2011-05-13T14:07:10-05:00 2010-06-30 Carbis Walker LLP 5700 Corporate Drive Ste 650 Pittsburgh PA 15237 990 2009-07-01 240795458 MID VALLEY HOSPITAL ASSOCIATION MIDV 7173835500 1400 S MAIN STREET PECKVILLE PA 18452 Karen M Murphy RN PhD 7173835500 2011-05-09 1 Jeffrey J Petrell CPA 4126356270 2009 2016-02-24 21:20:13Z Karen M Murphy RN PhD 1400 S MAIN STREET PECKVILLE PA 18452 14884350 0 X www.mth.org X 1908 PA TO PROVIDE MEDICAL AND NURSING CARE SERVICES TO PATIENTS. 12 8 200 13 0 0 164166 137329 13556775 14576753 9628 7638 113060 149286 13843629 14871006 0 0 6860848 7047239 0 0 5908916 7614862 12769764 14662101 1073865 208905 5467978 5447654 2718716 2525076 2749262 2922578 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 11857042 14607202 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 - 4,455Emergency Room Visits - 7,476Outpatient visits (excluding Emergency Room) - 28,450 11857042 1 1 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 10 0 1 200 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12 8 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 0 1 0 0 PA X JAMES BRITTAIN 5703402991 700 QUINCY AVE SCRANTON PA 18510 Karen M Murphy RN PhD 4.00 X X 0 178738 28503 Ann Marie Stevens 40.00 X X 96490 0 21855 James Brittain 4.00 X X 0 155943 35403 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 269211 16893 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 HAROLD E ANDERSON 4.00 X X 0 377859 56470 96490 981751 159124 0 0 1 0 EPMG 182 S Franklin Street WILKES BARRE PA 18701 EMERGENCY RM PHYS. 470214 Lab Corp 20 Johnson Drive Raritan NJ 08869 Lab Services 102975 2 127579 9750 137329 net patient service re 900099 14576753 14576753 14576753 7638 7638 107721 107721 107721 107721 24460 13344 11116 11116 Laboratory & X-Ray rev 900099 12740 12740 Medical Transcripts Re 900099 8801 8801 Cafeteria revenue 900099 5453 5453 3455 3455 30449 14871006 14607202 0 126475 96490 79986 16504 5464003 4529410 934593 209143 173370 35773 850202 704779 145423 427401 354296 73105 6264 6264 33830 33830 1804852 1207679 597173 24922 19029 5893 254355 185476 68879 21563 18795 2768 78269 46343 31926 394715 233710 161005 320059 189507 130552 Bad Debt 1783409 1783409 SUPPLIES 1426945 1409396 17549 PHYSICIAN FEES 550549 550549 Overhead 527664 527664 EQUIPMENT RENTAL & MAIN 367680 363959 3721 19786 7349 12437 14662101 11857042 2805059 0 5500 1029134 805903 1561661 1765493 22575 291504 303630 96781 76437 12499936 10132482 2391582 2367454 93316 97462 4000 3200 5467978 5447654 935811 695565 362791 1111836 1420114 717675 2718716 2525076 X 2694847 2903752 54415 18826 2749262 2922578 5467978 5447654 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 38000 38000 6294210 4706830 1587380 4243867 3802206 441661 1923859 1623446 300413 2367454 Due to Third Party Payor 59967 Due to Related Entities 657708 717675 14871006 14662101 208905 -35589 -35589 173316 14871006 0 14871006 0 14871006 14662101 0 14662101 0 14662101 Part X: Description of Uncertain Tax Positions Under FIN 48: The Hospital adopted the standard for accounting for uncertainty in income taxes recognized in an organization'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 not been met. The standard also provides guidance on derecognition, classification, interest and penalties, accounting for interim periods, and disclosure. Management has determined that the adoption of the standard did not have a material effect on the financial statements. The Hospital's policy is to recognize interest related to unrecognized tax benefits in interest expense and penalties in operating expenses. There were no interest or penalties recognized on the statements of operations as a result of the adoption. The Hospital's federal Forms 990, Return of Organization Exempt from Income Tax, filings for the years ended June 30, 2009, 2008, and 2007, remain subject to examination by the Internal Revenue Service and state agencies. Part XI, Line 8 - Other Adjustments: temporarily restricted - grant revenue: 34063. TEMPORARILY RESTRICTED - FORFEITURE OF GRANT FUNDS: -33830. TEMPORARILY RESTRICTED - NET ASSETS RELEASED FROM RESTRICTIONS: -35822. GOLF TOURNAMENT 24460 24460 2730 9341 1273 24460 24460 2730 9341 1273 13344 11116 1 1 1 X 1 X 1 1 0 0 3973 3973 0.00030 903581 518409 385172 0.02990 907554 518409 389145 0.03020 907554 518409 389145 0.03020 0 441882 6663298 6617652 45646 X 1 0 MID VALLEY HOSPITAL ASSOCIATION

1400 S MAIN STREET PECKVILLE PA 18452

X X X X 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, Line 7f: The Bad debt expense of 1,783,409 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. 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 few years, 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 6: 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 178738 0 0 0 0 0 27389 0 1114 0 207241 0 0 James Brittain 0 155943 0 0 0 0 0 23513 0 11890 0 191346 0 0 Rajan Mulloth MD 0 269211 0 0 0 0 0 5500 0 11393 0 286104 0 0 HAROLD E ANDERSON 0 377859 0 0 0 0 0 44580 0 11890 0 434329 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. FORM 990, PART XI, 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, 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 Moses Taylor Foundation INC PO Box 992 Scranton PA 18501 232281586 health care PA 501(c)(3) Line 7 MTH Resources Inc PO Box 1428 Scranton PA 18501 232281585 health care PA 501(c)(3) Line 11a, I Moses Taylor Foundation INC Moses Taylor Hospital 700 Quincy Ave Scranton PA 18510 240795461 health care PA 501(c)(3) Line 3 Moses Taylor Foundation INC PHYSICIANS HEALTH ALLIANCE INC 1401 ELECTRIC STREET DUNMORE PA 18509 232824685 health care PA MTH RESOURCES INC C 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0