2016-05-16T15:08:49-07:00 2015-06-30 990 2014-07-01 240792115 JERSEY SHORE HOSPITAL JERS 5703980100 1020 Thompson St Jersey Shore PA 17740 DAVID SHANNON PRESIDENT & CEO 5703983101 2016-05-16 2014 2016-08-17 19:52:53Z David A Shannon 1020 Thompson St Jersey Shore PA 17740 28855565 0 X www.jsh.org X 1922 PA Provide Inpatient, Outpatient, and Emergency Care Services for Residents of Jersey Shore Area. 12 10 320 10 641106 0 226863 56249 27263577 27917299 43060 29686 737350 791006 28270850 28794240 0 0 0 0 14017818 14917043 0 0 0 16359582 14644686 30377400 29561729 -2106550 -767489 25663302 23748049 21359776 22145857 4303526 1602192 TO BE THE COMMUNITIES FOUNDATION FOR INNOVATIVE PATIENT-CENTERED CARE. 0 0 26014418 0 27835387 AS A RURAL HEALTHCARE FACILITY AND DEDICATED COMMUNITY HOSPITAL WITH A COMMITMENT TO PROVIDING A HIGH QUALITY CIRCLE OF CARE, JERSEY SHORE HOSPITAL HAS DEVELOPED DELIVERY SYSTEMS THAT PROVIDE AN EFFICIENT BALANCE OF OUTPATIENT CARE, ACUTE AND SUB-ACUTE INPATIENT CARE, PRIMARY CARE, AND OUTREACH SERVICES. THE HOSPITAL MAXIMIZES THE EFFECTIVENESS OF ITS PROGRAMS FOR QUALITY, EFFICIENCY, AND ACCESSIBILITY BY INTEGRATING WITH OTHER PROVIDERS AND ALTERNATIVE CARE ORGANIZATIONS IN THE SERVICE COMMUNITY TO ASSURE THE COMMUNITY ACCESS TO A BROAD ARRAY OF SERVICE OPTIONS. THE HOSPITAL PROVIDES AN ENVIRONMENT OF CARE THAT IS COMPASSIONATE, HIGHLY-PERSONALIZED, AND FOCUSED ON THE PHYSICAL, PSYCHO-SOCIAL, AND SPIRITUAL NEEDS OF ITS PATIENTS THROUGH THE USE OF SKILLED NURSES, PHYSICIANS, TECHNICAL AND SUPPORT STAFF, MANAGEMENT, AND COMMUNITY LEADERS. THE HOSPITAL ALSO PROVIDES HEALTH EDUCATION, PROGRAMS IN PREVENTION, AND RELATED SUPPORT SERVICES TO THE COMMUNITY WITH THE GOAL OF IMPROVING THE OVERALL WELLNESS OF ITS RESIDENTS. THE HOSPITAL ENSURES THAT THE NECESSARY RESOURCES ARE AVAILABLE TO PROVIDE THE MOST COST EFFECTIVE MANNER WHILE MAINTAINING A SAFE, PLEASANT, AND MEANINGFUL WORK AND PATIENT CARE ENVIRONMENT. THE HOSPITAL PROVIDES CHARITY CARE TO PATIENTS WHO MEET CERTAIN CRITERIA WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. CHARGES FORGONE FOR SERVICES RENDERED AND SUPPLIES FURNISHED UNDER THE CHARITY CARE POLICY AMOUNTED TO APPROXIMATELY $439,000 DURING THE YEAR ENDED JUNE 30, 2015. 0 0 0 26014418 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 1 1 0 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0 0 0 1 36 0 1 320 1 1 1 0 0 0 0 1 1 0 0 0 0 X 12 10 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 PA X MARK RICE-CFO 5703985280 1020 Thompson St Jersey Shore PA 17740 X DAVID A SHANNON PRESIDENT & CEO (NONVOTING) 39 1 X X 0 0 0 RICHARD BEATTY DMD CHAIRPERSON 1 1 X X 0 0 0 SEAN SIMCOX VICE CHAIRPERSON 1 0 X X 0 0 0 LEROY H KEILER III SECRETARY 1 1 X X 0 0 0 JAMES ELY TREASURER 1 1 X X 0 0 0 THOMAS C CONNOLLY MD MEDICAL STAFF PRESIDENT 1 39 X 0 456225 37050 WILLIAMS R CAMERER III MEMBER 1 0 X 0 0 0 WALTER EISENHAUER MEMBER 1 0 X 0 0 0 CRAIG HARRIS MEMBER 1 0 X 0 0 0 STEPHEN P NEUN PH D MEMBER 1 0 X 0 0 0 CARMEN SPINNEY MD MEMBER 1 0 X 0 0 0 RICHARD DELANEY MEMBER (BEGAN 1.1.15) 1 0 X 0 0 0 BETSY CROSSLEY MEMBER (BEGAN 1.1.15) 1 0 X 0 0 0 JAMES REESER MEMBER (ENDED 4.14.15) 1 0 X 0 0 0 MARK RICE CFO 39 1 X 95342 0 20630 SHAIRKO MISSOURI ANESTHESOLOGIST 40 0 X 432446 0 19185 MICHAEL GERST PHYSICIAN 40 0 X 332527 0 18444 TAMAR BAITEL PHYSICIAN 40 0 X 285567 0 14235 AARON JAY KOLB PHYSICIAN 40 0 X 202274 0 18424 THEORDORE FEDEROFF PHYSICIAN 40 0 X 176016 0 10954 1524172 456225 138922 11 0 1 0 JERSEY SHORE RADIOLOGY 302 N THIRD STREET LEWISBURG PA 17837 RADIOLOGY TESTS INTREPRETATIONS 1069640 QUORUM HEALTH RESOURCES 105 CONTINENTAL PLACE ATTENTION DEPT 9100 BRENTWOOD TN 370271018 MANAGEMENT FEES 701625 LOCUM TENENS COM PO BOX 405547 ATLANTA GA 303845547 ER PHYSICIAN LOCUMS 322552 MEDICUS EMERGENCY ROOM SERVICE 22 ROULSTON ROAD ATTN ACCOUNTS RECEIVABLE WINDHAM NH 03087 ER PHYSICIAN LOCUMS 118688 QUEST DIAGNOSTICS 12436 COLLECTIONS CENTER DRIVE CHICAGO IL 606932436 LAB TEST INTERPRETATION 114743 6 0 0 3425 0 30741 22083 0 56249 PATIENT SERVICE REV 621110 27917299 27276193 641106 0 0 0 0 0 27917299 28386 0 0 28386 0 0 0 0 0 0 0 0 84256 0 51969 0 32287 0 32287 0 0 32287 0 1300 0 0 0 1300 1300 0 0 1300 18829 3425 9356 9473 0 9473 LHU CLINIC REVENUE 900099 301707 301707 0 0 MEANINGFUL USE 622000 257487 257487 0 0 CAFETERIA/VENDING REV 722210 97539 0 0 97539 92513 0 0 92513 749246 28794240 27835387 641106 261498 X 551567 479808 71759 40892 35572 5320 11182990 9728083 1454907 454589 395447 59142 1794899 1561383 233516 892106 776043 116063 662191 576040 86151 47146 0 47146 0 71071 0 71071 0 2472 2472 0 0 4300319 3740847 559472 62049 62049 434661 260868 173793 479885 288020 191865 540574 492325 48249 66672 58099 8573 16864 4645 12219 734244 734244 2018546 2018546 429213 429213 BAD DEBT EXPENSE 2272171 2272171 0 0 MEDICAL SUPPLIES 1120583 1120583 0 0 NONCHARGE SUPPLIES 448058 430395 17663 0 CHARGEABLE SUPPLIES 348234 348234 0 0 589733 199331 390402 29561729 26014418 3547311 0 1435 1435 1288441 1162103 6029 0 2887474 2538484 0 0 0 0 50000 33333 239137 200067 176371 193326 37918049 23726209 15800507 14191840 0 0 0 0 0 0 0 0 5213908 5427461 25663302 23748049 2947572 3314749 0 0 0 0 0 0 0 0 0 0 13889676 13944273 0 0 4522528 4886835 21359776 22145857 X 4244099 1542765 59427 59427 0 0 4303526 1602192 25663302 23748049 X -767489 0 0 0 0 -1933845 X 0 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2472 2472 0 Schedule C, Part II-B, Line 1 THE HOSPITAL PAYS DUES TO THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE HOSPITAL ASSOCIATION OF PENNSYLVANIA (HAP). A PORTION OF THE DUES PAID TO THESE TWO ORGANIZATIONS ($2472 DURING THE YEAR ENDED JUNE 30, 2015) WAS USED FOR LOBBYING PURPOSES. 0 154956 154956 0 18172538 7893732 10278806 0 0 0 0 0 18918947 15508540 3410407 0 671608 323937 347671 14191840 DUE FROM AFFILIATES 2564814 OTHER ASSET 2355656 DEFERRED FINANCING COSTS, NET 100776 RESTRICTED USE FUNDS 406215 5427461 ACCRUED PENSION COST 2763892 OBLIGATIONS UNDER CAPITAL LEASE 1102859 DEFERRED REVENUE 603293 SETTLEMENTS 416791 4886835 X 28855565 0 0 0 0 0 28855565 0 -61325 -61325 28794240 29623054 0 0 0 61325 61325 29561729 0 0 0 29561729 Schedule D, Part X, Line 2 THE HOSPITAL ACCOUNTS FOR UNCERTAINTY IN INCOME TAXES USING A RECOGNITION THRESHOLD OF MORE-LIKELY-THAN-NOT TO BE SUSTAINED UPON EXAMINATION BY THE APPROPRIATE TAXING AUTHORITY. MEASUREMENT OF THE TAX UNCERTAINTY OCCURS IF THE RECOGNITION THRESHOLD IS MET. MANAGEMENT DETERMINED THERE WERE NO TAX UNCERTAINTIES THAT MET THE RECOGNITION THRESHOLD IN 2015 AND 2014. THE HOSPITAL'S FEDERAL RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX AND EXEMPT ORGANIZATION BUSINESS TAX RETURN FOR THE YEAR ENDED PRIOR TO JUNE 30, 2013 NO LONGER REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. Schedule D, Part XI, Line 4b RENTAL EXPENSE-(51969) PLUS FUNDRAISING EXPENSE-(9356) EQUALS TOTAL SCHEDULE D, PART XI, LINE 4B- (61325) Schedule D, Part XII, Line 2d RENTAL EXPENSES-51,969 FUNDRAISING EXPENSE-9,356 TOTAL TO SCHEDULE D, PART XII, LINE 2D-61,3125 GOLF TOURNAMENT 22254 3425 18829 190 1320 4956 461 0 2429 0 0 22254 3425 18829 190 1320 4956 461 0 2429 9356 9473 1 1 X 1 X 1 X 1 0 0 167583 167583 0.0062 2070405 1936645 133760 0.005 0 0 2237988 1936645 301343 0.0112 211409 19116 192294 0.0072 1650 1650 0.0001 0 0 213059 19116 193944 0.0073 0 0 2451047 1955761 495287 0.0185 1 891984 0 4421445 4393699 27746 X 1 1 1 1 JERSEY SHORE HOSPITAL 1020 THOMPSON ST JERSEY SHORE PA 17740 HTTP://WWW.JSH.ORG 101401 X X X X JERSEY SHORE HOSPITAL 1 0 0 1 X X X X X X X X 12 1 0 0 1 X http://www.jsh.org/CHNA-JSH-2012.pdf X 1 12 1 http://www.jsh.org/2012ImplementationStrategy.pdf 0 0 1 X 200 250 X X X 1 1 X X X 1 X X X 1 0 X X X X 1 X 0 0 Schedule H, Part V, Section B, Line 5-JERSEY SHORE HOSPITAL TWO FOCUS GROUPS WITH COMMUNITY LEADERS AND STAKEHOLDERS WERE HELD ON AUGUST 15, 2012 AT JERSEY SHORE HOSPITAL. THE PURPOSE OF THE FOCUS GROUPS WAS TO GATHER QUALITATIVE DATA FROM "KEY INFORMANTS" ON LOCAL HEALTH ISSUES. KEY INFORMANTS WERE DEFINED AS AREA HEALTH CARE PROFESSIONALS, SOCIAL SERVICE PROVIDERS, NON-PROFIT LEADERS, BUSINESS LEADERS, FAITH-BASED ORGANIZATIONS, AND OTHER AREA AUTHORITIES. EACH SESSION LASTED APPROXIMATELY TWO HOURS. A DISCUSSION GUIDE WAS USED TO PROMPT DISCUSSION AND GUIDE THE FACILITATION. THE GUIDE FOCUSED ON GATHERING QUALITATIVE FEEDBACK REGARDING PERCEPTIONS OF COMMUNITY NEEDS ACROSS THREE KEY DOMAINS: HEALTH CARE ACCESS, KEY HEALTH ISSUES, AND COMMUNITY ASPIRATIONS & CAPACITY. IN TOTAL, 18 PEOPLE PARTICIPATED IN THE FOCUS GROUPS, REPRESENTING A VARIETY OF SECTORS INCLUDING PUBLIC HEALTH AND MEDICAL SERVICES, NON-PROFIT AND SOCIAL ORGANIZATIONS, CHILDREN YOUTH AGENCIES, AND THE BUSINESS COMMUNITY. Schedule H, Part V, Section B, Line 11-JERSEY SHORE HOSPITAL THE COMMUNITY HEALTH NEEDS ASSESSMENT IDENTIFIED 8 OVERALL NEEDS WITHIN THE COMMUNITY. THESE NEEDS IDENTIFIED ARE AS FOLLOWS: ACCESS TO CARE, MENTAL/BEHAVIORAL HEALTH/SUBSTANCE ABUSE, OVERWEIGHT & OBESITY, RESPIRATORY DISEASE/ASTHMA, DIABETES, HEART DISEASE, LYME DISEASE, AND MATERNAL/INFANT HEALTH. THE TOP FOUR PRIORIES THAT ARE BEING ADDRESSED ARE: ACCESS TO CARE, MENTAL BEHAVIORAL HEALTH, OVERWEIGHT & OBESITY, AND RESPIRATORY DISEASE/ASTHMA. BEING OVERWEIGHT OR OBESE HAS AN EFFECT ON DIABETES AND HEART DISEASE, THEREFORE IT WAS DECIDED TO INCLUDE DIABETES AND HEART DISEASE AS SUBSETS OF THE OVERWEIGHT AND OBESITY PRIORITY. THEREFORE THE ONLY TWO NEEDS IDENTIFIED THAT ARE NOT CURRENTLY BEING ADDRESSED ARE LYME DISEASE AND MATERNAL/INFANT HEALTH. THESE NEEDS WILL BE CONSIDERED AS FUTURE PROJECTS. Schedule H, Part V, Section B, Line 16i-JERSEY SHORE HOSPITAL POLICY WAS REFERENCED ON INVOICES AND VERBALLY DISCUSSED WITH PATIENTS. Schedule H, Part V, Section B, Line 22d-JERSEY SHORE HOSPITAL AS SOON AS THE PATIENT IS DEEMED ELIGIBLE FOR FINANCIAL ASSISTANCE, THE HOSPITAL RECORDS THE DISCOUNT AND BILLS THE PATIENT THE AMOUNT THAT THEY ARE RESPONSIBLE FOR UNDER THEIR FAP POLICY. THE DISCOUNT CHARGED IS IN LINE WITH THE COMMERCIAL PAYOR RATE. Schedule H, Part I, Line 7 THE HOSPITAL USED THE COST TO CHARGE RATIO. Schedule H, Part I, Line 7, Column f AMOUNT OF BAD DEBT EXPENSE FROM PART IX SUBTRACTED IN ORDER TO CALCULATE PERCENT OF TOTAL EXPENSE IN PART I LINE 7 COLUMN F WAS $2,272,171. Schedule H, Part III, Section A, Line 4 BAD DEBT EXPENSE IS CALCULATED BASED ON ACTUAL WRITE-OFFS THROUGHOUT THE YEAR AND IS ESTIMATED AT COST USING THE RATIO OF PATIENT CARE COST TO CHARGE. PATIENT ACCOUNTS RECEIVABLE ARE REPORTED AT NET REALIZABLE VALUE. ACCOUNTS ARE WRITTEN OFF WHEN THEY ARE DETERMINED TO BE UNCOLLECTIBLE BASED UPON MANAGEMENT'S ASSESSMENT OF INDIVIDUAL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF PATIENT ACCOUNTS RECEIVABLE, THE CORPORATION ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE CORPORATION ANALYZES CONTRACTUAL AMOUNTS DUE AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS, THE CORPORATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCES, WHICH INDICATED THAT MANY PATIENTS ARE UNABLE TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE BILLED RATES AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. BAD DEBT EXPENSE IS BASED ON THE NECESSARY ALLOWANCE AT THE END OF EACH MONTH. PATIENT DISCOUNTS ARE NOT INCLUDED IN BAD DEBT-THEY ARE INCLUDED IN CONTRACTUAL ADJUSTMENTS. PAYMENT ON PATIENT ACCOUNTS ARE INCLUDED IN THE ALLOWANCE FOR BAD DEBT. THE HOSPITAL IS DILIGENT IN THE CLASSIFICATION OF AMOUNTS AS CHARITY CARE OR BAD DEBT. WE BELIEVE NONE OF THE AMOUNTS IN BAD DEBT WOULD BE RECLASSIFIED TO CHARITY CARE GIVE ADDITIONAL INFORMATION. Schedule H, Part III, Section B, Line 8 THERE IS NO MEDICARE SHORTFALL-AS A CRITICAL ACCESS HOSPITAL, WE ARE REIMBURSED AT 101% OF COST FROM MEDICARE. ALLOWABLE COSTS WERE DETERMINED USING THE COST-TO-CHARGE RATIO FROM MEDICARE COST REPORT. Schedule H, Part III, Section C, Line 9b COLLECTIONS ARE PURSUED UP TO THE POINT THAT A PATIENT COMPLETES AND IS APPROVED FOR CHARITY CARE. ONCE CHARITY CARE IS APPROVED, NO FURTHER COLLECTION EFFORTS ARE MADE. Schedule H, Part VI, Line 2 JERSEY SHORE HOSPITAL (JSH) LED A COMPREHENSIVE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) TO EVALUATE THE HEALTH NEEDS OF INDIVIDUALS LIVING IN THE JERSEY SHORE HOSPITAL SERVICE AREA IN NORTH CENTRAL PENNSYLVANIA. THE PURPOSE OF THE ASSESSMENT WAS TO GATHER INFORMATION ABOUT LOCAL HEALTH NEEDS AND HEALTH BEHAVIORS. THE ASSESSMENT EXAMINED A VARIETY OF INDICATORS, INCLUDING SOCIAL DETERMINANTS OF HEALTH (POVERTY, HOUSING, EDUCATION), MORALITY RATES, RISKY BEHAVIORS (ALCOHOL USE, TOBACCO USE), AND CHRONIC HEALTH CONDITIONS (DIABETES, HEART DISEASE). METHODOLOGY-JSH DEFINED THEIR SERVICE AREA BASED ON ANALYSIS OF THE GEOGRAPHIC AREA WHERE INDIVIDUALS UTILIZING JSH HEALTH SERVICES RESIDE. BECAUSE JSH'S SERVICE AREA ENCOMPASSES RESIDENTS LIVING IN TWO COUNTIES IN NORTH CENTRAL PENNSYLVANIA, THE CHNA INCLUDES QUANTITATIVE AND QUALITATIVE RESEARCH DATA FOR BOTH CLINTON COUNTY AND LYCOMING COUNTY. THE CHNA WAS COMPRISED OF BOTH QUANTITATIVE AND QUALITATIVE RESEARCH COMPONENTS. THIS MULTI-FACETED APPROACH TOOK INTO ACCOUNT VARIOUS DATA SOURCES AND PERSPECTIVES. QUANTITATIVE DATA INCLUDED A SECONDARY DATA PROFILE DEPICTING POPULATION AND HOUSEHOLD STATISTICS, EDUCATION AND ECONOMIC MEASURES, MORBIDITY AND MORTALITY RATES, INCIDENCE RATES, AND OTHER HEALTH STATISTICS FOR CLINTON AND LYCOMING COUNTIES. QUALITATIVE DATA INCLUDED TWO FOCUS GROUPS HELD ON AUGUST 15, 2012 AT JERSEY SHORE HOSPITAL WITH KEY COMMUNITY LEADERS. JSH CONTRACTED WITH HOLLERAN, AN INDEPENDENT RESEARCH AND CONSULTING FIRM, TO CONDUCT RESEARCH IN SUPPORT OF THE CHNA. THE FIRM PROVIDED THE FOLLOWING ASSISTANCE: 1) COLLECTED AND INTERPRETED SECONDARY DATA, 2) CONDUCTED FOCUS GROUPS WITH COMMUNITY STAKEHOLDERS, AND 3) FACILITATED A PRIORITIZATION AND IMPLEMENTATING PLANNING SESSION. COMMUNITY ENGAGEMENT AND FEEDBACK WAS AN INTEGRAL PART OF THE CHNA PROCESS. JSH SOUGHT COMMUNITY INPUT THROUGH FOCUS GROUPS WITH COMMUNITY STAKEHOLDERS AND THROUGH INCLUSION OF COMMUNITY PARTNERS IN THE PRIORITIZATION AND IMPLEMENTATION PLANNING PROCESS. PUBLIC HEALTH AND HEALTHCARE PROFESSIONALS SHARED KNOWLEDGE AND EXPERTISE ABOUT HEALTH ISSUES, WHILE LEADERS AND REPRESENTATIVES OF NON-PROFIT AND COMMUNITY-BASED ORGANIZATIONS PROVIDED INSIGHT ON THE COMMUNITY SERVED BY JSH INCLUDING MEDICALLY UNDERSERVED, LOW INCOME, AND MINORITY POPULATIONS. JSH AND ITS PARTNERS USED THE RESULTS OF THE FOCUS GROUPS IN CONJUNCTION WITH SECONDARY STATISTICAL DATA TO PRIORITIZE PUBLIC HEALTH ISSUES AND DEVELOP A COMMUNITY HEALTH IMPLEMENTATION PLAN FOCUSED ON MEETING COMMUNITY NEEDS. Schedule H, Part VI, Line 3 PATIENTS ARE COUNSELED ON AN INDIVIDUAL BASIS IN PERSON OR PHONE CONVERSATION AS TO THE AVAILABILITY OF STATE OR CORPORATE PROGRAMS. AT THE TIME OF REGISTRATION, SELF-PAY PATIENTS ARE INFORMED OF ASSISTANCE AVAILABLE. PATIENT STATEMENTS INDICATE ASSISTANCE THAT IS AVAILABLE. THERE IS ALSO SIGNAGE INDICATING THAT ASSISTANCE PROGRAMS ARE AVAILABLE AND PATIENTS ARE PROVIDED A PAMPHLET AT REGISTRATION WITH THIS INFORMATION. PATIENTS ARE INFORMED OF WHAT CHARITY CARE IS AND THAT IT EXISTS. IF THE PATIENT IS INTEREST THE PROCESS IS EXPLAINED. Schedule H, Part VI, Line 4 JERSEY SHORE HOSPITAL'S PRIMARY SERVICE AREA (PSA) COVERS EASTERN CLINTON COUNTY AND WESTERN LYCOMING COUNTY-AN AREA WITH A POPULATION OF APPROXIMATELY 42,000. THE PSA FOR JERSEY SHORE HOSPITAL CONSISTS OF FIVE ZIP CODES: 17721-AVIS, 17740-JERSEY SHORE, 17745-LOCK HAVEN, 17779-WOOLRICH, AND 17751-MILL HALL. JERSEY SHORE HOSPITAL IS CONSIDERED TO BE IN A MEDICALLY UNDERSERVED AREA (MUA). JERSEY SHORE AND JERSEY SHORE HOSPITAL IS LOCATED IN LYCOMING COUNTY, WHICH HAS AN AREA OF 1,244 SQUARE MILES. IT IS THE LARGEST COUNTY IN PENNSYLVANIA AND OCCUPIES A HILLY AND HEAVILY FORESTED PART OF THE STATE. THE WEST BRANCH OF THE SUSQUEHANNA RIVER FLOWS THROUGH THE SOUTHERN PART OF THE COUNTY. JERSEY SHORE IS APPROXIMATELY 45 MILES NORTHEAST OF STATE COLLEGE, PENNSYLVANIA AND APPROXIMATELY 15 MILES WEST OF WILLIAMSPORT, PENNSYLVANIA. ABOUT SIXTEEN PERCENT (16%) OF INPATIENT STAYS IN THE PSA OCCUR AT JERSEY SHORE HOSPITAL. ABOUT FORTY PERCENT (40%) OF OUTPATIENT VISITS IN THE PSA OCCUR AT JERSEY SHORE HOSPITAL. JERSEY SHORE HOSPITAL RELIES UPON A RELATIVELY SMALL GEOGRAPHIC AREA TO SUPPORT THE HOSPITAL. THE SSA (SECONDARY SERVICE AREA) CONSISTS OF 9 ADDITIONAL ZIP CODES WHICH ARE IMPORTANT TO THE HOSPITAL. THESE ZIP CODES ARE PRIMARILY TO THE WEST AND NORTH OF THE PSA. ABOUT TWO PERCENT (2%) OF INPATIENT STAYS IN THE SSA OCCUR AT THE JERSEY SHORE HOSPITAL. ABOUT ELEVEN (11%) PERCENT OF OUTPATIENT VISITS IN THE SSA OCCUR AT JERSEY SHORE HOSPITAL. WITHIN THE PSA, THE TOTAL POPULATION IS EXPECTED TO INCREASE BY 1% BY 2019. A MAJOR DEMOGRAPHIC ISSUE AFFECTING JERSEY SHORE HOSPITAL IS THE AGING POPULATION. THE NUMBER OF INDIVIDUALS LIVING IN THE PSA OVER THE AGE OF 65 IS EXPECTED TO INCREASE 13.7% BY 2019. THIS AGE GROUP CURRENTLY MAKES UP OVER 16% OF THE POPULATION IN THE PSA COMPARED TO ABOUT 14% FOR THE U.S. THIS GROWING ELDERLY SEGMENT SHOULD GENERATE A FUTURE DEMAND FOR HEALTH CARE SERVICES, SINCE INDIVIDUALS OVER AGE 65 USE HEALTHCARE AND HOSPITAL SERVICES AT 2.7 TIMES THE RATE OF THE UNDER AGE 65 POPULATION. A DEMOGRAPHIC REALITY IS THE LOW INCOME LEVEL OF AREA HOUSEHOLDS. CURRENTLY, THE MEDIAN HOUSEHOLD INCOME IN THE PSA IS $47,303 COMPARED TO PA ($53,115) AND THE U.S. ($53,482). THE MEDIAN HOUSEHOLD INCOME IN THE SSA IS $41,085. THE SERVICE AREA IS NOT RACIALLY DIVERSIFIED TO A SIGNIFICANT DEGREE, WITH 98.6% OF THE POPULATION CONSIDERED WHITE. THE EDUCATIONAL PROFILE OF THE SERVICE AREA DEMONSTRATES THAT 40.8% OF THE POPULATION HAS A HIGH SCHOOL EDUCATION AND 9.4% OF THE POPULATION HAS AN ASSOCIATE DEGREE. THE PERCENTAGE ACHIEVING A BACHELOR OR PROFESSIONAL DEGREE IS 11.6% WHICH IS LESS THAN PENNSYLVANIA OR THE U.S. AS A WHOLE. A HIGHER PERCENTAGE OF THE LABOR FORCE IN THE AREA IS ENGAGED IN MANUFACTURING/CONSTRUCTION WHEN COMPARED TO THE STATE AND U.S. AS A WHOLE. IN TERMS OF PATIENTS SERVED, COMBINED INPATIENT AND OUTPATIENT PAYER MIX IN 2014 REMAINED FAIRLY CONSISTENT. MEDICARE AND MEDICARE ADVANTAGE MAKE UP ABOUT 44% OF OUR PAYERS IN TERMS OF GROSS CHARGES. MEDICAL ASSISTANCE BUSINESS CONTINUED TO HAVE A SIGNIFICANT IMPACT ON JERSEY SHORE HOSPITAL AS A CRITICAL ACCESS HOSPITAL. MEDICAL ASSISTANCE CHARGES ACCOUNT FOR ABOUT 11% OF OUR PAYERS. SELF-PAY CHARGES ACCOUNTED FOR ABOUT 4% OF OUR PAYERS. Schedule H, Part VI, Line 5 ALL OF THE PERSONS SERVING ON OUR BOARD LIVE IN THE PRIMARY COMMUNITIES BEING SERVED BY THE HOSPITAL. THE BOARD CONSISTS OF SOME PHYSICIANS WHO ARE EMPLOYEES OF A RELATED ENTITY. A FEW CONTRACTORS, AND SEVERAL OTHER COMMUNITY MEMBERS. THE HOSPITAL EXTENDS STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE AREA. AS APPLICABLE, THE HOSPITAL APPLIES SURPLUS FUNDS TO IMPROVEMENTS IN PATIENT CARE THROUGH NEW AND UPDATED EQUIPMENT PURCHASES, MAJOR FACILITY IMPROVEMENTS, AND COMMUNITY HEALTH PROGRAMS. THE HOSPITAL PARTICIPATES IN MEDICARE, MEDICAID, CHAMPUS, AND TRICARE. Schedule H, Part VI, Line 6 THE HOSPITAL IS PART OF JERSEY SHORE HOSPITAL FOUNDATION INC. THIS AFFILIATION INCLUDES A NON-PROFIT PHYSICIAN PRACTICE WITH FAMILY PRACTICE PHYSICIANS AND SURGEONS, AS WELL AS AN URGENT CARE CENTER. Schedule H, Part VI, Line 7 PA X X X 0 0 0 0 0 0 0 0 0 THOMAS C CONNOLLY MD MEDICAL STAFF PRESIDENT 0 456225 0 0 0 0 0 12100 0 24950 0 493275 0 0 SHAIRKO MISSOURI ANESTHESOLOGIST 432446 0 0 0 0 0 12867 0 6319 0 451632 0 0 0 MICHAEL GERST PHYSICIAN 332527 0 0 0 0 0 0 0 18444 0 350971 0 0 0 TAMAR BAITEL PHYSICIAN 285567 0 0 0 0 0 5200 0 9035 0 299802 0 0 0 AARON JAY KOLB PHYSICIAN 202274 0 0 0 0 0 6916 0 11508 0 220698 0 0 0 THEORDORE FEDEROFF PHYSICIAN 176016 0 0 0 0 0 0 0 10954 0 186970 0 0 0 JAMES ELY BOARD MEMBER AND BORTHER TO EMPLOYEE 40892 JAMES ELY IS A BOARD MEMBER AND IS ALSO THE BROTHER TO EMPLOYEE MARY HOLLICK. 0 Form 990, Part VI, Section A, Line 3 THE HOSPITAL UTILIZES THE MANAGEMENT SERVICES OF QUORUM HEALTH RESOURCES. Form 990, Part VI, Section B, Line 11b THE FORM 990 WAS REVIEWED IN DETAIL BY MANAGEMENT BEFORE FILING WITH THE IRS. A COPY OF THE 990 WAS PROVIDED TO ALL BOARD MEMBERS PRIOR TO ISSUANCE. Form 990, Part VI, Section B, Line 12c ALL BOARD MEMBERS AND EMPLOYEES ARE REQUIRED TO ANNUALLY COMPLETE A CONFLICT OF INTEREST STATEMENT. THE CEOS OFFICE MONITORS THE PROCESS AND COMPLETION OF THE STATEMENTS. THE COMPLETED STATEMENTS ARE REVIEWED BY MANAGEMENT. BOARD MEMBERS ARE REQUIRED TO RECUSE THEMSELVES FROM VOTING ON MATTERS THAT ARE RELATED TO ANY POTENTIAL CONFLICTS. THERE HAS NEVER BEEN AN ISSUE INVOLVING CONFLICTS OF INTEREST. Form 990, Part VI, Section B, Line 15 ON AN ANNUAL BASIS, THE PERSONNEL SALARY COMMITTEE AND QUORUM (MANAGEMENT COMPANY) REVIEWS AN EXECUTIVE COMPENSATION STUDY PERFORMED BY YAFFE, AN INDEPENDENT THIRD PARTY WHO IS EMPLOYED BY HOSPITAL ASSOCIATION OF PENNSYLVANIA TO CONDUCT A COMPENSATION STUDY. HUMAN RESOURCES ALSO PROVIDES A COMPENSATION STUDY FROM ACRS WHICH IS BASED ON THE APPALACHIAN REGION. THESE TWO STUDIES ARE USED TO DETERMINE FMV. THE RECOMMENDATIONS FOR COMPENSATION LEVELS ARE PASSED ON TO THE BOARD FOR THEIR APPROVAL. APPROVAL IS DOCUMENTED IN THE MINUTES. THE ACTUAL AMOUNT OF COMPENSATION IS NOT INCLUDED IN THE MINUTES FOR PRIVACY PURPOSES. Form 990, Part VI, Section C, Line 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. Form 990, Part VII, Section A, Line 1a THE PRESIDENT/CEO IS AN EMPLOYEE OF QUORUM (MANAGEMENT COMPANY). THE HOSPITAL PAYS QUORUM FOR THE PRESIDENT/CEO'S SALARY. FOR FISCAL YEAR 2015 HIS COMPENSATION WAS $222,500. Form 990, Part IX, Line 11g LAUNDRY- PROGRAM SERVICE EXPENSES: 72,237 MANAGEMENT AND GENERAL EXPENSES: 0 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 72,237 OTHER- PROGRAM SERVICE EXPENSES: 17,276 MANAGEMENT AND GENERAL EXPENSES: 543,189 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 560,465 CONTRACTED SERVICES- PROGRAM SERVICE EXPENSES: 287,781 MANAGEMENT AND GENERAL EXPENSES: 292,201 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 579,982 MEDICAL- PROGRAM SERVICE EXPENSES: 171,838 MANAGEMENT AND GENERAL EXPENSES: 0 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 171,838 MEDICAL LABS- PROGRAM SERVICE EXPENSES: 208,662 MANAGEMENT AND GENERAL EXPENSES: 0 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 208,662 TRANSPORTATION- PROGRAM SERVICE EXPENSES: 3,124 MANAGEMENT AND GENERAL EXPENSES: 0 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 3,124 MICROFILM- PROGRAM SERVICE EXPENSES: -12,914 MANAGEMENT AND GENERAL EXPENSES: 0 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: -12,914 COLLECTIONS- PROGRAM SERVICE EXPENSES: 51,079 MANAGEMENT AND GENERAL EXPENSES: 0 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 51,079 CONSULTING- PROGRAM SERVICE EXPENSES: 98,200 MANAGEMENT AND GENERAL EXPENSES: 35,655 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 133,855 BIOHAZARDOUS MATERIALS- PROGRAM SERVICE EXPENSES: 31,025 MANAGEMENT AND GENERAL EXPENSES: 0 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 31,025 MAINTENANCE AND REPAIRS- PROGRAM SERVICE EXPENSES: 480,618 MANAGEMENT AND GENERAL EXPENSES: 212,927 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 693,545 PROFESSIONAL FEES- PROGRAM SERVICE EXPENSES: 1,807,421 MANAGEMENT AND GENERAL EXPENSES: 0 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 1,807,421 TOTAL OTHER FEES: 4,300,319 Form 990, Part XI, Line 9 TRANSFER TO RELATED ORGANIZATION JERSEY SHORE HOSPITAL FOUNDATION INC 1020 THOMPSON ST JERSEY SHORE PA 17740 240792115 HEALTHCARE PA 501(C)(3) 3 JERSEY SHORE HOSPITAL 1 1 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 JERSEY SHORE HOSPITAL FOUNDATION INC a-iv 24000 reimbursement of actual costs JERSEY SHORE HOSPITAL FOUNDATION INC q 637271 cash JERSEY SHORE HOSPITAL FOUNDATION INC e 2564814 Cash