2014-05-15T08:38:25-05:00 2013-06-30 232932984 PARENTEBEARD LLC 1650 MARKET STREET SUITE 4500 PHILADELPHIA PA 19103 990 2012-07-01 240792115 JERSEY SHORE HOSPITAL JERS 5703980100 1020 THOMPSON STREET JERSEY SHORE PA 17740 DAVID SHANNON 5703980100 2014-05-14 1 JULIUS C GREEN CPA JD P00350393 2159720701 2012 2015-11-30 17:44:51Z DAVID SHANNON 1020 THOMPSON ST JERSEY SHORE PA 17740 32123907 0 X WWW.JSH.ORG X 1922 PA PROVIDE INPATIENT, OUTPATIENT, AND EMERGENCY CARE SERVICES FOR RESIDENTS OF JERSEY SHORE AREA. 11 8 338 8 579956 -5189 202636 241789 29702490 30018665 7186 5589 526999 1803734 30439311 32069777 2971067 0 0 0 14393091 14878300 0 0 0 16767536 16251815 34131694 31130115 -3692383 939662 26311495 28890899 22403553 22690697 3907942 6200202 X JERSEY SHORE HOSPITAL IS A RURAL HEALTHCARE FACILITY COMMITTED TO PROVIDING QUALITY HEALTH SERVICES WITH AN EFFICIENT BALANCE OF OUTPATIENT CARE, ACUTE AND SUB-ACUTE INPATIENT CARE AND OUTREACH SERVICES. THE HOSPITAL MAXIMIZES THE EFFECTIVENESS OF ITS PROGRAM THROUGH INTEGRATION WITH OTHER HEALTHCARE PROVIDERS TO ASSURE THE COMMUNITY ACCESS TO A BROAD ARRAY OF HEALTH CARE SERVICES. 0 0 27308333 30634176 AS A RURAL HEALTHCARE FACILITY AND DEDICATED COMMUNITY HOSPITAL WITH A COMMITMENT TO PROVIDING A HIGH QUALITY CIRCLE OF CARE, JERSEY SHORE HOSPITAL HAS DEVELOPED DELIVERY SYSTEMS THAT PROVIDE AN EFFICIENT BALANCE OF OUTPATIENT CARE, ACUTE AND SUB-ACUTE INPATIENT CARE, PRIMARY CARE, AND OUTREACH SERVICES. THE HOSPITAL MAXIMIZES THE EFFECTIVENESS OF ITS PROGRAMS FOR QUALITY, EFFICIENCY, AND ACCESSIBILITY BY INTEGRATING WITH OTHER PROVIDERS AND ALTERNATIVE CARE ORGANIZATIONS IN THE SERVICE COMMUNITY TO ASSURE THE COMMUNITY ACCESS TO A BROAD ARRAY OF SERVICE OPTIONS.THE HOSPITAL PROVIDES AN ENVIRONMENT OF CARE THAT IS COMPASSIONATE, HIGHLY PERSONALIZED, AND FOCUSED ON THE PHYSICAL, PSYCHO-SOCIAL, AND SPIRITUAL NEEDS OF ITS PATIENTS THROUGH THE USE OF SKILLED NURSES, PHYSICIANS, TECHNICAL AND SUPPORT STAFF, MANAGEMENT, AND COMMUNITY LEADERS. THE HOSPITAL ALSO PROVIDES HEALTH EDUCATION, PROGRAMS IN PREVENTION, AND RELATED SUPPORT SERVICES TO THE COMMUNITY WITH THE GOAL OF IMPROVING THE OVERALL WELLNESS OF ITS RESIDENTS. THE HOSPITAL ENSURES THAT THE NECESSARY RESOURCES ARE AVAILABLE TO PROVIDE FOR COMPREHENSIVE, MANAGED HEALTH PROGRAMS IN THE MOST COST EFFECTIVE MANNER WHILE MAINTAINING A SAFE, PLEASANT, AND MEANINGFUL WORK AND PATIENT CARE ENVIRONMENT.THE HOSPITAL PROVIDES CHARITY CARE TO PATIENTS WHO MEET CERTAIN CRITERIA WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. CHARGES FORGONE FOR SERVICES RENDERED AND SUPPLIES FURNISHED UNDER THE CHARITY CARE POLICY AMOUNTED TO APPROXIMATELY $586,398 DURING THE YEAR ENDED JUNE 30, 2013. 27308333 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 1 1 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 1 142 0 1 338 1 1 1 0 0 0 0 1 1 0 0 0 0 X 11 8 1 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 PA X DAVID SHANNON- PRESIDENTCEO 5703983101 1020 THOMPSON STREET JERSEY SHORE PA 17740 X CAREY PLUMMER DEPARTED 5114 39.00 1.00 X X 299155 0 0 LEROY H KEILER III 1.00 1.00 X 0 0 0 WILLIAM R CAMERER III 1.00 X X 0 0 0 CARMEN SPINNEY MD 1.00 39.00 X X 0 170183 5212 JAMES REESER 1.00 X 0 0 0 RICHARD BEATTY DMD 1.00 1.00 X X 0 0 0 WALTER EISENHAUER 1.00 X 0 0 0 JAMES ELY 1.00 1.00 X 0 0 0 SEAN SIMCOX 1.00 X X 0 0 0 ROB GLUNK 1.00 1.00 X 0 0 0 DOROTHY CHAPPEL PHD 1.00 X 0 0 0 LISA STRAWSER DO 1.00 X 0 0 0 MARK RICE 39.00 1.00 X 79210 0 12481 DEAN FLEMING 39.00 1.00 X 93325 0 816 AARON KOLB MD 40.00 X 308499 0 13247 THOMAS BURGE 40.00 X 149569 0 2849 RONALD EISTER 40.00 X 292791 0 10639 SHAIRKO MISSOURI 40.00 X 452015 0 10319 HOSNY MIKHAIL 39.00 X 319012 0 4454 1993576 170183 60017 9 0 1 0 JERSEY SHORE RADIOLOGY 302 N THIRD STREET LEWISBURG PA 17837 RADIOLOGY TESTS INTREPRETATIONS 1237219 QUORUM HEALTH RESOURCES 105 CONTINENTAL PLACE BRENTWOOD TN 370271018 MANAGEMENT FEES 573532 MEDICAL STAFFING NETWORK PO BOX 202996 DALLAS TX 753202996 ER PHYSICIAN LOCUMS 504844 SUSQUEHANNA HEALTH SYSTEM 1205 GRAMPIAN BOULEVARD WILLIAMSPORT PA 17701 IT SUPPORT/LAB TEST INTERPRETATION 392377 STAFF CARE INC PO BOX 281923 ATLANTA GA 303841923 ER PHYSICIAN LOCUMS 204193 8 11194 203147 27448 241789 PATIENT SERVICE REV 621110 30018665 30018665 30018665 19311 19311 83716 30763 52953 52953 52953 13722 -13722 -13722 -13722 9865 11194 9645 220 220 MEANINGFUL USE 622000 615511 615511 LAB SERVICES 900099 579956 579956 CLINIC REVENUE 621400 295390 295390 259704 259704 1750561 32069777 30634176 579956 613856 X 433289 433289 11415125 10245063 1170062 466775 404064 62711 1717349 1498133 219216 845762 732133 113629 56928 56928 70000 70000 3298 3298 4790923 3818628 972295 45305 45305 496005 290370 205635 726435 562569 163866 577336 533243 44093 61704 50995 10709 21683 5332 16351 856087 856087 2197967 2197967 405983 405983 BAD DEBT EXPENSE 3334032 3334032 MEDICAL SUPPLIES 1053774 1053774 NONCHARGE SUPPLIES 542660 517956 24704 CHARGEABLE SUPPLIES 469200 469200 542495 284201 258294 31130115 27308333 3821782 0 2175 1200 1156008 1161073 70945 11068 3798829 3446820 277097 243070 329609 201690 37003742 19514689 17449975 17489053 3226857 6336925 26311495 28890899 3256150 2863811 14417074 14761344 4730329 5065542 22403553 22690697 X 3581965 6056609 325977 143593 3907942 6200202 26311495 28890899 X 939662 1352598 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3298 3298 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE HOSPITAL PAYS DUES TO THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE HOSPITAL ASSOCIATION OF PENNSYLVANIA (HAP). A PORTION OF THE DUES PAID TO THESE TWO ORGANIZATIONS ($3,298 DURING THE YEAR ENDED JUNE 30, 2013) WAS USED FOR LOBBYING PURPOSES. 154956 154956 17966533 6411618 11554915 18105910 12826184 5279726 776343 276887 499456 17489053 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 2974095 DEFERRED FINANCING COSTS, NET 111384 DUE FROM AFFILIATES 3010866 FUNDED DEPRECIATION 169679 OTHER ASSET 70901 6336925 OBLIGATIONS UNDER CAPITAL LEASES 1573184 BLUE CROSS CURRENT FINANCING ADVANCE 158704 FAIR VALUE OF DERIVATIVE INSTRUMENT 179803 ACCRUED PENSION COST 2093360 DEFERRED REVENUE 1060491 5065542 X 33476505 1352598 1352598 32123907 -54130 -54130 32069777 31184245 54130 54130 31130115 0 31130115 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL ACCOUNTS FOR UNCERTAINTY IN INCOME TAXES USING A RECOGNITION THRESHOLD OF MORE-LIKELY-THAN-NOT TO BE SUSTAINED UPON EXAMINATION BY THE APPROPRIATE TAXING AUTHORITY. MEASUREMENT OF THE TAX UNCERTAINTY OCCURS IF THE RECOGNITION THRESHOLD IS MET. MANAGEMENT DETERMINED THERE WERE NO TAX UNCERTAINTIES THAT MET THE RECOGNITION THRESHOLD IN 2013 AND 2012. THE HOSPITAL'S FEDERAL RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX, EXEMPT ORGANIZATION BUSINESS TAX RETURN, AND CORPORATE INCOME TAX RETURN FOR THE YEARS ENDED PRIOR TO JUNE 30, 2011 NO LONGER REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN FAIR VALUE OF DERIVATIVE INSTRUMENT 152,239. PENSION LIABILITY ADJUSTMENT 1,200,359. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSE -30,763. FUNDRAISING EXPENSE -9,645. LOSS ON SALE OF ASSET -13,722. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 30,763. FUNDRAISING EXPENSE 9,645. LOSS ON SALE OF ASSET 13,722. GOLF TOURNAMENT 21059 11194 9865 390 1200 4400 1834 1821 21059 11194 9865 390 1200 4400 1834 1821 9645 220 1 1 1 X 1 X 1 0 1 1 227279 227279 0.00820 2521605 1655999 865606 0.03110 2748884 1655999 1092885 0.03930 258835 21552 237283 0.00850 4989 4989 0.00020 263824 21552 242272 0.00870 3012708 1677551 1335157 0.04800 1 1292307 4856258 4856278 -20 X 1 1 1 1 JERSEY SHORE HOSPITAL

1020 THOMPSON STREET JERSEY SHORE PA 17740

X X X X JERSEY SHORE HOSPITAL 1 1 X X X X X X X X 12 1 0 1 X X X X 0 0 1 1 200.000000000000 1 250.000000000000 1 X X X 1 1 X X X 0 0 X X X X 1 X 0 0 PART I, LINE 7: THE HOSPITAL USED THE COST TO CHARGE RATIO. PART I, L7 COL(F): AMOUNT OF BAD DEBT EXPENSE FROM PART IX SUBTRACTED IN ORDER TO CALCULATE PERCENT OF TOTAL EXPENSE IN PART I LINE 7 COLUMN F WAS $3,334,032. PART III, LINE 4: ACCOUNTS RECEIVABLE, PATIENTS ARE REPORTED AT NET REALIZABLE VALUE. ACCOUNTS ARE WRITTEN OFF WHEN THEY ARE DETERMINED TO BE UNCOLLECTIBLE BASED UPON MANAGEMENT'S ASSESSMENT OF INDIVIDUAL ACCOUNTS, GENERALLY AFTER 120 DAYS OF COLLECTION EFFORTS. THE ALLOWANCE FOR DOUBTFUL COLLECTIONS IS ESTIMATED BASED UPON A PERIODIC REVIEW OF THE ACCOUNTS RECEIVABLE AGING, PAYOR CLASSIFICATIONS, AND APPLICATION OF HISTORICAL WRITE-OFF PERCENTAGES.BAD DEBT EXPENSE IS BASED ON THE NECESSARY ALLOWANCE AT THE END OF EACH MONTH.PATIENT DISCOUNTS ARE NOT INCLUDED IN BAD DEBT - THEY ARE INCLUDED IN CONTRACTUAL ADJUSTMENTS. PAYMENTS ON PATIENT ACCOUNTS ARE INCLUDED IN THE ALLOWANCE FOR BAD DEBTS.THE HOSPITAL IS DILIGENT IN THE CLASSIFICATION OF AMOUNTS AS CHARITY CARE OR BAD DEBT. WE BELIEVE NONE OF THE AMOUNTS IN BAD DEBT WOULD BE RECLASSIFIED TO CHARITY CARE GIVEN ADDITIONAL INFORMATION. PART III, LINE 8: THERE IS NO MEDICARE SHORTFALL - AS A CRITICAL ACCESS HOSPITAL, WE ARE REIMBURSED AT 101% OF COST FROM MEDICARE.ALLOWABLE COSTS WERE DETERMINED USING THE COST-TO-CHARGE RATIO FROM MEDICARE COST REPORT. PART III, LINE 9B: COLLECTIONS ARE PURSUED UP TO THE POINT THAT A PATIENT COMPLETES AND IS APPROVED FOR CHARITY CARE. ONCE CHARITY CARE IS APPROVED, NO FURTHER COLLECTION EFFORTS ARE MADE. JERSEY SHORE HOSPITAL PART V, SECTION B, LINE 3: TWO FOCUS GROUPS WITH COMMUNITY LEADERS AND STAKEHOLDERS WERE HELD ON AUGUST 15, 2012 AT JERSEY SHORE HOSPITAL. THE PURPOSE OF THE FOCUS GROUPS WAS TO GATHER QUALITATIVE DATA FROM "KEY INFORMANTS" ON LOCAL HEALTH ISSUES. KEY INFORMANTS WERE DEFINED AS AREA HEALTH CARE PROFESSIONAL, SOCIAL SERVICE PROVIDERS, NON-PROFIT LEADERS, BUSINESS LEADERS, FAITH-BASED ORGANIZATIONS AND OTHER AREA AUTHORITIES. EACH SESSION LASTED APPROXIMATELY TWO HOURS. A DISCUSSION GUIDE WAS USED TO PROMPT DISCUSSION AND GUIDE THE FACILITATION. THE GUIDE FOCUSED ON GATHERING QUALITATIVE FEEDBACK REGARDING PERCEPTIONS OF COMMUNITY NEEDS ACCROSS THREE KEY DOMAINS: HEALTH CARE ACCESS, KEY HEALTH ISSURES, AND COMMUNITY ASPIRATIONS & CAPACITY. IN TOTAL, 18 PEOPLE PARTICIPATED IN THE FOCUS GROUPS, REPRESENTING A VARIETY OF SECTORS INCLUDING PUBLIC HEALTH AND MEDICAL SERVICES, NON-PROFIT AND SOCIAL ORGANIZATIONS, CHILDREN AND YOUTH AGENCIES, AND THE BUSINESS COMMUNITY. JERSEY SHORE HOSPITAL PART V, SECTION B, LINE 7: THE COMMUNITY HEALTH NEEDS ASSESSMENT IDENTIFIED 8 OVERALL NEEDS WITHIN THE COMMUNITY. THESE NEEDS IDENTIFIED ARE AS FOLLOWS: ACCESS TO CARE, MENTAL/BEHAVOIRAL HEALTH/SUBSTANCE ABUSE, OVERWIEGHT & OBESITY, RESPIRATORY DISEASE/ASTHMA, DIABETES, HEART DISEASE, LYME DISEASE, AND MATERNAL/INFANT HEALTH. THE TOP FOUR PRIORITIES THAT ARE BEING ADDRESSED ARE: ACCESS TO CARE, MENTAL & BEHAVIORAL HEALTH, OVERWEIGHT & OBESITY, AND RESPIRATORY DISEASE/ASTHMA. IT WAS RECOGNIZED THAT THE EFFECT THAT OVERWEIGHT AND OBESITY HAS ON DIABETES AND HEART DISEASE, THEREFORE IS WAS DECIDED TO INCLUDES THESE NEEDS AS SUBSETS WITHIN THE OVERWEIGHT AND OBESITY. THEREFORE THE ONLY TWO NEEDS IDENTIFIED THAT ARE NOT CURRENTLY BEING ADDRESSED IS LYME DISEASE AND MATERNAL/INFANT HEALTH. THESE NEEDS WILL BE CONSIDERED AS FUTURE PROJECTS. JERSEY SHORE HOSPITAL PART V, SECTION B, LINE 14G: POLICY WAS REFERENCED ON INVOICES AND VERBALLY DISCUSSED WITH PATIENTS. JERSEY SHORE HOSPITAL PART V, SECTION B, LINE 20D: JERSEY SHORE HOSPITAL DISCOUNTS BASED ON THE PROMPTNESS OF PAYING AT THE BILLING OFFICE. IF AN INVOICE IS PAID WITHIN 45 DAYS OF BILLING A DISCOUNT CAN BE APPLIED. PART VI, LINE 2: JERSEY SHORE HOSPITAL (JSH) LED A COMPREHENSIVE COMMUNITY HEALTH NEEDS ASSESSMENT TO EVALUATE THE HEALTH NEEDS OF INDIVIDUALS LIVING IN THE JERSEY SHORE HOSPITAL SERVICE AREA IN NORTH CENTRAL, PENNSYLVANIA. THE PURPOSE OF THE ASSESSMENT WAS TO GATHER INFORMATION ABOUT LOCAL HEALTH NEEDS AND HEALTH BEHAVIORS. THE ASSESSMENT EXAMINED A VARIETY OF INDICATORS, INCLUDING SOCIAL DETERMINANTS OF HEALTH (POVERTY, HOUSING, EDUCATION) MORTALITY RATES, RISKY BEHAVIORS (ALCOHOL USE, TOBACCO USE) AND CHRONIC HEALTH CONDITIONS (DIABETES, HEART DISEASE). METHODOLOGYJSH DEFINED THEIR SERVICE AREA BASED ON ANALYSIS OF THE GEOGRAPHIC AREA WHERE INDIVIDUALS UTILIZING JSH HEALTH SERVICES RESIDE. BECAUSE JSH'S SERVICE AREA ENCOMPASSES RESIDENTS LIVING IN TWO COUNTIES IN NORTH CENTRAL PENNSYLVANIA, THE CHNA INCLUDES QUANTITATIVE AND QUALITATIVE RESEARCH DATA FOR BOTH CLINTON COUNTY AND LYCOMING COUNTY.THE CHNA WAS COMPRISED OF BOTH QUANTITATIVE AND QUALITATIVE RESEARCH COMPONENTS. THIS MULTI-FACETED APPROACH TOOK INTO ACCOUNT VARIOUS DATA SOURCES AND PERSPECTIVES. QUANTITATIVE DATA INCLUDED A SECONDARY DATA PROFILE DEPICTING POPULATION AND HOUSEHOLD STATISTICS, EDUCATION AND ECONOMIC MEASURES, MORBIDITY AND MORTALITY RATES, INCIDENCE RATES, AND OTHER HEALTH STATISTICS FOR CLINTON AND LYCOMING COUNTIES. QUALITATIVE DATA INCLUDED TWO FOCUS GROUPS HELD ON AUGUST 15, 2012 AT JERSEY SHORE HOSPITAL WITH KEY COMMUNITY LEADERS. JSH CONTRACTED WITH HOLLERAN, AN INDEPENDENT RESEARCH AND CONSULTING FIRM, TO CONDUCT RESEARCH IN SUPPORT OF THE CHNA. THE FIRM PROVIDED THE FOLLOWING ASSISTANCE: 1) COLLECTED AND INTERPRETED SECONDARY DATA, 2) CONDUCTED FOCUS GROUPS WITH COMMUNITY STAKEHOLDERS, AND 3) FACILITATED A PRIORITIZATION AND IMPLEMENTATING PLANNING SESSION. COMMUNITY ENGAGEMENT AND FEEDBACK WAS AN INTEGRAL PART OF THE CHNA PROCESS. JSH SOUGHT COMMUNITY INPUT THROUGH FOCUS GROUPS WITH COMMUNITY STAKEHOLDERS AND THROUGH INCLUSION OF COMMUNITY PARTNERS IN THE PRIORITIZATION AND IMPLEMENTATION PLANNING PROCESS. PUBLIC HEALTH AND HEALTHCARE PROFESSIONALS SHARED KNOWLEDGE AND EXPERTISE ABOUT HEALTH ISSUES AND WHILE LEADERS AND REPRESENTATIVES OF NON-PROFIT AND COMMUNITY-BASED ORGANIZATIONS PROVIDED INSIGHT ON THE COMMUNITY SERVED BY JSH INCLUDING MEDICALLY UNDERSERVED, LOW INCOME, AND MINORITY POPULATIONS. JSH AND ITS PARTNERS USED THE RESULTS OF THE FOCUS GROPUS IN CONJUNCTION WITH SECONDARY STATISTICAL DATA TO PRIORITIZE PUBLIC HEALTH ISSUES AND DEVELOP A COMMUNITY HEALTH IMPLEMENTATION PLAN FOCUSED ON MEETING COMMUNITY NEEDS. PART VI, LINE 3: PATIENTS ARE COUNSELED ON AN INDIVIDUAL BASIS IN PERSON OR PHONE CONVERSATION AS TO THE AVAILABILITY OF STATE OR CORPORATE PROGRAMS. AT THE TIME OF REGISTRATION, SELF-PAY PATIENTS ARE INFORMED OF ASSISTANCE AVAILABLE. PATIENT STATEMENTS INDICATE ASSISTANCE THAT IS AVAILABLE.THERE IS ALSO SIGNAGE INDICATING THAT ASSISTANCE PROGRAMS ARE AVAILABLE AND PATIENTS ARE PROVIDED A PAMPHLET AT REGISTRATION WITH THIS INFORMATION.PATIENTS ARE INFORMED OF WHAT CHARITY CARE IS AND THAT IS EXISTS. IF THE PATIENT IS INTERESTED THE PROCESS IS EXPLAINED. PART VI, LINE 4: JERSEY SHORE HOSPITAL'S PRIMARY SERVICE AREA (PSA) COVERS EASTERN CLINTON COUNTY AND WESTERN LYCOMING COUNTY - AN AREA WITH A POPULATION OF APPROXIMATELY 41,000. THE PSA FOR JERSEY SHORE HOSPITAL CONSISTS OF FOUR ZIP CODES: 17720 - JERSEY SHORE, 17745 - LOCK HAVEN, 17779 - WOOLRICH AND 17751 MILL HALL. JERSEY SHORE HOSPITAL IS CONSIDERED TO BE IN A MEDICALLY UNDERSERVED AREA (MUA). JERSEY SHORE AND JERSEY SHORE HOSPITAL IS LOCATED IN LYCOMING COUNTY, WHICH HAS AN AREA OF 1,237 SQUARE MILES. IT IS THE LARGEST COUNTY IN PENNSYLVANIA AND OCCUPIES A HILLY AND HEAVILY FORESTED PART OF THE STATE. THE WEST BRANCH OF THE SUSQUEHANNA RIVER FLOWS THROUGH THE SOUTHERN PART OF THE COUNTY. JERSEY SHORE IS APPROXIMATELY 45 MILES NORTHEAST OF STATE COLLEGE PENNSYLVANIA AND APPROXIMATELY 15 MILES WEST OF WILLIAMSPORT, PENNSYLVANIA. ABOUT SIXTEEN PERCENT (16%) OF INPATIENT STAYS IN THE PSA OCCUR AT JERSEY SHORE HOSPITAL. ABOUT FORTY PERCENT (40%) OF OUTPATIENT VISITS IN THE PSA OCCUR AT JERSEY SHORE HOSPITAL. JERSEY SHORE HOSPITAL RELIES UPON A RELATIVELY SMALL GEOGRAPHIC AREA TO SUPPORT THE HOSPITAL.THE SSA (SECONDARY SERVICE AREA) CONSISTS OF 9 ADDITIONAL ZIP CODES WHICH ARE IMPORTANT TO THE HOSPITAL. THESE ZIP CODES ARE PRIMARILY TO THE WEST AND NORTH OF THE PSA. ABOUT TWO PERCENT (2%) OF INPATIENT STAYS IN THE PSA OCCUR AT JERSEY SHORE HOSPITAL. ABOUT ELEVEN PERCENT (11%) OF OUTPATIENT VISITS IN THE PSA OCCUR AT JERSEY SHORE HOSPITAL.WITHIN THE PSA, THE TOTAL POPULATION IS EXPECTED TO INCREASE BY 1.8% BY 2017. A MAJOR DEMOGRAPHIC ISSUE AFFECTING JERSEY SHORE HOSPITAL IS THE AGING POPULATION. THE NUMBER OF INDIVIDUALS LIVING IN THE PSA OVER THE AGE OF 65 IS EXPECTED TO INCREASE 11.2% BY 2017. THIS AGE GROUP CURRENTLY MAKES UP OVER 16% OF THE POPULATION IN THE PSA COMPARED TO ABOUT 13% FOR THE U.S. THIS GROWING ELDERLY SEGMENT SHOULD GENERATE A FUTURE DEMAND FOR HEALTH CARE SERVICES, SINCE INDIVIDUALS OVER AGE 65 USE HEALTHCARE AND HOSPITAL SERVICES AT 2.7 TIMES THE RATE OF THE UNDER AGE 65 POPULATION.A DEMOGRAPHIC REALITY IS THE LOW INCOME LEVEL OF AREA HOUSEHOLDS. CURRENTLY, THE MEDIAN HOUSEHOLD INCOME IN THE PSA IS $40,477, COMPARED TO PA ($47,478) AND THE U.S. ($47,529). THE MEDIAN HOUSEHOLD INCOME IN THE SSA IS $39,660.THE SERVICE AREA IS NOT RACIALLY DIVERSIFIED TO A SIGNIFICANT DEGREE, WITH 98.6 % OF THE POPULATION CONSIDERED WHITE. THE EDUCATIONAL PROFILE OF THE SERVICE AREA DEMONSTRATES THAT 44% OF THE POPULATION HAS A HIGH SCHOOL EDUCATION AND 7.1% OF THE POPULATION HAS AN ASSOCIATE DEGREE. THE PERCENTAGE ACHIEVING A BACHELOR OR PROFESSIONAL DEGREE IS LESS THAN PENNSYLVANIA OR THE U.S. AS A WHOLE. A HIGHER PERCENTAGE OF THE LABOR FORCE IN THE AREA IS ENGAGED IN MANUFACTURING / CONSTRUCTION WHEN COMPARED TO THE STATE AND US AS A WHOLE.IN TERMS OF PATIENTS SERVED, COMBINED INPATIENT AND OUTPATIENT PAYER MIX IN 2013 REMAINED FAIRLY CONSISTENT. MEDICARE AND MEDICARE ADVANTAGE MAKE UP ABOUT 42% OF OUR PAYERS IN TERMS OF GROSS CHARGES. MEDICAL ASSISTANCE BUSINESS CONTINUED TO HAVE A SIGNIFICANT IMPACT ON JSH AS A CRITICAL ACCESS HOSPITAL. MEDICAL ASSISTANCE CHARGES ACCOUNT FOR ABOUT 10% OF OUR PAYERS. SELF-PAY CHARGES ACCOUNTED FOR ABOUT 5% OF OUR PAYERS. PART VI, LINE 5: ALL OF THE PERSONS SERVING ON OUR BOARD LIVE IN THE PRIMARY COMMUNITIES BEING SERVED BY THE HOSPITAL. THE BOARD CONSISTS OF SOME PHYSICIANS WHO ARE EMPLOYEES OF A RELATED ENTITY, A FEW CONTRACTORS, AND SEVERAL OTHER COMMUNITY MEMBERS.THE HOSPITAL EXTENDS STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE AREA. AS APPLICABLE, THE HOSPITAL APPLIES SURPLUS FUNDS TO IMPROVEMENTS IN PATIENT CARE THROUGH NEW AND UPDATED EQUIPMENT PURCHASES, MAJOR FACILITY IMPROVEMENTS, AND COMMUNITY HEALTH PROGRAMS.THE HOSPITAL PARTICIPATES IN MEDICARE, MEDICAID, CHAMPUS, AND TRICARE. PART VI, LINE 6: THE HOSPITAL IS PART OF JERSEY SHORE HOSPITAL FOUNDATION, INC. THIS AFFILIATION INCLUDES A NON-PROFIT PHYSICIAN PRACTICE WITH FAMILY PRACTICE PHYSICIANS AND SURGEONS, AS WELL AS AN URGENT CARE CENTER. REPORTS FILED WITH STATES PART VI, LINE 7 PA IMPLEMENTATION PLAN PART VI IN SUPPORT OF THE 2012 COMMUNITY HEALTH NEEDS ASSESSMENT, AND ONGOING COMMUNITY BENEFIT INITIATIVES, JERSEY SHORE HOSPITAL PLANS TO IMPLEMENT THE FOLLOWING STRATEGIES TO IMPACT AND MEASURE COMMUNITY HEALTH IMPROVEMENT.OVERWEIGHT /OBESITY (HEALTHY EATING/PHYSICAL ACTIVITY/CHRONIC CONDITIONS)JERSEY SHORE HOSPITAL STAFF RECOGNIZES THE CONNECTION BETWEEN OVERWEIGHT AND OBESITY TO HEART DISEASE, DIABETES AND OTHER CHRONIC ILLNESSES. THE HOSPITAL WILL SEEK TO REDUCE THE PERCENTAGE OF OUR CLIENTS IDENTIFIED AS BEING EITHER OVERWEIGHT OR OBESE BY FOCUSING EDUCATION AND AWARENESS ON PROMOTING HEALTHY WEIGHT THROUGH DIET AND EXERCISE.GOAL:REDUCE THE PERCENTAGE OF COMMUNITY MEMBERS CONSIDERED OVERWEIGHT OR OBESE THROUGH PROMOTION OF HEALTHY EATING AND PHYSICAL ACTIVITY.OBJECTIVES:1) PARTNER WITH SCHOOL DISTRICTS TO IMPROVE THE EDUCATION AND AWARENESS OF PROPER DIETARY HABITS.STRATEGIES:-PARTNER WITH JERSEY SHORE AND KEYSTONE CENTRAL SCHOOL DISTRICTS TO PROVIDE EDUCATION TO STAFF AND FACULTY ABOUT HEALTHY EATING AND PHYSICAL ACTIVITY.-SUPPORT RESEARCH GRANT FOR STRETCH AND GROW PROGRAM THROUGH AMERICAN HEART ASSOCIATION.2)RAISE AWARENESS TO THE BENEFITS OF AREA TOURISM ATTRACTIONS BUILT AROUND EXERCISE ACTIVITY TO LOCAL RESIDENTS.STRATEGIES:-ORGANIZE 5K WALK WITH NATURALIST.3)PROVIDE COMMUNITY-WIDE EDUCATION EVENTS ON HEALTHY NUTRITION. STRATEGIES:-CONTINUE WITH PORTION DISTORTION PROGRAM TO EDUCATE RESIDENTS ON HEALTHY EATING AND PROPER MEALS PROPORTION.-CONTINUE BI-ANNUAL HEALTH SCREENINGS EVENT TO IDENTIFY HIGH CHL/TRIGLICERIDES AND OTHER HEALTH INDICATORS.-RESEARCH GRANT OPPORTUNITIES FOR SUCH EXERCISE AND HEALTHY EATING PROGRAMS INCLUDING STRETCH N' GROW.ACCESS TO CARE:ACCESS TO CARE INCLUDES PRIMARY CARE PROVIDERS, BEHAVIORAL HEALTH PROVIDERS, AND LOCATION OF SERVICES AS MAY BE IMPACTED BY AVAILABILITY OF TRANSPORTATION.JERSEY SHORE HOSPITAL STAFF BELIEVES THAT IMPROVED HEALTH STATUS IS CONTINGENT ON ACCESS TO PRIMARY CARE SERVICES BY ALL. WE WILL DESIGNATE RESOURCES TO IMPROVING ACCESS TO CARE FOR ALL RESIDENTS AND TO CREATING A STRUCTURE OF PROVIDERS THAT SUPPORTS COORDINATION OF CARE. GOAL:1) INCREASE ACCESS TO QUALITY HEALTH CARE PROVIDERS WITH A FOCUS ON PRIMARY CARE AND BEHAVIORAL SCIENCES.STRATEGY: INCREASE PHYSICIAN/PATIENT RATIO THROUGH RECRUITMENT AND PARTNERSHIP EFFORTS.2)IMPROVE COMMUNITY AWARENESS AND UNDERSTANDING OF CHOOSING BETWEEN EMERGENCY DEPARTMENT, URGENT CARE CENTER AND FAMILY PHYSICIAN WHEN SEEKING NON-EMERGENT CARE.STRATEGIES: -CONDUCT AWARENESS CAMPAIGN TO INCLUDE PRINT MATERIALS, RADIO AND PRINT ADVERTISING, AND SERVICE-EDUCATE INSURANCE CARRIERS ABOUT AVAILABILITY AND COVERAGE OF ALTERNATIVE CARE DELIVERY OPTIONS. X X X 0 0 0 0 0 0 0 0 0 CAREY PLUMMER DEPARTED 5114 299155 0 0 0 0 0 0 0 0 0 299155 0 0 0 CARMEN SPINNEY MD 0 170183 0 0 0 0 0 0 0 5212 0 175395 0 0 AARON KOLB MD 307453 0 0 0 1046 0 0 0 13247 0 321746 0 0 0 THOMAS BURGE 149569 0 0 0 0 0 0 0 2849 0 152418 0 0 0 RONALD EISTER 292791 0 0 0 0 0 0 0 10639 0 303430 0 0 0 SHAIRKO MISSOURI 452015 0 0 0 0 0 0 0 10319 0 462334 0 0 0 HOSNY MIKHAIL 319012 0 0 0 0 0 0 0 4454 0 323466 0 0 0 LISA STRAWSER MEDICAL STAFF DIRECTOR AND BOARD MEMBER 1200288 LISA STRAWSER IS A PART OWNER OF JERSEY SHORE RADIOLOGISTS. JERSEY SHORE RADIOLOGISTS HAS A CONTRACT WITH THE HOSPITAL TO PERFORM RADIOLOGY SERVICES FOR THE HOSPITAL. THE SERVICES ARE PROVIDED AT FMV. IN ACCORDANCE WITH THE CONFLICT OF INTEREST POLICY, LISA STRAWSER ABSTAINS FROM ANY DECISION MAKING AS IT RELATES TO THIS TRANSACTION. 0 JIM ELY BOARD MEMBER AND SISTER TO EMPLOYEE 26672 JIM ELY IS A BOARD MEMBER AND IS ALSO THE SISTER TO EMPLOYEE MARY HOLLICK 0 FORM 990, PART VI, SECTION A, LINE 2 MEMBERS LEROY KEILER, III, AND ROB GLUNK HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 3 THE HOSPITAL UTILIZES THE MANAGEMENT SERVICES OF QUORUM HEALTH RESOURCES. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WAS REVIEWED IN DETAIL BY MANAGEMENT BEFORE FILING WITH THE IRS. A COPY OF THE 990 WAS PROVIDED TO ALL BOARD MEMBERS PRIOR TO ISSUANCE. FORM 990, PART VI, SECTION B, LINE 12C ALL BOARD MEMBERS AND EMPLOYEES ARE REQUIRED TO ANNUALLY COMPLETE A CONFLICT OF INTEREST STATEMENT. THE CEOS OFFICE MONITORS THE PROCESS AND COMPLETION OF THE STATEMENTS. THE COMPLETED STATEMENTS ARE REVIEWED BY MANAGEMENT. BOARD MEMBERS ARE REQUIRED TO RECUSE THEMSELVES FROM VOTING ON MATTERS THAT ARE RELATED TO ANY POTENTIAL CONFLICTS. THERE HAS NEVER BEEN AN ISSUE INVOLVING CONFLICTS OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 ON AN ANNUAL BASIS, THE PERSONNEL SALARY COMMITTEE AND QUORUM (MANAGEMENT COMPANY) REVIEWS AN EXECUTIVE COMPENSATION STUDY PERFORMED BY YAFFE, AN INDEPENDENT THIRD PARTY WHO IS EMPLOYED BY HOSPITAL ASSOCIATION OF PENNSYLVANIA TO CONDUCT A COMPENSATION STUDY. HUMAN RESOURCES ALSO PROVIDES A COMPENSATION STUDY FROM ACRS WHICH IS BASED ON THE APPALACHIAN REGION. THESE TWO STUDIES ARE USED TO DETERMINE FMV. THE RECOMMENDATIONS FOR COMPENSATION LEVELS ARE PASSED ON TO THE BOARD FOR THEIR APPROVAL. APPROVAL IS DOCUMENTED IN THE MINUTES. THE ACTUAL AMOUNT OF COMPENSATION IS NOT INCLUDED IN THE MINUTES FOR PRIVACY PURPOSES. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VII, SECTION A: THE PRESIDENT AND CEO IS AN EMPLOYEE OF QUORUM (MANAGEMENT COMPANY). THE HOSPITAL PAYS QUORUM FOR THE PRESIDENT/CEOS SALARY. OTHER FEES FORM 990, PART IX, LINE 11G LAUNDRY: PROGRAM SERVICE EXPENSES 85,154. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 85,154. OTHER: PROGRAM SERVICE EXPENSES 48,467. MANAGEMENT AND GENERAL EXPENSES 452,056. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 500,523. CONTRACTED SERVICES: PROGRAM SERVICE EXPENSES 180,953. MANAGEMENT AND GENERAL EXPENSES 272,356. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 453,309. MEDICAL: PROGRAM SERVICE EXPENSES 217,400. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 217,400. MEDICAL LABS: PROGRAM SERVICE EXPENSES 305,247. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 305,247. TRANSPORTATION: PROGRAM SERVICE EXPENSES 5,890. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,890. MICROFILM: PROGRAM SERVICE EXPENSES 62,400. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 62,400. COLLECTIONS: PROGRAM SERVICE EXPENSES 42,992. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 42,992. CONSULTING: PROGRAM SERVICE EXPENSES 14,810. MANAGEMENT AND GENERAL EXPENSES 19,817. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 34,627. BIOHAZARDOUS MATERIALS: PROGRAM SERVICE EXPENSES 30,533. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 30,533. MAINTENANCE AND REPAIRS: PROGRAM SERVICE EXPENSES 589,262. MANAGEMENT AND GENERAL EXPENSES 228,066. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 817,328. PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 2,235,520. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,235,520. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: PENSION LIABILITY ADJUSTMENT 1,200,359. CHANGE IN FAIR VALUE OF DERIVATIVE INSTRUMENT 152,239. JERSEY SHORE HOSPITAL FOUNDATION INC 1020 THOMPSON STREET JERSEY SHORE PA 17740 232480603 HEALTHCARE PA 501(C)(3) 3 N/A 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 1 1 0 0 0