFSITE LAB COLLECTION SITE
9	LABORATORY COLLECTION SITE 13407 STATE ROUTE 12 BOONVILE,NY13309				OFFSITE LAB COLLECTION SITE
10	LABORATORY COLLECTION SITE BEECHES OFFICE COMPLEX-TURIN RD ROME,NY13440				OFFSITE LAB COLLECTION SITE
11	MEDICAL IMAGING 1819 BLACK RIVER BLVD ROME,NY13440	OFFSITE RADIOLOGY SERVICES
12	MEDICAL IMAGING 1617 N JAMES STREET ROME,NY13440	OFFSITE RADIOLOGY SERVICES
13	MEDICAL IMAGING 1801 BLACK RIVER BLVD ROME,NY13440	OFFSITE RADIOLOGY SERVICES

Schedule H (Form 990) 2010

Page 4

Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)

Name of Hospital Facility:ROME MEMORIAL HOSPITAL

Line Number of Hospital Facility (from Schedule H, Part V, Section A):1

				Yes	No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2010)
1	During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. .....................		1
	If “Yes,” indicate what the Needs Assessment describes (check all that apply):
	a	A definition of the community served by the hospital facility
	b	Demographics of the community
	c	Existing health care facilities and resources within the community that are available to respond to the health needs of the community
	d	How data was obtained
	e	The health needs of the community
	f	Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
	g	The process for identifying and prioritizing community health needs and services to meet those needs
	h	The process for consulting with persons representing the community’s interests
	i	Information gaps that limit the hospital facility’s ability to assess all of the community’s health needs
	j	Other (describe in Part VI)
2	Indicate the tax year the hospital facility last conducted a Needs Assessment: 20
3	In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted.		3
4	Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................		4
5	Did the hospital facility make its Needs Assessment widely available to the public? ...........		5
	If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
	a	Hospital facility’s website
	b	Available upon request from the hospital facility
	c	Other (describe in Part VI)
6	If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
	a	Adoption of an implementation strategy to address the health needs of the hospital facility’s community
	b	Execution of the implementation strategy
	c	Development of a community benefit plan for the facility
	d	Participation in community-wide community benefit plan
	e	Inclusion of a community benefit section in operational plans
	f	Adoption of a budget for provision of services that address the needs identified in the CHNA
	g	Prioritization of health needs in the community
	h	Prioritization of services that the hospital facility will undertake to meet health needs in its community
	i	Other (describe in Part VI)
7	Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed together with the reasons why it has not addressed such needs.		7
Financial Assistance Policy
	Did the hospital facility have in place during the tax year a written financial assistance policy that:
8	Explains eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?		8		No
9	Used federal poverty guidelines (FPG) to determine eligibility for providing free care to low incomeindividuals?..		9		No
	If “Yes,” indicate the FPG family income limit for eligibility for free care: %

Schedule H (Form 990) 2010

Page 5

Part VFacility Information (continued)

				Yes	No
10	Used FPG to determine eligibility for providing discounted care to low income individuals?.........		10		No
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: %
11	Explained the basis for calculating amounts charged to patients?.................		11		No
	If “Yes,” indicate the factors used in determining such amounts (check all that apply):
	a	Income level
	b	Asset level
	c	Medical indigency
	d	Insurance status
	e	Uninsured discount
	f	Medicaid/Medicare
	g	State regulation
	h	Other (describe in Part VI)
12	Explained the method for applying for financial assistance?...................		12		No
13	Included measures to publicize the policy within the community served by the hospital facility?.......		13		No
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
	a	The policy was posted at all times on the hospital facility’s web site
	b	The policy was attached to all billing invoices
	c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
	d	The policy was posted in the hospital facility’s admissions offices
	e	The policy was provided, in writing, to patients upon admission to the hospital facility
	f	The policy was available upon request
	g	Other (describe in Part VI)
Billing and Collections
14	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy that explained actions the hospital facility may take upon non-payment?........		14		No
15	Check all of the following collection actions against a patient that were permitted under the hospital facility's policies at any time during the tax year:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments or arrests
	e	Other (describe in Part VI)
16	Did the hospital facility engage in or authorize a third party to engage in any of the following collection actions during the tax year?...................................		16		No
	If “Yes,” check all collection actions in which the hospital facility or a third party engaged (check all that apply):
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other (describe in Part VI)
17	Indicate which actions the hospital facility took before initiating any of the collection actions checked in question 16 (check all that apply):
	a	Notified patients of the financial assistance policy upon admission
	b	Notified patients of the financial assistance policy prior to discharge
	c	Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
	d	Documented its determination of whether a patient who applied for financial assistance under the financial assistance policy qualified for financial assistance
	e	Other (describe in Part VI)

Schedule H (Form 990) 2010

Page 6

Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
				Yes	No
18	Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?..........		18		No
	If “No,” indicate the reasons why (check all that apply):
	a	The hospital facility did not provide care for any emergency medical conditions
	b	The hospital facility did not have a policy relating to emergency medical care
	c	The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
	d	Other (describe in Part VI)
Charges for Medical Care
19	Indicate how the hospital facility determined the amounts generally billed to individuals who had insurance covering emergency or other medically necessary care (check all that apply):
	a	The hospital facility used the lowest negotiated commercial insurance rate for those services at the hospital facility
	b	The hospital facility used the average of the three lowest negotiated commercial insurance rates for those services at the hospital facility
	c	The hospital facility used the Medicare rate for those services
	d	Other (describe in Part VI)
20	Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?.........		20		No
	If “Yes,” explain in Part VI.
21	Did the hospital facility charge any of its patients an amount equal to the gross charge for services provided to that patient?...................................		21		No
	If “Yes,” explain in Part VI.

Schedule H (Form 990) 2010

Page 7

Part VFacility Information (continued)

Section C. Other Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, measured by total revenue per facility, from largest to smallest) How many non-hospital facilities did the organization operate during the tax year?
Name and address		Type of Facility (Describe)
1
2
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2010

Page 8

Part VI

Supplemental Information

Complete this part to provide the following information.

1	Required descriptions. Provide the description required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 2, 4c, 6i, 7, 11i, 13i, 17l, 18l, 19e, 21d, 25, and 26.
2	Community health needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any community health needs assessments reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.

Identifier	ReturnReference	Explanation
		PART I, LINE 6A: ROME MEMORIAL HOSPITAL PREPARED A COMMUNITY SERVICE PLAN WHICH WAS UPDATED ON 9/15/2010. THIS IS MADE AVAILABLE TO THE PUBLIC THROUGH THE HOSPITAL'S WEBSITE.
		PART I, LINE 7: CHARITY CARE AT COST (7A) AND UNREIMBURSED COSTS - OTHER MEANS TESTED GOVERNMENT PROGRAMS (7C) WERE CALCULATED BY USING A COST TO CHARGE RATIO. THIS COST TO CHARGE RATIO WAS DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES, SUPPLIED BY THE IRS.UNREIMBURSED MEDICAID (7B) WAS CALCULATED BY USING ACTUAL COSTS.OTHER BENEFITS (7E & 7F) WERE CLACULATED BY DETERMINING ACTUAL COSTS AND ACTUAL REVENUE PER EVENT.THE MAIN SOURCE OR GUIDE OF HOW CALCULATIONS WERE DETERMINED WAS BY UTILIZING THE WORKSHEETS PROVIDED BY THE IRS AND THEN ADJUSTING ACCORDING TO ROME HOSPITAL SPECIFICS (IE. USING ACTUAL COSTS VS. COST TO CHARGE RATIO AS MENTIONED ABOVE).
		PART I, L7 COL(F): PERCENT OF TOTAL EXPENSE IS CALCULATED BY USING THE DENOMINATOR OF THE TOTAL FUNCTIONAL EXPENSES LESS BAD DEBT EXPENSE OF $6,147,555 (PER AUDITED FINANCIAL STATEMENTS).
		PART II: ROME MEMORIAL HOSPITAL HAS MAINTAINED A LONG-STANDING COMMITMENT TO WELLNESS AND PREVENTION THROUGH AN ACTIVE EDUCATION DEPARTMENT THAT PROVIDES ONGOING HEALTH EDUCATION LECTURES AND FREE SCREENINGS. IN ADDITION, THE HOSPITAL ASSURES ACCESS TO SERVICES BY CONTINUING TO PROVIDE CRITICAL SERVICES TO THE COMMUNITY, EVEN THOUGH THEY ARE OPERATED AT A LOSS TO THE HOSPITAL. THESE ARE SOME OF THE HOSPITAL'S PROGRAMS THAT SUPPORT THE STATE'S PREVENTION AGENDA AND PROMOTE HEALTHY IN OUR COMMUNITY: HEALTHY MOTHERS, HEALTHY BABIES, HEALTHY CHILDREN THE MATERNITY DEPARTMENT'S WEIGH STATION PROVIDES MOTHERS WHO ARE BREASTFEEDING ADDED SUPPORT AND ENSURE THAT BABIES ARE GAINING WEIGHT AT A HEALTHY LEVEL. BABYCARE BASICS AND BREASTFEEDING EDUCATION PROGRAMS FOR NEW PARENTS HELP THEM ACQUIRE THE NECESSARY SKILLS FOR TAKING CARE OF A NEWBORN.CHRONIC DISEASE EDUCATION HEALTH NIGHT, SENIOR LIVE & LEARN, SPEAKER'S BUREAU LECTURES, AND OUTREACH AT HEALTH FAIRS PROVIDE COMMUNITY MEMBERS WITH THE LATEST INFORMATION AVAILABLE TO HELP THEM MODIFY THEIR LIFESTYLES TO PREVENT THE ONSET OF CHRONIC DISEASE OR BETTER MANAGE THEIR CHRONIC CONDITIONS. SMOKING CESSATION CLASSES FOR THE COMMUNITY AND HOSPITAL EMPLOYEES, ALONG WITH SMOKING PREVENTION PROGRAMS FOR AREA SCHOOLS PROVIDES ESSENTIAL OUTREACH TO ERADICATE THE LEADING CAUSE OF PREMATURE DEATH. SPONSORSHIP SUPPORT OF THE AMERICAN CANCER SOCIETY, AMERICAN HEART ASSOCIATION, AMERICAN DIABETES ASSOCIATION AND OTHER HEALTH-RELATED ORGANIZATIONS TO PROVIDE FINANCIAL RESOURCES FOR EDUCATION AND RESEARCH.ACCESS TO QUALITY HEALTHCARE FREE ROUTINE SCREENINGS, INCLUDING BLOOD PRESSURE, PSAS, COLORECTAL CANCER AND DIABETES SCREENING, ARE OFFERED TO THE COMMUNITY TO PROMOTE EARLY DETECTION OF DISEASE. FACILITATED ENROLLMENT EFFORTS HELP LINK THE UNINSURED TO AVAILABLE INSURANCE OPTIONS TO ENABLE THEM TO ESTABLISH A RELATIONSHIP WITH A PRIMARY CARE PROVIDER. IMMUNIZATION CLINICS ARE OFFERED IN THE COMMUNITY TO PROTECT RESIDENTS FROM THE FLU. EFFORTS TO RECRUIT ADDITIONAL PHYSICIANS TO THE COMMUNITY ADDRESS THE FACT THAT THE MOHAWK VALLEY REGION HAS THE WORST PHYSICIAN TO POPULATION RATIO IN ALL OF NEW YORK STATE. THE NEWLY CONSTRUCTED DIAGNOSTIC CENTER INCLUDED INVESTMENTS IN THE LATEST TECHNOLOGY INCLUDING DIGITAL MAMMOGRAPHY AND A NEW MRI TO ENHANCE THE HOSPITAL'S DIAGNOSTIC CAPABILITIES. THE HOSPITAL ADDED A NURSE NAVIGATOR TO HELP COORDINATE CARE FOR PATIENTS WITH A POTENTIAL CANCER DIAGNOSIS.PHYSICAL FITNESS AND NUTRITION AN INDOOR WALKING PROGRAM HELPS AREA RESIDENTS INCORPORATE PHYSICAL FITNESS INTO THEIR LIVES TO PREVENT CHRONIC DISEASE AND ENHANCE THEIR MENTAL HEALTH.
		PART III, LINE 4: "SIGNIFICANT ESTIMATES MADE BY THE HOSPITAL INCLUDE, BUT ARE NOT LIMITED TO, THE RESERVE FOR UNCOLLECTIBLE ACCOUNTS, RESERVES FOR THIRD-PARTY CONTRACTUAL ADJUSTMENTS AND SETTLEMENTS AND INSURANCE RESERVES. THE CURRENT ECONOMIC ENVIRONMENT HAS INCREASED THE DEGREE OF UNCERTAINITY INHERENT IN THOSE ESTIMATES AND ASSUMPTIONS.""AN ALLOWANCE FOR DOUBTFUL ACCOUNTS RECEIVABLE IS ESTIMATED BY MANAGEMENT BASED ON PERIODIC REVIEWS OF THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE CONSIDERING HISTORICAL EXPERIENCE AND PREVAILING ECONOMIC CONDITIONS."FROM THE AGED ACCOUNTS RECEIVABLE TRIAL BALANCE, THE PAYOR CLASSES ARE SUMMARIZED INTO FOUR CATEGORIES: COLLECTION, SELF PAY, TIME PLAN AND OTHERS (ALL OTHER INSURANCE BALANCES) BY AGING BUCKET. IN ADDITION:THE ACCOUNTS THAT ARE "COLLECTION" ARE ALL PATIENT ACCOUNTS THAT HAVE BEEN SENT TO A COLLECTION AGENCY. FOR ALL ACCOUNTS THAT ARE CONSIDERED COLLECTION THESE ACCOUNTS ARE RESERVED AT:UNBILLED 150 DAYS - 98.63% LESS THE SURCHARGE PORTION OF THE SELF PAY OF 9.63%.151+ DAYS - 99.73% LESS THE SURCHARGE PORTION OF THE SELF PAY OF 9.63%.FOR SELF PAY ACCOUNTS THE FOLLOWING PERCENTAGES ARE USED:UNBILLED - 30%0-30 DAYS - 45%31-60 DAYS - 60%61-90 DAYS - 70%91-120 DAYS - 75%121-150 DAYS - 85%151+ DAYS - 90%FOR TIME PLAN ACCOUNTS THE FOLLOWING PERCENTAGES ARE USED:UNBILLED - 62.38%0-30 DAYS - 62.38%31-60 DAYS - 62.38%61-90 DAYS - 62.38%91-120 DAYS - 62.38%121-150 DAYS - 62.38%151+ DAYS - 62.38%FOR OTHER ACCOUNTS THE FOLLOWING PERCENTAGES ARE USED:UNBILLED - 5%0-30 DAYS - 5%31-60 DAYS - 0%61-90 DAYS - 0%91-120 DAYS - 0%121-150 DAYS - 0%151+ DAYS - 0%THE BAD DEBT RESERVE THAT IS CALCULATED MONTHLY USING THIS ANALYSIS IS COMPARED TO ACTUAL RESERVE AT MONTH END. IF NECESSARY AN ADJUSTMENT WILL BE RECORDED.COSTING METHODOLOGY USED IN DETERMINING THE AMOUNTS REPORTED ON LINES 2 & 3:RATIO OF PATIENT CARE COST TO CHARGES
		PART III, LINE 8: THE EXTENT TO WHICH THE SHORTFALL IN QUESTION 7 SHOULD BE TREATED AS A COMMUNITY BENEFIT IS BEST DESCRIBED BY INFORMATION AVAILABLE IN ROME MEMORIAL HOSPITAL'S COMMUNITY SERVICE PLAN AND ANNUAL UPDATES:FINANCIAL AID PROGRAM A. SUCCESSES AND CHALLENGES WITH TOUGH ECONOMIC TIMES BATTERING THE COUNTRY, MANY PEOPLE HAVE LOST THEIR HEALTH INSURANCE. MANY CANNOT AFFORD RISING PREMIUMS, WHILE OTHERS HAVE LOST THEIR JOBS COMPLETELY. SOME PEOPLE HAVE INSURANCE, BUT THEIR OUT-OF-POCKET COSTS ARE HIGH BECAUSE EMPLOYERS HAVE RAISED THEIR DEDUCTIBLES OR CO-PAYMENTS, OR REDUCED WHAT THEIR PLANS COVER. AS A RESULT, THE AMOUNT OF UNCOMPENSATED CARE PROVIDED BY RMH CONTINUES TO GROW.TO HELP THOSE WHO ARE UNINSURED LEARN MORE ABOUT POSSIBLE OPTIONS, THE HOSPITAL'S PATIENT REGISTRATION DEPARTMENT PROVIDES INFORMATION FROM INSURERS WHICH OFFER FREE OR LOW-COST HEALTH INSURANCE THROUGH NEW YORK STATE'S CHILD HEALTH PLUS AND FAMILY HEALTH PLUS, ALONG WITH SPACE FOR REPRESENTATIVES TO ANSWER QUESTIONS AND ENROLL ELIGIBLE RESIDENTS.IN ADDITION, THE HOSPITAL HAS PARTNERED WITH THE MOHAWK VALLEY PERINATAL NETWORK, WHOSE FACILITATED ENROLLER CAN ASSIST INDIVIDUALS IN APPLYING FOR COVERAGE FROM CHILD HEALTH PLUS, FAMILY HEALTH PLUS, AND MEDICAID. THE ENROLLER IS LOCATED DOWNTOWN IN THE HOSPITAL'S BUSINESS OFFICE, 155 W. DOMINICK ST. IN ADDITION TO HELPING PEOPLE OBTAIN INSURANCE COVERAGE, THE HOSPITAL ALSO PROVIDES A FINANCIAL ASSISTANCE PROGRAM AND WORKS WITH PATIENTS TO SET UP AFFORDABLE PAYMENT PLANS.FINANCIAL ASSISTANCE BROCHURES ARE LOCATED IN THE HOSPITAL'S WAITING AREAS AND APPLICATIONS ARE AVAILABLE ON THE WEBSITE. RMH DISCOUNTS PATIENT ACCOUNTS UP TO 100% DEPENDING UPON FAMILY INCOME IN COMPARISON TO THE FEDERAL POVERTY LEVEL. DISCOUNTS ARE BASED UPON THE BLUE CROSS RATE. ROME MEMORIAL HOSPITAL OFFERS DISCOUNTS TO THE UNINSURED/UNDERINSURED WHOSE INCOME IS UP TO 300% OF THE FEDERAL POVERTY LEVEL.BECAUSE LACK OF AWARENESS IS ONE OF THE BIGGEST BARRIERS, RMH PROVIDES INFORMATION ABOUT AVAILABLE PROGRAMS AT HEALTH FAIRS AND OTHER OUTREACH ACTIVITIES.CHANGES (ACTUAL OR POTENTIAL) IMPACTING COMMUNITY HEALTH, PROVISION OF CHARITY CARE, AND ACCESS TO SERVICES: REIMBURSEMENTS THAT FAIL TO KEEP PACE WITH RISING EXPENSES AND THE CONTINUED GROWTH IN UNCOMPENSATED CARE ARE SIGNIFICANT CHALLENGES THAT NEW YORK'S HOSPITALS FACE, INCLUDING RMH. OTHER CHALLENGES INCLUDE THE ESCALATION OF COSTS FOR DRUGS DUE TO INFLATION AND HAVING TO FIND ALTERNATE SUPPLIERS BECAUSE OF MANUFACTURER PRODUCTION SHORTAGES, SERVICES AND BAD DEBT, AND INVESTMENTS REQUIRED TO COMPLY WITH MANDATES. HERE ARE JUST A FEW EXAMPLES OF OUR CHALLENGES:UNCOMPENSATED CARE: THE COST OF FREE SERVICES PROVIDED TO OUR COMMUNITY CONTINUES TO RISE AS RESIDENTS LOSE THEIR JOBS OR THEIR ABILITY TO AFFORD THEIR INSURANCE PREMIUMS. IN 2010, ROME MEMORIAL HOSPITAL'S BAD DEBT AND CHARITY CARE TOTALED $7.8 MILLION, COMPARED TO $7.4 MILLION IN 2009. PHYSICIAN SHORTAGES: ROME MEMORIAL HOSPITAL HAS BEEN SUCCESSFUL IN RECRUITING SEVERAL NEW PHYSICIANS TO THE COMMUNITY, BUT AT A GREAT COST. TODAY'S PHYSICIAN WANTS TO BE EMPLOYED SO THEY DON'T HAVE TO BEAR THE RISK OF OPENING A NEW PRACTICE OR MANAGE THE ADMINISTRATIVE ASPECTS OF MEDICINE. ALTHOUGH THEY PROVIDE CRITICAL ACCESS TO CARE, THESE PRACTICES WILL STRUGGLE TO BREAK EVEN. LACK OF PRIMARY CARE: PATIENTS WHO DON'T HAVE INSURANCE OR WHO ARE COVERED BY MEDICAID OFTEN DON'T HAVE A REGULAR PHYSICIAN FOR PREVENTATIVE CARE OR TO MANAGE CHRONIC CONDITIONS. AS A RESULT, THEY USE THE EMERGENCY DEPARTMENT AS THEIR PRIMARY CARE OR DELAY CARE UNTIL THEIR CONDITION IS MORE CRITICAL AND MORE EXPENSIVE TO TREAT. SINCE ROME MEMORIAL HOSPITAL'S NEW EMERGENCY DEPARTMENT OPENED, THE NUMBER OF PATIENT VISITS HAS STEADILY INCREASED BY 19,000 IN 2006 TO 25,400 IN 2010. MANY PHYSICIANS DON'T ACCEPT MEDICAID PATIENTS BECAUSE OF LOW REIMBURSEMENT RATES. IN ADDITION, SENIORS MAY SOON FACE THE SAME ACCESS PROBLEMS. PHARMACEUTICALS: THE HOSPITAL CONTINUES TO SEE SIGNIFICANT INCREASE IN DRUG COSTS DUE TO INFLATION AND MANUFACTURER PRODUCTION SHORTAGES. IN MANY CASES, THESE SHORTAGES FORCE US TO TURN TO ALTERNATE SUPPLIERS, WHO CHARGE A PREMIUM PRICE. INTERPRETER SERVICES: AS OUR POPULATION BECOMES MORE DIVERSE WITH BURMESE AND BOSNIAN REFUGEES AND SPANISH SPEAKING RESIDENTS, THERE IS A GREATER DEMAND FOR INTERPRETER SERVICES. DDSO POPULATION - THE HIGH CONCENTRATION OF DDSO CLIENTS IN ONEIDA COUNTY AND ROME PLACES A UNIQUE BURDEN ON ROME MEMORIAL HOSPITAL. ONEIDA COUNTY IS HOME TO 54.6% OF THE DDSO BEDS IN THE CENTRAL NEW YORK REGION. OF THOSE BEDS, 47.7% (MORE THAN 500 DDSO CLIENTS) ARE LOCATED IN ROME. WHEN DDSO CLIENTS REQUIRE HOSPITALIZATION, THEIR CASES ARE OFTEN VERY COMPLEX AND THEIR LENGTH OF STAY IS NEARLY TWICE AS LONG AS THE AVERAGE PATIENT. AS A RESULT, THE HOSPITAL IS ONCE AGAIN FACED WITH ABSORBING THE FINANCIAL LOSS OF CARING FOR THESE PATIENTS. PROGRAM VIABILITY: AS A RESULT OF THESE SIGNIFICANT FINANCIAL CHALLANGES, RMH IS EVALUATING THE VIABILITY OF SOME OF ITS SERVICES. AS A PART OF THE EVALUATION, RMH WILL ASSESS THE NUMBER OF PEOPLE SERVED AND AVAILABILITY OF OTHER SERVICES TO ADDRESS THE COMMUNITY NEED, IN ADDITION TO THE FINANCIAL BURDEN ON THE HOSPITAL. IN DECEMBER 2010, AFTER CONSIDERABLE EVALUATION, RMH DECIDED TO CLOSE THE ACUTE PHYSICAL REHABILITATION DEPARTMENT DUE TO FINANCIAL REASONS. WHILE ELIMINATING A SERVICE IS ALWAYS DIFFICULT, IT ASSURES THAT RESOURCES CAN BE REDIRECTED TO MEET A GREATER NEED AND PROTECT THE OVERALL VIABILITY OF THE HOSPITAL.COSTING METHODOLOGY AND SOURCE FOR LINE 6:2010 ICR EXHIBIT 46 AND TENTATIVE MEDICARE SETTLEMENT RATES
		ROME MEMORIAL HOSPITAL FILES A COMMUNITY SERVICE PLAN WITH THE NEW YORK STATE DEPARTMENT OF HEALTH.
		PART VI, LINE 2: #2 NEEDS ASSESSMENT:ROME MEMORIAL HOSPITAL PARTICIPATES IN THE ASSESSMENT PROCESS LED BY THE ONEIDA COUNTY HEALTH DEPARTMENT, WHICH USES THE MAPP (MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIPS) FRAMEWORK TO CONDUCT THE MAJORITY OF ITS COMMUNITY HEALTH ASSESSMENT (CHA) ACTIVITIES. A COMMUNITY HEALTH ASSESSMENT PLANNING TEAM OF APPROXIMATELY 25-30 INDIVIDUALS WAS CONVENED IN JANUARY 2008 THAT CONSISTED OF THE STEERING COMMITTEE MEMBERS OF AN EXISTING COMMUNITY HEALTH PARTNERSHIP, THE ONEIDA COUNTY HEALTH COALITION, AND ADDITIONAL KEY COMMUNITY STAKEHOLDERS. THIS GROUP IS THE MAPP ADVISORY TEAM (MAT). SEVERAL SUB-COMMITTEES WERE CREATED TO ACCOMPLISH THE ASSESSMENT.THE COLLABORATING AGENCIES CONDUCTED PUBLIC VISIONING SESSIONS, HEALTHY CONVERSATION, FOCUS GROUPS, AND COMMUNITY SURVEYS TO COLLECT THE PERCEPTIONS OF THOSE WHO ARE UNABLE TO ATTEND ONE OF THE FACE TO FACE SESSIONS. THE FEEDBACK FROM SURVEYS AND PUBLIC OUTREACH SESSIONS PROVIDE THE QUALITATIVE INFORMATION TO ENRICH THE STATISTICAL FINDINGS OF THE NEEDS ASSESSMENT TO ADDRESS THE PRIORITY HEALTH NEEDS OF THE COMMUNITY.BASED UPON THIS PROCESS, THE FOLLOWING FIVE ITEMS FROM NEW YORK STATE'S PREVENTION AGENDA WERE IDENTIFIED AS PRIORITIES FOR THE COUNTY:HEALTHY MOTHERS, HEALTHY BABIES, HEALTHY CHILDRENMENTAL HEALTH AND SUBSTANCE ABUSECHRONIC DISEASEACCESS TO QUALITY HEALTHCAREPHYSICAL FITNESS AND NUTRITIONTHE FULL 2010-2013 ONEIDA COUNTY COMMUNITY HEALTH ASSESSMENT, ALONG WITH ITS DETAILED DATA BOOK CAN BE FOUND ONLINE AT WWW.OCGOV.NET/HEALTH/COMMUNITY-HEALTH-ASSESSMENT.ROME MEMORIAL HOSPITAL ALSO PARTICIPATES AND COLLABORATES WITH NUMEROUS COMMUNITY AND PROFESSIONAL ORGANIZATIONS. WITHIN THIS FRAMEWORK, IT IS POSSIBLE TO GAIN A BETTER UNDERSTANDING OF DIFFERENT NEED PERSPECTIVES AND ALSO EVALUATE COMMUNITY RESOURCES. THE ONGOING ANALYSIS OF QUANTITATIVE AND QUALITATIVE DATA IS UTILIZED TO CREATE ROME MEMORIAL HOSPITAL'S STRATEGIC PLAN, WHICH SERVES AS A BLUEPRINT FOR ADAPTING OUR AVAILABLE RESOURCES TO RESPOND TO THE CHANGING NEEDS OF THE COMMUNITY. ALTHOUGH THE 2009 COMMUNITY SERVICE PLAN AND UPDATES THEREAFTER (9/15/2010) WERE DESIGNED TO SPECIFICALLY ADDRESS THE STATE'S PREVENTION AGENDA, IT IS IMPORTANT TO NOTE THAT RMH'S STRATEGIC PLAN INCLUDES MANY ADDITIONAL INITIATIVES TO ADDRESS OUR COMMUNITY'S NEEDS AND ENSURE THE HOSPITAL'S CONTINUED FINANCIAL VIABILITY.RMH'S STRATEGIC PLAN PROVIDES A FRAMEWORK THAT GUIDES OUR DECISIONS AND BRINGS US FOCUS. THE SIX MAJOR OBJECTIVES ARE STRAIGHT-FORWARD, YET THE TACTICS TO ACHIEVE THEM ARE MULTI-FACETED IN SCOPE.QUALITY - WITH A COMMITMENT TO CONTINUOUS QUALITY IMPROVEMENT, PROVIDE THE NECESSARY LEADERSHIP AND RESOURCES TO DELIVER EVIDENCE-BASED, PATIENT-CENTERED HEALTHCARE SERVICES IN SUPPORT OF OUR MISSION. FOR EXAMPLE, AMONG ONEIDA COUNTY HOSPITALS, ROME MEMORIAL HOSPITAL EARNED THE HIGHEST OVERALL MARKS FOR ENSURING THAT PAITENTS RECEIVE THE RECOMMENDED TREATMENTS FOR PNEUMONIA, HEART FAILURE, AND SURGICAL INFECTION PREVENTION FOR PATIENTS DISCHARGED JULY 1, 2009 TO JUNE 30, 2010, ACCORDING TO THE NYS DEPARTMENT OF HEALTH (FIGURES LAST UPDATED 7/15/2011)RECRUITMENT & RETENTION - CONTINUE TO RECRUIT AND RETAIN OUR MOST VALUABLE RESOURCES, OUR PHYSICIANS AND EMPLOYEES, WHO CONSISTENTLY DEMONSTRATE OUR ORGANIZATIONAL MISSION AND VISION. DURING 2010 RMH WELCOMED 15 NEW DOCTORS AND ALLIED HEALTH PROFESSIONALS ON STAFF. PHYSICAL PLANT - UTILIZE THE FACILITY MASTER PLAN TO PROVIDE SERVICES IN ENVIRONMENTS THAT ARE SAFE, EFFICIENT AND SUPPORT OUR ORGANIZATIONAL MISSION AND VISION. IN 2010, ROME MEMORIAL HOSPITAL UPDATED ITS FACILITY MASTER PLAN TO ESTABLISH A FRAMEWORK TO GUIDE ORDERLY GROWTH AND DEVELOPMENT OF THE HOSPITAL CAMPUS.INFORMATION TECHNOLOGY - TO EXTEND THE SCOPE AND APPLICATION OF INFORMATION TECHNOLOGY (IT) ACROSS THE CONTINUUM OF CARE, TO ENHANCE PATIENT SAFETY, EFFICIENCY AND AVAILABILITY OF INFORMATION. DURING 2010, THE FOCUS WAS ON PREPARING FOR THE IMPLEMENTATION OF THE NEW HOSPITAL INFORMATION SYSTEM, NEW RADIOLOGY INFORMATION SYSTEM, AND PICTURE ARCHIVING AND CONTROL SYSTEM FOR MEDICAL IMAGING. BY THE END OF 2010 THE HOSPITAL HAD INVESTED MORE THAN $2.9 MILLION INOT WORK IN PROCESS REGARDING THE IT IMPLEMENTATION PROJECT. ROME HOSPITAL IS SCHEDULED TO "GO LIVE" WITH THE NEW SYSTEMS IN 2011. MARKET PENETRATION - INCREASE THE UTILIZATION OF OUR HEALTHCARE SERVICES BY MAXIMIZING OPPORTUNITIES THAT MEET THE NEEDS OF OUR CUSTOMERS. IN 2010, ROME MEMORIAL HOSPITAL JOINED ITS THREE OPHTALMOLOGISTS TO BREAK GROUND ON A NEW EYE CENTER THAT WILL OPEN IN 2011. THE PROJECT ALIGNS WITH THE HOSPITAL'S NEED TO PROVIDE MORE AVAILABLE OPERATING ROOM TIME FOR NEWLY RECRUITED GENERAL SURGEONS. FINANCE - ENGAGE IN PRUDENT, ETHICAL BUSINESS PRACTICES TO OPTIMIZE PROFITABILITY THAT ALLOW US TO MEET THE PRIORITY HEALTHCARE NEEDS OF OUR COMMUNITY. THE STRATEGIES THAT ROME MEMORIAL HOSPITAL IMPLEMENTED IN 2010 TO DELIVER COST EFFECTIVE QUALITY CARE GENERATED A POSITIVE BOTTOM LINE FOR THE HOSPITAL TO REINVEST IN TECHNOLOGY AND SERVICES.
		PART VI, LINE 3: #3 PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE:TO ENSURE THAT THE COMMUNITY IS AWARE OF THE HOSPITAL'S COMMITMENT TO PROVIDE HEALTHCARE SERVICESTO THOSE WHO ARE UNABLE TO PAY, THE HOSPITAL POSTS INFORMATION ABOUT ITS FINANCIAL ASSISTANCEPOLICY ON ITS WEBSITE. THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY CONFORMS WITH THE GUIDELINES ESTABLISHED BY THE HEALTHCARE ASSOCIATION OF NEW YORK STATE. THIS POLICY INCLUDES DETAILED INFORMATION REGARDING ELIGIBILITY, THE APPLICATION PROCESS, FINANCIAL GUIDELINES, TYPES OF FINANCIAL ASSISTANCE AVAILABLE, AND THE APPEAL PROCESS. RMH'S WEBSITE ALSO LISTS CONTACT INFORMATION IF YOU NEED HELP DETERMINING IF YOU QUALIFY FOR A DISCOUNT OR HAVE QUESTIONS REGARDING THE PROCESS. FREE, CONFIDENTIAL ASSISTANCE IS AVAILABLE BY CONTACTING THE ROME MEMORIAL HOSPITAL BUSINESS OFFICE. IF YOU DO NOT SPEAK ENGLSH, SOMEONE WILL HELP IN YOUR OWN LANGUAGE. ALSO, ROME MEMORIAL HOSPITAL HOSTS ENROLLMENT REPRESENTATIVES WHO CAN HELP ENROLL IN FREE OR LOW-COST INSURANCE PROGRAMS, SUCH AS MEDICAID, CHILD HEALTH PLUS AND FAMILY HEALTH PLUS.
		PART VI, LINE 4: #4 COMMUNITY INFORMATION:ROME MEMORIAL HOSPITAL SERVES THE RESIDENTS OF ROME, A CITY OF 34,220 PEOPLE, AS WELL AS THE SURROUNDING RURAL TOWNS AND VILLAGES IN ONEIDA COUNTY. THE POPULATION OF THE PRIMARY MARKET IS APPROXIMATELY 100,000 PEOPLE. FOR SELECTED SPECIALTIES, SUCH AS SENIOR BEHAVIORAL HEALTH CARE, RMH'S SERVICE AREA EXTENDS INTO THE SURROUNDING COUNTIES OF MADISON, HERKIMER, LEWIS AND ONONDAGA COUNTIES.ACCORDING TO THE MOST RECENT CENSUS ESTIMATES AVAILABLE, OVERALL POPULATION GROWTH HAS DECLINED APPROXIMATELY 3.78% IN THE CITY OF ROME AND ONEIDA COUNTY SINCE 2000. RESEARCH SHOWS THAT SOCIOECONOMIC CHARACTERISTICS HAVE AN IMPACT ON COMMUNITY HEALTH AND ARE AS IMPORTANT TO HEALTH STATUS AS OUR GENES, OUR BEHAVIORS AND EVEN ACCESS TO MEDICAL CARE. WHEN COMPARED AGAINST STATE FIGURES, THE POPULATION IN ROME AND ONEIDA COUNTY IS OLDER, LESS EDUCATED AND EARNS LESS THAN THE AVERAGE NEW YORKER, WHICH PUTS THEM AT HIGHER RISK FOR HEALTH PROBLEMS. IN ONEIDA COUNTY, OVER 15% OF ADULTS OF ALL INCOMES AGED 18-64 ARE UNINSURED; THIS RATE IS HIGHER THAN NEW YORK STATE (EXCLUDING NEW YORK CITY) AT 13.6%. IN ADDITION, APPROXIMATELY 6% OF CHILDREN AGED 18 AND YOUNGER LACK INSURANCE. IN ADDITION, ACCORDING TO THE MOST RECENT ONEIDA COUNTY COMMUNITY HEALTH ASSESSMENT 2010 - 2013, THE NUMBER OF MEDICAID ELIGIBLE CHILDREN AGED 12-17 INCREASED FROM 3,970 IN 2000 TO 5,954 IN 2005. CHILD HEALTH PLUS ENROLLMENT FOR ONEIDA COUNTY WAS 5,454 AS OF JULY 2009. THE NUMBER OF MEDICAID ELIGIBLE ADULTS IN ONEIDA COUNTY AGED 18 AND OLDER INCREASED 18% FROM 22,398 IN 2000 TO 26,346 IN 2005.THE CHALLENGE IS COMPOUNDED BY THE FACT THAT ONEIDA COUNTY IS A FEDERALLY-DESIGNATED MEDICALLY UNDERSERVED AREA. IN ADDITION, THE CITY OF ROME AND TOWNS OF AVA, BOONVILLE, FORESTPORT, FLOYD, LEE, VERONA, WESTERN, ANNSVILLE, CAMDEN, FLORENCE AND VIENNA ARE FEDERALLY-DESIGNATED HEALTH PROFESSIONAL SHORTAGE AREAS, WITH AN INADEQUATE NUMBER OF PRIMARY MEDICAL CARE PROVIDERS TO SERVE THE COMMUNITY.THE FOLLOWING TABLE HIGHLIGHTS AVAILABLE DEMOGRAPHIC AND SOCIOECONOMIC CHARACTERISTICS OF OUR COMMUNITY.SOCIO-ECONOMIC PROFILE ONEIDA COUNTY NEW YORKPOPULATION, 2010 ESTIMATE 234,878 19,378,102POPULATION, PERCENT CHANGE, 2000 TO 2010 -.3% 2.1%POPULATION ESTIMATES BASE (APRIL 1) 2000 235,461 18,976,811PERSONS UNDER 5 YEARS OLD, PERCENT, 2009 5.6% 6.3%PERSONS UNDER 18 YEARS OLD, PERCENT, 2009 21.5% 22.6%PERSONS 65 YEARS OLD AND OVER, PERCENT, 2009 16.3% 13.4%FEMALE PERSONS, PERCENT, 2009 50.0% 51.4% ONEIDA COUNTY NEW YORKWHITE PERSONS, PERCENT, 2010 (A) 87.1% 65.7%BLACK PERSONS, PERCENT, 2010 (A) 6.3% 15.9%AMERICAN INDIAN/ALASKA NATIVE PERSONS,%,2010(A) 0.3% 0.6%ASIAN PERSONS, %, 2010 (A) 2.8% 7.3%NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER, %,2010(A) Z 0.0%PERSONS REPORTING TWO OR MORE RACES, %, 2010 2.1% 3.0%PERSONS OF HISPANIC OR LATINO ORIGIN, %, 2010(B) 4.6% 17.6%WHITE PERSONS NOT HISPANIC, PERCENT, 2010 84.8% 58.3% ONEIDA COUNTY NEW YORK FOREIGN BORN PERSONS, PERCENT, 2005-2009 6.0% 21.3%LANGUAGE OTHER THAN ENGLISH SPOKEN AT HOME, PCT AGE 5+, 2005-2009 10.1% 28.5%HIGH SCHOOL GRADUATES, PERCENT OF PERSONS AGE 25+, 2005-2009 85.6% 84.2%BACHELOR'S DEGREE OR HIGHER, PCT OF PERSONS AGE 25+, 2005-2009 20.9% 31.8%VETERNS, 2005-2009 21,701 1,064,754 ONEIDA COUNTY NEW YORK HOUSING UNITS, 2009 103,876 8,017,881HOMEOWNERSHIP RATE, 2005-2009 68.2% 55.7%HOUSING UNITS IN MULTI-UNIT STRUCTURES, %,2005-2009 30.7% 50.5%MEDIAN VALUE OF OWNER-OCCUPIED HOUSING UNITS, 2000 $97,000 $300,600 ONEIDA COUNTY NEW YORKHOUSEHOLDS, 2005-2009 92,544 7,137,013PERSONS PER HOUSEHOLD, 2005-2009 2.33 2.64MEDIAN HOUSEHOLD INCOME, 2009 $45,663 $54,554PER CAPITA MONEY INCOME, 2005-2009 $23,224 $30,634PERSONS BELOW POVERTY LEVEL, PERCENT, 2009 14.4% 14.2% ROME NEW YORKPOPULATION, 2006 ESTIMATE 34,220 19,306,183POPULATION, % CHANGE, 4/1/2000 TO 7/1/2006 -2.1% 1.7%POPULATION, 2000 34,950 18,976,457PERSONS UNDER 5 YEARS OLD, PERCENT, 2000 5.9% 6.5%PERSONS UNDER 18 YEARS OLD, PERCENT, 2000 22.1% 24.7%PERSONS 65 YEARS OLD AND OVER, PERCENT, 2000 17.2% 12.9%FEMALE PERSONS, PERCENT, 2000 48.8% 51.8% ROME NEW YORKWHITE PERSONS, PERCENT, 2000 (A) 87.9% 67.9%BLACK PERSONS, PERCENT, 2000 (A) 7.6% 15.9%AMERICAN INDIAN & ALASKA NATIVE PERSONS, %, 2000 (A) 0.3% 0.4%ASIAN PERSONS, PERCENT, 2000 (A) 0.9% 5.5%NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER,%, 2000 (A) Z ZPERSONS REPORTING TWO OR MORE RACES, PERCENT, 2000 2.0% 3.1%PERSONS OF HISPANIC OR LATINO ORIGIN, %, 2000 (B) 4.7% 15.1% ROME NEW YORK LIVING IN SAME HOUSE IN 1995 & 2000, PCT 5 YRS/OVER 60.9% 61.8%FOREIGN BORN PERSONS, PERCENT, 2000 3.8% 20.4%LANGUAGE OTHER THAN ENGLISH SPOKEN AT HOME, PCT AGE 5+,2000 7.2% 28.0%HIGH SCHOOL GRADUATES, PCT OF PERSONS AGE 25+,2000 74.0% 79.1%BACHELOR'S DEGREE OR HIGHER, PCT OF PERSONS AGE 25+,2000 15.7% 27.4% ROME NEW YORKHOUSING UNITS, 2000 16,272 7,679,307HOMEOWNERSHIP RATE, 2000 57.1% 53.0%MEDIAN VALUE OF OWNER-OCCUPIED HOUSING UNITS,2000 $66,200 $148,700 ROME NEW YORK HOUSEHOLDS, 2000 13,653 7,056,860PERSONS PER HOUSEHOLD, 2000 2.3 2.61MEDIAN HOUSEHOLD INCOME, 1999 $33,643 $43,393PER CAPITA MONEY INCOME, 1999 $18,604 $23,389PERSONS BELOW POVERTY, PERCENT, 1999 15.0% 14.6% SOURCE: US CENSUS BUREAU STATE & COUNTY QUICKFACTS
		PART VI, LINE 6: #5 PROMOTION OF COMMUNITY HEALTH:1.ROME MEMORIAL HOSPITAL PROVIDES EMERGENCY SERVICES TO EVERYONE REGARDLESS OF ABILITY TO PAY.2.THE HOSPITAL'S INDEPENDENT GOVERNING BODY IS COMPRISED OF INDIVIDUALS WHO RESIDE OR WORK IN THE PRIMARY SERVICE AREA TO REPRESENT THE INTERESTS OF THE COMMUNITY.3.THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY.4.THE HOSPITAL USES ANY SURPLUS FUNDS TO IMPROVE CARE, EXPAND FACILITIES, RECRUIT STAFF AND ADVANCE MEDICAL TRAINING AND COMMUNITY EDUCATION.
		PART VI, LINE 7: #6 AFFILIATED HEALTH CARE SYSTEM:ROME MEMORIAL HOSPITAL, INC. (THE "HOSPITAL") IS A NEW YORK STATE NOT-FOR-PROFIT CORPORATION AND TAX EXEMPT UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE ("IRC"), AND IS PART OF THE FOLLOWING CORPORATE STRUCTURE: GREATER ROME AFFILIATES, INC. ("GRA"), A NEW YORK STATE NOT-FOR-PROFIT CORPORATION, TAX EXEMPT UNDER SECTION 501(C)(3) OF THE IRC, IS THE SOLE CORPORATE MEMBER, AND THEREFORE, THE "PARENT" OF THE HOSPITAL, AS WELL AS ROME MEMORIAL PROPERTIES, INC., A NEW YORK STATE NOT-FOR-PROFIT CORPORATION, TAX EXEMPT UNDER SECTION 501(C)(3) OF THE IRC. GRA IS ALSO THE SOLE SHAREHOLDER OF RMH SERVICES, INC., A NEW YORK STATE BUSINESS CORPORATION, WHICH WAS ESTABLISHED TO UNDERTAKE CERTAIN FOR-PROFIT BUSINESS ACTIVITIES AND WHICH HAS AN EQUITY OWNERSHIP INTEREST IN, AND IS A MEMBER OF, THREE NEW YORK STATE LIMITED LIABILITY COMPANIES: 1819 BLACK RIVER ASSOCIATES, LLC; CHESTNUT COMMONS, LLC; AND RMH RETAIL PHARMACY, LLC. MEMBERS OF THE HOSPITAL'S BOARD OF TRUSTEES AND ADMINISTRATIVE STAFF HAVE OVERLAPPING RESPONSIBILITIES ON THE BOARDS OF THE AFFILIATED CORPORATIONS TO ENSURE THAT THE HOSPITAL'S BEST INTERESTS ARE BEING SERVED. ROME MEMORIAL HOSPITAL FOUNDATION, INC., A NEW YORK STATE NOT-FOR-PROFIT CORPORATION, TAX EXEMPT UNDER SECTION 501(C)(3) OF THE IRC, IS A SEPARATE CORPORATION ESTABLISHED FOR THE SOLE PURPOSE OF CONDUCTING FUND RAISING ACTIVITIES ON BEHALF OF THE HOSPITAL, INCLUDING THE RECEIPT OF GIFTS AND BEQUESTS ON BEHALF OF THE HOSPITAL, INVESTING SUCH ASSETS, AND TRANSFERRING THEM TO THE HOSPITAL IN SUPPORT OF ITS MISSION. IT IS GOVERNED BY A SEPARATE BOARD OF DIRECTORS, WHICH HAS AMONG ITS MEMBERS HOSPITAL TRUSTEES AND MEMBERS OF THE HOSPITAL'S MEDICAL STAFF.THE SYSTEM ALSO INCLUDES TWO CAPTIVE PROFESSIONAL CORPORATIONS, INCLUDING ROME MEDICAL GROUP, P.C., A MULTI-PHYSICIAN PRIMARY CARE PRACTICE, AND ROME MEDICAL PRACTICE, P.C., A MULTI-PHYSICIAN, SPECIALTY GROUP. THE PCS ARE THE VEHICLES THROUGH WHICH PHYSICIANS ARE EMPLOYED TO SERVE THE COMMUNITY. IN TODAY'S ENVIRONMENT, MANY PHYSICIANS PREFER TO BE EMPLOYED VS. GOING OUT IN PRIVATE PRACTICE.
REPORTS FILED WITH STATES	PART VI, LINE 7	NY

Schedule H (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet

Attach to Form 990. SchJMediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

ROME MEMORIAL HOSPITAL

Employer identification number

16-1471634

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement orprovision of all the expenses described above? If "No," complete Part III to explain....

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....

Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? ...............

Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........

Participate in, or receive payment from, an equity-based compensation arrangement? ........

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.

For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 5a or 5b, describe in Part III.

For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 6a or 6b, describe in Part III.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regs. section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................

If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990

Cat. No. 50053T

Schedule J (Form 990) 2010

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use Schedule J-1 if additional space needed.

For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) must equal the applicable column (D) or column (E) amounts on Form 990, Part VII, line 1a.

(A) Name		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported in prior Form 990 or Form 990-EZ
(A) Name		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
(1) DARLENE BURNS	(i) (ii)	280,298 0	39,489 0	0 0	0 0	9,513 0	329,300 0	0 0
(2) WALEED ALBERT MD	(i) (ii)	236,426 0	22,247 0	0 0	0 0	14,874 0	273,547 0	0 0
(3) BASIL ARIGLIO	(i) (ii)	187,484 0	18,382 0	42,510 0	0 0	14,874 0	263,250 0	0 0
(4) NICHOLAS MAYHEW	(i) (ii)	165,522 0	15,917 0	22,613 0	0 0	14,803 0	218,855 0	0 0
(5) RAYMOND CARNEVALE	(i) (ii)	145,082 0	12,578 0	7,394 0	0 0	5,871 0	170,925 0	0 0
(6) BRUCE PETERSON	(i) (ii)	138,081 0	10,101 0	0 0	0 0	14,712 0	162,894 0	0 0

Schedule J (Form 990) 2010

Page 3

Part III

Supplemental Information

Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.

Identifier	Return Reference	Explanation

Schedule J (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax Exempt Bonds

Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Schedule O (Form 990).
SchKMediumBullet

Attach to Form 990. SchKMediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization
ROME MEMORIAL HOSPITAL

Employer identification number
16-1471634

Part I

Bond Issues

(a) Issuer Name		(b) Issuer EIN	(c) CUSIP #	(d) Date Issued	(e) Issue Price	(f) Description of Purpose	(g) Defeased		(h) On Behalf of Issuer		(i) Pool financing
(a) Issuer Name		(b) Issuer EIN	(c) CUSIP #	(d) Date Issued	(e) Issue Price	(f) Description of Purpose	Yes	No	Yes	No	Yes	No
A	ONEIDA COUNTY INDUSTRIAL DEVELOPMENT AGENCY	16-6158201	6824621LE	06-16-2005	11,900,000	FINANCE CONSTRUCTION		X	X			X
B	ONEIDA COUNTY LOCAL DEVELOPMENT CORPORATION	27-3190422		12-30-2010	6,900,000	FINANCE MRI CONSTRUCTION		X	X			X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired. . . . .
2 Amount of bonds defeased . . . .
3 Total proceeds of issue . . . .	11,900,000		6,900,000
4 Gross proceeds in reserve funds . .
5 Capitalized interest from proceeds.
6 Proceeds in refunding escrow. . . . .
7 Issuance costs from proceeds . . .	509,090		222,845
8 Credit enhancement from proceeds.
9 Working capital expenditures from proceeds . .
10 Capital expenditures from proceeds . .
11 Other spent proceeds . .
12 Other unspent proceeds. . .
13 Year of substantial completion . . .	2006		2009
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue?		X		X
15 Were the bonds issued as part of an advance refunding issue?		X		X
16 Has the final allocation of proceeds been made? . .	X		X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? .	X		X

Part III

Private Business Use

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? . . .		X		X
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . .		X		X

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50193E

Schedule K (Form 990) 2010

Page 2

Part III

Private Business Use (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
3a Are there any management or service contracts that may result in private business use?	X			X
b Are there any research agreements that may result in private business use of bond-financed property? . .		X		X
c Does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts or research agreements relating to the financed property? .	X		X
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government . . . . . . . . . . . . .
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government .
6 Total of lines 4 and 5 . . .. . . . . .
7 Has the organization adopted management practices and procedures to ensure the post-issuance compliance of its tax-exempt bond liabilities?	X		X

Part IV

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has a Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate, been filed with respect to the bond issue? . . .		X		X
2 Is the bond issue a variable rate issue?	X		X
3a Has the organization or the governmental issuer entered into a hedge with respect to the bond issue?	X			X
b Name of provider .	MANUFACTURERS AND TRUST
c Term of hedge . .	5.000000000000
d Was the hedge superintegrated? .		X
e Was a hedge terminated? .	X
4a Were gross proceeds invested in a GIC? .		X		X
b Name of provider .
c Term of GIC . .
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? .
5 Were any gross proceeds invested beyond an available temporary period? .		X		X
6 Did the bond issue qualify for an exception to rebate? . . .		X		X

Schedule K (Form 990) 2010

Page 3

Part V

Supplemental Information

Complete this part to provide additional information for responses to questions on Schedule K (see instructions).

Identifier	Return Reference	Explanation

Schedule K (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

Schedule L
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Transactions with Interested Persons

Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V lines 38a or 40b.
MediumBullet

Attach to Form 990 or Form 990-EZ. MediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

ROME MEMORIAL HOSPITAL

Employer identification number

16-1471634

Part I

Excess Benefit Transactions (section 501(c)(3) and section 501 (c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.

1(a) Name of disqualified person	(b) Description of transaction	(c) Corrected?
1(a) Name of disqualified person	(b) Description of transaction	Yes	No

Enter the amount of tax imposed on the organization managers or disqualified persons during the year under section 4958. ......................... Bullet Image

Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ....... Bullet Image

Part II

Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 26, or Form 990-EZ, Part V, line 38a.

(a) Name of interested person and purpose	(b) Loan to or from the organization?		(c)Original principal amount	(d)Balance due	(e) In default?		(f) Approved by board or committee?		(g)Written agreement?
(a) Name of interested person and purpose	To	From	(c)Original principal amount	(d)Balance due	Yes	No	Yes	No	Yes	No






Total ............... $

Part III

Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.

(a) Name of interested person	(b)Relationship between interested person and the organization	(c)Amount of grant or type of assistance

For Privacy Act and Paperwork Reduction Act Notice, see the
Instructions for Form 990 or 990-EZ.

Cat. No. 50056A

Schedule L (Form 990 or 990-EZ) 2010

Page 2

Part IV

Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of transaction	(d) Description of transaction	(e) Sharing of organization's revenues?
(a) Name of interested person		(c) Amount of transaction	(d) Description of transaction	Yes	No
(1) MARY ANN JONES	SISTER OF KEY EMPLOYEE	24,023	COMPENSATION		No
(2) SCOTT BURNS	CHILD OF OFFICER	130,435	COMPENSATION		No

Part V

Supplemental Information

Complete this part to provide additional information for responses to questions on Schedule L (see instructions).

Identifier	Return Reference	Explanation

Schedule L (Form 990 or 990-EZ) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE M
(Form 990)

Department of the Treasury

Internal Revenue Service

NonCash Contributions

Complete if the organization answered "Yes" on Form 990, Part IV, lines 29 or 30.
Right pointing arrow large image

Attach to Form 990.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

ROME MEMORIAL HOSPITAL

Employer identification number

16-1471634

Part I

Types of Property

	(a) Check if applicable	(b) Number of Contributions or items contributed	(c) Contribution amounts reported on Form 990, Part VIII, line 1g	(d) Method of determining contribution amounts
1 Art—Works of art ....
2 Art—Historical treasures .
3 Art—Fractional interests ..
4 Books and publications ..
5 Clothing and household goods .......
6 Cars and other vehicles ..
7 Boats and planes ....
8 Intellectual property ...
9 Securities—Publicly traded .
10 Securities—Closely held stock .
11 Securities—Partnership, LLC, or trust interests ....
12 Securities—Miscellaneous ..
13 Qualified conservation contribution—Historic structures .....
14 Qualified conservation contribution—Other ...
15 Real estate—Residential .
16 Real estate—Commercial ..
17 Real estate—Other ...
18 Collectibles .....
19 Food inventory ...
20 Drugs and medical supplies .
21 Taxidermy ......
22 Historical artifacts ....
23 Scientific specimens ..
24 Archeological artifacts ...
25 Other ( MEDICAL EQUIPMENT )	X	5	36,174	ACTUAL INVOICE COST
26 Other ( INFORMATION SYSTEMS )	X	1	63,760	ACTUAL INVOICE COST
27 Other ( EMERGENCY ROOM PROJECT )	X		17,882	ACTUAL INVOICE COST
28 Other ( MRI PROJECT )	X		15,908	ACTUAL INVOICE COST

Number of Forms 8283 received by the organization during the tax year for contributions
for which the organization completed Form 8283, Part IV, Donee Acknowledgement ...

Yes

30a

During the year, did the organization receive by contribution any property reported in Part I, lines 1-28 that it

must hold for at least three years from the date of the initial contribution, and which is not required to be used

for exempt purposes for the entire holding period? ..................

30a

If "Yes," describe the arrangement in Part II.

Does the organization have a gift acceptance policy that requires the review of any non-standard contributions?

Yes

32a

Does the organization hire or use third parties or related organizations to solicit, process, or sell non-cash

contributions? ............................

32a

If "Yes," describe in Part II.

If the organization did not report revenues in column (c) for a type of property for which column (a) is checked,

describe in Part II.

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 51227J

Schedule M (Form 990) 2010

Page 2

Part II

Supplemental Information. Complete this part to provide the information required by Part I, lines 30b,
32b, and 33. Also complete this part for any additional information.

Identifier	Return Reference	Explanation

Schedule M (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization

ROME MEMORIAL HOSPITAL

Employer identification number

16-1471634

Identifier	Return Reference	Explanation
CHANGES IN PROGRAM SERVICES	FORM 990, PART III, LINE 3	ROME MEMORIAL HOSPITAL CLOSED THE ACUTE PHYSICAL REHABILITATION DEPARTMENT IN DECEMBER 2010 DUE TO FINANCIAL REASONS.
FORM 990, PART VI, SECTION A, LINE 6		GREATER ROME AFFILIATES IS THE SOLE MEMBER OF ROME MEMORIAL HOSPITAL.
FORM 990, PART VI, SECTION A, LINE 7A		PER THE HOSPITAL BY-LAWS "THE SOLE CORPORATE MEMBER OF THE CORPORATION SHALL BE GREATER ROME AFFILIATES, INC. WHICH SHALL ACT HEREUNDER AS SUCH MEMBER BY DULY AUTHORIZED RESOLUTION OF ITS BOARD OF DIRECTORS AND WHICH SHALL COMMUNICATE ITS ACTIONS TO THIS BOARD THROUGH ITS PRESIDENT OR OTHER DULY AUTHORIZED OFFICER." GREATER ROME AFFILIATES APPOINTS THE GOVERNING BODY.
FORM 990, PART VI, SECTION B, LINE 11		THE COMPLETED 2010 990 WAS PRESENTED TO THE BOARD BY THE CFO OF THE HOSPITAL AT ITS SEPTEMBER 2011 BOARD MEETING.
	FORM 990, PART VI, SECTION B, LINE 12C	CONSISTENT WITH ROME HOSPITAL'S GIFTS, GRATUITIES AND CONFLICT OF INTEREST POLICY, THE COMPLIANCE MANAGER OF RMH HAS A CONFLICT OF INTEREST DISCLOSURE FORM COMPLETED ON AN ANNUAL BASIS BY ALL OFFICERS, DIRECTORS AND MANAGEMENT PERSONNEL. THE CEO COLLECTS AND REVIEWS THE BOARD OF TRUSTEES INTEREST DISCLOSURE FORMS ON AN ANNUAL BASIS. THE INFORMATION GATHERED ON THE DISCLOSURE IS REVIEWED AND ANY CONFLICTS ARE COMMUNICATED TO PRESIDENT/CEO AND BOARD OF TRUSTEES TO ENSURE ALL HOSPITAL TRANSACTIONS ARE COMPLETED FREE FROM OUTSIDE INFLUENCE. POTENTIAL CONFLICTS THAT MAY ARISE THROUGHOUT THE YEAR ARE BROUGHT TO THE ATTENTION OF THE COMPLIANCE OFFICER AND PRESIDENT/CEO FOR REVIEW.
	FORM 990, PART VI, SECTION B, LINE 15	USE OF IROQUOIS DATA, ASSOCIATION FOR HEALTHCARE PHILANTHROPY SALARY DATA, AND THE ROME HOSPITAL HUMAN RESOURCE DEPARTMENT ARE UTILIZED TO DETERMINE COMPENSATION FOR THE ORGANIZATION'S EMPLOYEES.
	FORM 990, PART VI, SECTION C, LINE 18	FORMS ARE AVAILABLE UPON REQUEST.
	FORM 990, PART VI, SECTION C, LINE 19	FORMS ARE AVAILABLE FOR PUBLIC INSPECTION UPON REQUEST OR THROUGH WWW.GUIDESTAR.ORG- A WEBSITE THAT PROVIDES NON-PROFIT INFORMATION TO THE PUBLIC. RMH MAKES ITS GOVERNING DOCUMENTS (BY - LAWS) AND CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC THROUGH RMH WEBSITE - WWW.ROMEHOSPITAL.ORG. ALSO, FINANCIAL FACTS AND FIGURES AND ECONOMIC IMPACT REPORTS CAN BE FOUND ON THIS WEBSITE.
CHANGES IN NET ASSETS OR FUND BALANCES:	FORM 990, PART XI, LINE 5:	NET UNREALIZED GAINS ON INVESTMENTS: 231,197. TOTAL CHANGE IN INTEREST IN FOUNDATION 32,272. CHANGE IN UNRESTRICTED INT IN FOUND 33,358. TOTAL TO FORM 990, PART XI, LINE 5: 296,827.
	FORM 990, PART XI, LINE 2C	THE FINANCE/AUDIT COMMITTEE CONSISTES OF LESS THAN 3 AND NOT MORE THAN 7 MEMBERS. THIS COMMITTEE IS RESPONSIBLE FOR GENERAL OVERSIGHT OF THE FINANCIAL AFFAIRS OF THE HOSPITAL. THE COMMITTEE REVIEWS, ADVISES, AND REPORTS TO THE BOARD OF TRUSTEES ON THE INVESTMENT AND MANAGEMENT OF THE FINANCIAL RESOURCES OF THE CORPORATION AND SHALL REVIEW THE ANNUAL BUDGET AND CAPITAL PLANS, FUND MANAGEMENT PROCEDURES, AND INTERNAL CONTROLS RELATING TO THE SAFEGUARD OF FINANCIAL ASSETS. THE COMMITTEE ACTS AS FINANCIAL ADVISOR, REVIEWS PROPOSED SCOPE OF ANNUAL AUDITS PERFORMED BY INDEPENDENT AUDITORS, REVIEWS INDEPENDENT AUDITORS MANAGEMENT LETTERS, REVIEWS THE ADEQUACY OF ACCOUNTING POLICIES AND INTERNAL CONTROL STRUCTURES, RECOMMMENDS THE APPOINTMENT OF INDEPENDENT AUDITORS TO THE BOARD OF TRUSTEES, AND REVIEWS PERIODICALLY THE CONFLICTS OF INTEREST POLICIES, AS WELL AS OVERSEES COMPLIANCE THEREWITH.

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

ROME MEMORIAL HOSPITAL

Employer identification number

16-1471634

Part I

Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)

(a) Name, address, and EIN of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity

Part II

Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled organization
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) GREATER ROME AFFILIATES 1500 N JAMES STREET ROME,NY13440 16-1508597	PARENT CORPORATION	NY	501C3	LINE 11A, I			No
(2) ROME MEMORIAL PROPERTIES 1500 N JAMES STREET ROME,NY13440 16-1492003	SUPPORT HOSPITAL ACTIVITIES	NY	501C3	3	GRA		No

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2010

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(h) Percentage ownership
(1) RMH SERVICES INC 1500 N JAMES STREET ROME,NY13440 16-1490045	FOR PROFIT	NY	GREATER ROME AFFILIATES	C	100.000 %
(2) ROME MEDICAL GROUP 1801 BLACK RIVER BLVD ROME,NY13440 16-1464822	CAPTIVE P.C.	NY	ROME MEMORIAL HOSPITAL	C
(3) ROME MEDICAL PRACTICE 1500 N JAMES STREET ROME,NY13440 20-3827393	CAPTIVE P.C.	NY	ROME MEMORIAL HOSPITAL	C

Schedule R (Form 990) 2010

Page 3

Part V

Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)

Note. Complete line 1 if any entity is listed in Parts II, III or IV.

Yes

1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?

a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .

b Gift, grant, or capital contribution to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

c Gift, grant, or capital contribution from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

d Loans or loan guarantees to or for other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

e Loans or loan guarantees by other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

f Sale of assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

g Purchase of assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

h Exchange of assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i Lease of facilities, equipment, or other assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

j Lease of facilities, equipment, or other assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

k Performance of services or membership or fundraising solicitations for other organization(s) . . . . . . . . . . . . . . . . . . . . . .

l Performance of services or membership or fundraising solicitations by other organization(s) . . . . . . . . . . . . . . . . . . . . . .

m Sharing of facilities, equipment, mailing lists, or other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

n Sharing of paid employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

o Reimbursement paid to other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

p Reimbursement paid by other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

q Other transfer of cash or property to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

r Other transfer of cash or property from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of other organization	(b) Transaction type(a-r)	(c) Amount involved	(d) Method of determining amount involved
(1)
(2)
(3)
(4)
(5)
(6)

Schedule R (Form 990) 2010

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Are all partners section 501(c)(3) organizations?		(e) Share of end-of-year assets	(f) Disproprtionate allocations?		(g) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(h) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(e) Share of end-of-year assets	Yes	No	(g) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2010

Page 5

Part VII

Supplemental Information

Complete this part to provide additional information for responses to questions on Schedule R (see instructions).

Identifier	Return Reference	Explanation

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: PROVIDE QUALITY, COMPASSIONATE CARE IN A SAFE ENVIRONMENT TO SERVE THE HEALTHCARE NEEDS OF THE PEOPLE OF ROME AND THE SURROUNDING COMMUNITIES.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ....	3	10
4	Number of independent voting members of the governing body (Part VI, line 1b) ....	4	10
5	Total number of individuals employed in calendar year 2010 (Part V, line 2a) ...	5	1,204
6	Total number of volunteers (estimate if necessary) ....	6	125
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ..	7a	253,882
b	Net unrelated business taxable income from Form 990-T, line 34 ..	7b	-214

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	246,449	432,566
9	Program service revenue (Part VIII, line 2g) .........	80,631,908	84,821,455
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	-341,034	142,569
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	1,003,883	1,034,217
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	81,541,206	86,430,807
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
14	Benefits paid to or for members (Part IX, column (A), line 4) ....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	44,982,418	48,494,172
16a	Professional fundraising fees (Part IX, column (A), line 11e)....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f)....	37,190,412	37,880,995
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	82,172,830	86,375,167
19	Revenue less expenses. Subtract line 18 from line 12......	-631,624	55,640
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16)............	56,991,481	61,433,977
21	Total liabilities (Part X, line 26)............	32,947,164	37,037,193
22	Net assets or fund balances. Subtract line 21 from line 20 .....	24,044,317	24,396,784

Sign Here

	Signature of officer	Date

	Type or print name and title.

Paid Preparer's Use Only	Preparer's signature	Date	Check if self- employed	Preparer’s taxpayer identification number (see instructions)
	Firm’s name (or yours if self-employed), address, and ZIP + 4			EIN
				Phone no.


4a	(Code: ) (Expenses $ 37,196,573 including grants of $ ) (Revenue $ 32,236,495 )
	INPATIENT CARE SERVICES, INPATIENT NURSING UNITS CONSIST OF THE FOLLOWING:ACUTE PHYSICAL REHABILITATION-4TH FLOOR,INTENSIVE CARE-2ND FLOOR, MATERNITY-4TH FLOOR, 2 EAST MEDICAL/SURGICAL-2ND FLOOR, 2 NORTH MEDICAL/SURGICAL WITH CARDIAC MONITORING-2ND FLOOR, PEDIATRICS-2ND FLOOR, AND SENIOR BEHAVIORIAL HEALTH- 2ND FLOOR.2010 INPATIENT DISCHARGES: 5,4672010 BIRTHS: 6182010 PATIENT DAYS: 25,556

4b	(Code: ) (Expenses $ 6,066,487 including grants of $ ) (Revenue $ 6,785,205 )
	RESIDENTIAL HEALTHCARE FACILITY (RHCF)BECAUSE OF OUR COMMITTMENT TO SERVE THE UNIQUE NEEDS OF SENIORS, WE HAVE AN 80-BED RESIDENTIAL HEALTH CARE FACILITY AND TWO SPECIALITY INPATIENT UNITS FOR ACUTE-PHYSICAL MEDICINE & REHABILITATION AND SENIOR BEHAVIORIAL HEALTH CARE. OUR RESIDENTIAL HEALTHCARE FACILITY CONSISTS OF THE FOLLOWING: LONG-TERM NURSING HOMECARE, SHORT-TERM SUB-ACUTE REHABILITATION, AND RESPITE CARE- ALL LOCATED ON THE 3RD FLOOR.2010 PATIENT DAYS = 26,0332010 OCCUPANCY PERCENTAGE = 89%

4c	(Code: ) (Expenses $ 9,476,614 including grants of $ 0 ) (Revenue $ 9,904,064 )
	EMERGENCY DEPARTMENT (ED)ROME MEMORIAL HOSPITAL EMERGENCY DEPARTMENT IS A SAFETY NET FOR THE MOST VULNERABLE POPULATIONS IN THE COMMUNITY. IN 2010, MORE THAN HALF OF THE PATIENTS LISTED NO PRIMARY CARE PHYSICIAN AND 45% WERE UNINSURED OR UNDER INSURED.2010 ED ADMISSIONS: 3,2732010 ED VISITS: 25,396

	(Code: ) (Expenses $ 21,555,610 including grants of $ ) (Revenue $ 29,184,708 )
	ALL OTHER ACHIEVEMENTS PROVIDE QUALITY, COMPASSIONATE CARE IN A SAFE ENVIRONMENT TO SERVE THE HEALTHCARE NEEDS OF THE PEOPLE OF ROME AND THE SURROUNDING COMMUNITIES.

4d	Other program services. (Describe in Schedule O.)
	(Expenses $ 21,555,610 including grants of $ ) (Revenue $ 29,184,708 )
4e	Total program service expenses$ 74,295,284

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)		(D) Reportable compensation from the organization (W- 2/1099-MISC)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and Title
(18) MARK SNYDERMAN VP	55.00	X	127,719	0	11,223
(19) DEBRA WURZ VP SENIOR SERVICES	55.00	X	120,552	0	11,196

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	1,721,838	0	108,292

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d
e	Government grants (contributions)1e		43,500

f	All other contributions, gifts, grants, and similar amounts not included above1f		389,066
g	Noncash contributions included in lines 1a-1f:$ 133,724
h	Total. Add lines 1a-1f.......			432,566
			Business Code
2a	HOSPITAL		621,990	84,821,455	84,821,455
b
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			84,821,455
3	Investment income (including dividends, interest
	and other similar amounts).....			35,251			35,251
4	Income from investment of tax-exempt bond proceeds..
5	Royalties............
		(i) Real	(ii) Personal
6a	Gross Rents	111,033
b	Less: rental expenses	135,647
c	Rental income or (loss)	-24,614
d	Net rental income or (loss).......			-24,614			-24,614
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	1,330,598	64,840
b	Less: cost or other basis and sales expenses	1,267,797	20,323
c	Gain or (loss)	62,801	44,517
d	Net gain or (loss)..........			107,318			107,318
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..
Miscellaneous Revenue			Business Code
11a	CAFETERIA SALES		722,210	290,037			290,037
b	ACCOUNTING & CONSULTIN		541,200	180,000		180,000
c	GAIN/LOSS CHANGE ANGEL		900,099	664	0		664
d	All other revenue ....			588,130		73,882	514,248
e	Total. Add lines 11a–11d ......			1,058,831
12	Total revenue. See Instructions....			86,430,807	84,821,455	253,882	922,904


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing ..........			24,396	1	3,031,569
2	Savings and temporary cash investments .......			2,456,924	2	2,274,926
3	Pledges and grants receivable, net .........				3
4	Accounts receivable, net .........			11,270,550	4	11,374,729
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........				5
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........				6
7	Notes and loans receivable, net .............			2,509,492	7	1,388,348
8	Inventories for sale or use ..............			1,592,849	8	1,959,094
9	Prepaid expenses and deferred charges ............			738,790	9	806,060
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	80,041,751
b	Less: accumulated depreciation. .....	10b	41,082,506	37,096,532	10c	38,959,245
11	Investments—publicly traded securities ..........				11
12	Investments—other securities. See Part IV, line 11 ......				12
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets .........				14
15	Other assets. See Part IV, line 11 ...........			1,301,948	15	1,640,006
16	Total assets. Add lines 1 through 15 (must equal line 34)...			56,991,481	16	61,433,977
17	Accounts payable and accrued expenses .			10,769,280	17	11,529,039
18	Grants payable ..........				18
19	Deferred revenue ..........				19
20	Tax-exempt bond liabilities ..........				20
21	Escrow or custodial account liability. Complete Part IV of Schedule D..				21
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........				22
23	Secured mortgages and notes payable to unrelated third parties ..			13,625,864	23	13,736,568
24	Unsecured notes and loans payable to unrelated third parties ....			5,712,593	24	6,575,000
25	Other liabilities. Complete Part X of Schedule D.....			2,839,427	25	5,196,586
26	Total liabilities. Add lines 17 through 25.....			32,947,164	26	37,037,193
	Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....			23,585,306	27	23,772,243
28	Temporarily restricted net assets .....			12,024	28	40,494
29	Permanently restricted net assets .....			446,987	29	584,051
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances .....			24,044,317	33	24,396,784
34	Total liabilities and net assets/fund balances .....			56,991,481	34	61,433,977