2013-05-02T11:50:26-05:00 2012-06-30 BKD LLP 910 E St Louis St Springfield MO 658062523 990 2011-07-01 232751183 Susquehanna Health System SUSQ 5703207900 1205 Grampian Blvd 2nd Floor Williamsport PA 17701 Charles J Santangelo 5703213171 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 265512568 0 X www.susquehannahealth.org X 1994 PA SHS provides management services for the delivery of healthcare through its affiliated entities. 21 12 0 13 0 0 0 57000 16634 15444 2489454 2117617 0 0 2506088 2190061 0 36088 0 0 0 0 0 0 0 192878 254647 192878 290735 2313210 1899326 46372155 46869129 55334 54722 46316821 46814407 X 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 become a world-class health system. Our Values - putting patients first, sharing ownership and being servant leaders. 0 0 92937 36088 15444 SHS is organized and operated to coordinate the activities of the Supported Organizations as they pursue their charitable, educational, benevolent, and other purposes related to health care, health education and training, health facilities, and scientific research and health. The Supported Organizations include: The Williamsport Hospital & Medical Center, Divine Providence Hospital of the Sisters of Christian Charity, Muncy Valley Hospital, and Susquehanna Physician Services. SHS also is operated to establish, sponsor, and develop, directly or indirectly, facilities and programs for the accommodation, care and treatment of individuals suffering from illness, injury, disease, disability or infirmity, including but not limited to hospitals, nursing homes, residential facilities for the elderly, life care centers, ambulatory medical treatment facilities, clinics, rehabilitation centers, aloholism treatment centers, home health programs, mental health centers, hospice programs, pharmacies, laboratories, and training and research facilities. 92937 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 0 0 1 0 0 1 0 0 0 0 0 0 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 X 261 0 1 0 0 1 CJ 0 0 0 0 0 0 0 0 X 21 12 0 0 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 0 0 0 PA X Susquehanna Health Finance Departme 5703207900 1205 Grampian Blvd 2nd Floor Williamsport PA 17701 X Ronald V DeFeo Jr 1.00 X X 0 0 0 Ann S Pepperman Esquire 1.00 X X 0 0 0 Davie Jane Gilmour PhD 1.00 X X 0 0 0 Sister Teresa Ann Jacobs 1.00 X 0 0 0 John M Burks MD 1.00 X 0 390349 25006 Leonard R Collins MD 1.00 X 0 272917 10724 Ronald E DiSimone MD 1.00 X 0 913765 28574 James E Douthat EdD 1.00 X 0 0 0 Timothy M Gage 1.00 X 0 0 0 Daniel J Glunk MD 1.00 X 0 188705 16843 Sister Joan Daniel Healy 1.00 X 0 0 0 Steven P Johnson 1.00 X X 0 635348 96200 Daniel A Klingerman 1.00 X 0 0 0 Lynda Livingston 1.00 X 0 0 0 Robert B Lytle 1.00 X 0 0 0 Philip H Johnson 1.00 X 0 0 0 James E Mothersbaugh 1.00 X X 0 0 0 Alexander R Nesbitt MD 1.00 X 0 171946 28150 Melissa E Welch Esq 1.00 X 0 0 0 Kevin Kist MD 1.00 X 0 342044 25034 Stephen F Weber MD 1.00 X 0 252865 24687 Charles J Santangelo 1.00 X 0 317516 27276 Neil G Armstrong 1.00 X 0 271346 25747 George A Manchester MD 1.00 X 0 314240 34427 0 4071041 342668 0 0 1 0 0 57000 57000 Interest on Note Recei 525990 13554 13554 Support allocation inc 900003 1347 1347 Misc other income 900003 543 543 15444 780610 780610 264659514 263322507 1337007 1337007 1337007 2190061 15444 0 2117617 36088 36088 197798 197798 11140 11140 43190 43190 635 635 1772 1772 Use of Funds 112 112 290735 92937 197798 0 76834 71392 277856 262941 806309 796207 11874 10102 45990034 46508630 15557 16064 46372155 46869129 32500 34100 22834 20622 55334 54722 X 45679253 46207453 637568 574545 32409 46316821 46814407 46372155 46869129 X 1899326 -1401740 X X 0 1 1 X 0 X X X 0 0 0 The Williamsport Hospital & Medical Center 240795508 3 1 0 Divine Providence Hospital 240799343 3 1 36088 Muncy Valley Hospital 240806023 3 1 0 Susquehanna Physician Services 232449454 3 1 0 4 36088 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 36722 1596 725 1000 38043 35555 0 2167 1000 36722 33758 0 1797 0 35555 34177 0 -419 0 33758 0.85190 0.14810 0 0 762929 752827 10102 43380 43380 0 10102 Deferred Annuity 10400 Due to Affiliates 10222 20622 2190061 290735 1899326 -1404062 2322 -1401740 497586 785999 -1404062 -1404062 2190061 0 2190061 290735 0 290735 0 290735 Description of Intended Use of Endowment Funds: Part V, Line 4: The Arthur R. Taylor, M.D. Endowment Fund for Continuing Medical Education will provide financial support for continuing medical education programs at Susquehanna Health System with a focus on primary care. These educational programs will be for the benefit of the physicians of Susquehanna Health and surrounding regions. Part XI, Line 8 - Other Adjustments: Endowment Fund Investment Transfer 2,322. 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. Central America 0 1 Program services Captive insurance company-Total investment 25661594 0 1 0 0 0 1 25661594 0 25661594 0 0 1 0 0 0 1 Divine Providence Hospital 1100 Grampian Blvd Williamsport PA 17701 240799343 501(c)(3) 36088 0 Used for construction and remodeling of the Divine Providence Hospital. 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 John M Burks MD 0 332610 0 0 0 57739 0 13767 0 11239 0 415355 0 0 Leonard R Collins MD 0 245335 0 0 0 27582 0 0 0 10724 0 283641 0 0 Ronald E DiSimone MD 0 845479 0 40000 0 28286 0 8850 0 19724 0 942339 0 0 Daniel J Glunk MD 0 179754 0 8331 0 620 0 8982 0 7861 0 205548 0 0 Steven P Johnson 0 497213 0 123453 0 14682 0 77384 0 18816 0 731548 0 0 Alexander R Nesbitt MD 0 170646 0 0 0 1300 0 9614 0 18536 0 200096 0 0 Kevin Kist MD 0 323253 0 0 0 18791 0 8850 0 16184 0 367078 0 0 Stephen F Weber MD 0 251656 0 0 0 1209 0 10740 0 13947 0 277552 0 0 Charles J Santangelo 0 292341 0 19176 0 5999 0 8850 0 18426 0 344792 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 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 4b Susquehanna Health System EIN#23-2751183 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. Danko Holdings IncDaniel Klingerman Pres (board member) Danko has an agreement to pay Community Basket a note at 5% interest X 300000 262941 0 1 1 262941 Form 990, Part VI, Section A, line 7a Two members of the board of directors shall be appointed by the Sisters of Christian Charity Health Care Corporation. These directors shall have all of the powers provided to the other directors except they shall not have the power to vote to appoint the President of the Corporation and they shall not participate in the discussions of, or vote on any matters contrary to the Directives. 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 filing electronically. 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. Form 990, Part VI, Section B, Line 15a&b: All top management is employed by The Williamsport Hospital EIN #24-0795508. The following paragraph describes the process they use. 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 presumptive 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 These documents are available to members of the public who request them. They would be produced by the corporate office. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -1,404,062. Endowment Fund Investment Transfer 2,322. Total to Form 990, Part XI, Line 5: -1,401,740. 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 utilizes a common paymaster which includes the following entities: Divine Providence Hospital of the Sisters of Christian Charity 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, no employees payroll expenses were recorded by Susquehanna Health System. 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 orgainizations: Divine Providence Hospital of the Sisters of Christian Charity 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. John M. Burks, Dr. Ronald E. DiSimone, and Dr Stephen F. Weber work 40 hours per week for Susquehanna Physician Services EIN#23-2449454. In addition, they devote 1 hour per week to Susquehanna Health System 23-2751183. Dr. Leonard R. Collins and Dr. Alexander R. Nesbitt work 40 hours per week for Susquehanna Physician Services EIN#23-2449454. In addition, they devote 1 hour per week to the following related organizations: Divine Providence Hospital of the Sisters of Christian Charity 24-0799343 The Williamsport Hospital 24-0795508 Susquehanna Health System 23-2751183. Dr. Kevin W. Kist works 40 hours per week for Susquehanna Physician Services EIN#23-2449454. In addition, he devotes 1 hour per week to the following related organizations: Divine Providence Hospital of the Sisters of Christian Charity 24-0799343 The Williamsport Hospital 24-0795508 Susquehanna Health System 23-2751183 Muncy Valey Hospital 24-0806023. Dr. Daniel J. Glunk works 40 hours per week for The Williamsport Hospital EIN#24-0795508. In addition, he devotes 1 hour per week to Susquehanna Health System 23-2751183. Divine Providence Hospital 1100 Grampian Blvd Williamsport PA 17701 240799343 Hospital PA 501(c)(3) 3 Susquehanna Health System 1 Muncy Valley Hospital 215 E Water St Muncy PA 17756 240806023 Hospital PA 501(c)(3) 3 Susquehanna Health System 1 The Williamsport Hospital 700 High Street Williamsport PA 17701 240795508 Hospital PA 501(c)(3) 3 Susquehanna Health System 1 Susquehanna Health Foundation 1100 Grampian Blvd Williamsport PA 17701 232743470 Fundraising for affiliated entities PA 501(c)(3) 11 Susquehanna Health System 1 Susquehanna Physician Services 1201 Grampian Blvd Williamsport PA 17701 232449454 Physician services & MRI services PA 501(c)(3) 3 Susquehanna Health System 1 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 Blvd Williamsport PA 17701 201195739 Rents real estate PA Susquehanna Health System & Susquehanna Health Foundation Excluded from tax 0 0 0.50000 Susquehanna Ventures Inc 1201 Grampian Blvd Williamsport PA 17701 232470263 Pharmacy & Infusion services PA Susquehanna Health System C 1803702 2588364 1.00000 Susquehanna Health System Insurance Network LTD PO Box 1159 Grand Caymans CJ KY1-1102 980458722 Captive Insurance Company CJ Susquehanna Health System 1582483 25664594 1.00000 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Divine Providence Hospital B 36088 Building Fund expenses 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.