2015-05-12T05:39:33-05:00 2014-06-30 BKD LLP 910 E St Louis St Springfield MO 658062523 990 2013-07-01 232751183 Susquehanna Health System SUSQ 5703207900 1205 Grampian Blvd 2nd Floor Williamsport PA 17701 Charles J Santangelo Executive Vice President/CFO 5703213171 2015-05-12 1 Brian D Todd P00422601 4178658701 2013 2016-03-07 17:11:31Z Steven P Johnson 700 High Street Williamsport PA 17701 96393725 0 X www.susquehannahealth.org X 1994 PA SHS provides management services for the delivery of healthcare through its affiliated entities. 17 10 0 12 0 0 37844569 0 14769 15918 2067773 3075688 0 -1313268 39927111 1778338 20720 1017971 0 0 554961 0 0 0 0 1550768 376860 2126449 1394831 37800662 383507 89980840 96644957 2061725 4269466 87919115 92375491 X The mission of SHS and affiliates is as follows: Our Mission - to extend God's healing love by improving the health of those we serve. Our Vision - to create an integrated community health system that delivers world class care. Our Values - to carefully place our patients and their families first, share ownership with all of our caregivers and lead with a servant's heart. 0 0 1074643 1017971 15918 SHS is organized and operated to coordinate the activities of the Supported Organizations as they pursue their charitable, educational, benevolent, and other purposes related to health care, health education and training, health facilities, and scientific research and health. The Supported Organizations include: The Williamsport Hospital & Medical Center, Divine Providence Hospital of the Sisters of Christian Charity, Muncy Valley Hospital, and Susquehanna Physician Services. Other supported entities include the Laurel Entities provided that each such Laurel Health Entity is an organization described in Section 501(c)(3) of the Code as a public charity under either Section 509(a)(1) or Section 509(a)(2) of the Code. SHS also is operated to establish, sponsor, and develop, directly or indirectly, facilities and programs for the accommodation, care and treatment of individuals suffering from illness, injury, disease, disability or infirmity, including but not limited to hospitals, nursing homes, residential facilities for the elderly, life care centers, ambulatory medical treatment facilities, clinics, rehabilitation centers, aloholism treatment centers, home health programs, mental health centers, hospice programs, pharmacies, laboratories, and training and research facilities. 1074643 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 1 0 0 1 0 0 0 0 0 0 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 X 422 0 1 0 0 1 CJ 0 0 0 0 0 0 0 0 X 17 10 1 0 0 0 0 1 0 1 1 0 0 0 1 1 1 1 1 0 0 0 PA X Susquehanna Health Finance Department 5703207900 1205 Grampian Blvd 2nd Floor Williamsport PA 17701 Ronald V DeFeo Jr Chairperson 1.00 1.00 X X 0 0 0 Ann S Pepperman Esquire Vice Chairperson 1.00 1.00 X X 0 0 0 Davie Jane Gilmour PhD Secretary 1.00 1.00 X X 0 0 0 Sister Teresa Ann Jacobs Director 1.00 2.00 X 0 0 0 Leonard R Collins MD Director 1.00 42.00 X 0 246377 25959 Ronald E DiSimone MD Director 1.00 40.00 X 0 1111934 32145 Timothy M Gage Director term end 12/2013 1.00 1.00 X 0 0 0 Daniel J Glunk MD Director 1.00 40.00 X 0 210233 30544 Steven P Johnson President/CEO 1.00 44.00 X X 0 539105 31861 Daniel A Klingerman Director 1.00 1.00 X 0 0 0 Lynda Livingston Director 1.00 2.00 X 0 0 0 Philip H Johnson Director 1.00 2.00 X 0 0 0 James E Mothersbaugh Treasurer 1.00 1.00 X X 0 0 0 Alexander R Nesbitt MD Director 1.00 42.00 X 0 209772 28838 Kevin Kist MD Director 1.00 43.00 X 0 379149 32818 Robert DeCamp Director 1.00 2.00 X 0 0 0 Dr Walter Laibinis Director term end 10/2013 1.00 42.00 X 0 252873 14783 Dr J Dennis Murray Director 1.00 2.00 X 0 0 0 Glenn Poirier Director 1.00 2.00 X 0 0 0 Charles J Santangelo Exec VP/CFO 0.00 41.00 X 0 338408 29440 Jan E Fisher Exec VP/COO 0.00 40.00 X 0 387968 19385 William C McCauley MD Sr. VP/President SPS 0.00 40.00 X 0 379609 30350 Ronald J Butler Exec VP/CBO 0.00 41.00 X 0 324224 15277 0 4379652 291400 0 0 1 0 0 Interest on Note Receivable 525990 14039 14039 Support allocation income 900003 1347 1347 Misc other income 900003 532 532 15918 1196931 1196931 96494144 94615387 1878757 1878757 1878757 Loss on inv in equity investee 900099 -1313268 -1313268 -1313268 1778338 15918 0 1762420 1017971 1017971 81544 81544 238203 238203 441 441 47679 47679 681 681 635 635 6922 6922 Use of Funds-Misc Expen 755 755 1394831 1074643 320188 0 110085 99971 247264 217956 223 223 806309 798901 8755 7408 51778254 58043586 37836259 38275813 89980840 96644957 36000 81539 2025725 4187927 2061725 4269466 X 83710294 88219853 1072292 1019109 3136529 3136529 87919115 92375491 89980840 96644957 383507 4072869 0 X X 0 1 X 1 0 X X X 0 0 0 The Williamsport Hospital & Medical Center 240795508 3 1 54463 Divine Providence Hospital 240799343 3 1 0 Muncy Valley Hospital 240806023 3 1 0 Susquehanna Physician Services 232449454 3 1 0 Soldiers & Sailors Memorial Hospital 232176963 3 1 963508 5 1017971 38919 0 2280 1000 40199 38043 100 1776 1000 38919 36722 1596 725 1000 38043 35555 2167 1000 36722 33758 1797 35555 0.80870 0.19130 0 0 762929 755521 7408 43380 43380 0 7408 Cash Value of Life Insurance 17146 Other Assets 31 Interest in Net Affiliate 37819654 Financing costs-basis swap-net 105932 Due from affiliates 333050 38275813 Deferred Annuity 8630 Due to Affiliates 3575744 Interest Rate swap agreements 603553 4187927 X 5849927 4072869 4072869 1777058 1280 1280 1778338 376860 0 376860 1017971 1017971 1394831 Part V, Line 4: The Arthur R. Taylor, M.D. Endowment Fund for Continuing Medical Education will provide financial support for continuing medical education programs at Susquehanna Health System with a focus on primary care. These educational programs will be for the benefit of the physicians of Susquehanna Health and surrounding regions. Part XI, Line 4b - Other Adjustments: Restricted investment earnings 1,280. Part XII, Line 4b - Other Adjustments: Restricted grants 1,017,971. Form 990, Part X, Line 2 Management has evaluated their income tax positions under the guidance included in ASC 740. Based on their review, management has not identified any material uncertain tax positions to be recorded or disclosed in the financial statements. Central America 0 1 Program services Captive insurance company-Total investment 33245526 0 1 0 0 0 1 33245526 0 33245526 0 0 1 0 0 0 1 The Williamsport Hospital 700 High Street Williamsport PA 17701 240795508 501(c)(3) 54463 0 Used for Cardiac Surgery Equipment and the inpatient rehab. Soldiers & Sailors Memorial Hospital 32-36 Central Avenue Wellsboro PA 16901 232176963 501(c)(3) 963508 0 For the Cancer Treatment Center & Pharmacy capital renovation projects. 2 Part I, Line 2: Grantees are related organizations and part of the Susquehanna Health System with consistent management oversight ensuring the use of funds for charitable purposes. 0 0 0 0 0 0 0 0 0 Leonard R Collins MD Director 0 243795 0 0 0 2582 0 9410 0 16549 0 272336 0 0 Ronald E DiSimone MD Director 0 897427 0 209482 0 5025 0 9650 0 22495 0 1144079 0 0 Daniel J Glunk MD Director 0 208983 0 0 0 1250 0 10560 0 19984 0 240777 0 0 Steven P Johnson President/CEO 0 524745 0 0 0 14360 0 13475 0 18386 0 570966 0 0 Alexander R Nesbitt MD Director 0 177978 0 5618 0 26176 0 11553 0 17285 0 238610 0 0 Kevin Kist MD Director 0 321749 0 2313 0 55087 0 9650 0 23168 0 411967 0 0 Dr Walter Laibinis Director term end 10/2013 0 182813 0 70060 0 0 0 6069 0 8714 0 267656 0 0 Charles J Santangelo Exec VP/CFO 0 331702 0 0 0 6706 0 9650 0 19790 0 367848 0 0 Jan E Fisher Exec VP/COO 0 383073 0 0 0 4895 0 9650 0 9735 0 407353 0 0 William C McCauley MD Sr. VP/President SPS 0 376409 0 0 0 3200 0 9650 0 20700 0 409959 0 0 Ronald J Butler Exec VP/CBO 0 320062 0 0 0 4162 0 9650 0 5627 0 339501 0 0 Part I, Line 3 The Williamsport Hospital EIN#24-0795508, a related organization, uses the following resources to establish the compensation of the top management officials: compensation committee, independent compensation consultant, written employment contract, compensation survey or study, and approval by the board. Part I, Line 6 In order for the Leadership Team to participate in the annual Variable Compensation Incentive Program (VCIP), a minimum operating margin must be achieved for the most recently completed year on a consolidated system-level basis. Individual goals and objectives related to the VCIP may also include individual entity operating performance. In FY 2014 the minimum threshold was not met that would trigger any VCIP payments. Danko Holdings IncDaniel Klingerman Pres (board member) President of Danko is a board member of SHS Danko has an agreement to pay Community Basket a note at 6% interest X 300000 217956 0 1 1 217956 Form 990, Part VI, Section A, line 2 Key employee Charles Santangelo and board members Philip Johnson and Steve Johnson all serve on the board of a related taxable organization. Form 990, Part VI, Section A, line 7a Two members of the board of directors shall be appointed by the Sisters of Christian Charity Health Care Corporation. These directors shall have all of the powers provided to the other directors except they shall not have the power to vote to appoint the President of the Corporation and they shall not participate in the discussions of, or vote on any matters contrary to the Directives. Form 990, Part VI, Section B, line 11 A high-level overview of Forms 990 is presented to the parent Board of Directors (Susquehanna Health System EIN #23-2751183) before filing and complete drafts of all returns are made available to all Board members through the CEO's and CFO's office. Form 990, Part VI, Section B, line 12c All members of the Board of Directors are required to submit a statement annually disclosing any conflict of interest that may arise. Requests for the annual form are distributed individually to each Board Member by the Office of the President and CEO. The CEO's executive assistant ensures that she receives a completed form from every Board Member. All Board Members agree to abstain when any issue involving the parties with conflicting interest is called to motion. Form 990, Part VI, Section B, line 15 Form 990, Part VI, Section B, Line 15a&b: All top management is employed by The Williamsport Hospital EIN #24-0795508. The following paragraph describes the process they use. 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 presumptive or reasonableness relative to executive compensation and benefits. The consultant annually provides detailed market information from its annual Executive Compensation Survey for Health Systems. In addition, other regional survey data is provided in order to supply the health system with a "national" picture of compensation. With this process established, the Executive Compensation Committee takes the proper steps to educate the Board of Directors to understand all of the above-mentioned oversight and to appropriately prepare them for community or media inquiry. In addition, the Board is made aware of the Form 990 and its role in the communication of information to the public. Form 990, Part VI, Section C, line 19 These documents are available to members of the public who request them. They would be produced by the corporate office. Form 990, Part XII, Line 2c The organization did not change its oversight process or selection process. Form 990, Part V, Line 1a Number reported in Box 3 of Form 1096 All 1099's are issued by Susquehanna Health System EIN #23-2751183. All expenses are then allocated back to all related entities. Form 990, Part V, Line 2a & 2b Number of employees reported on Form W-3 Susquehanna Health System EIN #23-2751183 utilizes a common paymaster which includes the following entities: Divine Providence Hospital #24-0799343 Muncy Valley Hospital #24-0806023 The Williamsport Hospital #24-0795508 Susquehanna Health Foundation #23-2743470 Susquehanna Physician Services #23-2449454 Susquehanna Ventures Inc #23-2470263 Williamsport Area Ambulance Service Cooperative #23-2416166 The total number of employees reported on Form W-3 would be 3,500 for Susquehanna Health System #23-2751183. Of that total, no employees payroll expenses were recorded by Susquehanna Health System. Divine Providence Hospital 1100 Grampian Blvd Williamsport PA 17701 240799343 Hospital PA 501(c)(3) Line 3 Susquehanna Health System 1 Muncy Valley Hospital 215 E Water St Muncy PA 17756 240806023 Hospital PA 501(c)(3) Line 3 Susquehanna Health System 1 The Williamsport Hospital 700 High Street Williamsport PA 17701 240795508 Hospital PA 501(c)(3) Line 3 Susquehanna Health System 1 Susquehanna Health Foundation 1100 Grampian Blvd Williamsport PA 17701 232743470 Fundraising for affiliated entities PA 501(c)(3) Line 11a, I Susquehanna Health System 1 Susquehanna Physician Services 1201 Grampian Blvd Williamsport PA 17701 232449454 Physician services & MRI services PA 501(c)(3) Line 3 Susquehanna Health System 1 Williamsport Area Ambulance Service Cooperative 700 High Street Williamsport PA 17701 232416166 Ambulance transports PA 501(c)(3) Line 9 N/A 0 Soldiers & Sailors Memorial Hospital 32-36 Central Ave Wellsboro PA 16901 232176963 Hospital PA 501(c)(3) Line 3 Susquehanna Health System 1 The Green Home 37 Central Ave Wellsboro PA 16901 240804365 Skilled nursing & assisted living PA 501(c)(3) Line 9 Susquehanna Health System 1 Tioga Health Care Providers 15 Meade Street Wellsboro PA 16901 251765538 Physician services PA 501(c)(3) Line 11b, II Susquehanna Health System 1 Laurel Management Services 15 Meade Street Wellsboro PA 16901 251644910 Mgmt consulting & supervisory svcs PA 501(c)(3) Line 11b, II Susquehanna Health System 1 Laurel Realty 15 Meade Street Wellsboro PA 16901 231403678 Own & manage real estate PA 501(c)(2) N/A Susquehanna Health System 1 Laurel Health System 15 Meade Street Wellsboro PA 16901 240795488 Coordinate & manage the delivery of healthcare PA 501(c)(3) Line 11b, II Susquehanna Health System 1 Laurel Health Foundation 15 Meade Street Wellsboro PA 16901 251810488 Fundraising for affiliated entities PA 501(c)(3) Line 11a, I Laurel Health System 1 Community Basket LLC 1205 Grampian Blvd Williamsport PA 17701 201195739 Rents real estate PA Susquehanna Health System & Susquehanna Health Foundation Excluded from tax 0 0 0.50000 Susquehanna Ventures Inc 1201 Grampian Blvd Williamsport PA 17701 232470263 Pharmacy & Infusion services PA Susquehanna Health System C 2229658 2526140 1.00000 1 Susquehanna Health System Insurance Network LTD PO Box 1159 Grand Caymans CJ KY1-1102 980458722 Captive Insurance Company CJ Susquehanna Health System 1810657 33509344 1.00000 1 Tyoga Carenet 15 Meade Street Wellsboro PA 16901 251810967 Integrate Health Care PA Susquehanna Health System C 192490 354036 1.00000 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 The Williamsport Hospital B 54463 Medical Equipment expenses Soldier's & Sailors Hospital B 963508 Capital building projects expense 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.