2018-05-15T08:37:43-05:00 2017-06-30 BKD LLP 910 E St Louis Street Suite 200 Springfield MO 65806 990 2016-07-01 240799343 Divine Providence Hospital of the Sisters of Christian Charity DIVI 5703207900 1100 Grampian Boulevard Williamsport PA 17701 Eric D Pohjala Executive Vice President / CFO 5703213175 2018-05-15 1 Brian D Todd P00422601 4178658701 2016 2022-09-23 18:48:47Z Steven P Johnson 700 High Street Williamsport PA 17701 159172191 0 0928 X www.upmcsusquehannahealth.org X 1947 PA Divine Providence Hospital of the Sisters of Christian Charity (DPH) is a 31 bed specialty hospital that offers inpatient psychiatric services and a wide array of outpatient hospital services, primarily serving Lycoming and surrounding counties. Effective January 1, 2004, through a merger with Susquehanna Regional Home Health (EIN # 24-0795499), DPH began providing home health services. X 22 16 0 229 0 0 844733 2223118 99007867 106457008 1684737 7050283 212693 236299 101750030 115966708 11955862 15272102 0 0 30299748 30676193 0 0 4912 59726659 62966112 101982269 108914407 -232239 7052301 127701804 79019938 34361459 13533235 93340345 65486703 X Divine Providence Hospital of the Sisters of Christian Charity (DPH) is a subsidiary of UPMC Susquehanna. The mission of UPMC Susquehanna and affiliates is as follows: To extend God's healing love by providing outstanding patient care and shaping tomorrow's health care through clinical and technological innovation and education. Our vision is to create and integrated community health system that delivers world class care. Our values are to carefullly place our patients and their families firts, share ownership with all caregivers and lead with a servant's heart. 0 0 92352860 15272102 106336568 For the fiscal year ended June 30, 2017, the hospital admitted 656 patients rendering 5,240 patient days and registered approximately 131,156 outpatients and provided 111,560 home health visits. DPH treats all patients without regard to their ability to pay. In addition, the Hospital treats Medicare and Medical Assistance patients and maintains a Medicare / Medical Assistance policy that provides patients enrolled in such programs with access to all covered inpatient, outpatient and diagnostic services that are available to non-Medicare / Medical Assistance patients. On an annual basis, DPH devotes a portion of its revenue and assets to community program services. The following reflects the breakout of $19,394,671 in quantifiable community benefits reported for FY 2017: Charity Care (at cost) $116,097; Bad Debts (at cost) $511,017; Government-sponsored health care (unpaid cost of Medicare, Medicaid, Indigent care programs, SCHIP and other safety net programs) $17,728,454. In addition, various Education, Community Health Services, Subsidized Health Services, Community Building, Financial and In-Kind Contributions and Community Benefit Operations totaling $1,039,103. 92352860 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 1 0 0 0 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 X 0 0 0 1 0 0 0 0 0 0 0 0 0 0 X 22 16 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 0 0 0 PA X Eric D Pohjala Executive VP CFO 5703207900 700 High Street Williamsport PA 17701 Ann S Pepperman Chair 2.00 10.00 X X 0 0 0 Davie Jane Gilmour Vice Chair 2.00 8.00 X X 0 0 0 Sister Teresa Ann Jacobs Secretary 2.00 8.00 X X 0 0 0 Phillip Johnson Treasurer 2.00 10.00 X X 0 0 0 Mark D Beyer DO Director 2.00 2.00 X 0 0 0 Susan Branton MD Director 2.00 42.00 X 0 477115 30846 Jill A Burns Director 2.00 48.00 X 0 259810 33044 Ronald E DiSimone MD Director 2.00 46.00 X 0 1072681 31403 Durriya S Esaa MD Director 2.00 6.00 X 0 0 0 Kevin W Kist DO Director 2.00 42.00 X 0 421770 35537 Daniel A Klingerman Director 2.00 8.00 X 0 0 0 Keith S Kuzio Director 2.00 10.00 X 0 0 0 Donald Leathers MD Director 2.00 6.00 X 0 0 0 Lynda Livingston Director 2.00 8.00 X 0 0 0 J Dennis Murray PhD Director 2.00 10.00 X 0 0 0 Alexander R Nesbitt MD Director 2.00 46.00 X 0 241117 31052 Thomas M Owlett Esquire Director 2.00 10.00 X 0 0 0 Shailesh D Patel MD Director 2.00 8.00 X 0 0 0 Glenn B Poirier Director 2.00 10.00 X 0 0 0 Peter B Trevouledes MD Director 2.00 2.00 X 0 0 0 Patrick Wilson Director 2.00 8.00 X 0 0 0 Steven P Johnson President / CEO 2.00 48.00 X X 0 960096 33271 Eric D Pohjala Executive VP / CFO 2.00 42.00 X 0 430438 32395 David Lopatofsky MD Executive VP / CMO 2.00 40.00 X 0 593514 37048 Jan E Fisher Executive VP / COO 2.00 42.00 X 0 551981 31238 Robert E Kane President 40.00 X 235372 0 28625 Rajesh Manoharan Medical Physicist 40.00 X 198222 0 34191 Michelle R Gaida Executive Director Cancer Services 40.00 X 148123 0 16341 Patricia A McGee Executive Director Home Care 40.00 X 147347 0 7354 Harry E Hefty Physical Therapist 40.00 X 127881 0 26660 Ronald J Butler Former Exec VP/CBO (retired) 0.00 40.00 X 0 335670 0 856945 5344192 409005 17 1 1 0 The Williamsport Hospital 700 High Street Williamsport PA 17701 Management services 10775154 Aramark Healthcare 24863 Network Place Chicago IL 60673 Management / environmental services 9151359 Varian Medical Systems 70140 Network Place Chicago IL 60673 Oncology services 735082 Susquehanna Lithotripsy 100 West 3rd Avenue Columbus OH 43201 Lithotripsy services 482800 Williamsport Pathology Association 700 High Street Williamsport PA 17701 Pathology services 127489 7 7979 1664456 543183 7500 2223118 Net patient service revenue 621990 103284827 103284827 Affiliate rent income 531120 2284297 2284297 Sports Medicine - athletic traine 621400 687277 687277 Cafeteria 722514 200607 200607 106457008 217987 217987 49721069 234650 42692856 430567 7028213 -195917 6832296 6832296 127060 7979 82060 45000 45000 Auxiliary activity 900099 99505 99505 Oncology - clinical trials 900099 42126 42126 Diabetes education 621990 22543 22543 27125 15498 11627 191299 115966708 106336568 0 7407022 15272102 15272102 24480195 21430910 3045365 3920 1157736 1013527 144024 185 3295531 2885035 409968 528 1742731 1525654 216798 279 10775154 10775154 1572 1572 5501 5501 56098 56098 10373097 9648678 724419 15689 8439 7250 1762145 1351118 411027 227773 80224 147549 72719 61981 10738 2693830 2454729 239101 598181 578122 20059 81700 63691 18009 265379 265379 3785239 3776684 8555 485004 414699 70305 Medical supplies 23794051 23790135 3916 Inter-entity costs 3609358 3609358 Bad debt 2003003 2003003 Repairs and maintenance 1761767 1731100 30667 598852 388292 210560 108914407 92352860 16556635 4912 2406148 382741 12116069 12077500 1671825 2095877 789399 607509 121295128 85522870 34633669 35772258 51755974 24328720 28084053 127701804 79019938 6531997 6050655 374471 385918 20521213 6933778 7096662 34361459 13533235 X 91291118 62959126 1085957 1612376 963270 915201 93340345 65486703 127701804 79019938 X 7052301 -5418464 -29487479 X 0 1 X 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 5501 0 0 0 5501 0 Part II-B, Line 1: The hospital holds memberships in the American Hospital Association (AHA)which engage in lobbying as part of their mission to represent the interests of hospitals at both the Federal and State levels. For the year ended 06/30/17, the amount of dues to AHA totaled $25,255 of which 21.78% or $5,501, was used for lobbying purposes. 135100 135100 60969977 44078823 16891154 275159 104824 170335 50836427 38772334 12064093 9078465 2566889 6511576 35772258 Investment in net assets of affiliates 849402 Due from affiliates 26472069 Other Receivables 244541 Other 518041 28084053 Accrued medical malpractice cost 168000 Estimated third party settlements / deferred reimbursement 1152014 Asbestos abatement 158000 Due to Affiliates, net 5618648 7096662 X Part X, Line 2: Management has evaluated their income tax positions under the guidance included in ASC 740. Based on their review, management has not identified any material uncertain tax positions to be recorded or disclosed in the financials statements. Central America 0 1 Program services Captive insurance company 280065 0 1 0 0 0 1 280065 0 280065 0 0 0 0 0 0 Fall Festival 40938 40938 12350 Jewelry Sale 32002 32002 22293 8 62099 7979 54120 47417 135039 7979 127060 82060 82060 45000 1 1 X 1 X 1 X 1 1 1 0 1 1 116097 116097 0.00110 10372831 4305969 6066862 0.05680 10488928 4305969 6182959 0.05790 274730 2530 272200 0.00250 35262 0 35262 0.00030 229191 47235 181956 0.00170 244923 0 244923 0.00230 784106 49765 734341 0.00680 11273034 4355734 6917300 0.06470 1655 0 1655 0.00000 10000 500 9500 0.00010 11655 500 11155 0.00010 1 2003003 100150 29787493 41403733 -11616240 X 1 1 1 1 Divine Providence Hospital 1100 Grampian Boulevard Williamsport PA 17701 www.upmcsusquehannahealth.org 041001 X X Wide array of outpatient hospital services Divine Providence Hospital 1 0 0 1 X X X X X X X X X 15 1 1 0 1 X See Part V, Page 7 X 1 15 1 See Part V, Page 7 0 1 X 200.000000000000 400.000000000000 X X X X X 1 1 X X X 1 X See Part V, Page 7 X See Part V, Page 7 X See Part V, Page 7 X X X X X X 1 X 0 1 X 0 0 Divine Providence Hospital Part V, Section B, Line 5: In conducting its CHNA, the hospital took into account input from representatives of the community served, including those with special knowledge of or expertise in public health. This was accomplished by conducting 9 key informant meetings, with 55 people answering the key informant interview. A web-based tool was utilized to conduct the key informant interview; however, paper questionnaires identical to the electronic version were distributed to those who may not have access to the internet or generationally are more likely to complete a paper questionnaire. For more details concerning the key informant meeting process or the key informant interview process, including a list of those individuals interviewed, a copy of the key informant interview, and results gathered you may view the CHNA and related implementation plan at www.upmcsusquehanna.org/communityhealth. Divine Providence Hospital Part V, Section B, Line 6a: Divine Providence Hospital; located in Williamsport, PA is one of four hospitals that comprise of UPMC Susquehanna based in Williamsport, Pennsylvania. For purposes of conducting CHNA's, three of these hospitals, The Williamsport Hospital (DBA: Williamsport Regional Medical Center), Divine Providence Hospital, and Muncy Valley Hospital, share the same definition of community served, which is Lycoming County, PA. The fourth hospital that is part of UPMC Susquehanna is Soldiers & Sailors located in Wellsboro, PA and their defined community is Tioga County, PA. UPMC Susquehanna's approach to providing community benefit is to leverage the assets and expertise of all four hospitals to meet the needs and improve the health status of those who reside in the communities located in Lycoming and Tioga counties. Accordingly, a certain amount of collaboration between these related hospitals occurred in the development of their CHNA's and related Implementation Plans. For more details concerning these four hospitals, as well as their definition of community served you may view the CHNA and related implementation Plans as www.upmcsusquehanna.org/communityhealth. Divine Providence Hospital Part V, Section B, Line 11: Health needs were identified based on information gathered and analyzed through the 2016 CHNA conducted by the Health System. For the health needs prioritization process, the Health System engaged a hospital leadership team to review the most significant health needs reported the prior CHNA using the following criteria, 1) Current area of hospital focus. 2) Established relationships with community partners to address the health need. 3) Organizational capacity and existing infrastructure to address the health need.Based on the criteria outlined above, the leadership team ranked each of the health needs. As a result of the priority setting process, the identified priority areas that will be addressed through the Health System's Implementation Strategy for fiscal years 2017 through 2019 will be, 1) Substance abuse 2) Lack of mental health services 3) Heart disease 4) Financial barriers/poverty/low socioeconomic 5) Cancer 6) Lack of preventative care 7) Lack of health knowledge/education 8) Obesity 9) Lack of primary care physicians.The Health System's next step included developing an Implementation Strategy to address these priority areas which can be found at www.upmcsusquehanna.org/communityhealth.In some cases the hospital does not have the resources and specialty staff that would be required to adequately address all the identified needs. In other words, there may already be other agencies and healthcare providers working to effect change in these areas by providing related community resources and services. For more detailed discussion regarding identified health needs you may view the CHNA and related implementation strategy at www.upmcsusquehanna.org/communityhealth.To date, our progress on the implementation strategies are as follows: (1) Improve access to primary / specialty services and programs available within Lycoming County. Implementing longer office hours, walk-in access and 24/7 to nurse triage and ability to make an appointment in primary care; improve acess to specialty service lines (i.e. Cancer, Heart, Ortho, GI....); working with various organizations to establish a more robust way to connect the community to services within the county and wellness fairs available. (2) Continue to partner in the fight against opiate addiction and support local services/task forces. Authorize implementation of prescription drug monitoring program system wide; access to certified recovery specialist for all Susquehanna Emergency departments; collaborate with organizations to help educate the community. (3) Collaborate with community organizations on health and wellness initiatives, such as routine wellness check-ups and cancer screenings. Promote routine cancer screenings for breast, colon and lung cancer; Susquehanna signed the 80% by 2018 initiative to have 80% of individuals ages 50 or older screened for colon cancer in Lycoming County; continue to partner with River Valley Regional YMCA to suport health and wellness programs for both children and adults; continue to grow and expand the Spirit of Women programs. (4) Support mental health services; Have licensed clinical socal workers available at all primary care offices; ease access into behavioral health specialists. (5) Support transportation options to healthcare for rural areas; establish a stronger connection to STEP; bring wellness clinics to rural area. Divine Providence Hospital Part V, Section B, Line 16j: Other - Brochure Part V, line 7a https://www.susquehannahealth.org/in-the-community/community-health-nee ds-assessments Part V, line 10a https://www.susquehannahealth.org/in-the-community/community-health-nee ds-assessments Part V, line 16a, FAP website https://www.susquehannahealth.org/patients-visitors/for-patients/billin g-insurance/financial-assistance-program Part V, line 16b, FAP application website https://www.susquehannahealth.org/patients-visitors/for-patients/billin g-insurance/financial-assistance-program Part V, line 16c, FAP plain language summary website https://www.susquehannahealth.org/patients-visitors/for-patients/billin g-insurance/financial-assistance-program Part V, line 16i There are no groups with limited english proficiency that exceed IRC section 501 (r) thresholds. However, language translations of the financial assistance policy and related documents are available by request at the financial counseling department of the hospital. 2 1 - The Meadows 2160 Warrensville Road Montoursville PA 17754 Assisted living facility 2 - The Wenner Building 1705 Warren Avenue Williamsport PA 17701 Outpatient diagnostics Part I, Line 6a: The community benefit report is prepared on a system wide basis under UPMC Susquehanna. Part I, Line 7g: The Divine Providence Hospital has various subsidized services which are included within the Medicare and Medical Assistance unreimbursed costs. Part I, Line 7, Column (f) The Bad Debt expense included on Form 990, Part IX, Line 25(C), but subtracted for purposes of calculating the percentage in this column is $2,003,003. Part II, Community Building Activities: Community building activities at Divine Providence Hospital (DPH) center on workforce development through providing student observations and the development of volunteens. By supporting volunteens in a health care setting, some budding nurses, doctors and other allied health professionals are developed. DPH also supports/provides a physical site for the statewide radio system. This system is critical to the emergency preparedness system. Part III, Line 2: Bad debt consists of the actual bad debt written off, plus a reserve calculation based on a progressive percentage for self-pay and other non-contract accounts receivable aging categories. This figure is the amount of bad debt in the audited financial statements. Part III, Line 3: An estimate of 5% is used based on looking at patients that were in a bad debt status and eventually through the annual bad debt sale, determined they did not have the resources to pay and were really charity care. Part III, Line 4: The System reports patient accounts receivable for services rendered at net realizable amounts from third-party payers, patients and others. The System provides an allowance for doubtful accounts based upon a review of outstanding receivables, historical collection information and existing economic conditions. As a service to the patient, the System bills third-party payers directly and bills the patient when the patient's liability is determined. Patient accounts receivable are due in full when billed. Accounts are considered delinquent and subsequently written off as bad debts based on individual credit evaluation and specific circumstances of the account. Part III, Line 8: The costing methodology is based on a modified cost accounting system. We cost our patient data for the previous fiscal year and then we apply relational factors to the costs based upon the change in charges from the prior fiscal year to the current fiscal year.Serving patients with government health benefits, such as Medicare, is a component of the community benefit standard that tax-exempt hospitals are held to. This implies that serving Medicare patients is a community benefit and that the hospital operates to promote the health of the community. Part III, Line 9b: UPMC Susquehanna will provide financial assistance under the Financial Assistance Program for patients that require medically necessary services during the period in which family income and financial resources meets the defined guidelines, and after all other payment resources have been exhausted. The UPMC Susquehanna Financial Assistance Program is always the coverage of the last resort.Eligible services include inpatient and outpatient hospital services which are medically necessary and are provided directly by UPMC Susquehanna(Hospitals and Susquehanna Physician Services) or by employees of UPMC Susquehanna for the treatment of an illness or injury.All payer resources must be exhausted. Pennsylvania Medical Assistance screening and application must be completed for all considered individuals. All other payment arrangements must be explored. The income guideline source is the annual poverty income published in the Federal Register by the Department of Health and Human Services. The federal poverty guidelines are used to determine four tiers of SHS Financial Assistance Program eligibility. Income guidelines are updated annually according to federal poverty guideline updates. Family income must be at or below the eligibility guidelines for program consideration.It is the responsibility of the patient or guarantor to initiate and complete the SHS Financial Assistance Program by applying. Part VI, Line 2: The Health System engaged BKD, LLP to conduct a formal CHNA. BKD, LLP is one of the largest CPA and advisory firms in the United States, with approximately 2,000 partners and employees in 34 offices. BKD serves more than 900 hospitals and health care systems across the country. The CHNA was conducted from February 2016 to June 2016.The following steps were conducted as part of the Health System's CHNA, 1) An evaluation of the impact of actions taken to address the significant health needs identified in the tax year 2012 CHNA was completed to understand the effectiveness of the Health System's current strategies and programs. 2) The "community" served by the Health System was defined by utilizing inpatient data regarding patient origin. This process is further described in Community Served by the Health System. 3) Population demographics and socioeconomic characteristics of the community were gathered and reported utilizing various third parties. The health status of the community was then reviewed. Information on the leading causes of death and morbidity information was analyzed in conjunction with health outcomes and factors reported for the community by the Center for Disease Control and Prevention (Community Health Status Indicators). Health factors with significant opportunity for improvement were noted. 4) Community input was provided through nine key stakeholder meetings and a community health survey. Results and findings are described in the Community Input - Key Stakeholder Interviews and Survey section of the CHNA at www.upmcsusquehanna.org/communityhealth. 5) Information gathered in the above steps was analyzed and reviewed to identify health issues of uninsured persons, low-income persons and minority groups and the community as a whole. Health needs were ranked utilizing a weighing method that weighs the size of the problem, the seriousness of the problem, the impact of the issues on vulnerable populations, the prevalence of common themes, how important the issue is to the community, and how the issue aligns with the Hospital's strategic plan. 6) An inventory of health care facilities and other community resources potentially available to address the significant health needs identified through the CHNA was prepared and collaborative efforts were identified.Health needs were then prioritized taking into account the perceived degree of influence the Health System has to impact the need and the health needs impact an overall health for the community.To help see the implementation plan come to fruition an implementation team has been formed which is comprised of various individuals from community organization throughout Lycoming and Tioga counties. Such partnered organizations include Lycoming County Health Improvement Coalition, Tioga County Partnership for Community Health, River Valley YMCA, Project Bald Eagle, STEP, YWCA, PA Department of Health, to name a few. Part VI, Line 3: UPMC Susquehanna will provide financial assistance under the Financial Assistance Program for patients that require medically necessary services during the period in which family income and financial resources meets the defined guidelines, and after all other payment resources have been exhausted. The UPMC Susquehanna Financial Assistance Program is always the coverage of the last resort. The UPMC Susquehanna Financial Assistance program is an income/assets based package designed to meet the healthcare financial needs of eligible individuals and households who receive medically necessary inpatient and outpatient services from TWH, DPH, MVH,or SSMH.The first hospital claim sent to guarantors of uninsured accounts will include a statement to briefly explain the availability and contacts for referral to the Financial Assistance program. Subsequent guarantor billings also reference the availability of The Financial Assistance program.It is the responsibility for the patient or guarantor to initiate the UPMC Susquehanna Financial Assistance Program by applying. It is the responsibility of the UPMC Susquehanna Finance personnel to administrate the program according to this policy. Part VI, Line 4: The hospitals that comprise UPMC Susquehanna Lycoming county operations are: The Williamsport Hospital (TWH), Divine Providence Hospital (DPH) and Muncy Valley Hospital (MVH). The county is in the north central region of the state, about three and half hours northeast of Pittsburgh and the same distance northwest of Philadelphia. Lycoming County is designated as rural and has small towns nestled within a stunning natural landscape. The City of Williamsport, with the majestic Susquehanna River running through it, is designated as urban, and is the home of Little League World Series. Unfortunately, the City of Williamsport and the surrounding rural area are also home for many individuals and families who cannot afford the primary health and dental care services provided in their county. In addition, Soldiers & Sailors Memorial Hospital (SSMH) located in Wellsboro, PA, Tioga County, is also part of UPMC Susquehanna.For a more detailed discussion regarding the community served, as well as associate socio-economic characteristics, you may view CHNA and related implementation plan at www.upmcsusquehannahealth.org Part VI, Line 5: The hospitals of UPMC Susquehanna all have entity specific boards that are composed of persons who reside in Lycoming County.In addition to this UPMC Susquehanna extends medical staff privileges to all qualified physicians in the county in all areas of primary and specialty care according to the UPMC Susquehanna Medical Staff Bylaws. Bylaws excerpts pertaining to this area are as follows:3.1) Nature of Membership - Medical Staff membership is available to qualified physicians, dentists, maxillofacial/oral surgeons, and podiatrists and confers both responsibilities and prerogatives, but only as provided in these Bylaws. No physician, dentist, or podiatrist, including those employed by or otherwise under contract with the Hospital(s), may admit a patient or independently provide patient care services in the Hospital(s) unless he is a Medical Staff member with applicable clinical privileges pursuant to these Bylaws. A member shall have only those clinical privileges, including admitting privileges, as have been granted in accordance with these Bylaws.3.2) Qualifications - No individual shall be considered eligible for appointment on reappointment to the Medical Staff unless he meets each of the following required qualifications/criteria. If any change in personal or professional status occurs which would inhibit practitioner's ability to effectively meet the obligations for patient care and Medical Staff membership under these Bylaws, the practitioner shall immediately notify the Medical Director.3.2-1) Professional Licensure Qualification - A member must be a physician, dentist, or podiatrist and must be duly licensed to practice in the Commonwealth of Pennsylvania.3.2-2) Clinical Privileges Qualification - A member of the Medical Staff must have clinical privileges (or in the case of a new applicant, is granted clinical privileges at the time of the appointment), except those appointed to the Emeritus Staff or as otherwise specified in these Bylaws.3.2-3) Professional Competence - A member must demonstrate sufficient professional education, training, experience, competence, and good judgement to perform Medical Staff responsibilities and clinical privileges requested.3.2-4) Health Status - A member must have sufficient physical and mental health to perform Medical Staff responsibilities and exercise clinical privileges requested.3.2-5) Basic Responsibilities - A member must discharge the basic responsibilities of Medical Staff membership noted in 3.3-2.3.2-6) Board Certification Requirement - All practitioners who are current staff members at UPMC Susquehanna as of 7/1/10 and who have met prior qualifications for membership shall be exempt from board certification requirements.3.2-7) Standing with Federal Payors - A member must not be excluded from participation in federally funded programs such as Medicare and Medicaid.3.2-8) Waiver - The Board Certification requirement described in 3.2-6 may be waived under very special circumstances in which an applicant for Medical Staff membership is capable of providing specific unique expertise presently not available or insufficiently available on the Medical Staff which will fulfill an unmet medical need in the community. Such waiver may be granted by the Board(s) only upon recommendation of the Department Chairman, Credentials Committee, and the Medical Executive Committee (MEC)3.2-9) Prohibited Criteria - Medical Staff membership or assignment to a Medical Staff category shall not be denied, terminated, revoked, suspended, modified, or otherwise restricted based upon:(a) Gender, race, creed, color, national origin, handicap, or disability, if the individual is otherwise qualified under these Bylaws, or(b) Economic considerations as the sole or primary criterion, or(c) Any criterion not set forth as a required qualification in these Bylaws, or(d) Any other criterion lacking professional or ethical justification.3.2-10) Effect of Other Affiliations - No individual shall be granted Medical Staff membership or be assigned to any Medical Staff category merely because he:(a) Holds a certain degree,(b) Is licensed to practice in the Commonwealth of Pennsylvania or any other state,(c) Is a member of any professional organization,(d) Is certified by any clinical Board,(e) Had, or presently has, Medical Staff membership or clinical privileges at another health care facility,(f) Is employed by or is otherwise under contract with the Hospital(s) or(g) Is employed by or otherwise practices with a group composed of one or Medical Staff members. The volunteer program at UPMC Susquehanna supports the services at our 4 campuses, MVH, DPH, TWH, and SSMH as well as our LifeCenter located within the River Valley Regional YMCA in Williamsport, PA. Volunteers, ranging in age from 14, assist staff and patients in almost every department.The volunteers come from Lycoming and surrounding counties to support our services. They provide over 65,000 hours of service in both office, customer service and patient care areas to support our service partners. They become ambassadors for the hospital, make new friends, financially support the hospital, become involved in the auxiliary, remain an active member of society, often stay healthier longer, enjoy the camaraderie with staff and other volunteers, serve on hospital committees, recruit other volunteers, increase their volunteer hours and offer constructive suggestions for improvement. Volunteers are recruited through fairs, internet information and on-line applications, volunteer referrals and presentations to groups. They are a highly regarded, integral part of our operational support system. Part VI, Line 6: Divine Providence Hospital (DPH) is one of four hospitals which are part of UPMC Susquehanna. The mission of UPMC Susquehanna is to promote health by acting as the parent of a nonprofit health system in North Central Pennsylvania and by raising funds and otherwise supporting the system. MVH is a critical access hospital, primarily serving Lycoming and surrounding counties. MVH also provides a full range of outpatient and emergency services, as well as, operates a long-term care facility.Divine Providence Hospital (DPH) is a specialty hospital that offers inpatient psychiatric services and a wide array of outpatient hospital services, as well as, home health and Hospice services.The Williamsport Hospital (TWH) is an acute care community hospital providing diagnostic and treatment facilities, educational and training programs, and a rehabilitation facility.Soldiers & Sailors Memorial Hospital (SSMH) is an acute care community hospital providing diagnostic and treatment facilities, educational and training programs, and a rehabilitation facility.The hospitals treat Medicare and Medical Assistance patients and maintains a Medicare / Medical Assistance policy that provides patients enrolled in such programs with access to all covered inpatient, outpatient and diagnostic services that are available to non-Medicare / Medical Assistance patients.The community benefit report is prepared on a system-wide basis under SHS. On an annual basis, UPMC Susquehanna devotes a portion of its revenue and assets to community program services. The following reflects the breakout of $98,755,622 in quantifiable community benefits reported for FY 2017: Charity Care (at cost) $1,629,207; Bad Debt (at cost) $7,909,280; Government-sponsored health care (unpaid cost of Medicare, Medicaid, indigent care programs, SCHIP and other safety net programs) $81,482,454. In addition, various other programs such as Research, Health Professions Education, Community Building, Financial and In-Kind Contributions, and Community Benefit Operations totaling $7,734,681. 1 Susquehanna Physician Services 1201 Grampian Boulevard Williamsport PA 17701 232449454 501(c)(3) 15189102 Support of affiliate Susquehanna Community Health and Dental Clinic 469-471 Hepburn Street Williamsport PA 17701 208979596 501(c)(3) 83000 Financial support 2 Part I, Line 2: Susquehanna Physician Services is a related organization and part of UPMC Susquehanna with consistent management oversight ensuring the use of funds for charitable purposes. Susquehanna Community Health and Dental Clinic is a former service of UPMC Susquehanna that is being converted to a Federally Qualified Health Clinic (FQHC). "Look-alike" status was received effective 12/6/11. Susquehanna Health System continues to support the clinics financially until full FQHC status is obtained and they are able to operate by their own means. All requests for funding are supported by detailed records of cash receipts and disbursements, as well as cash flow projections prepared by an independent accounting firm. 1 0 0 0 0 0 0 0 0 Susan Branton MD Director 0 408412 0 19117 0 49586 0 9950 0 20896 0 507961 0 0 Jill A Burns Director 0 224371 0 34600 0 839 0 9950 0 23094 0 292854 0 0 Ronald E DiSimone MD Director 0 1007081 0 27445 0 38155 0 9950 0 21453 0 1104084 0 0 Kevin W Kist DO Director 0 326783 0 18531 0 76456 0 9950 0 25587 0 457307 0 0 Alexander R Nesbitt MD Director 0 215177 0 23675 0 2265 0 12965 0 18087 0 272169 0 0 Steven P Johnson President / CEO 0 703292 0 226453 0 30351 0 13925 0 19346 0 993367 0 0 Eric D Pohjala Executive VP / CFO 0 362196 0 66436 0 1806 0 9950 0 22445 0 462833 0 0 David Lopatofsky MD Executive VP / CMO 0 425773 0 141731 0 26010 0 11275 0 25773 0 630562 0 0 Jan E Fisher Executive VP / COO 0 401814 0 138186 0 11981 0 9950 0 21288 0 583219 0 0 Robert E Kane President 200765 0 29649 0 4958 0 11380 0 17245 0 263997 0 0 0 Rajesh Manoharan Medical Physicist 196949 0 990 0 283 0 8192 0 25999 0 232413 0 0 0 Michelle R Gaida Executive Director Cancer Services 133259 0 13929 0 935 0 6514 0 9827 0 164464 0 0 0 Patricia A McGee Executive Director Home Care 133417 0 13125 0 805 0 6406 0 948 0 154701 0 0 0 Harry E Hefty Physical Therapist 126396 0 705 0 780 0 5983 0 20677 0 154541 0 0 0 Ronald J Butler Former Exec VP/CBO (retired) 0 0 0 0 0 335670 0 0 0 0 0 335670 0 0 Part I, Line 4a Ronald J. Butler, Former Executive VP/CBO, retired on April 15, 2015. His entire reportable compensation, $335,670 paid by a related organization, is a severence payment. Part I, Line 6 In order for the Leadership Team to participate in the annual Variable Compensation Incentive Program (VCIP) a minimum operating margin must be achieved for the most recently completed year on a consolidated system-level basis. Individual goals and objectives related to the VCIP may also include individual entity operating performance. For FY 2017, the minimum threshold was met that would trigger a VCIP payment. In September 2016, President / CEO Steven P. Johnson received variable compensation award in the amount of $226,453. Part I, Line 3 The Williamsport Hospital EIN #24-0795508, a related organization, uses the following resources to establish the compensation of the top management officials; compensation committee, independent compensation consultant, written employment contract, compensation survey or study and approval by the board. UPMC Susquehanna investments were liquidated and cash was transferred to UPMC (parent). 2017-10-01 50723777 Cash value 251423657 UPMC 600 Grant Street Pittsburgh PA 15219 501 (c) 3 1 0 0 0 Part II, Line 2e: Person(s) Involved: Ann S. Pepperman Part II, Line 2e: Explanation of Involvement: Ann S. Pepperman also serves on the UPMC (parent) EIN #25-1423657 board. Form 990, Part V, Line 1A All 1099's are issued by UPMC Susquehanna EIN #23-2751183. All expenses are then allocated back to all related entities. Form 990, Part VI, Section A, line 6 UPMC Susquehanna, EIN # 23-2751183, is a sole member of the governing body. Form 990, Part VI, Section A, line 7a UPMC Susquehanna, EIN # 23-2751183, may elect or remove members of the governing body. Form 990, Part VI, Section A, line 7b All business and affairs of the corporation shall be managed and controlled by the Board of Directors, subject to the oversight of the Member of the management and operation of the corporation, except that the following powers are reserved exclusively to the sole Member of the corporation, and no attempted exercise of any such powers by anyone other than the sole Member shall be valid or of any force or effect whatsoever. The sole Member shall exercise its powers through its Board of Directors. The Member shall have the exclusive authority to exercise the following powers: A) To approve the appointment and removal of the President of the corporation, subject to all applicable provisions of the Creation Agreement. B) To elect and remove, with or without cause, a Director of the corporation. C) To establish the overall policy and long range plans of the corporation, determine or change the mission of the corporation, approve the programs and services of the corporation and the termination of any programs of services of the corporation, and monitor and maintain the philosophy, goals and purposes for which the corporation was formed and exists, subject to an in accordance with the provisions of the Creation Agreement. D) To adopt, amend or repeal the Articles of Incorporation or these bylaws. E) To establish requirements for a unified budget, the approval of new capital debt, any increment to any existing capital debt, and/or any change in capital debt obligations of the corporation. F) To establish requirements for the approval of the acquisition, purchase, sale, leasing outside the ordinary course of business, transfer outside the ordinary course of business or encumbrance outside the ordinary course of business of land or buildings and the construction or demolition of buildings owned by the corporation. G) To require a certified audit of corporate funds at any time. H) To approve any guaranty of the indebtedness of any person, the granting of any security interest in or the creation of any encumbrance on any assets of the corporation outside the ordinary course of business, or any transfer of any asset of the corporation outside the ordinary course of business, except transfers between or among affiliated corporations. I) To approve any merger, consolidation, organization, reorganization, joint venture or other modification of corporate structure or affiliations affecting the autonomy, governance, or operations of the corporation. J) To dissolve or terminate the existence of the corporation and determine the distribution of assets upon such termination or dissolution, as provided in these bylaws. K) To appoint annually the external fiscal auditor of the corporation. L) To approve the nominees for elected officers of the Board of Directors of the corporation, and to return the list of approved nominees to the Board of Directors for election. M) To remove any elected officer of the corporation; N) To approve the annual capital and operating budget of the corporation; O) To coordinate managed care plans, including decisions concerning entry into or renewal of any contract or agreement relating thereto. Form 990, Part VI, Section B, line 11b A high-level overview of Forms 990 is presented to the parent Board of Directors (UPMC Susquehanna, #23-2751183) before filing and complete drafts of all returns were made available to all Board members through the CEO's and CFO's office. Form 990, Part VI, Section B, line 12c As required by law, Hospital policy states that all members of the Board of Managers must sign a statement each year disclosing any conflict of interest that may arise and agree to abstain when issues involving those parties with conflicting interests are called to motion. Any conflicts of interest are reviewed by the Hospital's attorneys. Form 990, Part VI, Section B, line 15 Form 990, Part VI, Line 15a & 15b: All top management officials are paid by The Williamsport Hospital, EIN # 24-0795508. The Board of Directors, through the Executive Compensation Committee, retains an independent outside consultant to provide guidance with respect to the annual establishment of the rebuttable presumption or reasonableness relative to executive compensation and benefits. The consultant annually provides detailed market information from its annual Executive Compensation Survey for Health Systems. In addition, other regional survey data is provided in order to supply the health system with a "national" picture of compensation. With this process established, the Executive Compensation Committee takes the proper steps to educate the Board of Directors to understand all of the above mentioned oversight and to appropriately prepare them for the community or media inquiry. In addition, the Board is made aware of the Form 990 and its role in the communication of information to the public. Form 990, Part VI, Section C, line 19 The organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Form 990, Part XI, line 9: Change in interest in net assets of affiliate 166,554. Net contributions released from restrictions for use 130,000. Endowment funds released for use 6,725. Barclay loan payoff 4,078,272. Transfer of debt to UPMC 16,884,580. Transfer of liquidated investments to UPMC -50,723,777. Investment in SHF -29,833. Form 990, Part XII, Line 2C UPMC, the sole member of UPMC Susquehanna, has assumed the responsibility for oversight of the audited financial statements at a system level for FY 2017. UPMC SENIOR COMMUNITIES INC 600 GRANT STREET PITTSBURGH PA 15219 251574736 SR. LIVING PA 501(c)(3) Line 10 UPMC 1 PITTSBURGH LIFETIME CARE COMMUNITY 600 GRANT STREET PITTSBURGH PA 15219 251335247 CCRC PA 501(c)(3) Line 10 UPMC SR COMM 1 CANTERBURY PLACE 600 GRANT STREET PITTSBURGH PA 15219 250965334 SR. LIVING PA 501(c)(3) Line 10 UPMC SR COMM 1 SENECA PLACE 600 GRANT STREET PITTSBURGH PA 15219 721562844 SR. 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However, they are listed on Schedule R to reflect that they are part of the UPMC system of entities, as they all share UPMC as their ultimate parent corporation.