2017-05-02T11:40:14-05:00 2016-06-30 440160260 BKD LLP 910 E St Louis Street Suite 200 Springfield MO 65806 990 2015-07-01 232176963 Soldiers and Sailors Memorial Hospital SOLD 5707230605 32-36 Central Avenue No Acctg Wellsboro PA 16901 Eric D Pohjala Executive Vice President / CFO 5703213175 2017-05-02 1 Brian D Todd P00422601 4178658701 2015 2017-02-10 21:41:12Z Steven P Johnson 700 High Street Williamsport PA 16901 67636108 0 X upmcsusquehanna.org X 1919 PA Soldiers & Sailors Memorial Hospital (SSMH) is a 67 bed, acute care hospital, primarily serving Tioga and surrounding counties. SSMH provides a full range of outpatient, inpatient and emergency services. 15 12 480 71 0 0 481561 175809 62924956 66821206 782980 185871 410678 359362 64600175 67542248 1100 14845 0 0 28831700 29994636 0 0 0 29552837 32494822 58385637 62504303 6214538 5037945 91358783 164178815 51680634 117731570 39678149 46447245 X Soldiers & Sailors Memorial Hospital is a subsidiary of UPMC Susquehanna. The mission of UPMC Susquehanna and its 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 our caregivers and lead with a servant's heart. 0 0 56431079 14845 66821206 The hospital is an 67 bed acute care hospital, which provides care to patients who meet certain criteria without charge or at amounts less than its established rates. The hospital does not pursue collection of amounts determined to qualify as charity care, nor are such amounts reported as revenue. The charity care charges foregone amounted to $897,375 in 2016. The following is a summary of the services provided to patients in 2016;Inpatient admissions 1,775Outpatient visits 105,251Newborn deliveries 264Emergency department visits 17,249Surgeries performed 3,231Laboratory tests 241,279CAT Scans 6,186Ultrasound tests 7,562Radiology tests 26,775MRI tests 1,888Nuclear Medicine tests 967PT treatments 54,354Speech Therapy treatments 4,095Occ Therapy treatments 17,828Oncology Procedures 4,268During 2016 Medicare and Medical Assistance charges accounted for 65% of the hospital's total charges. SSMH 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, SSMH devotes a portion of its revenue and assets to community program services. The following reflects the breakout of $14,933,000 in quantifiable community benefits reported for FY 2016. Charity care (at cost) $261,000; Bad Debt (at cost) $4,837,000; Government-sponsored health care (unpaid cost of Medicare, Medicaid, indigent care programs, and other safety net programs) $9,480,000. In addition, various other programs such as Community Building, Community Wellness and recreation, Financial and InKind Contributions and Community Benefit Operations totalling $355,000. 56431079 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 1 0 0 1 480 1 0 0 0 0 0 0 0 0 0 0 X 15 12 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 PA X Management 5707230605 15 Meade Street Suite U-6 Wellsboro PA 16901 Lisa V Feil Psy D Director 0.33 1.67 X 0 0 0 Robert PFitzgerald Director 0.33 1.67 X 0 0 0 Harold F Hoose III Director 0.33 1.67 X 0 0 0 Michael W Lichty Director 0.33 1.67 X 0 0 0 JDennis Murray PhD Director 0.33 7.67 X 0 0 0 Thomas M Owlett Esq Chairman 0.33 7.67 X X 0 0 0 Glenn BPoirier Vice Chairman 0.33 7.67 X X 0 0 0 Wendy SSwartz CPA Director 0.33 1.67 X 0 0 0 Aneurin J Williams Jr Director 0.33 1.67 X 0 0 0 Donna R Wilson Director 0.33 1.67 X 0 0 0 Kathy J Wright PhD Secretary 0.33 1.67 X X 0 0 0 Jill ABurns MD Director 0.33 45.67 X 0 296503 37541 Walter J Laibinis DO Director 0.33 43.67 X 0 293550 33435 Steven P Johnson President/CEO 0.33 53.67 X X 0 832199 35182 Craig Litchfeild Former Treasurer (ended 6/2015) 0.33 3.67 X X 0 0 0 James D Baker Jr Director 0.33 1.67 X 0 0 0 Janie M Hilfiger VP/President 40.00 1.67 X 180881 0 17488 Eric Pohjala Executive VP/CFO (hired 3/30/15) 1.00 42.00 X 0 255157 27349 Jan E Fisher Executive VP/COO 1.00 40.00 X 0 459806 31992 David Lopatofsky MD Executive VP/CMO (hired 1/31/15) 1.00 41.00 X 0 437276 38887 Enrico Doganiero Physician 40.00 1.00 X 494729 0 37562 Leonard Dale Physician 40.00 1.00 X 160101 0 13308 Craig Konzen Pharmacist 40.00 1.00 X 141279 0 29582 Craig Davenport Former Pharmacist (retired 9/4/15) 40.00 1.00 X 185123 0 15239 Candy Klotz Pharmacist 40.00 1.00 X 130993 0 6384 Charles J Santangelo Former Exec VP/CFO (retired 5/2/15) 0.00 0.00 X 0 338073 24988 William C McCauley MD Former Exec VP/CMO(retired 1/31/15) 0.00 0.00 X 0 185372 4271 Ronald J Butler Former Exec VP/CBO (retired 4/15/15) 0.00 2.00 X 0 518626 13502 1293106 3616562 366710 6 1 1 0 The Williamsport Hospital 700 High Street Williamsport PA 17701 Management Services 3363176 Aramark Healthcare 24863 Network Place Chicago IL 60673 Management Services/Environmental 1191971 Laboratory Corp of America PO Box 12140 Burlington NC 27216 Lab testing 555980 Nightrays PA PO Box 204367 Dallas TX 75320 Interpretation services 266371 Morel & Associates 846 Bent Creek Drive Lititz PA 17543 Consulting services 237200 12 19754 156055 175809 Patient service revenue 621990 64041768 64041768 Electronic Health Incentives 621990 963851 963851 Employee Pharmacy revenue 446110 795960 795960 Paramedic revenue 621910 508872 508872 Cafeteria revenue 722210 269719 269719 241036 241036 66821206 78392 78392 359362 0 359362 359362 359362 200000 1339 48399 45461 151601 -44122 107479 107479 67542248 66821206 0 545233 14845 14845 1107983 927102 180881 21320207 20964617 355590 1447317 1259166 188151 4514213 3927365 586848 1604916 1396277 208639 3363176 3363176 11517 11517 1447 1447 10195 10195 5011792 4844761 167031 39640 20305 19335 1556913 1526582 30331 44075 44075 945970 922870 23100 138458 129411 9047 63123 57315 5808 696381 696381 2886772 2886772 655904 655904 Medical Supplies and Dr 8515919 8515919 Bad Debt Expenses 4837291 4837291 Repairs and Maintenance 1681291 1654606 26685 Medical Assessment 780827 780827 1254131 1149515 104616 62504303 56431079 6073224 0 X 7853946 1284889 810971 53478 5684694 6072693 1023462 623862 1382762 1104901 645453 384786 93059253 49370966 35942504 43688287 71064 71100 37943927 110894819 91358783 164178815 12222964 14845740 17150839 18347079 453616 348656 21853215 84190095 51680634 117731570 X 38703448 46262929 974701 184316 39678149 46447245 91358783 164178815 X 5037945 -70735 1801886 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 7389 7389 0 Part II-B, Line 1 Lobbying Activities: Line 1 i: 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 June 30, 2016, the amount of dues paid to HAP totaled $11,867 of which 24.94% or $2,960, was used for lobbying purposes. Dues paid to AHA totaled $20,022, of which 22.12% or $4,429, 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. 810767 810767 41811502 18719340 23092162 113336 104114 9222 37808468 28808911 8999557 12515180 1738601 10776579 43688287 Due from Affiliates 107707286 Deferred Financing costs 178849 Assets designated for capital acquisition 3008684 110894819 Due to Other Affiliates 83770499 Estimated amounts due to third-party payers 419596 84190095 62505901 -70735 -4837291 -4908026 67413927 128321 128321 67542248 57667012 0 57667012 4837291 4837291 62504303 Part XI, Line 2d - Other Adjustments: Bad debt expense added back to net patient revenue -4,837,291. Part XI, Line 4b - Other Adjustments: TRNA donations 128,321. Part XII, Line 4b - Other Adjustments: Bad Debt Expense added to expenses 4,837,291. 1 1 1 X 1 X 1 1 1 0 1 1 254855 0 254855 0.00410 9835832 3102800 6733032 0.10770 10090687 3102800 6987887 0.11180 10090687 3102800 6987887 0.11180 74342 74342 0.00120 280887 280887 0.00450 355229 355229 0.00570 1 4837291 241865 12507596 15263962 -2756366 X 1 1 1 1 Soldiers & Sailors Memorial Hospital 32-36 Central Avenue Wellsboro PA 16901 www.upmcsusquehannahealth.org 390043 X X X Soldiers & Sailors Memorial 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 1 X 0 X X X X 1 X 0 0 Soldiers & Sailors Memorial 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 interviews with 55 people answering the key informant interview. A web-based tool was utilized to conduct the key informant interviews; however, paper questionnaires identical to the electronic version were distributed to populations who may not have had access to the internet or generally are more likely to complete a paper questionnaire. For more details concerning the Key Informant Interview Process or the Community Health Input Questionnaire process, including a list of those individuals interviewed, a copy of the Community Health Input Questionnaire, and results gathered you may view the CHNA and related Implementation Plan at www.upmcsusquehanna.org/community health. Soldiers & Sailors Memorial Hospital Part V, Section B, Line 6a: Soldiers and Sailors Memorial Hospital; located in Wellsboro, PA is one of four hospitals that comprise 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 Hospital, share the same definition of community served, which is Lycoming County, PA. The fourth hospital that is part of UPMC Susquehanna is Soldiers and Sailors Memorial Hospital located in Wellsboro, PA and their defined community is Tioga County, PA. The health systems' approach to providing community benefits 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.upmcsusquehanna.org/community health. Soldiers & Sailors Memorial 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 in the 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 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 socioeconomics 5) Cancer 6) Lack of preventive care physicians 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 areas. 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. Soldiers & Sailors Memorial Hospital Part V, Section B, Line 16i: Other Method Brochure Soldiers & Sailors Memorial 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 I, Line 6a: The community benefit report is prepared on a system wide basis under UPMC Susquehanna. Part I, Line 7: Part I Line 7 Column (F): The Bad Debt expense included on Form 990, Part IX, Line 25 (A) but subtracted for purposes of calculating the percentage in this column is $4,837,291. Part I, Line 7g: Soldiers & Sailors Memorial Hospital has various subsidized services which are included within the Medicare and Medical Assistance unreimbursed costs. Part II, Community Building Activities: Soldiers & Sailors Memorial Hospital participates in community building through various means such as making parts of the building (conference rooms cafeteria, etc) available for public meetings, blood drives, CPR classes, expectant parent classes, and EMS education among others. The hospital has a large group of volunteers from the community who donate time to assist the organization providing care and well being to the community it serves. For fiscal year 2016, SSMH had 71 volunteers donate approximately 8658 hours of their time. Part III, Line 2: Bad Debt expense consists of the actual bad debts 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 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 costs. 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 Medicare cost report uses a cost per day for the routine service costs times the number of Medicare days. Ancillary costs are calculated based on the cost to charge ratio by department. The Medicare cost report does not capture all charges and reimbursements provided to the facility under Medicare. For the fiscal year ended June 30, 2016, the facility had approximately $13 million in Medicare charges provided at a cost of approximately $15 million. This resulted in a $2 million shortfall for the 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 must be completed for all considered individuals. All other payment arrangements must be explored. The income guidelines 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 three tiers of UPMC Susquehanna 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 for the patient or guarantor to initiate the UPMC Susquehanna 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 the 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/community health. 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 on 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 organizations 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 , just 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 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 or outpatient services from TWH, DPH, MVH, or SSMH. The first hospital claim sent to guarantors of uninsured accounts will include a statement briefly explaining 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 the policy. Part VI, Line 4: The organization serves Tioga County and surrounding areas. Tioga County is located in rural North Central Pennsylvania and has a population 41,981 as of the 2010 census. The median household income was $44,187 with 15.3 percent of the residents below two times the Federal Poverty level. Part VI, Line 5: The hospitals of UPMC Susquehanna all have entity specific boards that are composed of persons who reside in Lycoming and Tioga Counties.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 or 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 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 more Medical Staff members.The volunteer program at UPMC Susquehanna supports the services at our 4 campuses, SSMH, MVH, DPH and TWH as well as our Life Center 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 Tioga 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 active members 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: Soldiers and Sailors Memorial Hospital (SSMH) 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.SSMH is an acute care community hospital providing diagnostic and treatment facilities, educational and training programs and a rehabilitation facility.Divine Providence Hospital (DVH) 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.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. The Williamsport Hosital (TWH)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 Debts (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. Part VI, Line 7, Reports Filed With States PA 1 Form 990 Part IV There were no grants of $5,000 or more to any domestic organization or domestic government reported on Part IX line 1. 0 0 0 0 0 0 0 0 0 Jill ABurns MD Director 0 247243 0 44446 0 4814 0 9950 0 27591 0 334044 0 0 Walter J Laibinis DO Director 0 231118 0 45655 0 16777 0 9950 0 23485 0 326985 0 0 Steven P Johnson President/CEO 0 668195 0 133858 0 30146 0 15925 0 19257 0 867381 0 0 Janie M Hilfiger VP/President 163729 0 14229 0 2923 0 7416 0 10072 0 198369 0 0 0 Eric Pohjala Executive VP/CFO (hired 3/30/15) 0 252402 0 0 0 2755 0 9720 0 17629 0 282506 0 0 Jan E Fisher Executive VP/COO 0 409956 0 36987 0 12863 0 9950 0 22042 0 491798 0 0 David Lopatofsky MD Executive VP/CMO (hired 1/31/15) 0 412757 0 18458 0 6061 0 11275 0 27612 0 476163 0 0 Enrico Doganiero Physician 493726 0 0 0 1003 0 9950 0 27612 0 532291 0 0 0 Leonard Dale Physician 160101 0 0 0 0 0 6803 0 6505 0 173409 0 0 0 Craig Konzen Pharmacist 138503 0 0 0 2776 0 6290 0 23292 0 170861 0 0 0 Craig Davenport Former Pharmacist (retired 9/4/15) 101074 0 0 0 84049 0 6186 0 9053 0 200362 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 Form 990 Part 1 Line 3 Explanation: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. Form 990 Part 1 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-wide 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. Form 990, Part VI, Section A, line 6 UPMC Susquehanna, EIN #23-2751183, is the sole member of the governing body. Effective October 1, 2016 the University of Pittsburgh Medical Center (UPMC) became the sole corporate member of the Susquehanna Health System (EIN #23-2751183) and the name was formally changed to UPMC Susquehanna. 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 sole 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 effort whatsoever. The sole Member shall exercise its power through its Board of Directors. The sole 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 or services of the corporation, monitor and maintain the philosophy, goals and purposes for which the corporation was formed and exists, subject to and 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 transfers of any assets of the corporation outside the ordinary course of business, except transfers between or among 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 Form 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 As required by law, Hospital policy states that all members of the Board of Directors and 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, Lines 15a and 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 of reasonableness relative to executive compensation and benefits. The consultant annually provides detailed market information from its annual Executive Compensation Survey for the 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: Pension Liability Adjustment -1,810,507. Postretirement benefit liability adjustment 177,031. Transfers from other affiliates 2,618,819. Transfers to other affiliates 816,543. Form 990 Part V Line 2a and 2b Explanation: UPMC Susquehanna EIN #23-2751183 utilizes a common paymaster which includes the following entities: Divine Providence Hospital EIN# 24-0499343 Muncy Valley Hospital EIN #24-0806023 The Williamsport Hospital EIN #24-0795508 Susquehanna Health Foundation EIN# 23-2743470 Susquehanna Physician Services EIN# 23-2449454 Williamsport Area Ambulance Service EIN# 23-2416166 Laurel Realty EIN# 23-1403678 Laurel Management Services EIN# 25-1644910 Soldiers & Sailors Memorial Hospital EIN# 23-2176963 The Green Home EIN# 24-0804365 Tioga Healthcare 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. If that total 480 employees payroll expenses were recorded by Soldiers & Sailors Memorial Hospital. Form 990 Part XII Line 2c The organization did not change its oversight process or selection process. Form 990 Part X Line 20 The Tax Exempt Bond Liabilities listed on the balance sheet line 20 are reported in their entirety on the 990 for Laurel Health System EIN # 24-0795488. The issuer is the Tioga County Industrial Development Authority. These bonds are allocated to all to Soldiers & Sailors Memorial Hospital. Laurel Health System 32-36 Central Ave Wellsboro PA 16901 240795488 Support entities affiliated with Laurel Health System PA 501(c)(3) Line 11b, II UPMC Susquehanna 0 Laurel Realty 32-36 Central Ave Wellsboro PA 16901 231403678 Owns and manages real estate PA 501(c)(2) NA UPMC Susquehanna 0 Laurel Management Services 32-36 Central Ave Wellsboro PA 16901 251644910 Management, consulting and supervisory services PA 501(c)(3) Line 11b, II UPMC Susquehanna 0 The Green Home 37 Central Avenue Wellsboro PA 16901 240804365 Skilled nursing & assisted living facilities. PA 501(c)(3) Line 9 UPMC Susquehanna 0 Tioga Health Care Providers 1201 Grampian Blvd Williamsport PA 17701 251765538 Employs physician specialists PA 501(c)(3) Line 11b, II UPMC Susquehanna 0 North Penn Comprehensive Health Services 22 Walnut Street Wellsboro PA 16901 231889724 Provides General Health and Social services PA 501(c)(3) Line 11b, II N/A 0 Divine Providence Hospital 1100 Grampian Blvd Williamsport PA 17701 240799343 Hospital PA 501(c)(3) Line 3 UPMC Susquehanna 0 Muncy Valley Hospital 215 East 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 Susquehanna Physician Services 1201 Grampian Blvd Williamsport PA 17701 232449454 Physician Services and MRI services PA 501(c)(3) Line 3 UPMC Susquehanna 0 Williamsport Area Ambulance Services 700 High Street Williamsport PA 17701 232416166 Ambulance transport PA 501(c)(3) Line 9 N/A 0 Laurel Health Foundation 32-36 Central Ave Wellsboro PA 16901 251810488 Manages Endowments and other investments PA 501(c)(3) Line 11a, I Laurel Health System 0 Susquehanna Health Innovation Center Inc 700 High Street Williamsport PA 17701 471600873 Supporting organization of affilaited entities PA 501(c)(3) Line 11a, I UPMC Susquehanna 0 UPMC Susquehanna 1205 Grampian Blvd Williamsport PA 17701 232751183 Coordinate and manage the delivery of healthcare PA 501(c)(3) Line 11b, II N/A 0 Community Basket LLC 1205 Grampian Blvd Williamsport PA 17701 201195739 Rents real estate PA UPMC Susquehanna & Susquehanna Health Excluded from tax 0 0 Tyoga Carenet 32-36 Central Avenue Wellsboro PA 16901 251810967 Integrate Healthcare Regionally PA UPMC Susquehanna C 0 Susquehanna Ventures Inc 1201 Grampian Blvd Williamsport PA 17701 232470263 Pharmacy and Infusion Services PA UPMC Susquehanna C 0 Susquehanna Health System Insurance Network LTD PO Box 1159 Grand Caymans CJ 980458722 Captive Insurance Company CJ UPMC Susquehanna 0 0 0 0 1 1 0 0 0 0 0 1 1 1 1 1 0 0 1 1 Laurel Realty K 115788 FMV Form 990 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 is Susquehanna Health System 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 taxes.