2014-04-10T10:14:32-05:00 2013-06-30 520783935 SMITH ELLIOTT KEARNS & COMPANY LLC 804 WAYNE AVENUE CHAMBERSBURG PA 17201 990 2012-07-01 230465970 THE CHAMBERSBURG HOSPITAL CHAM 7172673000 112 NORTH SEVENTH STREET CHAMBERSBURG PA 17201 KIMBERLY M RZOMP 7172677107 2014-04-04 1 GREGORY P HALL CPA P00156653 7172633910 2012 2015-11-30 17:44:51Z KIMBERLY M RZOMP 112 NORTH SEVENTH STREET CHAMBERSBURG PA 17201 285041040 0 X WWW.SUMMITHEALTH.ORG X 1904 PA THE CHAMBERSBURG HOSPITAL IS A REGIONAL NONPROFIT HEALTH CARE ORGANIZATION COMMITTED TO THE IMPROVEMENT OF THE HEALTH AND WELL-BEING OF THE PEOPLE IN SOUTH-CENTRAL PENNSYLVANIA. 18 16 2006 486 4688826 -99832 183791 481961 277222023 262845673 2402832 6889284 3563416 8174116 283372062 278391034 1421143 851828 0 0 139995575 141671387 0 0 0 109339410 94930820 250756128 237454035 32615934 40936999 444750411 458263420 291294782 250437151 153455629 207826269 THE CHAMBERSBURG HOSPITAL IS A REGIONAL NONPROFIT HEALTH CARE ORGANIZATION COMMITTED TO THE IMPROVEMENT OF THE HEALTH AND WELL-BEING OF THE PEOPLE IN SOUTH-CENTRAL PENNSYLVANIA. 0 0 172533826 266062176 THE CHAMBERSBURG HOSPITAL PROVIDES NEEDED MEDICAL CARE TO THE COMMUNITY REGARDLESS OF ANY PATIENT'S ABILITY TO PAY. HEALTH CARE SERVICES INCLUDE INPATIENT ROUTINE, INPATIENT ANCILLARY AND OUTPATIENT CARE. ALL MANAGEMENT AND GENERAL EXPENSES ARE CONSIDERED PROGRAM RELATED. 851828 851828 GRANTS TO VARIOUS NON-PROFIT ORGANIZATIONS IN THE COMMUNITY TO DEVELOP OR EXPAND HEALTH CARE PROGRAMS TO EDUCATE THE COMMUNITY ABOUT HEALTH CARE ISSUES. CHAMBERSBURG HOSPITAL PARTNERS WITH COMMUNITY ORGANIZATIONS LIKE THE PENN STATE MONT ALTO NURSING PROGRAM, WAYNESBORO COMMUNITY AND HUMAN SERVICES AND FRANKLIN COUNTY LITERACY COUNCIL TO ENHANCE, PROMOTE AND OFFER COMMUNITY PROGRAMS FOR THE HEALTH AND WELLBEING OF RESIDENTS IN SOUTH CENTRAL PENNSYLVANIA. 173385654 1 1 0 0 0 0 0 0 0 1 1 1 0 0 1 1 1 1 0 0 1 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 174 0 1 2006 1 1 1 1 CJ 0 0 0 0 0 0 0 0 X 18 16 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 PA X KIMBERLY M RZOMP - VICE PRESIDENT AND CFO 7172677107 112 N SEVENTH STREET CHAMBERSBURG PA 17201 PHILIP E FAGUE 0.10 X X 0 0 0 JOHN VANHORN 0.10 X X 0 0 0 MICHAEL J COLLI MD 0.20 X X 0 0 0 PATRICK W O'DONNELL 24.00 16.00 X X 325255 216836 99213 NORMAN B EPSTEIN 28.00 12.00 X X 1174116 503193 101974 NANCY H MEYERS ESQUIRE 0.20 X 0 0 0 DENNIS L WILSON 0.30 X 0 0 0 DENISE B BARROWS CPA 0.30 X 0 0 0 PETER LAGIOVANE 0.20 X 0 0 0 CHRISTINE A MOLLY MD 0.30 X 0 0 0 ROGER J ROBERTSON MD 0.30 X 0 0 0 LYNN C ROTZ CPA 0.10 X 0 0 0 MICHAEL STARR 0.10 X 0 0 0 CHERYL PLUMMER 0.10 X 0 0 0 JEFF REEDER 0.10 X 0 0 0 L MICHAEL ROSS 0.10 X 0 0 0 SUZANNE TRINH 0.10 X 0 0 0 JOHN BOOZER 0.10 X 0 0 0 JOHN MASSIMILLA 40.00 X 283820 0 60253 KIMBERLY M RZOMP 33.00 7.00 X 174957 9209 47209 LOUIS GREGORIO 40.00 X 241764 0 47492 THOMAS ANDERSON MD 32.00 8.00 X 328232 82058 42225 PATRICIA BARBAROWICZ 30.00 10.00 X 144508 48169 60220 SHERRI STAHL 32.00 8.00 X 212528 53132 47558 BARBARA ROSSINI 30.00 10.00 X 92389 30797 18496 MICHELE ZEIGLER 28.00 12.00 X 197014 84435 50810 DAVID GRANT 40.00 X 202673 0 40352 EVAN T PRIESTON 40.00 X 160874 0 51631 AMANDA G SCHMEIDER 40.00 X 168563 0 33985 MELISSA YOWONSKE 40.00 X 160495 0 15176 KELLAN COOK 40.00 X 160022 0 30674 4027210 1027829 747268 77 0 1 0 AMERISOURCE BERGEN PO BOX 5187 NEW YORK NY 10087 PARAMEDICALS 6615786 CUMERLAND VALLEY ER ASSOCIATION 720 ORCHARD COURT CHAMBERSBURG PA 17201 ER DOCTORS 6384508 OWENS & MINOR INC PO BOX 360878 PITTSBURGH PA 15251 MEDICAL SUPPLIES 6363266 GE MEDICAL SYSTEMS 5517 COLLECTIONS CENTER DRIVE CHICAGO IL 60693 MEDICAL SUPPLIES 4219797 HOSPITAL BUILDING & EQUIPMENT 11330 OLIVE BOULEVARD ST LOUIS MO 63141 CONSTRUCTION CONTRACTOR 3089752 151 481961 481961 PATIENT SERVICE REVENUE 621990 262845673 262845673 262845673 3568727 3568727 475472 649736 -174264 -174264 -174264 4212664 5108163 0 6000270 4212664 -892107 3320557 3320557 UNRELATED BUSINESS INCOME 621990 2926705 2926705 EHR MEANINGFUL USE REIMBURSEMENT 621990 2404935 2404935 COURIER AND LAB SERVICES 621500 1762121 1762121 1254619 811568 443051 8348380 278391034 266062176 4688826 7158071 851828 851828 3721033 3721033 96875791 72706750 24169041 11574733 8634583 2940150 22232133 16238356 5993777 7267697 5276291 1991406 384969 384969 65038 65038 13524663 6227768 7296895 965821 628140 337681 480358 236466 243892 4713333 1160596 3552737 162902 39861 123041 133596 12116 121480 4308832 3337937 970895 12706471 9843365 2863106 2028369 1571323 457046 SUPPLIES 36079421 33524198 2555223 CONTRACTED SERVICES 13694251 10170298 3523953 EQUIPMENT RENTAL & MAIN 4196833 2761445 1435388 TELEPHONE 481738 36567 445171 1004225 127766 876459 237454035 173385654 64068381 0 6929 6840 9802491 25116917 117070 20950348 21869564 3125408 3162468 2164527 2182608 3356332 3787742 350171555 190469339 151460383 159702216 29923261 44410638 189202580 180549497 34641082 17474930 444750411 458263420 33378549 24206683 140683727 138683656 117232506 87546812 291294782 250437151 X 146627998 200321084 303 6827631 7504882 153455629 207826269 444750411 458263420 X 40936999 4467288 8966353 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1234952 202502 158035 -30902 1564587 1254623 -627 -19044 1234952 1056054 217297 18728 1254623 962458 110820 17224 1056054 1196623 -204425 29740 962458 0.63000 0.37000 1 0 6257981 6257981 161525784 50216358 111309426 167760143 134682858 33077285 10574677 4052970 5570123 9057524 159702216 18151514 F CASH AND MONEY FUNDS 11861053 F FIXED INCOME SECURITIES 103916004 F OTHER INVESTMENTS 105401 F HEDGE FUNDS 21001367 F GOVERNMENT AGENCY OBLIGATIONS 10782994 F CORPORATE AND FOREIGN BONDS 14731164 F 180549497 ADVANCES FROM THIRD-PARTY PAYORS 11978424 OTHER LIABILITIES 4088116 ESTIMATED AMOUNTS PAYABLE UNDER THIRD PARTY AGREEMENTS 8351061 ACCRUED PENSION OBLIGATION 46530826 OBLIGATIONS UNDER INTEREST RATE SWAP AGREEMENTS 16598385 87546812 X 286969599 15711020 15711020 271258579 7132455 7132455 278391034 236602207 0 236602207 851828 851828 237454035 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ENDOWMENT FUNDS ARE TO BE USED FOR DEVELOPMENT OR EXPANSION OF COMMUNITY HEALTHCARE INIATIVES AND PROGRAMS. FUNDS ARE ALSO USED TO EDUCATE THE COMMUNITY ABOUT HEALTHCARE ISSUES. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AND HAS BEEN RECOGNIZED AS TAX-EXEMPT PURSUANT TO SEC. 501(C) (3) OF THE INTERNAL REVENUE CODE. IT IS CLASSIFIED AS A PUBLIC CHARITY. THE HOSPITAL RECOGNIZED INCOME FROM PAYMENTS AND REFUNDS OF $ 8,000 AND EXPENSED $ 222,000 FOR ESTIMATED UNRELATED BUSINESS INCOME TAXES FOR THE YEARS ENDED JUNE 30, 2013 AND 2012, RESPECTIVELY. WITH FEW EXCEPTIONS, THE HOSPITAL IS NO LONGER SUBJECT TO FEDERAL INCOME TAX EXAMINATIONS BY TAX AUTHORITIES FOR YEARS BEFORE 2010. WHEN TAX RETURNS ARE FILED, IT IS HIGHLY CERTAIN THAT SOME POSITIONS TAKEN WOULD BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES, WHILE OTHERS ARE SUBJECT TO UNCERTAINTY ABOUT THE MERITS OF THE POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD BE ULTIMATELY SUSTAINED. THE BENEFIT OF A TAX POSITION IS RECOGNIZED IN THE FINANCIAL STATEMENTS IN THE PERIOD DURING WHICH, BASED ON ALL AVAILABLE EVIDENCE, MANAGEMENT BELIEVES IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING THE RESOLUTION OF APPEALS OR LITIGATION PROCESSES, IF ANY. TAX POSITIONS TAKEN ARE NOT OFFSET OR AGGREGATED WITH OTHER POSITIONS. TAX POSITIONS THAT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD ARE MEASURED AS THE LARGEST AMOUNT OF TAX BENEFIT THAT IS MORE THAN 50 PERCENT LIKELY OF BEING REALIZED UPON SETTLEMENT WITH THE APPLICABLE TAXING AUTHORITY. THE PORTION OF THE BENEFITS ASSOCIATED WITH TAX POSITIONS TAKEN THAT EXCEEDS THE AMOUNT MEASURED AS DESCRIBED ABOVE WOULD BE REFLECTED AS A LIABILITY FOR UNRECOGNIZED TAX BENEFITS IN THE ACCOMPANYING BALANCE SHEETS ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. INTEREST AND PENALTIES ASSOCIATED WITH UNRECOGNIZED TAX BENEFITS WOULD BE CLASSIFIED AS EXPENSES AGAINST OTHER OPERATING REVENUE IN THE STATEMENTS OF OPERATIONS. AT JUNE 30, 2013 AND 2012, THERE WAS NO LIABILITY FOR UNRECOGNIZED TAX BENEFITS. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN VALUE OF DERIVATIVES 15,711,020. PART XI, LINE 4B - OTHER ADJUSTMENTS: NET REALIZED LOSSES SHOWN ELSEWHERE ON FINANCIAL STATEMENTS 4,212,664. INVESTMENT INCOME SHOWN ELSEWHERE ON FINANCIAL STATEMENTS 3,568,727. RENTAL INCOME (EXPENSE) SHOWN ELSEWHERE ON FINANCIAL STATEMENTS -174,264. GAIN(LOSS) ON DISPOSAL OF EQUIPMENT SHOWN ELSEWHERE ON FINANCIAL STATEMENTS -892,107. CONTRIBUTION INCOME SHOWN ELSEWHERE ON FINANCIAL STATEMENTS 417,435. PART XII, LINE 4B - OTHER ADJUSTMENTS: GRANT EXPENSE SHOWN ELSEWHERE ON FINANCIAL STATEMENTS 851,828. CENTRAL AMERICAN AND CARRIBBEAN 0 0 INVESTMENT IN ALTERNATIVE VEHICLE 19469735 0 0 0 0 0 0 19469735 0 19469735 0 0 1 0 0 0 1 1 X 1 X 1 X 1 1 1 0 1 1 3616604 3616604 0.01520 11760116 11760116 0.04950 36680 36680 0.00020 15413400 15413400 0.06490 17 10852 284883 284883 0.00120 2 241 134502 134502 0.00060 2 19 1979744 1979744 0.00830 0 5 1205341 1205341 0.00510 26 11112 3604470 3604470 0.01520 26 11112 19017870 19017870 0.08010 1 29 6771 6771 0.00000 2 84 3 113 6771 6771 0 21406537 69280187 85349093 -16068906 X 1 1 1 1 THE CHAMBERSBURG HOSPITAL

112 NORTH SEVENTH STREET CHAMBERSBURG PA 17201

X THE CHAMBERSBURG HOSPITAL 1 1 X X X X X X X X X 12 1 1 1 X X X X X X X 1 0 1 1 150.000000000000 1 300.000000000000 1 X X X X 1 1 X X X X X X 1 1 X X X X 1 X 0 0 PART I, LINE 3C: THE ORGANIATION USES FEDERAL POVERTY GUIDELINES (FPG) TO DETERMINE CHARITY CARE. PART I, LINE 7: THE ORGANIZATION USES FEDERAL POVERTY GUIDLINES (FPG) TO DETERMINE CHARITY CARE. NOTE 1. TO THE FINANCIAL STATEMENTS: PATIENT RECEIVABLESTHE HOSPITAL PROVIDES CREDIT IN THE NORMAL COURSE OF ITS BUSINESS TO PATIENTS. PATIENT RECEIVABLES ARE GENERALLY DUE 30 DAYS AFTER BILLED. AN ALLOWANCE FOR DOUBTFUL ACCOUNTS IS CARRIED FOR PATIENT ACCOUNTS THAT MAY BECOME UNCOLLECTIBLE IN FUTURE PERIODS. THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IS BASED ON MANAGEMENT'S JUDGMENT OF UNCOLLECTIBLE ACCOUNTS, HISTORICAL TRENDS, AND OTHER INFORMATION. PATIENT RECEIVABLES ARE CHARGED AGAINST THE ALLOWANCE WHEN, IN THE JUDGMENT OF MANAGEMENT, IT IS UNLIKELY THEY WILL BE COLLECTED. THE SHORTFALL FOR MEDICARE IS NOT INCLUDED IN OUR COMMUNITY BENEFIT REPORTING. A COST TO CHARGE RATIO WAS USED TO CALCULATE THE MEDICARE ALLOWABLE COST. ALL PATIENTS ARE SUBJECT TO THE DEBT COLLECTION POLICY, REGARDLESS OF THEIR ABILITY TO PAY. PART II: CHAMBERSBURG HOSPITAL WORKS TO STRENGTHEN OUR COMMUNITY THROUGH HEALTH EDUCATION EFFORTS FOR CHILDREN AND ADULTS, HEALTH FAIRS PROVIDING HEALTH SCREENINGS, EDUCATING COMMUNITY GROUPS ON SPECIFIC HEALTH TOPICS, FUNDING HEALTH PROGRAMS OF LOCAL NONPROFIT ORGANIZATIONS THROUGH THE SUMMIT ENDOWMENT PROGRAM, PROVIDING CAPACITY-BUILDING WORKSHOPS AND ASSISTANCE THROUGH SUMMIT ENDOWMENT, PARTICIPATING IN MANY LOCAL CIVIC ORGANIZATIONS, SPONSORING EVENTS HELD BY LOCAL CHARITABLE ORGANIZATIONS, AND SUPPORTING WORKFORCE DEVELOPMENT INITIATIVES THROUGH SUMMIT HEALTH'S SCHOOL LIAISON PROGRAMS. PART III, LINE 4: THE HOSPITAL PROVIDES CREDIT IN THE NORMAL COURSE OF ITS BUSINESS TO PATIENTS. PATIENT RECEIVABLES ARE GENERALLY DUE 60 DAYS AFTER BILLED. AN ALLOWANCE FOR DOUBTFUL ACCOUNTS IS CARRIED FOR PATIENT ACCOUNTS THAT MAY BECOME UNCOLLECTIBLE IN FUTURE PERIODS. THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IS BASED ON MANAGEMENT'S JUDGMENT OF UNCOLLECTIBLE ACCOUNTS, HISTORICAL TRENDS AND OTHER INFORMATION. PATIENT RECEIVABLES ARE CHARGED AGAINST THE ALLOWANCE WHEN, IN THE JUDGMENT OF MANAGEMENT, IT IS UNLIKELY THEY WILL BE COLLECTED. THE SHORTFALL FOR MEDICARE IS NOT INCLUDED IN OUR COMMUNITY BENEFIT REPORTING. A COST TO CHARGE RATIO WAS USED TO CALCULATE THE MEDICARE ALLOWABLE COST. ALL PATIENTS ARE SUBJECT TO THE DEBT COLLECTION POLICY REGARDLESS OF THEIR ABILITY TO PAY. PART III, LINE 8: THE INFORMATION WAS OBTAINED USING COST METHODS USED IN PREPARING THE MEDICARE COST REPORT. THE SHORTFALL ABOVE RELATES TO OUR MISSION OF PROVIDING SERVICES TO MEMBERS OF OUR COMMUNITY. THE CHAMBERSBURG HOSPITAL PART V, SECTION B, LINE 3: THE ORGANIZATION FORMED AN ADVISORY GROUP WHICH IS COMPOSED OF A CORE GROUP OF AGENCIES AND COMMUNITY LEADERS IN FRANKLIN COUNTY. THE ORGANIZATION ALSO CONTRACTED THE PENN STATE HARRISBURG'S INSTITUTE OF STATE AND REGIONAL AFFAIRS.PENN STATE OBTAINED DATA THROUGH THE USE OF FOCUS GROUPS, A COMMUNITY SURVEY, AND RESEARCHING SECONDARY DEMOGRAPHIC AND HEALTH DATA. THE CHAMBERSBURG HOSPITAL PART V, SECTION B, LINE 4: WAYNESBORO HOSPITAL THE CHAMBERSBURG HOSPITAL PART V, SECTION B, LINE 12H: UNINSURED PATIENTS ARE OFFERED A 35% DISCOUNT IF PAYMENT IS MADE IN 30 DAYS. THE CHAMBERSBURG HOSPITAL PART V, SECTION B, LINE 20D: A SLIDING SCALE IS USED TO DETERMINE THE DISCOUNTED RATE. ANYONE WHO QUALIFIES RECEIVES A MINIMUM OF 25% OFF CHARGES. PART VI, LINE 2: HEALTH NEEDS OF FRANKLIN COUNTY RESIDENTS AND SURROUNDING COMMUNITIES ARE ASSESSED THROUGH NUMEROUS RESEARCH METHODS INCLUDING CONDUCTING A COMMUNITY HEALTH NEEDS ASSESSMENT (TELEPHONE SURVEY FORMAT) IN 2012. THE NEEDS WERE IDENTIFIED BY KEY LEADERS AND NONPROFITS WITHIN THE COMMUNITY. FOUR PRIORITIES WERE DETERMINED. PART VI, LINE 3: PATIENTS ARE MADE AWARE OF THE CHARITY PROGRAM AND OTHER BILLING ASSISTANCE SERVICES AT REGISTRATION, DURING EMERGENCY ROOM VISITS, AND NOTICES PLACED IN SERVICE AREAS. BILLING STATEMENTS ALSO INFORM PATIENTS OF CHARITY CARE AND OTHER BILLING ASSISTANCE PROGRAMS. AVAILABILITY OF CHARITY PROGRAMS IS ALSO LISTED ON OUR WEBSITE. PART VI, LINE 4: CHAMBERSBURG HOSPITAL PRIMARILY SERVES COMMUNITY MEMBERS FROM FRANKLIN COUNTY, PA, AND NEARBY COMMUNITIES IN FULTON COUNTY, PA, CUMBERLAND COUNTY, PA, AND WASHINGTON COUNTY, MD. ACCORDING TO U.S. CENSUS DATA, FRANKLIN COUNTY RESIDENTS HAVE A SLIGHTLY LOWER INCOME AND ARE SLIGHTLY OLDER THAN THE STATE AVERAGE. FOR A HEALTH SYSTEM, THIS TYPICALLY RESULTS IN AN INCREASED NEED FOR HEALTHCARE SERVICES. PART VI, LINE 5: CHAMBERSBURG HOSPITAL PROVIDES FINANCIAL AND MANAGERIAL SUPPORT TO KEYSTONE HEALTH, A RURAL HEALTH CENTER THAT SERVES THE UNDERPRIVLEGED COMMUNITY. IN ADDITION, THE HOSPITAL SUPPORTS LOCAL NON-PROFIT ORGANIZATIONS WITH FINANCIAL GRANTS FROM THE SUMMIT ENDOWMENT AS WELL AS PARTNERING WITH OTHER NON-PROFITS IN THE COMMUNITY TO HELP ENHANCE PROGRAMS THAT IMPROVE THE HEALTH AND WELL-BEING IN OUR COMMUNITY. PART VI, LINE 6: THE HOSPITAL IS PART OF SUMMIT HEALTH, A REGIONAL NETWORK OF TWO HOSPITALS, OUTPATIENT DIAGNOSTIC AND ANCILLARY SERVICES OFFICES, AND HEALTHCARE PROVIDERS. CHAMBERSBURG HOSPITAL AND THESE SUMMIT ENTITIES ARE SERVED BY THE ORGANIZATION'S COMMUNITY HEALTH DEPARTMENT. THIS DEPARTMENT'S MISSION IS TO IMPROVE THE HEALTH OF THE COMMUNITY THROUGH EDUCATION, EARLY DETECTION AND PREVENTION PROGRAMS INCLUDING HEALTH FAIRS, SCREENINGS, AND SEMINARS. MANY OF THE DEPARTMENT'S PROGRAMS ARE PLANNED AND PROVIDED THROUGH COLLABORATION WITH OTHER COMMUNITY ORGANIZATIONS, INCLUDING THE PA DEPARTMENT OF HEALTH. 1 PSMA NURSING PROGRAM PSU MONT ALTO 1 CAMPUS DR MONT ALTO PA 17237 130000 PROVIDE SUPPORT FOR TWO NURSING FACULTY POSITIONS IN THE REGISTERED NURSE ASSOCIATE DEGREE PROGRAM. WAYNESBORO COMMUNITY & HUMAN SERVICES 123 WALNUT STREET WAYNESBORO PA 17268 72582 PROVIDE COMMUNITY NURSING PROGRAM IN WASHINGTON TOWNSHIP. INTERFAITH HOUSING ALLIANCE 731 NORTH MARKET STREET FREDERICK MD 21701 7340 PROVIDE GROWING STRONGER PROGRAM, IMPLEMENTING ONSITE HEALTH AND WELLNESS PROGRAM PENN STATE CO-OPERATIVE EXTENSION (ADAMS COUNTY) 670 OLD HARRISBURG ROAD SUITE 204 GETTYSBURG PA 17325 10503 PROVIDE DINING WITH DIABETES, A RESEARCH-BASED EDUCATION PROGRAM THROUGH PENN STATE COOPERATIVE EXTENSION, 3 SERIES OF 6 CLASSES WILL BE OFFERED LIU 2 FRANKLIN COUNTY LITERACY 65 BILLERBECK STREET NEW OXFORD PA 17350 13567 PROVIDE AN ESL HEALTHY LITERACY PROGRAM GREENCASTLE ANTRIM ENDOWMENT SCHOLARSHIPS 785 5TH AVENUE SUITE 1 CHAMBERSBURG PA 17201 6000 PROVIDES THREE ONE-YEAR SCHOLARSHIPS. PROVIDES A CARDIAC INTERVENTIONAL MEDICINE PROGRAM. KEYSTONE RURAL HEALTH CENTER - DENTAL CARE 767 FIFTH AVENUE SUITE B-3A CHAMBERSBURG PA 17201 5000 PROVIDES AN INFANT AND TODDLER CAVITIES PREVENTION PROGRAM. VOUCHERS PROVIDED TO INDIVIDUALS FOR PURCHASE OF CARDIAC MEDICATIONS. 13 5000 FMV PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: ALL FUNDING DECISIONS ARE MADE BY THE SUMMIT ENDOWMENT COMMITTEE, A COMMITTEE OF THE SUMMIT HEALTH BOARD. THE ENDOWMENT MANAGER PROCESSES GRANT APPLICATIONS, ASSISTS GRANTEES IN DEVELOPING SOUND PROGRAM EVALUATION METHODOLOGIES, RECEIVES AND SUMMARIZES PERIODIC REPORTS, AND VISITS PROGRAM SITES, REPORTING ALL ACTIVITIES TO THE SUMMIT ENDOWMENT COMMITTEE. AS WELL, ENDOWMENT COMMITTEE MEETING MINUTES ARE SHARED WITH WAYNESBORO HOSPITAL, CHAMBERSBURG HOSPITAL AND SUMMIT HEALTH BOARDS. X X 1 1 X X X X X 0 1 0 0 0 0 0 1 0 PATRICK W O'DONNELL 246407 164271 60734 40489 18114 12076 48072 32048 11456 7637 384783 256521 0 0 NORMAN B EPSTEIN 993363 425727 150150 64350 30603 13116 54673 23431 16709 7161 1245498 533785 0 0 JOHN MASSIMILLA 219642 0 42532 0 21646 0 41307 0 18946 0 344073 0 0 0 KIMBERLY M RZOMP 145801 7674 27930 1470 1226 65 26584 1399 18265 961 219806 11569 0 0 LOUIS GREGORIO 188561 0 37267 0 15936 0 28177 0 19315 0 289256 0 0 0 THOMAS ANDERSON MD 260476 65119 47124 11781 20632 5158 20577 5144 13203 3301 362012 90503 0 0 PATRICIA BARBAROWICZ 118336 39445 20233 6744 5939 1980 42715 14238 2450 817 189673 63224 0 0 SHERRI STAHL 166119 41530 30606 7651 15803 3951 24926 6231 13121 3280 250575 62643 0 0 MICHELE ZEIGLER 154838 66359 28182 12078 13994 5998 24015 10292 11552 4951 232581 99678 0 0 DAVID GRANT 179373 0 23000 0 300 0 26996 0 13356 0 243025 0 0 0 EVAN T PRIESTON 145897 0 13000 0 1977 0 32417 0 19214 0 212505 0 0 0 AMANDA G SCHMEIDER 150813 0 17750 0 0 0 20176 0 13809 0 202548 0 0 0 MELISSA YOWONSKE 157495 0 3000 0 0 0 6628 0 8548 0 175671 0 0 0 KELLAN COOK 142272 0 17750 0 0 0 6288 0 24386 0 190696 0 0 0 PART I, LINE 1A THE OFFICERS RECEIVE AN ALLOWANCE THAT CAN BE CONSIDERED A DISCRETIONARY SPENDING ACCOUNT. THE MONIES ARE IN LIEU OF AN AUTOMOBILE ALLOWANCE, TO PURCHASE ADDITIONAL LIFE INSURANCE, ETC. THESE MONIES ARE INCLUDED IN COMPENSATION AS REPORTED IN THE COMPENSATION OF OFFICERS TABLE. RESULTS FITNESS CLUB MEMBERSHIP IS AVAILABLE FREE OF CHARGE FOR ANY OFFICER AND ACTIVE BOARD MEMBER. PART I, LINE 4B NORMAN EPSTEIN - NONE PATRICK W. O'DONNELL - NONE LOUIS GREGORIO - NONE JOHN MASSIMILLA - NONE PAT BARBAROWICZ - NONE TOM ANDERSON - NONE SHERRI STAHL - NONE PART I, LINE 7 INCENTIVE COMPENSATION IS BASED ON PRE-DETERMINED, MEASURABLE GOALS APPROVED BY THE BOARD OF DIRECTORS' EXECUTIVE COMPENSATION COMMITTEE. THE MEASURABLE GOALS ARE BASED ON QUALITY, COMMUNITY ACCESS TO CARE, PATIENT SAFETY AND LEADERSHIP. A FCIDA HEALTH CARE REVENUE BONDS SERIES 2009-08-24 30000000 ISSUED TO REFINANCE SERIES OF 2000 0 0 0 B FRANKLIN COUNTY INDUSTRIAL DEVELOPMENT 230458500 2010-08-28 127225000 NEW BUILDING AND REFINANCE 1998 BOND 0 0 0 A 30000000 117184 0 1 1 1 B 127225000 9955256 5217332 1721680 8664801 33199963 0 1 1 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 A 0 0 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 SUMMIT HEALTH, A 501(C)(3) ENTITY, IS A MEMBER OF THIS ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A SUMMIT HEALTH, A 501(C)(3) ENTITY, ELECTS THE GOVERNING BODY OF THIS ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7B SUMMIT HEALTH, A 501(C)(3) ENTITY, HAS CERTAIN RESERVE POWERS OVER THIS ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11 PRIOR TO FILING THE 990 IS REVIEWED BY THE AUDIT COMMITTEE AND PRESENTED TO FULL BOARD OF DIRECTORS FOR APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C MEMBERS ARE ASKED TO ANNUALLY DISCLOSE ANY CONFLICTS OF INTEREST THEY MAY HAVE. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION IS DISCUSSED WITH AN INDEPENDENT COMPENSATION COMMITTEE. THIS IS PERFORMED IN CONCERT WITH A COMPENSATION CONSULTANT WHO ASSISTS THE COMMITTEE IN SETTING THE COMPENSATION FOR THESE INDIVIDUALS. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. THESE DOCUMENTS ARE HELD IN THE FINANCE DEPARTMENT OF THE CHAMBERSBURG HOSPITAL. HOSPITAL BYLAWS AND ALL POLICIES AND PROCEDURES ARE FOUND ON THE CHAMBERSBURG HOSPITAL INTRANET. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: TRANSFER TO AFFILLIATED ORGANIZATION - SUMMIT HEALTH -2,563,122. TRANSFER TO AFFILLIATED ORGANIZATION - SUMMIT PHYSICIAN SERVICES -19,374,796. CHANGE IN VALUE OF DERIVATIVE 15,711,020. PENSION RELATED CHANGES OTHER THAN NET PERIODIC PENSION COST 15,193,251. 990 PART XII LINE 2C THE PROCESS HAS NOT CHANGED SINCE THE PRIOR YEAR. SUMMIT HEALTH 112 NORTH SEVENTH STREET CHAMBERSBURG PA 17201 251515371 MANAGE AND ADMINISTER THE LOCAL AND REGIONAL NETWORK OF HEALTHCARE PROVIDERS PA 501(C)(3) 7 SUMMIT HEALTH 0 WAYNESBORO HOSPITAL 501 EAST MAIN STREET WAYNESBORO PA 17268 231360854 SERVE THE HEALTH CARE NEEDS OF FRANKLIN COUNTY PA AND THE SURROUNDING COMMUN PA 501(C)(3) 3 SUMMIT HEALTH 0 CHAMBERSBURG HEALTH SERVICES 260 NORTH SEVENTH STREET CHAMBERSBURG PA 17201 251515376 SERVE THE HEALTH CARE NEEDS OF FRANKLIN COUNTY PA AND THE SURROUNDING COMMUN PA 501(C)(3) 11A - TYPE 1 SUMMIT HEALTH 0 SUMMIT PHYSICIAN SERVICES 785 FIFTH AVENUE SUITE 3 CHAMBERSBURG PA 17201 251716306 MANAGE AND ADMINISTER THE LOCAL AND REGIONAL NETWORK OF HEALTHCARE PROVIDERS PA 501(C)(3) 11A - TYPE 1 SUMMIT HEALTH 0 SUMMIT SURGERY CENTER LP 757 NORLAND AVENUE CHAMBERSBURG PA 17201 251845303 SERVE THE SURGICAL HEALTH NEEDS OF FRANKLIN COUNTY PA AND THE SURROUNDING CO PA NOT A DISREGARDED ENTITY FOR TAX PURPOSES RELATED 6244 17419 0 0 0.00650 SURGERY CENTER ASSOCIATES LLC 757 NORLAND AVENUE CHAMBERSBURG PA 17201 251845304 SERVE THE SURGICAL HEALTH NEEDS OF FRANKLIN COUNTY PA AND THE SURROUNDING CO PA NOT A DISREGARDED ENTITY FOR TAX PURPOSES RELATED 125 203 0 1 0.01000 0 0 1 0 0 0 0 0 0 1 1 0 0 0 0 1 1 1 0