2017-05-02T12:49:30-05:00 2016-06-30 440160260 BKD LLP 910 E St Louis Street Suite 200 Springfield MO 65806 990 2015-07-01 240804365 The Green Home GREE 5707230605 32-36 Central Ave Wellsboro PA 16901 Eric D Pohjala Executive Vice President/CFO 5703213175 2017-05-02 1 Brian D Todd P00422601 4178658701 2015 2021-01-29 14:40:06Z X Steven P Johnson 700 High Street Williamsport PA 17701 10775774 0 X www.susquehannahealth.org X 1974 PA The Green Home is a subsidiary of UPMC Susquehanna. The mission of UPMC Susquehanna and affiliates is as follows: To extend God's healing love by improving the health of those we serve. Our vision is to create a world class health system. Our values are putting patients first, sharing ownership and being servant leaders. 15 12 150 15 0 0 1255 660 10855937 10760546 10129 13021 3070 1547 10870391 10775774 0 0 0 0 6613170 6642272 0 0 0 4804000 5152155 11417170 11794427 -546779 -1018653 9721822 20020382 6100455 17288534 3621367 2731848 X The Green Home is a subsidiary of UPMC Susquehanna. The mission of UPMC Susquehanna and affiliates is as follows: To extend God's healing love by improving the health of those we serve. Our vision is to create a world class health system. Our values are putting patients first, sharing ownership and being servant 0 0 10127786 9940870 The Green Home operated a 120-bed skilled nursing facility that provided both long-term care and short-term services for residents. Services provided include round-the-clock professional nursing; physical, occupational, and speech rehabilitation services; medical social work and counseling services; nutrition services; podiatry services; radiology services; dentistry; and a variety of activities and recreational programs.The average daily census was 101. The payor mix was 75% Medicaid, 10% Medicare and 15% self-pay residents. Rehabilitation services provided included 14,674 physical therapy treatments, 15,565 occupational therapy treatments and 4,669 speech therapy treatments. 705783 821223 The Green Home operated The Laurels, a 30 unit personal care home serving individuals aged 62 and older. The Laurels had an occupancy rate of 82% with 100% self pay residents. 10833569 1 0 0 0 0 0 0 0 1 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 150 1 0 0 0 0 0 0 0 0 0 0 X 15 12 0 0 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1 0 0 0 PA X Management 5707230605 15 Meade St Ste U-6 Wellsboro PA 16901 Jill A Burns Director 0.33 45.67 X 0 296503 37541 James D Baker Jr Director 0.33 1.67 X 0 0 0 Lisa V Feil PsyD Director 0.33 3.67 X 0 0 0 Robert P Fitzgerald Director 0.33 1.67 X 0 0 0 Harold F Hoose II Director 0.33 1.67 X 0 0 0 Steven P Johnson CEO 0.33 53.67 X X 0 832199 35182 Walter J Laibinis DO Director 0.33 43.67 X 0 293550 33435 Michael W Lichty Director 0.33 1.67 X 0 0 0 Craig G Litchfield Treasurer (ending 6/15) 0.33 3.67 X X 0 0 0 J Dennis Murray Director 0.33 7.67 X 0 0 0 Thomas M Owlett Esq Chairman 0.33 7.67 X X 0 0 0 Glenn B Poirer Vice Chairman 0.33 7.67 X X 0 0 0 Wendy S Swartz CPA Director 0.33 1.67 X 0 0 0 Aneurin J Williams Jr Director 0.33 1.67 X 0 0 0 Donna R Wilson Director 0.33 1.67 X 0 0 0 Kathy J Wright PhD Secretary 0.33 1.67 X X 0 0 0 Janie M Hilfiger President SSMH 0.33 41.67 X 0 180881 17488 Eric D Pohjala Exec VP/CFO 1.00 42.00 X 0 255157 27349 Jan E Fisher Exec VP/COO 1.00 42.00 X 0 459806 31992 David Lopatofsky MD Exec VP/CMO 1.00 42.00 X 0 437276 38887 Cindy Frost Nursing Home Administrator 40.00 X 119176 0 18163 Jacqueline B Werts Director Nursing Home Admin/TGH 40.00 X 109271 0 5963 Paula Davis Supvisor Asst DON/TGH 40.00 X 104896 0 17808 Daisy Bova Supvisor RN/Hospital/LTC 40.00 X 103623 0 15087 Charles Santangelo Former Exec VP/CFO (retired) 0.00 X 0 338073 24988 William McCauley MD Former Exec VP/CMO (retired) 0.00 X 0 185372 4271 Ronald J Bulter Former Exec VP/CBO (retired) 0.00 2.00 X 0 518626 13502 436966 3797443 321656 4 1 1 0 Genesis Eldercare Rehab 101 East State St Kennett Square PA 19348 Rehabilitation Services 834176 1 660 660 Skilled Nursing Care 623000 9926539 9926539 Personal Care Home 623000 821223 821223 Employee & Guest Meals 722210 6987 6987 Beauty Shop 812900 5797 5797 10760546 13021 13021 OTHER INCOME 900099 1547 1547 1547 10775774 10762093 0 13021 X 4983452 4742753 240699 265324 249155 16169 1034003 1031940 2063 359493 338233 21260 375885 25278 350607 8495 8495 2229480 2229480 39369 28050 11319 2045 679 1366 420706 402311 18395 4098 3150 948 10378 10378 312493 312493 139692 139692 Resident Care Supplies 1591540 1302798 288742 Bad Debt 17000 17000 Dues 974 179 795 11794427 10833569 960858 0 1250 1250 1099032 985536 1592070 1549966 3499524 0 11518 8089 9900 11501030 8082842 3521857 3418188 0 14044024 9721822 20020382 1351472 1387942 157887 160842 80604 89529 4510492 15650221 6100455 17288534 X 3621367 2731848 3621367 2731848 9721822 20020382 X -1018653 129134 X X 0 1 X 1 0 X 6623 1225 2840 1255 660 12603 10441744 9866886 10538292 10857087 10731412 52435421 10448367 9868111 10541132 10858342 10732072 52448024 0 0 0 52448024 -1759 114578 25115 12049 13021 163004 -1759 114578 25115 12049 13021 163004 10446608 9982689 10566247 10870391 10745093 52611028 0.99690 0.99310 0.00310 0.00690 X 0 1 X 305800 -335097 29815 518 272788 34234 1222 305800 278971 -5086 1097 272788 318358 318358 7622208 5542957 2079251 3283413 2339151 944262 277051 200734 76317 3418188 Due to/from affiliates 13999710 Due to/from 3rd parties 44314 14044024 Due to Affiliates 15650221 15650221 10758774 -17000 -17000 10775774 0 10775774 11777427 0 11777427 17000 17000 11794427 Part IV, Line 2b: Security deposits and personal care account funds Part V, Line 4: The endowment funds are used to fund the mission of the organization. Part XI, Line 2d - Other Adjustments: Bad Debt - (17,000) Part XII, Line 4b - Other Adjustments: Bad Debt - 17,000 Part X Line 2 The System companies, with the exception of SVI, CB, SHSIN, TMSO and TCN, have been recognized as exempt from imcome taxes under Section 501 of the Internal Revenue Code and a similar provision of state law. However these entites are subject to federal income tax on any unrelated business taxable income. SVI, CB, SHSIN, TMSO and TCN account for income in accordance with income tax accounting guidance (ASC 740 Income Taxes). 0 0 0 0 0 0 0 0 0 Jill A Burns Director 0 247243 0 44446 0 4814 0 9950 0 27591 0 334044 0 0 Steven P Johnson CEO 0 668195 0 133858 0 30146 0 15925 0 19257 0 867381 0 0 Walter J Laibinis DO Director 0 231118 0 45655 0 16777 0 9950 0 23485 0 326985 0 0 Janie M Hilfiger President SSMH 0 163729 0 14229 0 2923 0 7416 0 10072 0 198369 0 0 Eric D Pohjala Exec VP/CFO 0 252402 0 0 0 2755 0 9720 0 17629 0 282506 0 0 Jan E Fisher Exec VP/COO 0 409956 0 36987 0 12863 0 9950 0 22042 0 491798 0 0 David Lopatofsky MD Exec VP/CMO 0 412757 0 18458 0 6061 0 11275 0 27612 0 476163 0 0 Charles Santangelo Former Exec VP/CFO (retired) 0 186916 0 71895 0 79262 0 9950 0 15038 0 363061 0 0 William McCauley MD Former Exec VP/CMO (retired) 0 108272 0 45384 0 31716 0 0 0 4271 0 189643 0 0 Ronald J Bulter Former Exec VP/CBO (retired) 0 112293 0 32105 0 374228 0 9950 0 3552 0 532128 0 0 Form 990 Schedule J Part I Line 3 The Williamsport Hospital EIN #24-0795508, a related organization, uses the following resources to establish the compensation of the top management officials: compensation committee, independent compensation consultant, written employment contract, compensation survey or study, and approval by the board. Form 990 Schedule J Part I Line 6 In order for the Leadership Team to participate in the annual Variable Compensation Incentive Program (VCIP) a minimum operating margin must be achieved for the most recently completed year on a consolidated system-level basis. Individual goals and objectives related to the VCIP may also include individual entity operating performance. For FY 2016, the minimum threshold was met that would trigger VCIP payments. In December 2015, President/CEO Steven P. Johnson received a variable compensation award in the amount of $133,858. Form 990, Part VI, Section A, line 7a UPMC Susquehanna, EIN 23-2751183, may elect or remove members of the governing body. Form 990, Part VI, Section A, line 7b All the business and affairs of the Entity shall be managed and controlled by the Board of Directors, subject to the oversight of the sole Member, UPMC Susquehanna, of the management and operation of the Entity, except that the following powers are reserved exclusively to the sole Member of the Entity, and no attempted exercise of any such powers by anyone other than the sole Member shall be valid of any force or effect whatsoever. The sole Member shall exercise its powers through its Board of Directors. The sole Member shall have the exclusive authority to exercise the following powers: A) to appoint or elect the directors B) to appoint and remove the President following consultation with the Entity C) to approve the nominees for elected officers and to return the list of approved nominees to the governing bodies for election D) to remove, with or without cause, any director or any elected officer E) to amend the Governing Instruments and to approve all amendments to the Governing Instruments which are proposed for adoption F) to approve the annual operating and capital budgets G) to establish requirements for unified budget H) to approve the incurrence or issuance of debt proposed by Entity and the encumbrance of any Entity assets to secure any such incurred debt I) to incur debt (or to cause debt to be incurred) on behalf of the Entity J) to require contributions in cash or cash equivalents to support the working capital needs or capital projects of any one or more System Entities K) to require that any debt incurred on a System wide basis by or at the direction of SHS shall be the joint and several obligation of each System Entity L) to direct or approve any cash contributions or any other capital contributions made by one System Entity to another System Entity M) to allocate any financial resources in such manner as SHS determines to be necessary N) to approve the sale, transfer or other disposition of Entity or Entity property unless it is made in the ordinary course of business or involves assets with a fair market value of less than one hundred dollars O) to direct the transfer of property from the Entity to one or more other System Entities P) to approve of any investment of assets by Entity not within the limits of the System's approved investment policy Q) to establish requirements for the approval of the acquisition, purchase, sale, transfer, encumbrance, leasing, construction or demolition of land or buildings outside the ordinary course of business R) to approve any decision with respect to the addition, modification or discontinuance of any patient care or diagnostic program or health care service Entity to add, modify, relocate or discontinue any patient care or diagnostic program or health care service U) to approve or direct any merger, consolidation, organization, reorganization, joint venture, corporate division, sale conversion, lease or exchange of substantially all the assets, dissolution, liquidation or any other modification of corporate structure or affiliations affecting the autonomy, governance, or operations, and the creation or acquisition of any new affiliate by Entity V) to dissolve or terminate the existence of Entity and to determine the distribution of assets upon such termination or dissolution W) to coordinate managed care plans involving Entit on behalf of Entity. Form 990, Part VI, Section B, line 11 A high-level overview of Forms 990 is presented to the parent Board of Directors (UPMC Susquehanna, #23-2751183) before filing and complete drafts of all returns are made available to all Board members through the CEO's and CFO's office. Form 990, Part VI, Section B, line 12c Annually on the 1st day of January, the UPMC Susquehanna CEO sends to all Directors, Officers, Management staff and contracted physicians a questionnaire to be completed and returned by January 15. A report is submitted to the Board of Directors to notify them of any conflicts of interest disclosed. Form 990, Part VI, Section B, line 15 On a bi-annual basis an independent compensation consulting firm performs an analysis of the Leadership salary structure in relationship to the labor market using data from four different salary surveys. Their analysis is reviewed with the Governance Committee of the Board of Directors. The firm then outlines its recommendations for the proposed executive salary structure to the Committee for their consideration and approval. Form 990, Part VI, Section C, line 19 Governing documents and financial statements are available to the public upon request. The conflict of interest policy is also available to the public. Form 990, Part IX, line 11g Other Purchased Services: Program service expenses 1709467. Management and general expenses 0. Fundraising expenses 0. Total expenses 1709467. Consulting: Program service expenses 1353. Management and general expenses 0. Fundraising expenses 0. Total expenses 1353. Inter-entity purchased services: Program service expenses 518660. Management and general expenses 0. Fundraising expenses 0. Total expenses 518660. Form 990, Part XI, line 9: Pension Liability Adjustment -220866. Transfer from affiliates 350000. FORM 990, Part XII, Line 2c The Organization Has changed neither the oversight process nor the independent accountant selection process during the fiscal year. Form 990 Effective October 1, 2016 the University of Pittsburgh Medical Center (UPMC) became the sole corporate member of Susquehanna Health System, EIN# 23-2751183 and the name was formally changed to UPMC Susquehanna. Laurel Health System 22 Walnut St Wellsboro PA 16901 240795488 Coordinate & Manage the delivery of healthcare PA 501 (c) (3) 11 B II UPMC Susquehanna 0 Laurel Management Services 22 Walnut St Wellsboro PA 16901 251644910 Management consulting and supervisory services PA 501 (c) (3) 11 B II UPMC Susquehanna 0 Soldiers Sailors Memorial Hospital 32-36 Central Ave Wellsboro PA 16901 232176963 Operate acute care hospital PA 501 (c) (3) 3 UPMC Susquehanna 0 Tioga Health Care Providers 15 Meade St Wellsboro PA 16901 251765538 Physician Services PA 501 (c) (3) 11 B II UPMC Susquehanna 0 Laurel Realty 15 Meade St Wellsboro PA 16901 231403678 Own and manage real estate in support of Laurel Health PA 501 (c) (2) UPMC Susquehanna 0 Divine Providence Hospital 1100 Grampian Blvd Williamsport PA 17701 240799343 Hospital PA 501 (c) (3) 3 UPMC Susquehanna 0 Muncy Valley Hospital 215 E Water St Muncy PA 17756 240806023 Hospital PA 501 (c) (3) 3 UPMC Susquehanna 0 The Williamsport Hospital 700 High Street Williamsport PA 17701 240795508 Hospital PA 501 (c) (3) 3 UPMC Susquehanna 0 Susquehanna Health Foundation 1100 Grampian Blvd Williamsport PA 17701 232743470 Fundraising for affiliated entities PA 501 (c) (3) 11 A I UPMC Susquehanna 0 Susquehanna Physician Services 1201 Grampian Blvd Williamsport PA 17701 232449454 Physician services & MRI services PA 501 (c) (3) 3 UPMC Susquehanna 0 Williamsport Area Ambulance Service Cooperative 700 High Street Williamsport PA 17701 232416166 Ambulance transports PA 501 (c) (3) 9 N/A 0 UPMC Susquehanna 1205 Grampian Blvd Williamsport PA 17701 232751183 Coordinate and manage the delivery of healthcare PA 501 (c) (3) 11 B II N/A 0 Laurel Health Foundation 15 Meade St Wellsboro PA 16901 251810488 Fundraising for affiliated entities PA 501 (c) (3) 11 A I Laurel Health System 0 North Penn Comprehensive Health Services 22 Walnut St Wellsboro PA 16901 231889724 Provides general health and social services PA 501 (c) (3) 3 N/A 0 Susquehanna Health Innovation Center Inc 700 High Street Williamsport PA 17701 471600873 Supporting organization of affiliated entities PA 501 (c) (3) 11 A I UPMC Susquehanna 0 Community Basket LLC 1205 Grampian Blvd Williamsport PA 17701 201195739 Rents real estate PA UPMC Susquehanna & Susquehanna Health Foundation Excluded from tax 0 0 Tyoga Carenet 22 Walnut St Wellsboro PA 16901 251810967 Integrate health care PA UPMC Susquehanna C 0 Susquehanna Ventures Inc 1201 Grampian Blvd Williamsport PA 17701 232470263 Pharmacy & Infusion services PA UPMC Susquehanna C 0 Susquehanna Health System Insurance Network LTD PO Box 1159 Grand Caymans CJ 980458722 Captive Insurance Company CJ UPMC Susquehanna 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 1 0 1 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 had been granted an exemption until September 2022 for any such taxes that might be introduced. SHSIN's sole shareholder, UPMC Susquehanna EIN#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.