2022-05-16T16:19:33-05:00 2021-06-30 135565207 KPMG LLP 8350 BROAD STREET SUITE 900 MCLEAN VA 22102 990 2020-07-01 520591531 UPMC WESTERN MARYLAND CORPORATION UPMC 2409648002 PO BOX 539 CUMBERLAND MD 215010539 MICHELE MARTZ PRESIDENT 2409648002 2022-05-16 1 MICHELE MARTZ 999009999 MARGARET A BRADSHAW P00501222 7032868000 2022-05-15 3 AAL1 IAL1 2020 2022-09-23 18:48:47Z MICHELE MARTZ PO BOX 539 CUMBERLAND MD 215010539 389852403 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 2647 270 778015 0 2745715 12128886 332012049 357369023 39958547 18373573 3718422 1425944 378434733 389297426 17388 273809 0 0 186359977 174640440 0 0 0 159061722 158604346 345439087 333518595 32995646 55778831 634435651 700315252 451473053 468104878 182962598 232210374 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 181330588 223365413 ANCILLARY CARE - REGULATEDUPMC WESTERN MARYLAND (UMPCWM) 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. 51459089 273809 63381984 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, 10,088 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. 54873579 17979036 PHYSICIAN PRACTICES, CLINICS, AND HOME CAREUPMC WESTERN MARYLAND (UMPCWM) OPERATES 21 PHYSICIAN PRACTICES, 2 URGENT CARE CLINICS, AND A HOME CARE PRACTICE. THE PHYSICIAN PRACTICES HAD 157,110 ENCOUNTERS; THE CLINICS HAD 47,187 ENCOUNTERS AND HOME CARE HAD 33,176 VISITS FOR THE YEAR. 14504030 53434464 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. 35,894 VISITS WERE REGISTERED IN THE EMERGENCY ROOM FOR THE YEAR ENDING JUNE 30, 2021. 14504030 53434464 302167286 1 1 0 0 0 0 0 0 0 1 1 0 1 0 1 1 0 1 0 0 1 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 1 137 0 1 2647 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 ROLF K HAARSTAD AIA CHAIRMAN 4.00 0.00 X X 0 0 0 MARY ANN JENKINS VICE CHAIR 4.00 0.00 X X 0 0 0 KEITH L FUNKHOUSER TREASURER 4.00 0.00 X X 0 0 0 DAVID T MARTIN SECRETARY 4.00 0.00 X X 0 0 0 DAVID BURWELL MD 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 JONATHAN HUTCHERSON BOARD MEMBER 3.00 0.00 X 0 0 0 KIM B LEONARD BOARD MEMBER 3.00 0.00 X 0 0 0 PATRICIA NOBLE RN 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 BARRY P RONAN PRESIDENT/CEO (UNTIL 3/31/21) 40.00 0.00 X 1487316 0 532448 NANCY D ADAMS SR VP/COO 40.00 0.00 X 783460 0 94525 GERALD GOLDSTEIN MD SR VP/CMO 40.00 0.00 X 327461 0 148372 MICHELE R MARTZ PRESIDENT/CEO (AS OF 4/1/21) 40.00 0.00 X 554950 0 79644 AMBER RUBLE CFO 40.00 0.00 X 151642 0 35970 JO M WILSON VP, POPULATION HEALTH 40.00 0.00 X 285752 0 36170 KEVIN R TURLEY VP, SUPPORT OPERATIONS 40.00 0.00 X 417799 0 47454 WILLIAM BYERS VP, CIO 40.00 0.00 X 395991 0 47925 JAMES KARSTETTER VP, CNO 40.00 0.00 X 395343 0 47876 STEVEN R SMITH MD MEDICAL DIRECTOR 40.00 0.00 X 329245 0 169875 MARK G NELSON MD CARDIOTHORACIC SURGEON 40.00 0.00 X 753858 0 59700 NII LAMPTEY-MILLS MD GASTROENTEROLOGIST 40.00 0.00 X 617478 0 57202 CHRISTOPHER HAAS MD CARDIOLOGIST 40.00 0.00 X 768387 0 53317 OR COHEN-INBAR MD NEUROSURGEON 40.00 0.00 X 1005927 0 74849 BLANCHE MAVROMATIS MD ONCOLOGIST 40.00 0.00 X 655970 0 56375 8930579 0 1541702 183 0 1 0 HAYSTACK IMAGING SERVICES PO BOX 539 CUMBERLAND MD 215010539 DIAGNOSTIC 3344148 USACS INTEGRATED ACUTE CARE 4535 DRESSLER ROAD NW CANTON OH 44718 PHYSICIAN STAFFING 3089090 NORTH AMERICAN PARTNERS IN ANESTHESIA 68 SOUTH SVC ROAD STE 350 MELVILLE NY 11747 ANESTHESIA SERVICES 2636743 WEATHERBY LOCUMS PO BOX 972633 DALLAS TX 753972633 PHYSICIAN STAFFING 1806254 MEP HEALTH 4535 DRESSLER ROAD NW CANTON OH 44718 PHYSICIAN STAFFING 1397993 27 1800395 9531973 796518 12128886 ANCILLARY PATIENT CARE 621990 222890209 222375105 515104 INPATIENT ROUTINE CARE 621990 63247128 63247128 CLINICS, HH, & HOSPICE 621990 53396454 53396454 EMERGENCY CARE 621990 17835232 17835232 357369023 11569442 11569442 770800 4500 425087 0 345713 4500 350213 350213 6824282 109739 129890 0 6694392 109739 6804131 6804131 REIMBURSEMENT OF EXPENSES 900099 791874 791874 CONDO REVENUES 621500 262911 262911 PHYSICIAN VENDING & CAFETERIA 722514 20946 20946 1075731 389297426 357645793 778015 18744732 264809 264809 9000 9000 6332402 5889134 443268 129829362 120741307 9088055 9576229 8905893 670336 19779871 18395280 1384591 9122576 8483996 638580 631213 631213 110500 110500 85280 85280 22542574 20964594 1577980 374127 347938 26189 401877 373746 28131 7736392 7194845 541547 882960 821153 61807 385244 358277 26967 7766408 7766408 22954390 21347583 1606807 3045097 2831940 213157 SUPPLIES 59804338 55618034 4186304 MEDICAL PROF FEES 21726837 20205958 1520879 UTILITIES 4099500 3812535 286965 MINORITY INT IN CONS SU 2090384 1944057 146327 3967225 3657207 310018 333518595 302167286 31351309 0 20750477 12059704 261737710 341528990 39138720 42968496 6514801 7417175 3946606 2475506 577822306 358679455 231516112 219142851 13788084 7380163 37580429 47728101 19462712 19614266 634435651 700315252 32276065 25442963 13849337 9281710 66880 405280771 433380205 451473053 468104878 X 182138928 231300961 823670 909413 182962598 232210374 634435651 700315252 X 55778831 -6423752 -107303 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 7835269 221846 503718 346585 8214248 8453886 3734675 268104 4621396 7835269 10988945 459723 178047 3172829 8453886 10830910 234245 362489 438699 10988945 10650335 182225 190259 191909 10830910 0.88929 0.06226 0.04845 1 0 14713472 14713472 315101752 151384196 163717556 2586770 643083 1943687 239125712 206652176 32473536 6294600 6294600 219142851 INVESTMENT - MARYLAND CARE 44328101 C INVESTMENT - ASC 3400000 C 47728101 PAYABLE TO EXEMPT AFFILIATE 343614113 PAYABLE TO 3RD PARTY PROG. 73499087 PROFESSIONAL INSUR LIABILITY 11440704 MINORITY INTEREST PAYABLE 1564145 DEFERRED COMP 2043896 LEASE LIABILITY - LONG TERM 1218260 433380205 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: LIABILITY FOR UNCERTAIN TAX POSITIONS (FIN 48 FOOTNOTE) 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 DECEMBER 31, 2021, AND 2020, THERE WERE NO UNCERTAIN TAX POSITIONS. CERTAIN OF UPMC'S SUBSIDIARIES ARE SUBJECT TO TAXATION IN THE UNITED STATES AND FOREIGN JURISDICTIONS. AS OF DECEMBER 31, 2021, UPMC'S RETURNS FOR THE CALENDAR YEARS ENDED DECEMBER 31, 2018 THROUGH DECEMBER 31, 2020, ARE OPEN FOR EXAMINATION BY THE VARIOUS TAXING AUTHORITIES. CENTRAL AMERICA AND THE CARIBBEAN 0 0 INVESTMENTS 22025851 0 0 0 0 0 0 22025851 0 22025851 1 0 1 0 0 0 PART III ACCOUNTING METHOD: 1 1 1 X 1 X 1 1 1 0 1 1 14029126 14029126 0.04210 6042287 5007667 1034620 0.00310 20071413 5007667 15063746 0.04520 1482964 1482964 0.00440 2224668 202182 2022486 0.00610 93970345 44098271 49872074 0.14950 313534 9000 304534 0.00090 97991511 44309453 53682058 0.16090 118062924 49317120 68745804 0.20610 50695 25000 25695 0.00010 2524 2524 0.00000 558159 558159 0.00170 611378 25000 586378 0.00180 1 3765003 147352809 132894697 14458112 X 1 1 1 HAYSTACK IMAGING HEALTH CARE 0.50000 0.50000 2 SURGCENTER OF WM HEALTH CARE 0.41180 0.58820 1 999 UPMC WESTERN MARYLAND 12500 WILLOWBROOK ROAD CUMBERLAND MD 21502 WWW.WMHS.COM 01.0007 X X X A UPMC WESTERN MARYLAND 0 0 1 X X X X X X X X X X 20 1 0 1 1 X WWW.WMHS.COM X HTTP://WWW.ALLEGANYHEALTHPLANNINGCOALITION.COM 1 20 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 X X X X 1 X 0 1 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. PART V, SECTION B FACILITY REPORTING GROUP A FACILITY REPORTING GROUP A CONSISTS OF: - FACILITY 999: UPMC WESTERN MARYLAND UPMC WESTERN MARYLAND 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 PART V, SECTION B, LINE 11: ADDRESSING SIGNIFICANT NEEDS IN THE CHNAPRIOR CHNAS WERE COMPLETED IN 2011, 2014 AND 2017. THE ASSESSMENT BEING COMPLETED IN JUNE 2020 IS THE FOURTH CYCLE AND BUILD UPON IMPROVEMENTS MADE AND LESSONS LEARNED IN PRIOR CYCLES. THE PRIORITIES IN THE 2017 CHNA WERE SUBSTANCE ABUSE, POVERTY, HEART DISEASE, AND ACCESS TO CARE/HEALTHLITERACY. 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 HEALTHACTION 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 WMHS DENTAL ED VISITS MD COLLEGE SURVEY DRUG AND ALCOHOL RELATED DEATHS- BHA, MDH HOMELESS DATA-HRDC TOP 10 REASONS WMHS ED VISITS AND ADMISSIONS WMHS 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 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 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 4: BAD DEBT EXPENSEPATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY ALLOWANCES FOR BAD DEBTS. IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE HEALTH SYSTEM ANALYZES HISTORICAL COLLECTIONS AND WRITE-OFFS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOUCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR BAD DEBTS AND PROVISION FOR UNCOLLECTABLE ACCOUNTS. MANAGEMENT REGULARLY REVIEWS ITS ESTIMATE AND EVALUATES THE SUFFICIENCY OF THE ALLOWANCE FOR BAD DEBTS. THE HEALTH SYSTEM ANALYZES CONTRACTUAL AMOUNTS DUE FROM PATIENTS WHO HAVE THIRD-PARTY COVERAGE AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS. FOR PATIENT ACCOUNTS RECEIVABLE ASSOCIATED WITH SELF-PAY PATIENTS, WHICH INCLUDES THOSE PATIENTS WITHOUT INSURANCE COVERAGE FOR A PORTION OF THE BILL, THE HEALTH SYSTEM RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS FOR PATIENTS THAT ARE UNABLE OR UNWILLING TO PAY FOR THE PORTION OF THE BILLREPRESENTING THEIR FINANCIAL RESPONSIBILITY. ACCOUNT BALANCES ARE CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS AFTER ALL MEANS OF COLLECTION HAS BEEN EXHAUSTED. 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: COST TO CHARGE RATIO 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 (WMHS) IS RESPONSIBLE FOR FACILITATING THE NEEDS ASSESSMENT PROCESS. ALLEGANY COUNTY IS LOCATED IN RURAL WESTERN MARYLAND WITH A POPULATION OF 71,977. 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 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 (WMHS) 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 REPORTWMHS FILES A COMMUNITY BENEFIT REPORT WITH THE MARYLAND HEALTH SERVICES COST REVIEW COMMISSION (HSCRC). 0 WMHS FOUNDATION PO BOX 539 CUMBERLAND MD 20501 352289841 501(C)(3) 264809 GENERAL SUPPORT SCHOLARSHIPS 9 9000 SCHEDULE I, PART I AN ACCOUNTANT COMPLETES AN ANNUAL REVIEW OF THE CONTRIBUTIONS IN ORDER TO SUBSTANTIATE THE INTENDED USE OF THE FUNDS EXPENDED. APPLICATIONS ARE SUBMITTED IN ORDER TO APPLY FOR A SCHOLARSHIP, ALONG WITH A ONE PAGE TYPED ESSAY DESCRIBING THE STUDENT'S EDUCATIONAL AND PROFESSIONAL GOALS. FUNDS ARE PAID DIRECTLY TO THE SCHOOL UPON RECEIPT OF A TRANSCRIPT SHOWING A MINIMUM 3.0 GPA. X X X X X X 0 1 0 0 0 0 0 1 0 BARRY P RONAN PRESIDENT/CEO (UNTIL 3/31/21) 854979 0 321206 0 311131 0 512912 0 19536 0 2019764 0 302311 0 OR COHEN-INBAR MD NEUROSURGEON 632455 0 373472 0 0 0 52431 0 22418 0 1080776 0 0 0 NANCY D ADAMS SR VP/COO 554438 0 168150 0 60872 0 74469 0 20056 0 877985 0 60872 0 CHRISTOPHER HAAS MD CARDIOLOGIST 656698 0 111689 0 0 0 42100 0 11217 0 821704 0 0 0 MARK G NELSON MD CARDIOTHORACIC SURGEON 721205 0 32653 0 0 0 40080 0 19620 0 813558 0 0 0 BLANCHE MAVROMATIS MD ONCOLOGIST 513468 0 142502 0 0 0 36327 0 20048 0 712345 0 0 0 NII LAMPTEY-MILLS MD GASTROENTEROLOGIST 556373 0 61105 0 0 0 34455 0 22747 0 674680 0 0 0 MICHELE R MARTZ PRESIDENT/CEO (AS OF 4/1/21) 399160 0 131800 0 23990 0 57268 0 22376 0 634594 0 23990 0 STEVEN R SMITH MD MEDICAL DIRECTOR 299245 0 30000 0 0 0 147350 0 22525 0 499120 0 0 0 GERALD GOLDSTEIN MD SR VP/CMO 290836 0 0 0 36625 0 140647 0 7725 0 475833 0 36625 0 KEVIN R TURLEY VP, SUPPORT OPERATIONS 294495 0 123304 0 0 0 25016 0 22438 0 465253 0 0 0 WILLIAM BYERS VP, CIO 316296 0 79695 0 0 0 25574 0 22351 0 443916 0 0 0 JAMES KARSTETTER VP, CNO 291143 0 104200 0 0 0 25034 0 22842 0 443219 0 0 0 JO M WILSON VP, POPULATION HEALTH 220888 0 64864 0 0 0 18402 0 17768 0 321922 0 0 0 AMBER RUBLE CFO 151642 0 0 0 0 0 11134 0 24836 0 187612 0 0 0 PART I, LINE 4B SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN BARRY P. RONAN RECEIVED A SERP PAYMENT IN THE AMOUNT OF $140,582 ON 01/03/20 AND $161,549 ON 12/24/2020. MICHELE MARTZ RECEIVED A SERP PAYMENT IN THE AMOUNT OF $23,990 ON 12/24/2020. NANCY D. ADAMS RECEIVED A SERP PAYMENT IN THE AMOUNT OF $28,442 ON 01/03/20 AND $32,429 ON 12/24/2020. GERALD GOLDSTEIN RECEIVED A SERP PAYMENT IN THE AMOUNT OF $23,305 ON 01/03/20 AND $13,320 ON 09/22/2020. PART I, LINE 7 BONUSES ARE BASED UPON THE ACHIEVEMENT OF TARGETS AND IN MINIMAL OCCURENCES, ARE DISCRETIONARY IN NATURE. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF UPMC WESTERN MARYLAND CORPORATION IS UPMC (UNIVERSITY OF PITTSBURGH MEDICAL CENTER), A PENNSYLVANIA NONPROFIT CORPORATION. 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 SHALL BE 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. 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. FORM 990, PART XI, LINE 9: FNRC TRANSFER -107,303. 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