2011-05-12T13:10:15-05:00 2010-06-30 BKD LLP 910 E St Louis St Springfield MO 658062523 990 2009-07-01 232751183 Susquehanna Health System SUSQ 5703207900 1205 Grampian Blvd 2nd Floor Williamsport PA 17701 Charles J Santangelo 5703213171 2011-05-12 1 4178658701 2009 2016-02-24 21:20:13Z Steven P Johnson 777 Rural Ave Williamsport PA 17701 43202992 0 X www.susquehannahealth.org X 1994 PA SHS provides management services for the delivery of healthcare through its affiliated entities. 24 18 0 0 0 0 0 50413 25880 -1701200 1487022 19104 9182 -1631683 1522084 44836 0 0 55 0 0 0 97213 201145 142104 201145 -1773787 1320939 35291634 40143039 237594 307819 35054040 39835220 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 create a high quality patient centered integrated delivery system. Our Values - to demonstrate 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 29811 0 35062 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. 29811 1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 1 181 0 1 0 0 1 CJ 0 0 0 0 0 0 0 24 18 0 0 0 0 0 1 0 1 1 0 0 0 1 1 1 1 1 1 1 0 PA X Susquehanna Health Finance Departme 5703207900 1205 Grampian Blvd 2nd Floor Williamsport PA 17701 Ronald V DeFeo Jr 1.00 X X 0 0 0 Ann S Pepperman Esquir 1.00 X X 0 0 0 Birch B Phillips Jr 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 William R Beltz MD 40.00 X 0 123040 20138 John M Burks MD 1.00 X 0 0 0 Leonard R Collins MD 1.00 X 0 0 0 Richard W DeWald 1.00 X 0 0 0 Ronald E DiSimone MD 40.00 X 0 845755 18442 James E Douthat EdD 1.00 X 0 0 0 Timothy M Gage 1.00 X 0 0 0 Sister Joan Daniel Healy 1.00 X 0 0 0 Steven P Johnson 40.00 X X 0 497381 82981 Daniel A Klingerman 1.00 X 0 0 0 Donald J Leathers MD 1.00 X 0 25000 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 Peyton D McDonald 1.00 X 0 0 0 James E Mothersbaugh 1.00 X 0 0 0 Ralph A Nardi Jr 1.00 X 0 0 0 Alexander R Nesbitt M 40.00 X 0 185359 28790 Melissa E Welch MD 1.00 X 0 0 0 Charles J Santangelo 40.00 X 0 290174 22871 Neil G Armstrong 40.00 X 0 261117 21029 George A Manchester M 40.00 X 0 289814 33574 0 2517640 227825 0 0 1 0 0 Support allocation inc 900003 25880 25880 25880 758572 758572 42409358 41680908 728450 728450 728450 Interest on note recei 525990 8651 8651 Miscellaneous other in 900003 531 531 9182 1522084 35062 0 1487022 -10006 -10006 181340 181340 1766 1766 635 635 27410 27410 201145 29811 171334 0 260 51201 292044 806309 792408 41311 13901 34969938 39519241 280125 266652 35291634 40143039 35062 31157 202532 276662 237594 307819 X 34371595 39196652 682445 638568 35054040 39835220 35291634 40143039 X 0 1 1 X 0 X X X 0 0 0 The Williamsport Hospital & Medical Center 240795508 3 1 1 1 0 Divine Providence Hospital 240799343 3 1 1 1 0 Muncy Valley Hospital 240806023 3 1 1 1 0 Susquehanna Physician Services 232449454 3 1 1 1 0 4 0 762929 750133 12796 43380 42275 1105 13901 Scholarship Program Obligation 251701 Deferred Annuity 12170 Due to Affiliates 12791 276662 1522084 201145 1320939 2388121 1072120 3460241 4781180 5404868 2388121 1494663 3882784 1522084 0 1522084 623688 593877 593877 29811 171334 171334 201145 Part XI Other includes: A distribution from Community Basket a related entity of $1,665,997 and a transfer to Susquehanna Ventures Inc. a related entity of ($550,000) and a change in net assets of affiliate of ($43,877) for a total of $1,072,120. Part XII Other includes: Investment fees of ($181,340), a credit on audit fees of $10,006, and a distribution from Community Basket a related entity of $1,665,997 for a total of $1,494,663. Part XIII Other includes: A transfer to Susquehanna Ventures Inc. a related entity of $550,000 and a change of net assets of affiliate of $43,877 for a total of $593,877. Investment fees of $181,340 and a credit on audit fees of ($10,006) for a total of $171,334. 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. X X X X X 0 1 0 0 0 0 0 0 0 Ronald E DiSimone MD 0 820383 0 0 0 25372 0 0 0 18442 0 864197 0 0 Steven P Johnson 0 488422 0 0 0 8959 0 68748 0 14233 0 580362 0 0 Alexander R Nesbitt MD 0 184757 0 0 0 602 0 9448 0 19342 0 214149 0 0 Charles J Santangelo 0 286557 0 0 0 3617 0 8400 0 14471 0 313045 0 0 Neil G Armstrong 0 258400 0 0 0 2717 0 14092 0 6937 0 282146 0 0 George A Manchester MD 0 288008 0 0 0 1806 0 11850 0 21724 0 323388 0 0 Part I, Line 4a Steven P. Johnson-$56,898 Susquehanna Ventures Inc Philip Johnson is a board member on SVI and SHS 550000 SVI is a taxable entity with the Susquehanna Health System. SHS gave a one time payment of $550,000 in support. Philip Johnson received no compensation from Susquehanna Ventures, Inc. or Susquehanna Health System. 0 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 with the Board Members at a combined SHS Finance/Executive/and Audit/Compliance Committee meeting 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 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 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. Form 990, Part V, Line 1a Number reported in Box 3 of Form 1096 All 1099's are issued by Susquehanna Health System 23-2751183. All expenses are then allocated back to all related entities. Form 990, Part V, Line 2a & 2b Number of employees reported on Form W-3 Susquehanna Health System 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 Providence Cancer Treatment Services 23-2925354 The total number of employees reported on Form W-3 would be 3,363 for Susquehanna Health System EIN#23-2751183. Of that total, no employees payroll expenses were recorded by Susquehanna Health System. 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 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. Divine Providence Hospital 1100 Grampian Blvd Williamsport PA 17701 240799343 Hospital PA 501(c)(3) 3 N/A Muncy Valley Hospital 215 E Water St Muncy PA 17756 240806023 Hospital PA 501(c)(3) 3 N/A The Williamsport Hospital 777 Rural Ave Williamsport PA 17701 240795508 Hospital PA 501(c)(3) 3 N/A Susquehanna Health Foundation 1100 Grampian Blvd Williamsport PA 17701 232743470 Fundraising for affiliated entities PA 501(c)(3) 11 N/A Susquehanna Physician Services 1201 Grampian Blvd Williamsport PA 17701 232449454 Physician services & MRI services PA 501(c)(3) 3 N/A Providence Cancer Treatment Services 1100 Grampian Blvd Williamsport PA 17701 232925354 Outpatient radiation therapy services PA 501(c)(3) 3 N/A Community Basket LLC 1205 Grampian Blvd Williamsport PA 17701 201195739 Rents real estate PA Susquehanna Health System & Susquehanna Health Foundation Excluded from tax 852361 0 0 Susquehanna Ventures Inc 1201 Grampian Blvd Williamsport PA 17701 232470263 Pharmancy & Infusion Services PA N/A C Williamsport Area Ambulance Service Cooperative 1205 Grampian Blvd Williamsport PA 17701 232416166 Ambulance Transport PA N/A C Central PA Provider Network 1205 Grampian Blvd 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 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 Susquehanna Ventures Inc Q 550000 Community Basket LLC R 1665997