2019-05-13T11:33:42-05:00 2018-06-30 990 2017-07-01 231352202 LEHIGH VALLEY HOSPITAL - SCHUYLKILL LEHI 4848840130 2100 MACK BLVD PO BOX 4000 ALLENTOWN PA 181054000 THOMAS MARCHOZZI EXECUTIVE VP & CFO 4848840130 2019-05-13 192.234.106.29 2019-05-13 12:21:57 ED P 8A070E74AE8581237DBB2AD4CBE985160B1554C1 8A070E74AE8581237DBB2AD4CBE985160B1554C1 2017 2020-04-17 16:48:07Z BRIAN A NESTER 2100 MACK BLVD PO BOX 4000 ALLENTOWN PA 181054000 52173425 0 X WWW.LVHN.ORG X 2008 PA TO MAKE A POSITIVE DIFFERENCE IN THE SCOPE AND QUALITY OF HEALTHCARE FOR THE SCHUYLKILL COMMUNITY. 16 14 741 95 0 0 332910 179247 57167665 48810219 495602 2259871 664619 826363 58660796 52075700 100 0 0 0 40502410 41340483 0 0 0 32387459 28236168 72889969 69576651 -14229173 -17500951 69680127 155180965 72130994 135969599 -2450867 19211366 X LEHIGH VALLEY HOSPITAL - SCHUYLKILL'S MISSION IS TO MAKE A POSITIVE DIFFERENCE IN THE SCOPE AND QUALITY OF HEALTHCARE AVAILABLE FOR THE SCHUYLKILL COUNTY COMMUNITY. 0 0 58816535 48810219 LEHIGH VALLEY HOSPITAL - SCHUYLKILL (LVH-S), THROUGH THE COMBINED EFFORTS OF ITS HIGHLY QUALIFIED MEDICAL STAFF, EMPLOYEES, AND VOLUNTEERS, OFFERS A BROAD RANGE OF HEALTHCARE SERVICES TO THE RESIDENTS OF SCHUYLKILL COUNTY, PA.INPATIENT HEALTHCARE SERVICES ARE PROVIDED IN MATERNITY, PEDIATRIC (UNTIL MARCH 2018), AND BEHAVIORAL HEALTH SERVICES. THERE WERE 15,265 EMERGENCY DEPARTMENT VISITS.LVH-S PROVIDES A WIDE ARRAY OF DIAGNOSTIC AND TREATMENT PROGRAMS INCLUDING A HOSPITAL-BASED HOME HEALTH DEPARTMENT, PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPIES, OCCUPATIONAL MEDICINE, AS WELL AS CT, MRI, MAMMOGRAPHY, ULTRASOUND, DEXA SCAN, NUCLEAR MEDICINE, AND OTHER IMAGING TECHNOLOGIES. THE INDUSTRA-MED PROGRAM OF THE MEDICAL CENTER PROVIDED OCCUPATIONAL AND INDUSTRIAL HEALTH SERVICES TO OVER 200 OF THE REGION'S EMPLOYERS.THE MEDICAL CENTER PROVIDES MANY COMMUNITY OUTREACH AND EDUCATIONAL PROGRAMS THROUGHOUT THE YEAR AS WELL AS SCREENINGS, EVENTS, AND HEALTH FAIR PARTICIPATION.LEHIGH VALLEY HEALTH NETWORK (LVHN) AND SCHUYLKILL HEALTH SYSTEM (SHS) MERGED EFFECTIVE SEPTEMBER 16, 2016. UNDER THE MERGER, LVHN IS THE SURVIVING PARENT ORGANIZATION OF THE ENTITIES PREVIOUSLY CONTROLLED BY SHS, INCLUDING SCHUYLKILL MEDICAL CENTER - S. JACKSON STREET DBA LEHIGH VALLEY HOSPITAL - SCHUYLKILL S. JACKSON STREET, SCHUYLKILL MEDICAL CENTER - E. NORWEGIAN STREET DBA LEHIGH VALLEY HOSPITAL - SCHUYLKILL E. NORWEGIAN STREET, SCHUYLKILL HEALTH SYSTEM MEDICAL GROUP, INC. DBA LEHIGH VALLEY PHYSICIAN GROUP - SCHUYLKILL, SCHUYLKILL REHABILITATION CENTER, INC. DBA LEHIGH VALLEY HEALTH NETWORK REHABILITATION CENTER - SCHUYLKILL, AND SCHUYLKILL HEALTH SYSTEM DEVELOPMENT CORP. DBA LEHIGH VALLEY HEALTH NETWORK DEVELOPMENT CORPORATION - SCHUYLKILL. IN ADDITION, SCHUYLKILL MEDICAL CENTER - S. JACKSON STREET AND SCHUYLKILL MEDICAL CENTER - E. NORWEGIAN STREET MERGED EFFECTIVE JUNE 1, 2018. UNDER THE MERGER, SCHUYLKILL MEDICAL CENTER - S. JACKSON STREET IS THE SURVIVING ORGANIZATION. EFFECTIVE UPON MERGER, SCHUYLKILL MEDICAL CENTER - S. JACKSON STREET CHANGED ITS LEGAL NAME TO LEHIGH VALLEY HOSPITAL - SCHUYLKILL. 58816535 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 X 70 0 1 741 1 0 0 0 0 0 0 0 0 0 0 X 16 14 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 PA X X X THE ORGANIZATION 4848840130 2100 MACK BLVD PO BOX 4000 ALLENTOWN PA 181054000 ANTHONY BARAN TRUSTEE 1.00 3.00 X X 0 0 0 DEBRA C BLASCHAK SECRETARY 1.00 3.00 X X 0 0 0 JEANNE BOYER PORTER VICE CHAIRPERSON 1.00 3.00 X X 0 0 0 DARNELL FURER TRUSTEE 1.00 3.00 X 0 0 0 RICHARD GONZALEZ TRUSTEE 1.00 3.00 X 0 0 0 REV HAROLD L HAND TRUSTEE 1.00 3.00 X 0 0 0 THOMAS L KENNEDY ESQ TRUSTEE 1.00 3.00 X 0 0 0 WILLIAM E KIRWAN CPA ESQ CHAIRPERSON 1.00 3.00 X X 0 0 0 AMRIT P NARULA MD TRUSTEE 1.00 3.00 X 0 0 0 WILLIAM J REPPY PRESIDENT 20.00 20.00 X X 0 337825 23133 FRANKLIN K SCHOENEMAN TRUSTEE 1.00 3.00 X X 0 0 0 SYED SHAH MD TRUSTEE 1.00 3.00 X 0 0 0 E LORI SMITH TREASURER 1.00 3.00 X 0 0 0 TIMOTHY P TWARDZIK TRUSTEE 1.00 3.00 X 0 0 0 THOMAS V WHALEN MD MMM TRUSTEE 1.00 60.00 X 0 1162765 38422 ROBERT M ZIMMERMAN JR DO TRUSTEE 1.00 3.00 X 0 0 0 DIANE DOYNE ASSISTANT SECRETARY 20.00 20.00 X 0 64653 23324 RICHARD BINDIE DIRECTOR OF PATHOLOGY 40.00 X 275782 0 29494 ELIZABETH FLANNERY CRNA 40.00 X 196006 0 28277 KRISTINA GUERS CRNA 40.00 X 214231 0 15138 MARIBETH JOHNSON CRNA 40.00 X 199658 0 28387 HEIDI I LAPACHINSKY CRNA 40.00 X 194154 0 24718 DIANE BORIS VP FINANCE 18.00 22.00 X 0 222396 24383 SUE CURRY VP NURSING/CNO 18.00 22.00 X 0 240631 26587 1079831 2028270 261863 24 1 1 0 EMCARE INC 7032 COLLECTIONS CENTER DRIVE CHICAGO IL 606930001 PHYSICIAN STAFFING 1337519 ALLENTOWN ANESTHESIA ASSOCIATES INC 4905 W TILGHMAN STREET SUITE 250 ALLENTOWN PA 181049131 PHYSICIAN STAFFING 1049836 HORIZON HEALTH PO BOX 840839 DALLAS TX 752840839 BEHAVIORAL HEALTH 758450 INSIGHT HEALTH CORP PO BOX 847689 DALLAS TX 752847689 MRI 758450 SODEXO INC AND AFFILIATES PO BOX 360170 PITTSBURGH PA 152516922 DIETARY SERVICES 740223 10 179247 179247 OUTPATIENT REVENUE 621400 27166116 27166116 INPATIENT REVENUE 621400 21644103 21644103 48810219 2213229 2213229 114971 97725 17246 17246 17246 46642 0 46642 46642 46642 MEANINGFUL USE 561439 568199 568199 CAFETERIA & VENDING 900099 194446 194446 46472 46472 809117 52075700 48810219 0 3086234 33544992 30894350 2650642 1583031 1310750 272281 3764520 3117023 647497 2447940 2026894 421046 38691 38691 5727114 5118720 608394 5907 5907 226460 95996 130464 401182 4182 397000 3711550 2345946 1365604 215784 79475 136309 6853 6853 283730 283730 2759504 2759504 669741 669741 CONTRACT PERSONNEL 4241465 2430222 1811243 BAD DEBT EXPENSE 3932720 3932720 MEDICAL SUPPLIES 3337159 3337159 2678308 403270 2275038 69576651 58816535 10760116 0 2400 4580 369295 2803059 545343 2909492 16070898 814914 1394758 324795 1551482 48387039 10581343 12405801 37805696 504444 6718754 702869 7059646 313810 51646117 80912939 69680127 155180965 6974716 15821380 27648331 76435463 37507947 43712756 72130994 135969599 X -7719749 13428346 112563 179876 5156319 5603144 -2450867 19211366 69680127 155180965 X -17500951 39163184 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 0 0 PART II-B, LINE 1: LEHIGH VALLEY HOSPITAL - SCHUYLKILL IS A MEMBER OF THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE HOSPITAL & HEALTH SYSTEM ASSOCIATION OF PENNSYLVANIA (HAP). A PERCENTAGE OF THE DUES PAID TO THESE ORGANIZATIONS GOES TOWARDS LOBBYING EFFORTS. THEIR MISSION IS TO ADVANCE THE HEALTH OF INDIVIDUALS AND COMMUNITIES TO LEAD, REPRESENT, AND SERVE HEALTH CARE PROVIDER ORGANIZATIONS THAT ARE ACCOUNTABLE TO THE COMMUNITY AND COMMITTED TO HEALTH IMPROVEMENT. THE MEMBERSHIP DUES FOR AHA AND HAP ARE PAID BY LEHIGH VALLEY HOSPITAL, INC. THEREFORE, THE LOBBYING PORTION OF THE DUES ARE REFLECTED ON THE LEHIGH VALLEY HOSPITAL, INC. FORM 990, SCHEDULE C. 3340004 3340004 32814876 5551049 27263827 8305071 3574131 4730940 3927088 1456163 2470925 37805696 DUE FROM AFFILIATES 33390008 GOODWILL 46619695 SERP INVESTMENT 114375 DEFERRED COMP INSURANCE 788861 80912939 OBLIGATION UNDER CAPITAL LEASE 870967 DUE TO AFFILIATES 22769275 ACCRUED PENSION LIABILITY 18005384 DEFERRED REVENUE 24527 ESTIMATED MALPRACTICE LIABILITY 1139367 SERP LIABILITY 114375 DEFERRED COMP INSURANCE 788861 43712756 X PART X, LINE 2: LVHN, ITS HOSPITALS, AND OTHER SUBSIDIARIES ARE GENERALLY EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE OF 1986, AS AMENDED, EXCEPT FOR TAX IMPOSED ON UNRELATED BUSINESS INCOME. THE MOST RECENT DETERMINATION LETTER, RECEIVED BY THE ORGANIZATION, IS DATED MAY 1, 2014. LVHN AND ITS SUBSIDIARIES ACCOUNT FOR UNCERTAIN TAX POSITIONS IN ACCORDANCE WITH ACCOUNTING STANDARDS CODIFICATION (ASC) TOPIC 740. THE ORGANIZATION'S FOR-PROFIT COMPONENTS RECOGNIZE DEFERRED TAX ASSETS AND LIABILITIES FOR THE FUTURE TAX IMPACT OF TEMPORARY DIFFERENCES BETWEEN AMOUNTS RECORDED IN THE CONSOLIDATED FINANCIAL STATEMENTS AND THEIR RESPECTIVE TAX BASES AND THE FUTURE BENEFIT OF UTILIZATION NET OPERATING LOSS CARRYFORWARDS. DEFERRED TAX ASSETS AND LIABILITIES ARE MEASURED USING ENACTED TAX RATES EXPECTED TO APPLY TO TAXABLE INCOME IN THE YEARS IN WHICH THOSE TEMPORARY DIFFERENCES ARE EXPECTED TO BE RECOVERED OR SETTLED. INCOME TAXES OF THE ORGANIZATION'S TAX-EXEMPT AND FOR-PROFIT COMPONENTS ARE NOT MATERIAL TO THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. 1 1 X 1 X 175.000000000000 1 X 1 1 0 1 1 265872 265872 0.00410 14202517 545894 13656623 0.20800 14468389 545894 13922495 0.21210 190649 190649 0.00290 2299363 1510486 788877 0.01200 3744786 2219772 1525014 0.02320 6234798 3730258 2504540 0.03810 20703187 4276152 16427035 0.25020 1 1525422 1525422 9135567 10184085 -1048518 X 1 1 1 1 LEHIGH VALLEY HOSPITAL - SCHUYLKILL 420 SOUTH JACKSON STREET POTTSVILLE PA 17901 WWW.LVHN.ORG X X X LEHIGH VALLEY HOSPITAL - SCHUYLKILL 1 0 1 1 X X X X X X X X X 16 1 1 0 1 X WWW.LVHN.ORG/ABOUT_US X X 1 16 1 WWW.LVHN.ORG/ABOUT_US 0 1 X 175.000000000000 250.000000000000 X X X 1 1 X X X 1 X WWW.LVHN.ORG/OUR_SERVICES/KEY_SUPPORT_SERVICES/FINANCIAL_ASSISTANCE X WWW.LVHN.ORG/OUR_SERVICES/KEY_SUPPORT_SERVICES/FINANCIAL_ASSISTANCE X WWW.LVHN.ORG/OUR_SERVICES/KEY_SUPPORT_SERVICES/FINANCIAL_ASSISTANCE X X X X X 1 X 0 X X X 1 X 0 0 LEHIGH VALLEY HOSPITAL - SCHUYLKILL PART V, SECTION B, LINE 5: THE SCHUYLKILL HEALTH SYSTEM (SHS) COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) WAS DEVELOPED WITH THE SUPPORT OF STRATEGY SOLUTIONS, INC. (SSI), THE CONSULTING GROUP ENGAGED BY SHS TO ASSIST WITH THE ASSESSMENT. REPRESENTATIVES FROM SHS AND SSI WORKED COLLABORATIVELY TO GUIDE AND CONDUCT THE ASSESSMENT. A STEERING COMMITTEE MADE UP OF SENIOR REPRESENTATIVES OF SHS, AS WELL AS REPRESENTATIVES FROM LOCAL HEALTH DEPARTMENTS, LEADING HEALTH AND SOCIAL SERVICE ORGANIZATIONS, LOCAL AREA SCHOOL DISTRICTS AND COUNTY GOVERNMENT PROVIDED ADDITIONAL INPUT. THE COMBINED EXPERTISE, INPUT AND KNOWLEDGE OF THE MEMBERS OF THE STEERING COMMITTEE WAS VITAL TO THE PROJECT. THIS GROUP DESERVES SPECIAL RECOGNITION FOR THEIR TIRELESS OVERSIGHT AND SUPPORT OF THE CHNA PROCESS.DURING THIS CHNA PROJECT, FOURTEEN INDIVIDUALS WERE INTERVIEWED BY SSI INCLUDING REPRESENTATIVES FROM HEALTH AND SOCIAL SERVICE AGENCIES, SCHOOL DISTRICT PERSONNEL, FAITH-BASED CONGREGATION, GOVERNMENT REPRESENTATIVE, HIGHER EDUCATION AND SENIOR POPULATION.THESE INFORMATION-GATHERING EFFORTS ALLOWED THE PROJECT TEAM AND STEERING COMMITTEE TO GAIN A BETTER UNDERSTANDING OF THE HEALTH STATUS, HEALTH CARE NEEDS, SERVICE GAPS AND BARRIERS TO CARE OF THOSE LIVING IN THE COUNTY OF SCHUYLKILL (PA), WHICH REPRESENT THE PRIMARY AND SECONDARY SERVICE AREA OF SHS. THE ADMINISTRATION OF SHS WOULD LIKE TO THANK ALL OF THOSE WHO WERE INVOLVED IN THIS PROJECT, PARTICULARLY THOSE WHO PARTICIPATED IN INTERVIEWS AND INFORMATION GATHERING. LEHIGH VALLEY HOSPITAL - SCHUYLKILL PART V, SECTION B, LINE 6A: LEHIGH VALLEY HOSPITAL - SCHUYLKILL (EAST NORWEGIAN STREET) LEHIGH VALLEY HOSPITAL - SCHUYLKILL PART V, SECTION B, LINE 7D: OUR COMMUNITY HEALTH NEEDS ASSESSMENT IS ALSO AVAILABLE UPON REQUEST. LEHIGH VALLEY HOSPITAL - SCHUYLKILL PART V, SECTION B, LINE 2: LEHIGH VALLEY HEALTH NETWORK (LVHN) AND SCHUYLKILL HEALTH SYSTEM (SHS) MERGED EFFECTIVE SEPTEMBER 16, 2016. UNDER THE MERGER, LVHN IS THE SURVIVING PARENT ORGANIZATION OF THE ENTITIES PREVIOUSLY CONTROLLED BY SHS, INCLUDING SCHUYLKILL MEDICAL CENTER - S. JACKSON STREET DBA LEHIGH VALLEY HOSPITAL - SCHUYLKILL S. JACKSON STREET, SCHUYLKILL MEDICAL CENTER - E. NORWEGIAN STREET DBA LEHIGH VALLEY HOSPITAL - SCHUYLKILL E. NORWEGIAN STREET, SCHUYLKILL HEALTH SYSTEM MEDICAL GROUP, INC. DBA LEHIGH VALLEY PHYSICIAN GROUP - SCHUYLKILL, SCHUYLKILL REHABILITATION CENTER, INC. DBA LEHIGH VALLEY HEALTH NETWORK REHABILITATION CENTER - SCHUYLKILL, AND SCHUYLKILL HEALTH SYSTEM DEVELOPMENT CORP. DBA LEHIGH VALLEY HEALTH NETWORK DEVELOPMENT CORPORATION - SCHUYLKILL. IN ADDITION, SCHUYLKILL MEDICAL CENTER - S. JACKSON STREET AND SCHUYLKILL MEDICAL CENTER - E. NORWEGIAN STREET MERGED EFFECTIVE JUNE 1, 2018. UNDER THE MERGER, SCHUYLKILL MEDICAL CENTER - S. JACKSON STREET IS THE SURVIVING ORGANIZATION. EFFECTIVE UPON MERGER, SCHUYLKILL MEDICAL CENTER - S. JACKSON STREET CHANGED ITS LEGAL NAME TO LEHIGH VALLEY HOSPITAL - SCHUYLKILL. LEHIGH VALLEY HOSPITAL - SCHUYLKILL PART V, SECTION B, LINE 11: COMMUNITY ENGAGEMENT1.1 PROMOTE LVHN COMMUNITY EXCHANGE (CE) TIME-BANKING PROGRAM TO INCREASE SOCIAL CONNECTIONS, NEIGHBORS HELPING NEIGHBORS.IN THE FALL OF 2017, COMMUNITY EXCHANGE LEADERSHIP MET WITH SCHUYLKILL VISION AND COUNTY REPRESENTATIVES TO DISCUSS CREATING A TIME BANK IN SCHUYLKILL COUNTY. DURING THE FORMATIVE PROCESS, COMMUNITY EXCHANGE'S FUNDING ENDED FOR THE PROGRAM IN THE LEHIGH VALLEY SCHUYLKILL PARTNERS CONTINUE TO EXPLORE POTENTIAL WAYS TO INCLUDE TIMEBANKING IN THE WORK IN THE COUNTY.2.1 PARTNER WITH UNITED WAY 211 TO CREATE AND MAINTAIN A DATABASE (UW211 EAST) OF COMMUNITY RESOURCES, ACCESSIBLE TO LVHN CASE MANAGERS, CLINICIANS, PATIENTS, CAREGIVERS AND COMMUNITY ORGANIZATIONS.SCHUYLKILL COUNTY'S UNITED WAY HAS A CORRESPONDING STAFF MEMBER WHO IS RESPONSIBLE FOR UPDATING COUNTY RESOURCES IN UNITED WAY 211. LVHN'S DEPARTMENT OF COMMUNITY HEALTH REACHED OUT TO THIS STAFF MEMBER IN THE SPRING OF 2017. NO FORMAL COLLABORATION HAS BEGUN, BUT THIS WILL BE AN ONGOING GOAL FOR POTENTIAL COLLABORATION.AT-RISK POPULATIONS2.1 PUBLIC HEALTH DESTIGMATIZATION AND INFORMATIONAL CAMPAIGN TO PROMOTE IMPORTANCE OF EARLY IDENTIFICATION, CONNECTION TO TREATMENT, EMPLOYEE ASSISTANCE PROGRAMS.IN FY17 INITIAL CONVERSATIONS WERE HELD ABOUT THE IDEA OF A PUBLIC HEALTH CAMPAIGN TO REDUCE STIGMA AROUND MENTAL HEALTH. LVHN LEADERSHIP FROM MARKETING, COMMUNITY HEALTH, AND PSYCHIATRY ENGAGED IN THE PLANNING OF THIS CAMPAIGN. THE CAMPAIGN WILL BE ENTITLED "TELL YOUR STORY AND IS ALSO BEING DONE IN ALIGNMENT WITH NAMI AND LOCAL DIGITAL STORYTELLING EFFORTS WITHIN ALLENTOWN. FY17 PRIMARILY INCLUDED PLANNING AND DEVELOPMENT AND CONTINUES THROUGH FY18 WITH EXPANSION TO THE COUNTIES OUTSIDE OF THE LEHIGH VALLEY.3.1 IN COOPERATION WITH THE CENTER FOR COUNSELING SERVICES, THE MATERNITY TEAM AND OTHERS FROM LVH-SCHUYLKILL E. NORWEGIAN STREET, LVH- SCHUYLKILL S. JACKSON STREET WILL CONTINUE TO OFFER A TOBACCO CESSATION PROGRAM THROUGH CHILDBIRTH FOR MOTHER AND PARTNER.3.2 DEVELOP A TOBACCO USE SURVEY FOR THE CHILDBIRTH CLASS AND AT TIME OF CHILDBIRTH.3.3 OFFER TIME TO QUIT PROGRAM, 5-6-WEEK COACHING SESSION, AT EITHER THE HOSPITAL, COMPREHENSIVE WOMEN'S HEALTH.THIS ADDRESSES 3.1 - 3.3 LVH-S RECEIVED A DEPARTMENT OF HEALTH GRANT TO CREATE A SURVEY TO ASSESS CURRENT AND HISTORICAL USE OF TOBACCO DURING PREGNANCY, AS WELL AS DETERMINE KNOWLEDGE OF HARMFUL EFFECTS OF PRIMARY AND SECONDARY TOBACCO USE WHILE PREGNANT. THOSE WHO COMPLETED THE SURVEY WERE ALSO OFFERED RESOURCES FOR TOBACCO CESSATION. THE PROPOSED SERVICE FOCUSED ON POINTS OF INTERSECTION BETWEEN THE PATIENT AND THE HEALTHCARE DELIVERY SYSTEM DURING PREGNANCY. THIS INCLUDED OB-GYN PRACTICE, LABOR AND DELIVERY, AND CHILDBIRTH CLASSES. SURVEYS WERE ADMINISTERED BETWEEN APRIL 2017 AND JUNE 2017. THE GOAL WAS TO COLLECT 40 SURVEYS, AND THIS GOAL WAS SURPASSED BY COLLECTING 60 SURVEYS. 65% WERE COLLECTED AT THE TIME OF INITIAL OB APPOINTMENT AT PHYSICIAN PRACTICE OFFICE. 11 PARTICIPANTS REPORTED A QUIT ATTEMPT WITHIN THE LAST 30 DAYS, AND 8 REFERRALS WERE MADE TO THE PA QUIT LINE. 1 OF THE 8 INDIVIDUALS REFERRED, ENGAGED WITH TIME TO QUIT. OF THE 60 WHO COMPLETED THE SURVEY, 33% REPORTED SMOKING DAILY OR SOME DAYS WITHIN THE LAST 30 DAYS WHILE PREGNANT. 70% OF THOSE USING TOBACCO, USED IT DAILY. IN FY18, THE SURVEY CONTINUED TO BE ADMINISTERED. A TOTAL OF 598 SURVEYS WERE COMPLETED, AND 40 REFERRALS WERE MADE TO THE PA QUIT LINE.3.4 PROMOTE TOBACCO CESSATION PROGRAMS TO OTHER OB/GYN PRACTICES ON THE MEDICAL STAFF.EVERY NEW OB PATIENT RECEIVES AN INFORMATION PACKET WITH INFORMATION ABOUT SMOKING CESSATION AND THE RISKS OF SMOKING. AND, ALL PATIENTS ARE COUNSELED ABOUT SMOKING AND PREGNANCY. THIS PROCESS BEGAN IN THE FIRST QUARTER OF 2017. STAFF ASKS PATIENTS AT EACH APPOINT IF THEY SMOKE, AND IF SO, HOW MUCH. IN EACH MONTH OF FY18, 100% OF PATIENTS COMPLETED THE TOBACCO SURVEY AT EACH APPOINTMENT WITH THE EXCEPTION OF JULY 2017, IN WHICH 63% OF PATIENTS COMPLETED THE SURVEY.ACCESS TO CARE1.1 MAINTAIN AND BROADLY COMMUNICATE LVHN'S FINANCIAL ASSISTANCE POLICY, PROVIDING FREE OR DISCOUNTED CARE FOR QUALIFYING PATIENTS.FROM JULY THROUGH DECEMBER OF 2016, 414 FAP APPLICATIONS WERE RECEIVED. 386 WERE APPROVED AND 28 WERE DENIED. AVERAGE DAY TO TURNAROUND WAS 5 DAYS. FROM JANUARY 2017 TO JUNE 2017, 35 APPLICATIONS WERE RECEIVED. 28 APPLICATIONS WERE APPROVED, 4 APPLICATIONS WERE DENIED, AND 3 ARE PENDING REVIEW. IN FY18, 309 APPLICATIONS WERE APPROVED, 32 WERE DENIED, AND 91 ARE PENDING.3.1 RECRUIT PRIMARY CARE CLINICIANS TO IMPROVE ACCESS TO CARE FOR MEMBERS OF COMMUNITY.A FIVE YEAR RECRUITMENT GROWTH GRID AND FISCAL BUDGET WAS CREATED TO SUPPORT RECRUITMENT. FROM JULY THROUGH DECEMBER OF 2016, CONDUCTED THREE INTERVIEWS FOR FAMILY PHYSICIANS WHICH RESULTED IN 1 HIRE. FROM JANUARY THROUGH JUNE 2017, 27 INTERVIEWS WERE CONDUCTED WHICH RESULTED IN TWO HIRES. IN FY18, THIS CRITICAL WORK CONTINUED WITH 1 FAMILY MEDICINE, 2 INTERNAL MEDICINE, AND 2 PEDIATRICIAN PHYSICIANS BEING HIRED. 2 FAMILY MEDICINE AND 1 INTERNAL MEDICINE APC WERE ALSO HIRED.4.1 PROVIDE LVHN COLLEAGUES WITH CULTURAL, LINGUISTIC TRAINING VIA A VARIETY OF DELIVERY MECHANISMS.ON APRIL 3, 2017, LVHN'S DIVERSITY AND CULTURAL LIAISON PROVIDED AN EDUCATION SESSION TO THE LVH-S MANAGEMENT TEAM. THERE WERE 49 PARTICIPANTS IN ATTENDANCE. WE ARE EXPLORING WAYS TO CONTINUE BUILDING ON THIS WORK IN FY19.4.2 PATIENT'S PREFERRED LANGUAGE FOR HEALTH CARE DISCUSSIONS IS RECORDED AT TIME OF REGISTRATION.AT LVH-S SOUTH JACKSON, 71,014 UNIQUE PATIENTS HAD A DOCUMENTED LANGUAGE RECORDED AT TIME OF REGISTRATION IN FY17 (BOTH INPATIENT AND OUTPATIENT). AT LVH-S EAST NORWEGIAN. 38,234 UNIQUE PATIENTS HAD A DOCUMENTED LANGUAGE RECORDED AT TIME OF REGISTRATION IN FY17 (BOTH INPATIENT AND OUTPATIENT)AT LVH-S SOUTH JACKSON, 71,291 UNIQUE PATIENTS HAD A DOCUMENTED LANGUAGE RECORDED AT TIME OF REGISTRATION IN FY18 (BOTH INPATIENT AND OUTPATIENT). AT LVH-S EAST NORWEGIAN. 38,709 UNIQUE PATIENTS HAD A DOCUMENTED LANGUAGE RECORDED AT TIME OF REGISTRATION IN FY18 (BOTH INPATIENT AND OUTPATIENT). THERE ARE 20 PREFERRED LANGUAGES IDENTIFIED INCLUDING ENGLISH.4.3 ASSESS AVAILABILITY OF LANGUAGE-ASSISTANCE RESOURCES IN ALL CARE DELIVERY SITES TO MEET NEEDS OF PATIENTS WITH LIMITED ENGLISH PROFICIENCY.IN FY 17, A SITE VISIT WAS HELD AT LVH-S TO CONDUCT A NEEDS ASSESSMENT. LVH-S RECEIVED IPADS TO USE FOR LANGUAGE TRANSLATIONS WHICH WILL BE ROLLED OUT IN FY18. IN FY18, 101 INTERPRETER CALLS WERE MADE USING 678 MINUTES AND RESULTED IN $588.10 IN CHARGES.PREVENTION AND WELLNESS1.2 REDUCE NO-SHOWS FOR MAMMOGRAMS BY COMMUNICATING A REMINDER FOR SCHEDULED PATIENTS AND CALLING NO-SHOWS TO RESCHEDULE. THOSE UNABLE TO BE REACHED FOR NO-SHOW WILL BE SENT A LETTER.THE AVERAGE NO SHOW RATE FOR MAMMOGRAMS BETWEEN AUGUST THROUGH DECEMBER 2016 WAS 8.3%. THE AVERAGE NO SHOW RATE FOR JANUARY THROUGH JUNE 2017 WAS 5.9%. IN FY18, THE AVERAGE NO SHOW RATE WAS 7.38%.2.1 GUIDELINE DEVELOPMENT FOR ACUTE AND CHRONIC PAIN MANAGEMENT, PATIENT SCREENING FOR SAFE PRESCRIBING OF OPIOID ANALGESICS; PHYSICIAN OUTREACH AND EDUCATION.IN AUGUST 2016, LVH-S BEGAN USING OPIOID OVERDOSE RISK ASSESSMENT SCALE AND GIVING OPIOID PATIENTS NARCAN UNIVERSAL STANDING ORDERS TO OBTAIN NARCAN AT PHARMACIES. IN FY18, THE OPIOID PATHWAYS AND LINKAGE TO TREATMENT COMMITTEE CONDUCTED THREE EDUCATION SESSIONS WITH A TOTAL OF 30 PROVIDERS.3.1 INVESTIGATE FEASIBILITY OF WORKING WITH LOCAL LAW ENFORCEMENT AND COMMUNITY ORGANIZATIONS TO OFFER A DRUG GIVE-BACK DAY.LVH-S REACHED OUT TO THE LOCAL SHERIFF'S DEPARTMENT TO DISCUSS PARTNERSHIP ON DRUG GIVE-BACK DAY IN DECEMBER 2016. MULTIPLE ATTEMPTS HAVE BEEN MADE TO DISCUSS, HOWEVER, BOTH ORGANIZATIONS HAVE NOT BEEN ABLE TO CONNECT TO DETERMINE IF THIS IS FEASIBLE. THE DIALOGUE WILL CONTINUE THROUGH FY18. NO UPDATES TO REPORT IN FY18.4.2 DEVELOP AND IMPLEMENT PROTOCOLS FOR TIMELY REFERRALS TO DRUG & ALCOHOL TREATMENT SYSTEM FOR PATIENTS WHO PRESENT TO THE EMERGENCY DEPARTMENT WITH ADDICTION-RELATED PROBLEMS.A REFERRAL SYSTEM WAS NOT OFFICIALLY ESTABLISHED IN FY 17, BUT ONE MEETING WAS HELD IN FEBRUARY 2017 TO DISCUSS COMMUNITY-BASED AGENCY NARCAN EDUCATION SYSTEM. THIS WILL CONTINUE TO BE DEVELOPED IN FY 18. IN MARCH OF 2017, A MEETING WAS HELD WITH CARE MANAGEMENT AND THE ED ON IMPROVING PATIENT FLOW FOR SUBSTANCE ABUSE CASES IN THE ED AND FACILITATING "WARM HAND-OFFS." IN FY18, THERE WERE 100 REFERRALS MADE TO DRUG AND ALCOHOL SERVICES FROM LVH-S. 28 OF THOSE PATIENTS ATTENDED A FIRST APPOINTMENT. PART V, SECTION B, LINE 11 (CONTINUATION) 5.1 ESTABLISH AND MAINTAIN CLOSE WORKING RELATIONSHIP WITH SCHUYLKILL COUNTY DRUG & ALCOHOL PROGRAM AND RESOURCES.IN FY 17, LVH-S HELD 5 MEETINGS WITH COLLEAGUES IN SCHUYLKILL COUNTY DRUG AND ALCOHOL. OUT OF THESE MEETINGS THERE WILL BE A NEW SERVICE CONTRACT FOR A GROUP PROVIDED TO CRIMINAL JUSTICE PATIENTS GOING THROUGH THE DRUG COURT IN THE COUNTY. THE GROUP WILL CONTINUE TO MEET THROUGH FY18. ONE MEETING WAS HELD IN FY18 DUE TO STAFFING CHANGES. THIS WILL BE REVISITED IN THE FUTURE.6.1 WORK WITH SCHUYLKILL PREVENTION PARTNERSHIP TO EDUCATE SCHOOL-AGE CHILDREN IN SCHUYLKILL COUNTYFROM JULY 2016 THROUGH DECEMBER 2016, 143 PRESENTATIONS WERE GIVEN TO 3,170 STUDENTS ACROSS 8 SCHOOLS. FROM JANUARY THROUGH APRIL OF 2017, 99 SCHOOL PRESENTATIONS WERE GIVEN TO MORE THAN 2,600 STUDENTS IN GRADES K-12 ACROSS 7 SCHOOLS. IN FY18, THERE WERE 94 PRESENTATIONS FOR 8,210 STUDENTS ACROSS 35 SCHOOLS.7.1 IN COLLABORATION WITH SCHUYLKILL VISION, SUPPORT SELECTION OF COMMUNITY-BASED ACTIVITIES TO PROMOTE HEALTH, WELLNESS AND NUTRITION IN SCHUYLKILL COUNTY.7.2 INVITE DIETITIANS, COOKS, DIABETIC EDUCATORS AND OTHER HOSPITAL STAFF TO PARTICIPATE IN SCHUYLKILL VISION-SPONSORED HEALTH FAIRS AND EVENTS.THE FOLLOWING IS FOR BOTH 7.1 AND 7.2:DURING FY17, SCHUYLKILL VISION WAS CONTRACTED TO PROVIDE ESTABLISHED HEALTH EDUCATION PROGRAMMING IN THE THREE (3) HEALTHY SCHUYLKILL, PENNSYLVANIA COMMUNITIES: SCHUYLKILL HAVEN; MAHANOY CITY; AND, SHENANDOAH (EACH, A "REGION," TOGETHER, THE "COMMUNITY"). THEY WILL BE PROVIDING PERSONAL AND COMMUNITY EDUCATION ON TOPICS RELATED TO HEALTH AND SAFETY. THESE EDUCATIONAL PROGRAMS WILL BE PROVIDED TO ESTABLISHED COMMUNITY GROUPS OF ALL AGES WITHIN THESE AREAS. IN ADDITION TO EDUCATIONAL PROGRAMS, SCHUYLKILL VISIONS WILL FACILITATE AND/OR LEAD GROUP WALKS AND PHYSICAL ACTIVITY WITHIN THE COMMUNITIES LISTED.IN ADDITION, THEY WILL DEVELOP CURRICULUM AND DISTRIBUTE EDUCATIONAL MATERIALS FOR THE HEALTHY SCHUYLKILL SUMMER PROGRAM IN SCHUYLKILL COUNTY PUBLIC LIBRARIES. THIS PROGRAMMING OFFERS HEALTH RELATED EDUCATION, PRESENTED BY THE SUMMER READING PROGRAM FACILITATORS, TO ALL OF THE CHILDREN AND YOUTH WHO PARTICIPATE IN THE SUMMER READING PROGRAMS.IN FY17, VISION HELD 82 EVENTS AND IN FY18, AN ADDITION 58 EVENTS COVERING 17 TOPICS INCLUDING PERSONAL AND COMMUNITY EDUCATION RELATED TO HEALTH AND SAFETY.SOUTH-JACKSON SPECIFIC TACTICSAT-RISK POPULATIONS1.1 COORDINATE EFFORTS TO PROVIDE MENTAL HEALTH SERVICES, SUPPORT FOR PATIENTS' OTHER CONDITIONS, GROUP AND FAMILY SUPPORT, ETC. WITHIN THE INPATIENT MENTAL HEALTH UNIT.FROM JULY THROUGH DECEMBER 2016, THE REFERRAL PROCESS FOR DRUG AND ALCOHOL SERVICES FROM THE INPATIENT UNIT HAD NOT BEEN ESTABLISHED. MEETINGS WERE HELD TO ESTABLISH TRACKING OF REFERRALS WHICH WENT LIVE JANUARY 2017. IN FY18, 218 PATIENTS WERE REFERRED. 65% OF THOSE REFERRALS ATTENDED THEIR FIRST APPOINTMENT. 108 PATIENTS ATTENDED NUTRITION SESSIONS WITH A DIETICIAN ON THE INPATIENT UNIT.ACCESS TO CARE AND HEALTH EQUITY2.1 INVESTIGATE FEASIBILITY OF ESTABLISHING URGENT CARE/EXPRESSCARE ACCESS AT LVH-SCHUYLKILL.THE PLAN FOR URGENT CARE WAS DELAYED IN NOVEMBER 2016 DUE TO REGULATORY INTERVENTION THAT REQUIRED LVH-S MAINTAIN A FULL SERVICE ED AT BOTH CAMPUSES. THEY ARE CURRENTLY EXPLORING AT LEAST TWO DIFFERENT OPPORTUNITIES FOR URGENT CARE IN THE CITY AND SURROUNDING AREA. WHILE NO DEFINITE DATE YET SET, LVH-SCHUYLKILL HAS IDENTIFIED A LIKELY SITE FOR SCHUYLKILL COUNTY'S FIRST EXPRESSCARE AND IS OPTIMISTIC TO INTRODUCE THAT SERVICE BY MARCH OF 2018. ADDITIONALLY, LVH-SCHUYLKILL IS IDENTIFYING OTHER LOCATIONS IN SCHUYLKILL COUNTY WHERE EXPRESSCARE SERVICES LIKELY COULD AND WILL BE OFFERED. NO OFFICIAL ACTION HAS YET BEEN TAKEN IN THAT REGARD.IN FY18, THE SOUTH JACKSON AND EAST NORWEGIAN CAMPUSES WERE MERGED UNDER ONE LICENSE. UNDER THE NEW MERGED LICENSE, THE ED AT SOUTH JACKSON STREET IS CURRENTLY SERVING THE NEED FOR AN URGENT CARE. ACUTE SERVICES IN THE ED HAVE ALL BEEN CENTRALIZED TO EAST NORWEGIAN STREET.WHEN THE NEW FAMILY BIRTH AND NEWBORN CENTER OPENS IN JANUARY, THE SOUTH ED WILL CLOSE. IT IS ANTICIPATED THAT THE "FAST TRACK" AREA OF THE EAST ED WILL BECOME MORE AVAILABLE FOR PATIENTS.3.2 RECRUIT VARIOUS SPECIALTY PHYSICIANS TO MEET NEEDS IDENTIFIED IN THE 2016 CHNA.A FIVE YEAR RECRUITMENT GROWTH GRID AND FISCAL BUDGET WAS CREATED TO SUPPORT RECRUITMENT. IN FY18, 1 CARDIOLOGIST, 1 EMERGENCY MEDICINE, 1 HOSPITAL MEDICINE, 1 OB-GYN, 1 OCCUPATIONAL MEDICINE, 1 PEDIATRIC PHYSICAL MEDICINE AND REHAB, 2 PULMONARY AND CRITICAL CARE, AND 3 RADIOLOGY PHYSICIANS WERE HIRED. 1 HEMATOLOGY/ONCOLOGY AND 1 PSYCH APC WERE HIRED.PREVENTION AND WELLNESS1.1 OFFER LOW-COST MAMMOGRAMS IN OCTOBER AT WOMEN'S IMAGING CENTER.IN OCTOBER 2016 THERE WERE A TOTAL OF 6 LOW COST MAMMOGRAMS CONDUCTED AND IN OCTOBER 2017 THERE WERE A TOTAL OF 8 LOW COST MAMMOGRAMS CONDUCTED.1.3 CONTINUE PARTNERSHIP WITH MATERNAL & FAMILY HEALTH SERVICES IN WILKES-BARRE, PA., TO OFFER FREE MAMMOGRAMS FOR THOSE WHO CANNOT AFFORD THIS SCREENING.LVH-S WAS NOT ABLE TO FILL THE NP POSITION NEEDED TO SUPPORT THIS TACTIC IN FY17. IN OCTOBER 2017, 8 FREE MAMMOGRAMS WERE PROVIDED. 1.4 EDUCATE COMMUNITY ON THE IMPORTANCE OF MAMMOGRAMS BY HANDING OUT SELF-BREAST EXAM SHOWER CARDS AT HEALTH FAIRS, SPEAKING ENGAGEMENTS AND ALL LOCAL OB/GYN OFFICES, AS WELL AS MAKE AVAILABLE IN WAITING AREAS OF THE HOSPITAL.IN OCTOBER 2017, 1,500 SHOWER CARDS WERE DISTRIBUTED ACROSS 4 LOCATIONS.4.1 CREATE A COLLABORATION BETWEEN THE HOSPITAL, SCHUYLKILL COUNTY DRUG & ALCOHOL PROGRAM RESOURCES AND OB/GYN PROVIDERS IN COMMUNITY TO OFFER CONTINUUM OF CARE FOR PREGNANT MOTHERS ADDICTED TO HEROIN, INCLUDING CREATION OF TEAM TO CONSULT WHEN PREGNANT MOTHER IS ADMITTED TO THE HOSPITAL OR IDENTIFIED AT OB/GYN VISIT - OFFER NUTRITION, REFERRAL FOR SUBSTANCE USE TREATMENT, AT-HOME SUPPORT, MEDICAL HOME, ETC.IN DECEMBER OF 2016, A MULTIDISCIPLINARY COMMITTEE FOR DRUG ADDICTED OB PATIENTS WAS DEVELOPED AND MET. THEIR GOAL IS TO DEVELOP A PLAN TO BETTER MANAGE THE OB PATIENTS THAT ARE GOING INTO WITHDRAWAL AS WELL AS A PREVENTION STRATEGY. THE FIRST THING THE GROUP IS WORKING ON IS DEVELOPING A STANDING ORDER SETS FOR PATIENTS ADMITTED INTO INPATIENT CARE THAT DEMONSTRATE SYMPTOMS OF WITHDRAWAL DURING THEIR STAY IN ORDER TO BETTER MANAGE THEIR STAY. NO ACTIVITY OCCURRED IN FY18, BUT DISCUSSIONS IN FY19 ARE OCCURRING TO EXPLORE TELE-MED FOR MAT PROVISION AND EXPANSION OF THE CONNECTIONS CLINIC. PART I, LINE 7: LEHIGH VALLEY HOSPITAL - SCHUYLKILL COMPUTED A COST TO CHARGE RATIO USING INFORMATION FROM THE MOST RECENTLY FILED MEDICARE COST REPORT (FYE 6/30/18) FOR THE CALCULATION OF COSTS FOR CHARITY CARE AND MEDICAID. DIRECT COSTS ARE OBTAINED FROM THE HOSPITAL COMPUTER SYSTEM FOR EACH COST CENTER FOR ALL OTHER BENEFITS. INDIRECT COSTS ARE COMPUTED UTILIZING THE MOST RECENTLY FILED MEDICARE COST REPORT (FYE 6/30/18). PART I, LINE 7G: THERE ARE NO PHYSICIAN CLINICAL SERVICES INCLUDED. PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25(A) IS $3,932,720. PART III, LINE 2: AMOUNTS REPORTED AS BAD DEBT EXPENSE ARE REPORTED NET OF APPLICABLE PATIENT PAYMENTS, INSURANCE PAYMENTS AND CONTRACTUAL ALLOWANCES AS WELL AS OTHER HOSPITAL DISCOUNTS FOR WHICH THE PATIENT IS DEEMED ELIGIBLE. THE RATIO OF COSTS-TO-CHARGES (RCC) IS APPLIED TO THE NET AMOUNT TO DETERMINE THE BAD DEBT EXPENSE. PART III, LINE 3: THIS AMOUNT IS THE COST TO PROVIDE CARE TO UNINSURED PATIENTS THAT DO NOT PARTICIPATE IN THE PROCESS TO DETERMINE IF THEY ARE ELIGIBLE FOR FINANCIAL ASSISTANCE. THE COST IS DETERMINED USING COST TO CHARGE RATIOS. THE RATIONALE FOR INCLUDING THE COST TO PROVIDE CARE TO UNINSURED PATIENTS THAT DO NOT PARTICIPATE IN THE FINANCIAL ASSISTANCE PROCESS IS THE HOSPITAL'S EXPERIENCE WITH UNINSURED PATIENTS THAT DO PARTICIPATE IN THE FINANCIAL ASSISTANCE PROGRAM. WHEN THE HOSPITAL EVALUATES UNINSURED PATIENTS FOR FINANCIAL ASSISTANCE, THE MOST COMMON FINDING IS THAT UNINSURED PATIENTS HAVE INCOME LESS THAN 400% OF THE FEDERAL POVERTY GUIDELINE AND QUALIFY FOR FINANCIAL ASSISTANCE. THE HOSPITAL BELIEVES THAT UNINSURED PEOPLE WHO CHOOSE NOT TO PARTICIPATE IN THE FINANCIAL ASSISTANCE PROCESS AND HAVE THEIR ACCOUNTS WRITTEN OFF AS BAD DEBT, HAVE INCOME THAT WOULD QUALIFY FOR THE HOSPITAL FINANCIAL ASSISTANCE PROGRAM. PART III, LINE 4: BAD DEBTS - THE ORGANIZATION RECORDS A PROVISION FOR BAD DEBTS RELATED TO UNINSURED ACCOUNTS NET OF THE AGB DISCOUNT TO RECORD THE NET SELF-PAY ACCOUNTS RECEIVABLE AT THE ESTIMATED AMOUNTS THE ORGANIZATION EXPECTS TO COLLECT. COINSURANCES AND DEDUCTIBLES WITHIN THE THIRD-PARTY PAYER AGREEMENTS ARE THE PATIENT'S RESPONSIBILITY SO THE ORGANIZATION INCLUDES THESE AMOUNTS IN THE SELF-PAY ACCOUNTS RECEIVABLE AND CONSIDERS THESE AMOUNTS IN ITS DETERMINATION OF THE PROVISION FOR BAD DEBTS BASED ON HISTORICAL COLLECTION EXPERIENCE.IN INSTANCES WHERE THE ORGANIZATION BELIEVES A PATIENT HAS THE ABILITY TO PAY FOR SERVICES AND, AFTER APPROPRIATE COLLECTION EFFORT, PAYMENT IS NOT MADE, THE AMOUNT OF SERVICES NOT PAID IS WRITTEN-OFF AS BAD DEBTS. AMOUNTS RECORDED AS PROVISION FOR BAD DEBTS DO NOT INCLUDE CHARITY CARE. PART III, LINE 8: THE HOSPITAL USES THE COST-TO-CHARGE RATIO TO DETERMINE THE MEDICARE ALLOWABLE COSTS.THE MEDICARE SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT AS THE HOSPITAL IS TREATING MEDICARE PATIENTS DESPITE THE RISE IN UNREIMBURSED COST. PART III, LINE 9B: THE ORGANIZATION DOES HAVE A WRITTEN DEBT COLLECTION POLICY. ALL STAFF INVOLVED IN DEBT COLLECTION (EMPLOYEES OF THE MEDICAL CENTER AND ANY THIRD PARTY AGENCIES) ARE TRAINED ON THE POLICY AS WELL AS THE CHARITY CARE POLICY. IN DEALING WITH PATIENTS IN DEBT COLLECTION, STAFF WILL INFORM PATIENTS OF THE CHARITY CARE POLICY THAT IS AVAILABLE AND ALSO ANY OTHER FINANCIAL ASSISTANCE POLICIES OF THE MEDICAL CENTER THAT MAY BE APPLICABLE TO THE PATIENT. THE STAFF WILL INSTRUCT PATIENTS ON APPROPRIATE PAPERWORK THAT NEEDS TO BE COMPLETED WITH REGARDS TO CHARITY CARE OR FINANCIAL ASSISTANCE. PART VI, LINE 2: THE 2016 SCHUYLKILL HEALTH SYSTEM (SHS) COMMUNITY HEALTH NEEDSASSESSMENT (CHNA) WAS CONDUCTED TO IDENTIFY SIGNIFICANT HEALTH ISSUES ANDNEEDS, AS WELL AS TO PROVIDE CRITICAL INFORMATION TO SHS AND OTHERS IN APOSITION TO MAKE A POSITIVE IMPACT ON THE HEALTH OF THE REGION'S RESIDENTS. THE RESULTS ENABLE THE HOSPITAL AND OTHER COMMUNITY PARTNERS TO MORE STRATEGICALLY ESTABLISH PRIORITIES, DEVELOP INTERVENTIONS AND DIRECT RESOURCES TO IMPROVE THE HEALTH OF PEOPLE LIVING IN THE SHS SERVICE AREA.TO ASSIST WITH THE CHNA PROCESS, SHS RETAINED STRATEGY SOLUTIONS, INC. (SSI), A PLANNING AND RESEARCH FIRM BASED IN ERIE, PA WHOSE MISSION IS TO CREATE HEALTHY COMMUNITIES TO CONDUCT THE COLLABORATIVE STUDY. THE ASSESSMENT FOLLOWED BEST PRACTICES AS OUTLINED BY THE ASSOCIATION OF COMMUNITY HEALTH IMPROVEMENT. THE ASSESSMENT WAS ALSO DESIGNED TO ENSURE COMPLIANCE WITH CURRENT INTERNAL REVENUE SERVICE (IRS) GUIDELINES FOR CHARITABLE 501(C)(3) TAX-EXEMPT HOSPITALS THAT WAS PUBLISHED IN DECEMBER 2014. THIS CHNA AND ITS SUPPLEMENTAL RESOURCE DATA LOCATED IN THE APPENDICES DOCUMENT INCLUDE A DETAILED EXAMINATION OF THE FOLLOWING AREAS:- EVALUATION OF THE 2013 SHS CHNA- DEMOGRAPHICS & SOCIO-ECONOMIC INDICATORS- ACCESS TO QUALITY HEALTH CARE- CHRONIC DISEASE- HEALTHY ENVIRONMENT- HEALTHY MOTHERS, BABIES AND CHILDREN- INFECTIOUS DISEASE- MENTAL HEALTH AND SUBSTANCE ABUSE- PHYSICAL ACTIVITY AND NUTRITION- TOBACCO USE- INJURYSECONDARY PUBLIC HEALTH DATA ON DISEASE INCIDENCE AND MORTALITY, AS WELL AS BEHAVIORAL RISK FACTORS, WERE GATHERED FROM NUMEROUS SOURCES INCLUDING THE PENNSYLVANIA DEPARTMENT OF HEALTH, THE CENTERS FOR DISEASE CONTROL, HEALTHY PEOPLE 2020, AND COUNTY HEALTH RANKINGS, AS WELL AS A NUMBER OF OTHER REPORTS AND PUBLICATIONS. DATA WERE COLLECTED FOR SHS, ALTHOUGH SOMESELECTED NATIONAL DATA IS INCLUDED WHERE LOCAL/REGIONAL DATA WAS NOT AVAILABLE. DEMOGRAPHIC DATA WERE COLLECTED FROM THE NIELSEN/CLARITASDEMOGRAPHIC DATABASE. PRIMARY QUALITATIVE DATA COLLECTED SPECIFICALLY FOR THIS ASSESSMENT INCLUDED A TOTAL OF 14 IN-DEPTH INTERVIEWS. IN ADDITION TOGATHERING INPUT FROM STAKEHOLDER INTERVIEWS, INPUT AND GUIDANCE ALSO CAMEFROM SHS AND COMMUNITY REPRESENTATIVES WHO SERVED ON THE SHS STEERINGCOMMITTEE.AFTER ALL PRIMARY (STAKEHOLDER INTERVIEWS) AND SECONDARY DATA WERE REVIEWED AND ANALYZED BY THE STEERING COMMITTEE, THE DATA SUGGESTED A TOTAL OF 39 DISTINCT ISSUES, NEEDS AND POSSIBLE PRIORITY AREAS FOR POTENTIAL INTERVENTION BY SHS. MEMBERS OF THE SHS CHNA STEERING COMMITTEE MET TO REVIEW THE FINAL PRIORITIES SELECTED BY THE SHS STEERING COMMITTEE. LOOKING AT THE FINAL RANK ORDERING BASED ON THE FOUR PRIORITIZATION CRITERIA OF (I) ACCOUNTABLE ROLE OF THE HOSPITAL, (II) MAGNITUDE OF THE PROBLEM, (III) IMPACT ON OTHER HEALTH OUTCOMES AND (IV) CAPACITY (SYSTEMS AND RESOURCES) TO IMPLEMENT EVIDENCE-BASED SOLUTIONS, ALONG WITH THE RANK ORDER OF THE FINAL PRIORITIES SELECTED BY THE SHS STEERING COMMITTEE, THE STEERING COMMITTEE IDENTIFIED FOUR PRIORITY AREAS THAT WILL BE ADDRESSED IN THE IMPLEMENTATION STRATEGY:1. ACCESS TO CARE: URGENT CARE SERVICES2. ACCESS TO CARE: MAMMOGRAM SCREENINGS3. ACCESS TO CARE: PRIMARY/SPECIALTY MEDICAL CARE4. MENTAL HEALTH AND SUBSTANCE ABUSE: DRUG AND ALCOHOL ABUSEIT IS IMPORTANT TO NOTE THAT THE PRIORITIZATION CRITERIA THAT WERE UTILIZED FOR THE 2016 SHS CHNA ARE DIFFERENT FROM THE CRITERIA UTILIZED FOR THE PREVIOUS (2013) CHNA. IN 2013, THE SHS LEADERSHIP SELECTED CRITERIA THAT THEY FELT WERE RELEVANT TO THEIR NEEDS AT THE TIME. SINCE THAT TIME, AND IN LIGHT OF THE 2014 IRS RULING, SSI HAS ENCOURAGED HOSPITALS TO USE THE SAME CRITERIA, ACCOUNTABLE ROLE, MAGNITUDE, IMPACT AND CAPACITY.THE IMPLEMENTATION STRATEGIES SELECTED BY SHS AND ITS COMMUNITY PARTNERS WILL ADDRESS THE MOST SIGNIFICANT NEEDS THROUGH A VARIETY OF IMPLEMENTATION STRATEGIES. PART VI, LINE 3: EACH PATIENT IS REGISTERED INTO THE HOSPITAL COMPUTER SYSTEM WHEN THEY ARRIVE FOR SERVICES. AS PART OF THE REGISTRATION, INFORMATION IS OBTAINED ON ANY HEALTH INSURANCE THEY HAVE. INDIVIDUALS WITHOUT HEALTH INSURANCE ARE INFORMED AT THAT TIME OF THE MEDICAL CENTER'S CHARITY CARE POLICY. PATIENTS ARE GIVEN INFORMATION ON CONTACTING STAFF WITHIN THE HOSPITAL PATIENT ACCOUNTING DEPARTMENT TO DISCUSS APPLYING FOR THE HOSPITAL CHARITY CARE PROGRAM. SPECIFIC STAFF HAVE BEEN TRAINED AND ARE RESPONSIBLE FOR ADMINISTERING THE CHARITY CARE PROGRAM FOR THE HOSPITAL. HOSPITAL STAFF CONTACT PATIENTS WITHOUT INSURANCE AND EXPLAIN THE POLICY AND THE INFORMATION NEEDED TO APPLY. HOSPITAL STAFF WILL ALSO ASSIST PATIENTS IN APPLYING FOR MEDICAL ASSISTANCE. THEY WILL ALSO ASSIST PATIENTS IN COMPLETING THE APPLICATION AND GATHERING THE NECESSARY FINANCIAL DOCUMENTS.THE HOSPITAL ALSO POSTS INFORMATION WITHIN THE ADMISSION AND EMERGENCY ROOM AREAS INFORMING PATIENTS THAT THERE IS A CHARITY CARE POLICY AVAILABLE. ALL REGISTRATION PERSONNEL ARE TRAINED ON THE POLICY SO THAT THEY ARE ABLE TO INFORM PATIENTS WHEN THEY ARE REGISTERED.OTHER HOSPITAL STAFF MEMBERS THAT MAY COME IN CONTACT WITH PATIENTS ARE ALSO EDUCATED REGARDING THE CHARITY CARE POLICY. THIS WOULD INCLUDE SOCIAL WORKERS, CARE MANAGERS, NURSING STAFF, AND ALL DEPARTMENT DIRECTORS. THE CHARITY CARE POLICY IS AVAILABLE ON THE HOSPITAL INTRANET WHICH IS ACCESSIBLE BY ALL EMPLOYEES. THE HOSPITAL IS ALSO IN THE PROCESS OF PLACING THE POLICY ON THE HOSPITAL WEBSITE.ALL PATIENT ACCOUNTING, CASHIERING, AND COLLECTION STAFF ARE ALSO EDUCATED ON THE CHARITY CARE POLICY AND CAN ASSIST PATIENTS IN APPLYING FOR CHARITY CARE. ALSO ALL THIRD PARTY ORGANIZATIONS THAT WORK ON BEHALF OF THE MEDICAL CENTER IN PERFORMING COLLECTIONS HAVE BEEN EDUCATED ON THE CHARITY CARE POLICY AND CAN ADVISE PATIENTS ON APPLYING FOR THIS BENEFIT. PART VI, LINE 4: LVH-S IS LOCATED IN POTTSVILLE, PENNSYLVANIA. THE HOSPITAL SERVES ALL OF SCHUYLKILL COUNTY. SCHUYLKILL COUNTY IS A RURAL COUNTY IN PENNSYLVANIA. POTTSVILLE IS THE LARGEST POPULATION CENTER OF SCHUYLKILL COUNTY AND IS ALSO THE COUNTY SEAT. THE COUNTY IS COMPRISED OF ONE SMALL CITY AS WELL AS SEVERAL BOROUGHS AND TOWNSHIPS.THE POPULATION OF THE COUNTY IS APPROXIMATELY 144,000. APPROXIMATELY 20% OF THE POPULATION IS UNDER THE AGE OF 18 AND 19% IS OVER THE AGE OF 65. THE POPULATION IS 49% FEMALE AND 94% WHITE. APPROXIMATELY 16% OF THE POPULATION HAS A BACHELOR'S DEGREE OR HIGHER. 12.5% OF THE POPULATION IS BELOW THE POVERTY LEVEL. THE UNEMPLOYMENT RATE IS 6.9%.23% OF THE POPULATION IS INSURED BY MEDICAID. 42% OF THAT NUMBER ARE UNDER THE AGE OF 18, 10% ARE OVER THE AGE OF 65, AND 18% ARE DISABLED. 55% OF THE BIRTHS ARE COVERED BY THE MEDICAID PROGRAM.IN A RECENT REPORT RELEASED BY THE ROBERT WOOD JOHNSON FOUNDATION AND THE UNIVERSITY OF WISCONSIN'S POPULATION HEALTH INSTITUTE, SCHUYLKILL COUNTY WAS RANKED THE 61ST HEALTHIEST OF THE 67 COUNTIES IN PENNSYLVANIA. SCHUYLKILL COUNTY HAD HIGHER THAN THE STATE AND NATIONAL RATES FOR SMOKING, OBESITY, EXCESSIVE DRINKING, AND MOTOR VEHICLE CRASH DEATH RATES. THIS REPORT ALSO SHOWED THAT THE COUNTY HAD ACCESS TO FEWER PRIMARY CARE PHYSICIANS.THE DEMOGRAPHICS OF THE PATIENTS ADMITTED TO LVH-S WERE 25% MEDICARE, 46% MEDICAID, AND 2% SELF-PAY. EMERGENCY PATIENTS ARE 16% MEDICARE, 41% MEDICAID, AND 11% SELF-PAY.SCHUYLKILL COUNTY HAS THREE HOSPITALS SERVING THE COUNTY. LVH-S INCLUDES TWO LOCATIONS: SOUTH JACKSON STREET AND EAST NORWEGIAN STREET, WHICH ARE BOTH LOCATED IN POTTSVILLE AND SERVE THE MAJORITY OF THE COUNTY RESIDENTS. ST. LUKE'S MINERS MEMORIAL HOSPITAL IS LOCATED IN COALDALE, NEAR THE CARBON COUNTY BORDER. PART VI, LINE 5: THE BOARD OF LVH-S IS COMPRISED OF SIXTEEN INDIVIDUALS, FOURTEEN OF WHICH FROM THE SCHUYLKILL COUNTY COMMUNITY WHO ARE NOT EMPLOYED BY THE HOSPITAL. THEY ARE INVOLVED IN EDUCATION, SOCIAL SERVICES, GERIATRIC SERVICES, MATERNAL/CHILD SERVICES, PRIMARY MEDICAL CARE, CRIMINAL JUSTICE, SMALL BUSINESS AND MANUFACTURING. ALL PHYSICIANS ARE ENCOURAGED TO APPLY FOR MEDICAL STAFF PRIVILEGES FOR THE MEDICAL CENTER.LVH-S ALSO WORKS WITH VARIOUS COMMUNITY ORGANIZATIONS TO HELP IDENTIFY COMMUNITY NEEDS AND WORK TOGETHER TO MEET THOSE NEEDS. THE MEDICAL CENTER HAS INPATIENT ADOLESCENT AND ADULT BEHAVIORAL HEALTH SERVICES AVAILABLE TO THE RESIDENTS OF SCHUYLKILL COUNTY. THIS ALLOWS COUNTY RESIDENTS TO OBTAIN NECESSARY INPATIENT CARE WITHIN THE COUNTY WITHOUT REQUIRING FAMILIES TO TRAVEL OUTSIDE OF THE COUNTY. THE MEDICAL CENTER ALSO HAS A CERTIFIED DIABETES EDUCATOR AVAILABLE TO CONSULT WITH PATIENTS AND ALSO WITH PHYSICIANS WHEN THEY HAVE A PATIENT THAT IS NEWLY DIAGNOSED WITH DIABETES. THE MEDICAL CENTER IS THE ONLY FACILITY IN THE COUNTY WITH A MATERNITY DEPARTMENT AND NEWBORN NURSERY. THIS ALLOWS COUNTY RESIDENTS TO REMAIN IN THE COUNTY FOR MATERNITY CARE. MORE THAN 50% OF THE BIRTHS EACH YEAR ARE MEDICAID.THE EMERGENCY DEPARTMENT OF LVH-S IS A 24-HOUR EMERGENCY ROOM AVAILABLE TO ALL REGARDLESS OF THEIR ABILITY TO PAY. THE MEDICAL CENTER PARTICIPATES IN MANY INSURANCE PROGRAMS SUCH AS MEDICARE, MEDICAID, CHAMPUS, AND VA. THE MEDICAL CENTER ALSO HAS A CHARITY CARE POLICY THAT PROVIDES ASSISTANCE TO ELIGIBLE INDIVIDUALS IN PROVIDING FREE OR DISCOUNTED CARE BASED ON THEIR ABILITY TO PAY AND THE FEDERAL POVERTY GUIDELINES.LVH-S ALSO PROVIDES OPPORTUNITIES TO STUDENTS IN HEALTHCARE FIELDS TO GAIN EXPERIENCE WORKING IN THE HEALTH CARE ENVIRONMENT SUCH AS NURSING STUDENTS (RN AND LPN), PHARMACY STUDENTS, PHYSICIAN ASSISTANT STUDENTS, PHYSICAL THERAPY STUDENTS, RADIOLOGY TECHNICIANS AND MEDICAL ASSISTANTS. THE MEDICAL CENTER ALSO PROVIDES A VOLUNTEER PROGRAM FOR JUNIOR HIGH AND HIGH SCHOOL STUDENTS TO BECOME FAMILIAR WITH THE MEDICAL SERVICES OFFERED AND THE EDUCATIONAL OPPORTUNITIES AVAILABLE WITHIN THE HEALTHCARE ENVIRONMENT.THE HOSPITAL ALSO SPONSORS AND PARTICIPATES IN HEALTH FAIRS AT COMMUNITY EVENTS SUCH AS THE COUNTY FAIR, EVENTS AT THE LOCAL MALL, HEALTH SCREENINGS, BLOOD PRESSURE SCREENINGS AND CLINICS, VETERANS BREAKFAST EVENT, MEALS ON WHEELS, SKIN CANCER SCREENINGS, MAMMOGRAPHY SCREENINGS, SUPPORT GROUPS, AND LOCAL AMERICAN CANCER SOCIETY RELAY FOR LIFE.ANY EXCESS FUNDS THAT ARE GENERATED FROM THE OPERATIONS ARE INVESTED BACK INTO THE MEDICAL CENTER BY PURCHASING THE NECESSARY CAPITAL EQUIPMENT, FUNDING CAPITAL IMPROVEMENT PROJECTS, FUNDING NEW SERVICES, IMPROVING AND EXPANDING EXISTING SERVICES, AND ANY OTHER GENERAL IMPROVEMENTS TO PATIENT CARE. PART VI, LINE 6: LVHN'S COMMUNITY HEALTH NEEDS IMPLEMENTATION PLANS HAVE BEEN PREPARED IN RESPONSE TO CONCERNS IDENTIFIED IN THE CHNA REPORTS. EACH LICENSED FACILITY WITHIN LVHN - LVH CEDAR CREST/LVH 17TH STREET, LVH MUHLENBERG, LVH HAZLETON AND THE TWO NEW CAMPUSES AT LVH SCHUYLKILL (LVH SOUTH JACKSON AND LVH EAST NORWEGIAN) - HAS PREPARED AN IMPLEMENTATION PLAN. OUR IMPLEMENTATION PLANS INCLUDE ACTIVITIES DESIGNED TO ADDRESS NEEDS WITHIN OUR COMMUNITIES, WHILE ALSO PROMOTING HEALTH. NOTE THAT THE IMPLEMENTATION PLANS ARE PRESENTED IN TWO SEPARATE DOCUMENTS - ONE FOR THELVH SCHUYLKILL CAMPUSES AND ONE FOR THE OTHER LVHN COMMUNITIES. SCHUYLKILL HEALTH SYSTEM CONDUCTED ITS COMMUNITY HEALTH NEEDS ASSESSMENT PRIOR TO JOINING LVHN. WHILE WE WORKED TOGETHER TO CRAFT ITS IMPLEMENTATION PLAN, THE TEAM AT LVH SCHUYLKILL AND THE RESIDENTS OF SCHUYLKILL COUNTY HAVE A MUCH DEEPER UNDERSTANDING OF WHAT NEEDS TO BE DONE THERE. WE FELT IT WAS IMPORTANT TO PRESENT SCHUYLKILL'S CHNA REPORT AND IMPLEMENTATION PLAN AS A SEPARATE "MATCHED SET". THE IMPLEMENTATION PLANS ARE PRESENTED IN A TABLE FORMAT AND ARE ORGANIZED BY FOUR KEY FOCUS AREAS: COMMUNITY ENGAGEMENT, AT-RISK POPULATIONS, ACCESS TO CARE AND HEALTH EQUITY, AND PREVENTION AND WELLNESS. WITHIN EACH KEY FOCUS AREA, OBJECTIVES AND TACTICS ARE DESCRIBED. THESE ADDRESS "PRIORITY AREAS" NAMED IN THE CHNA REPORTS (HOUSING AND HOMELESSNESS, FOR EXAMPLE). EACH LVHN CAMPUS HAS ITS OWN COLUMN, WITH THEIR SPECIFIC TACTICS MARKED. SOME ACTIVITIES WILL BE ADOPTED ACROSS MULTIPLE CAMPUSES. COMMUNITY COLLABORATORS FOR A PARTICULAR ITEM ALSO ARE LISTED.THE IMPLEMENTATION PLANS FOR ALL FACILITIES ARE FOUND AT WWW.LVHN.ORG/ABOUT_US/COMMUNITY_HEALTH_NEEDS_ASSESSMENT/COMMUNITY_HEALTH_NEEDS_IMPLEMENTATION_PLANS X X X X X 0 1 0 0 0 0 0 0 0 WILLIAM J REPPY PRESIDENT 0 293528 0 35000 0 9297 0 0 0 23133 0 360958 0 0 THOMAS V WHALEN MD MMM TRUSTEE 0 666727 0 314718 0 181320 0 0 0 38422 0 1201187 0 0 RICHARD BINDIE DIRECTOR OF PATHOLOGY 269720 0 500 0 5562 0 0 0 29494 0 305276 0 0 0 ELIZABETH FLANNERY CRNA 195932 0 74 0 0 0 0 0 28277 0 224283 0 0 0 KRISTINA GUERS CRNA 162620 0 51012 0 599 0 0 0 15138 0 229369 0 0 0 MARIBETH JOHNSON CRNA 199549 0 109 0 0 0 0 0 28387 0 228045 0 0 0 HEIDI I LAPACHINSKY CRNA 194088 0 66 0 0 0 0 0 24718 0 218872 0 0 0 DIANE BORIS VP FINANCE 0 166383 0 55691 0 322 0 0 0 24383 0 246779 0 0 SUE CURRY VP NURSING/CNO 0 183012 0 57252 0 367 0 0 0 26587 0 267218 0 0 PART I, LINE 4B THOMAS V. WHALEN, MD, MMM - $158,164 THIS AMOUNT IS AN ACCURAL TO A NONQUALIFIED SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN. A CITY OF POTTSVILLE HOSPITAL AUTHORITY 232289554 738435CQ7 2016-12-20 56602260 PURCHASE OF HOSPITAL FACILITIES 0 0 0 A 56698912 772198 48867511 7059203 2018 0 0 0 1 A 0 0 0 0 0 0 1 A 0 0 1 0 0 0 0 0 1 A 1 FORM 990, PART V, LINE 3B THE ORGANIZATION HAS EVALUATED THE COST OF PROVIDING PARKING TO EMPLOYEES AND DETERMINED THE PRIMARY USE OF ITS PARKING FACILITIES TO BE BY PATIENTS, VISITORS, AND/OR GUESTS, NOT EMPLOYEES. THEREFORE, THE ORGANIZATION HAS NO UNRELATED BUSINESS INCOME TAX DUE RELATED TO EMPLOYEE PARKING. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION'S SOLE CORPORATE MEMBER IS LEHIGH VALLEY HEALTH NETWORK, INC. FORM 990, PART VI, SECTION A, LINE 7A THE ORGANIZATION'S SOLE CORPORATE MEMBER, LEHIGH VALLEY HEALTH NETWORK, INC., HAS THE POWER TO ELECT, APPOINT, APPROVE, OR REJECT MEMBERS OF THE ORGANIZATION'S GOVERNING BODY. FORM 990, PART VI, SECTION A, LINE 7B THE ORGANIZATION'S SOLE CORPORATE MEMBER, LEHIGH VALLEY HEALTH NETWORK, INC., HAS THE POWER TO APPROVE OR REJECT CERTAIN MAJOR OPERATING DECISIONS MADE BY THE ORGANIZATION'S GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11B THE PROCESS TO REVIEW THE 990'S INCLUDES: DRAFT 1 OF THE RETURNS IS REVIEWED IN DETAIL WITH A FOCUS ON ACCURACY, COMPLETENESS, AND PERSPECTIVE BY THE LVHN VICE-PRESIDENT, FINANCE AND CONTROLLER. DRAFT 2 OF THE RETURNS IS REVIEWED BY THE EXECUTIVE VICE PRESIDENT & CHIEF FINANCIAL OFFICER. ALL COMPENSATION DISCLOSURES ARE REVIEWED BY THE DIRECTOR, COMPENSATION - HUMAN RESOURCES. DRAFT 3 OF THE RETURNS IS REVIEWED TOGETHER WITH THE PRESIDENT & CEO, THE EXECUTIVE VICE PRESIDENT & CHIEF FINANCIAL OFFICER, THE VICE-PRESIDENT, FINANCE AND CONTROLLER AND THE DIRECTOR, TAX. FINAL RETURNS ARE REVIEWED WITH THE LVHN BOARD LEADERSHIP GROUP (THE BOARD CHAIR AND THREE VICE CHAIRS). COPIES OF ALL 990'S ARE PROVIDED TO THE FULL BOARD PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C IN JANUARY 2016, LVHN IMPLEMENTED AN ELECTRONIC TOOL DESIGNED TO SEND NOTIFICATIONS AND TRACK DISCLOSURES REPORTED ON CONFLICT OF INTEREST QUESTIONNAIRES. THE NETWORK ALSO EXPANDED THE SCOPE OF THE CONFLICT OF INTEREST OR COMMITMENT POLICY, SUCH THAT ADDITIONAL COLLEAGUES ARE NOW REQUIRED TO COMPLETE A QUESTIONNAIRE EACH YEAR. PRIOR TO JANUARY, THE VP, INTERNAL AUDIT AND COMPLIANCE SERVICES ISSUED A NOTICE TO BOARD MEMBERS AND MEMBERS OF THE SENIOR MANAGEMENT COUNCIL WHEN IT WAS TIME FOR THEM TO SUBMIT THEIR CONFLICT OF INTEREST QUESTIONNAIRES. THE VP ALSO INSTRUCTED MEMBERS OF THE SENIOR MANAGEMENT COUNCIL TO IDENTIFY AND REQUEST COMPLETED CONFLICT OF INTEREST QUESTIONNAIRES FROM INDIVIDUALS WHO HAD POTENTIAL CONFLICTS OF INTEREST AND TO PROVIDE HER WITH THE IDENTITY OF THOSE INDIVIDUALS. COMPLIANCE SERVICES TRACKED COMPLETION OF THE QUESTIONNAIRES. ALL PHYSICIANS ON LVHN'S MEDICAL STAFF ARE ALSO REQUIRED TO COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE ANNUALLY. MEDICAL STAFF SERVICES MONITORS THIS PROCESS TO ENSURE THAT ALL PHYSICIANS COMPLY. POTENTIAL CONFLICTS ARE MANAGED BY THE LVHN CONFLICT OF INTEREST COMMITTEE AND/OR BY THE BOARD OF TRUSTEES, DEPENDING ON WHOSE INTEREST(S) POSE THE CONFLICT AND THE NATURE OF THE CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 LEHIGH VALLEY HEALTH NETWORK 2018 EXECUTIVE COMPENSATION REVIEW IN COMPLIANCE WITH THE REBUTTABLE PRESUMPTION OF REASONABLENESS PROCESS OUTLINED IN THE INTERMEDIATE SANCTIONS REGULATIONS (ISSUED UNDER SECTION 4958 OF THE INTERNAL REVENUE CODE); SULLIVAN COTTER AND ASSOCIATES, INC. (SULLIVAN COTTER) QUALIFIES AS AN INDEPENDENT EXECUTIVE COMPENSATION EXPERT, SPECIALIZING IN THE HEALTH CARE INDUSTRY. SULLIVAN COTTER PROVIDES ADVICE TO THE LEHIGH VALLEY HEALTH NETWORK EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES TO SUPPORT ITS ATTAINMENT OF THE REBUTTABLE PRESUMPTION OF REASONABLENESS UNDER THE INTERMEDIATE SANCTIONS REGULATIONS. THEY ALSO SUPPORT THE COMMITTEE IN ENSURING THAT THE LVHN EXECUTIVE COMPENSATION PROGRAM IS COMPETITIVE AND ALIGNED WITH THE ORGANIZATION'S EXECUTIVE COMPENSATION PHILOSOPHY. CHIEF EXECUTIVE OFFICER TOTAL COMPENSATION REVIEW: PROGRAM ANALYSIS: ANALYZE THE MARKET POSITION OF TOTAL COMPENSATION (BASE SALARY, INCENTIVE, BENEFITS, AND PERQUISITES) FOR LVHN'S PRESIDENT AND CHIEF EXECUTIVE OFFICER (CEO) IN RELATION TO CEO MARKET DATA OBTAINED FOR A DEFINED PEER GROUP OF COMPARABLE HEALTH SYSTEMS. THIS INCLUDES THE PREPARATION OF TALLY SHEETS FOR THE PRESIDENT AND CEO AS WELL AS AN ANALYSIS OF FORM 990 COMPENSATION DATA. THEY ASSESS THE ALIGNMENT OF THE PRESIDENT AND CEO'S COMPENSATION WITH LVHN'S COMPENSATION PHILOSOPHY AND NOTE THE IMPLICATIONS OF THE REVIEW. SULLIVAN COTTER'S ANALYSES AND FINDINGS ARE SUMMARIZED IN A REPORT TO THE COMMITTEE THAT PROVIDES A REASONABLENESS OPINION FOR THE INTERMEDIATE SANCTIONS COMPLIANCE. THE REPORT WAS PROVIDED BY SULLIVAN COTTER AT THE AUGUST 15, 2017 EXECUTIVE COMPENSATION COMMITTEE MEETING. CEO COUNCIL EXECUTIVE TOTAL COMPENSATION REVIEW: PROGRAM ANALYSIS: ANALYZE THE MARKET POSITION OF TOTAL COMPENSATION (SALARIES, INCENTIVES, BENEFITS, AND PERQUISITES) FOR LVHN'S CEO COUNCIL EXECUTIVES (APPROXIMATELY 12 TOTAL POSITIONS) IN RELATION TO COMPARABLE POSITIONS IN PEER ORGANIZATIONS. THIS INCLUDES THE PREPARATION OF TALLY SHEETS FOR EACH INDIVIDUAL. SULLIVAN COTTER'S ANALYSES AND FINDINGS ARE SUMMARIZED IN A REPORT TO THE COMMITTEE THAT ALSO PROVIDES AN OPINION OF REASONABLENESS FOR INTERMEDIATE SANCTIONS COMPLIANCE. THE REPORT WAS PROVIDED BY SULLIVAN COTTER AT THE AUGUST 15, 2017 EXECUTIVE COMPENSATION COMMITTEE MEETING. SUMMARY OF METHODOLOGY TO CONDUCT THIS ANALYSIS, SULLIVAN COTTER: COLLECTED BACKGROUND INFORMATION REGARDING LVHN'S OPERATIONS, STRUCTURE, SIZE AND SCOPE, AS WELL AS EACH POSITION'S DUTIES. COMPILED MARKET DATA FOR CEO COUNCIL EXECUTIVES CONSISTENT WITH THE EXECUTIVE COMPENSATION PHILOSOPHY APPROVED BY THE COMMITTEE DURING ITS SEPTEMBER 13, 2017 MEETING: THE MARKET DATA USED FOR LVHN SYSTEM EXECUTIVES IN THIS ASSESSMENT ARE AN EQUALLY WEIGHTED BLEND OF (1) A PEER GROUP OF 30 NOT-FOR-PROFIT HEALTH SYSTEMS LOCATED IN THE NORTHEAST REGION (EXCLUDING NEW YORK CITY) WITH NET OPERATING REVENUES BETWEEN $1.3 BILLION AND $5.0 BILLION (AVERAGE OF $2.4 BILLION), AND (2) NATIONAL DATA REFLECTING ORGANIZATIONS OF SIMILAR SCOPE AND SIZE TO LVHN. NATIONAL DATA ARE USED WHERE PEER GROUP DATA ARE NOT AVAILABLE. PEER GROUP AND NATIONAL MARKET DATA WERE ABSTRACTED FROM SULLIVAN COTTER'S 2016 SURVEY OF MANAGER AND EXECUTIVE COMPENSATION IN HOSPITALS AND HEALTH SYSTEMS, AS WELL AS OTHER PUBLISHED COMPENSATION SURVEYS REFLECTING PAY AT COMPARABLY SIZED ORGANIZATIONS, WHICH INCLUDED NATIONAL HOSPITALS AND NATIONAL MEDICAL GROUPS. SULLIVAN COTTER NOTES THAT NO MARKET DATA ARE PROVIDED FOR THE SVP, MEDICAL SERVICES AS THE RESPONSIBILITIES OF THAT POSITION ARE UNIQUE, SO NO BENCHMARK DATA ARE AVAILABLE. THEY RECOMMEND THAT THE COMMITTEE ASSESS THE COMPENSATION FOR THAT POSITION BASED ON INTERNAL EQUITY CONSIDERATIONS. COMPILED MARKET DATA FOR THE LVHN CLINICAL CHAIRS PREPARED BY THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES (AAMC) FOR THE CHAIRS OF CLINICAL DEPARTMENTS IN MEDICAL SCHOOLS, LVHN'S TRADITIONAL COMPARATOR GROUP FOR THESE JOBS. ADJUSTED THE MARKET DATA TO AN EFFECTIVE DATE OF JANUARY 1, 2018 AT AN ANNUALIZED RATE OF 3.0% BASED ON SALARY INCREASE TRENDS. COMPARED EACH COMPONENT OF LVHN'S BENEFIT PROGRAM AGAINST TYPICAL MARKET BENEFIT PRACTICES IN HEALTH SYSTEMS AND HOSPITALS BASED ON MULTIPLE PUBLISHED SURVEYS, SUPPLEMENTED BY SULLIVAN COTTER'S PROPRIETARY DATA AND EXPERIENCE. DEVELOPED MARKET TOTAL COMPENSATION DATA BY COMBINING MARKET TCC WITH TYPICAL MARKET BENEFIT COSTS. COMPARED LVHN'S TC TO MARKET RATES AND ASSESSED OVERALL POSITIONING. FOR PHYSICIAN EXECUTIVES HAVING BOTH CLINICAL AND ADMINISTRATIVE ROLES, RELEVANT MARKET DATA WERE COLLECTED BASED ON FTE ALLOCATION. SULLIVAN COTTER HAS NOT COMPLETED AN ASSESSMENT OF THE PHYSICIANS' PRODUCTIVITY OR THE FAIR MARKET VALUE (FMV) OF THEIR CLINICAL COMPENSATION, AS LVHN HAS ADVISED THAT SUCH AMOUNTS ARE APPROPRIATE AND WITHIN FMV. SULLIVAN COTTER USED THE FOLLOWING METHODOLOGY TO ASSESS THE COMPETITIVENESS AND REASONABLENESS OF LVHN'S EXECUTIVE TOTAL COMPENSATION LEVELS: COLLECTED BACKGROUND INFORMATION REGARDING LVHN'S OPERATIONS, STRUCTURE, SIZE AND SCOPE. COLLECTED INFORMATION ON EACH CEO COUNCIL EXECUTIVE MEMBER'S CURRENT COMPENSATION. DATA COLLECTED INCLUDE BASE SALARIES, ANNUAL INCENTIVE OPPORTUNITY LEVELS (TARGET AND MAXIMUM), ACTUAL ANNUAL INCENTIVE PAYOUT AMOUNTS, ANNUAL COSTS OF ALL STANDARD AND SUPPLEMENTAL BENEFITS AND ANNUAL COST AND DESCRIPTION OF EXECUTIVE PERQUISITES. REVIEWED JOB DESCRIPTIONS AND ORGANIZATIONAL CHARTS TO IDENTIFY EACH POSITION'S FUNCTIONAL RESPONSIBILITIES AND REPORTING RELATIONSHIPS. SELECTED THE APPROPRIATE BENCHMARK POSITION MATCH FOR EACH POSITION AND APPLIED PREMIUMS/DISCOUNTS TO THE MARKET DATA IN INSTANCES WHERE LVHN'S JOB DUTIES DIFFER MATERIALLY FROM BENCHMARK POSITION MATCHES. POSITION MATCHES AND MARKET ADJUSTMENTS WERE REVIEWED WITH LVHN'S SENIOR VICE PRESIDENT, HUMAN RESOURCES AND COMPENSATION STAFF. LVHN'S PROJECTED FY2017 NET REVENUES AND PHYSICIAN FTE'S WERE USED AS THE SCOPE SIZE FOR EACH ENTITY. FORM 990, PART VI, SECTION C, LINE 18 ANOTHER'S WEBSITE - GUIDESTAR. UPON REQUEST - HARD COPIES WITH SENIOR MANAGEMENT AND MARKETING. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC THROUGH ITS ANNUAL REPORT TO THE COMMUNITY. THE ANNUAL REPORT IS DISTRIBUTED TO ALL ATTENDEES AT THE ORGANIZATIONS ANNUAL PUBLIC MEETING. IN ADDITION, IT IS DISTRIBUTED VIA MAIL TO MEMBERS OF THE COMMUNITY. THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 9: PENSION LIABILITY ADJUSTMENT 4,566,028. PURCHASE ACCOUNTING -3,899,226. TRANSFER FROM SCHUYLKILL MEDICAL CENTER - E. NORWEGIAN ST., EIN #23-0880420 38,496,382. LEHIGH VALLEY HEALTH NETWORK 1200 S CEDAR CREST BLVD ALLENTOWN PA 181036202 222458317 PARENT COMPANY PA 501(C)(3) LINE 12C, III-FI N/A 0 LEHIGH VALLEY HOSPITAL 2100 MACK BLVD ALLENTOWN PA 181035622 231689692 HEALTH CARE ORGANIZATION PA 501(C)(3) LINE 3 LEHIGH VALLEY HEALTH NETWORK 0 LEHIGH VALLEY HOSPITAL-MUHLENBERG 1200 S CEDAR CREST BLVD ALLENTOWN PA 181036202 232367707 HEALTH CARE ORGANIZATION PA 501(C)(3) LINE 3 LEHIGH VALLEY HEALTH NETWORK 0 LEHIGH VALLEY PHYSICIAN GROUP 1200 S CEDAR CREST BLVD ALLENTOWN PA 181036202 232700908 PHYSICIAN PRACTICE ORGANIZATION PA 501(C)(3) LINE 3 LEHIGH VALLEY HEALTH NETWORK 0 MUHLENBERG REALTY CORPORATION 1200 S CEDAR CREST BLVD ALLENTOWN PA 181036202 232245513 REAL ESTATE RENTALS PA 501(C)(3) LINE 12C, III-FI LEHIGH VALLEY HEALTH NETWORK 0 LEHIGH VALLEY HEALTH NETWORK REALTY HOLDING CO 1200 S CEDAR CREST BLVD ALLENTOWN PA 181036202 232586770 REAL ESTATE HOLDING CO. 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