2017-05-02T07:38:49-05:00 2016-06-30 BKD LLP 910 E St Louis Street Suite 200 Springfield MO 65806 990 2015-07-01 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 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 167640598 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. 20 16 412 253 0 0 938294 844733 93633576 99007867 2965840 1684737 220244 212693 97757954 101750030 10640232 11955862 0 0 28279301 30299748 0 0 4808 57014773 59726659 95934306 101982269 1823648 -232239 125289168 127701804 30451476 34361459 94837692 93340345 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 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 out patients and their families first, share ownership with all of our caregivers and lead with a servant's heart. 0 0 89791086 11955862 98923843 For the fiscal year ended June 30, 2016, the hospital admitted 637 patients rendering 5,648 patient days and registered approximately 132,046 outpatients and provided 103,088 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 $19,974,845 in quantifiable community benefits reported for FY 2016: Charity Care (at cost) $176,493; Bad Debts (at cost) $514,458; Government-sponsored health care (unpaid cost of Medicare, Medicaid, Indigent care programs, SCHIP and other safety net programs) $18,358,849. In addition, various Education, Community Health Services, Subsidized Health Services, Community Building, Financial and In-Kind Contributions and Community Benefit Operations totaling $925,045. 89791086 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 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 X 0 0 412 1 0 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 0 0 0 PA X Management 5703207900 1205 Grampian Boulevard Williamsport PA 17701 Christian 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 Pagana Secretary 2.00 2.00 X X 0 1845 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 DO 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 2.00 52.00 X X 0 832199 35182 Eric D Pohjala Executive VP / CFO 2.00 42.00 X 0 255157 27349 David Lopatofsky MD Executive VP / CMO 2.00 42.00 X 0 437276 38887 Jan E Fisher Executive VP / COO 2.00 40.00 X 0 459806 31992 Robert E Kane President 40.00 0.00 X 227852 0 28465 Rajesh Manoharan Medical Physicist 40.00 0.00 X 199709 0 33501 Candace P Dewar Dir DON/DPH & INF Prev Control 40.00 0.00 X 159677 0 21183 Patricia A McGee Executive Director Home Ca 40.00 0.00 X 147277 0 7392 Harry E Hefty Physical Therapist 40.00 0.00 X 149947 0 26302 Charles J Santangelo Former Exec VP/CFO (retired 5/2/15) 0.00 40.00 X 0 338073 24988 William C McCauley MD Former Exec VP/CMO (retired 1/31/15) 0.00 40.00 X 0 185372 4271 Ronald J Butler Former Exec VP/CBO (retired 4/15/15) 0.00 40.00 X 0 518626 13502 884462 3682962 360330 20 1 1 0 The Williamsport Hospital 700 High Street Williamsport PA 17701 Management services 9743931 Aramark Healthcare 24863 Network Place Chicago IL 60673 Management / environmental services 9283515 Susquehanna Lithotripsy 100 West 3rd Avenue Columbus OH 43201 Lithotripsy services 629000 Varian Medical Systems 70140 Network Place Chicago IL 60673 Oncology services 566948 Michele Tedesco 1626 Meade Street Williamsport PA 17701 Home Health Physical Therapist 191435 13 9414 330778 496716 7825 844733 Net patient service revenue 621990 96214490 96214490 Affiliate rent income 531120 2011776 2011776 Sports Medicine - athletic traine 621400 602158 602158 Cafeteria 722514 179443 179443 99007867 834774 834774 66688463 65838500 849963 849963 849963 86016 9414 52068 33948 33948 Auxiliary activity 900099 71839 71839 Oncology - clinical trials 900099 31228 31228 Fitness center 900099 25311 25311 50367 38880 11487 178745 101750030 98923843 0 1981454 11955862 11955862 23570400 22788733 777927 3740 1194879 1155253 39436 190 3846438 3718879 126949 610 1688031 1632051 55712 268 9744243 9744243 1286 1286 10168 10168 183629 183629 9822500 9479771 342729 12649 9681 2968 1628235 1277750 350485 223311 81150 142161 62644 57678 4966 2624880 2482844 142036 609829 589036 20793 52946 39569 13377 905799 905799 3532049 3532049 466529 466529 Medical supplies 22816962 22812788 4174 Inter-entity costs 3036088 3036088 Bad debt 2052607 2052607 Repairs and maintenance 1470160 1431216 38944 470145 285753 184392 101982269 89791086 12186375 4808 8541542 2406148 10705084 12116069 1847406 1671825 2717515 789399 117099662 82465993 29687466 34633669 50392314 51755974 21397841 24328720 125289168 127701804 6210415 6531997 313761 374471 17393805 20521213 6533495 6933778 30451476 34361459 X 92735576 91291118 1139846 1085957 962270 963270 94837692 93340345 125289168 127701804 X -232239 -1488732 223624 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 10168 0 0 0 10168 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 State levels. For the year ended 06/30/16, the amount of dues to HAP totaled $18,808 of which 24.94% or $4,691, was used for lobbying purposes. Dues paid to AHA totaled $24,760 of which 22.12% or $5,477, 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 is negligible. 163100 163100 57818892 42814460 15004432 275159 76418 198741 47356388 37163221 10193167 11486123 2411894 9074229 34633669 Investment in net assets of affiliates 712655 Due from affiliates 22872417 Other Receivables 398697 Other 344951 24328720 Accrued medical malpractice cost 161000 Estimated third party settlements / deferred reimbursement 1374947 Asbestos abatement 168947 Due to Affiliates, net 5228884 6933778 X 98204544 -1488732 -1799830 -3288562 101493106 256924 256924 101750030 88012796 0 88012796 13969473 13969473 101982269 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. Part XI, Line 2d - Other Adjustments: Bad Debt expense -2,052,607. Net assets released from restrictions 252,777. Part XI, Line 4b - Other Adjustments: Contributions received 325. Transfer from affiliates - SHF 330,778. Investment return -118,184. Auxiliary activity 44,005. Part XII, Line 4b - Other Adjustments: Auxiliary activity 44,005. Bad Debt expense 2,052,607. Transfer to affiliate - SHMG 11,872,861. Central America 0 1 Program services Captive insurance company 284016 0 1 0 0 0 1 284016 0 284016 0 0 0 0 0 0 Fall Festival 32086 32086 9736 Lights of Love 9414 9414 1038 7 53930 53930 41294 95430 9414 86016 52068 52068 33948 1 1 X 1 X 1 X 1 1 1 0 1 1 176493 0 176493 0.00180 9295469 2985797 6309672 0.06310 9471962 2985797 6486165 0.06490 282073 2365 279708 0.00280 18712 0 18712 0.00020 0 0 209123 32228 176895 0.00180 144460 144460 0.00140 654368 34593 619775 0.00620 10126330 3020390 7105940 0.07110 520 0 520 0.00000 11346 500 10846 0.00010 11866 500 11366 0.00010 1 2052607 102630 27891087 39838360 -11947273 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 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 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. Divine Providence Hospital Part V, Section B, Line 16i: Other - Brochure Divine Providence 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 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 $2,052,607. 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.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: 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 $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) 11872861 Support of affiliate Susquehanna Community Health and Dental Clinic 469-471 Hepburn Street Williamsport PA 17701 208979596 501(c)(3) 83001 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. 0 0 0 0 0 0 0 0 0 Kevin W Kist DO 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 0 668195 0 133858 0 30146 0 15925 0 19257 0 867381 0 0 Eric D Pohjala Executive VP / CFO 0 252402 0 0 0 2755 0 9720 0 17629 0 282506 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 0 409956 0 36987 0 12863 0 9950 0 22042 0 491798 0 0 Robert E Kane President 201735 0 21284 0 4833 0 11064 0 17401 0 256317 0 0 0 Rajesh Manoharan Medical Physicist 199425 0 0 0 284 0 8193 0 25308 0 233210 0 0 0 Candace P Dewar Dir DON/DPH & INF Prev Control 91915 0 8481 0 59281 0 7524 0 13659 0 180860 0 0 0 Patricia A McGee Executive Director Home Ca 131294 0 15224 0 759 0 6406 0 986 0 154669 0 0 0 Harry E Hefty Physical Therapist 149166 0 0 0 781 0 6581 0 19721 0 176249 0 0 0 Charles J Santangelo Former Exec VP/CFO (retired 5/2/15) 0 186916 0 71895 0 79262 0 9950 0 15038 0 363061 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) 0 112293 0 32105 0 374228 0 9950 0 3552 0 532128 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. 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. A Lycoming County Authority 236760375 550804AH1 2009-10-22 17445802 See Part VI 0 0 0 B Lycoming County Authority 236760375 NoneAvail 2015-06-18 4400000 See Part VI 0 0 0 A 17428769 1252810 324433 15851526 2010 0 0 1 1 B 4400000 37485 3101943 1260572 0 0 0 1 A 0 0 0 1 1 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 1 1 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 0 0 0 1 A 1 B 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, $17,445,802 was allocated to Divine Providence Hospital at the time of issue, while the balance of $147,688,732 was allocated to The Williamsport Hospital (EIN #24-0795508). The proceeds of the Lycoming County Authority, Series 2009A bonds were used, together with other available funds, to undertake a project consisting of the expansion and renovation of the Cancer Treatment Center at Divine Providence Hospital. Form 990, Schedule K, Part II, Bond A, Line 3 The difference between the Total Proceeds of Issue and the amount reflected in Part I, (e) is due to accumulated investment results, net of accumulated Investment Management Fees. Form 990, Schedule K, Part IV, Bond A, Line 2c Rebate calculations 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, (e) and (f) The total issue price per Form 8038, Part III (b) is $40,000,000. Of this total, $4,400,000 was allocated to Divine Providence Hospital at the time of issue, while $11,200,000 was allocated to Muncy Valley Hospital (EIN #24-0806023) and $24,400,000 was allocated to The Williamsport Hospital (EIN #24-0795508). 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 Hosital, 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 B, 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 B, Line 2c As a draw-down obligation with no funds held in investments, rebate calculation requirements are not applicable. 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 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, 412 employees payroll expenses were recorded by Divine Providence Hospital. 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 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 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 48,213. Contributions released from permanent restrictions for use 175,411. Form 990, Part XII, Line 2C The organization did not change it oversight process or selection process. The Williamsport Hospital 700 High Street Williamsport PA 17701 240795508 Hospital PA 501(c)(3) 3 UPMC Susquehanna 0 The 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 transport 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 System 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 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 0 1 1 0 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.