2023-05-15T16:37:54-05:00 2022-06-30 135565207 KPMG LLP 8350 BROAD STREET SUITE 900 MCLEAN VA 22102 990 2021-07-01 520591531 UPMC WESTERN MARYLAND CORPORATION UPMC 2409648002 PO BOX 539 CUMBERLAND MD 215010539 AMBER RUBLE CHIEF FINANCIAL OFFICER 2409648032 2023-05-15 1 AMBER RUBLE 999009999 MARGARET A BRADSHAW P00501222 7032868000 2023-05-15 3 AAL1 IAL1 2021 2023-04-26 12:10:37Z AMBER RUBLE PO BOX 539 CUMBERLAND MD 215010539 373540676 0 X WWW.WMHS.COM X 1905 MD SEE SCHEDULE OUPMC WESTERN MARYLAND IS DEDICATED TO PROVIDING PATIENT CENTERED CARE AND IMPROVING THE HEALTH AND WELL-BEING OF PEOPLE IN THE COMMUNITIES WE SERVE. 12 12 2553 270 597116 0 12128886 1745934 357369023 362943847 18373573 5580430 1425944 2897000 389297426 373167211 273809 0 0 0 174640440 193548793 0 0 0 158604346 159278531 333518595 352827324 55778831 20339887 700315252 429073665 468104878 57957990 232210374 371115675 X THE MISSION OF UPMC WESTERN MARYLAND IS TO SERVE OUR COMMUNITY BY PROVIDING OUTSTANDING PATIENT CARE AND TO SHAPE TOMORROW'S HEALTH SYSTEM THROUGH CLINICAL & TECHNOLOGICAL INNOVATION, RESEARCH AND EDUCATION. 0 0 185140071 216534431 ANCILLARY CARE - REGULATEDUPMC WESTERN MARYLAND (UPMCWM) OFFERS A COMPREHENSIVE RANGE OF GENERAL AND SPECIALTY SERVICES FOR PATIENTS. SURGICAL, LABORATORY, RADIOLOGY, CARDIOLOGY, CANCER, RESPIRATORY AND PULMONARY ARE THE LARGER SERVICES PROVIDED AT THE HOSPITAL. 60172163 69009597 INPATIENT ROUTINE CARE - REGULATEDUPMC WESTERN MARYLAND IS A FULL-SERVICE COMMUNITY HOSPITAL LICENSED FOR 224 BEDS INCLUDING MEDICAL-SURGICAL INTENSIVE CARE, HIGH LEVEL CARE, OBSTETRIC, PEDIATRIC, PSYCHIATRIC, REHABILITATION, AND NURSERY. FOR THE YEAR, 9,464 PATIENTS WERE ADMITTED TO THE HOSPITAL. UPMC WESTERN MARYLAND ACCEPTS PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. THOSE PATIENTS WHO MEET CERTAIN CRITERIA UNDER THE CHARITY CARE POLICIES RECEIVE SERVICES AT NO CHARGE OR AT AN AMOUNT LESS THAN FULL CHARGES. 62893846 58666130 PHYSICIAN PRACTICES, CLINICS, AND HOME CAREUPMC WESTERN MARYLAND OPERATES 22 PHYSICIAN PRACTICES, 3 URGENT CARE CLINICS, AND A HOME CARE PRACTICE. THE PHYSICIAN PRACTICES HAD 165,199 ENCOUNTERS; THE URGENT CARE CLINICS HAD 68,317 ENCOUNTERS AND HOME CARE HAD 34,531 VISITS FOR THE YEAR. 19707611 18990684 EMERGENCY CARE - REGULATEDUPMC WESTERN MARYLAND (UPMCWM) OPERATES A 24-HOUR/7-DAY-A-WEEK EMERGENCY ROOM WHICH SERVES AS THE DESIGNATED AREA-WIDE TRAUMA CENTER. 36,070 VISITS WERE REGISTERED IN THE EMERGENCY ROOM FOR THE YEAR ENDING JUNE 30, 2022. 19707611 18990684 327913691 1 1 0 0 0 0 0 0 0 1 1 0 1 1 1 1 0 1 0 0 1 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 1 1 0 1 2553 1 1 1 1 CJ 0 0 0 0 0 0 0 0 0 0 X 12 12 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 1 1 MD X AMBER RUBLE 2409648002 PO BOX 539 CUMBERLAND MD 215010539 MARY ANN JENKINS BOARD CHAIR 4.00 0.00 X X 0 0 0 JONATHAN HUTCHERSON BOARD VICE CHAIR 4.00 0.00 X X 0 0 0 KEITH L FUNKHOUSER BOARD TREASURER 4.00 0.00 X X 0 0 0 DAVID T MARTIN BOARD SECRETARY 4.00 0.00 X X 0 0 0 DAVID BURWELL MD BOARD MEMBER 3.00 0.00 X 0 0 0 ROLF K HAARSTAD AIA BOARD MEMBER 3.00 0.00 X 0 0 0 DAVID C RUSSELL BOARD MEMBER 3.00 0.00 X 0 0 0 EILEEN SIMMONS BOARD MEMBER 3.00 0.00 X 0 0 0 CARISSA RODEHEAVER BOARD MEMBER 3.00 0.00 X 0 0 0 KIM B LEONARD BOARD MEMBER 3.00 0.00 X 0 0 0 JOHN N PAPPAS MD BOARD MEMBER 3.00 0.00 X 0 0 0 COURTNEY A THOMAS-WINTERBERG BOARD MEMBER 3.00 0.00 X 0 0 0 MICHELE R MARTZ PRESIDENT 40.00 0.00 X 405579 0 124131 AMBER RUBLE CFO 40.00 0.00 X 163806 0 28919 KEVIN R TURLEY VP, OPERATIONS 40.00 0.00 X 301034 0 101193 JAMES KARSTETTER VP, CNO 40.00 0.00 X 304286 0 56166 MATTHEW SIMMONS MD VP, MEDICAL AFFAIRS 40.00 0.00 X 424048 0 13852 EMME CHAPMAN-JACKSON MD MEDICAL STAFF PRESIDENT 40.00 0.00 X 452960 0 24351 OR COHEN-INBAR MD NEUROSURGEON 40.00 0.00 X 2136239 0 29636 CHRISTOPHER HAAS MD CARDIOLOGIST 40.00 0.00 X 828627 0 45711 MARK G NELSON MD CARDIOTHORACIC SURGEON 40.00 0.00 X 780354 0 67284 VAMSHIDHAR VOOTLA MD PHYSICIAN 40.00 0.00 X 721010 0 30551 BLANCHE MAVROMATIS MD ONCOLOGIST 40.00 0.00 X 698731 0 37873 7216674 0 559667 354 0 1 0 USACS INTEGRATED ACUTE CARE 4535 DRESSLER ROAD NW CANTON OH 44718 PHYSICIAN STAFFING 5655614 NORTH AMERICAN PARTNERS IN ANESTHESIA 68 SOUTH SERVICE ROAD STE 350 MELVILLE NY 11747 ANESTHESIA SERVICES 3345072 WEATHERBY LOCUMS PO BOX 972633 DALLAS TX 753972633 PHYSICIAN STAFFING 3249935 HAYSTACK IMAGING SERVICES PO BOX 539 CUMBERLAND MD 215010539 DIAGNOSTIC IMAGING 2211635 PROLINK HEALTHCARE LLC 4600 MONTGOMERY RD SUITE 300 CINCINNATI OH 45212 PHYSICIAN STAFFING 1693988 76 1298336 447598 1745934 ANCILLARY CARE 621990 216533312 216202627 330685 INPATIENT ROUTINE CARE 621990 68901758 68901758 CLINICS, HH, & HOSPICE 621990 58553413 58553413 EMERGENCY CARE 621990 18955364 18955364 362943847 5579830 5579830 694904 373465 321439 321439 321439 600 0 600 600 600 CARES ACT FUNDING 900099 1704034 1704034 REIMBURSEMENT OF EXPEN 900099 587681 587681 CONDO REVENUES 621500 266431 266431 17415 17415 2575561 373167211 363200843 597116 7623318 6761799 6288473 473326 149382748 138925956 10456792 4383409 4076570 306839 26531095 24673918 1857177 6489742 6035460 454282 523754 523754 -33925 -33925 127708 127708 31240802 29053945 2186857 514643 478618 36025 550564 512025 38539 4384328 4077425 306903 6398490 5950595 447895 377880 351428 26452 17716 16476 1240 6457391 6005374 452017 23922198 22247644 1674554 1083675 1007818 75857 SUPPLIES 61756851 57433871 4322980 MEDICAL PROFESSIONAL FE 14404376 13396070 1008306 BAD DEBT 5122737 5122737 2429343 2259288 170055 352827324 327913691 24913633 0 12059704 24097135 341528990 42968496 72115562 7417175 2666296 2475506 1247408 253240868 48754638 219142851 204486230 7380163 6850741 47728101 50743006 19614266 66867287 700315252 429073665 25442963 8710623 3335479 9281710 4921562 433380205 40990326 468104878 57957990 X 231300961 370222739 909413 892936 232210374 371115675 700315252 429073665 20339887 118565414 0 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 8214248 295541 -1036723 84329 7388737 7835269 221846 503718 346585 8214248 8453886 3734675 268104 4621396 7835269 10988945 459723 178047 3172829 8453886 10830910 234245 362489 438699 10988945 0.87967 0.09780 0.02253 1 0 7694809 7694809 191120977 27851600 163269377 2130511 373870 1756641 44121838 16823984 27297854 8172733 3705184 4467549 204486230 INVESTMENT - MARYLAND CARE 47343006 C INVESTMENT - ASC 3400000 C 50743006 NONQUALIFIED PENSION 1500445 NOTE REC INTERNAL 65346187 INVEST IN CONSOL SUBSIDIARIES 20655 66867287 PAYABLE TO 3RD PARTY PROG. 12772172 LEASE LIABILITY - LONG TERM 426502 AR PAYOR ADVANCES 25272352 ACCRUED PAYROLL TAXES AND DED 2519300 40990326 X PART V, LINE 4: ENDOWMENT FUNDS INTENDED USES OF THE INCOME FROM THE PUGH ENDOWMENT FUND ARE TO PROVIDE FREE BEDS AND FREE SERVICE TO THOSE WHO MAY BECOME PATIENTS AND WHO THROUGH FINANCIAL INABILITY MAY BE UNABLE TO MAKE PROVISIONS FOR THEIR OWN MEDICAL AND/OR SURGICAL RELIEF. PART X, LINE 2: AN EXTERNAL AUDIT IS COMPLETED AT A CONSOLIDATED UPMC SYSTEM LEVEL ONLY, INCLUDING UPMC AND ALL TAXABLE AND TAX-EXEMPT SUBSIDIARIES. TAX BENEFITS ARE RECOGNIZED WHEN IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION BY THE TAX AUTHORITIES BASED ON THE TECHNICAL MERITS OF THE POSITION. SUCH TAX POSITIONS ARE MEASURED AS THE LARGEST AMOUNT OF TAX BENEFIT THAT IS GREATER THAN 50% LIKELY TO BE REALIZED UPON ULTIMATE SETTLEMENT WITH THE TAX AUTHORITIES ASSUMING FULL KNOWLEDGE OF THE POSITION AND ALL RELEVANT FACTS. AS OF JUNE 30, 2022, UPMC DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS RECORDED. CENTRAL AMERICA AND THE CARIBBEAN 0 0 INVESTMENTS 21926257 0 0 0 0 0 0 21926257 0 21926257 1 0 1 0 0 0 PART III ACCOUNTING METHOD: 1 1 1 X 1 X 1 1 1 0 1 1 13988602 13988602 0.04020 5425733 4386394 1039339 0.00300 19414335 4386394 15027941 0.04320 651399 651399 0.00190 279484 279484 0.00080 105576782 52739776 52837006 0.15200 146014 146014 0.00040 106653679 52739776 53913903 0.15510 126068014 57126170 68941844 0.19830 27977 27977 0.00010 427895 427895 0.00120 455872 455872 0.00130 1 5122737 123070323 113597984 9472339 X 1 1 1 HAYSTACK IMAGING HEALTH CARE 0.50000 0.50000 2 SURGCENTER OF WM HEALTH CARE 0.41180 0.58820 1 1 UPMC WESTERN MARYLAND CORPORATION 12500 WILLOWBROOK ROAD CUMBERLAND MD 21502 WWW.WMHS.COM X X X UPMC WESTERN MARYLAND CORPORATION 1 0 0 1 X X X X X X X X X X 22 1 0 1 1 X WWW.WMHS.COM X HTTP://WWW.ALLEGANYHEALTHPLANNINGCOALITION.COM 1 22 1 WWW.WMHS.COM 0 1 X 200.000000000000 400.000000000000 X X X X 1 1 X X X 1 X WWW.WMHS.COM X WWW.WMHS.COM X WWW.WMHS.COM X X X X X 1 X 0 1 X 0 1 UPMC WESTERN MARYLAND CORPORATION PART V, SECTION B, LINE 6B: CHNA CONDUCTED WITH OTHER ORGANIZATIONS THE CHNA WAS CONDUCTED JOINTLY WITH THE ALLEGANY COUNTY HEALTH DEPARTMENT. UPMC WESTERN MARYLAND CORPORATION PART V, SECTION B, LINE 11: THE MOST RECENT ASSESSMENT WAS COMPLETED IN JUNE 2020 AND BUILDS UPON IMPROVEMENTS MADE AND LESSONS LEARNED IN PRIOR CYCLES FROM 2011, 2014 AND 2017. THE PRIORITIES IN THE 2017 CHNA WERE SUBSTANCE ABUSE, POVERTY, HEART DISEASE, AND ACCESS TO CARE/HEALTH LITERACY. AFTER REVIEW OF HEALTH STATUS INDICATORS AND CAUSATIVE FACTORS, THE FOLLOWING PRIORITIES WERE SELECTED FOR THE MOST RECENT CHNA: TRANSPORTATION, SOCIAL DETERMINANTS OF HEALTH, AND PREVENTION-YOUTH RISK REDUCTION. THROUGHOUT EACH THREE-YEAR CYCLE, PROGRESS ON THE LOCAL HEALTH ACTION PLAN WAS MONITORED AND ITS IMPACT ON THE IDENTIFIED OUTCOME MEASURES WAS EVALUATED.KEY MEASURES AND THE CHANGES SEEN OVER TIME:- RESIDENTS THAT REPORTED MISSING APPOINTMENTS DUE TO TRANSPORTATION INCREASED FROM 16% TO 19%- LEVEL 1 AND 2 EMERGENCY DEPARTMENT VISITS INCREASED FROM 6,476 TO 7,345- 21.2% PERCENT OF ELEMENTARY AGE CHILDREN ARE IN THE 95TH PERCENTILE OR HIGHER F OR BODY MASS INDEX AND THE PERCENTAGE IS INCREASING- EMERGENCY DEPARTMENT VISITS FOR HYPERTENSION ARE AT 453.3 PER 100,000 POPULATION AND THE RATE HAS INCREASED STEADILY SINCE 2010- 52.6 DRUG INDUCED DEATHS CAUSED BY ILLICIT OR PRESCRIPTION DRUGS PER 100,000 POPULATION AND DEATHS ARE RISING.AFTER REVIEWING PROGRESS AND AREAS FOR IMPROVEMENT IN BOTH PRIOR AND THE CURRENT LOCAL HEALTH ACTION PLAN, A VARIETY OF SECONDARY DATA SOURCES WERE COMPILED AND REVIEWED BY THE LHAP WORKGROUP. THE WORKGROUP INCLUDES REPRESENTATIVES FROM THE HOSPITAL, HEALTH DEPARTMENT, COMMUNITY ACTION AGENCY AND AREA HEALTH EDUCATION CENTER. EACH OF THESE REPRESENTATIVES WAS TASKED WITH PULLING SOURCES AVAILABLE TO THEM AND SHARING THEM FOR REVIEW. 4 THE METRICS AND SOURCES INCLUDED: MARYLAND'S STATE HEALTH IMPROVEMENT PROCESS (SHIP) COUNTY HEALTH RANKING COMMUNITY COMMONS US NEWS CIVIC RANKING ALLEGANY COUNTY YOUTH RISK BEHAVIORAL SURVEY (YRBS)KIDS COUNT AMERICAN COMMUNITY SURVEY HEALTHY PEOPLE 2020 ALLEGANY COUNTY PUBLIC SCHOOL BMI DATA OPPORTUNITY NATION COMMUNITY NEEDS INDEX FEEDING AMERICA STATE CANCER PROFILE LOCAL TRANSPORTATION SURVEY UPMCWM DENTAL ED VISITS MD COLLEGE SURVEY DRUG AND ALCOHOL RELATED DEATHS- BHA, MDH HOMELESS DATA-HRDC TOP 10 REASONS UPMCWM ED VISITS AND ADMISSIONS UPMCWM DIMENSIONAL INSIGHT NEEDS TRENDING IN THE WRONG DIRECTION OR OFF TARGET COMPARED TO THE STATE OR NATION WERE COMPILED FOR REVIEW BY THE ALLEGANY COUNTY HEALTH PLANNING COALITION. THE COUNTY HEALTH RANKING DATA FROM 2010-2019 WERE REVIEWED AND COMPARED OVER TIME WHEN VALID. DATA POINTS WERE ELIMINATED FROM CONTINUED REVIEW IF THE SAMPLE SIZE WAS TOO SMALL, NEED APPEARED STABLE, OR ISSUE WAS REPRESENTED BY ANOTHER METRIC.COMMUNITY HEALTH AND WELLNESS CONNECTIONS ARE IDENTIFIED BETWEEN THE IMPLEMENTATION STRATEGY AND THE STRATEGIC PLAN AS PART OF THE COMMUNITY BENEFIT PLANNING.THE POPULATION HEALTH COUNCIL REVIEWS THE FINDINGS TO IDENTIFY KEY OPPORTUNITIES FOR INVOLVEMENT OF UPMC WESTERN MARYLAND INTERNALLY AND WITH THE LOCAL HEALTH IMPROVEMENT COALITION (LHIC) REGARDING THE COMMUNITY. AS A CYCLE OF LEARNING, THESE OPPORTUNITIES ARE THEN CONSIDERED IN THE STRATEGIC PLANNING PROCESS. ONCE PRIORITIES, PLANS AND METRICS ARE APPROVED AND ALIGNED WITH THE BUDGET PROCESS, THE CHNA AND IMPLEMENTATION PLAN ARE PRESENTED TO THE BOARD FOR APPROVAL, THENIMPLEMENTED, TRACKED AND MEASURED.THE FOLLOWING ARE SOME OF THE STRATEGIC OBJECTIVES FOR 2018-2021 IN THE UPMC WESTERN MARYLAND STRATEGIC PLAN THAT HAVE A CONNECTION TO THE COALITION'S LOCAL HEALTH ACTION PLAN.* IMPROVE HEALTH STATUS AND SOCIAL DETERMINANTS OF HEALTH* EXPAND PRE-HOSPITALIZATION AND POST-ACUTE CARE SERVICES TO REDUCE UTILIZATION* TRANSFORM CARE DELIVERY MODELS UPMC WESTERN MARYLAND CORPORATION PART V, SECTION B, LINE 24: INDIVIDUALS ELIGIBLE FOR FINANCIAL ASSISTANCE MARYLAND'S REGULATORY SYSTEM CREATES A UNIQUE PROCESS FOR HOSPITAL PAYMENT THAT DIFFERS FROM THE REST OF THE NATION. THE HEALTH SERVICES COST REVIEW COMMISSION (HSCRC) DETERMINES PAYMENT THROUGH A RATE SETTING PROCESS AND ALL PAYORS, INCLUDING GOVERNMENT PAYORS, PAY THE SAME AMOUNT FOR THE SAME SERVICES DELIVERED AT THE SAME HOSPITAL. IN ACCORDANCE WITH MARYLAND LAW, UPMC WESTERN MARYLAND HAS A FINANCIAL ASSISTANCE POLICY AND PATIENTS MAY BE ENTITLED TO RECEIVE FINANCIAL ASSISTANCE WITH THE COST OF MEDICALLY NECESSARY HOSPITAL SERVICES IF THEY HAVE A LOW INCOME, DO NOT HAVE INSURANCE, OR THEIR INSURANCE DOES NOT COVER MEDICALLY-NECESSARY HOSPITAL CARE. UPMC WESTERN MARYLAND ALSO CONSIDERS PERSONS WHO DO NOT MEET THE FAP INCOME GUIDELINES UNDER EXPANSION OF THE FAP POLICY FOR FINANCIAL HARDSHIP THAT WOULD LIMIT THE AMOUNT EXPECTED TO BE PAID BASED ON PERCENTAGE OF INCOME. SCHEDULE H, PART V, SECTION B, LINE 3 AND 5; LINE 3, COMMUNITY HEALTH NEEDS ASSESSMENT AND LINE 5, PERSONS CONSULTEDTHE ALLEGANY COUNTY HEALTH DEPARTMENT AND THE UPMC WESTERN MARYLAND CO-CHAIR THE ALLEGANY COUNTY HEALTH PLANNING COALITION (COMPRISED OF 78 INDIVIDUALS REPRESENTING FOUNDING PARTNERS, AN ADVISORY BOARD, AND COMMUNITY AFFILIATES). THE MISSION OF THE ALLEGANY COUNTY HEALTH PLANNING COALITION IS "HEALTHY LIFESTYLES THROUGH COLLABORATIVE PARTNERSHIPS, EVIDENCE-BASED PRACTICES, AND PERSONAL COMMITMENTS." OVER THE YEARS, VARIOUS COMMUNITY STAKEHOLDERS HAVE PARTNERED TO IMPROVE THE HEALTH OF OUR COMMUNITY. THE ALLEGANY COUNTY HEALTH DEPARTMENT WORKS TO PROMOTE HEALTH IN ALLEGANY COUNTY AND UPMC WESTERN MARYLAND IS A TOTAL PATIENT REVENUE HOSPITALAND THE ONLY HOSPITAL IN THE COUNTY, PROVIDING A UNIQUE OPPORTUNITY TO IMPACT COMMUNITY HEALTH. SCHEDULE H, PART V, SECTION B, LINE 13B PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES THAT MAY INCLUDE:A. ACTIVE MEDICAL ASSISTANCE PHARMACY COVERAGE;B. QUALIFIED MEDICARE BENEFICIARY ("QMB") COVERAGE (COVERS MEDICARE DEDUCTIBLES) AND SPECIAL LOW-INCOME MEDICARE BENEFICIARY ("SLMB") COVERAGE (COVERS MEDICARE PART B PREMIUMS);C. HOMELESSNESS;D. MARYLAND PUBLIC HEALTH SYSTEM EMERGENCY PETITION PATIENTS;E. PARTICIPATION IN WOMEN, INFANTS AND CHILDREN PROGRAMS ("WIC");F. FOOD STAMP ELIGIBILITY;G. ELIGIBILITY FOR OTHER STATE OR LOCAL ASSISTANCE PROGRAMS;H. PATIENT IS DECEASED WITH NO KNOWN ESTATE; ANDI. PATIENTS THAT ARE DETERMINED TO MEET ELIGIBILITY CRITERIA ESTABLISHED UNDER FORMER STATE ONLY MEDICAL ASSISTANCE PROGRAM. SCHEDULE H, PART V, SECTION B, LINE 22; FINANCIAL ASSISTANCE POLICYUPMCWM DETERMINES THE MAXIMUM AMOUNTS THAT CAN BE CHARGED TO THE FINANCIAL ASSISTANCE POLICY ("FAP") ELIGIBLE INDIVIDUALS BY USING HSCRC RATE ORDER AND REGULATIONS. PART II, COMMUNITY BUILDING ACTIVITIES: COMMUNITY SUPPORT - UPMC WESTERN MARYLAND HAS IN PLACE A DISASTER READINESS PROGRAM. AS THE LARGEST HOSPITAL IN THE AREA AND THE LARGEST EMPLOYER, UPMC WESTERN MARYLAND HAS INCURRED COSTS TO BE ABLE TO DEAL WITH A DISASTER IF THE NEED ARISES.COALITION BUILDING - UPMC WESTERN MARYLAND WORKS WITH COMMUNITY PARTNERS TO IMPROVE THE HEALTH IN THE COMMUNITY. EDUCATION PROGRAMS, SCREENINGS, AND VARIOUS OTHER EVENTS ARE CONDUCTED BY UPMC WESTERN MARYLAND.WORKFORCE DEVELOPMENT - UPMC WESTERN MARYLAND IS ACTIVELY INVOLVED IN THE RECRUITMENT OF PHYSICIANS AND OTHER HEALTH PROFESSIONALS FOR THE FEDERALLY MEDICAL UNDERSERVED AREA THROUGH A COLLABORATION WITH REGIONAL PARTNERS. PART III, LINE 8: MEDICAREMARYLAND'S REGULATORY SYSTEM CREATES A UNIQUE PROCESS FOR HOSPITAL PAYMENT THAT DIFFERS FROM THE REST OF THE NATION. THE HEALTH SERVICES COURT REVIEW COMMISSION ("HSCRC") DETERMINES PAYMENT THROUGH A RATE SETTING PROCESS AND ALL PAYORS, INCLUDING GOVERNMENTAL PAYORS, PAY THE SAME AMOUNT FOR THE SAME SERVICES DELIVERED AT THE SAME HOSPITAL. MARYLAND'S UNIQUE ALL PAYOR SYSTEM INCLUDES A METHOD FOR REFERENCING UNCOMPENSATED CARE IN EACH PAYORS' RATES, WHICH DOES NOT ENABLE MARYLAND HOSPITALS TO BREAKOUT ANY OFFSETTING REVENUE RELATED TO UNCOMPENSATED CARE.METHOD USED: OTHER PART III, LINE 9B: COLLECTION PRACTICESUPMC WESTERN MARYLAND PROVIDES CARE TO ALL PATIENTS SEEKING CARE, REGARDLESS OF THEIR ABILITY TO PAY. AN ABILITY TO PAY IS BASED ON A REVIEW WHICH IS DONE BY A MEMBER OF THE HEALTH SYSTEM'S BUSINESS OFFICE. THIS REVIEW ASSURES THAT ALL PATIENTS WHO SEEK EMERGENCY OR URGENT CARE RECEIVE THOSE SERVICES REGARDLESS OF THE PATIENT'S ABILITY TO PAY.-IN ACCORDANCE WITH MARYLAND LAW, UPMC WESTERN MARYLAND HAS A FINANCIAL ASSISTANCE POLICY AND PATIENTS MAY BE ENTITLED TO RECEIVE FINANCIAL ASSISTANCE WITH THE COST OF MEDICALLY NECESSARY HOSPITAL SERVICES IF THEY HAVE A LOW INCOME, DO NOT HAVE INSURANCE, OR THEIR INSURANCE DOES NOT COVER MEDICALLY-NECESSARY HOSPITAL CARE.-UPMC WESTERN MARYLAND MEETS OR EXCEEDS THE STATE'S LEGAL REQUIREMENT BY PROVIDING FINANCIAL ASSISTANCE BASED ON INCOME ESTABLISHED BY AND PUBLISHED BY THE FEDERAL GOVERNMENT EACH YEAR.-THOSE PATIENTS THAT MEET THE FINANCIAL ASSISTANCE POLICY CRITERIA DESCRIBED ABOVE MAY RECEIVE ASSISTANCE FROM THE HEALTH SYSTEM IN PAYING THEIR BILL. IF A PATIENT BELIEVES HE HAS WRONGLY BEEN REFERRED TO A COLLECTION AGENCY, HE HAS THE RIGHT TO CONTACT THE HOSPITAL TO REQUEST ASSISTANCE.- UPMC WESTERN MARYLAND POLICIES MEET ALL 501R REQUIREMENTS. PART VI, LINE 2: COMMUNITY HEALTH NEEDS ASSESSMENTTHE COMMUNITY HEALTH NEEDS ASSESSMENT IS COMPLETED EVERY THREE YEARS. THE LATEST PLAN WAS APPROVED BY THE HOSPITAL'S GOVERNING BODY ON JUNE 29, 2020 AND IS AVAILABLE AT HTTP://WWW.ALLEGANYHEALTHPLANNINGCOALITION.COM THE ALLEGANY COUNTY HEALTH DEPARTMENT AND UPMC WESTERN MARYLAND ARE RESPONSIBLE FOR FACILITATING THE NEEDS ASSESSMENT PROCESS. ALLEGANY COUNTY IS LOCATED IN RURAL WESTERN MARYLAND WITH A POPULATION OF 70,416. IT IS PART OF THE APPALACHIAN REGION AND HAS LOW EDUCATION LEVELS, LIMITED RACIAL DIVERSITY, A LARGE ELDERLY POPULATION AND LOW HOUSEHOLD INCOMES.ALLEGANY COUNTY AND ITS SERVICE PROVIDERS ARE IMPACTED BY BEING PART OF A TRI-STATE REGION WHICH INCLUDES PENNSYLVANIA AND WEST VIRGINIA. UPMC WESTERN MARYLAND SERVES 7 COUNTIES IN 3 STATES. THE PROCESS INVOLVES THE REVIEW OF THE 3 PRIORITY AREAS THAT WERE IDENTIFIED IN THE PREVIOUS CHNA AS WELL AS UPDATES FOR THE COUNTY. PROBLEM AREAS AND TRENDS IDENTIFIED THROUGH COUNTY HEALTH RANKINGS AND COMMUNITY COMMONS ARE ALSO REVIEWED. IN THE REVIEW, BOTH HEALTH STATUS INDICATORS AND CAUSATIVE FACTORS ARE CONSIDERED. DATA SOURCES FROM THE LAST NEEDS ASSESSMENT ARE REVIEWED AND UTILIZED TO CLARIFY ISSUES.AFTER REVIEW OF HEALTH STATUS INDICATORS AND CAUSATIVE FACTORS, THE FOLLOWING PRIORITIES WERE SELECTED FOR THE MOST RECENT CHNA: TRANSPORTATION, SOCIAL DETERMINANTS OF HEALTH, AND PREVENTION-YOUTH RISK REDUCTION. PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE UPMC WESTERN MARYLAND IS COMMITTED TO PROVIDING FINANCIAL ASSISTANCE TO PERSONS WHO HAVE HEALTH CARE NEEDS AND ARE UNINSURED, UNDERINSURED, INELIGIBLE FOR A GOVERNMENT PROGRAM, OR OTHERWISE UNABLE TO PAY, FOR MEDICALLY NECESSARY CARE BASED ON THEIR INDIVIDUAL SITUATION. A PATIENT CAN QUALIFY FOR FINANCIAL ASSISTANCE EITHER THROUGH LACK OF SUFFICIENT INSURANCE OR FINANCIAL HARDSHIP.UPMC WESTERN MARYLAND IS COMMITTED TO PROVIDING QUALITY HEALTH CARE FOR ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY AND WITHOUT DISCRIMINATION ON THE GROUNDS OF RACE, COLOR, NATIONAL ORIGIN OR CREED.NOTICE OF THE AVAILABILITY OF FINANCIAL ASSISTANCE:A. UPMCWM WILL MAKE AVAILABLE BROCHURES INFORMING THE PUBLIC OF ITS FINANCIAL ASSISTANCE POLICY. SUCH BROCHURES WILL BE AVAILABLE AT UPMCWM' LOCATIONS.B. NOTICES OF THE AVAILABILITY OF FINANCIAL ASSISTANCE WILL BE POSTED AT APPROPRIATE ADMISSION AREAS, THE BILLING OFFICE, WEBSITE, AND OTHER KEY PATIENT ACCESS AREAS.C. A STATEMENT ON THE AVAILABILITY OF FINANCIAL ASSISTANCE WILL BE INCLUDED ON PATIENT BILLING STATEMENTS.D. A PLAIN LANGUAGE SUMMARY OF UPMCWM' FINANCIAL ASSISTANCE POLICY WILL BE PROVIDED TO PATIENTS RECEIVING INPATIENT SERVICES WITH THEIR SUMMARY BILL AND WILL BE MADE AVAILABLE TO ALL PATIENTS UPON REQUEST.E. UPMCWM' FINANCIAL ASSISTANCE POLICY, A PLAIN LANGUAGE SUMMARY OF THE POLICY, AND THE FINANCIAL ASSISTANCE APPLICATION ARE AVAILABLE TO PATIENTS UPON REQUEST AT UPMCWM OR VIA MAIL AS WELL AS ON UPMCWM' WEBSITE AT HTTPS://WWW.WMHS.COM/PATIENTS-AND-VISITORS/PATIENTS/FINANCIAL-ASSISTANCEF. UPMCWM' FINANCIAL ASSISTANCE POLICY, PLAIN LANGUAGE SUMMARY, AND FINANCIAL ASSISTANCE APPLICATION ARE AVAILABLE IN A DIFFERENT LANGUAGE UPON REQUEST. PART VI, LINE 4: COMMUNITY INFORMATION UPMC WESTERN MARYLAND PROVIDES HEALTHCARE SERVICES FOR RESIDENTS IN ALLEGANY AND GARRETT COUNTIES IN MARYLAND AND SURROUNDING COUNTIES IN WEST VIRGINIA AND PENNSYLVANIA. ALLEGANY COUNTY, MARYLAND, IS CONSIDERED UPMC WESTERN MARYLAND'S COMMUNITY BENEFIT SERVICE AREA. PART VI, LINE 5: PROMOTION OF COMMUNITY HEALTHSEE COMMUNITY BENEFIT SUMMARYTHE ALLEGANY COUNTY HEALTH DEPARTMENT AND THE UPMC WESTERN MARYLAND LEAD COMMUNITY HEALTH NEEDS ASSESSMENTS EFFORTS. THE ALLEGANY COUNTY HEALTH DEPARTMENT WORKS TO PROMOTE HEALTH IN ALLEGANY COUNTY AND UPMCWM IS A GLOBAL BUDGET REVENUE HOSPITAL AND THE ONLY HOSPITAL IN THE COUNTY, PROVIDING A UNIQUE OPPORTUNITY TO IMPACT COMMUNITY HEALTH. PART VI, LINE 6: AFFILIATED HEALTH CARE SYSTEM-WMHS FOUNDATION (EIN: 35-2289841), TAX EXEMPT UNDER 501(C)(3), PUBLIC CHARITY STATUS 12 TYPE III, FUNDRAISING-UPMC (EIN: 25-1423657), C CORPORATION, TAX EXEMPT UNDER 501(C)(3) HEALTHCARE, EDUCATION, AND RESEARCH-WILLOWBROOK HC CONDO (37-1538510), C CORPORATION, CONDO MANAGEMENT-HAYSTACK CONSOLIDATED (52-1335895), C CORPORATION, MEDICAL SERVICES SCHEDULE H, PART VI, LINE 7; STATE FILING OF COMMUNITY BENEFIT REPORTUPMCWM FILES A COMMUNITY BENEFIT REPORT WITH THE MARYLAND HEALTH SERVICES COST REVIEW COMMISSION (HSCRC).SCHEDULE H, PART V, FAPPART V, SECTION B, LINE 19 & 20UPMC'S POLICIES DO NOT PERMIT HOSPITAL FACILITIES OR ANY OTHER AUTHORIZED PARTIES TO ENGAGE IN EXTRAORDINARY COLLECTIONS ACTIONS IN ANY CIRCUMSTANCE. THEREFORE, LINE 20 HAS BEEN LEFT BLANK SINCE IT IS NOT APPLICABLE AND UPMC BELIEVES IT WOULD BE MISLEADING TO CHECK ANY OF THE BOXES. X X X X 0 0 X X X X X X 0 1 0 0 0 0 0 1 0 OR COHEN-INBAR MD NEUROSURGEON 951065 0 1182959 0 2215 0 17400 0 12236 0 2165875 0 0 0 CHRISTOPHER HAAS MD CARDIOLOGIST 666560 0 158546 0 3521 0 26996 0 18715 0 874338 0 0 0 MARK G NELSON MD CARDIOTHORACIC SURGEON 725751 0 42846 0 11757 0 48750 0 18534 0 847638 0 0 0 VAMSHIDHAR VOOTLA MD PHYSICIAN 572688 0 146966 0 1356 0 17400 0 13151 0 751561 0 0 0 BLANCHE MAVROMATIS MD ONCOLOGIST 531644 0 164292 0 2795 0 26154 0 11719 0 736604 0 0 0 MICHELE R MARTZ PRESIDENT 330103 0 52200 0 23276 0 101836 0 22295 0 529710 0 0 0 EMME CHAPMAN-JACKSON MD MEDICAL STAFF PRESIDENT 416464 0 35500 0 996 0 17400 0 6951 0 477311 0 0 0 MATTHEW SIMMONS MD VP, MEDICAL AFFAIRS 353366 0 50000 0 20682 0 8375 0 5477 0 437900 0 0 0 KEVIN R TURLEY VP, OPERATIONS 241228 0 46358 0 13448 0 80121 0 21072 0 402227 0 0 0 JAMES KARSTETTER VP, CNO 228371 0 54788 0 21127 0 35464 0 20702 0 360452 0 0 0 AMBER RUBLE CFO 163806 0 0 0 0 0 28919 0 0 0 192725 0 0 0 PART I, LINE 1A UPMC MAY PROVIDE THE FOLLOWING BENEFITS TO CERTAIN EXECUTIVES WHEN THEY ARE NECESSARY TO ACHIEVE UPMC'S CHARITABLE MISSION OBJECTIVES: FIRST-CLASS OR CHARTER TRAVEL; TRAVEL FOR COMPANIONS; TAX INDEMNIFICATION OR GROSS UP PAYMENTS; AND/OR BUSINESS CLUB DUES OR INITIATION FEES. PROVISION OF ANY SUCH BENEFITS IS PREDICATED ON COMPLIANCE WITH THE ORGANIZATION'S POLICIES, IS SUBJECT TO REVIEW AND APPROVAL PROCESSES, AND IS TREATED AS TAXABLE INCOME TO THE EXECUTIVES WHERE REQUIRED UNDER THE INTERNAL REVENUE CODE. PART I, LINE 4B ALL PERSONS PARTICIPATING IN A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN ARE DISCLOSED IN SCHEDULE J WITH CORRESPONDING AMOUNTS DISCLOSED WITHIN THE TOTAL AMOUNT IN SCHEDULE J COLUMN C "RETIREMENT AND OTHER DEFERRED COMPENSATION". DUE TO RESTRICTIONS IMPOSED BY THE INTERNAL REVENUE CODE ("CODE"), CERTAIN OFFICERS AND KEY EMPLOYEES ARE LIMITED IN THE AMOUNT OF BENEFITS WHICH MAY BE RECEIVED UNDER A TAX QUALIFIED RETIREMENT PROGRAM. LIKE MANY EMPLOYERS, UPMC SUPPLEMENTS ITS RETIREMENT BENEFITS THROUGH A SUPPLEMENTAL RETIREMENT PROGRAM. THE SUPPLEMENTAL RETIREMENT PROGRAM IS SUBJECT TO MULTI YEAR VESTING WHICH PLACES THE OFFICERS AND KEY EMPLOYEES' RETIREMENT BENEFIT AT RISK OF FORFEITURE IF THE VESTING REQUIREMENTS ARE NOT SATISFIED. ONCE VESTED HOWEVER, PROVISIONS OF THE CODE REQUIRE THAT THE VESTED AMOUNTS BE REPORTED ON THE FORM 990 AND THE VESTED OFFICER OR KEY EMPLOYEE INCLUDE IN CURRENT INCOME THE VALUE OF HER OR HIS SUPPLEMENTAL RETIREMENT BENEFIT. NOTWITHSTANDING THE TAX REQUIREMENT TO RECOGNIZE THE VESTED AMOUNT OF THE SUPPLEMENTAL RETIREMENT BENEFIT AS CURRENT INCOME FOR FICA TAXATION AND REPORTING PURPOSES, THIS BENEFIT, WHICH GENERALLY HAS BEEN EARNED OVER HER OR HIS ENTIRE CAREER, HAS NOT AND WILL NOT BE DISTRIBUTED UNTIL THE OFFICER OR KEY EMPLOYEE RETIRES OR SEPARATES FROM SERVICE FROM UPMC AND SATISFIED THE NON-COMPETE PROVISION OF THEIR EMPLOYMENT AGREEMENT AND/OR SATISFY A POST-RETIREMENT SEPARATION AGREEMENT. THE SUPPLEMENTAL RETIREMENT PROGRAM PROVIDES FOR THE CURRENT DISTRIBUTION OF ONLY THE AMOUNT NECESSARY TO SATISFY ANY INCOME TAX LIABILITY RESULTING FROM THE VESTING DURING ACTIVE EMPLOYMENT. FINALLY, IT SHOULD BE NOTED THAT IN ACCORDANCE WITH IRS INSTRUCTIONS, A SUBSTANTIAL PORTION OF THE AMOUNT REPORTED ON THE FORM 990 ATTRIBUTABLE TO SUPPLEMENTAL RETIREMENT PROGRAM VESTING HAS BEEN REPORTED IN PREVIOUSLY FILED FORMS 990. MICHELE MARTZ - $30,253 ROY TURLEY - $679 JAMES KARSTETTER - $835 PART I, LINE 7 UPMC PROVIDES INCENTIVE COMPENSATION AS PART OF ITS TOTAL COMPENSATION PROGRAM FOR OFFICERS AND KEY EMPLOYEES. THIS COMPONENT IS BASED UPON THE ACCOMPLISHMENT OF PREDETERMINED PERFORMANCE GOALS AND OBJECTIVES WHICH FOCUS ON THE ACHIEVEMENT OF MULTIPLE ANNUAL AND THREE YEAR INDIVIDUAL AND GROUP PERFORMANCE CRITERIA IN THE CONTEXT OF APPROPRIATE RISK TAKING. THESE CRITERIA DIRECTLY SUPPORT UPMC'S MISSION AND INCLUDE: PATIENT QUALITY AND SATISFACTION, COMMUNITY BENEFITS, OPERATIONAL AND FINANCIAL STRENGTH, LEADERSHIP DEVELOPMENT, AND STRATEGIC BUSINESS INITIATIVES AMONG OTHERS. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF UPMC WESTERN MARYLAND CORPORATION IS UPMC, A PENNSYLVANIA STATE NONPROFIT CORPORATION. NON-PROFIT, FEDERALLY TAX EXEMPT UNDER SECTION 501C3 OF THE INTERNAL REVENUE CODE. UPMC IS THE PARENT OF A LARGE INTEGRATED DELIVERY AND FINANCIAL SYSTEM. FORM 990, PART VI, SECTION A, LINE 7A UPMC, THE MEMBER, HAS THE OVERALL RESPONSIBILITY AND AUTHORITY FOR THE GOVERNANCE AND OPERATION OF UPMC WESTERN MARYLAND CORPORATION. OF THE 12 VOTING DIRECTORS OF THE UPMC WESTERN MARYLAND CORPORATION BOARD, 4 DIRECTORS ARE APPOINTED BY UPMC. FORM 990, PART VI, SECTION A, LINE 7B UPMC, AS THE SOLE MEMBER OF UPMC WESTERN MARYLAND CORPORATION, WILL HAVE THE POWER, RIGHT, AND PRIVILEGE, ON ITS OWN, TO MAKE DECISIONS AND INITIATE/IMPLEMENT ACTIONS INVOLVING UPMC WESTERN MARYLAND CORPORATION, AND TO REVERSE ACTIONS TAKEN BY THE BOARD, SUCH POWER, RIGHT AND PRIVILEGE TO BE LIMITED AS EXPRESSLY PROVIDED IN THE CORPORATION'S BYLAWS AND INTEGRATION AGREEMENT. FORM 990, PART VI, SECTION B, LINE 11B ON AN ANNUAL BASIS, FORM 990 AND 990-T IS MADE AVAILABLE TO UPMC CORPORATE TAX FOR REVIEW AND APPROVAL BEFORE IT IS FILED WITH THE INTERNAL REVENUE SERVICE. ALL BOARD MEMBERS OF UPMC WESTERN MARYLAND CORPORATION ARE PROVIDED WITH A COPY OF THE 990 PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST POLICY COMPLIANCE THE UPMCWM BOARD OF DIRECTORS MONITORS PROPOSED OR ONGOING TRANSACTIONS FOR CONFLICTS OF INTEREST AND ADDRESS ANY POTENTIAL OR ACTUAL CONFLICTS. PURSUANT TO THE CONFLICTS OF INTEREST POLICY, AN ANNUAL CONFLICT QUESTIONNAIRE IS DISTRIBUTED TO ALL INTERESTED PERSONS INCLUDING OFFICERS, DIRECTORS, AND KEY EMPLOYEES. INTERESTED PERSONS ARE REQUIRED TO DISCLOSE REAL OR POTENTIAL CONFLICTS AT THE TIME WHEN SUCH CONLFICTS ARISE. WHEN ONE BECOMES AN INTERESTED PERSON AND ANNUALLY THEREAFTER, THEY ARE REQUIRED TO SIGN A STATEMENT AFFIRMING THAT THEY HAVE RECEIVED, READ, UNDERSTAND, AND AGREE TO COMPLY WITH THE POLICY. THE COMPLETED QUESTIONNAIRES ARE REVIEWED BY THE BOARD. THE PROCEDURES FOR ADDRESSING ANY CONFLICT INCLUDE THE CONFLICT BEING FULLY DISCLOSED AND DISCUSSED WITH THE INTERESTED PERSON ALONG WITH THE POTENTIAL RESOLUTIONS OF THE CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 PROCESS FOR DETERMINING COMPENSATION TO SUPPORT UPMC'S MISSION AND AS SET FORTH IN THE UPMC BYLAWS, THE BOARD OF DIRECTORS HAS FORMED AN EXECUTIVE COMPENSATION COMMITTEE ("COMMITTEE") AND DELEGATED TO IT THE RESPONSIBILITY FOR ESTABLISHMENT AND IMPLEMENTATION OF OFFICER AND KEY EMPLOYEE TOTAL COMPENSATION PROGRAMS. AS PART OF THIS RESPONSIBILITY THE COMMITTEE REPORTS REGULARLY TO THE BOARD OF DIRECTORS. WITH BOARD OF DIRECTORS APPROVAL, THE COMMITTEE HAS ADOPTED A FORMAL CHARTER, WHICH INCLUDES THE ESTABLISHMENT OF A COMPENSATION PHILOSOPHY AND RELATED POLICIES WITH RESPECT TO THE TOTAL COMPENSATION PAID BY UPMC TO ITS OFFICERS AND KEY EMPLOYEES. THE UPMC TOTAL COMPENSATION PROGRAM FOR OFFICERS AND KEY EMPLOYEES IS PREDICATED UPON AN INCENTIVE COMPENSATION COMPONENT. THIS COMPONENT IS BASED UPON THE ACCOMPLISHMENT OF PREDETERMINED PERFORMANCE GOALS AND OBJECTIVES WHICH FOCUS ON THE ACHIEVEMENT OF MULTIPLE ANNUAL AND THREE-YEAR INDIVIDUAL AND GROUP PERFORMANCE CRITERIA IN THE CONTEXT OF APPROPRIATE RISK TAKING. THESE CRITERIA DIRECTLY SUPPORT UPMC'S MISSION AND INCLUDE PATIENT QUALITY AND SATISFACTION, COMMUNITY BENEFITS, OPERATIONAL AND FINANCIAL STRENGTH, LEADERSHIP DEVELOPMENT, AND STRATEGIC BUSINESS INITIATIVES AMONG OTHERS. THE TOTAL COMPENSATION PROGRAM IS INTEGRATED WITH AND REINFORCES THE UPMC BUSINESS PLANNING CYCLE AS WELL AS MANAGEMENT DEVELOPMENT AND SUCCESSION PLANNING PROCESSES. IT IS THE COMMITTEE'S JUDGMENT THAT THE STRUCTURE OF THE TOTAL COMPENSATION PROGRAM IS VITAL TO, AND STRONGLY SUPPORTIVE OF, THE HIGH LEVEL OF ONGOING SUCCESS OF UPMC AND FOSTERS THE RETENTION OF CRITICAL OFFICER AND KEY EMPLOYEE TALENT. THE TOTAL COMPENSATION DETERMINATION PROCESS UTILIZED BY THE COMMITTEE IS INTENDED TO SATISFY THE "REBUTTABLE PRESUMPTION OF REASONABLENESS" AS SET FORTH IN THE REGULATIONS TO SECTION 4958 OF THE INTERNAL REVENUE CODE ("CODE"). THIS MEANS THAT COMPENSATION PROGRAMS AND LEVELS ARE APPROVED IN ADVANCE BY THE COMMITTEE WHICH IS COMPOSED ENTIRELY OF OUTSIDE DIRECTORS WHO DO NOT HAVE A CONFLICT OF INTEREST, AS DEFINED BY THE RELEVANT REGULATIONS, WITH RESPECT TO THE COMPENSATION PROGRAM AND LEVELS. THE COMMITTEE OBTAINS AND RELIES UPON A BROAD RANGE OF APPROPRIATE DATA AS TO COMPARABILITY PRIOR TO MAKING ITS DETERMINATIONS. THE COMMITTEE THEN CONTEMPORANEOUSLY DOCUMENTS, IN FORMAL MEETING MINUTES, THE BASIS AND REASONS FOR ITS DETERMINATIONS. THE TOTAL COMPENSATION PROGRAM IS DESIGNED AND ADMINISTERED IN ACCORDANCE WITH THE UPMC BYLAWS, SOUND BUSINESS PRACTICES, THE TENETS OF COMMON LAW BUSINESS JUDGMENT AND FIDUCIARY RESPONSIBILITY AS WELL AS ADHERENCE TO ALL RELEVANT FEDERAL, STATE, AND LOCAL LAWS. IN ADDITION TO CODE SECTION 4958, AS SET FORTH ABOVE, THIS INCLUDES BUT IS NOT LIMITED TO CODE SECTION 501(C)(3) AND THE APPLICABLE REGULATIONS THEREUNDER AS WELL AS ALL LAWS AND REGULATIONS PROHIBITING PRIVATE INUREMENT, PRIVATE BENEFIT TRANSACTIONS AND DISCRIMINATION. FURTHER, THE COMMITTEE HAS IDENTIFIED AND ADOPTED, AS APPROPRIATELY MODIFIED FOR UPMC, COMPENSATION PROGRAM "BEST PRACTICES" FROM THE BUSINESS WORLD (E.G. SARBANES OXLEY, SEC, ETC.). THE COMMITTEE BELIEVES THAT WHILE THESE PRACTICES ARE NOT REQUIRED IN THE TAX-EXEMPT SECTOR, THEY ARE IN THE BEST INTERESTS OF THE ORGANIZATION AND FURTHER SUPPORT UPMC'S NONPROFIT MISSION. IN ACCORDANCE WITH THE ABOVE, DETERMINATION OF TOTAL COMPENSATION FOR THE CEO IS MADE EXCLUSIVELY BY THE COMMITTEE. DETERMINATION OF TOTAL COMPENSATION FOR OTHER OFFICERS AND KEY EMPLOYEES IS RECOMMENDED BY THE CEO AND SUBJECT TO REVIEW AND APPROVAL BY THE COMMITTEE. THE COMMITTEE, WHICH MEETS AT LEAST FOUR TIMES A YEAR, OBTAINS PROFESSIONAL ADVICE FROM ITS OWN EXPERTS, INCLUDING ACCOUNTANTS, EXECUTIVE COMPENSATION CONSULTANTS AND LEGAL COUNSEL. FORM 990, PART VI, SECTION C, LINE 19 AVAILABILITY OF GOVERNING DOCUMENTS TO PUBLIC FORM WHILE THE FEDERAL TAX LAWS DO NOT MANDATE THAT THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS BE MADE AVAILABLE FOR PUBLIC INSPECTION, THE ORGANIZATION MAKES ITS FINANCIAL STATEMENTS AVAILABLE UPON REQUEST. IN MARYLAND, THE ORGANIZATION'S FINANCIAL STATEMENTS ARE ALSO SUBMITTED TO THE HEALTH SERVICES COST REVIEW COMMISSION WHICH IS AVAILABLE FOR PUBLIC INSPECTION AS WELL. 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