2012-03-09T13:45:51-06:00 2011-06-30 CARBIS WALKER LLP 5700 CORPORATE DRIVE STE 650 PITTSBURGH PA 15237 990 2010-07-01 251002946 MEYERSDALE COMMUNITY HOSPITAL MEYE 8146345911 200 HOSPITAL DRIVE MEYERSDALE PA 15552 EDWARD DEPASQUALE 8144108271 2012-03-01 1 JEFFREY J PETRELL CPA 4126356270 2012-03-01 2010 2016-02-24 21:20:13Z MEYERSDALE MEDICAL CENTER SCOTT BECKER 1086 FRANKLIN STREET JOHNSTOWN PA 15905 12488246 0 X WWW.CONEMAUGH.ORG X 1952 PA GENERAL ACUTE CARE CRITICAL ACCESS HOSPITAL PROVIDING INPATIENT, SWING BED, OUTPATIENT, AND CLINIC SERVICES TO THE SOUTHERN SOMERSET COUNTY POPULATION. 15 13 145 33 0 0 214339 293413 11557120 12050144 33906 43877 -20082 32561 11785283 12419995 0 0 0 0 4892117 5072276 0 0 0 6581558 6622387 11473675 11694663 311608 725332 7127524 8268640 3558392 3908920 3569132 4359720 X GENERAL ACUTE CARE CRITICAL ACCESS HOSPITAL PROVIDING INPATIENT, SWING BED, OUTPATIENT, AND CLINIC SERVICES TO THE SOUTHERN SOMERSET COUNTY POPULATION. 0 0 10012624 12050144 MEYERSDALE COMMUNITY HOSPITAL SERVES A RURAL AREA IN SOUTHWESTERN PENNSYLVANIA'S HISTORIC SOMERSET COUNTY. SPECIALIZING IN FAMILY AND PRIMARY CARE, IT IS A STATE-DESIGNATED CRITICAL CARE ACCESS HOSPITAL AND HAS BEEN DEEMED A NECESSARY HEALTH CARE PROVIDER BY THE COMMONWEALTH OF PENNSYLVANIA. MEYERSDALE COMMUNITY HOSPITAL OFFERS 24/7 EMERGENCY CARE, OPERATING ROOMS FOR MINOR PROCEDURES, RADIOLOGY AND PATHOLOGY SERVICES, PHYSICAL AND RESPIRATORY THERAPY, CARDIAC REHABILITATION, AND OB/GYN OUTPATIENT CARE. IN ADDITION A STEPDOWN SWING UNIT IS AVAILABLE FOR PATIENTS.DURING FISCAL YEAR 2011, THE HOSPITAL TREATED 295 ACUTE PATIENTS FOR A TOTAL OF 1,008 DAYS AND 88 SWING BED PATIENTS FOR A TOTAL OF 667 DAYS. ALSO, 43,740 OUTPATIENTS WERE TREATED THROUGHOUT THE FACILITY'S CLINICAL DEPARTMENTS AND RURAL HEALTH CLINICS. 10012624 1 1 0 1 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 25 0 145 1 0 0 0 0 0 0 0 0 0 0 X 15 13 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 PA X HEATHER SMITH 8146345911 200 HOSPITAL DRIVE MEYERSDALE PA 15552 X ATTY DOUGLAS MCCALL BELL 1.00 X X 0 0 0 CLIFFORD MAUST 1.00 X X 0 0 0 M SUSAN DOM 1.00 X X 0 0 0 SAMUEL P MCCLURE 1.00 X X 0 0 0 REBECCA BOWER 1.00 X 0 0 0 MARK FOLK 1.00 X 0 0 0 DAVID LAUVER 1.00 X 0 0 0 M RAY LECKEMBY 1.00 X 0 0 0 KEVIN MILLER 1.00 X 0 0 0 HAROLD NICHOLSON 1.00 X 0 0 0 DANIEL ROUGH 1.00 X 0 0 0 JOHN SMAILA 1.00 X 0 0 0 NATHAN O THOMAS MD 1.00 X 0 177058 32592 ROGER WAHL 1.00 X 0 0 0 LEROY NEWELL 1.00 X 0 0 0 MARY L LIBENGOOD 50.00 X 187851 0 7023 SCOTT BECKER 1.00 X 0 1236437 42969 EDWARD DEPASQUALE 1.00 X 0 538638 35167 DAVID CARLSON DO 4.00 X 0 678102 30611 JOSEPH DADO 2.00 X 0 442586 16131 STEVEN TUCKER 3.00 X 0 531509 35347 187851 3604330 199840 1 0 1 0 MEMORIAL MEDICAL CENTER 1086 FRANKLIN STREET JOHNSTOWN PA 15905 FINANCIAL, IT, REFERENCE LAB, PHARMACY S 931086 CONEMAUGH HEALTH INITIATIVES 1086 FRANKLIN STREET JOHNSTOWN PA 15905 ER PHYSICIAN, OFFICE STAFF 865150 CDL 6400 BROOKTREE COURT WEXFORD PA 15090 NUCLEAR MEDICINE 270291 ALLIANCE IMAGING PO BOX 96485 CHICAGO IL 60693 MRI 193572 CAMCO 1454 SCALP AVENUE JOHNSTOWN PA 15904 PHYSICAL & OCCUPATIONAL THERAPY 155232 8 69795 223618 293413 NET PATIENT SERVICE RE 900099 11998587 11998587 BLOOD SCREENING 900099 51015 51015 MEDICAL RECORDS & VERI 900099 542 542 12050144 43877 43877 56663 64428 -7765 -7765 -7765 10469 3823 6646 6646 MISCELLANEOUS 900099 33680 33680 33680 12419995 12050144 0 76438 164031 32806 131225 4048591 3436102 612489 3425 2980 445 546816 446887 99929 309413 262558 46855 147319 147319 771766 710025 61741 61190 61190 68801 55041 13760 235833 188666 47167 26939 21551 5388 132698 132698 455134 364107 91027 153098 153098 PURCHASED SERVICES 2419850 2419850 PATIENT SUPPLIES AND FO 1109528 1109528 BAD DEBT EXPENSE 504568 504568 REPAIRS AND MAINTENANCE 340578 272462 68116 LEASE & RENTAL 147127 147127 47958 38366 9592 11694663 10012624 1682039 0 1609331 2670965 287388 286360 1025227 1127045 19211 17088 9258053 6282276 3273446 2975777 912921 1191405 7127524 8268640 648820 685400 104498 41387 2245259 2247954 331589 244067 228226 690112 3558392 3908920 X 2719450 3458583 184326 211210 665356 689927 3569132 4359720 7127524 8268640 X 725332 65256 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 600 600 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: MEMBERSHIP DUES PAID TO THE HOSPITAL COUNCIL OF WESTERN PENNSYLVANIA INDICATED THAT A SPECIFIC PERCENTAGE OF THE DUES WOULD BE RELATED TO LOBBYING ACTIVITIES. 136049 136049 5531092 3267913 2263179 3565434 3007428 558006 25478 6935 18543 2975777 ACCRUED INTEREST RECEIVABLE 35 MISCELLANEOUS ACCOUNTS RECEIVABLE 95474 INTEREST IN INCOME TRUSTS 689927 RESTRICTED CASH FOUNDATION 151297 RESTRICTED CASH FOUNDATION - CITIZENS NATIONAL BANK 59913 DEFERRED FINANCING EXPENSE 48266 ASSETS HELD BY TRUSTEE 142156 DUE FROM MA 4337 1191405 ASSET RETIREMENT OBLIGATION 66705 DUE TO MEMORIAL MEDICAL CENTER 166411 DUE TO CONEMAUGH HEALTH INITIATIVES, INC. 76996 DUE TO MC 380000 690112 1 1 X 1 X 1 X 0.0 1 1 0 0 306476 0 306476 0.02740 1064166 1145575 -81409 0.00000 7520 5587 1933 0.00020 1378162 1151162 227000 0.02760 40094 0 40094 0.00360 40094 40094 0.00360 1418256 1151162 267094 0.03120 0 248298 220464 3220279 3032778 187501 X 1 0 3 1 MEYERSDALE COMMUNITY HOSPITAL

200 HOSPITAL DRIVE MEYERSDALE PA 15552

X X X X 2 FAMILY HEALTHCARE RHC MEYERSDALE

202 BEACHLEY STREET MEYERSDALE PA 15552

RURAL HEALTH CLINIC 3 FAMILY HEALTHCARE RHC SALISBURY

231 ORD STREET SALISBURY PA 15558

RURAL HEALTH CLINIC NOT REQUIRED 1 PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS REPORTED ON PART I, LINES 7A, 7B, AND 7C WAS BASED ON THE CONEMAUGH HEALTH SYSTEM'S COST ACCOUNTING SYSTEM AND ADDRESSES ALL PATIENT SEGMENTS. FOR FURTHER DETAILS OF THIS SYSTEM, SEE THE DESCRIPTION FOR PART III, LINE 8. THE METHODOLOGY USED TO CALCULATE THE AMOUNTS REPORTED ON PART I, LINES 7E THROUGH 7I AS APPLICABLE, WAS BASED ON ACTUAL REVENUES AND EXPENSES INCURRED. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 504568. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED ARE REPORTED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYORS, PATIENTS AND OTHERS. CONEMAUGH HEALTH SYSTEM (CHS) 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, CHS BILLS THIRD-PARTY PAYORS 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.THE METHODOLOGY UTILIZED TO DETERMINE THE AMOUNT REPORTED ON LINE 2 IS BASED ON THE ORGANIZATION'S COST TO CHARGE RATIO. THE METHODOLOGY FOR LINE 3 IS BASED ON A PREDICTIVE ANALYSIS SCORING SYSTEM DEVELOPED BY ACUMEN THAT HAS BEEN IMPLEMENTED AS PART OF THE HEALTH SYSTEM'S PRESUMPTIVE CHARITY CARE PROGRAM. THE SCORING PROGRAM CONSISTS OF A FOUR DIGIT SCORE; THE FIRST TWO DIGITS ARE BASED UPON THE FEDERAL POVERTY GUIDELINES AND THE LAST TWO DIGITS ARE THE PROBABILITY/PROPENSITY TO PAY SCORE. THE PERCENTAGES INCLUDED ON THE 990 HAVE BEEN DERIVED BY FOUR MONTHS OF ACTUAL EXPERIENCE (JULY-OCTOBER 2011) OF ACCOUNTS THAT HAVE GONE THROUGH THE NORMAL BILLING CYCLE OF 120 DAYS; BEING SCORED AND CONSIDERED FOR PRESUMPTIVE CHARITY CARE VS. SENDING TO COLLECTION AGENCY. THE ACCOUNTS THAT WERE SELECTED AND INCLUDED FOR PRESUMPTIVE CHARITY CONSIDERATION WERE BASED ON MEDIAN HOUSEHOLD INCOME AND AVERAGE HOUSEHOLD SIZE THAT FELL BELOW 150% OF THE FEDERAL POVERTY GUIDELINES. THAT SAME PERCENTAGE EXPERIENCE IS BEING APPLIED TO THE FISCAL YEAR 2011 BAD DEBT EXPENSE TO DERIVE AN AMOUNT THAT COULD POTENTIALLY QUALIFY FOR CHARITY CARE. PART III, LINE 8: CONEMAUGH HEALTH SYSTEM UTILIZES MCKESSON'S HORIZON PERFORMANCE MANAGER (HPM) FOR COST ACCOUNTING. HPM PROVIDES THE ABILITY TO ALLOCATE ALL DEPARTMENTAL EXPENSES AT THE INDIVIDUAL CHARGE FOR EACH CHARGING DEPARTMENT, AS WELL AS ALLOCATE OVERHEAD EXPENSES IN A CONSISTENT MANNER. THE ENCOUNTER COSTING FUNCTIONALITY OF HPM PROVIDES THE ABILITY TO THEN DETERMINE AN ACCURATE ESTIMATE OF COST AT THE PATIENT LEVEL BASED ON THE CHARGE UNIT COSTS. THE SYSTEM THEN PROVIDES THE ABILITY TO SUMMARIZE THE PATIENT VOLUME, CHARGES, AND COSTS IN ANY NUMBER OF WAYS, INCLUDING PAYER SPECIFIC COST ALLOCATION. PART I, LINE 3B: THE ORGANIZATION USES A SLIDING SCALE TO DETERMINE ELIGIBILITY FOR DISCOUNTED CARE. PART VI, LINE 2: CHS IS AN ACTIVE MEMBER OF THE COMMUNITY AND AN ADVOCATE FOR THE HEALTH, WELL BEING, AND ECONOMIC STRENGTH OF THE REGION. CHS ADMINISTRATORS HAVE TEAMED UP WITH THE UNITED WAY OF THE LAUREL HIGHLANDS OVER THE PAST FEW YEARS TO IDENTIFY COMMUNITY NEEDS. THIS YEAR, CHS INVESTED NEARLY 1,000 HOURS OF WORK INTO A COMMUNITY NEEDS ANALYSIS FOR CAMBRIA AND SOMERSET COUNTIES. THIS INCLUDED DOZENS OF INTERVIEWS OF AREA LEADERS, HEALTHCARE PROFESSIONALS, EDUCATORS, CLERGY, AND SOCIAL SERVICE PROFESSIONALS. THE FINDINGS HAVE BEEN SHARED WITH THE BOARDS OF CONEMAUGH HEALTH SYSTEM, THE UNTIED WAY OF THE LAUREL HIGHLANDS, AND OVER 20 HUMAN SERVICES AGENCIES. THE 70 PAGE FINAL REPORT WILL BE SHARED WITH COMMUNITY LEADERS AND A CONDENSED HIGHLIGHT VERSION WILL BE RELEASED TO THE MEDIA. THE UNITED WAY HAS BEGUN TO REDIRECT FUNDING TO KEY AREAS OF NEED INCLUDING: PROGRAMS TO HELP CHILDREN STAY IN SCHOOL TO INCREASE THEIR POTENTIAL TO BE SUCCESSFUL; DRUG AND ALCOHOL PROGRAMS; AND MENTAL HEALTH PROGRAMS. CONEMAUGH AND THE UNITED WAY WILL PERIODICALLY MEASURE COMMUNITY IMPACT.IN ADDITION TO PROVIDING THE COMMUNITY NEEDS REPORT, VARIOUS CHS LEADERS HAVE SERVED IN MANY ROLES FOR THE UNITED WAY INCLUDING CHAIRMAN OF THE BOARD, CHAIRMAN OF THE COMMUNITY IMPACT COMMITTEE, AND PARTICIPATION IN THE LOANED EXECUTIVE PROGRAM. SENIOR LEADERS AND DIRECTORS THROUGHOUT THE HEALTH SYSTEM ARE ALSO ENCOURAGED TO SERVE ON OTHER COMMUNITY BOARDS AND ORGANIZATIONS. SOME OF THOSE REPRESENTED INCLUDE THE AMERICAN RED CROSS, THE LEUKEMIA AND LYMPHOMA SOCIETY, THE JOHNSTOWN SYMPHONY, WOMEN'S HELP CENTER, JUNIOR ACHIEVEMENT, LAUREL HIGHLANDS FOOD PANTRY, AND THE GREATER JOHNSTOWN YMCA. PART VI, LINE 3: CONEMAUGH HEALTH SYSTEM COMMUNICATES TO PATIENTS THE AVAILABILITY OF FINANCIAL ASSISTANCE UNDER FEDERAL, STATE AND LOCAL PROGRAMS, AS WELL AS THE CHARITY CARE PROGRAM, ON OUR WEBSITE, WHICH INCLUDES A DOWNLOADABLE CHARITY CARE APPLICATION AND INSTRUCTIONS. TABLE TOP BROCHURES ARE PROVIDED AT ALL POINTS OF REGISTRATION, AND BROCHURES ARE INCLUDED IN PATIENT ADMISSION PACKETS. INFORMATION ON THE AVAILABILITY OF FINANCIAL ASSISTANCE IS ALSO INCLUDED ON PATIENT STATEMENTS. ASSISTANCE IS PROVIDED TO PATIENTS TO APPLY FOR MEDICAL ASSISTANCE THROUGH A THIRD-PARTY VENDOR. A ROBUST FINANCIAL COUNSELING AND CUSTOMER SERVICE DEPARTMENT IS AVAILABLE TO HANDLE SPECIFIC PATIENT NEEDS. PART VI, LINE 4: MEYERSDALE MEDICAL CENTER (MYMC) SERVES A RURAL AREA IN SOUTHWESTERN PENNSYLVANIA'S HISTORIC SOMERSET COUNTY. SPECIALIZING IN FAMILY AND PRIMARY CARE, IT IS A STATE-DESIGNATED CRITICAL CARE ACCESS HOSPITAL AND HAS BEEN DEEMED A NECESSARY HEALTH CARE PROVIDER BY THE COMMONWEALTH OF PENNSYLVANIA. MEYERSDALE OFFERS 24/7 EMERGENCY CARE, OPERATING ROOMS FOR MINOR PROCEDURES, RADIOLOGY AND PATHOLOGY SERVICES, PHYSICAL AND RESPIRATORY THERAPY, CARDIAC REHABILITATION AND OB/GYN OUTPATIENT CARE. IN ADDITION A STEPDOWN SWING UNIT IS AVAILABLE FOR PATIENTS WHO ARE NO LONGER IN NEED OF HOSPITALIZATION BUT NEED A LITTLE EXTRA CARE BEFORE HEADING HOME. PHYSICIAN SPECIALISTS MAKE VISITS TO MYMC ON A REGULAR BASIS TO HELP IMPROVE ACCESS FOR PATIENTS IN THIS RURAL COMMUNITY. WEEKLY CLINIC SERVICES INCLUDE CARDIOLOGY, OBSTETRICS/GYNECOLOGY, OPHTHALMOLOGY, GASTROENTEROLOGY, NEPHROLOGY, WELL BABY CLINIC, WOUND CARE CENTER, HEARING AIDE CENTER, AND PODIATRY. AERO MEDICAL HELICOPTER TRANSPORTATION IS AVAILABLE TO PATIENTS IN THE MEYERSDALE AREA TO TRANSPORT THEM TO MEMORIAL MEDICAL CENTER OR OTHER FACILITIES IF NEEDED. MYMC HAS TWENTY LICENSED BEDS WITH AN AVERAGE INPATIENT CENSUS OF 5. THERE ARE 4 ACTIVE PHYSICIANS ON THE MEDICAL STAFF. DEMOGRAPHICALLY, NEARLY 20 PERCENT OF RESIDENTS IN THE CONEMAUGH HEALTH SYSTEM SERVICE AREA ARE 65 OR OLDER, ONE OF THE HIGHEST PERCENTAGES IN THE STATE AND WELL ABOVE THE PENNSYLVANIA AVERAGE OF 15.3 PERCENT. THE PAYOR MIX FOR THE REGION IS SKEWED HEAVILY TOWARD MEDICARE AND MEDICAID. AT 9.7 PERCENT, THE CONEMAUGH HEALTH SYSTEM'S SERVICE AREA HAS ONE OF THE STATE'S HIGHEST UNEMPLOYMENT RATES, AND MEDIAN HOUSEHOLD INCOMES OF $34,000 LAG 30 PERCENT BEHIND STATE AND NATIONAL AVERAGES. THE DEMOGRAPHIC MAKE UP OF THE REGION IS CONSIDERED WHEN PLANNING EDUCATION OPPORTUNITIES AND HEALTH INFORMATION PROGRAMS. THE CONEMAUGH HEALTH SYSTEM'S COVERAGE REGION ALSO PRESENTS SOME GEOGRAPHIC CHALLENGES. MOUNTAINOUS TOPOGRAPHY AND HIGHWAY INFRASTRUCTURE MAKE TIMELY TRAVEL A CONCERN FOR SOME PATIENTS. CHS CONTINUES TO LOOK FOR OPPORTUNITIES TO BRING PRIMARY CARE AND PHYSICIAN SPECIALISTS TO RURAL REGIONS OF THE MARKET. IN THE PAST YEAR, A CONCENTRATED EFFORT HAS BEEN MADE TO DEVELOP AND DELIVER HEALTH AND WELLNESS EDUCATION AND SCREENINGS TO CONSTITUENTS IN RURAL REGIONS. WHEN POSSIBLE, CHS TEAMS UP WITH OTHER COMMUNITY ORGANIZATIONS TO DELIVER THESE PROGRAMS AND SERVICES TO RURAL CONSTITUENTS. PART VI, LINE 6: THE CONEMAUGH HEALTH SYSTEM, WHICH INCLUDES MEYERSDALE MEDICAL CENTER (MYMC), IS THANKFUL FOR SUPPORT FROM THE LOCAL COMMUNITY IN THE FORM OF BOARD OF DIRECTOR PARTICIPATION. THE CHS BOARDS ARE MADE UP OF A WIDE VARIETY OF COMMUNITY LEADERS REPRESENTING A NUMBER OF INDUSTRIES INCLUDING BANKING, COMMUNICATION, INDUSTRIAL, EDUCATION, AND CUSTOMER SERVICE. PHYSICIAN LEADERS ARE ALSO INCLUDED ON THE BOARD, SOME WITH TIES TO THE CONEMAUGH HEALTH SYSTEM AND OTHERS WHO ARE INDEPENDENT. VALUABLE INPUT ALSO COMES FROM OUR PATIENT ADVISORY COMMITTEE; A VOLUNTEER BOARD OF PASSIONATE COMMUNITY MEMBERS WHO ARE DEDICATED TO PROVIDING SUGGESTIONS FOR INNOVATIVE SOLUTIONS TO IMPROVE THE PATIENT EXPERIENCE. MEDICAL STAFF PRIVILEGES ARE EXTENDED TO CLOSE TO 400 PHYSICIANS THROUGHOUT A WIDE GEOGRAPHIC REGION IN BOTH PRIMARY CARE AND SPECIALTY FIELDS. IN THE PAST YEAR, GREAT ENERGY, EFFORT, AND FINANCIAL SUPPORT HAVE BEEN DEDICATED TO A NUMBER OF KEY INITIATIVES DESIGNED TO IMPROVE PATIENT CARE. FOR EXAMPLE: $2.6 MILLION DOLLARS WAS USED TO BRING DIGITAL MAMMOGRAPHY EQUIPMENT TO PATIENTS IN OUR REGION WITH EIGHT NEW DIGITAL MAMMOGRAPHY UNITS INSTALLED IN SIX DIFFERENT HEALTH SYSTEM LOCATIONS; A WOUND HEALING CENTER WAS ADDED TO A THIRD LOCATION TO BETTER SERVE PATIENTS IN THE NORTHERN PORTION OF OUR COVERAGE AREA; CONEMAUGH REGIONAL HOSPICE ADDED A HELPING HEARTS PROGRAM TO ASSIST THOSE PATIENT SUFFERING FROM CONGESTIVE HEART FAILURE; A BRAND NEW WEBSITE WAS LAUNCHED PROVIDING MORE EDUCATIONAL RESOURCES AND SUPPORT GROUP INFORMATION FOR THE COMMUNITY; AND A NUMBER OF WELLNESS EVENTS AND SCREENINGS TOOK PLACE THROUGHOUT THE REGION TO RAISE AWARENESS AND PREVENTION FOR HEALTH ISSUES INCLUDING DIABETES, OBESITY, HEART DISEASE, AND PERIPHERAL VASCULAR DISEASE. MYMC IS COMMITTED TO PROVIDING EDUCATIONAL INFORMATION AND SCREENINGS TO THE COMMUNITY. NEARLY 50 MEYERSDALE EMPLOYEES PARTICIPATED IN "WELLNESS" ACTIVITIES FOR THE COMMUNITY INCLUDING SCREENINGS FOR BLOOD SUGARS, PFTS, EKGS, VASCULAR SCREENS, VISION SCREENING, CHOLESTEROL, BONE DENSITY AND BODY FAT ANALYSIS. MYMC DONATES SPACE IN ITS DINING ROOM AND CONFERENCE ROOM EACH WEEK FOR ALCOHOLICS ANONYMOUS MEETINGS. MEYERSDALE COMMUNITY HOSPITAL FACILITY HIGHLIGHTS:LICENSED BEDS - 20BEDS IN SERVICE - 20PATIENT DAYS OF SERVICE - 1,675INPATIENT DAILY CENSUS - 5ADMISSIONS - 383AVERAGE LENGTH OF STAY - 4.4FULL TIME EQUIVALENT EMPLOYEES - 108.7VOLUNTEERS - 33PHYSICIANS:ACTIVE - 4SERVICES:EMERGENCY VISITS - 4,110SAME DAY/AMBULATORY SURGERY - 182PHYSICAL THERAPY TREATMENTS - 5,406LABORATORY TESTS - 69,785RADIOLOGY DIAGNOSTIC/MAMMOGRAPHY - 6,349ULTRASOUND PROCEDURES - 1,135CT SCANS - 2,252MRI PROCEDURES - 524CARDIO/RESPIRATORY PROCEDURES - 14,197 X X X X X 0 1 0 0 0 1 1 0 0 NATHAN O THOMAS MD 0 145481 0 11846 0 19731 0 14708 0 17884 0 209650 0 0 MARY L LIBENGOOD 129562 0 20683 0 37606 0 0 0 7023 0 194874 0 23133 0 SCOTT BECKER 0 571461 0 210076 0 454900 0 13224 0 29745 0 1279406 0 204798 EDWARD DEPASQUALE 0 313637 0 66488 0 158513 0 18798 0 16369 0 573805 0 98604 DAVID CARLSON DO 0 400722 0 86056 0 191324 0 12606 0 18005 0 708713 0 103693 JOSEPH DADO 0 254066 0 53829 0 134691 0 13099 0 3032 0 458717 0 80488 STEVEN TUCKER 0 313307 0 66488 0 151714 0 19435 0 15912 0 566856 0 97025 PART I, LINE 4B THE CONEMAUGH HEALTH SYSTEM'S 457(F) EXECUTIVE COMPENSATION PROGRAM WAS TERMINATED DECEMBER 10, 2010 RESULTING IN A TAXABLE EVENT. ON THAT DATE, EACH PARTICIPANT'S ENTIRE ACCOUNT BALANCE WAS RECOGNIZED AS TAXABLE INCOME PER IRS REGULATIONS. THESE AMOUNTS, WHICH ARE INCLUDED ON THE 990 CORE FORM AND SCHEDULE J AS REPORTABLE COMPENSATION ARE AS FOLLOWS: $430,918 FOR SCOTT BECKER; $148,478 FOR EDWARD DEPASQUALE; $180,982 FOR DAVID CARLSON, DO; $130,649 FOR JOSEPH DADO; $136,362 FOR STEVEN TUCKER; AND $37,606 FOR MARY LIBENGOOD. PLEASE NOTE THAT THESE AMOUNTS LESS ALL APPLICABLE TAXES, WHICH HAVE BEEN REMITTED UPON THE PLAN'S TERMINATION, WILL NOT BE DISTRIBUTED TO THE PARTICIPANTS UNTIL 1 YEAR AND 1 DAY AFTER THE TERMINATION DATE HAS PASSED. PART I, LINE 6 MARY LIBENGOOD RECEIVED A BONUS FROM MEYERSDALE COMMUNITY HOSPITAL. SCOTT BECKER, EDWARD DEPASQUALE, DAVID CARLSON, DO, AND JOSEPH DADO RECEIVED A BONUS FROM THE CONEMAUGH HEALTH SYSTEM, A RELATED ORGANIZATION. STEVEN TUCKER RECEIVED A BONUS FROM MEMORIAL MEDICAL CENTER, A RELATED ORGANIZATION. EXECUTIVE BONUSES ARE CALCULATED AS A PERCENTAGE OF BASE SALARY. THE PERCENTAGE IS CONTINGENT ON VARIOUS FINANCIAL AND NON-FINANCIAL INCENTIVE CRITERIA, GOVERNED BY THE EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD OF CONEMAUGH HEALTH SYSTEM. SUPPLEMENTAL INFORMATION PART III PART II, COLUMN (F): PAST CONTRIBUTIONS MADE TO THE 457(F) PLAN ARE INCLUDED AS REPORTABLE COMPENSATION IN THE CURRENT YEAR DUE TO THE PLAN'S TERMINATION. AMOUNTS SHOWN REPRESENT CONTRIBUTIONS THAT WERE RECOGNIZED AS DEFERRED COMPENSATION ON PAST FORM 990S. LISA SCHAFER FAMILY MEMBER OF M. SUSAN DOM (TRUSTEE) 32765 EMPLOYMENT 0 FORM 990, PART VI, SECTION A, LINE 6 THE MEMBERS OF MEYERSDALE COMMUNITY HOSPITAL CONSIST OF THREE CLASSES: PERPETUAL MEMBERS, LIFE MEMBERS, AND CONEMAUGH HEALTH SYSTEM, INC. (THE CORPORATE MEMBER). FORM 990, PART VI, SECTION A, LINE 7A THE CORPORATE MEMBER OF MEYERSDALE COMMUNITY HOSPITAL, CONEMAUGH HEALTH SYSTEM, INC., HAS THE POWER TO APPROVE OR DISAPPROVE THE ELECTION OF OR REMOVAL OF MEMBERS OF THE GOVERNING BODY. FORM 990, PART VI, SECTION A, LINE 7B ALL DECISIONS OF THE GOVERNING BODY OF MEYERSDALE COMMUNITY HOSPITAL ARE SUBJECT TO APPROVAL BY ITS CORPORATE MEMBER, CONEMAUGH HEALTH SYSTEM, INC. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PROVIDED TO THE ORGANIZATION'S BOARD OF DIRECTORS BEFORE IT IS FILED. ONCE THE FORM IS COMPLETE, BOARD MEMBERS ARE GIVEN THE OPPORTUNITY TO REVIEW THE CONTENTS OF THE FORM AND SUBMIT ANY COMMENTS OR QUESTIONS. IN ADDITION, SINCE THE ORGANIZATION IS A SUBSIDIARY WITHIN A LARGER HEALTH SYSTEM, THE FORM IS REVIEWED BY THE HEALTH SYSTEM'S MANAGER, TAX & COMPLIANCE; DIRECTOR, FINANCIAL OPERATIONS; VICE-PRESIDENT, FINANCIAL OPERATIONS; CHIEF FINANCIAL OFFICER; AND THE AUDIT AND COMPLIANCE COMMITTEE. AN EXTERNAL CPA FIRM IS ENGAGED TO REVIEW AND ELECTRONICALLY FILE THE RETURN. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION IS A SUBSIDIARY OF A LARGER HEALTH SYSTEM AND IS GOVERNED BY THE SYSTEM'S CONFLICT OF INTEREST POLICY, WHICH HAS BEEN APPROVED BY THE HEALTH SYSTEM'S BOARD. UNDER THIS POLICY, EVERY BOARD MEMBER IS GIVEN A COPY OF THE POLICY AS WELL AS A FORM THAT MUST BE COMPLETED ON AN ANNUAL BASIS. NO BOARD MEMBER IS APPROVED OR RE-APPOINTED UNTIL HE OR SHE HAS COMPLETED AND SIGNED THE CONFLICT OF INTEREST FORM. ONCE THE FORM IS RETURNED, IT IS REVIEWED BY THE SYSTEM'S COMPLIANCE OFFICER AND CEO. IF ANY CONFLICTS ARE DISCLOSED, THE DETAILS ARE FORWARDED TO THE BOARD CHAIR TO BE ADDRESSED. DEPENDING ON THE CONFLICT, THE BOARD MEMBER COULD BE GIVEN CERTAIN RESTRICTIONS, SUCH AS BEING PROHIBITED FROM PARTICIPATING IN CERTAIN BOARD DECISIONS. THE HEALTH SYSTEM'S AUDIT AND COMPLIANCE COMMITTEE HAS THE FINAL DECISION-MAKING REGARDING ALL CONFLICTS OF INTEREST. THROUGHOUT THE FISCAL YEAR, BOARD MEMBERS MUST NOTIFY THE BOARD CHAIR, COMPLIANCE OFFICER, AND/OR CEO IF A NEW CONFLICT OF INTEREST HAS DEVELOPED. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION'S PARENT, A HEALTH SYSTEM, MANAGES THE DETERMINATION OF COMPENSATION AND THE PROCESS IS OUTLINED IN ITS BY-LAWS. AN OUTSIDE CONSULTING FIRM IS UTILIZED TO ENSURE THAT EXECUTIVE COMPENSATION PACKAGES ARE FAIR AND COMPARABLE WITH SIMILAR ORGANIZATIONS. THE HEALTH SYSTEM HAS ALSO ESTABLISHED AN EXECUTIVE COMPENSATION COMMITTEE TO REVIEW AND RECOMMEND THE COMPENSATION DECISIONS MADE. THIS COMMITTEE REPORTS DIRECTLY TO THE HEALTH SYSTEM'S BOARD. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION IS PART OF A HEALTH SYSTEM AND ALL REQUESTS FOR THIS INFORMATION ARE HANDLED BY THE SYSTEM'S MARKETING/PUBLIC RELATIONS DEPARTMENT. FORM 990, PART VI, LINES 12A, 13, AND 14: ALL APPLICABLE POLICY QUESTIONS HAVE BEEN ANSWERED YES SINCE THE ORGANIZATION IS A SUBSIDIARY OF A LARGER HEALTH SYSTEM AND IS GOVERNED BY THE SYSTEM'S POLICIES. ALL POLICIES HAVE BEEN APPROVED BY THE HEALTH SYSTEM'S BOARD. FORM 990, PART VII, SECTION A, LINE 1A, COLUMN B: IN ADDITION TO THE HOURS DEVOTED TO THE FILING ORGANIZATION SHOWN IN PART VII, THE FOLLOWING OFFICERS AND TRUSTEES ALSO DEVOTED HOURS TO RELATED ORGANIZATIONS DURING THE YEAR. THE HOURS SHOWN REPRESENT THE AVERAGE NUMBER OF HOURS PER WEEK. SCOTT BECKER, CEO: CONEMAUGH HEALTH SYSTEM - 53 CONEMAUGH VALLEY MEMORIAL HOSPITAL - 4 MINERS HOSPITAL - 1 GOOD SAMARITAN MEDICAL CENTER - 0.3 CONEMAUGH HEALTH FOUNDATION - 3.5 CONEMAUGH HOUSING, INC. - 0.2 CONEMAUGH HEALTH INITIATIVES - 7 EDWARD DEPASQUALE, CFO: CONEMAUGH HEALTH SYSTEM - 22 CONEMAUGH VALLEY MEMORIAL HOSPITAL - 14 MINERS HOSPITAL - 1 GOOD SAMARITAN MEDICAL CENTER - 1 CONEMAUGH HEALTH FOUNDATION - 0.5 CONEMAUGH HOUSING, INC. - 0.5 CONEMAUGH HEALTH INITIATIVES - 10 DAVID CARLSON, DO, CMO: CONEMAUGH HEALTH SYSTEM - 20 CONEMAUGH VALLEY MEMORIAL HOSPITAL - 10 MINERS HOSPITAL - 4 GOOD SAMARITAN MEDICAL CENTER - 0.5 CONEMAUGH HEALTH FOUNDATION - 0.5 CONEMAUGH HOUSING, INC. - 1 CONEMAUGH HEALTH INITIATIVES - 10 JOSEPH DADO, CIO: CONEMAUGH HEALTH SYSTEM - 20 CONEMAUGH VALLEY MEMORIAL HOSPITAL - 16 MINERS HOSPITAL - 2 GOOD SAMARITAN MEDICAL CENTER - 1 CONEMAUGH HEALTH FOUNDATION - 1 CONEMAUGH HEALTH INITIATIVES - 8 STEVEN TUCKER, COO: CONEMAUGH HEALTH SYSTEM - 15 CONEMAUGH VALLEY MEMORIAL HOSPITAL - 25 MINERS HOSPITAL - 3 GOOD SAMARITAN MEDICAL CENTER - 1 CONEMAUGH HEALTH FOUNDATION - 0.5 CONEMAUGH HOUSING, INC. - 1 CONEMAUGH HEALTH INITIATIVES - 1.5 NATHAN THOMAS, DO: CONEMAUGH HEALTH INITIATIVES - 40 CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CHANGE IN CHF FAS 136 RECEIVABLE 26,884. CHANGE IN INCOME TRUST 24,572. MEDICAL DIRECTOR REIMBURSEMENT FROM CHS 13,800. TOTAL TO FORM 990, PART XI, LINE 5: 65,256. FORM 990, PART XI, LINE 2: THE ORGANIZATION'S FINANCIAL STATEMENTS FOR THE FISCAL YEAR ENDING JUNE 30, 2011 WERE AUDITED AS PART OF THE AUDIT OF THE CONSOLIDATED FINANCIAL STATEMENTS OF THE CONEMAUGH HEALTH SYSTEM, INC. AND SUBSIDIARIES. THE HEALTH SYSTEM'S AUDIT AND COMPLIANCE COMMITTEE ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND THE SELECTION OF THE INDEPENDENT ACCOUNTANT. CONEMAUGH HEALTH SYSTEM 1086 FRANKLIN STREET JOHNSTOWN PA 15905 232801799 SUPPORT MEMBER HOSPITALS PA 501(C)(3) 11A N/A 0 CONEMAUGH HEALTH FOUNDATION 1086 FRANKLIN STREET JOHNSTOWN PA 15905 251719695 SUPPORTS CONEMAUGH HEALTH SYSTEM PA 501(C)(3) 11B CONEMAUGH HEALTH SYSTEM 0 CONEMAUGH VALLEY MEMORIAL HOSPITAL DBA MEMORIAL MEDICAL CENTER 1086 FRANKLIN STREET JOHNSTOWN PA 15905 250965307 HEALTHCARE SERVICES PA 501(C)(3) 3 CONEMAUGH HEALTH SYSTEM 0 MINERS HOSPITAL DBA MINERS MEDICAL CENTER 290 HAIDA AVENUE HASTINGS PA 16646 250977902 HEALTHCARE SERVICES PA 501(C)(3) 3 CONEMAUGH HEALTH SYSTEM 0 GOOD SAMARITAN MEDICAL CENTER 1020 FRANKLIN STREET JOHNSTOWN PA 15905 250965428 HEALTHCARE SERVICES PA 501(C)(3) 3 CONEMAUGH HEALTH SYSTEM 0 CONEMAUGH HOUSING INC 1086 FRANKLIN STREET JOHNSTOWN PA 15905 251606936 PROVIDES SENIOR HOUSING FACILITIES PA 501(C)(3) 9 CONEMAUGH VALLEY MEMORIAL HOSPITAL 0 LAUREL HIGHLANDS ADVANCED IMAGING 1450 SCALP AVENUE JOHNSTOWN PA 15904 251864587 DIAGNOSTIC SERVICES PA N/A GREATER JOHNSTOWN TECH PARK 1086 FRANKLIN STREET JOHNSTOWN PA 15905 260389121 OPERATES MULTI TENANT COMMERCE OFFICE PARK PA N/A CONEMAUGH HEALTH INITIATIVES INC 1086 FRANKLIN STREET JOHNSTOWN PA 15905 251658283 PHYSICIAN SERVICES PA N/A C 1086 REAL ESTATE 1086 FRANKLIN STREET JOHNSTOWN PA 15905 251489704 REAL ESTATE PA N/A C CONEMAUGH ENTERPRISES INC 1086 FRANKLIN STREET JOHNSTOWN PA 15905 202998473 ECONOMIC DEVELOPMENT PA N/A C SINDO INC 1086 FRANKLIN STREET JOHNSTOWN PA 15905 251144116 COMMUNITY RENTALS PA N/A C 0 0 0 0 0 0 1 0 0 0 0 1 0 0 1 0 0 0