2017-05-01T06:35:51-05:00 2016-06-30 BKD LLP 910 E St Louis St Springfield MO 658062523 990 2015-07-01 471600873 Susquehanna Health Innovation Center Inc SUSQ 5703207900 700 High Street Williamsport PA 17701 Eric D Pohjala Executive Vice President/CFO 5703213171 2017-05-01 1 Brian D Todd CPA P00422601 4178658701 2015 2017-02-10 21:41:12Z Steven P Johnson 700 High Street Williamsport PA 17701 354525 0 X www.susquehannahealth.org X 2013 PA Supporting organization of UPMC Susquehanna. 6 4 0 4 0 0 0 0 145835 350004 7904 4521 0 0 153739 354525 0 2000000 0 0 0 0 0 0 0 540900 1369820 540900 3369820 -387161 -3015295 28790813 25775518 18177974 18177974 10612839 7597544 X The mission of UPMC Susquehanna and affiliates is as follows: Our mission - to extend God's healing love by improving the health of those we serve. Our vision - to create a clinically integrated community health system that delivers world class care. Our values - to place patients and their families first, share ownership with all of our caregivers, and lead with a servant's heart. 0 0 3312268 2000000 350004 SHICI is a supporting organization for The Williamsport Hospital, Divine Providence Hospital, Muncy Valley Hospital, and Susquehanna Physician Services. 3312268 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 X 0 0 1 0 0 0 0 0 0 0 0 0 0 0 X 6 4 1 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 0 0 0 PA X UPMC Susquehanna Finance Department 5703207900 1205 Grampian Blvd Williamsport PA 17701 Christian DeWald Chairperson 2.00 4.00 X X 0 0 0 Keith Kuzio Vice Chairman 2.00 6.00 X X 0 0 0 Ann Pepperman Secretary 2.00 4.00 X X 0 0 0 Ronald DeFeo Treasurer 2.00 4.00 X X 0 0 0 Steven P Johnson President/CEO 2.00 50.00 X X 0 832199 35182 Eric D Pohjala Exec VP/CFO-elected 8/27/15 2.00 40.00 X X 0 255157 27349 Jan E Fisher Exec VP/COO 2.00 42.00 X 0 459806 31992 David Lopatofsky MD Exec VP/CMO 2.00 42.00 X 0 437276 38887 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 42.00 X 0 518626 13502 0 3026509 176171 0 1 1 0 0 Affiliate rent income 621990 350004 350004 350004 4521 4521 354525 350004 0 4521 2000000 2000000 20452 20452 2100 2100 35000 35000 235752 235752 1076516 1076516 3369820 3312268 57552 0 2948772 24863 1152978 1000058 24309656 1211755 23607295 23097901 1081768 1652696 28790813 25775518 17600000 17600000 577974 577974 18177974 18177974 X 10612839 7597544 10612839 7597544 28790813 25775518 -3015295 0 X X 0 1 X 1 0 X X X 4 The Williamsport Hospital 240795508 3 1 727273 0 Susquehanna Physician Services 232449454 3 1 0 0 Divine Providence Hospital 240799343 3 1 0 0 Muncy Valley Hospital 240806023 3 1 1272727 0 4 2000000 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 2300000 2300000 15247638 678600 14569038 5169384 341756 4827628 1592634 191399 1401235 23097901 Other Assets 252000 Due from affiliates 1400696 1652696 Due to affiliates 577974 577974 X 354525 0 354525 0 354525 1369820 0 1369820 2000000 2000000 3369820 Part XII, Line 4b - Other Adjustments: Transfer to affiliates 2,000,000. Form 990, 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. 1 The Williamsport Hospital 700 High Street Williamsport PA 17701 240795508 501(c)(3) 727273 0 Support of affiliate Muncy Valley Hospital 215 E Water Street Muncy PA 17756 240806023 501(c)(3) 1272727 0 Support of affiliate 2 0 Part I, Line 2: Grantees are related organizations and part of UPMC Susquehanna with consistent management oversight ensuring the use of funds for charitable purposes. 0 0 0 0 0 0 0 0 0 Steven P Johnson President/CEO 0 668195 0 133858 0 30146 0 15925 0 19257 0 867381 0 0 Eric D Pohjala Exec VP/CFO-elected 8/27/15 0 252402 0 0 0 2755 0 9720 0 17629 0 282506 0 0 Jan E Fisher Exec VP/COO 0 409956 0 36987 0 12863 0 9950 0 22042 0 491798 0 0 David Lopatofsky MD Exec VP/CMO 0 412757 0 18458 0 6061 0 11275 0 27612 0 476163 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 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. 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 a variable compensation award in the amount of $133,858. Form 990, Part VI, Section A, line 2 Board member Steve Johnson, Keith Kuzio, and Christian DeWald all serve on the board of a related taxable corporation. 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 one or more board members to the governing body. Form 990, Part VI, Section A, line 7b UPMC Susquehanna EIN #23-2751183, the sole member shall have exclusive authority to exercise the powers: To elect and remove, with or without cause, a Director of the Corporation. To establish the overall policy and long range plans of the corporation. To adopt, amend or repeal the Articles of Incorporation. 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. To establish policies and requirement for the approval of the acquisition, purchase, sale, leasing, or encumbrance outside the ordinary course of business of land or buildings and the construction or demolition of buildings owned by the corporation. To cause debt to be incurred by the corporation. To require a certified audit of corporate funds at any time. To establish requirements and policies governing the approval of any guaranty of the indebtedness of any person, the granting of any security interest in or the creation of any encumbrance on any asset of the corporation. 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. To dissolve or terminate the existence of the corporation and determine the distribution of assets upon such termination. To appoint annually the external fiscal auditor of the corporation. To approve the nominees for elected officers of the Board of Directors of the corporation. To remove any elected officer of the corporation. To adopt the annual capital and operating budget of the corporation. To coordinate manager care plans. To approve any change in licensure of the corporation. 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 EIN #23-2751183) before filing and complete drafts of all returns are made available to all Board members through the CEO's and CFO's office. Form 990, Part VI, Section B, line 12c All members of the Board of Directors are required to submit a statement annually disclosing any conflict of interest that may arise. Requests for the annual form are distributed individually to each Board Member by the Office of the President and CEO. The CEO's executive assistant ensures that she receives a completed form from every Board Member. All Board Members agree to abstain when any issue involving the parties with conflicting interest is called to motion. Form 990, Part VI, Section B, line 15 All top management is employed by The Williamsport Hospital EIN #24-0795508. The following paragraph describes the process they use. 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 members of the public who request them. They would be produced by the Corporate office. Form 990, Part XII, Line 2c The organization did not change its oversight process or selection process. Form 990, Part V, Line 1a Number reported in Box 3 of Form 1096 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 Blvd Williamsport PA 17701 240799343 Hospital PA 501(c)(3) Line 3 UPMC Susquehanna 0 Muncy Valley Hospital 215 E Water Street Muncy PA 17756 240806023 Hospital PA 501(c)(3) Line 3 UPMC Susquehanna 0 The Williamsport Hospital 700 High Street Williamsport PA 17701 240795508 Hospital PA 501(c)(3) Line 3 UPMC Susquehanna 0 Susquehanna Health Foundation 1100 Grampian Blvd Williamsport PA 17701 232743470 Fundraising for Affiliated entities PA 501(c)(3) Line 11a, I UPMC Susquehanna 0 UPMC Susquehanna 1205 Grampian Blvd Williamsport PA 17701 232751183 Coordinate & manage the delivery of healthcare PA 501(c)(3) Line 11b, II N/A 0 Susquehanna Physician Services 1201 Grampian Blvd Williamsport PA 17701 232449454 Physician services PA 501(c)(3) Line 3 UPMC Susquehanna 0 Williamsport Area Ambulance Service Cooperative 700 High Street Williamsport PA 17701 232416166 Ambulance transports PA 501(c)(3) Line 9 N/A 0 Soldiers & Sailors Memorial Hospital 32-36 Central Ave Wellsboro PA 16901 232176963 Hospital PA 501(c)(3) Line 3 UPMC Susquehanna 0 The Green Home 37 Central Ave Wellsboro PA 16901 240804365 Skilled nursing & assisted living PA 501(c)(3) Line 9 UPMC Susquehanna 0 Tioga Health Care Providers 15 Meade Street Wellsboro PA 16901 251765538 Physician services PA 501(c)(3) Line 11b, II UPMC Susquehanna 0 Laurel Managment Services 15 Meade Street Wellsboro PA 16901 251644910 Mgmt consulting & supervisory svcs PA 501(c)(3) Line 11b, 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) Line 11b, II UPMC Susquehanna 0 Laurel Health Foundation 15 Meade Street Wellsboro PA 16901 251810488 Fundraising for Affiliated entities PA 501(c)(3) Line 11a, I Laurel Health System 0 Community Basket LLC 1205 Grampian Blvd Williamsport PA 17701 201195739 Rents real estate PA UPMC Susquehanna & Susquehanna Health Foundation excluded from tax 0 0 Susquehanna Ventures Inc 1201 Grampian Blvd Williamsport PA 17701 232470263 Pharmacy & Infusion services PA UPMC Susquehanna C 0 Susquehanna Health System Insurance Network LTD PO Box 1159 CJ 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 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 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.