2017-05-02T07:41:25-05:00 2016-06-30 BKD LLP 910 E St Louis Street Suite 200 Springfield MO 65806 990 2015-07-01 240795508 The Williamsport Hospital WILL 5703207900 700 High Street Williamsport PA 17701 Eric D Pohjala Executive Vice President / CFO 5703207900 2017-05-02 1 Brian D Todd P00422601 4178658701 2015 2021-01-29 14:40:06Z Steven P Johnson 700 High Street Williamsport PA 17701 404352567 0 X www.upmcsusquehannahealth.org X 1873 PA The Williamsport Hospital (TWH) is a 223 bed acute care community hospital primarily serving Lycoming and surrounding counties. Services provided include, but are not limited to, Acute and Intensive Care, Surgical Services, Heart and Lung Services, Rehabilitation Services, Dialysis, Laboratory, Radiology, Psychology and Emergency Room Services. 20 16 1718 224 836620 -148227 7889752 3563869 310839784 324262075 2735635 2166214 902304 2319118 322367475 332311276 11560796 12678222 0 0 124266315 129862659 0 0 22372 167509835 166540493 303336946 309081374 19030529 23229902 409268241 521644871 239186118 330020008 170082123 191624863 X The Williamsport Hospital (TWH) is a subsidiary of UPMC Susquehanna. The mission of UPMC Susquehanna and affiliates is as follows: To extend God's healing love by improving the health of those we serve. Our vision is to create an integrated community health system that delivers world class care. Our values are to carefully place our patients and their families first, share ownership with all of our caregivers and lead with a servant's heart. 0 0 277638447 12678222 325236877 The Williamsport Hospital (TWH) is a 223 bed acute care community hospital primarily serving Lycoming and surrounding counties. Services provided include, but are not limited to, Acute and Intensive Care, Surgical Services, Heart and Lung Services, Rehabilitation Services, Dialysis, Laboratory, Radiology, Psychology and Emergency Room Services. TWH also provides Labor and Delivery Services while maintaining a 20 bed Nursery. During the fiscal year ended June 30, 2016, TWH admitted 11,454 patients rendering 48,370 patient days and registered approximately 227,376 outpatient procedures. TWH treats all patients without regard to their ability to pay. In addition, the Hospital treats Medicare / 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, TWH devotes a portion of its revenue and assets to community program services. The following reflects the breakout of $49,064,401 in quantifiable community benefits for FY 2016: Charity Care (at cost) $967,782; Bad Debt (at cost) $3,474,317; Government-sponsored health care (unpaid cost of Medicare, Medicaid, indigent care programs, SCHIP and other safety net programs) $41,927,000. In addition, various other programs such as Research, Health Professions Education, Community Health Services, Subsidized Health Services, Community Building, Financial and In-kind Contributions and Community Benefit Operations totaling $2,695,302. 277638447 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 1 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 X 0 0 1718 1 1 1 0 0 0 0 0 0 0 0 0 X 20 16 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 PA X Management 5703207900 1205 Grampian Boulevard Williamsport PA 17701 Chris H Dewald Chair 2.00 4.00 X X 0 0 0 Keith Kuzio Vice Chair 2.00 6.00 X X 0 0 0 Kathleen D Pagana Secretary 2.00 2.00 X X 1845 0 0 Geneva Peck Treasurer 2.00 4.00 X X 0 0 0 Daniel C Berninger Director 2.00 2.00 X 0 0 0 Mark Beyer DO Director 2.00 2.00 X 0 0 0 Sister Teresa Ann Jacobs Director 2.00 6.00 X 0 0 0 Roger D Jarrett Director 2.00 4.00 X 0 0 0 Kevin W Kist MD Director 2.00 46.00 X 0 432005 36767 Patrick Marty Director 2.00 2.00 X 0 0 0 Robert E More Director 2.00 2.00 X 0 0 0 Paul Moulton Director 2.00 2.00 X 0 0 0 Alexander R Nesbitt MD Director 2.00 46.00 X 0 222603 30549 Shailesh Patel MD Director 2.00 2.00 X 0 0 0 Kent Trachte PhD Director 2.00 2.00 X 0 0 0 Peter B Trevouledes MD Director 2.00 2.00 X 0 0 0 Patrick Wilson Director 2.00 2.00 X 0 0 0 Mary Wolf Director 2.00 2.00 X 0 0 0 Steven E Yordy MD Director 2.00 0.00 X 0 0 0 Steven P Johnson President / CEO 42.00 12.00 X X 832199 0 35182 Eric D Pohjala Executive VP / CFO 40.00 2.00 X 255157 0 27349 David Lopatofsky MD Executive VP / CMO 2.00 42.00 X 0 437276 38887 Jan E Fisher Executive VP / COO 40.00 0.00 X 459806 0 31992 Kenneth B Young VP / Legal Services 40.00 0.00 X 314279 0 10587 Daniel Glunk MD AVP / Chief Quality Office 40.00 0.00 X 283845 0 35435 Timothy E Schoener VP CIO 40.00 0.00 X 231039 0 36051 Teresa A Stackhouse Mgr. Anesthesia / Chief CRNA 40.00 0.00 X 228828 0 27381 Glenda L Stroud CRNA 40.00 0.00 X 227238 0 22224 Charles J Santangelo Former Exec VP/CFO (retired 5/2/15) 40.00 0.00 X 338073 0 24988 William C McCauley MD Former Exec VP/CMO (retired 1/31/15) 40.00 0.00 X 0 185372 4271 Ronald J Butler Former Exec VP/CBO (retired 4/15/15) 40.00 0.00 X 518626 0 13502 3690935 1277256 375165 133 1 1 0 Aramark Healthcare 24863 Network Place Chicago IL 60673 Management / environmental services 28827758 Anesthesia Associates 700 High Street Williamsport PA 17701 Anesthesia services 1393999 Paris Companies 67 Hoover Aveneue DuBois PA 15801 Linen services 908173 Cleveland Clinic Foundation PO Box 931760 Cleveland OH 44193 Cardiology & Cardiovascular services 733333 Paths LLC 9 Executive Campus Cherry Hill NJ 08002 Collection services 624958 26 2483676 244811 835382 3563869 Net patient revenue 621990 298521003 298521003 Support from alliance affiliates 900099 22199165 22199165 Cafeteria 722514 1423865 1423865 Affiliate rent income 531120 1317657 1317657 Meaningful Use Revenue 900099 467052 467052 333333 333333 324262075 1074883 1074883 73022918 109704 71933334 107957 1089584 1747 1091331 1091331 North Penn - management 561000 654169 654169 River Valley ACO 900099 481157 481157 Cardiology - consulting physician 561000 338562 338562 845230 155083 182451 507696 2319118 332311276 325236877 836620 2673910 12678222 12678222 2165760 2165760 65929 65929 98218315 89414982 8786028 17305 4928616 4496677 431090 849 17429083 15901616 1524464 3003 7054956 6436667 617074 1215 600 600 676335 676335 261937 261937 23133 23133 257141 2735 254406 30717645 26908722 3808923 1077367 1070765 6602 7642988 6776566 866422 5935047 4450766 1484281 91831 91386 445 5144013 5082642 61371 485648 419313 66335 333375 98363 235012 7568062 7568062 22811159 22811159 3358124 3358124 Medical Supplies 46377813 46377237 576 Bad Debt 12592668 12592668 Repairs & maintenance 8550743 8463045 87698 Inter-entity costs 7651655 7651655 4983209 407041 4576168 309081374 277638447 31420555 22372 28999345 38269446 25217181 32377664 4608396 4835055 6997018 6129360 466553580 215475551 240715763 251078029 63877980 68344411 38852558 120610906 409268241 521644871 40774929 42575845 2000000 1666666 158749775 163832803 37661414 121944694 239186118 330020008 X 169436838 190985560 434173 435990 211112 203313 170082123 191624863 409268241 521644871 X 23229902 -1627975 -59187 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 23133 0 0 0 23133 0 Part II-B, Line 1: The Hospital holds memberships in the American Hospital Association, (AHA), and the Hospital Association of Pennsylvania, (HAP), both of which engage in lobbying as part of their mission to represent the interests of hospitals at both the Federal and the State levels. For the year ended 6/30/16, the amount of dues paid to HAP totaled $54,633, of which 24.94% or $13,625, was used for lobbying purposes. Dues paid to AHA totaled $42,984, of which 22.12% or $9,508, was used for lobbying purposes. On occasion, HAP requests the help of member providers to communicate concerns to legislators regarding pending legislation which could impact hospitals. This can involve direct contact with legislators or letter-writing. This occurs infrequently, and the cost to the Hospital in negligible. 22867374 22867374 183479603 86679034 96800569 278105 67715 210390 191602216 108517632 83084584 68326282 20211170 48115112 251078029 Other receivables 1414618 Funds held by others 101724 Interest in net affiliate 230540 Other 705859 Due from affiliates 105584365 Other long-term receivables 12573800 120610906 Due to third parties 2140888 Estimated medical legal liability costs 861000 Other liabilities 3233840 Due to affiliates, net 115347026 Interest rate swap agreement 361940 121944694 X 315586459 -1627975 -11763187 -13391162 328977621 3333655 3333655 332311276 284793927 0 284793927 24287447 24287447 309081374 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 financial statements. Part XI, Line 2d - Other Adjustments: Bad debt expense -12,592,668. Net assets released 829,481. Part XI, Line 4b - Other Adjustments: Temporary restricted contributions 857,778. Permanently restricted investment contributions -7,799. Transfer from affiliates - UPMC Susquehanna 75,000. Transfer from affiliates - SHF 2,408,676. Part XII, Line 4b - Other Adjustments: Bad debt expense 12,592,668. Transfer to affiliate - SHMG 11,694,779. Central America 0 1 Program services Captive insurance company 1757860 0 1 0 0 0 1 1757860 0 1757860 0 0 0 0 0 0 1 1 X 1 X 1 X 1 1 1 0 1 1 967857 0 967857 0.00330 39476728 22537617 16939111 0.05710 40444585 22537617 17906968 0.06040 485518 10185 475333 0.00160 430889 0 430889 0.00150 0 0 0 0 1341442 0 1341442 0.00450 2257849 10185 2247664 0.00760 42702434 22547802 20154632 0.06800 49351 0 49351 0.00020 1715 0 1715 0.00000 51066 51066 0.00020 1 12592669 629633 104898715 129887152 -24988437 X 1 1 1 1 The Williamsport Hospital 700 High Street Williamsport PA 17701 www.upmcsusquehannahealth.org 234601 X X X The Williamsport 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 0 1 X 150.000000000000 300.000000000000 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 X X X X 1 X 0 0 The Williamsport 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. The Williamsport Hospital Part V, Section B, Line 6a: The Williamsport Hospital; located in Williamsport, PA is one of four hospitals that comprise the Susquehanna Health System (the System) based in Williamsport, Pennsylvania. For purposes of conducting the 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 the System is Soldiers & Sailors Memorial Hospital located in Wellsboro, PA, and their defined community is Tioga County, PA. The Systems 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 at www. upmcsusquehannahealth.org/communityhealth. The Williamsport 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. The Williamsport Hospital Part V, Section B, Line 16i: Other - Brochure The Williamsport Hospital Part V, Section B, Line 22d: They may also be eligible for discounts of 50%, 60%, 80%, and 100% of charges following application to our Financial Assistance Program which is a greater discount than what has been computed as amounts generally billed utilizing a look back method. 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 2 1 - The Medical Center 699 Rural Avenue Williamsport PA 17701 Outpatient clinic 2 - The Montoursville Clinic Savoy Plaza 900 Plaza Drive Montoursville PA 17754 Outpatient clinic / lab Part I, Line 6a: The community benefit report is prepared on a system wide basis under UPMC Susquehanna. Part I, Line 7g: The Williamsport 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 24(B), but subtracted for purposes of calculating the percentage in this column is $12,592,668. Part II, Community Building Activities: Activities focus on leadership development and training for community members through support to the Patient Advisory Council, as well as a newly developed Heroin Task Force team.The Williamsport Hospital (TWH) supports workforce development through participation on health care career education programs and by providing student observations for nursing and allied health professionals. 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 on 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.upmcsusquehannahealh.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 70,000 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: The Williamsport Hospital (TWH) is one of four hospitals which are part of UPMC Susquehanna. The mission of SHS 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. Muncy Valley Hospital (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 UPMC Susquehanna. On an annual basis, UPMC Susquehanna devotes a portion of its revenue and assets to community program services. The following reflects the breakout of $94,467,383 in quantifiable community benefits reported for FY 2016: Charity Care (at cost) $1,524,334; Bad Debt (at cost) $8,097,385; Government-sponsored health care (unpaid cost of Medicare, Medicaid, indigent care programs, SCHIP and other safety net programs) $78,563,849. In addition, various other programs such as Research, Health Professions Education, Community Building, Financial and In-Kind Contributions, and Community Benefit Operations totaling $6,281,815. 1 Susquehanna Physician Services 1201 Grampian Boulevard Williamsport PA 17701 232449454 501(c)(3) 11694779 Support of affiliate Susquehanna Community Health & Dental Clinic 469-471 Hepburn Street Williamsport PA 17701 208979596 501(c)(3) 357503 Financial support Williamsport Area Ambulance Service Cooperative 700 High Street Williamsport PA 17701 232416166 501(c)(3) 500000 Support of affiliate Project Bald Eagle Inc One College Avenue DIF 17 Williamsport PA 17701 473821707 501(c)(3) 25000 Financial contribution The Commonwealth Medical College 525 Pine Street Scranton PA 18509 260812968 501(c)(3) 100000 Financial contribution 5 Schedule I, Part 1, Line 2 Susquehanna Physician Services and Williamsport Area Ambulance Service Cooperative are related organizations and part of the 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 Susquehanna Health System that is being converted to a Federally Qualified Health Clinic (FQHC). "Look-alike" status was received effective 12/06/11. UPMC Susquehanna 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. UPMC Susquehanna has partnered with Project Bald Eagle a 501(c)(3) exempt organization to help combat the opioid issues that our area is currently facing. UPMC Susquehanna has pledged financial support for the founding of the new medical school in Northeastern Pennsylvania, known as The Commonwealth Medical College. The pledge money will be used to help recruit faculty and students, construct facilities, provide scholarships, and fund other expenses associates with the development of a new medical school. X X X X X 0 0 0 0 0 1 1 0 0 Kevin W Kist MD Director 0 333862 0 10206 0 87937 0 9950 0 26817 0 468772 0 0 Alexander R Nesbitt MD Director 0 219808 0 0 0 2795 0 12116 0 18433 0 253152 0 0 Steven P Johnson President / CEO 668195 0 133858 0 30146 0 15925 0 19257 0 867381 0 0 0 Eric D Pohjala Executive VP / CFO 252402 0 0 0 2755 0 9720 0 17629 0 282506 0 0 0 David Lopatofsky MD Executive VP / CMO 0 412757 0 18458 0 6061 0 11275 0 27612 0 476163 0 0 Jan E Fisher Executive VP / COO 409956 0 36987 0 12863 0 9950 0 22042 0 491798 0 0 0 Kenneth B Young VP / Legal Services 283890 0 29746 0 643 0 9950 0 637 0 324866 0 0 0 Daniel Glunk MD AVP / Chief Quality Office 262900 0 19157 0 1788 0 12600 0 22835 0 319280 0 0 0 Timothy E Schoener VP CIO 205698 0 20521 0 4820 0 10167 0 25884 0 267090 0 0 0 Teresa A Stackhouse Mgr. Anesthesia / Chief CRNA 214422 0 13638 0 768 0 10107 0 17274 0 256209 0 0 0 Glenda L Stroud CRNA 217005 0 0 0 10233 0 10784 0 11440 0 249462 0 0 0 Charles J Santangelo Former Exec VP/CFO (retired 5/2/15) 186916 0 71895 0 79262 0 9950 0 15038 0 363061 0 0 0 William C McCauley MD Former Exec VP/CMO (retired 1/31/15) 0 108272 0 45384 0 31716 0 0 0 4271 0 189643 0 0 Ronald J Butler Former Exec VP/CBO (retired 4/15/15) 112293 0 32105 0 374228 0 9950 0 3552 0 532128 0 0 0 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 2016, the minimum threshold was met that would trigger a VCIP payment. In December 2015, President / CEO Steven P. Johnson received variable compensation award in the amount of $133,858. A Lycoming County Authority 236760375 550804AH1 2009-10-22 147688732 See Part VI 0 0 0 B Lycoming County Authority 236760375 NoneAvail 2011-11-21 25000000 See Part VI 0 0 0 C Lycoming County Authority 236760375 NoneAvail 2015-06-18 24400000 See Part VI 0 0 0 A 153692252 10568333 11118563 53252545 2696993 76055818 2012 1 0 1 1 B 25000000 25000000 2012 0 0 1 1 C 24400000 207869 12622679 11569452 0 0 0 1 A 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 1 C 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 0 0 0 0 1 B 0 0 1 0 1 1 Manufacturers And Traders Trust 7.000000000000 0 0 0 0 1 C 0 0 1 0 1 0 0 0 1 A 1 B 1 C 1 Form 990, Schedule K, Part I, Bond A, (e) and (f) The total issue price per Form 8038, Part III (b) is $165,134,534. Of this total, $147,688,732 was allocated to The Williamsport Hospital at the time of issue, while the balance of $17,445,802 was allocated to Divine Providence Hospital (EIN #24-0799343). The proceeds of the Lycoming County Authority, Series 2009A bonds were used, together with other available funds, to undertake a project consisting of (i) construction at Williamsport Hospital of a new energy services center that will allow the hospital to meet current energy demands, provide capacity to support further growth, including hot and cold water, steam, electricity, heat and air conditioning, and installation of cogeneration equipment, constuction of a new patient service tower that will expand and remodel the hospital's Emergency Department, Diagnostic Imaging Center, and surgical suites, renovation of existing duel-occupancy patient rooms into private patient rooms, and provision of new private room patient nursing unit: (ii) refunding of the outstanding amount of the issuer's hospital revenue bonds (The Williamsport Hospital Project) Series of 2008, the proceeds of which were used to provide interim financing for certain of the construction projects; (iii) refunding of the outstanding amount of issuer's hospital revenue bonds (The Williamsport Hospital Obligated Group) 1995 series, the proceeds of which were used (a) for the advance refunding of the outstanding portion of the issuer's hospital revenue bonds, Series B of 1986 and (b) to finance certain capital facilities, including reimbursement of capital expenditures. Form 990, Schedule K, Part II, Bond A, Line 3 The difference between Total Proceeds of Issue and the amount reflected in Part I, (e) is due to investment earnings of $503,521 and deposit of State RACP grant funds into the Project fund in the amount of $5,500,000. In 2007, The Williamsport Hospital applied to the Commonwealth of Pennsylvania for RACP grant money in order to pay a portion of the costs of the Project more fully noted above, which included the construction of a new energy services center. On December 6, 2011, The Williamsport Hospital was informed that the RACP Grant was approved in the amount of $5,500,000 to cover the costs of the Energy Services Center and would be distributed upon execution of the RACP Grant Agreement with the State. The Hospital received $5,362,500 of the RACP Grant Funds on December 12, 2012 and deposited them into the Project account held by the trustee for the 2009 bonds. The Hospital received the remaining $137,500 of RACP Grant Funds on May 5, 2014 and also deposited them into the Project account held by the trustee for the 2009 bonds. Form 990, Schedule K, Part IV, Bond A, Line 2c Rebate computations are performed annually, the most recent being from the issue date of October 22, 2009 to October 21, 2015. Form 990, Schedule K, Part I, Bond B, (f) The proceeds of the Lycoming County Authority, Series 2011, Revenue Note was used together with other available funds to undertake a project consisting of the architectural and planning expenses of a new patient service tower, replacement of the Emergency Department and Diagnostic Imaging Center, replacement of surgical suites, replacement of the Nursery and OB/GYN areas, and the addition of new private patient rooms. Form 990, Schedule K, Part II, Bond B, Line 3 The note is a draw-down obligation which was fully drawn in the amount of $25,000,000 on October 29, 2012. Form 990, Schedule K, Part IV, Bond B, Line 2c As a draw-down obligation with no funds held in investments, rebate calculation requirements are not applicable. Form 990, Schedule K, Part I, Bond C, (e) and (f) The total issue price per Form 8038, Part III (b) is $40,000,000. Of this total, $24,400,000 was allocated to The Williamsport Hospital at the time of issue, while $11,200,000 was allocated to Muncy Valley Hospital (EIN #24-0806023) and $4,400,000 was allocated to Divine Providence Hospital (EIN #24-0799343). The proceeds of the financing will be used to finance all, or a portion of projects consisting of (i) construction at Williamsport Hospital, Patient Tower 4th Floor of three (3) Operating Rooms, four (4) Cardiology procedural rooms, and related clinical equipment; (ii) renovation at Williamsport Hospital, East Building 2nd Floor of existing entrance and interior hallway space to improve patient throughput; create a new Pre-Admission Testing area; and expand clinical staff locker area; (iii) installation at Williamsport Hospital, Energy Services Center, of 1,000 ton chiller and cooling tower creating new capacity to support the added demand from the Health Innovation Center and Patient Tower and creating additional back-up capacity; (iv) replacement at Williamsport Hospital, West Building and Energy Center, of the hot water system with hot water sourced from the Energy Services Center, thus providing more efficient hot water and heating to the West Building; (v) construction of Muncy Valley Hospital, Emergency Room expansion and renovation of a 5,400 square foot addition and 11,000 square feet of renovation to upgrade and expand the Emergency Department, installing eight (8) private bed rooms and five (5) specialty rooms, upgraded Radiology; and site-work to relocate Shady Lane, and create a new walk-in entrance, parking lot, and helipad; (vi) renovation at Divine Providence Hospital, Health Sciences Building 2nd Floor, to accommodate the relocation of Sports Medicine from the hospital, creating additional examination rooms and offices to accommodate seven (7) clinical providers and two (2) additional Radiology rooms, with related clinical equipment; (vii) renovation at Divine Providence Hospital, 1st Floor, to accommodate the expansion of the Work Center and relocation of Radiology services; (viii)renovation at Divine Providence Hospital, 1st Floor, to accommodate expansion of the Cancer Center to provide twelve (12) additional examination rooms, physician and management offices and nurse stations; (ix) the funding of any necessary reserves, and (x) the payment of all or a portion of the costs of the Financing. Form 990, Schedule K, Part II, Bond C, Line 3 This issue is a draw-down obligation from which funds are not requested and drawn until capital expenditures have been incurred. Form 990, Schedule K, Part IV, Bond C, Line 2c As a draw-down obligation with no funds held in investments, rebate calculation requirements are not applicable. Richard Fisher Son of key employee 65929 Compensation 0 Form 990, Part V, Line 2A & 2B UPMC Susquehanna EIN #23-2751183 utilizes a common paymaster which includes the following entities: Divine Providence Hospital EIN #24-0799343 Muncy Valley Hospital EIN #24-0806023 The Williamsport Hospital EIN #24-0795508 Susquehanna Health Foundation EIN #23-2743470 Susquehanna Physician Services EIN #23-2449454 Susquehanna Ventures, Inc. EIN #23-2470263 Williamsport Are Ambulance Services EIN #23-2416166 Laurel Management Services EIN #25-1644910 Laurel Realty EIN #23-1403678 Soldiers & Sailors Memorial Hospital EIN #23-2176963 The Green Home EIN #24-0804365 Tioga Health Care Providers EIN #25-1765538 Tyoga Carenet EIN #25-1810967 The total number of employees reported on Form W-3 would be 3,871 for UPMC Susquehanna EIN #23-2751183. Of that total, 1,718 employees payroll expenses were recorded by The Williamsport Hospital. Form 990, Part VI, Section A, line 6 UPMC Susquehanna, EIN # 23-2751183, is the 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 the 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 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. 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 or services of the corporation, and monitor and maintain the philosophy, goals and purposes for which the corporation was formed and exists. 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 increments 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 of land or buildings and the construction or demolition of building 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 of the ordinary course of business, or any transfer of any assets 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 the 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 11 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 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 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 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 fair value interest swap -59,187. Form 990, Part XII, Line 2C The organization did not change it oversight process or selection process. 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. Divine Providence Hospital of the Sisters of Christian Charity 1100 Grampian Boulevard Williamsport PA 17701 240799343 Hospital PA 501(c)(3) 3 UPMC Susquehanna 0 Muncy Valley Hospital 215 East Water Street Muncy PA 17756 240806023 Hospital PA 501(c)(3) 3 UPMC Susquehanna 0 Susquehanna Health Foundation 1100 Grampian Boulevard Williamsport PA 17701 232743470 Fundraising for affiliated entities PA 501(c)(3) 11 A I UPMC Susquehanna 0 UPMC Susquehanna 1205 Grampian Boulevard Williamsport PA 17701 232751183 Coordinate & manage the delivery of healthcare PA 501(c)(3) 11 A I N/A 0 Susquehanna Physician Services 1201 Grampian Boulevard Williamsport PA 17701 232449454 Physician services & MRI services PA 501(c)(3) 3 UPMC Susquehanna 0 Williamsport Area Ambulance Service Cooperative 700 High Street Williamsport PA 17701 232416166 Ambulance transports PA 501(c)(3) 9 N/A 0 Soldiers & Sailors Memorial Hospital 32-36 Central Avenue Wellsboro PA 16901 232176963 Hospital PA 501(c)(3) 3 UPMC Susquehanna 0 The Green Home 37 Central Avenue Wellsboro PA 16901 240804365 Skilled nursing & assisted living PA 501(c)(3) 9 UPMC Susquehanna 0 Tioga Health Care Providers 15 Meade Street Wellsboro PA 16901 251765538 Physician services PA 501(c)(3) 11 B II UPMC Susquehanna 0 Laurel Management Services 15 Meade Street Wellsboro PA 16901 251644910 Mgmt consulting & supervisory svcs PA 501(c)(3) 11 B II UPMC Susquehanna 0 Laurel Realty 15 Meade Street Wellsboro PA 16901 231403678 Own & manage real estate PA 501(c)(2) N/A UPMC Susquehanna 0 Laurel Health Systems 15 Meade Street Wellsboro PA 16901 240795488 Coordinate & manage the delivery of healthcare PA 501(c)(3) 11 B II UPMC Susquehanna 0 Laurel Health Foundation 15 Meade Street Wellsboro PA 16901 251810488 Fundraising for affiliated entities PA 501(c)(3) 11 A I Laurel Health System 0 Susquehanna Health Innovation Center Inc 700 High Street Williamsport PA 17701 471600873 Supporting organization of affiliated entities PA 501(c)(3) 11 A I UPMC Susquehanna 0 Community Basket LLC 1205 Grampian Boulevard Williamsport PA 17701 201195739 Rents real estate PA UPMC Susquehanna & Susquehanna Health Foundation excluded from tax 0 0 Susquehanna Ventures Inc 1201 Grampian Boulevard Williamsport PA 17701 232470263 Pharmacy & infusion services PA UPMC Susquehanna C 0 Susquehanna Health System Insurance Network LTD PO Box 1159 Grand Caymans CJ KY1-1102 980458722 Captive insurance company CJ UPMC Susquehanna 0 Tyoga Carenet 15 Meade Street Wellsboro PA 16901 251810967 Integrate health care PA UPMC Susquehanna C 0 0 1 1 0 0 0 0 0 0 1 0 1 1 1 1 0 0 1 1 Form 990, Schedule R, Part IV Susquehanna Health System Insurance Network, LTD (SHSIN) EIN #98-0458722, is a foreign corporation, incorporated under the laws of the Cayman Islands. There are no income, capital, or premium taxes levied in the Cayman Islands and SHSIN has been granted an exemption until September 2022 for any such taxes that might be introduced. SHSIN's sole shareholder, UPMC Susquehanna EIN #23-2751183, is a 501 (c)(3) organization exempt from federal income taxes. SHSIN conducts no business in the United States. It files an 1120F protective filing which implies that its income is not subject to US Federal Income tax.