2015-05-12T07:32:00-05:00 2014-06-30 BKD LLP 910 E St Louis Street Springfield MO 65806 990 2013-07-01 240806023 Muncy Valley Hospital MUNC 5703207900 215 East Water Street Muncy PA 17756 Charles J Santangelo Executive Vice President / CFO 5703207900 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 80790566 0 X www.susquehannahealth.org X 1922 PA Muncy Valley Hospital (MVH) is a 25 bed, critical access hospital, primarily serving Lycoming and surrounding counties. MVH also provides a full range of outpatient and emergency services, as well as, 139 hospital based Long Term Care beds. 11 8 330 145 0 0 628025 962057 46458819 49825053 701015 945779 118663 75102 47906522 51807991 2644350 3353561 0 0 16685437 16882182 0 0 0 24401748 25698470 43731535 45934213 4174987 5873778 47856404 54884015 4393198 4031888 43463206 50852127 X Muncy Valley Hospital (MVH) 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 our patients and their families first, share ownership with all of our caregivers and lead with a servant's heart. 0 0 39849966 3353561 49833497 During the fiscal year ended June 30, 2014, the Hospital admitted 611 acute care patients, rendering 4,540 patient days and registered approximately 50,960 outpatients. Long Term Care days totaled 46,324. MVH 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, MVH devotes a portion of its revenue and assets to community program services. The following reflects the breakout of $6,145,284 in quantifiable community benefits reported for FY 2014: Charity Care (at cost) $195,750; Bad Debt (at cost) $1,006,183; Government-sponsored health care (unpaid cost of Medicare, Medicaid, indigent care programs, SCHIP and other safety net programs) $4,878,759. In addition, various other programs such as Research, Health Professions Education, Community Building, Financial and In-Kind Contributions and Community Benefit Operations totaling $64,592. 39849966 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 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 1 3 0 1 330 1 0 0 0 0 0 0 0 0 0 0 X 11 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 Daniel Beringer Chair 1.00 0.00 X X 0 0 0 Geneva Peck Vice Chair 1.00 1.00 X X 0 0 0 Robert E More Secretary 1.00 0.00 X X 0 0 0 Roger D Jarrett Treasurer 1.00 1.00 X X 0 0 0 Dr Mark Beyer Director 1.00 0.00 X 0 0 0 Sister Teresa Ann Jacobs Director 1.00 2.00 X 0 0 0 Kevin Kist DO Director 1.00 43.00 X 0 379149 32818 Paul Moulton Director 1.00 2.00 X 0 0 0 Dr Peter B Trevouledes Director 1.00 0.00 X 0 0 0 Steven E Yordy MD Director 1.00 40.00 X 0 11429 0 Steven P Johnson President / CEO 1.00 44.00 X X 0 539105 31861 Charles J Santangelo Executive Vice President/C 0.00 41.00 X 0 338408 29440 William C McCauley MD Sr. Vice President/Preside 0.00 40.00 X 0 379609 30350 Jan E Fisher Executive Vice President/C 0.00 40.00 X 0 388968 19385 Ronald J Butler Executive Vice President / 0.00 41.00 X 0 324224 15277 Ronald J Reynolds President 40.00 0.00 X 173607 0 27092 Debra A Morin Physical Therapist 40.00 0.00 X 116822 0 14912 Anne E Holladay Nursing Home Administrator 40.00 0.00 X 103464 0 7693 Bobbie J Woolcock Director of Nsg / Nsg Home 40.00 0.00 X 101671 0 4390 495564 2360892 213218 4 0 1 0 Susquehanna Health System 1001 Grampian Boulevard Williamsport PA 17701 Management services 4702041 Aramark Healthcare 24863 Network Place Chicago IL 60673 Management / environmental services 4286993 Genesis Eldercare Rehab PO Box 821322 Philadelphia PA 19182 Rehab services 1052780 Respiratory Health Services LLC PO Box 821322 Philadelphia PA 19182 Respiratory services 730121 Emcare Inc 7032 Collection Center Drive Chicago IL 60693 ER management services 408359 6 17296 2773 17252 924736 962057 Net patient service revenue 621990 48139832 48139832 Supplemental payments associated 623000 1507832 1507832 Affiliate rental income 621990 114828 114828 Sports Medicine - athletic traine 621990 36437 36437 Meaningful use revenue 621990 26124 26124 49825053 374745 374745 29438765 28867680 51 571085 -51 571034 571034 75501 17296 114844 -39343 -39343 Cafeteria 624200 64284 64284 Miscellaneous 900099 43663 8444 35219 Television 900099 6498 6498 114445 51807991 49833497 0 1012437 X 3353561 3353561 13043900 12371205 672695 589231 558843 30388 2247434 2131530 115904 1001617 949962 51655 4702038 4702038 5871 5871 76064 76064 7144075 6894453 249622 3610 3418 192 1389508 1313433 76075 135743 135354 389 18499 18420 79 876914 818892 58022 16609 16330 279 21999 21674 325 1347700 1347700 514856 514856 Medical supplies 3681385 3681359 26 Bad Debt Expense 3292486 3292486 Miscellaneous 1482411 1439291 43120 Repairs & maintenance 988702 987199 1503 45934213 39849966 6084247 0 9586584 14762401 5971262 6304205 436736 0 145047 172573 145671 169819 41519224 28449083 12904864 13070141 16361314 18653584 2304926 1751292 47856404 54884015 2836441 2897591 1556757 1134297 4393198 4031888 X 43016547 50392672 220918 235572 225741 223883 43463206 50852127 47856404 54884015 X 5873778 1499015 16128 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 5871 0 0 0 5871 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 06/30/14, the amount of dues paid to HAP totaled $10,218 of which 22.85% or $2,335, was used for lobbying purposes. Dues paid to AHA totaled $14,953, of which 23.65% or $3,536, 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. 390346 390346 22338258 15834809 6503449 15678 15678 0 15877903 12205601 3672302 2897039 392995 2504044 13070141 Estimated third party settlements 950297 Estimated medical legal liability costs 184000 1134297 X 49087131 1499015 15513 1514528 47572603 4235388 4235388 51807991 39288166 0 39288166 6646047 6646047 45934213 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. Part XI, Line 2d - Other Adjustments: Net assest released from restrictions 15,513. Part XI, Line 4b - Other Adjustments: Bad debt expense 3,292,486. Contributions received 941,987. Investment return -1,858. Transfer from affiliate - SHF 2,773. Part XII, Line 4b - Other Adjustments: Bad Debt expense 3,292,486. Transfer to affiliate - SHMG 3,353,561. Central America 0 1 Program services Captive insurance company 293552 0 1 0 0 0 1 293552 0 293552 0 0 0 0 0 0 Lawn Party 22940 11631 11309 45447 Gift Box 18888 18888 19517 8 50969 5665 45304 49880 92797 17296 75501 114844 114844 -39343 1 1 X 1 X 1 X 1 1 1 0 1 1 195750 0 195750 0.00460 13838790 11343324 2495466 0.05850 14034540 11343324 2691216 0.06310 2870 0 2870 0.00010 847 847 0.00000 1910 1910 0.00000 5627 5627 0.00010 14040167 11343324 2696843 0.06320 846 0 846 0.00000 846 846 1 3292485 164624 11976372 14359665 -2383293 X 1 1 1 1 Muncy Valley Hospital 215 East Water Street Muncy PA 17756 www.susquehannahealth.org 134301 X X X Muncy Valley Hospital 1 1 X X X X X X X X X 13 1 1 1 X www.susquehannahealth.org X X X X X 0 0 1 1 200.000000000000 1 300.000000000000 1 X X X X X 1 1 X X X X X X 1 0 X X X X 1 X 0 0 Muncy Valley Hospital Part V, Section B, Line 3: 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 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 Muncy Valley Hospital Part V, Section B, Line 4: The Muncy Valley Hospital; located in Muncy, 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 Memorial Hospital located in Wellsboro, PA and whose 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 Implemenation 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. Muncy Valley Hospital Part V, Section B, Line 7: 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 colloboratively 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 psyciatrists and an additional certified registered nurse practioner to increase patient access to services. 7) Implemented telesychiatry consult services with local nursing homes to increase acces 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) Develop 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. Muncy Valley Hospital Part V, Section B, Line 14g: Other method - brochure Muncy Valley Hospital Part V, Section B, Line 20d: 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 I, Line 6a: The community benefit report is prepared on a system wide basis under Susquehanna Health System. Part I, Line 7g: Muncy Valley Hospital has various subsidized services which are included within the Medicare and Medical Assistance unreimbursed costs. Part II, Community Building Activities: Community building activities at the Muncy Valley Hospital (MVH) involves staff participation / involvement on various boards and committees to help better serve the community. 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 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 on 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 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: 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 community health needs assessments in Lycoming county. In addition, Soldiers & Sailors Memorial Hospital is part of SHS and is located in Wellsboro, PA which is part of Tioga County.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 respresenting 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 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 necesary inpatient or outpatient services from TWH, DPH, MVH 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 responsiblity 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 cannnot 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 charteristics, you may view the CHNA and related Implementation plan at www.susquehannahealth.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 priviledges 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 dully 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 judgement 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 Responsibilites - 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 7/1/13 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 (H) 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 in Lycoming Mall. 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: Muncy Valley Hospital (MVH) is one of four hospitals which is 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 services.The Williamsport Hospital (TWH) is an acute care community hospital providing diagnostic and treatment facilities, educational and training programs, and a rehabiliation facility.Soldiers & Sailors Memorial Hospital (SSMH) is an acute care community hospital providing diagnostic and treatment facilities, educational and training programs, and a rehabiliation 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 $90,482,855 in quantifiable community benefits reported for FY 2014: Charity Care (at cost) $3,702,071; Bad Debt (at cost) $11,022,824; Government-sponsored health care (unpaid cost of Medicare, Medicaid, indigent care programs, SCHIP and other safety net programs) $69,261,993. In addition, various other programs such as Research, Health Professions Education, Community Building, Financial and In-Kind Contributions, and Community Benefit Operations totaling $6,495,967. 1 Susquehanna Physician Services 1201 Grampian Boulevard Williamsport PA 17701 232449454 501(c)(3) 3353561 Support of affiliate 1 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 Kevin Kist DO Director 0 321749 0 2313 0 55087 0 9650 0 23168 0 411967 0 0 Steven P Johnson President / CEO 0 524745 0 0 0 14360 0 13475 0 18386 0 570966 0 0 Charles J Santangelo Executive Vice President/C 0 331702 0 0 0 6706 0 9650 0 19790 0 367848 0 0 William C McCauley MD Sr. Vice President/Preside 0 376409 0 0 0 3200 0 9650 0 20700 0 409959 0 0 Jan E Fisher Executive Vice President/C 0 383073 0 0 0 5895 0 9650 0 9735 0 408353 0 0 Ronald J Butler Executive Vice President / 0 320062 0 0 0 4162 0 9650 0 5627 0 339501 0 0 Ronald J Reynolds President 173206 0 0 0 401 0 7342 0 19750 0 200699 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 acheived 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 2014, the minimum threshold was not met that would trigger any VCIP payments. 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. SVI The corporation has common board members or officers 484339 Sale of pharmaceuticals 0 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 the 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 the 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 or services of the corporation, and monitor and maintain the philosophy, goals and purposes for which the corporation was formed and exists, subject to and 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 assets of the corporation outside the ordinary course of business, except transfes 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, goverance, 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 are made available to all board memebers 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 that proper steps to educate the Board of Directors to understand all of the above-mentioned oversight and to appropriately prepare them for community or media inquiry. In addition, the Board is made aware of the Form 990 and its role in the communication of information to the public. Form 990, Part VI, Section C, line 19 The organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Form 990, Part IX, line 11g Other: Program service expenses 4,146,366. Management and general expenses 161,322. Fundraising expenses 0. Total expenses 4,307,688. Physician / Medical fees: Program service expenses 475,391. Management and general expenses 88,300. Fundraising expenses 0. Total expenses 563,691. Aramark contracted services: Program service expenses 2,272,696. Management and general expenses 0. Fundraising expenses 0. Total expenses 2,272,696. Form 990, Part XI, line 9: Change in net asset of affiliate 16,128. FORM 990, PART XII, LINE 2C The organization did not change its oversight process or selection process. 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 Williamsport Area Ambulance Service Cooperative EIN #23-2416166 The total number of employees reported on Form W-3 would be 3,500 for Susquehanna Health System EIN #23-2751183. Of that total, 330 employees payroll expenses were recorded by Muncy Valley Hospital. Divine Providence Hospital of the Sister of Christian Charity 1100 Grampian Boulevard Williamsport PA 17701 240799343 Hospital PA 501(c)(3) 3 Susquehanna Health System 0 The Williamsport Hospital 700 High Street Williamsport PA 17701 240795508 Hospital PA 501(c)(3) 3 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 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 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 transports 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 nursing & assisted living PA 501(c)(3) 9 Susquehanna Health System 0 Tioga Health Care Providers 15 Meade Streeet Wellsboro PA 16901 251765538 Physician services PA 501(c)(3) 11 B II Susquehanna Health System 0 Laurel Management Services 15 Meade Streeet Wellsboro PA 16901 251644910 Mgmt consulting & supervisory svcs PA 501(c)(3) 11 B II Susquehanna Health System 0 Laurel Realty 15 Meade Streeet Wellsboro PA 16901 231403678 Own & manage real estate PA 501(c)(2) N/A Susquehanna Health System 0 Laurel Health System 15 Meade Streeet 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 Streeet Wellsboro PA 16901 251810488 Fundraising for affiliated entities PA 501(c)(3) 11 A I Laurel 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 exempte 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.