2016-05-13T12:41:41-05:00 2015-06-30 BKD LLP 910 E St Louis St Springfield MO 658062523 990 2014-07-01 232743470 Susquehanna Health Foundation SUSQ 5703207900 1100 Grampian Boulevard Williamsport PA 17701 Eric D Pohjala Executive Vice President/CFO 5703213171 2016-05-13 1 Brian D Todd P00422601 4178658701 2014 2016-08-17 19:52:53Z Steven P Johnson 700 High Street Williamsport PA 17701 22918357 0 X www.susquehannahealth.org X 1986 PA SHF provides fundraising, investment, and financial support to the Susquehanna Health System. 16 15 6 23 0 0 5965164 2188138 0 0 448791 809172 7813 29827 6421768 3027137 830103 393268 0 0 474677 561398 0 0 417254 652005 560994 1956785 1515660 4464983 1511477 18458587 19906930 249730 214630 18208857 19692300 X SHF is a subsidiary of SHS. The mission of SHS 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 carefully place patients and their families first, share ownership with all of our caregivers and lead with a servant's heart. 0 0 867605 393268 SHF is organized and operated to carry out the charitable health care mission of the Supported Organizations which include: The Williamsport Hospital, Divine Providence Hospital of the Sisters of Christian Charity, Muncy Valley Hospital, Soldiers and Sailors Memorial Hospital, The Green Home, and Susquehanna Physician Services. SHF also is operated to solicit and raise funds and endowments, and to receive by way of gift, purchase, grant, devise, will or otherwise, property, real, personal or mixed, and to hold, use, maintain, lease, donate, pledge, encumber, sell, convey and otherwise dispose of all such property in the futherance of the objectives and purposes of this Corporation. 867605 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 1 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 X 8 0 1 6 1 0 0 0 0 0 1 1 0 0 0 0 X 16 15 1 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 0 0 0 PA X Susquehanna Health Finance Department 5703207900 1205 Grampian Blvd Williamsport PA 17701 Keith Kuzio Chairperson 1.00 3.00 X X 0 0 0 John C Becker MD Director-Term end 6/19/15 1.00 0.00 X 0 0 0 Steven P Johnson President/CEO 1.00 46.00 X X 0 906099 31524 Timothy J Crotty Director-Term end 6/19/15 1.00 0.00 X 0 0 0 Douglas Doherty Director 1.00 0.00 X 0 0 0 Mary C Fish Director-Retired 11/2014 1.00 0.00 X 0 0 0 Roger D Jarrett Director 1.00 1.00 X 0 0 0 Stephen D Keener Director 1.00 0.00 X 0 0 0 Lynda Livingston Director 1.00 2.00 X 0 0 0 Richard L Michael Director 1.00 0.00 X 0 0 0 Geneva Peck Director 1.00 1.00 X 0 0 0 Paul Rooney Director 1.00 0.00 X 0 0 0 Marvin H Staiman Director-Term end 6/19/15 1.00 0.00 X 0 0 0 Robert P Crockett Director 1.00 0.00 X 0 0 0 Barbara Hudock Treasurer 1.00 0.00 X X 0 0 0 Mark A Huffman Director 1.00 0.00 X 0 0 0 Joseph L Reighard Director 1.00 0.00 X 0 0 0 Jerry Wertz Secretary 1.00 0.00 X X 0 0 0 Rodney Bailey Director-Term end 6/19/15 1.00 1.00 X 0 0 0 Donna Bastian Director 1.00 0.00 X 0 0 0 John Young Director 1.00 0.00 X 0 0 0 Charles J Santangelo Exec VP/CFO-Retired 5/2015 1.00 42.00 X 0 356800 31856 Eric D Pohjala Exec VP/CFO-Hired 3/2015 1.00 40.00 X 0 0 0 Jan E Fisher Exec VP/COO 1.00 40.00 X 0 413779 29747 William C McCauley MD Exec VP/CMO-Retired 1/2015 1.00 40.00 X 0 410053 34276 Ronald J Butler Exec VP/CBO-Retired 4/2015 1.00 41.00 X 0 344778 22032 David Lopatofsky MD Exec VP/CMO-Hired 1/2015 1.00 40.00 X 0 336647 35227 Sherry E Watts VP Development 40.00 0.00 X 147419 0 7055 147419 2768156 191717 1 0 1 0 0 141832 590376 1455930 83198 2188138 255311 255311 20374053 19820192 553861 553861 553861 82057 141832 68878 13179 13179 18798 2150 16648 16648 3027137 0 0 838999 393268 393268 479290 191716 287574 18805 7522 11283 27351 10940 16411 35952 14381 21571 99408 99408 66485 66485 21089 21089 47780 19112 28668 58895 28590 30305 27903 27903 28188 28188 588 235 353 455 455 8530 8530 41589 41589 7242 7242 1173 1173 Gifts in Kind 67952 67952 Donor recognition gala 59730 59730 Use of Funds-misc expen 20987 20987 Bad Debt-Uncollectible 3000 3000 1515660 867605 230801 417254 582778 2314226 3217829 2361012 3674 192 25448 24436 228144 106482 128904 121662 14348824 14920553 151130 164849 18458587 19906930 59416 65747 190314 148883 249730 214630 X 6878796 6725269 11325061 12962031 5000 5000 18208857 19692300 18458587 19906930 1511477 -28034 0 X X 0 1 X 1 0 X X X 6 Divine Providence Hospital of the Sisters of Christian Charity 240799343 3 1 324540 0 Muncy Valley Hospital 240806023 3 1 20366 0 The Williamsport Hospital & Medical Center 240795508 3 1 48362 0 Susquehanna Physician Services 232449454 3 1 0 0 Soldiers & Sailors Memorial Hospital 232176963 3 1 0 0 The Green Home 240804365 3 1 0 0 6 393268 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 5578 1474 250 6802 5170 658 250 5578 5065 355 250 5170 4872 193 5065 4750 122 4872 0.73500 0.26500 0 0 228144 106482 121662 121662 Deferred Gift Annuities 137195 Due to Affiliates 11688 148883 X 1059902 -28034 10200 220516 202682 857220 2169917 2169917 3027137 1203620 10200 71028 81228 1122392 393268 393268 1515660 Part V, Line 4: The Life's Work Award for Nursing Excellence Endowment Fund was created to provide an annual award to a deserving nurse who has been nominated by his/her peers. Part XI, Line 2d - Other Adjustments: Assets released from restriction 220,516. Part XI, Line 4b - Other Adjustments: Restricted Grants 590,376. Temporarily Restricted Contributions 1,649,345. Temporarily Restricted Investment Return 1,224. Golf Tournament & Gaming expenses -71,028. Part XII, Line 2d - Other Adjustments: Golf Tournament & Gaming expenses 71,028. Part XII, Line 4b - Other Adjustments: Restricted grants 393,268. 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. SH Golf Tournament 133422 92100 41322 5935 3724 19773 0 0 3335 Breast Health Golf Tournament 42515 26770 15745 0 52 10783 0 0 898 2 47952 22962 24990 0 5755 12931 2777 2915 223889 141832 82057 5935 9531 43487 2777 7148 68878 13179 18798 1650 500 0 18798 1650 500 2150 16648 PA 1 0 0 0 1.00000 0.00000 Sherry Watts VP Development Susqu 1100 Grampian Boulevard Williamsport PA 17701 0 Sherry Watts VP Development Susqu 0 Manages raffle income and cash prizes as part of her job as VP Development. X 0 Part II Line 11 and Part III Line 8 All net income from fundraising and gaming is used to carry out the charitable health care mission of the supported organizations. 1 Divine Providence Hospital 1100 Grampian Blvd Williamsport PA 17701 240799343 501(c)(3) 324540 Used for general expenses of the Divine Providence Hospital including Sports Medicine, Cancer Treatment Center, Gatehouse, and Home Care & Hospice. The Williamsport Hospital 700 High Street Williamsport PA 17701 240795508 501(c)(3) 48362 Expenses for OB Fetal Monitor System and training room equipment and renovations. Muncy Valley Hospital 215 E Water Street Muncy PA 17756 240806023 501(c)(3) 20366 Emergency Room stretcher and bladder scanner. 3 0 Part I, Line 2: Grantees are related organizations and part of the Susquehanna Health System 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 531335 0 345329 0 29435 0 13700 0 17824 0 937623 0 0 Charles J Santangelo Exec VP/CFO-Retired 5/2015 0 341221 0 10767 0 4812 0 9800 0 22056 0 388656 0 0 Jan E Fisher Exec VP/COO 0 395220 0 10795 0 7764 0 9800 0 19947 0 443526 0 0 William C McCauley MD Exec VP/CMO-Retired 1/2015 0 390991 0 15748 0 3314 0 9800 0 24476 0 444329 0 0 Ronald J Butler Exec VP/CBO-Retired 4/2015 0 329125 0 10897 0 4756 0 9800 0 12232 0 366810 0 0 David Lopatofsky MD Exec VP/CMO-Hired 1/2015 0 312802 0 15628 0 8217 0 11100 0 24127 0 371874 0 0 Sherry E Watts VP Development 128535 0 18706 0 178 0 6095 0 960 0 154474 0 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. In September 2014, President/CEO Steven P. Johnson received a payout from a 3-year Performance Goals Plan that covered the period of July 1, 2011 through June 30, 2014. Payment was in the amount of $271,788. X 1 10000 Retail price of sculptur X 4 40640 Cashed in at fair market X Misc items 218 31908 Retail price of item X Banners 1 650 Retail price of bann 0 0 1 Part I, Line 32b: M&T Investment Group (the trustee/custodian of our investment portfolio) cashes in the donated stock at fair market value and deposits the stock value into our portfolio as a stock contribution. Form 990, Part VI, Section A, line 2 Key employee Charles Santangelo and board members Rodney Bailey and Steve Johnson all serve on the board of a related taxable organization. Form 990, Part VI, Section A, line 6 Susquehanna Health System 23-2751183 is a sole member of the governing body. Form 990, Part VI, Section A, line 7a Susquehanna Health System 23-2751183 may elect or remove one or more board members to the governing body. Form 990, Part VI, Section A, line 7b Susquehanna Health System 23-2751183, the sole member shall have exclusive authority to exercise the powers: To appoint and remove the President of the Corporation. To elect and remove, with or without cause, a Director of the Corporation. To determine or change the mission and to monitor and maintain the philosophy, goals and purposes for which the Corporation was formed and exists. To adopt, amend or repeal the Articles of Incorporation. To establish requirements for 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 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. To require a certified audit of corporate funds at any time. 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 asset of the Corporation outside of 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. 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 or dissolution, as provided in these bylaws. 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, and to return the list of approved nominees to the Board of Directors for election. To remove any elected officer of the Corporation. To approve the annual capital and operating budget 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 (Susquehanna Health System 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 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 Susquehanna Health System EIN #23-2751183. All expenses are then allocated back to all related entities. Form 990, Part V, Line 2a & 2b Number of employees reported on Form W-3 Susquehanna Health System EIN #23-2751183 utilizes a common paymaster which includes the following entities: Divine Providence Hospital #24-0799343 Muncy Valley Hospital #24-0806023 The Williamsport Hospital #24-0795508 Susquehanna Health Foundation #23-2743470 Susquehanna Physician Services #23-2449454 Susquehanna Ventures Inc. 23-2470263 Williamsport Area Ambulance Service Cooperative #23-2416166 Laurel Management Services #25-1644910 Laurel Realty #23-1403678 Soldiers & Sailors Memorial Hospital #23-2176963 The Green Home #24-0804365 Tioga Health Care Providers #25-1765538 Tyoga Carenet #25-1810967 The total number of employees reported on Form W-3 would be 3,956 for Susquehanna Health System #23-2751183. Of that total, 6 employees payroll expenses were recorded by Susquehanna Health Foundation #23-2743470. Divine Providence Hospital of the Sisters of Christian Charity 1100 Grampian Blvd Williamsport PA 17701 240799343 Hospital PA 501(c)(3) Line 3 Susquehanna Health System 0 Muncy Valley Hospital 215 E Water Street Muncy PA 17756 240806023 Hospital PA 501(c)(3) Line 3 Susquehanna Health System 0 The Williamsport Hospital 700 High Street Williamsport PA 17701 240795508 Hospital PA 501(c)(3) Line 3 Susquehanna Health System 0 Susquehanna Health System 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 & MRI services PA 501(c)(3) Line 3 Susquehanna Health System 0 Williamsport Area Ambulance Service 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 Susquehanna Health System 0 The Green Home 37 Central Ave Wellsboro PA 16901 240804365 Skilled nursing & assisted living PA 501(c)(3) Line 9 Susquehanna Health System 0 Tioga Health Care Providers 15 Meade Street Wellsboro PA 16901 251765538 Physician services PA 501(c)(3) Line 11b, II Susquehanna Health System 0 Laurel Management Services 15 Meade Street Wellsboro PA 16901 251644910 Mgmt consulting & supervisory svcs PA 501(c)(3) Line 11b, II Susquehanna Health System 0 Laurel Realty 15 Meade Street Wellsboro PA 16901 231403678 Own & manage real estate PA 501(c)(2) N/A Susquehanna Health System 0 Laurel Health System 15 Meade Street Wellsboro PA 16901 240795488 Coordinate & manage the delivery of healthcare PA 501(c)(3) Line 11b, II Susquehanna Health System 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 Susquehanna Health Innovation Center Inc 700 High Street Williamsport PA 17701 471600873 Supporting organization for affiliated entities PA 501(c)(3) Line 11b, II Susquehanna Health System 0 Community Basket LLC 1205 Grampian Blvd Williamsport PA 17701 201195739 Rents real estate PA Susquehanna Health System & Susquehanna Health Foundation Excluded from tax 179 11476 0 0 0.50000 Susquehanna Ventures Inc 1201 Grampian Blvd Williamsport PA 17701 232470263 Pharmacy & Infusion Services PA N/A C 0 Susquehanna Health System Insurance Network LTD PO Box 1159 CJ 980458722 Captive Insurance Company CJ N/A 0 Tyoga Carenet 15 Meade Street Wellsboro PA 16901 251810967 Integrate Health Care PA N/A C 0 0 1 1 0 0 0 0 0 0 0 0 1 1 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, 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 tax.