2016-05-13T12:50:18-05:00 2015-06-30 BKD LLP 910 E St Louis Street Suite 200 Springfield MO 65806 990 2014-07-01 240799343 Divine Providence Hospital of the Sisters of Christian Charity DIVI 5703207900 1100 Grampian Boulevard Williamsport PA 17701 Eric D Pohjala Executive Vice President / CFO 5703213175 2016-05-13 1 Brian D Todd P00422601 4178658701 2014 2016-12-15 16:53:06Z Steven P Johnson 700 High Street Williamsport PA 17701 164908653 0 0928 X www.susquehannahealth.org X 1947 PA Divine Providence Hospital of the Sisters of Christian Charity (DPH) is a 31 bed specialty hospital that offers inpatient psychiatric services and a wide array of outpatient hospital services, primarily serving Lycoming and surrounding counties. Effective January 1, 2004, through a merger with Susquehanna Regional Home Health (EIN # 24-0795499), DPH began providing home health services. 12 8 430 195 0 0 1312423 938294 89297600 93633576 2156354 2965840 170066 220244 92936443 97757954 8047206 10640232 0 0 27405607 28279301 0 0 2295 52140786 57014773 87593599 95934306 5342844 1823648 118311037 125289168 25029251 30451476 93281786 94837692 X Divine Providence Hospital of the Sisters of Christian Charity (DPH) 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 an integrated community health system that delivers world class care. Our values are to carefully place out patients and their families first, share ownership with all of our caregivers and lead with a servant's heart. 0 0 82904957 10640232 93628752 For the fiscal year ended June 30, 2015, the hospital admitted 663 patients rendering 6,190 patient days and registered approximately 116,707 outpatients and provided 101,269 home health visits. DPH 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, DPH devotes a portion of its revenue and assets to community program services. The following reflects the breakout of $16,551,704 in quantifiable community benefits reported for FY 2015: Charity Care (at cost) $263,080; Bad Debts (at cost) $678,168; Government-sponsored health care (unpaid cost of Medicare, Medicaid, Indigent care programs, SCHIP and other safety net programs) $14,622,932. In addition, various Education, Community Health Services, Subsidized Health Services, Community Building, Financial and In-Kind Contributions and Community Benefit Operations totaling $987,524. 82904957 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 1 0 0 0 1 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 X 0 0 430 1 0 0 0 0 0 0 0 0 0 0 X 12 8 1 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 0 0 0 PA X Management 5703207900 1205 Grampian Boulevard Williamsport PA 17701 Christian Dewald Chair 1.00 2.00 X X 0 0 0 Keith Kuzio Vice Chair 1.00 3.00 X X 0 0 0 Kathleen Pagana Secretary 1.00 1.00 X X 0 2431 0 Patrick Marty Treasurer 1.00 1.00 X X 0 0 0 Kevin W Kist DO Director 1.00 43.00 X 0 418691 34026 Paul Moulton Director 1.00 2.00 X 0 0 0 Alexander R Nesbitt MD Director 1.00 42.00 X 0 202673 27681 Shailesh Patel MD Director (Elected June 2014) 1.00 2.00 X 0 0 0 Melissa E Welch Director 1.00 1.00 X 0 0 0 Patrick Wilson Director 1.00 1.00 X 0 0 0 Mary Wolf Director 1.00 1.00 X 0 0 0 Steven P Johnson President / CEO 1.00 46.00 X X 0 906099 31524 Charles J Santangelo Executive VP / CFO (Retired 5/2/15) 1.00 42.00 X 0 356800 31856 Eric D Pohjala Exective VP / CFO (Hired 3/30/15) 0.00 0.00 X 0 0 0 William C McCauley MD Executive VP / CMO (Retired 1/31/15) 1.00 40.00 X 0 410053 34276 David Lopatofsky MD Executive VP / CMO (Hired 1/31/15) 1.00 40.00 X 0 336647 35227 Jan E Fisher Executive VP / COO 1.00 40.00 X 0 413779 29747 Ronald J Butler Executive VP / CBO (Retired 4/15/15) 1.00 41.00 X 0 344778 22032 Robert E Kane President 40.00 1.00 X 210475 0 26120 Rajesh Manoharan Medical Physicist 40.00 0.00 X 197640 0 29023 Patricia A McGee Executive Director Home Care 40.00 0.00 X 127553 0 6617 Joseph B Lecrone Pharmacist 40.00 0.00 X 127552 0 25401 Michelle R Gaida Executive Director / Cancer Services 40.00 0.00 X 126172 0 15606 789392 3391951 349136 13 0 1 0 Susquehanna Health System 1001 Grampian Boulevard Williamsport PA 17701 Management services 9293143 Aramark Healthcare 24863 Network Place Chicago IL 60673 Management / environmental services 8326053 Susquehanna Lithotripsy 100 West 3rd Avenue Columbus OH 43201 Lithotripsy services 686800 Varian Medical Systems 70140 Network Place Chicago IL 60673 Oncology services 481348 Michele Tedesco 1626 Meade Street Williamsport PA 17701 Home Health Physical Therapist 186669 12 10205 324540 592705 10844 938294 Net patient service revenue 621990 90010730 90010730 Affiliate rent income 621990 2883984 2883984 Sports Medicine - athletic traine 621400 604779 604779 Cafeteria 624200 134083 134083 93633576 768243 768243 63793866 5524661 62039802 5081128 1754064 443533 2197597 2197597 55576 10205 29769 25807 25807 FQHC 621400 58031 58031 Auxiliary activity 900099 47734 47734 Miscellaneous 900099 35375 17931 17444 53297 53297 194437 97757954 93628752 0 3190908 10640232 10640232 22327121 20560371 1764937 1813 1150439 1059405 90941 93 3170740 2919839 250644 257 1631001 1501940 128929 132 9293143 9293143 8845 8845 185534 185534 8556357 8277501 278856 9488 8870 618 1585574 1267138 318436 208016 81702 126314 42705 41637 1068 3727554 3433989 293565 562560 538222 24338 38771 35110 3661 881752 881752 3952131 3952131 491962 491962 Medical supplies 20154224 20111563 42661 Inter-entity costs 2698916 2698916 Bad debt 2601750 2601750 Repairs and maintenance 1396086 1358749 37337 619405 442178 177227 95934306 82904957 13027054 2295 879746 8541542 9374486 10705084 1222260 1847406 2458923 2717515 108794133 79106667 34387445 29687466 46882657 50392314 23105520 21397841 118311037 125289168 5773271 6210415 6213 313761 17330855 17393805 1918912 6533495 25029251 30451476 X 91208624 92735576 1112892 1139846 960270 962270 93281786 94837692 118311037 125289168 X 1823648 -175811 -91931 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 8845 0 0 0 8845 0 Part II-B, Line 1: 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 06/30/15, the amount of dues to HAP totaled $18,555 of which 17.77% or $3,297, was used for lobbying purposes. Dues paid to AHA totaled $24,334 of which 22.80% or $5,548, 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. 163100 163100 56029493 41577863 14451630 275159 48012 227147 44897779 35182553 9715226 7428602 2298239 5130363 29687466 Investment in net assets of affiliates 664441 Due from affiliates 19980822 Other Receivables 317790 Other 434788 21397841 Accrued medical malpractice cost 155000 Estimated third party settlements / deferred reimbursement 1304576 Asbestos abatement 179525 Due to Affiliates, net 4894394 6533495 X 94685312 -175811 -2402117 -2577928 97263240 494714 494714 97757954 82719568 0 82719568 13214738 13214738 95934306 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 financials statements. Part XI, Line 2d - Other Adjustments: Auxiliary activity -13,510. Bad Debt expense -2,601,750. Net assets released from restrictions 213,143. Part XI, Line 4b - Other Adjustments: Contributions received 1,825. Transfer from affiliates - SHF 324,540. Investment return 84,603. Auxiliary activity 83,746. Part XII, Line 4b - Other Adjustments: Auxiliary activity 97,256. Bad Debt expense 2,601,750. Transfer to affiliate - SHMG 10,515,732. Central America 0 1 Program services Captive insurance company 259126 0 1 0 0 0 1 259126 0 259126 0 0 0 0 0 0 Fall Festival 27228 27228 10698 Lights of Love 10205 10205 332 11 28348 28348 18739 65781 10205 55576 29769 29769 25807 1 1 X 1 X 1 X 1 1 1 0 1 1 263080 0 263080 0.00280 8520035 4213638 4306397 0.04610 8783115 4213638 4569477 0.04890 269477 2365 267112 0.00290 8986 8986 0.00010 208132 28970 179162 0.00190 179792 179792 0.00190 666387 31335 635052 0.00680 9449502 4244973 5204529 0.05570 467 467 0.00000 11326 500 10826 0.00010 11793 500 11293 0.00010 1 2601750 130088 19916998 30124407 -10207409 X 1 1 1 1 Divine Providence Hospital 1100 Grampian Boulevard Williamsport PA 17701 www.susquehannahealth.org 041001 X X Wide array of outpatient hospital services Divine Providence 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 1 X 0 X X X X 1 X 0 0 Divine Providence 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 access to the internet or generationally 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. Divine Providence Hospital Part V, Section B, Line 6a: Divine Providence Hospital; located in Williamsport, PA is one of four hospitals that comprise the Susquehanna Health System (the System) 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 Valley Hospital, share the same definition of community served, which is Lycoming County, PA. The fourth hospital that is part of the System is Soldiers & Sailors located in Wellsboro, PA and their defined community is Tioga County, PA. The Systems approach to providing community benefit 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 as www.susquehannahealth.org. Divine Providence 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 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, MVH, along with TWH, DPH, and SSMH, 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 campus of SSMH 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 physician needs study to assess and document community need for various physician specialties in Lycoming and Tioga counties. 4) Based upon the physician needs study noted above, revised 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 practitioner to increase patient access to services. 7) Implemented telepsychiatry 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 among 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 included a new, expanded program to provide smoking-cessation counseling and low-dose computed tomography lung cancer screenings. 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. Divine Providence Hospital Part V, Section B, Line 16i: Other - Brochure Divine Providence Hospital Part V, Section B, Line 22d: 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 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 V, Section B, Line 16 Financial Assistance Policy Website Availability Divine Providence Hospital Part V, Section B, line 16a website: www.susquehannahealth.org Divine Providence Hospital Part V, Section B, line 16b website: www.susquehannahealth.org 2 The Meadows 2160 Warrensville Road Montoursville PA 17754 Assisted living facility The Wenner Building 1705 Warren Avenue Williamsport PA 17701 Outpatient diagnostics Part I, Line 6a: The community benefit report is prepared on a system wide basis under Susquehanna Health System. Part I, Line 7g: The Divine Providence Hospital has various subsidized services which are included within the Medicare and Medical Assistance unreimbursed costs. Part I, Line 7, Column (f) The Bad Debt expense included on Form 990, Part IX, Line 25(C), but subtracted for purposes of calculating the percentage in this column is $2,601,750 Part II, Community Building Activities: Community building activities at Divine Providence Hospital (DPH) center on workforce development through providing student observations and the development of volunteens. By supporting volunteens in a health care setting, some budding nurses, doctors and other allied health professionals are developed. DPH also supports/provides a physical site for the statewide radio system. This system is critical to the emergency preparedness system. Part III, Line 2: Bad debt consists of the actual bad debt written off, plus a reserve calculation based on a progressive percentage for self-pay and other non-contract accounts receivable aging categories. Part III, Line 3: An estimate of 5% is used based on looking at patients that were in a 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. 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 costing methodology is based on a modified cost accounting system. We cost our patient data for the previous fiscal year and then we apply relational factors to the costs based upon the change in charges from the prior fiscal year to the current 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: 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 guideline 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: Susquehanna Health System (SHS) which is comprised of The Williamsport Hospital (TWH), Divine Providence Hospital (DPH) and Muncy Valley Hospital (MVH), supports and collaborates with the Lycoming County Health Improvement Coalition (LCHIC). LCHIC conducts periodic conduct community health needs assessments in Lycoming county. In addition, Soldiers & Sailors Memorial Hospital (SSMH) located in Wellsboro, PA and is in Tioga County is also part of SHS.LCHIC is a healthy community's initiative in existence since 1994. It is a voluntary collaboration of 37 board members and over 100 Task Force Team volunteers representing various sectors of the community, including religious organizations, schools and higher education, minority groups, municipal and county government, public health, health care, civic and community organizations, the private sector, and social welfare organizations.The mission of LCHIC is to improve the health status of the Lycoming county community by identifying and facilitating response to priority health and wellness issues through a collaborative, community-driven process.In addition to these assessments SHS also looks at assessments from the United Way and The Commonwealth Medical College (TCMC). The LCHIC assessment is structured heavily around the Behavioral Risk Factor Surveillance System (BRFSS). In addition to this LCHIC also conducts the PA Youth Survey for all students in grades 6, 8, 10 and 12 in the county every other year. Each of the above mentioned surveys except the TCMC survey are county focused. TCMC is regional in nature but has future implications in the development of local community benefit activities. For example, it highlighted the need to do primary research in the Amish communities in Lycoming County and the need to further investigate the increasing incidence of STD in the county as well. To enhance the quantitative data of these surveys LCHIC also conducts focus groups for the following sub populations: women, low income families, employers and seniors. LCHIC has historically prioritized the needs, developed a strategic plan and distributed the results to the community.In order to faciliate support for LCHIC's strategic plan, SHS has created a community benefit group. This workgroup reports to the Mission and Ethics Committee of the SHS Board of Directors. On this workgroup are respresentatives from all three hospital campuses, the Department of Health, LCHIC, The United Way, The Williamsport-Lycoming Foundation, TCMC, and The Susquehanna Community Medical and Dental Clinic Inc. (an independent FQHC).The role of the workgroup is to develop systems and processes to improve and promote the integrity of community benefit. To develop and/or adopt best practices in community benefit operations.The workgroup will be comprised of at least one representative from each hospital and Susquehanna Physician Services (SPS), a representative from LCHIC, SHS director of Community Benefit, key community leaders and 1 or 2 members of the mission & effectiveness committee. Part VI, Line 3: Susquehanna Health System (SHS) 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. The SHS Charity Care Assistance program is an income based package designed to meet the healthcare financial needs of eligible individuals and households who receive medically necessary inpatient and outpatient services from TWH, DPH, MVH, SSMH or SPS.The first hospital claim sent to guarantors of uninsured accounts will include a statement to briefly explain the availability and contacts for referral to the Charity Care program. Subsequent guarantor billings also reference the availability of Charity Care.It is the responsibility for the patient or guarantor to initiate the SHS Charity Care Assistance Program by applying. It is the responsibility of the SHS Finance personnel to administrate the program according to this policy. Part VI, Line 4: The hospitals that comprise Susquehanna Health System's (SHS) Lycoming county operations are: The Williamsport Hospital (TWH), Divine Providence Hospital (DPH) and Muncy Valley Hospital (MVH. The county is in the north central region of the state, about three and half hours northeast of Pittsburgh and the same distance northwest of Philadelphia. Lycoming County is designated as rural and has small towns nestled within a stunning natural landscape. The City of Williamsport, with the majestic Susquehanna River running through it, is designated as urban, and is the home of Little League World Series. Unfortunately, the City of Williamsport and the surrounding rural area are also home for many individuals and families who cannot afford the primary health and dental care services provided in their county. In addition, Soldiers & Sailors Memorial Hospital (SSMH) located in Wellsboro, PA, Tioga County, is also part of SHS.For a more detailed discussion regarding the community served, as well as associate socio-economic characteristics, you may view CHNA and related implementation plan at www.susquehannahealh.org Part VI, Line 5: The hospitals of Susquehanna Health System (SHS) all have entity specific boards that are composed of persons who reside in Lycoming County. In addition to this SHS extends medical staff privileges to all qualified physicians in the county in all areas of primary and specialty care according to Susquehanna Health 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 on 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 fully 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 clinical 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 judgment 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 SHS as of 7/1/14 and who have met prior qualifications for membership shall be exempt from board certification requirements.3.2-7 Departmental Qualifications - Each department will reserve the right to further specify qualifications for membership (as noted in individual departmental Bylaws), which may be more restrictive than those specified here. Any initial applicant for Medical Staff membership must meet both the general criteria for Medical Staff membership as specified in these Bylaws and the criteria for membership established by the department to which he is applying.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.The volunteer program at SHS supports the services at our 4 campuses, MVH, DPH, TWH and SSMH, as well as our LifeCenter 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 Lycoming and surrounding counties to support our services. They provide over 75,000 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 an active member 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: Divine Providence Hospital (DPH) 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. 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.Divine Providence Hospital (DPH) 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.The Williamsport Hospital (TWH) is an acute care community hospital providing diagnostic and treatment facilities, educational and training programs, and a rehabilitation facility.Soldiers & Sailors Memorial Hospital (SSMH) 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 $85,031,419 in quantifiable community benefits reported for FY 2015: Charity Care (at cost) $2,068,338; Bad Debt (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. 1 Susquehanna Physician Services 1201 Grampian Boulevard Williamsport PA 17701 232449454 501(c)(3) 10515732 Support of affiliate Susquehanna Community Health and Dental Clinic 469-471 Hepburn Street Williamsport PA 17701 208979596 501(c)(3) 124500 Financial support 2 Part I, Line 2: Susquehanna Physician Services is a related organization and part of the Susquehanna Health System with consistent management oversight ensuring the use of funds for charitable purposes. Susquehanna Community Health and Dental Clinic is a former service of the Susquehanna Health System that is being converted to a Federally Qualified Health Clinic (FQHC). "Look-alike" status was received effective 12/6/11. Susquehanna Health System continues to support the clinics financially until full FQHC status is obtained and they are able to operate by their own means. All requests for funding are supported by detailed records of cash receipts and disbursements, as well as cash flow projections prepared by an independent accounting firm. 0 0 0 0 0 0 0 0 0 Kevin W Kist DO Director 0 329222 0 12706 0 76763 0 9800 0 24226 0 452717 0 0 Alexander R Nesbitt MD Director 0 181666 0 5618 0 15389 0 11067 0 16614 0 230354 0 0 Steven P Johnson President / CEO 0 531335 0 345329 0 29435 0 13700 0 17824 0 937623 0 0 Charles J Santangelo Executive VP / CFO (Retired 5/2/15) 0 341221 0 10767 0 4812 0 9800 0 22056 0 388656 0 0 William C McCauley MD Executive VP / CMO (Retired 1/31/15) 0 390991 0 15748 0 3314 0 9800 0 24476 0 444329 0 0 David Lopatofsky MD Executive VP / CMO (Hired 1/31/15) 0 312802 0 15628 0 8217 0 11100 0 24127 0 371874 0 0 Jan E Fisher Executive VP / COO 0 395220 0 10795 0 7764 0 9800 0 19947 0 443526 0 0 Ronald J Butler Executive VP / CBO (Retired 4/15/15) 0 329125 0 10897 0 4756 0 9800 0 12232 0 366810 0 0 Robert E Kane President 187092 0 19079 0 4304 0 10029 0 16091 0 236595 0 0 0 Rajesh Manoharan Medical Physicist 197368 0 0 0 272 0 7921 0 21102 0 226663 0 0 0 Joseph B Lecrone Pharmacist 127453 0 0 0 99 0 5824 0 19577 0 152953 0 0 0 Part I, Line 6 In order for the Leadership Team to participate in the annual Variable Compensation Incentive Program (VCIP) a minimum operating margin must be achieved for the most recently completed year on a consolidated system-level basis. Individual goals and objectives related to the VCIP may also include individual entity operating performance. For FY 2015, the minimum threshold was met that would trigger any VCIP payments. In September 2014, President / CEO Steven P. Johnson received 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. 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. A Lycoming County Authority 236760375 550804AH1 2009-10-22 17445802 See Part VI 0 0 0 B Lycoming County Authority 236760375 NoneAvail 2015-06-18 4400000 See Part VI 0 0 0 A 17433839 1257880 324433 15851526 2010 0 0 1 1 B 4400000 37485 4362515 0 0 0 1 A 0 0 0 1 1 0 0 1 B 0 0 0 1 1 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 0 0 0 0 1 B 0 0 1 0 1 0 0 0 1 A 1 B 1 Form 990, Schedule K, Part I, Bond A (e) and (f) The total issue price per Form 8038, Part III(b) is $165,134,534. Of this total, $17,445,802 was allocated to Divine Providence Hospital at the time of issue, while the balance of $147,688,732 was allocated to The Williamsport Hospital (EIN #24-0795508). The proceeds of the Lycoming County Authority, Series 2009A bonds were used, together with other available funds, to undertake a project consisting of the expansion and renovation of the Cancer Treatment Center at Divine Providence Hospital. Form 990, Schedule K, Part II, Bond A, Line 3 The difference between the Total Proceeds of Issue and the amount reflected in Part I, (e) is due to accumulated investment results, net of accumulated Investment Management Fees. Form 990, Schedule K, Part IV, Bond A, Line 2c Rebate calculations are performed annually, the most recent being from the issue date of October 22, 2009 to October 21, 2014. Form 990, Schedule K, Part I, Bond B, (e) and (f) The total issue price per Form 8038, Part III (b) is $40,000,000. Of this total, $4,400,000 was allocated to Divine Providence Hospital at the time of issue, while $11,200,000 was allocated to Muncy Valley Hospital (EIN #24-0806023) and $24,400,000 was allocated to The Williamsport Hospital (EIN #24-0795508). The proceeds of the financing will be used to finance all, or a portion of projects consisting of (i) construction at Williamsport Hospital, Patient Tower 4th Floor of three (3) Operating Rooms, four (4) Cardiology procedural rooms, and related clinical equipment; (ii) renovation at Williamsport Hospital, East Building 2nd Floor of existing entrance and interior hallway space to improve patient throughput; create a new Pre-Admission Testing area; and expand clinical staff locker area; (iii) installation at Williamsport Hospital, Energy Services Center, of 1,000 ton chiller and cooling tower creating new capacity to support the added demand from the Health Innovation Center and Patient Tower and creating additional back-up capacity; (iv) replacement at Williamsport Hospital, West Building and Energy Center, of the hot water system with hot water sourced from the Energy Services Center, thus providing more efficient hot water and heating to the West Building; (v) construction of Muncy Valley Hospital, Emergency Room expansion and renovation of a 5,400 square foot addition and 11,000 square feet of renovation to upgrade and expand the Emergency Department, installing eight (8) private bed rooms and five (5) specialty rooms, upgraded Radiology; and site-work to relocate Shady Lane, and create a new walk-in entrance, parking lot, and helipad; (vi) renovation at Divine Providence Hospital, Health Sciences Building 2nd Floor, to accommodate the relocation of Sports Medicine from the hospital, creating additional examination rooms and offices to accommodate seven (7) clinical providers and two (2) additional Radiology rooms, with related clinical equipment; (vii) renovation at Divine Providence Hospital, 1st Floor, to accommodate the expansion of the Work Center and relocation of Radiology services; (viii)renovation at Divine Providence Hosital, 1st Floor, to accommodate expansion of the Cancer Center to provide twelve (12) additional examination rooms, physician and management offices and nurse stations; (ix) the funding of any necessary reserves, and (x) the payment of all or a portion of the costs of the Financing. Form 990, Schedule K, Part II, Bond B, Line 3 This issue is a draw-down obligation from which funds are not requested and drawn until capital expenditures have been incurred. Form 990, Schedule K, Part IV, Bond B, Line 2c As a draw-down obligation with no funds held in investments, rebate calculation requirements are not applicable. Form 990, Part V, Line 1A 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 Susquehanna Health System EIN #23-2751183 utilizes a common paymaster which includes the following entities: Divine Providence Hospital EIN #24-0799343 Muncy Valley Hospital EIN #24-0806023 The Williamsport Hospital EIN #24-0795508 Susquehanna Health Foundation EIN #23-2743470 Susquehanna Physician Services EIN #23-2449454 Susquehanna Ventures, Inc. EIN #23-2470263 Williamsport Are Ambulance Services EIN #23-2416166 Laurel Management Services EIN #25-1644910 Laurel Realty EIN #23-1403678 Soldiers & Sailors Memorial Hospital EIN #23-2176963 The Green Home EIN #24-0804365 Tioga Health Care Providers EIN #25-1765538 Tyoga Carenet EIN #25-1810967 The total number of employees reported on Form W-3 would be 3,956 for Susquehanna Health System EIN #23-2751183. Of that total, 430 employees payroll expenses were recorded by Divine Providence Hospital. Form 990, Part VI, Section A, line 2 Key employee Charles Santangelo and board member Steven Johnson both serve on the board of a related taxable organization. Form 990, Part VI, Section A, line 6 Susquehanna Health System, EIN # 23-2751183, is a sole member of the governing body. Form 990, Part VI, Section A, line 7a Susquehanna Health System, EIN # 23-2751183, may elect or remove members of the governing body. Form 990, Part VI, Section A, line 7b All business and affairs of the corporation shall be managed and controlled by the Board of Directors, subject to the oversight of the 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 or of any force or effect whatsoever. The sole Member shall exercise its powers through its Board of Directors. The 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 of services of the corporation, and monitor and maintain the philosophy, goals and purposes for which the corporation was formed and exists, subject to an 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 transfer of any asset of the corporation outside the ordinary course of business, except transfers between or among affiliated 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 Forms 990 is presented to the parent Board of Directors (Susquehanna Health System, #23-2751183) before filing and complete drafts of all returns were 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 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, Line 15a & 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 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 the 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: Change in interest in net assets of affiliate -91,931. Form 990, Part XII, Line 2C The organization did not change it oversight process or selection process The Williamsport Hospital 700 High Street Williamsport PA 17701 240795508 Hospital PA 501(c)(3) 3 Susquehanna Health System 0 The Muncy Valley Hospital 215 East Water Street Muncy PA 17756 240806023 Hospital PA 501(c)(3) 3 Susquehanna Health System 0 Susquehanna Health Foundation 1100 Grampian Boulevard Williamsport PA 17701 232743470 Fundraising for affiliated entities PA 501(c)(3) 11 A I Susquehanna Health System 0 Susquehanna Health System 1205 Grampian Boulevard Williamsport PA 17701 232751183 Coordinate & manage the delivery of healthcare PA 501(c)(3) 11 A I N/A 0 Susquehanna Physician Services 1201 Grampian Boulevard Williamsport PA 17701 232449454 Physician services & MRI services PA 501(c)(3) 3 Susquehanna Health System 0 Williamsport Area Ambulance Service Cooperative 700 High Street Williamsport PA 17701 232416166 Ambulance transport PA 501(c)(3) 9 N/A 0 Soldiers & Sailors Memorial Hospital 32-36 Central Avenue Wellsboro PA 16901 232176963 Hospital PA 501(c)(3) 3 Susquehanna Health System 0 The Green Home 37 Central Avenue Wellsboro PA 16901 240804365 Skilled nursinng & assisted living PA 501(c)(3) 9 Susquehanna Health System 0 Tioga Health Care Providers 15 Meade Street Wellsboro PA 16901 251765538 Physician services PA 501(c)(3) 11 B II Susquehanna Health System 0 Laurel Management Services 15 Meade Street Wellsboro PA 16901 251644910 Mgmt consulting & supervisory svcs PA 501(c)(3) 11 B 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 Systems 15 Meade Street Wellsboro PA 16901 240795488 Coordinate & manage the delivery of healthcare PA 501(c)(3) 11 B II Susquehanna Health System 0 Laurel Health Foundation 15 Meade Street Wellsboro PA 16901 251810488 Fundraising for affiliated entities PA 501(c)(3) 11 A I Laurel Health System 0 Susquehanna Health Innovation Center Inc 700 High Street Williamsport PA 17701 471600873 Supporting organization of affiliated entities PA 501 (c)(3) 11 B II Susquehanna Health System 0 Community Basket LLC 1205 Grampian Boulevard Williamsport PA 17701 201195739 Rents real estate PA Susquehanna Health System & Susquehanna Health Foundation excluded from tax 0 0 Susquehanna Ventures Inc 1201 Grampian Boulevard Williamsport PA 17701 232470263 Pharmacy & infusion services PA N/A C 0 Susquehanna Health System Insurance Network LTD PO Box 1159 Grand Caymans CJ KY1-1102 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 1 0 0 0 0 0 0 0 1 1 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.