2012-11-15T14:43:04-06:00 2011-12-31 250988255 CARBIS WALKER LLP 5700 CORPORATE DRIVE STE 650 PITTSBURGH PA 15237 990 2011-07-01 240795458 MID VALLEY HOSPITAL ASSOCIATION MIDV 7173835500 1400 S MAIN STREET PECKVILLE PA 18452 KAREN M MURPHY RN PHD 7173835500 2012-11-15 1 JEFFREY J PETRELL CPA P00138808 4126356270 2012-11-15 2011 2016-02-24 21:20:13Z X KAREN M MURPHY RN PHD 1400 S MAIN STREET PECKVILLE PA 18452 6758346 0 X WWW.MTH.ORG X 1908 PA TO PROVIDE MEDICAL AND NURSING CARE SERVICES TO PATIENTS. 12 9 178 9 0 0 172779 2952 13672286 6678524 2982 2338 188890 74532 14036937 6758346 0 0 0 0 6806409 3883799 0 0 0 7382423 2950839 14188832 6834638 -151895 -76292 4652895 0 1900393 0 2752502 0 MID VALLEY HOSPITAL, THROUGH ITS COMMUNITY HEALTH ASSESSMENT, WILL BE ACCOUNTABLE FOR MEETING COMMUNITY NEEDS IN A MANNER THAT REFLECTS EXCELLENCE IN CARE AND WITH RESPECT AND DIGNITY TO THE PATIENT. 0 0 5742977 6753056 NON-PROFIT CRITICAL ACCESS HOSPITAL LOCATED IN PECKVILLE, PENNSYLVANIA OPERATING 25 INPATIENT CARE BEDS AND PROVIDING OUTPATIENT, HOME HEALTH, AND EMERGENCY CARE SERVICES TO RESIDENTS OF THE REGION.TOTAL PATIENT DAYS - 2,452EMERGENCY ROOM VISITS - 3,927OUTPATIENT VISITS (EXCLUDING EMERGENCY ROOM) - 11,396 5742977 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 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 1 0 0 1 0 0 0 0 1 14 0 1 178 1 0 0 0 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 0 1 0 0 PA X THOMAS KELLY 5703402991 700 QUINCY AVE SCRANTON PA 18510 KAREN M MURPHY RN PHD 4.00 X X 0 331400 4495 ANN MARIE STEVENS RN BSN 40.00 X X 100687 0 150 MARIA A MARSILI ESQ 1.00 X X 0 0 0 ROBERT A MAZZONI ESQ 1.00 X X 0 0 0 RAJAN MULLOTH MD 1.00 X X 0 322116 18336 R SEAN BUCKMAN 1.00 X X 0 0 0 LOUIS RAPOCH 1.00 X 0 0 0 ENRICO CESARINI 1.00 X 0 0 0 DAVID MORAN 1.00 X 0 0 0 JEFFREY HEMAK 1.00 X 0 0 0 JOHN LEMONCELLI PHD 1.00 X 0 0 0 FRANCES TARAMELLI 1.00 X 0 0 0 THOMAS KELLY 4.00 X 0 199614 2242 JAMES BRITTAIN 4.00 X 0 157851 4806 100687 1010981 30029 1 1 1 0 EPMG 182 S FRANKLIN STREET WILKES BARRE PA 18701 EMERGENCY RM PHYS. 255341 1 2629 323 2952 NET PATIENT SERVICE RE 900099 6678524 6678524 6678524 2338 2338 45694 0 45694 45694 45694 LABORATORY & X-RAY REV 900099 18493 18493 MEDICAL TRANSCRIPTS RE 900099 3973 3973 CAFETERIA REVENUE 900099 2959 2959 3413 3413 28838 6758346 6753056 0 2338 100837 100837 3086420 2730427 355993 104284 89337 14947 592258 507370 84888 1980 1980 50950 50950 626962 315293 311669 91253 69225 22028 119451 87104 32347 539 470 69 22024 12529 9495 152408 86705 65703 41985 23885 18100 BAD DEBT EXPENSE 928909 928909 SUPPLIES 566467 556325 10142 PHYSICIANS FEES 307838 307838 REPAIRS AND MAINTENANCE 23974 22961 1013 16099 4599 11500 6834638 5742977 1091661 0 15550 0 593175 0 0 1234448 0 0 0 55545 0 288409 0 179338 0 0 2204195 0 0 79835 0 0 0 2400 0 4652895 0 653771 802540 444082 0 1900393 0 X 2751857 0 645 0 2752502 0 4652895 0 X -76292 -2676210 X X 0 1 1 X 0 X SCHEDULE A, PART IV, SUPPLEMENTAL INFORMATION: THE 2011 990 IS A SHORT YEAR RETURN FROM JULY 1, 2011 TO DECEMBER 31, 2011 SINCE THE ORGANIZATION CEASED OPERATIONS ON DECEMBER 31, 2011. 0 6758346 6834638 -76292 -2676210 -2676210 -2752502 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE SYSTEM FOLLOWS THE GUIDANCE FOR ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS THAT PRESCRIBES A RECOGNITION THRESHOLD OF MORE-LIKELY-THAN-NOT TO BE SUSTAINED UPON EXAMINATION BY THE APPROPRIATE TAXING AUTHORITY. MEASUREMENT OF THE TAX UNCERTAINTY OCCURS IF THE RECOGNITION THRESHOLD HAS BEEN MET. THE GUIDANCE ALSO ADDRESSES DERECOGNITION, CLASSIFICATION, INTEREST AND PENALTIES, ACCOUNTING IN INTERIM PERIODS, AND DISCLOSURE. GENERALLY, TAX RETURNS FOR YEARS ENDED JUNE 30, 2008, AND THEREAFTER REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. PART XI, LINE 8 - OTHER ADJUSTMENTS: TEMPORARILY RESTRICTED - NET ASSETS RELEASED FROM RESTRICTIONS -645. EQUITY TRANSFER FROM AFFILIATE 242,959. TRANSFER OF NET ASSETS - DISSOLUTION -2,918,524. TOTAL TO SCHEDULE D, PART XI, LINE 8: -2,676,210. 1 1 1 X 1 X 1 1 0 0 4417 4417 0.00070 483735 147751 335984 0.05690 488152 147751 340401 0.05760 488152 147751 340401 0.05760 0 227778 2837060 3467110 -630050 X 1 0 1 1 MID VALLEY HOSPITAL ASSOCIATION

1400 S MAIN STREET PECKVILLE PA 18452

X X X X MID VALLEY HOSPITAL ASSOCIATION 1 0 1 1 200.000000000000 1 256.000000000000 0 1 0 0 0 1 X 0 0 PART I, LINE 7: A COST-TO-CHARGE RATIO CALCULATED FROM WORKSHEET 2, RATIO OF PATIENT CARE COSTS-TO-CHARGES IS THE COSTING METHODOLOGY USED TO DETERMINE THE AMOUNTS REPORTED ON PART I, LINE 7. PART I, L7 COL(F): THE BAD DEBT EXPENSE OF 928,909 INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN A WAS SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE OF TOTAL EXPENSES. PART III, LINE 4: MID VALLEY HOSPITAL'S FINANCIAL STATEMENTS DO NOT INCLUDE A BAD DEBT FOOTNOTE. THE BAD DEBT EXPENSE IS CALCULATED AS A PERCENTAGE OF MONTHLY REVENUE, BASED ON THE PERCENTAGE USED FOR THE BUDGET. THAT AMOUNT IS THEN ADJUSTED UP OR DOWN BASED UPON THE ACTUAL ACCOUNTS RECEIVABLE BALANCES, CASH COLLECTIONS, AND AMOUNTS WRITTEN OFF.A COST-TO-CHARGE RATIO CALCULATED FROM WORKSHEET 2, RATIO OF PATIENT CARE COSTS-TO-CHARGES IS THE COSTING METHODOLOGY USED TO DETERMINE THE AMOUNTS REPORTED ON LINES 2 AND 3 OF PART III. PART III, LINE 8: A COST-TO-CHARGE RATIO CALCULATED FROM WORKSHEET 2, RATIO OF PATIENT CARE COSTS-TO-CHARGES IS THE COSTING METHODOLOGY USED TO DETERMINE THE AMOUNTS REPORTED ON PART III, LINE 6. MID VALLEY HOSPITAL ASSOCIATION PART V, SECTION B, LINE 19D: THE PREVAILING GROSS CHARGE FOR THE SERVICE RENDERED IS CHARGED TO THE PATIENT'S ACCOUNT. IF THE PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE THESE CHARGES ARE DISCOUNT ACCORDING TO HIS OR HER ABILITY TO PAY BASED UPON INCOME AND FAMILY SIZE. PART VI, LINE 2: MID VALLEY HOSPITAL DOES NOT CURRENTLY HAVE A FORMALIZED METHOD TO ASSESS THE COMMUNITY FOR ITS HEALTH NEEDS. IN THE NEXT YEAR, THE ORGANIZATION PLANS TO LAUNCH A MORE FORMALIZED PROCESS TO ASSESS OUR COMMUNITY NEEDS. PART VI, LINE 3: IN ACCORDANCE WITH THE FINANCIAL ASSISTANCE POLICY, WHEN INDIVIDUALS QUALIFY UNDER THIS POLICY, THE AMOUNT OF FREE OR DISCOUNTED SERVICE FOR WHICH THEY QUALIFY IS ADJUSTED OFF THE ACCOUNT AT THE TIME APPROVAL IS GRANTED. IF THEY QUALIFY FOR A DISCOUNT FROM ACTUAL CHARGES, THE ORGANIZATION WILL TRY TO SET THE PATIENT UP ON A MONTHLY PAYMENT PLAN. AS PART OF THE FINANCIAL ASSISTANCE POLICY, IF THEY HAVE BEEN APPROVED FOR FREE OR DISCOUNTED SERVICE IN THE PAST 6 MONTHS, THE APPROVAL WILL APPLY FOR THE CURRENT SERVICE AS WELL. FOR INDIVIDUALS THAT DO NOT QUALIFY UNDER THE FINANCIAL ASSISTANCE POLICY, THE NORMAL COLLECTION PRACTICES ARE FOLLOWED. PART VI, LINE 4: MID-VALLEY HOSPITAL IS A COMMUNITY BASED, CRITICAL ACCESS HOSPITAL, LOCATED IN PECKVILLE, PA. MID-VALLEY HOSPITAL SERVES THE RESIDENTS OF LACKAWANNA COUNTY, PENNSYLVANIA. LACKAWANNA COUNTY IS 459 SQUARE MILES AND HAS A POPULATION OF 208,801. THE 2009 ESTIMATED MEDIAN HOUSEHOLD INCOME WAS $44,481 WHICH IS BELOW THE PENNSYLVANIA ESTIMATED HOUSEHOLD INCOME OF $49,520. APPROXIMATELY 15% OF RESIDENTS LIVE IN POVERTY. PART VI, LINE 5: MID-VALLEY HOSPITAL IS A COMMUNITY BASED, CRITICAL ACCESS HOSPITAL, LOCATED AT 1400 MAIN ST., PECKVILLE, PA. A MEMBER OF THE MOSES TAYLOR HEALTH CARE SYSTEM, MID-VALLEY HOSPITAL'S CORE VALUE IS COMPASSIONATE, HIGH-QUALITY CARE. CONVENIENTLY LOCATED BETWEEN SCRANTON AND EYNON, PA., AND A STRONG SUPPORTER OF COMMUNITY PROGRAMS SUCH AS NUTRITION AND HEALTH FAIRS, AND THE ANNUAL HUNTERS' SCREENING PROGRAM, MID-VALLEY HOSPITAL HAS A WATCHFUL EYE ON THE HEALTH AND WELL-BEING OF ITS NEIGHBORS. SHOULD YOU HAVE AN EMERGENCY, OUTPATIENT SERVICES, OR NEED AN INPATIENT STAY, YOU CAN REST ASSURED THAT MID-VALLEY HOSPITAL WILL CARE FOR YOU LIKE FAMILY. SHOULD YOU NEED MORE EXTENSIVE SERVICES, ITS ASSOCIATION WITH THE MOSES TAYLOR HEALTH CARE SYSTEM AND PHYSICIANS HEALTH ALLIANCE WILL ASSURE THAT YOU WILL RECEIVE THE SAME ATTENTION THAT YOU HAVE COME TO EXPECT AT MID-VALLEY HOSPITAL. A MAJORITY OF ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS RESIDING IN PRIMARY SERVICE AREA AND ARE NOT EMPLOYEES OR CONTRACTORS OF THE ORGANIZATION OR FAMILY MEMBERS. THE ORGANIZATION USES SURPLUS FUNDS TO PROVIDE THE LATEST IN TECHNOLOGY TO IMPROVE PATIENT CARE. X 0 0 0 0 0 0 0 0 0 KAREN M MURPHY RN PHD 0 325000 0 0 0 6400 0 0 0 4495 0 335895 0 0 RAJAN MULLOTH MD 0 322116 0 0 0 0 0 0 0 18336 0 340452 0 0 THOMAS KELLY 0 199614 0 0 0 0 0 0 0 2242 0 201856 0 0 JAMES BRITTAIN 0 157851 0 0 0 0 0 0 0 4806 0 162657 0 0 MARY CLAIRE CORNALL FAMILY MEMBER OF ANN MARIE STEVENS, BOARD MEMBER/DIRECTOR OF OPERATIONS 13199 EMPLOYEE OF MID VALLEY HOSPITAL ASSOCIATION 0 ROBERT THOMAS FAMILY MEMBER OF ANN MARIE STEVENS, BOARD MEMBER/DIRECTOR OF OPERATIONS 26439 EMPLOYEE OF MID VALLEY HOSPITAL ASSOCIATION 0 CASH 2011-12-31 678673 BOOK VALUE 452672049 PECKVILLE HOSPITAL COMPANY LLC 4000 MERIDIAN BOULEVARD FRANKLIN TN 37067 ACCOUNTS RECEIVABLE 2011-12-31 978210 BOOK VALUE 452672049 PECKVILLE HOSPITAL COMPANY LLC 4000 MERIDIAN BOULEVARD FRANKLIN TN 37067 INVENTORY 2011-12-31 288409 BOOK VALUE 452672049 PECKVILLE HOSPITAL COMPANY LLC 4000 MERIDIAN BOULEVARD FRANKLIN TN 37067 BUILDING & EQUIPMENT 2011-12-31 2058654 BOOK VALUE 452672049 PECKVILLE HOSPITAL COMPANY LLC 4000 MERIDIAN BOULEVARD FRANKLIN TN 37067 LAND 2011-12-31 38000 BOOK VALUE 452672049 PECKVILLE HOSPITAL COMPANY LLC 4000 MERIDIAN BOULEVARD FRANKLIN TN 37067 INVESTMENTS 2011-12-31 78903 BOOK VALUE 452672049 PECKVILLE HOSPITAL COMPANY LLC 4000 MERIDIAN BOULEVARD FRANKLIN TN 37067 PREPAID EXPENSES 2011-12-31 124114 BOOK VALUE 452672049 PECKVILLE HOSPITAL COMPANY LLC 4000 MERIDIAN BOULEVARD FRANKLIN TN 37067 0 0 0 0 1 1 1 1 0 0 FORM 990, PART VI, SECTION A, LINE 6 MOSES TAYLOR FOUNDATION, INC. IS THE SOLE MEMBER OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE MEMBER (MOSES TAYLOR FOUNDATION, INC.) OF THE CORPORATION ELECTS THE BOARD MEMBERS. FORM 990, PART VI, SECTION A, LINE 7B THE SOLE MEMBER (MOSES TAYLOR FOUNDATION, INC.) SHALL HAVE THE SOLE AND EXCLUSIVE RIGHT TO ACT WITH RESPECT TO THE FOLLOWING AFFAIRS OF THE CORPORATION: (A) AMENDMENT OF THE BYLAWS OR THE ARTICLES OF INCORPORATION OF THE CORPORATION (B) APPROVAL OF THE MERGER OR CONSOLIDATION OF THE CORPORATION WITH ANY OTHER ORGANIZATION OR ENTITY (C) ELECTION TO DISSOLVE AND WIND UP THE AFFAIRS OF THE CORPORATION (D) SALE, LEASE, EXCHANGE, MORTGAGE, PLEDGE OR OTHER DISPOSITION OF ALL, OR SUBSTANTIALLY ALL, THE PROPERTY AND ASSETS OF THE CORPORATION (E) APPROVAL OF ANNUAL OPERATING, CASH AND CAPITAL BUDGETS, AND MODIFICATIONS THEREOF (F) APPROVAL OF STRATEGIC PLANS (G) APPROVAL OF INCURRENCE OF DEBT OR CAPITAL EXPENDITURES WHICH ARE NOT OTHERWISE INCLUDED IN A BUDGET APPROVED BY THE MEMBERS (H) GUARANTEEING THE DEBTS OR OBLIGATIONS OF ANY OTHER PERSON, FIRM, CORPORATION, PARTNERSHIP, ASSOCIATION OR OTHER ENTITY (I) MATERIAL ADDITIONS OR DELETIONS OF SERVICES OR CESSATION OF SERVICES (J) SELECTION OR REMOVAL OF THE CHIEF OPERATING OFFICER (K) DEVELOPMENT OF MANAGED CARE STRATEGY FOR THE CORPORATION FORM 990, PART VI, SECTION B, LINE 11 MID VALLEY HOSPITAL ASSOCIATION HAS A CPA FIRM PREPARE ITS FORM 990. THE RETURN IS COMPLETED IN DRAFT FORM AND REVIEWED BY MANAGEMENT OF THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 12C MID VALLEY HOSPITAL ANNUALLY REQUIRES ITS BOARD MEMBERS, OFFICERS AND KEY EMPLOYEES TO FILL OUT A CONFLICTS OF INTEREST FORM. DURING BOARD MEETINGS, IF AN INTERESTED PARTY HAS A CONFLICT, HE OR SHE RECUSES THEMSELVES FROM VOTING. FORM 990, PART VI, SECTION B, LINE 15A MID VALLEY HOSPITAL'S BOARD OF DIRECTORS ANNUALLY REVIEWS AND APPROVES THE COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT. FORM 990, PART VI, SECTION C, LINE 18 MID VALLEY HOSPITAL MAKES ITS FORM 990 AND FORM 1023 AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 MID VALLEY HOSPITAL DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICTS OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE GENERAL PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: TEMPORARILY RESTRICTED - NET ASSETS RELEASED FROM RESTRICTIONS -645. EQUITY TRANSFER FROM AFFILIATE 242,959. TRANSFER OF NET ASSETS - DISSOLUTION -2,918,524. TOTAL TO FORM 990, PART XI, LINE 5: -2,676,210. FORM 990, PART XII, LINE 2C: THE ORGANIZATION'S BOARD OF DIRECTORS ASSUME RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT. THE PROCESS IS CONSISTENT WITH PRIOR YEARS AND HAS NOT CHANGED. FORM 990, PART VII, COLUMN B THE OFFICER KAREN M. MURPHY, RN, PHD, PRESIDENT & CEO SPLITS THE HOURS WORKED PER WEEK BETWEEN EACH OF THE MOSES TAYLOR ENTITIES IN THE FOLLOWING MANNER: MOSES TAYLOR HOSPITAL - 30 HOURS MID VALLEY HOSPITAL ASSOCIATION - 4 HOURS MOSES TAYLOR FOUNDATION, INC - 1 HOUR MTH RESOURCES, INC. - 1 HOUR PHYSICIANS HEALTH ALLIANCE, INC. - 4 HOURS THE OFFICER JAMES G. BRITTAIN, FORMER ACTING CFO SPLITS THE HOURS WORKED PER WEEK BETWEEN EACH OF THE MOSES TAYLOR ENTITIES IN THE FOLLOWING MANNER: MOSES TAYLOR HOSPITAL - 32 HOURS MID VALLEY HOSPITAL ASSOCIATION - 4 HOURS MOSES TAYLOR FOUNDATION, INC - 1 HOUR MTH RESOURCES, INC. - 1 HOUR PHYSICIANS HEALTH ALLIANCE, INC. - 2 HOURS THE OFFICER THOMAS KELLY, CFO SPLITS THE HOURS WORKED PER WEEK BETWEEN EACH OF THE MOSES TAYLOR ENTITIES IN THE FOLLOWING MANNER: MOSES TAYLOR HOSPITAL - 32 HOURS MID VALLEY HOSPITAL ASSOCIATION - 4 HOURS MOSES TAYLOR FOUNDATION, INC - 1 HOUR MTH RESOURCES, INC. - 1 HOUR PHYSICIANS HEALTH ALLIANCE, INC. - 2 HOURS MOSES TAYLOR FOUNDATION INC PO BOX 992 SCRANTON PA 18501 232281586 HEALTH CARE PA 501(C)(3) LINE 7 0 MTH RESOURCES INC PO BOX 1428 SCRANTON PA 18501 232281585 HEALTH CARE PA 501(C)(3) LINE 11A, I MOSES TAYLOR FOUNDATION INC 0 MOSES TAYLOR HOSPITAL 700 QUINCY AVE SCRANTON PA 18510 240795461 HEALTH CARE PA 501(C)(3) LINE 3 MOSES TAYLOR FOUNDATION INC 0 PHYSICIANS HEALTH ALLIANCE INC 1401 ELECTRIC STREET DUNMORE PA 18509 232824685 HEALTH CARE PA MTH RESOURCES INC C 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0