2014-05-13T10:34:58-05:00 2013-06-30 BKD LLP 910 E St Louis St Springfield MO 658062523 990 2012-07-01 232743470 Susquehanna Health Foundation SUSQ 5703207900 1100 Grampian Boulevard Williamsport PA 17701 Charles J Santangelo 5703213171 2014-05-13 1 Brian D Todd P00422601 4178658701 2012 2015-11-30 17:44:51Z Steven P Johnson 700 High Street Williamsport PA 17701 29467819 0 X www.susquehannahealth.org X 1986 PA SHF provides fundraising, investment, and financial support to the Susquehanna Health System. 24 23 5 26 0 0 2519319 1392335 0 0 402048 378857 10935 6828 2932302 1778020 3973702 3126488 0 0 438952 441796 0 0 381454 420460 552422 4833114 4120706 -1900812 -2342686 14916858 13196545 199716 226652 14717142 12969893 X SHF is a subsidiary of SHS. 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 a world-class health system. Our Values - putting patients first, sharing ownership and being servant leaders. 0 0 3558425 3126488 771 SHF is organized and operated to carry out the charitable health care mission of the Supported Organizations which include: The Williamsport Hospital, Divine Providence Hospital of the Sisters of Christian Charity, Muncy Valley Hospital, and Susquehanna Physician Services. SHF also is operated to solicit and raise funds and endowments, and to receive by way of gift, purchase, grant, devise, will or otherwise, property, real, personal or mixed, and to hold, use, maintain, lease, donate, pledge, encumber, sell, convey and otherwise dispose of all such property in the futherance of the objectives and purposes of this Corporation. 3558425 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 1 0 0 0 1 X 6 0 1 5 1 0 0 0 0 0 1 1 0 0 0 0 X 24 23 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 0 0 0 PA X Susquehanna Health Finance Department 5703207900 1205 Grampian Blvd Williamsport PA 17701 X John M Young 1.00 0.00 X X 0 0 0 Keith Kuzio 1.00 2.00 X X 0 0 0 Donna L Bastian 1.00 0.00 X X 0 0 0 Rodney N Bailey 1.00 0.00 X X 0 0 0 John C Becker MD 1.00 0.00 X 0 0 0 Steven P Johnson 1.00 43.00 X X 0 962143 32509 John C Lundy 1.00 0.00 X 0 0 0 Timothy J Crotty 1.00 0.00 X 0 0 0 Douglas Doherty 1.00 0.00 X 0 0 0 Mary C Fish 1.00 0.00 X 0 0 0 Roger D Jarrett 1.00 1.00 X 0 0 0 Stephen D Keener 1.00 0.00 X 0 0 0 Lynda Livingston 1.00 2.00 X 0 0 0 Richard L Michael 1.00 0.00 X 0 0 0 Geneva Peck 1.00 1.00 X 0 0 0 Paul Rooney 1.00 0.00 X 0 0 0 Marvin H Staiman 1.00 0.00 X 0 0 0 Robert P Crockett 1.00 0.00 X 0 0 0 Paul E Heise 1.00 0.00 X 0 0 0 Barbara Hudock 1.00 0.00 X 0 0 0 Mark A Huffman 1.00 0.00 X 0 0 0 Allen Kiessling 1.00 0.00 X 0 0 0 Joseph L Reighard 1.00 0.00 X 0 0 0 Jerry Wertz 1.00 0.00 X 0 0 0 Charles J Santangelo 0.00 40.00 X 0 358326 29369 Jan E Fisher 0.00 40.00 X 0 333591 22798 William C McCauley MD 0.00 40.00 X 0 403160 31423 Ronald J Butler 0.00 40.00 X 0 367109 19857 Neil G Armstrong 0.00 40.00 X 0 293762 27670 0 2718091 163626 0 0 1 0 0 123980 1268355 55312 1392335 150180 150180 27844829 27616152 228677 228677 228677 79704 123980 73647 6057 6057 Miscellaneous other income 900099 771 771 771 1778020 771 0 384914 3126488 3126488 376888 150755 226133 13679 5472 8207 22861 9144 13717 28368 11347 17021 66301 66301 33374 33374 49467 49467 70689 28276 42413 66958 43634 23324 31144 31144 27228 27228 1954 782 1172 565 565 8038 8038 46871 46871 5094 5094 1280 1280 Golf Tournament expense 73647 73647 Gifts in Kind 48125 48125 Bad Debt-Uncollectible 15330 15330 Use of Funds-misc expen 6357 6357 4120706 3558425 180827 381454 5403020 4367472 1117112 698377 12790 6372 23323 26173 228144 91998 83948 136146 8145518 7822165 131147 139840 14916858 13196545 52030 55920 147686 170732 199716 226652 X 6618642 6674582 8093500 6290311 5000 5000 14717142 12969893 14916858 13196545 -2342686 595437 0 X X 0 1 X 1 0 X X X 0 0 0 Divine Providence Hospital of the Sisters of Christian Charity 240799343 3 1 650038 Muncy Valley Hospital 240806023 3 1 7012 The Williamsport Hospital & Medical Center 240795508 3 1 2469438 Susquehanna Physician Services 232449454 3 1 0 4 3126488 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 5065 355 250 5170 4872 193 5065 4750 122 4872 0.96710 0.03290 0 1 1 228144 91998 136146 136146 Deferred Gift Annuities 133951 Due to Affiliates 36781 170732 X 1255634 595437 339672 935109 320525 1457495 1457495 1778020 1068584 74365 74365 994219 3126487 3126487 4120706 Description of Intended Use of Endowment Funds: Part V, Line 4: The Life's Work Award for Nursing Excellence Endowment Fund was created to provide an annual award to a deserving nurse who has been nominated by his/her peers. Part XI, Line 2d - Other Adjustments: Assets released from restriction 265,307. Donated services 74,365. Part XI, Line 4b - Other Adjustments: Restricted net assets 1,457,495. Part XII, Line 2d - Other Adjustments: Donated services 74,365. Part XII, Line 4b - Other Adjustments: Restricted grants 3,126,487. 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. SH Golf Tournament 112540 78410 34130 8262 2745 18637 2437 Breast Health Golf Tournament 45420 24960 20460 0 563 12864 1535 2 45724 20610 25114 0 5723 12856 2643 5382 203684 123980 79704 8262 9031 44357 2643 9354 73647 6057 1 Divine Providence Hospital 1100 Grampian Blvd Williamsport PA 17701 240799343 501(c)(3) 650038 Used for general expenses of the Divine Providence Hospital including Breast Health Center, Cancer Treatment Center, Diabetes Renovations, Gatehouse Renovations, and Home Care & Hospice. The Williamsport Hospital 777 Rural Ave Williamsport PA 17701 240795508 501(c)(3) 2469438 Expenses for construction and remodeling of The Williamsport Hospital including the Emergency Department, OB, Lab, Ortho Gym, and Entranceway. Equipment for the OR and OB departments. A new call bell system, patient beds, and furniture. Muncy Valley Hospital 215 E Water Street Muncy PA 17756 240806023 501(c)(3) 7012 Used to purchase a new maxi move scale for the Muncy Valley Hospital Skilled Nursing Unit. 3 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, 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 1 1 0 0 Steven P Johnson 0 511232 0 139282 0 311629 0 13250 0 19259 0 994652 0 0 Charles J Santangelo 0 331316 0 19112 0 7898 0 9500 0 19869 0 387695 0 0 Jan E Fisher 0 283326 0 49437 0 828 0 10346 0 12452 0 356389 0 0 William C McCauley MD 0 376235 0 23425 0 3500 0 9500 0 21923 0 434583 0 0 Ronald J Butler 0 293922 0 72441 0 746 0 13971 0 5886 0 386966 0 0 Neil G Armstrong 0 276505 0 14286 0 2971 0 15750 0 11920 0 321432 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 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. X 20 10674 Retail price of artwork X 5336 Retail price of books X 3 7187 Cashed in at fair market X 9 6716 Retail cost of food don. X TV 1 3626 Retail price of TV X Misc small items for golf tournament prizes 47 9715 Retail price of items X Hyfrecator 2000 for doctor's office 1 975 Retail price of item X Gift certificates for golf tournament prizes 58 11083 Retail price of items 0 0 1 Third Party Use: Part I, Line 32b: M&T Investment Group (the trustee/custodian of our investment portfolio) cashes in the donated stock at fair market value and deposits the stock value into our portfolio as a stock contribution. Form 990, Part VI, Section A, line 6 Susquehanna Health System 23-2751183 is a sole member of the governing body. Form 990, Part VI, Section A, line 7a Susquehanna Health System 23-2751183 may elect or remove one or more board members to the governing body. Form 990, Part VI, Section A, line 7b Susquehanna Health System 23-2751183, the sole member shall have exclusive authority to exercise the powers: To appoint and remove the President of the Corporation. To elect and remove, with or without cause, a Director of the Corporation. To determine or change the mission and to monitor and maintain the philosophy, goals and purposes for which the Corporation was formed and exists. To adopt, amend or repeal the Articles of Incorporation. To establish requirements for the approval of new capital debt, any increment to any existing capital debt, and/or any change in capital debt obligations of the Corporation. 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. To require a certified audit of corporate funds at any time. 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 asset of the Corporation outside of 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. 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. 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. To appoint annually the external fiscal auditor of the Corporation. 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. To remove any elected officer of the Corporation. To approve the annual capital and operating budget of the Corporation. 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. 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 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 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. Number reported in Box 3 of Form 1096 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. Number or employees reported on Form W-3 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 24-0799343 Muncy Valley Hospital 24-0806023 The Williamsport Hospital 24-0795508 Susquehanna Health Foundation 23-2743470 Susquehanna Physician Services 23-2449454 Williamsport Area Ambulance Service Cooperative 23-2416166 The total number of employees reported on Form W-3 would be 3482 for Susquehanna Health System 23-2751183. Of that total, 5 employees payroll expenses were recorded by Susquehanna Health Foundation EIN #23-2743470. Divine Providence Hospital of the Sisters of Christian Charity 1100 Grampian Blvd Williamsport PA 17701 240799343 Hospital PA 501(c)(3) Line 3 Susquehanna Health System 0 Muncy Valley Hospital 215 E Water Street Muncy PA 17756 240806023 Hospital PA 501(c)(3) Line 3 Susquehanna Health System 0 The Williamsport Hospital 700 High Street Williamsport PA 17701 240795508 Hospital PA 501(c)(3) Line 3 Susquehanna Health System 0 Susquehanna Health System 1205 Grampian Blvd Williamsport PA 17701 232751183 Coordinate & manage the delivery of healthcare PA 501(c)(3) Line 11b, II N/A 0 Susquehanna Physician Services 1201 Grampian Blvd Williamsport PA 17701 232449454 Physician services & MRI services PA 501(c)(3) Line 3 Susquehanna Health System 0 Williamsport Area Ambulance Service 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 0 The Green Home 37 Central Ave Wellsboro PA 16901 240804365 Skilled nursing & assisted living PA 501(c)(3) Line 9 Susquehanna Health System 0 Tioga Health Care Providers 15 Meade Street Wellsboro PA 16901 251765538 Physician services PA 501(c)(3) Line 11b, II Susquehanna Health System 0 Laurel Management Services 15 Meade Street Wellsboro PA 16901 251644910 Mgmt consulting & supervisory svcs PA 501(c)(3) Line 11b, 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 System 15 Meade Street Wellsboro PA 16901 240795488 Coordinate & manage the delivery of healthcare PA 501(c)(3) Line 11b, II Susquehanna Health System 0 Laurel Health Foundation 15 Meade Street Wellsboro PA 16901 251810488 Fundraising for affiliated entities PA 501(c)(3) Line 11a, I Laurel Health System 0 Community Basket LLC 1205 Grampian Blvd Williamsport PA 17701 201195739 Rents real estate PA Susquehanna Health System & Susquehanna Health Foundation Excluded from tax -1881 11808 0 0 0.50000 Susquehanna Ventures Inc 1201 Grampian Blvd Williamsport PA 17701 232470263 Pharmacy & Infusion Services PA N/A C 0 Susquehanna Health System Insurance Network LTD PO Box 1159 CJ 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 Tioga Management Services Org 15 Meade Street Wellsboro PA 16901 232886336 Manage Physician Practices PA N/A C 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 0 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. If files an 1120F protective filing which implies that its income is not subject to US Federal Income tax.