2017-05-15T14:14:14-07:00 2016-06-30 990 2015-07-01 240792115 JERSEY SHORE HOSPITAL JERS 5703980100 1020 Thompson St Jersey Shore PA 17740 DAVID SHANNON PRESIDENT & CEO 5703983101 2017-05-15 2015 2021-01-29 14:40:06Z David A Shannon 1020 Thompson St Jersey Shore PA 17740 26047658 0 X www.jsh.org X 1922 PA Provide Inpatient, Outpatient, and Emergency Care Services for Residents of Jersey Shore Area. 13 12 57 12 643891 0 56249 75845 27917299 24963411 29686 39058 791006 902285 28794240 25980599 0 0 0 0 14917043 12583473 0 0 0 14644686 13873531 29561729 26457004 -767489 -476405 23748049 20821259 22145857 23326144 1602192 -2504885 TO BE THE COMMUNITIES FOUNDATION FOR INNOVATIVE PATIENT-CENTERED CARE. 0 0 22517864 0 24959082 AS A RURAL HEALTHCARE FACILITY AND DEDICATED COMMUNITY HOSPITAL WITH A COMMITMENT TO PROVIDING A HIGH QUALITY CIRCLE OF CARE, JERSEY SHORE HOSPITAL HAS DEVELOPED DELIVERY SYSTEMS THAT PROVIDE AN EFFICIENT BALANCE OF OUTPATIENT CARE, ACUTE AND SUB-ACUTE INPATIENT CARE, PRIMARY CARE, AND OUTREACH SERVICES. THE HOSPITAL MAXIMIZES THE EFFECTIVENESS OF ITS PROGRAMS FOR QUALITY, EFFICIENCY, AND ACCESSIBILITY BY INTEGRATING WITH OTHER PROVIDERS AND ALTERNATIVE CARE ORGANIZATIONS IN THE SERVICE COMMUNITY TO ASSURE THE COMMUNITY ACCESS TO A BROAD ARRAY OF SERVICE OPTIONS. THE HOSPITAL PROVIDES AN ENVIRONMENT OF CARE THAT IS COMPASSIONATE, HIGHLY-PERSONALIZED, AND FOCUSED ON THE PHYSICAL, PSYCHO-SOCIAL, AND SPIRITUAL NEEDS OF ITS PATIENTS THROUGH THE USE OF SKILLED NURSES, PHYSICIANS, TECHNICAL AND SUPPORT STAFF, MANAGEMENT, AND COMMUNITY LEADERS. THE HOSPITAL ALSO PROVIDES HEALTH EDUCATION, PROGRAMS IN PREVENTION, AND RELATED SUPPORT SERVICES TO THE COMMUNITY WITH THE GOAL OF IMPROVING THE OVERALL WELLNESS OF ITS RESIDENTS. THE HOSPITAL ENSURES THAT THE NECESSARY RESOURCES ARE AVAILABLE TO PROVIDE THE MOST COST EFFECTIVE MANNER WHILE MAINTAINING A SAFE, PLEASANT, AND MEANINGFUL WORK AND PATIENT CARE ENVIRONMENT. THE HOSPITAL PROVIDES CHARITY CARE TO PATIENTS WHO MEET CERTAIN CRITERIA WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. CHARGES FORGONE FOR SERVICES RENDERED AND SUPPLIES FURNISHED UNDER THE CHARITY CARE POLICY AMOUNTED TO APPROXIMATELY $439,000 DURING THE YEAR ENDED JUNE 30, 2015. 0 0 0 22517864 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 1 1 0 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0 0 0 1 35 0 1 57 1 1 1 0 0 0 0 1 1 0 0 0 0 0 0 X 13 12 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 PA X MARK RICE-CFO 5703985280 1020 Thompson St Jersey Shore PA 17740 X DAVID A SHANNON PRESIDENT & CEO (NONVOTING) 39 1 X X 0 0 0 SEAN SIMCOX CHAIRPERSON 1 1 X X 0 0 0 JAMES ELY VICE CHAIRPERSON 1 1 X X 0 0 0 LEROY H KEILER III SECRETARY 1 1 X X 0 0 0 WILLIAM R CAMERER III TREASURER 1 0 X X 0 0 0 STEPHEN GOYKOVICH DO MEDICAL STAFF PRESIDENT 1 39 X 0 159912 11542 WALTER EISENHAUER MEMBER 1 0 X 0 0 0 CRAIG HARRIS MEMBER 1 0 X 0 0 0 STEPHEN P NEUN PH D MEMBER 1 0 X 0 0 0 CARMEN SPINNEY MD MEMBER 1 0 X 0 0 0 RICHARD DELANEY MEMBER (ENDED 10.1.16) 1 0 X 0 0 0 BETSY CROSSLEY MEMBER 1 0 X 0 0 0 BARBARA KOZLOWSKI MEMBER 1 1 X 0 0 0 MARK RICE CFO 39 1 X 98603 0 24019 THEORDORE FEDEROFF PHYSICIAN 40 0 X 298133 0 22491 SHAIRKO MISSOURI ANESTHESOLOGIST 40 0 X 290014 0 16157 MICHAEL GERST PHYSICIAN 40 0 X 222553 0 13659 TAMAR BAITEL PHYSICIAN 40 0 X 204211 0 10819 DANIEL STAIRS CRNA 40 0 X 150048 0 13837 1263562 159912 112524 14 0 1 0 JERSEY SHORE RADIOLOGY 302 N THIRD STREET LEWISBURG PA 17837 RADIOLOGY TESTS INTREPRETATIONS 946868 QUORUM HEALTH RESOURCES 105 CONTINENTAL PLACE ATTENTION DEPT 9100 BRENTWOOD TN 370271018 MANAGEMENT FEES 723880 EMERGENCY PHYSICIAN ASSOC INC PO BOX 634850 CINCINNATI OH 452634850 ER PHYSICIAN LOCUMS 345671 DELL MARKETING PO BOX 416634 BOSTON MA 022416634 COMPUTER SERVICE 245783 GULFSTREAM ANESTHESIA CONSULTANTS 11440 OKEECHOBEE BLVD SUITE 215 ROYAL PALM BEACH FL 33411 ANESTHESIOLOGIST SERVICES 163770 7 0 0 4625 0 53785 17435 0 75845 PATIENT SERVICE REV 621110 24963411 24319520 643891 0 0 0 0 0 24963411 27655 0 0 27655 0 0 0 0 0 0 0 0 84923 0 59020 0 25903 0 25903 0 0 25903 0 11403 0 0 0 11403 11403 0 0 11403 20583 4625 8039 12544 0 12544 LHU CLINIC REVENUE 900099 342788 342788 0 0 MEANING USE 622000 296774 296774 0 0 CAFETERIA/VENDING REVENUE 722210 88962 0 0 88962 135314 0 0 135314 863838 25980599 24959082 643891 301781 X 294076 255846 38230 0 42547 37016 5531 9466798 8040160 1426638 415453 361444 54009 1546623 1345562 201061 817976 711639 106337 723880 629773 94107 35499 35499 47297 47297 2472 2472 4434294 3236725 1197569 91733 91733 447660 290538 157122 558892 353796 205096 538236 498321 39915 52960 42611 10349 16898 4590 12308 758067 758067 1921282 1921282 393414 393414 BAD DEBT EXPENSE 1683812 1683812 0 0 MEDICAL SUPPLIES 1172188 1172188 0 0 NONCHARGE SUPPLIES 367986 366086 1900 0 CHARGEABLE SUPPLIES 163813 163813 0 0 463148 156976 306172 0 26457004 22517864 3939140 0 1435 1420 1162103 1594442 0 0 2538484 2229325 0 0 0 0 33333 0 200067 252192 193326 152857 37838648 25550221 14191840 12288427 0 0 0 0 0 0 0 0 5427461 4302596 23748049 20821259 3314749 4334478 0 0 0 0 0 0 0 0 0 0 13944273 13682329 0 0 4886835 5309337 22145857 23326144 X 1542765 -2564809 59427 59924 0 0 1602192 -2504885 23748049 20821259 X -476405 0 0 0 0 -3630672 X 0 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2472 2472 0 Schedule C, Part II-B, Line 1 THE HOSPITAL PAYS DUES TO THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE HOSPITAL ASSOCIATION OF PENNSYLVANIA (HAP). A PORTION OF THE DUES PAID TO THESE TWO ORGANIZATIONS ($2472 DURING YEAR ENDED JUNE 30, 2016) WAS USED FOR LOBBYING PURPOSES. 0 154956 154956 0 18195149 8622497 9572652 0 0 0 0 0 18817024 16580438 2236586 0 671519 347286 324233 12288427 DUE TO AFFILIATES 3791692 SETTLEMENTS 185122 INVESTMENT CHART 117478 LIMITED ASSETS 112832 DEFERRED FINANCING NET 95472 4302596 0 ACCRUED PENSION COST 4394513 OBLIGATIONS UNDER CAPITAL 532860 DEFERRED REVENUE 381964 5309337 X 26047658 0 0 0 0 0 26047658 0 -67059 -67059 25980599 26524063 0 0 0 67059 67059 26457004 0 0 0 26457004 Schedule D, Part X, Line 2 THE HOSPITAL ACCOUNTS FOR UNCERTAINTY IN INCOME TAXES USING 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 IS MET. MANAGEMENT DETERMINED THERE WERE NO TAX UNCERTAINTIES THAT MET THE RECOGNITION THRESHOLD IN 2016 AND 2015. THE HOSPITAL'S FEDERAL RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX AND EXEMPT ORGANIZATION BUSINESS TAX RETURN FOR THE YEAR ENDED PRIOR TO JUNE 30, 2014 NO LONGER REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. Schedule D, Part XI, Line 4b RENTAL EXPENSE-(59,020) PLUS FUNDRAISING EXPENSE-(8,039) EQUALS TOTAL SCHEDULED D, PART XI, LINE 4B-(67,059) Schedule D, Part XII, Line 2d RENTAL EXPENSES-59,020 PLUS FUNDRAISING EXPENSE-8,039 TOTAL TO SCHEDULE D, PART XII,LINE 2D-67,059 GOLF TOURNAMENT 25208 4625 20583 195 780 4340 12 0 2712 0 0 25208 4625 20583 195 780 4340 12 0 2712 8039 12544 1 1 X 1 X 1 X 1 0 0 127161 127161 0.0047 3291892 2513768 778124 0.0289 0 0 3419053 2513768 905285 0.0336 82526 19588 102114 0.0039 1780 1780 0.0001 0 0 84306 19588 103894 0.0040 0 0 3503359 2533356 1009179 0.0376 1 635481 0 3803617 3881242 -77625 X 1 1 1 1 JERSEY SHORE HOSPITAL 1020 THOMPSON ST JERSEY SHORE PA 17740 HTTP://WWW.JSH.ORG 101401 X X X X JERSEY SHORE HOSPITAL 1 0 0 1 X X X X X X X X X 16 1 1 0 1 X http://www.jsh.org X 1 16 1 WWW.JSH.ORG 0 0 1 X 200 250 X X X 1 1 X X X 1 X X X 1 0 X X X X 1 X 0 0 Schedule H, Part V, Section B, Line 3a-JERSEY SHORE HOSPITAL JERSEY SHORE HOSPITAL IN CONJUNCTION WITH QUORUM, DEFINES ITS SERVICE ARE AS CLINTON AND LYCOMING COUNTY IN PENNSYLVANIA. IN 2014, THE HOSPITAL RECEIVED 85% OF ITS PATIENTS FROM THIS AREA. Schedule H, Part V, Section B, Line 3b-JERSEY SHORE HOSPITAL DEMOGRAPHICS OF THE COMMUNITY ARE AS FOLLOWS: 2016 POPULATION WAS 155,153. 91,7% WAS WHITE, NON-HISPANIC, 3.9% WAS BLACK, NON-HISPANIC. 40.2 WAS THE MEDIAN AGE, $49,146 IS THE MEDIAN HOUSEHOLD INCOME. UNEMPLOYMENT RATE IS 5.5. 18.2% OF THE POPULATION IS LESS THAN AGE 65 AND 18.8% WERE WOMEN OF CHILDBEARING AGE. Schedule H, Part V, Section B, Line 3c-JERSEY SHORE HOSPITAL FACILITIES AND RESOURCES AVAILABLE TO RESPOND TO THE HEALTH NEEDS OF THE COMMUNITY ARE AS FOLLOWS: SUSQUEHANNA HEALTH, LYCOMING & CLINTON COUNTIES MHID, THE MEADOWS, MOUNT NITTANY HEALTH SYSTEM, GEISINGER HEALTH SYSTEM. OTHER FACILITIES AND ORGANIZATIONS SUCH AS SUSAN G KOMEN FOUNDATION, AMERICAN CANCER SOCIETY (RELAY FOR LIFE). OTHER LOCAL RESOURCES THAT ARE AVAILABLE TO RESPOND ARE SUSQUEHANNA HEALTH SYSTEM, CANCER CARE OF CENTRAL PA, CANCER CENTERS OF AMERICAN, GEISINGER HEALTH SYSTEM, AND MOUNT NITTANY HOSPITAL. Schedule H, Part V, Section B, Line 3d-JERSEY SHORE HOSPITAL MOST DATA USED IN THE ANALYSIS IS AVAILABLE FROM PUBLIC INTERNET SOURCES AND QUORUM PROPRIETARY DATA FROM TRUVEN. ANY CRITICAL DATA NEEDED TO ADDRESS SPECIFIC REGULATIONS OR DEVELOPED BY THE LOCAL EXPERT ADVISOR INDIVIDUALS COOPERATING WITH IS IN THE STUDY AND THEY ARE AS FOLLOWS: WWW.COUNTYHEALTHRANKINGS.ORG-ASSESSMENT OF HEALTH NEEDS OF CLINTON COUNTY AND WESTERN LYCOMING COUNTY COMPARED TO ALL STATE COUNTIES. WWW.COMMUNITYHEALTH.HHS.GOV-ASSESSMENT OF HEALTH NEEDS OF CLINTON COUNTY AND WESTERN LYCOMING COUNTY COMPARED TO ITS NATIONAL SET OF 'PEER COUNTIES'. TRUVEN MARKET (FORMERLY KNOWN AS THOMPSON)-ASSESS CHARACTERISTICS OF THE HOSPITAL'S PRIMARY SERVICE AREA, AT A ZIP CODE LEVEL BASED ON CLASSIFYING THE POPULATION INTO VARIOUS SOCIO-ECONOMIC GROUPS, DETERMINING THE HEALTH AND MEDICAL TENDENCIES OF EACH GROUP AND CREATING AN AGGREGATE COMPOSITION OF THE SERVICE AREA ACCORDING TO THE PROPORTION OF EACH GROUP IN THE ENTIRE AREA; AND, TO ACCESS POPULATION SIZE, TRENDS, AND SOCIO-ECONOMIC CHARACTERISTICS. WWW.CAPC.ORG AND WWW.GETPALLIATIVE.ORG-TO IDENTIFY THE AVAILABILITY OF PALLIATIVE CARE PROGRAMS AND SERVICES IN THE AREA. WWW.CARINGINFO,ORG AND IWEB.NHPCO.ORG-TO IDENTIFY THE AVAILABILITY OF HOSPICE PROGRAMS IN THE COUNTY. WWW,HEALTHMETRICSANDEVALUATION.ORG-TO EXAMINE THE PREVALENCE OF DIABETIC CONDITIONS AND CHANGE IN LIFE EXPECTANCY. Schedule H, Part V, Section B, Line 3e-JERSEY SHORE HOSPITAL WE USED PRIORITY RANKING OF AREA HEALTH NEEDS BY LOCAL EXPERT ADVISORS TO ORGANIZE THE SEARCH FOR LOCALLY AVAILABLE RESOURCES AS WELL AS THE RESPONSE TO THE NEEDS BY JSH. THE FOLLOWING LIST: IDENTIFIES THE RANK OF EACH SIGNIFICANT NEED, PRESENTS THE FACTOR CONSIDERED IN DEVELOPING THE RANKING, ESTABLISHES A PROBLEM STATEMENT TO SPECIFY THE PROBLEM INDICATED BY USE OF THE SIGNIFICANT NEED TERM, IDENTIFIES JSH CURRENT EFFORTS RESPONDING TO THE NEED INCLUDING ANY WRITTEN COMMENTS RECEIVED REGARDING PRIOR JSH IMPLEMENTATION ACTIONS, ESTABLISHES THE IMPLEMENTATION STRATEGY PROGRAMS AND RESOURCES JSH WILL DEVOTE TO ATTEMPT TO ACHIEVE IMPROVEMENTS, DOCUMENTS THE LEADING INDICATORS JSH WILL USE TO MEASURE PROGRESS, PRESENTS THE LAGGING INDICATORS JSH BELIEVES THE LEADING INDICATORS WILL INFLUENCE IN A POSITIVE FASHION, AND PRESENTS THE LOCALLY AVAILABLE RESOURCES NOTED DURING THE DEVELOPMENT OF THIS REPORT AS BELIEVED TO BE CURRENTLY AVAILABLE TO RESPOND TO THIS NEED. Schedule H, Part V, Section B, Line 3f-JERSEY SHORE HOSPITAL INFORMATION ANALYSIS AUGMENTED BY LOCAL OPINIONS SHOWED HOW CLINTON COUNTY AND WESTERN LYCOMING COUNTY RELATE TO PEERS IN TERMS OF PRIMARY AND CHRONIC NEEDS AND OTHER ISSUES OF UNINSURED PERSONS, LOW-INCOME PERSONS AND MINORITY GROUPS, RESPONDENTS COMMENTED ON WHETHER THEY BELIEVE CERTAIN POPULATION GROUPS ("PRIORITY POPULATIONS) NEED HELP TO IMPROVE THEIR CONDITION, AND IF SO, WHO NEEDS TO DO WHAT TO IMPROVE THE CONDITIONS OF THE GROUPS. Schedule H, Part V, Section B, Line 3g-JERSEY SHORE HOSPITAL LOCAL EXPERTS OFFERING SOLICITED WRITTEN COMMENTS ON 2013 PRIORITIES AND IMPLEMENTATION SURVEY. THEY RANKED THE FOLLOWING: PUBLIC HEALTH EXPERTISE, DEPARTMENTS AND AGENCIES WITH RELEVANT DATA/INFORMATION REGARDING HEALTH NEEDS OF THE COMMUNITY SERVED BY THE HOSPITAL, PRIORITY POPULATIONS, REPRESENTATIVE/MEMBER OF CHRONIC DISEASE GROUP OR ORGANIZATION, AND REPRESENTS THE BOARD INTEREST OF THE COMMUNITY. Schedule H, Part V, Section B, Line 3h-JERSEY SHORE HOSPITAL THE FINAL REGULATIONS PROVIDE THAT CHNA (COMMUNITY HEALTH NEEDS ASSESSMENT) REPORT DOES NOT NEED TO NAME OR OTHERWISE IDENTIFY ANY SPECIFIC INDIVIDUAL PROVIDING INPUT ON THE CHNA, WHICH WOULD INCLUDE PROVIDED BY INDIVIDUALS IN THE FORM OF WRITTEN COMMENTS. THE "LOCAL EXPERT" IS AN ADVISORY GROUP OF AT LEAST 15 LOCAL RESIDENTS, INCLUSIVE OF AT LEAST ONE MEMBER SELF-IDENTIFYING WITH OF THE THE FIVE QHR WRITTEN COMMENTS SOLICITATION CLASSIFICATIONS, WITH WHOM THE HOSPITAL SOLICITED TO PARTICIPATE IN QHR/HOSPITAL CHNA PROCESS, Schedule H, Part V, Section B, Line 3i-JERSEY SHORE HOSPITAL QUORUM ALSO TAKES A COMPREHENSIVE APPROACH TO ASSESS HEALTH NEEDS. WE PREFORM SEVERAL INDEPENDENT DATA INCONSISTENCY OR DISCREPANCIES BY REVIEWING THE COMBINES OPTIONS FORMED FROM LOCAL EXPERTS. WE RELY ON SECONDARY SOURCE DATA, AND MOST SECONDARY SOURCE USE THE COUNTY AS THE SMALLEST UNIT ANALYSIS. WE ASKED OUR LOCAL EXPERT ARE RESIDENTS TO NOTE IF THEY PERCEIVED THE PROBLEMS OR NEEDS IDENTIFIED BY SECONDARY SOURCES EXISTED IN THEIR PROPORTION OF THE COUNTY. WHEN THE ANALYSIS WAS COMPLETE, WE PUT THE INFORMATION AND SUMMARY CONCLUSION BEFORE OUR LOCAL EXPERT AD VISOR WHO WERE ASKED TO AGREE OR DISAGREE WITH THE SUMMARY CONCLUSION, THEY WERE FREE TO AUGMENT POTENTIAL CONCLUSIONS WITH ADDITIONAL COMMENTS OF NEED AND NEW NEEDS DID EMERGE FROM THIS EXCHANGE. Schedule H, Part V, Section B, Line 5-JERSEY SHORE HOSPITAL HAVING TAKEN THE STEPS TO IDENTIFY POTENTIAL COMMUNITY NEEDS, THE LOCAL EXPERTS THAN PARTICIPATED IN A STRUCTURED COMMUNICATION TECHNIQUE CALLED 'WISDOM CROWDS' METHOD. THE PREMISE OF THIS APPROACH RELIES ON A PANEL OF EXPERTS WITH THE ASSUMPTION THAT THE COLLECTIVE WISDOM OF PARTICIPANTS IS SUPERIOR TO THE OPINION OF ANY ONE INDIVIDUAL, REGARDLESS OF THEIR PROFESSIONAL CREDENTIALS. HOSPITAL SOLICITED WRITTEN COMMENTS ABOUT ITS 2012 CHNA. 16 INDIVIDUALS RESPONDED TO THE REQUEST FOR COMMENTS. Schedule H, Part V, Section B, Line 6a-JERSEY SHORE HOSPITAL JSH PARTNERED WITH QUORUMS HEALTH RESOURCES Schedule H, Part V, Section B, Line 8a-JERSEY SHORE HOSPITAL SIGNIFICANT NEEDS WHERE HOSPITAL HAS IMPLEMENTATION RESPONSIBILITY ARE CANCER, OBESITY/OVERWEIGHT HEART DISEASE, AND EDUCATION/PREVENTION. SIGNIFICANT NEEDS WHERE HOSPITAL DID NOT IMPLEMENTATION STRATEGY WAS MENTAL HEALTH/SUBSTANCE ABUSE. Schedule H, Part V, Section B, Line 11-JERSEY SHORE HOSPITAL OTHER LOCAL RESOURCES IDENTIFIED DURING CHNA PROCESS THAT ARE BELIEVE AVAILABLE TO RESPOND TO THIS NEED ARE SUSQUEHANNA HEALTH, LYCOMING & CLINTON COUNTIES MHID SERVICES, THE MEADOWS, MOUNT NITTANY HEALTH SYSTEM, AND GEISINGER HEALTH SYSTEM. Schedule H, Part V, Section B, Line 16i-JERSEY SHORE HOSPITAL JERSEY SHORE HOSPITAL-POLICY REFERENCED ON INVOICES AND VERBALLY DISCUSSED WITH PATIENTS. Schedule H, Part V, Section B, Line 22d-JERSEY SHORE HOSPITAL JERSEY SHORE HOSPITAL-AS SOON AS THE PATIENT IS DEEMED ELIGIBLE FOR FINANCIAL ASSISTANCE, THE HOSPITAL RECORDS THE DISCOUNT AND BILLS THE PATIENT THE AMOUNT THAT THEY ARE RESPONSIBLE FOR UNDER THEIR FAP POLICY. THE DISCOUNT CHARGED IS IN LINE WITH THE COMMERCIAL PAYOR RATE. Schedule H, Part I, Line 7 THE HOSPITAL USED THE COST TO CHARGE RATIO Schedule H, Part I, Line 7, Column f AMOUNT OF BAD DEBT FROM PART IX SUBSTRACTED IN ORDER TO CALCULATE PERCENT OF TOTAL EXPENSE IN PART I LINE 7 COLUMN F WAS $ Schedule H, Part III, Section A, Line 4 BAD DEBT EXPENSE IS CALCULATED BASED ON ACTUAL WRITE-OFFS THROUGHOUT THE YEAR AND IS ESTIMATED AT COST USING THE RATIO OF PATIENT CARE COST TO CHARGE. PATIENT ACCOUNTS RECEIVABLE ARE REPORTED AT NET REALIZABLE VALUE. ACCOUNTS ARE WRITTEN OFF WHEN THEY ARE DETERMINED TO BE UNCOLLECTIBLE BASED UPON MANAGEMENT'S ASSESSMENT OF INDIVIDUAL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF PATIENT ACCOUNTS RECEIVABLE. THE CORPORATION ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE. THE CORPORATION ANALYZES CONTRACTUAL AMOUNTS DUE AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS. THE CORPORATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCES, WHICH INDICATED THAT MANY PATIENTS ARE UNABLE TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE BILLED RATES AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. BAD DEBT EXPENSE IS BASED ON THE NECESSARY ALLOWANCE AT THE END OF EACH MONTH. PATIENT DISCOUNTS ARE NOT INCLUDED IN THE ALLOWANCE FOR BAD DEBT. THE HOSPITAL IS DILIGENT IN THE CLASSIFICATION OF AMOUNTS AS CHARITY CARE OF BAD DEBT. WE BELIEVE NONE OF THE AMOUNTS IN BAD DEBT WOULD BE RECLASSIFIED TO CHARITY CARE GIVE ADDITIONAL INFORMATION. Schedule H, Part III, Section B, Line 8 THERE IS NO MEDICARE SHORTFALL-AS A CRITICAL ACCESS HOSPITAL, WE ARE REIMBURSED AT 101% OF COST FROM MEDICARE. ALLOWANCE COSTS WERE DETERMINED USING THE COST-TO-CHARGE RATIO FROM MEDICARE COST REPORT. Schedule H, Part III, Section C, Line 9b COLLECTIONS ARE PURSUED UP TO THE POINT THAT A PATIENT COMPLETES AND IS APPROVED FOR CHARITY CARE. ONCE CHARITY CARE IS APPROVED, NO FURTHER COLLECTION EFFORTS ARE MADE. Schedule H, Part VI, Line 2 JERSEY SHORE HOSPITAL (JSH) HAS PERFORMED A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) TO DETERMINE THE HEALTH NEEDS OF THE LOCAL COMMUNITY, DEVELOP AN IMPLEMENTATION PLAN TO OUTLINE AND ORGANIZE HOW TO MEET THOSE NEEDS AND FULFILL FEDERAL REQUIREMENTS. DATA WERE GATHERED FROM MULTIPLE WELL-RESPECTED SECONDARY SOURCES TO BUILD AN ACCURATE PICTURE OF THE CURRENT COMMUNITY AND HEALTH NEEDS. A SURVEY OF A SELECT GROUP OF LOCAL EXPERTS WAS PERFORMED TO REVIEW THE PRIOR CHNA AND PROVIDE FEEDBACK, AND TO ASCERTAIN WHETHER THE PREVIOUSLY IDENTIFIED NEEDS ARE STILL PRIORITY, A SECOND SURVEY WAS DISTRIBUTED TO THE DAME GROUP THAT REVIEWED THE DATA GATHERED FROM THE SECONDARY SOURCES AND DETERMINED THE SIGNIFICANT NEEDS FOR THE COMMUNITY. THE SIGNIFICANT HEALTH NEEDS FOR CLINTON COUNTY AND LYCOMING COUNTY ARE MENTAL HEALTH/SUBSTANCE ABUSE, CANCER, OBESITY/OVERWEIGHT, HEART DISEASE, EDUCATION/PREVENTION. THE HOSPITAL HAS DEVELOPED IMPLEMENTATION STRATEGIES FOR FOUR OF THE FIVE NEEDS INCLUDING CANCER, OBESITY/OVERWEIGHT, HEART DISEASE, AND EDUCATION/PREVENTION/ THE STRATEGIES INCLUDE ACTIVITIES TO CONTINUE/PURSUE, COMMUNITY PARTNERS TO WORK ALONGSIDE, AND LEADING AND LAGGING INDICATORS TO TRACK. THE HOSPITAL IS NOT PLANNING TO ADDRESS MENTAL HEALTH/SUBSTANCE ABUSE AT THIS TIME DUE TO RESOURCE CONSTRAINTS, RELATIVE LACK OF EXPERTISE/COMPETENCY TO EFFECTIVELY ADDRESS THE NEED, AND THE AVAILABILITY OF OTHER RESOURCES TO ADDRESS THE NEED. IT IS BELIEVED THAT THE COMMUNITY WILL SEE MORE BENEFIT IF TIME AND RESOURCES ARE DEVOTED TO THE OTHER FOUR NEEDS. Schedule H, Part VI, Line 3 PATIENTS ARE COUNSELED ON AN INDIVIDUAL BASIS IN PERSON OR PHONE CONVERSATION AS TO THE AVAILABILITY OF STATE OR CORPORATE PROGRAMS. AT THE TIME OF REGISTRATION SELF-PAY PATIENTS ARE INFORMED OF ASSISTANCE AVAILABLE. PATIENTS STATEMENTS INDICATE ASSISTANCE THAT IS AVAILABLE. THERE IS ALSO SIGNAGE INDICATING THAT ASSISTANCE PROGRAMS ARE AVAILABLE AND PATIENTS ARE PROVIDED A PAMPHLET AT REGISTRATION WITH THIS INFORMATION. PATIENTS ARE INFORMED OR WHAT CHARITY CARE IS AND THAT IS EXISTS. IF THE PATIENT IS INTERESTED THE PROCESS IS EXPLAINED. Schedule H, Part VI, Line 4 JERSEY SHORE HOSPITAL'S PRIMARY SERVICE AREA (PSA) COVERS EASTERN CLINTON COUNTY AND WESTERN LYCOMING COUNTY-AN AREA WITH POPULATION OF APPROXIMATELY 42,000. THE PSA FOR JERSEY SHORE HOSPITAL CONSISTS OF FIVE ZIP CODES: 17721-AVIS, 17740-JERSEY SHORE, 17745-LOCK HAVEN, 17779-WOOLRICH, AND 17751-MILL HALL. JERSEY SHORE HOSPITAL IS CONSIDERED TO BE MEDICALLY UNDERSERVED AREA (MUA). JERSEY SHORE AND JERSEY SHORE HOSPITAL IS LOCATED IN LYCOMING COUNTY, WHICH HAS AN AREA OF 1,244 SQUARE MILES. IT IS THE LARGEST COUNTY IN PENNSYLVANIA AND OCCUPIES A HILLY AND HEAVILY FORESTED PART OF THE STATE. THE WEST BRANCH OF THE SUSQUEHANNA RIVER FLOWS THROUGH THE SOUTHERN PART OF THE COUNTY. JERSEY SHORE IS APPROXIMATELY 45 MILES NORTHEAST OF STATE COLLEGE, PENNSYLVANIA AND APPROXIMATELY 15 MILES WEST OF WILLIAMSPORT, PENNSYLVANIA. ABOUT SIXTEEN PERCENT (16%) OF INPATIENT STAYS IN THE PSA OCCUR AT JERSEY SHORE HOSPITAL. ABOUT FORTY PERCENT (40%) OF OUTPATIENT VISITS IN THE PSA OCCUR AT JERSEY SHORE HOSPITAL. JERSEY SHORE HOSPITAL RELIES UPON A RELATIVELY SMALL GEOGRAPHIC AREA TO SUPPORT THE HOSPITAL. THE SSA (SECONDARY SERVICE AREA) CONSISTS OF 20 ADDITIONAL ZIP CODES WHICH ARE IMPORTANT TO THE HOSPITAL. THESE ZIP CODES ARE PRIMARY TO THE WEST AND NORTH OF THE PSA. ABOUT TWO PERCENT (2%) OF INPAITENT STAYS IN THE SSA OCCUR AT JERSEY SHORE HOSITPAL. ABOUT ELEVEN (11%) PERCENT OF OUTPATIENT VISITS IN THE SSA OCCUR AT JERSEY SHORE HOSPITAL. WITHIN THE PSA, THE TOTAL POPULATION IS EXPECTED TO INCREASE BY 1% BY 2019. A MAJOR DEMOGRAPHIC ISSUE AFFECTING JERSEY SHORE HOSPITAL IS THE AGING POPULATION. THE NUMBER OF INDIVIDUALS LIVING IN THE PSA OVER THE AGE OF 65 IS EXPECTED TO INCREASE 13.7% BY 2019. THIS AGE GROUP CURRENTLY MAKE UP OVER 16% OF THE POPULATION IN THE PSA COMPARED TO ABOUT 14% FOR THE U.S. THIS GROWING ELDERLY SEGMENT SHOULD GENERATE A FUTURE DEMAND FOR HEALTH CARE SERVICES. SINCE INDIVIDUALS OVER AGE 65 USE HEALTHCARE AND HOSPITAL SERVICES 2.7 TIMES THE RATE OF THE UNDER AGE 65 POPULATION. A DEMOGRAPHIC REALITY IS THE LOW INCOME LEVEL OF AREA HOUSEHOLDS. CURRENTLY, THE MEDIAN HOUSEHOLD INCOME IN THE PSA IS $47,303 COMPARED TOE PA ($53,115) AND THE U.S. ($53,482). THE MEDIAN HOUSEHOLD INCOME IN THE SSA IS $41,085. THE SERVICE AREA IS NOT RACIALLY DIVERSIFIED TO A SIGNIFICANT DEGREE, WITH 98.6% OF THE POPULATION CONSIDERED WHITE. THE EDUCATIONAL PROFILE OF THE SERVICE AREA DEMONSTRATES THAT 40.8% OF THE POPULATION HAS A HIGH SCHOOL EDUCATION AND 9.4% OF THE POPULATION HAS AN ASSOCIATE DEGREE. THE PERCENTAGE ACHIEVING A BACHELOR OR PROFESSIONAL DEGREE IS 11.6% WHICH IS LESS THAN PENNSYLVANIA OR THE U.S. AS A WHOLE. A HIGHER PERCENTAGE OF THE LABOR FORCE IN THE AREA IS ENGAGED IN MANUFACTURING/CONSTRUCTION WHEN COMPARED TO THE STATE AND U.S. AS A WHOLE IN TERMS OF PATIENTS SERVED. COMBINED INPATIENT AND OUTPATIENT PAYER MIX IN 2014 REMAINED FAIRLY CONSISTENT/ MEDICARE AND MEDICARE ADVANTAGE MAKE UP ABOUT 44% OF OUR PAYERS IN TERMS OF GROSS CHARGES. MEDICAL ASSISTANCE BUSINESS CONTINUED TO HAVE A SIGNIFICANT IMPACT ON JERSEY SHORE HOSPITAL. AS A CRITICAL ACCESS HOSPITAL. MEDICAL ASSISTANCE CHARGES ACCOUNT FOR ABOUT 11% OF OUR PAYERS. SELF-PAY CHARGES ACCOUNTED FOR ABOUT 4% OF OUR PAYERS. Schedule H, Part VI, Line 5 ALL OF THE PERSONS SERVING ON OUR BOARD LIVE IN THE PRIMARY COMMUNITIES BEING SERVED BY THE HOSPITAL. THE BOARD CONSISTS OF SOME PHYSICIANS WHO ARE EMPLOYEES OF A RELATED ENTITY, A FEW CONTRACTORS, AND SEVERAL OTHER COMMUNITY MEMBERS. THE HOSPITAL EXTENDS STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE AREA. AS APPLICABLE, THE HOSPITAL APPLIES SURPLUS FUNDS TO IMPROVEMENTS IN PATIENT CARE THROUGH NEW AND UPDATED EQUIPMENT, MAJOR FACILITY IMPROVEMENTS, AND COMMUNITY HEALTH PROGRAMS. THE HOSPITAL PARTICIPATES IN MEDICARE, MEDICAID, CHAMPUS, AND TRICARE. Schedule H, Part VI, Line 6 THE HOSPITAL IS PART OF JERSEY SHORE HOSPITAL FOUNDATION, INC. THIS AFFILIATION INCLUDES A NON-PROFIT PHYSICIAN PRACTICE WITH FAMILY PRACTICE PHYSICIANS AND SURGEONS, AS WELL AS AN URGENT CARE CENTER. Schedule H, Part VI, Line 7 PA X X X 0 0 0 0 0 0 0 0 0 THEORDORE FEDEROFF PHYSICIAN 298133 0 0 0 0 0 0 2856 0 19635 298133 22491 0 0 SHAIRKO MISSOURI ANESTHESOLOGIST 289378 0 0 0 0 636 0 11684 0 4473 289378 16793 0 0 MICHAEL GERST PHYSICIAN 176452 0 0 0 0 46101 0 5922 0 7736 176452 59759 0 0 TAMAR BAITEL PHYSICIAN 174900 0 0 0 0 29310 0 3201 0 7618 174900 40129 0 0 DANIEL STAIRS CRNA 174900 0 0 0 0 0 0 3918 0 9919 174900 13837 0 0 STEPHEN GOYKOVICH DO MEDICAL STAFF PRESIDENT 159912 0 0 0 0 0 0 5220 0 82 159912 5302 0 0 James Ely Board Member and brother 42547 James Ely is a board member 0 Form 990, Part VI, Section A, Line 3 THE HOSPITAL UTILIZES THE MANAGEMENT SERVICES OF QUORUM HEALTH RESOURCES. Form 990, Part VI, Section B, Line 11b THE FORM 990 WAS REVIEWED IN DETAIL BY MANAGEMENT BEFORE FILING WITH THE IRS. A COPY OF THE 990 WAS PROVIDED TO ALL BOARD MEMBERS PRIOR TO ISSUANCE. Form 990, Part VI, Section B, Line 12c ALL BOARD MEMBERS AND EMPLOYEES ARE REQUIRED TO ANNUALLY COMPLETE A CONFLICT OF INTEREST STATEMENT. THE CEOS OFFICE MONITORS THE PROCESS AND COMPLETION OF THE STATEMENTS. THE COMPLETED STATEMENTS ARE REVIEWED BY MANAGEMENT. BOARD MEMBERS ARE REQUIRED TO RECUSE THEMSELVES FROM VOTING ON MATTERS THAT ARE RELATED TO ANY POTENTIAL CONFLICTS. THESE HAS NEVER BEEN AM ISSUE INVOLVING CONFLICTS OF INTEREST. Form 990, Part VI, Section B, Line 15 ON AN ANNUAL BASIS, THE PERSONNEL SALARY COMMITTEE AND QUORUM (MANAGEMENT COMPANY) REVIEWS AN EXECUTIVE COMPENSATION STUDY PERFORMED BY YAFFE, AN INDEPENDENT THIRD PARTY WHO IS EMPLOYED BY HOSPITAL ASSOCIATION OF PENNSYLVANIA TO CONDUCT A COMPENSATION STUDY. HUMAN RESOURCES ALSO PROVIDES A COMPENSATION STUDY FROM ACRS WHICH IS BASED ON THE APPALACHIAN REGION. THESE TWO STUDIES ARE USED TO DETERMINE FMV. THE RECOMMENDATIONS FOR COMPENSATION LEVELS ARE PASSED ON TO THE BOARD FOR THEIR APPROVAL. APPROVAL IS DOCUMENTED IN THE MINUTES. THE ACTUAL AMOUNT OF COMPENSATION IS NOT INCLUDED IN THE MINUTES FOR PRIVACY PURPOSED. Form 990, Part VI, Section C, Line 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. Form 990, Part VII, Section A, Line 1a THE PRESIDENT/CEO IS AN EMPLOYEE OF QUORUM (MANAGEMENT COMPANY). THE HOSPITAL PAYS QUORUM FOR THE PRESIDENT/CEO'S SALARY. FOR FISCAL YEAR 2016 HIS COMPENSATION WAS $233,625. Form 990, Part IX, Line 11g LAUNDRY-PROGRAM SERVICE EXPENSES: 80,395 MANAGEMENT AND GENERAL EXPENSES: 0 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 80,395, OTHER-PROGRAM SERVICE EXPENSES: 25,318 MANAGEMENT AND GENERAL EXPENSES: 531,689 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 555,007, CONTRACT SERVICES-PROGRAM SERVICE EXPENSES: 343,712 MANAGEMENT AND GENERAL EXPENSES: 447,183 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 790,895, MEDICAL-PROGRAM SERVICE EXPENSES: 79,928 MANAGEMENT AND GENERAL EXPENSES: 0 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 79,928, MEDICAL LAB-PROGRAM SERVICE EXPENSES: 206,267 MANAGEMENT AND GENERAL EXPENSES: 0 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 206,267, TRANSPORTATION-PROGRAM SERVICE EXPENSES: 2,908 MANAGEMENT AND GENERAL EXPENSES: 0 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 2,908, COLLECTIONS-PROGRAM SERVICE EXPENSES: 44,299 MANAGEMENT AND GENERAL EXPENSES: 0 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 44,299, CONSULTING-PROGRAM SERVICE EXPENSES: 99,400 MANAGEMENT AND GENERAL EXPENSES: 2,945 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 102,345,BIOHAZARDOUS MATERIALS-PROGRAM SERVICE EXPENSES: 30,632 MANAGEMENT AND GENERAL EXPENSES: 0 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 30,632, MAINTENANCE AND REPAIRS-PROGRAM SERVICE EXPENSES: 434,670 MANAGEMENT AND GENERAL EXPENSES: 215,751 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 650,421, PROFESSIONAL FEES-PROGRAM SERVICE EXPENSES: 1,889,195 MANAGEMENT AND GENERAL EXPENSES: 0 FUNDRAISING EXPENSES: 0 TOTAL EXPENSES: 1,889,195, TOTAL OTHER FEES: 4,434,294 Form 990, Part XI, Line 9 TRANSFER TO OTHER ORGANIZATION JERSEY SHORE HOSPITAL FOUNDATION INC 1020 THOMPSON ST JERSEY SHORE PA 17740 240792115 HEALTHCARE PA 501(C)(3) 3 JERSEY SHORE HOSPITAL 1 1 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 JERSEY SHORE HOSPITAL FOUNDATION INC e 3791692 CASH