2016-05-20T10:27:48-05:00 2015-06-30 440160260 BKD LLP 910 E St Louis Street Suite 200 Springfield MO 65806 990 2014-07-01 232176963 Soldiers and Sailors Memorial Hospital SOLD 5707230605 32-36 Central Avenue Wellsboro PA 16901 Eric D Pohjala Chief Financial Officer 5703213175 2016-05-20 1 P00422601 4178658701 2014 2016-08-17 19:52:53Z Steven P Johnson 700 High Street Williamsport PA 16901 64682172 0 X susquehannahealth.org X 1919 PA Soldiers & Sailors Memorial Hospital is a subsidiary of Susquehanna Health System (SHS). The mission of SHS and affiliates is as follows: To extend God's healing love by improving the health of those we serve. Our vision is to create a world-class health system. Our values are putting patients first, sharing ownership and being servant leaders. 16 12 496 88 0 0 844097 481561 61098714 62924956 94783 782980 403324 410678 62440918 64600175 2000 1100 0 0 30041210 28831700 0 0 0 27761582 29552837 57804792 58385637 4636126 6214538 61203069 91358783 29288557 51680634 31914512 39678149 X Soldiers & Sailors Memorial Hospital is a subsidiary of Susquehanna Health System (SHS). The mission of SHS and affiliates is as follows: To extend God's healing love by improving the health of those we serve. Our Vision is to create a world-class health system. Our values are putting patients first, sharing ownership and being servant leaders. 0 0 51265919 1100 62924956 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 $1,435,595 in 2015. The following is a summary of the services provided to patients in 2015;Inpatient admissions 1,883Outpatient visits 106,643Newborn deliveries 306Emergency department visits 17,594Surgeries performed 3,335Laboratory tests 257,691CAT Scans 5,590Ultrasound tests 7,297Radiology tests 28,020MRI tests 1,781Nuclear Medicine tests 975PT treatments 54,478Speech Therapy treatments 3,342Occ Therapy treatments 15,427Oncology Procedures 1,604During 2015 Medicare and Medical Assistance charges accounted for 66% of the hospital's total charges. 51265919 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 1 1 1 0 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0 1 0 1 X 0 0 1 496 1 0 0 0 0 0 0 0 0 0 0 X 16 12 1 0 0 0 0 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 James D Baker Jr Director 1.00 1.00 X 0 0 0 RRobert DeCamp Secretary 1.00 4.00 X X 0 0 0 Lisa V Feil Psy D Director 1.00 1.00 X 0 0 0 Robert PFitzgerald Director 1.00 1.00 X 0 0 0 Harold F Hoose III Director 1.00 1.00 X 0 0 0 Michael W Lichty Director 1.00 1.00 X 0 0 0 Craig G Litchfield Treasurer 1.00 2.00 X X 0 0 0 JDennis Murray PhD Director 1.00 4.00 X 0 0 0 Thomas M Owlett Esq Chairman 1.00 2.00 X X 0 0 0 Glenn BPoirier Vice Chairman 1.00 4.00 X X 0 0 0 Wendy SSwartz CPA Director 1.00 1.00 X 0 0 0 Aneurin J Williams Jr Director 1.00 1.00 X 0 0 0 Donna R Wilson Director 1.00 1.00 X 0 0 0 Kathy J Wright PhD Director 1.00 1.00 X 0 0 0 Jill ABurns MD Director 1.00 41.00 X 0 264986 34311 Walter J Laibinis DO Director 1.00 44.00 X 0 208775 26866 Janie M Hilfiger SSMH/TGH/THCP President 40.00 1.00 X 174511 0 23764 Ronald J Butler LHS President(Retired 4/2015) 1.00 40.00 X 0 344778 22032 Steven P Johnson SHS President 0.00 44.00 X 0 906099 31524 Charles Santangelo CFO(Retired 4/2015) 0.00 40.00 X 0 356800 31856 William C McCauley MD Executive VP(Retired 1/2015) 0.00 40.00 X 0 410053 34276 David Lopatofsky MD Executive VP (Hired 2/2015) 0.00 40.00 X 0 336647 35227 Jan E Fisher Executive Vice President 0.00 40.00 X 0 413779 29747 Enrico Doganiero Physician 40.00 0.00 X 486798 0 32788 Leonard Dale Physician 40.00 0.00 X 179511 0 12063 Craig Devenport Pharmacist 40.00 0.00 X 135234 0 14004 Craig Konzen Pharmacist 40.00 0.00 X 129451 0 27071 Craig Osborn Director of Radiology 40.00 0.00 X 115622 0 19108 1221127 3241917 374637 6 0 1 0 Laboratory Corp of America PO Box 12140 Burlington NC 27216 Lab testing 193538 Nightrays PA PO Box 204367 Dallas TX 75320 Interpretation services 133247 2 51869 429692 481561 Patient service revenu 621990 59878265 59878265 Electronic Health Ince 900099 1410804 1410804 Employee Pharmacy reve 900099 721683 721683 Paramedic revenue 446110 479253 479253 Cafeteria revenue 722210 262634 262634 172317 172317 62924956 297295 297295 387997 0 387997 387997 387997 528143 360 42818 0 485325 360 485685 485685 61860 39179 22681 22681 64600175 62924956 0 1193658 1100 1100 198275 198275 43646 43646 21282162 19613489 1668673 1204292 1099880 104412 4569462 4173290 396172 1533863 1400877 132986 3422504 3422504 1284 1284 1416 1416 7234 7234 3268586 2370720 897866 9375 7781 1594 1962083 1798302 163781 50201 50201 1064227 1064227 153654 150454 3200 54192 52097 2095 691994 691994 2641472 2641472 706222 706222 Medical Supplies and Dr 6889608 6888337 1271 Bad Debt Expenses 4398643 4398643 Repairs and Maintenance 1491648 1491558 90 Physician Services 1094919 1094919 1643575 1576911 66664 58385637 51265919 7119718 0 4521509 7853946 478344 810971 5356183 5684694 0 14854589 1023462 1124621 1382762 658042 645453 83735002 47792498 33862136 35942504 113811 71064 233834 37943927 61203069 91358783 10796259 12222964 18417258 17150839 75040 453616 0 21853215 29288557 51680634 X 31155828 38703448 758684 974701 31914512 39678149 61203069 91358783 X 6214538 -18904 1568003 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 977 977 0 Part II-B, Line 1: Lobbying fees associated with dues payments. 810767 810767 41578345 17395649 24182696 108914 98755 10159 36126523 28862496 7264027 5110453 1435598 3674855 35942504 Due from Affiliates 35522752 Deferred Financing costs 205395 Assets designated for capital acquisition 2215780 37943927 Due To Other Affiliates 21853215 21853215 X 59881755 -18906 17146 -1760 59883515 4716660 4716660 64600175 54004138 17146 17146 53986992 4398645 4398645 58385637 Part X, Line 2: Management has evaluated their income tax positions under the guidance included in ASC 740. Based on that review, management has not identified any material uncertain tax positions to be recorded or disclosed in the financial statements. Part XI, Line 2d - Other Adjustments: Reclass of gaming expenses 17146. Part XI, Line 4b - Other Adjustments: Bad Debt Expense added back to net revenue 4398643. TRNA Donations 318017. Part XII, Line 2d - Other Adjustments: Reclass of gaming expenses 17146. Part XII, Line 4b - Other Adjustments: Bad Debt Expense added to expenses 4398643. Rounding issue 2. 61860 39179 0 61860 39179 39179 22681 PA 1 0 1 0 0.99000 0.01000 Gretchen Regina 15 Meade Street Wellsboro PA 16901 0 Melissa Coolidge Special Events Coordinator SHS 55993 Chairperson of a 15 member committee that coordinates raffle activities. X 0 1 1 1 X 1 X 1 1 1 0 1 1 425824 0 425824 0.00790 7913896 5317507 2596389 0.04810 8339720 5317507 3022213 0.05600 8339720 5317507 3022213 0.05600 74342 0 74342 0.00140 74342 74342 0.00140 1 4398643 439864 13596390 16118322 -2521932 X 1 1 1 1 Soldiers & Sailors Memorial Hospital 32-36 Central Avenue Wellsboro PA 16901 susquehannahealth.org 390043 X X X Soldiers & Sailors Memorial Hospital 1 0 0 1 X X X X X X X X X 12 1 1 0 1 X www.susquehannahealth.org X 1 12 1 www.susquehannahealth.org 0 0 1 X 200.000000000000 300.000000000000 X X X X X 1 1 X X X 1 X www.susquehannahealth.org X www.susquehannahealth.org X X X X 1 X 0 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 25 Key Informant Interviews, as well as developing and disseminating a Community Health Input Questionnaire. A web-based tool was utilized to conduct the community input process; 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.susquehannahealth.org. 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 the Susquehanna Health System (the System) based in Williamsport, PA. 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 the System, Soldiers and Sailors Memorial Hospital located in Wellsboro, PA and their defined community is Tioga County, PA. The 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.susquehannahealth.org. Soldiers & Sailors Memorial Hospital Part V, Section B, Line 11: A number of health needs were identified in the CHNA that will not be addressed in this first 3 year assessment cycle. In some cases the hospital does not have the resources and specialty staff that would be required to adequately address all the identified needs. In others, there may already be other agencies and healthcare providers working to effect change in these areas by providing related community resources and services. For a more detailed discussion regarding identified health needs you may view the CHNA and related Implementation Plan at www.susquehannahealth.org. Throughout the first full year subsequent to its initial CHNA, SSMH, along with MVH, DPH and TWH, have worked collaboratively to address identified health needs in Lycoming and Tioga counties.Highlights of year 1 accomplishments include, 1) the October 1, 2014 opening of a new cancer center on the SSMH campus to increase access to cancer services in Tioga county. 2) Conducted a transportation study, including 5 focus groups, to help identify and remedy transportation barriers for cancer patients in Lycoming and Tioga counties. 3) Conducted a physicain needs study to access and document community need for various physician specialties in Lycoming and Tioga counties. 4) Based upon the physician needs study, revised the physician recruitment plan as to number and mix of physicians and advanced practice professionals needed. 5) Implemented a primary care extended hours clinic in Lycoming county to provide additional patient access for evening and weekend hours. 6) Increased the number of Mental Health providers in Lycoming county by adding additional per diem psychiatrists and an additional certified registered nurse practioner to increase patient access to services. 7) Implemented telepsychiaty consult services with local nursing homes to increase access to Mental Health services to nursing home patients. 8) Completed plans for Mental Health facility upgrades and renovations. 9) Implemented new group therapy programs to expand access to Mental Health services. 10) Developed a primary care physician (PCP) outreach program to educate PCP's in how to better identify Mental Health needs amoung their patients and better understand the community resources that are available. In addition to continued work on the initiatives highlighted as year 1 accomplishments, year 2 highlights include a new, expanded program to provide smoking-cessation counseling and low-dose computed tomography lung cancer screeeings. The new program follows guidelines established by the National Lung Screening Trial, and the Centers for Medicaid and Medicare services and provides lung screening navigators in Lycoming and Tioga counties with resources to help patients and providers determine eligibility, offer complete shared decision making conversations around the benefits and harms of low-dose computed tomography, provide counseling on smoking cessation and follow up on future screenings. Soldiers & Sailors Memorial Hospital Part V, Section B, Line 13b: Uninsured patients receive a 45% discount from charges paid within 30 days from the first statement. They may also be eligible for discounts of 60% to 100% of charges follwing 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. Soldiers & Sailors Memorial Hospital Part V, Section B, Line 16i: Other Method Brochure Part V, Section B, Line 16 Financial Assistance Policy Website Availability Soldiers & Sailors Memorial Hospital Part V, Section B, line 16a website: www.susquehannahealth.org Soldiers & Sailors Memorial Hospital Part V, Section B, line 16b website: www.susquehannahealth.org Part I, Line 7, Column (f): The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 4398643. Part II, Community Building Activities: The organization 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 2015, SSMH had 88 volunteers donate approximately 10318 hours of their time. Part III, Line 2: The bad debt expense reported on Line 2 is bad debt per the audited financial statements. Part III, Line 3: The estimated amount of Bad Debts attributable to the organization's financial assistance policy is 10% of the total expense. Part III, Line 4: The System reports patient accounts receivable for services rendered at net realizable amounts from third-party, 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, the facility had approximately $14 million in Medicare charges provided at a cost of approximately $16 million. This resulted in a $2 million shortfall for the fiscal year. Part III, Line 9b: Susquehanna Health System will provide financial assistance under the Charity Care 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 SHS Charity Care 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 Susquehanna Health System (Hospitals and Susquehanna Physician Services) or by employees of SHS 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. All self pay balances identified in the Charity Care application must be paid in full to maintain eligibility.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 SHS Charity Care eligibility. Income guidelines are updated annually during the month of April. 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 SHS Charity Care Assistance Program by applying. Part VI, Line 2: Throughout the first full year subsequent to its initial CHNA, Soldiers & Sailors Memorial Hospital (SSMH), along with Lycoming County affiliates; Williamsport Hospital, Divine Providence Hospital, and Muncy Valley Hospital, have worked collaboratively to address identified health needs in Lycoming and Tioga counties. Highlights include; 1) the opening on October 1, 2014 the new Cancer Center on the campus of SSMH to increase access to cancer services in Tioga County, 2) conducted a Transportation Study, including 5 separate Focus Groups, to help identify and remedy transportation barriers for cancer patients, 3) conducted a Physician needs study to access and document community needs for various physician specialties, 4)Based upon the Physician needs study mentioned above, revised the Physician Recruitment Plan as to number and mix of both Physicians and Advanced Practice Professionals, 5) implemented a Primary Care extended hours clinic in Lycoming County to provide additional patient access for evening and weekend hours, 6) increased the number of Mental Health providers to increase patient access to services, by adding additional per diem Psychiatrists and an additional Certified Registered Nurse Practitioner, 7) implemented Telepsychiatry consult services with local nursing homes to increase access to Mental Health evaluations and services. 8) completed plans for Mental Health facility upgrades and renovations, 9) implemented new group therapy programs to expand Mental Health services, 10) developed a Primary Care Physician (PCP) Outreach Program to educate PCP's in how to better identify Mental Health needs among their patients and better understand the Community resources that are available to them. Part VI, Line 3: The organization's Patient Financial Assistance policy is posted at every registration office including the patient account representatives offices and the Emergency Department. The policy is also advertised annually in the newspaper, 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 facility has an open medical policy. The Board of Directors is composed of various community leaders who provide insight on the needs of the community and how best to guide the organization to best serve those needs. Surplus funds are reinvested into the facility to allow the system to better serve the community. Part VI, Line 6: Soldiers and Sailors Memorial Hospital (SSMH) is one of four hospitals which are part of Susquehanna Health System (SHS). The mission of SHS 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 speciality 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 SHS. On an annual basis, SHS devotes a portion of its revenue and assets to community program services. The following reflects the breakout of $95,031,419 in quantifiable community benefits reported for FY2015: Charity Care (at cost) $2,068,338; Bad Debts (at cost) $10,803,145; Government sponsored health care (unpaid cost of Medicare, Medicaid, indigent care programs, SCHIP and other safety net programs)$65,763,932. In addition, various other programs such as Research, Health Professions Education, Community Building, Financial and In-Kind contributions, and Community Benefit Operations totaling $6,396,004. Part VI, Line 7, Reports Filed With States PA 0 0 0 0 0 0 0 0 0 Jill ABurns MD Director 0 203544 0 33050 0 28392 0 9800 0 24511 0 299297 0 0 Walter J Laibinis DO Director 0 172016 0 0 0 36759 0 8153 0 18713 0 235641 0 0 Janie M Hilfiger SSMH/TGH/THCP President 157424 0 15893 0 1194 0 7036 0 16728 0 198275 0 0 0 Ronald J Butler LHS President(Retired 4/2015) 0 329125 0 10897 0 4756 0 9800 0 12232 0 366810 0 0 Steven P Johnson SHS President 0 531335 0 345329 0 29435 0 13700 0 17824 0 937623 0 0 Charles Santangelo CFO(Retired 4/2015) 0 341221 0 10767 0 4812 0 9800 0 22056 0 388656 0 0 William C McCauley MD Executive VP(Retired 1/2015) 0 390991 0 15748 0 3314 0 9800 0 24476 0 444329 0 0 David Lopatofsky MD Executive VP (Hired 2/2015) 0 312802 0 15628 0 8217 0 11100 0 24127 0 371874 0 0 Jan E Fisher Executive Vice President 0 395220 0 10795 0 7764 0 9800 0 19947 0 443526 0 0 Enrico Doganiero Physician 485877 0 0 0 921 0 9800 0 22988 0 519586 0 0 0 Leonard Dale Physician 179511 0 0 0 0 0 7385 0 4678 0 191574 0 0 0 Craig Konzen Pharmacist 129086 0 0 0 365 0 5873 0 21198 0 156522 0 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 of the board. Form 990 Part 1 Line 6 Explanation: 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 the FY2015, the minimum threshold was met that would trigger any VCIP payments. 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. Richard Fisher Son of Executive Vice President 43646 Compensation 0 Owlett & Lewis PC Owned by a Board Member 496647 Legal Fees 0 Form 990 Part V Line 2A and 2B Explanation: Susquehanna Health System 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 Cooperative 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 3956 for Susquehanna Health System EIN # 23-2751183. Of that total 496 employees payroll expenses were recorded by Soldiers & Sailors Memorial Hospital. Form 990, Part VI, Section A, line 2 Key employees Steve Johnson and Charlie Santangelo serve on the board of a related taxable organization. Form 990, Part VI, Section A, line 7a Susquehanna Health System (SHS), 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, Susquehanna Health System (SHS), 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 appoint or elect the directors B.) to appoint and remove the President following consultation with the Entity, C.) to approve the nominees elected officers and to return the list of approved nominees to the governing bodies for election, D.) to remove, with or without cause, any director or any elected officer, E.) to amend the Governing Instruments and to approve all amendments to the Governing Instruments which are proposed for adoption, F.) to approve the annual operating and capital budgets, G.) to establish requirements for a unified budget, H.) to approve the incurrence or issuance of debt proposed by Entity and the encumbrance of any Entity assets to secure such incurred debt, I.) to incur debt (or cause debt to be incurred) on behalf of the Entity, J.) to require contributions in cash or cash equivalents to support the working capital needs or capital projects of any one or more System entities, K.) to require that any debt incurred on a System-wide basis by or at the direction of SHS shall be the joint and several obligation of each Entity, L.) to direct or approve any cash contributions or any other capital contributions made by one System Entity to another System Entity. M.) to allocate any financial resources in such manner as SHS determines to be necessary, N.) to approve the sale, transfer or other disposition of Entity or Entity property unless it is made in the ordinary course of business or involves assets with a fair market value of less than one hundred thousand dollars, O.) to direct the transfer of property from the Entity to one within or not within the limits of the System's approved investment policy, P.) to approve any investment of assets by Entity not within the limits of the System's approved investment policy, Q.) to establish requirements for the approval of the acquisition, purchase, sale, transfer, encumbrance, leasing, construction or demolition of land or building outside the ordinary course of business, R.) to approve any decision with respect to the addition, modification or discontinuance of any patient care or diagnostic program or health care service, S.) to approve of any change in licensure of Entity; licensure of any Facility certification, registration, accreditation, permit or related approval of any activity, T.) to require Entity to add, modify, relocate or discontinue any patient care or diagnostic program or health care service. U.) to approve or direct any merger, consolidation, organization, reorganization, joint venture, corporate division, sale, conversion,lease or exchange of substantially all the assets, dissolution, liquidation or any other modification of corporate structure or affiliations affecting the autonomy, governance, or operations, and the creation or acquisition of any new affiliate by Entity, V.) to dissolve or terminate the existence of Entity and dissolve or terminate the existence of assets upon such termination or dissolution, W.) to coordinate managed care plans involving Entity, including decisions concerning entry into or renewal of any contract or agreement relating there to, X.) to develop and/or enter into key strategic relationships on behalf of Entity, Y.) to select any outside financial auditors, general legal counsel or investment advisors to provide services on behalf of the Entity. Form 990, Part VI, Section B, line 11 A high-level overview of Form 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 Annually on the 1st day of January, Susquehanna Health System sends to all directors, officers, management staff and contracted physicians a questionnaire to be completed and returned by January 15th. A report is submitted to the Board of Directors to notify them of any conflicts of interest disclosed. Form 990, Part VI, Section B, line 15 On a bi-annual basis an independent compensation consulting firm performs an analysis of the leadership salary structure in relationship to the labor market using data from four different salary surveys. Their analysis is reviewed with the Governance Committee of the Board of Directors. The firm then outlines its recommendations for the proposed executive salary structure to the committee for their consideration and approval. Form 990, Part VI, Section C, line 19 Governing documents and financial statements are available to the public upon request. The conflict of interest policy is also available upon request. Form 990, Part XI, line 9: Pension Liability Adjustment -1648414. Postretirement benefit liability adjustment 627351. Transfers from other affiliates 2589066. Part XII, Line 2C The organization did not change its oversight process or selection process. Laurel Health System 15 Meade Street Wellsboro PA 16901 240795488 Support entities affiliated with Laurel Health Systems PA 501(c)(3) Line 11a, I Susquehanna Health System 0 Laurel Realty 15 Meade Street Wellsboro PA 16901 231403678 Owns and manages real estate in support of Laurel Health System PA 501(c)(2) Susquehanna Health System 0 Laurel Management Services 15 Meade Street Wellsboro PA 16901 251644910 Management, consulting and supervisory services PA 501(c)(3) Line 11b, II Susquehanna Health System 0 The Green Home 37 Central Avenue Wellsboro PA 16901 240804365 Operates skilled nursing & assisted living facilities. PA 501(c)(3) Line 9 Susquehanna Health System 0 Tioga Health Care Providers 22 Walnut Street Wellsboro PA 16901 251765538 Employs physician specialists PA 501(c)(3) Line 11b, II Susquehanna Health System 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 Susquehanna Health System 0 Divine Providence Hospital 1100 Grampian Blvd Williamsport PA 17701 240799343 Hospital PA 501(c)(3) Line 3 Susquehanna Health System 0 Muncy Valley Hospital 215 East 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 Foundation 1100 Grampian Blvd Williamsport PA 17701 232743470 Fundraising for affiliated entities PA 501(c)(3) Line 11a, I Susquehanna Health System 0 Susquehanna Physician Services 1201 Grampian Blvd Williamsport PA 17701 232449454 Physician Services and MRI services PA 501(c)(3) Line 3 Susquehanna Health System 0 Williamsport Area Ambulance Services 700 High Street Williamsport PA 17701 232416166 Ambulance transport PA 501(c)(3) Line 9 N/A 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 Laurel Health Foundation 22 Walnut Street Wellsboro PA 16901 251810488 Manages Endowments and other investments PA 501(c)(3) Line 11a, I N/A 0 Susquehanna Health Innovation Center Inc 700 High Street Williamsport PA 17701 471600873 Supporting organization of affilaited 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 Excluded from tax 0 0 Tyoga Carenet 15 Meade Street Wellsboro PA 16901 251810967 Integrate Healthcare Regionally PA Laurel Health System C 0 Susquehanna Ventures Inc 1201 Grampian Blvd Williamsport PA 17701 232470263 Pharmacy and Infusion Services PA Susquehanna Health System C 0 Susquehanna Health System Insurance Network LTD PO Box 1159 Grand Caymans CJ 980458722 Captive Insurance Company CJ Susquehanna Health System 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 Laurel Realty D 56910 FMV Laurel Realty O 35915 At cost 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. Part III Name of Related Organization: Community Basket, LLC Direct Controlling Entity: Susquehanna Health System & Susquehanna Health Foundation.