2012-05-07T07:14:21-05:00 2011-06-30 BKD LLP 910 E St Louis Street Suite 200 Springfield MO 65806 990 2010-07-01 240795508 The Williamsport Hospital WILL 5703207900 700 High Street Williamsport PA 17701 Charles J Santangelo 5703207900 2012-05-07 1 4178658701 2010 2016-02-24 21:20:13Z X Steven P Johnson 700 High Street Williamsport PA 17701 272380388 0 X www.susquehannahealth.org X 1873 PA The Williamsport Hospital (TWH) is a 223 bed acute care community hospital primarily serving Lycoming and surrounding counties. Services provided include, but are not limited to, Acute and Intensive Care, Surgical Services, Heart and Lung Services, Rehabilitation Services, Dialysis, Laboratory, Radiology, Psychology and Emergency Room Services. 16 12 1781 175 5728 0 3295509 1418918 205291856 225047065 2001787 2373969 1988364 625876 212577516 229465828 7262237 8185303 0 0 97361746 95662129 0 0 24854 102699375 111089390 207323358 214936822 5254158 14529006 288320376 328504001 204148960 226530141 84171416 101973860 X The Williamsport Hospital (TWH) 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 195882246 8185303 223357060 The Williamsport Hospital (TWH) is a 223 bed acute care community hospital primarily serving Lycoming and surrounding counties. Services provided include, but are not limited to, Acute and Intensive Care, Surgical Services, Heart and Lung Services, Rehabilitation Services, Dialysis, Laboratory, Radiology, Psychology and Emergency Room Services. TWH also provides Labor and Delivery Services while maintaining a 22 bed Nursery. During the fiscal year ended June 30, 2011, TWH admitted 11,335 patients rendering 47,874 patient days and registered approximately 240,308 outpatient procedures. TWH treats all patients without regard to their ability to pay. In addition, the Hospital treats Medicare / 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, TWH devotes a portion of its revenue and assets to community program services. The following reflects the breakout of $24,809,136 in quantifiable community benefits for FY 2011: Charity Care (at cost) $974,320; Bad Debt (at cost) $4,440,202; Government-sponsored health care (unpaid cost of Medicare, Medicaid, indigent care programs, SCHIP and other safety net programs) $16,569,000. In addition, various other programs such as Research, Health Professions Education, Community Health Services, Subsidized Health Services, Community Building, Financial and In-kind Contributions and Community Benefit Operations totaling $2,825,614. 195882246 1 1 0 1 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 0 0 1781 1 1 1 0 0 0 0 0 0 0 0 0 X 16 12 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 PA X Management 5703207900 1205 Grampian Boulevard Williamsport PA 17701 Chris H Dewald 1.00 X X 0 0 0 Keith Kuzio 1.00 X X 0 0 0 Kathleen D Pagana 1.00 X X 3461 0 0 Claire Strouse 1.00 X X 0 0 0 Jane Beachem 1.00 X 0 0 0 Leonard R Collins MD 1.00 X 0 88362 9844 Gregory R Frailey DO 1.00 X 0 0 0 Donald J Leathers MD 1.00 X 0 0 0 George E Logue 1.00 X 0 0 0 Paul Moulton 1.00 X 0 0 0 Dr Alexander R Nesbitt 1.00 X 0 177080 26375 James W Redka 1.00 X 0 0 0 Lucile Reynolds 1.00 X 0 0 0 Patrick Wilson 1.00 X 0 0 0 Mary Wolf 1.00 X 0 0 0 Steven P Johnson 40.00 X X 619955 0 87088 Charles J Santangelo 40.00 X 310862 0 23118 Neil G Armstrong 40.00 X 275905 0 23228 George A Manchester MD 40.00 X 307532 0 31445 William J McClain 40.00 X 211334 0 23882 Glenn C Mechling 40.00 X 210358 0 23156 Kenneth B Young 40.00 X 204412 0 8010 Glenda L Stroud 40.00 X 203442 0 18365 Karen M Armstrong 40.00 X 199318 0 18745 2546579 265442 293256 54 0 1 0 Aramark Healthcare PO Box 33170 Newark NJ 01788 Management / environmental services 9815947 L F Driscoll Company Partnership 9 Presidental Boulevard Bala Cynwyd PA 19004 Consulting services 1913218 Interior Construction Specialist 339 ESouthern Avenue SWilliamsport PA 17702 Construction services 1042545 Paris Companies 67 Hoover Avenue DuBois PA 15801 Linen services 818490 Bestpactices Inc 10306 Eaton Place Fairfax VA 22030 ER management services 620000 30 5620 518479 894819 1418918 Net patient revenue 621990 207727143 207727143 Support from alliance 900099 13050904 13050904 Information support sy 900099 1750982 1750982 Affiliate rent income 621990 1403080 1403080 Cafeteria 624200 781623 781623 333333 333333 225047065 1102328 1102328 44182238 3963 42756124 158436 1426114 -154473 1271641 1271641 Paramedic 900099 217278 217278 Abstracting 900099 165097 165097 Purchase discounts 900099 125022 125022 118479 60977 5728 51774 625876 229465828 223357060 5728 4684122 8185303 8185303 1710109 1710109 239285 239285 72871573 68125717 4726417 19439 4079677 3714613 364004 1060 11512351 10482184 1027176 2991 5249134 4779422 468348 1364 1228819 1209999 18820 359701 261889 97812 177071 18454 158617 89233 89233 249163 1245 247918 22264927 16582034 5682893 923150 860641 62509 40283850 39682974 600876 4048395 3935498 112897 153790 118716 35074 4750443 4371453 378990 132639 123846 8793 256616 208967 47649 2156373 2156373 10572428 10572428 3110412 3110412 Bad debt 13297725 13297725 Repairs & maintenance 4126886 4082353 44533 Miscellaneous 2907769 2907769 214936822 195882246 19029722 24854 17785307 20571860 21028548 23699826 2192021 2648155 6184287 5427571 333705783 135163602 126769509 198542181 113346892 74670315 1013812 2944093 288320376 328504001 24500028 31696645 145012033 143646769 34636899 51186727 204148960 226530141 X 83713273 101469426 267241 297628 190902 206806 84171416 101973860 288320376 328504001 X 14529006 3273438 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 17787 1 71446 0 0 89233 0 Explanation of Other Lobbying Activities: Part II-B, Line 1i: 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 the State levels. For the year ended 6/30/11, the amount of dues paid to HAP totaled $38,613, of which 21.26% or $8,209, was used for lobbying purposes. Dues paid to AHA totaled $39,221, of which 24.42% or $9,578, 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 in negligible. On an annual basis the Hospital utilizes professional services to help procure various types of federal and state funding. Such services may include direct contact with legislators, their staff, and various government officials. For the year ended 6/30/11, the amount paid for such services amounted to $71,446. 17782824 17782824 92565611 67593016 24972595 93725400 56916047 36809353 129631948 10654539 118977409 198542181 Deferred revenue 27333333 Due to third parties 4166728 Estimated medical legal liability costs 626000 Other liabilities 8680015 Due to affiliates, net 10380651 51186727 229465828 214936822 14529006 3254238 19200 3273438 17802444 232739266 3254238 19200 3273438 229465828 0 229465828 214936822 0 214936822 0 214936822 Part XI, line 8 - Change interest of net assets of affilate $530 Increase in permanently restricted net assets $15,904 Investment in Susquehanna Health Foundation $2,766 Part XII, line 2d - Change in interest of net assets of affiliate $530 Increase in permanently restricted net assets $15,904 Investment in Susquehanna Health Foundation $2,766 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 2140329 1 0 1 2140329 0 2140329 0 0 0 0 0 0 1 1 X 1 X 1 X 1 1 1 0 1 1 974320 0 974320 0.00480 22962246 14108042 8854204 0.04390 0 0 23936566 14108042 9828524 0.04870 511812 73633 438179 0.00220 234334 0 234334 0.00120 49608 0 49608 0.00020 0 0 1915055 0 1915055 0.00950 2710809 73633 2637176 0.01310 26647375 14181675 12465700 0.06180 35480 0 35480 0.00020 35480 35480 0.00020 1 4440202 488422 70905403 78620191 -7714788 X 1 1 1 1 The Williamsport Hospital

700 High Street Williamsport PA 17701

X X X X Not Required 1 3 The Medical Center

699 Rural Avenue Williamsport PA 17701

Outpatient clinic The Montoursville Clinic Savoy Plaza

900 Plaza Drive Montoursville PA 17754

Outpatient clinic / lab The Hepburn Plaza Outpatient Lab

465 Hepburn Plaza Williamsport PA 17701

Outpatient lab Part I, Line 6a: The community benefit report is prepared on a system wide basis under Susquehanna Health System. Part I, Line 7g: The Williamsport Hospital has various subsidized services which are included within the Medicare and Medical Assistance unreimbursed costs. Part I, column F The amount of total expenses used to calculate the percent of total expense in column F was reduced by bad debt expense of $13,297,725. Part I, Line 7 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. Part II: Activities focus on leadership development and training for community members through support to Leadership Lycoming and Youth Leadership Lycoming. Leadership Lycoming is a training program designed to understand the needs of the communities it serves; then educate and motivate potential leaders to commit themselves to address those needs through a variety of community leadership roles.Graduates of Leadership Lycoming are seen throughout the community as participants on boards, committees, forums and task forces. Many find that the information they received as a Leadership Lycoming participant provides them with the insight to better understand the issues facing our community today and tomorrow.The Williamsport Hospital (TWH) supports workforce development through participation on health care career education programs and by providing student observations for nursing and allied health professionals. TWH also supports Special Response Team (SRT) training. 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 guideline 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 responsiblity for the patient or guarantor to initiate the SHS Charity Care Assistance Program by applying. Part III, Section A, line 3 This estimated amount represents the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy - bad debt at cost multiplied by an estimated 11%. 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. The studies are currently underway. The results are anticipated in approximately 8 months. The results will be shared broadly and used to develop a response. 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 responsibility 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 6: 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 3.2-6 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 71,000 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 7: The Williamsport Hospital (TWH) 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 $45,641,204 in quantifiable community benefits reported for FY 2011: Charity Care (at cost) $1,666,014; Bad Debt (at cost) $7,498,578; Government-sponsored health care (unpaid cost of Medicare, Medicaid, indigent care programs, SCHIP and other safety net programs) $32,158,701. In addition, various other programs such as Research, Health Professions Education, Community Building, Financial and In-Kind Contributions, and Community Benefit Operations totaling $4,317,911. 1 Susquehanna Physician Services 1201 Grampian Boulevard Williamsport PA 17701 232449454 501(c)(3) 6523797 Support of affiliate Susquehanna Community Health & Dental Clinic 469-471 Hepburn Street Williamsport PA 17701 208979596 501(c)(3) 1661506 Financial support 2 Other Information: Part IV: Schedule I, Part I, line 2: Susquehanna Physician Services is a related organizations and part of the Susquehanna Health System with consistent management oversight ensuring the use of funds for charitable purposes. Susquehanna Community Health and Dental Clinic is a former service of Susquehanna Health System that is being converted to a Federally Qualified Health Clinic (FQHC). "Look-alike" status was received effective 12/06/11. Susquehanna Health System continues to support the clinics financially until full FQHC status is obtained and they are able to operate by their own means. All requests for funding are supported by detailed records of cash receipts and disbursements, as well as cash flow projections prepared by an independent accounting firm. 0 1 0 0 0 0 0 0 0 Dr Alexander R Nesbitt 0 170303 0 5302 0 1475 0 10006 0 16369 0 203455 0 0 Steven P Johnson 487740 0 118573 0 13642 0 72603 0 14485 0 707043 0 0 0 Charles J Santangelo 284401 0 20653 0 5808 0 8850 0 14268 0 333980 0 0 0 Neil G Armstrong 257300 0 15623 0 2982 0 14975 0 8253 0 299133 0 0 0 George A Manchester MD 287407 0 17969 0 2156 0 12525 0 18920 0 338977 0 0 0 William J McClain 166667 0 2707 0 41960 0 10804 0 13078 0 235216 0 0 0 Glenn C Mechling 193092 0 14826 0 2440 0 13672 0 9484 0 233514 0 0 0 Kenneth B Young 189987 0 14137 0 288 0 7200 0 810 0 212422 0 0 0 Glenda L Stroud 203103 0 0 0 339 0 10419 0 7946 0 221807 0 0 0 Karen M Armstrong 185154 0 12053 0 2111 0 11746 0 6999 0 218063 0 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 2010, the amount was $60,077. Supplemental Information Part III Part I, line 3: Susquehanna Health System (SHS), EIN # 23-2751183, 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. Lycoming County Authority 236760375 550804AH1 2009-10-22 147688732 See Part V 0 0 0 148250698 10650589 5073109 53252545 2696993 53083653 28594943 2012 1 0 0 1 0 0 1 0 1 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 Part I, (E) The total issue price per Form 8038, Part III (b) is $165,134,534. Of this total $147,688,732 was allocated to The Williamsport Hospital at the time of issue, while the balance of $17,445,802 was allocated to Divine Providence Hospital, EIN # 24-0799343. Part I, (F) The proceeds of the Lycoming County Authority, Series 2009A Bonds will be used, together with other available funds, to undertake a project consisting of (i) construction at Williamsport Hospital of a new energy service center that will allow the hospital to meet current energy demands, provide the capacity to support further growth, including hot and cold water, steam electricity, heat and air conditioning and installation of cogeneration equipment, construction of a new patient service tower that will expand and remodel the hospital's Emergency Department, Diagnostic Imaging Center and surgical suites, renovation of existing dual-occupancy patient rooms into private patient rooms and provision for a new private room patient nursing unit; (ii) refunding of the outstanding amount of the Issuer's Hospital Revenue Bonds (The Williamsport Hospital Project) Series of 2008, the proceeds of which were used to provide interim financing for certain of the Construction projects; (iii) refunding of the outstanding amount of the Issuer's Hospital Revenue Bonds (The Williamsport Hospital Obligated Group) 1995 Series, the proceeds of which were used (a) for the advance refunding of the outstanding portion of the Issuer's Hospital Revenue Bonds Series B issued in 1996 and (b) to finance certain capital facilities, including reimbursement of capital expenditures. Part II, line 3 The difference between "total proceeds of issue" and the amount reflected in Part I, (e) is due to investment earnings of $561,966. Part II, line 13 Expected date of completion is March 2012. Karen M Armstrong Spouse of key employee 218063 Compensation 0 Brenda Terry-Manchester Spouse of key employee 21222 Compensation 0 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 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. 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. 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 increments 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 of land or buildings and the construction or demolition of building 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 of the ordinary course of business, or any transfer of any assets of the corporation outside the ordinary course of business, except transfers 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, governance, or operations of the corporation. J) To dissolve or terminate the existence of the corporation and determine the distribution of assets upon the 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 tot he 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, Section B, line 15 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 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 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 gains on investments: 3,254,238. Change in interest of net assets of affiliate 530. Increase in permanently restricted net assets 15,904. Investment in SHF 2,766. Total to Form 990, Part XI, Line 5: 3,273,438. 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. Form 990, Part V, Line 2a & 2b Susquehanna Health System (SHS), EIN # 23-2751183 utilizes a common paymaster which includes the following entities: Divine Providence Hospital of the Sisters of Christian Charity, EIN #24-0799343 Muncy Valley Hospital, EIN # 24-0806023 The Williamsport Hospital, EIN # 24-0795508 Susquehanna Health Foundation, EIN # 23-2743470 Susquehanna Physician Services, EIN # 23-2449454 Williamsport Area Ambulance Service Cooperative, EIN # 23-2416166 The total number of employees reported on Form W-3 were 3,351 for Susquehanna Health System. Included with that total were 1,781 employees whose expenses were reported by The Williamsport Hospital. Form 990, Part VII, Section A, line 1a, column b Steven P. Johnson, Charles J. Santangelo, Neil G. Armstrong and George A. Manchester, M.D. 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 of the Sisters of Christian Charity, EIN # 24-0799343 Muncy Valley Hospital, EIN # 24-0806023 Susquehanna Health Foundation, EIN #23-2743470 Susquehanna Health System, EIN # 23-2751183 Susquehanna Physician Services, EIN # 23-2449454 Dr. Leonard R. Collins and Dr. Alexander Nesbitt work 40 hours per week for Susquehanna Physician Services, EIN # 23-2449454. In addition, they devote 1 hour each to the following related organizations: Susquehanna Physician Services, EIN # 23-2751183 The Williamsport Hospital, EIN # 24-0795508 Divine Providence Hospital of the Sisters of Christian Charity 1100 Grampian Boulevard Williamsport PA 17701 240799343 Hospital PA 501(c)(3) 3 N/A 0 Muncy Valley Hospital 215 East Water Street Muncy PA 17756 240806023 Hospital PA 501(c)(3) 3 N/A 0 Susquehanna Health Foundation 1100 Grampian Boulevard Williamsport PA 17701 232743470 Fundraising for affiliated entities PA 501(c)(3) 11 A I N/A 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 Physician Services 1201 Grampian Boulevard Williamsport PA 17701 232449454 Physician services & MRI services PA 501(c)(3) 3 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 Williamsport Area Ambulance Service Cooperative 1205 Grampian Boulevard Williamsport PA 17701 232416166 Ambulance transport 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 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, 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.