2013-05-02T12:03:52-05:00 2012-06-30 BKD LLP 910 E St Louis Street Springfield MO 65806 990 2011-07-01 240806023 Muncy Valley Hospital MUNC 5703207900 215 East Water Street Muncy PA 17756 Charles J Santangelo 5703207900 2013-05-02 1 Brian D Todd P00422601 4178658701 2011 2016-02-25 16:41:14Z Steven P Johnson 700 High Street Williamsport PA 17701 117643675 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. 12 9 363 140 0 0 32176 1000164 43579973 44236972 463188 1071491 96801 278565 44172138 46587192 1993292 2030802 0 0 15967499 15692078 0 0 2221 21322007 23461576 39282798 41184456 4889340 5402736 37511605 41704225 4571061 3594973 32940544 38109252 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 a high quality patient centered integrated delivery system. Our values are to demonstrate extraordinary CARE for those who receive our services; share ownership with those who provide our services; and be servant leaders whose behaviors are rooted in quality service, dedicated partnership, responsible stewardship, and commitment to our regional community. 0 0 36085070 2030802 44395403 During the fiscal year ended June 30, 2012, the Hospital admitted 755 acute care patients, rendering 4,670 patient days and registered approximately 53,003 outpatients. Long Term Care days totaled 46,733. 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 $4,443,229 in quantifiable community benefits reported for FY 2012: Charity Care (at cost) $201,913; Bad Debt (at cost) $1,003,763; Government-sponsored health care (unpaid cost of Medicare, Medicaid, indigent care programs, SCHIP and other safety net programs) $3,173,000. In addition, various other programs such as Research, Health Professions Education, Community Building, Financial and In-Kind Contributions and Community Benefit Operations totaling $64,553. 36085070 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 0 0 0 0 0 0 1 0 0 0 0 1 X 4 0 1 363 1 0 0 0 0 0 0 0 0 0 0 X 12 9 0 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 X Daniel C Berninger 1.00 X X 0 0 0 Geneva Peck 1.00 X X 0 0 0 Robert E More 1.00 X X 0 0 0 Roger D Jarrett 1.00 X X 0 0 0 Dr Mark Beyer 1.00 X 0 0 0 Sister Teresa Ann Jacobs 1.00 X 0 0 0 Dr Kevin Kist 1.00 X 0 342044 25034 Paul Moulton 1.00 X 0 0 0 Dale Stebner 1.00 X 0 0 0 Dr Peter B Trevouledes 1.00 X 0 0 0 Steven E Yordy MD 1.00 X 0 183880 26221 Steven P Johnson 1.00 X X 0 635348 96200 Charles J Santangelo 1.00 X 0 317516 27276 Christine A Ballard 40.00 X 147786 0 14413 Neil G Armstrong 1.00 X 0 271346 25747 George A Manchester MD 1.00 X 0 314240 34427 Margaret M Austin 40.00 X 108097 0 13523 Anne E Holladay 40.00 X 102779 0 6379 358662 2064374 269220 3 0 1 0 Susquehanna Health System 1001 Grampian Boulevard Williamsport PA 17701 Management services 3897121 Aramark Healthcare PO Box 33170 Newark NJ 01788 Management / environmental services 3132505 Alexander Building Construction LLC 315 Vaughn Street Harrisburg PA 17110 Construction services 1186490 Sundance Rehabilitation 6549 Paysphere Circle Chicago IL 60674 Therapy services 883155 Emcare Inc 7032 Collection Center Drive Chicago IL 60693 ER management services 389064 12 6335 918637 65889 9303 1000164 Net patient service re 621990 42850336 42850336 Supplemental payments 623000 1250479 1250479 Affiliate rental incom 621990 103559 103559 Sports Medicine - athl 621990 32598 32598 44236972 236405 236405 68948390 2931000 68628668 2415636 319722 515364 835086 835086 43880 6335 12179 31701 31701 EHR - Meaningful Use 900099 150000 150000 Cafeteria 624200 72916 72916 Television 900099 7446 7446 16502 8431 8071 246864 46587192 44395403 0 1191625 2030802 2030802 162199 162199 12364240 11883983 478486 1771 486343 461931 24343 69 1767000 1691995 74753 252 912296 866503 45664 129 3897121 3897121 2000 2000 6306 6306 55770 55770 6426377 6288866 137511 4510 2358 2152 5082795 5020709 62086 136056 133710 2346 23118 23103 15 786345 711092 75253 14859 12994 1865 29385 24206 5179 1535839 1535839 550090 550090 Bad Debt Expense 2769213 2769213 Miscellaneous 1428486 1364807 63679 Repairs & maintenance 701127 698690 2437 Auxiliary activity 12179 12179 41184456 36085070 5097165 2221 7997891 6430910 5232980 5385690 0 484184 154763 124648 137071 139170 38451537 26272859 13853913 12178678 10005153 14705309 129834 2255636 37511605 41704225 2826935 2465896 1744126 1129077 4571061 3594973 X 32622097 37816175 106575 83542 211872 209535 32940544 38109252 37511605 41704225 X 5402736 -234028 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 6306 0 0 0 6306 0 Explanation of Lobbying Activities: 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 06/30/12, the amount of dues paid to HAP totaled $11,201 of which 25.04% or $2,805, was used for lobbying purposes. Dues paid to AHA totaled $14,232, of which 24.6% or $3,501, 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 21635306 14894578 6740728 15678 15678 0 15007466 10988716 4018750 1402741 373887 1028854 12178678 Other receivables 273705 Interest in net affiliates 73783 Due from affiliates, net 1908148 2255636 Estimated third party settlements 969077 Estimated medical legal liability costs 160000 1129077 46587192 41184456 5402736 -204508 -29520 -234028 5168708 43571772 -204508 -2810912 -3015420 46587192 0 46587192 38432584 29520 29520 38403064 2781392 2781392 41184456 Part XI, Line 8 - Other Adjustments: Change in interest in net assets of affiliate -29,520. Part XII, Line 2d - Other Adjustments: Change in interest of net assets of affiliates -29,520. Bad Debt expense -2,769,213. MVH Auxiliary -12,179. Part XIII, Line 2d - Other Adjustments: Change in interest in net assets of affiliate 29,520. Part XIII, Line 4b - Other Adjustments: Bad Debt expense 2,769,213. MVH Auxiliary 12,179. Management has evaluated their income tax positions under the guidance included in ASC 740. Based on their review, management has not identified any material uncertain tax positions to be recorded or disclosed in the financial statements. Central America 0 1 Program services Captive insurance company 481289 0 1 0 0 0 1 481289 0 481289 0 0 0 0 0 0 Lawn Party 35898 35898 9231 Lights of Love 6335 6335 305 7 7982 7982 2643 50215 6335 43880 12179 12179 31701 1 1 X 1 X 1 X 1 1 1 0 1 1 201877 0 201877 0.00490 10673751 8532484 2141267 0.05200 0 0 10875628 8532484 2343144 0.05690 9404 715 8689 0.00020 2240 0 2240 0.00010 1835 0 1835 0.00000 9313 0 9313 0.00020 22792 715 22077 0.00050 10898420 8533199 2365221 0.05740 2474 2474 0.00010 2474 2474 0.00010 1 2769213 304613 11915836 12947369 -1031533 X 1 1 1 1 Muncy Valley Hospital

215 East Water Street Muncy PA 17756

X X X Muncy Valley Hospital 1 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 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 at the Muncy Valley Hospital (MVH) center on workforce development thru providing observations and the development of volunteens. By supporting volunteens in a health care setting, some budding nurses, doctors and other allied health professionals are developed. 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. Muncy Valley Hospital Part V, Section B, Line 13g: Other method - brochure Muncy Valley Hospital Part V, Section B, Line 19d: 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. 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), as a member of the Lycoming County Health Improvement Coalition (LCHIC) conducts a community health needs assessment every 2 years.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 to this assessment 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 a newly created 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.The duties of the workgroup is to participate in conducting a "community health assessment" using data that already exists. Developing the community benefit plan with strategic goals and interventions, review and validate current system-wide reporting structure, share ideas and best practices on program evaluation, and advocates for the community benefit program, both internally and externally.Using the various assessments and the LCHIC strategic plan as a basis, the workgroup decides what goals and objectives SHS can support with the talent and resources it has available. These are opportunities that meet the mission of the SHS family of hospitals. Once decided they are then communicated at the campus level and to service line managers by the campus administrator and the Director of Community Benefits for SHS. Though ongoing communication, staffing allocations and scheduling to permit participation in the community benefit programming (that supports needs identified by LCHIC) is achieved. 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 (SHS) are: The Williamsport Hospital (TWH), Divine Providence Hospital (DPH) and Muncy Valley Hospital (MVH) are all located in Lycoming County, Pennsylvania. 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.The population is the underserved of the county and the target population of our community outreach. It is comprised of residents with income at or below 200% of the Federal Poverty Level and amounts to about 38,931 individuals. This population lives mainly in three Medically Underserved Areas (MUAs) and three Priminary Care Health Professional Shortage Areas(HPSAs). There is also a Dental Health HPSA in the City of Williamsport and a Mental Health HPSA throughout the entire county. No priminary health or dental providers in the county are accepting under and uninsured patients.MUA listing:ID#02975 - Cogan House Service Area - Designated 12/5/94 - IMU score 55.80ID#02976 - Jordan Service Area - Designated 12/5/94 - IMU score 54.20ID#07495 - Western Williamsport - Designated 8/9/05 - IMU score 58.40HPSA listing:ID#142999422Q - Eastern Lycoming County - Geographic area - score 11ID#14299942E9 - Canton Service Area - Geographic area - score 7ID#64299942OF - Low-income Dental/Wmspt - Population group - score 15ID#74299942K8 - Clinton/Lycoming Mental Health - Geographic area -score 12Compared to the overall population of Pennsylvania, Lycoming County residents are older, earn less per capita, have received less formal education, and are more likely to be uninsured and unemployed. Furthermore, Lycoming County residents face health disparities compared to state and national levels. The health issues below are of particular concerns in Lycoming County because they all occur at frequencies that do not meet national benchmarks. All except the diabetes measure do not meet the "severe benchmark".* Diabetes - Diabetes Mortality Rate = 30 per 100,000 people* Cardiovascular Disease - Adults reporting diagnosis of high blood pressure = 28%* Cancer - Percent of women 18 and older with no Pap test in past 3 years = 20%* Prenatal and Perinatal Health - Cigarette use during pregnancy = 22%* Child Health - Pediatric asthma hospital admission rate = 357.2 per 100,000* Behavioral Health - Heavy alcohol use, Binge drinkers = 16%* Asthma - Adult current asthma prevalance = 8%Socio-Economic characteristics in PA and Lycoming County (US Census Bureau, 2006-2008)* High school graduates - PA 86.8% - Lycoming County 84.5%* Bachelor's degree or higher - PA 25.9% - Lycoming County 18.7%* Population age 65 or over - PA 15.2% - Lycoming County 16.4%* Unemployment rate - PA 5.4% - Lycoming County 6.0%* Per capita income - PA $27,025 - Lycoming County $21,868* Median household income - PA $50,272 - Lycoming County $50,856* Population with income below poverty level - PA 11.9% - Lycoming County 13.9%Our community benefit programming focuses on 2 sub-groups that are culturally unique, ethnically diverse, and challenging to quantify:1) Vulnerable urban residents who live within the City of Williamsport who have no medical or dental home and have a history of being non-compliant, in that they often do not show up for appointments. They are mostly without insurance or depend on that which is government funded. This includes the 1,016 people living in public and Section 8 housing and the 222 homeless individuals.2) Individuals, and their families, who work on small farms, at businesses, and in manufacturing settings who do have adequate insurance or access to primary health care or dental care. This population is predominantly Caucasian, aging, and has a high incidence of chronic illness, including diabetes and hypertension. Many in this population exhibit poor health habits and a lack of knowledge about health related concepts. A lack of transportation is a large barrier for this population, especially for individuals living in rural parts of the county. 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 7/1/10 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 3 campuses, MVH, DPH and TWH, 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 three 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.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 $64,636,443 in quantifiable community benefits reported for FY 2012: Charity Care (at cost) $1,514,665; Bad Debt (at cost) $8,954,593; Government-sponsored health care (unpaid cost of Medicare, Medicaid, indigent care programs, SCHIP and other safety net programs) $47,969,226. In addition, various other programs such as Research, Health Professions Education, Community Building, Financial and In-Kind Contributions, and Community Benefit Operations totaling $6,197,958. 1 Susquehanna Physician Services 1201 Grampian Boulevard Williamsport PA 17701 232449454 501(c)(3) 2028591 Support of affiliate 1 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 1 0 0 0 1 1 0 0 Dr Kevin Kist 0 323253 0 0 0 18791 0 8850 0 16184 0 367078 0 0 Steven E Yordy MD 0 175576 0 0 0 8304 0 7518 0 18703 0 210101 0 0 Steven P Johnson 0 497213 0 123453 0 14682 0 77384 0 18816 0 731548 0 0 Charles J Santangelo 0 292341 0 19176 0 5999 0 8850 0 18426 0 344792 0 0 Christine A Ballard 138764 0 7940 0 1082 0 5523 0 8890 0 162199 0 0 0 Neil G Armstrong 0 255796 0 12493 0 3057 0 14975 0 10772 0 297093 0 0 George A Manchester MD 0 295318 0 15048 0 3874 0 12525 0 21902 0 348667 0 0 Part I, Line 4b Susquehanna Health System maintains an unfunded deferred compensation plan for the purpose of providing supplemental retirement benefits for Steven P. Johnson. An annual book-entry is recorded consisting of an annual contribution plus interest earnings. For 2011, the amount was $64,859. 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. Supplemental Information Part III 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. 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 The IRS Form 990 was first reviewed by an independent accounting firm, then senior management, and then reviewed with the full Board of the Parent company (Susquehanna Health System, EIN # 23-2751183) before being filed electronically. 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, 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. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -204,508. Change in interest in net assets of affiliate -29,520. Total to Form 990, Part XI, Line 5: -234,028. 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 of employees reported on Form W-3 Form 990, Part V, Line 2a & 2b Susquehanna Health System EIN #23-2751183 utlilizes 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 3,400 for Susquehanna Health System EIN #23-2751183. Of that total, 363 employees payroll expenses were recorded by Muncy Valley Hospital. Hours for Related Organizations Form 990, Part VII, Section A, Line 1a, Column B Steven P. Johnson, Charles J. Santangelo, Neil G. Armstrong, and George A. Manchester work 40 hours per week for the Williamsport Hospital EIN 24-0795508. In addition, they devote 1 hour per week to the following related organizations: Divine Providence Hospital 24-0799343 Muncy Valley Hospital 24-0806023 Susquehanna Health Foundation 23-2743470 Susquehanna Health System 23-2751183 Susquehanna Physician Services 23-2449454 Williamsport Area Ambulance Service Cooperative 23-2416166 Dr. Steven E. Yordy works 40 hours per week for Susquehanna Physician Services EIN 23-2449454. In addition, he devotes 1 hour per week to the Muncy Valley Hospital EIN 24-0806023. Dr. Kevin Kist works 40 hour per week for Susquehanna Physician Services EIN 23-2449454. In addition, he devotes 1 hour per week to the Muncy Valley Hospital EIN 24-0806023, Susquehanna Health System EIN 23-2751183, the Williamsport Hospital EIN 24-0795508, and Divine Providence Hospital 24-0799343. 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 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 Central PA Provider Network 1205 Grampian Boulevard Williamsport PA 17701 232949121 Physician insurance for central PA PA N/A C Susquehanna Health System Insurance Network LTD PO Box 1159 Grand Caymans CJ KY1-1102 980458722 Captive insurance company CJ N/A 0 1 1 0 0 0 0 0 0 0 0 0 0 0 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. It files an 1120F protective filing which implies that its income is not subject to US Federal Income tax.