2015-05-14T07:06:05-05:00 2014-06-30 390859910 BAKER TILLY VIRCHOW KRAUSE LLP 1650 MARKET STREET SUITE 4500 PHILADELPHIA PA 19103 990 2013-07-01 240792115 JERSEY SHORE HOSPITAL JERS 5703980100 1020 THOMPSON STREET JERSEY SHORE PA 17740 DAVID A SHANNON PRESIDENT & CEO 5703980100 2015-05-13 1 JULIUS C GREEN CPA JD P00350393 2159720701 2013 2016-02-25 16:41:14Z DAVID A SHANNON 1020 THOMPSON ST JERSEY SHORE PA 17740 28315541 0 X WWW.JSH.ORG X 1922 PA PROVIDE INPATIENT, OUTPATIENT, AND EMERGENCY CARE SERVICES FOR RESIDENTS OF JERSEY SHORE AREA. 11 8 324 8 602147 0 241789 226863 30018665 27263577 5589 43060 1803734 737350 32069777 28270850 0 0 0 0 14878300 14017818 0 0 0 16251815 16359582 31130115 30377400 939662 -2106550 28890899 25663302 22690697 21359776 6200202 4303526 X JERSEY SHORE HOSPITAL IS A RURAL HEALTHCARE FACILITY COMMITTED TO PROVIDING QUALITY HEALTH SERVICES WITH AN EFFICIENT BALANCE OF OUTPATIENT CARE, ACUTE AND SUB-ACUTE INPATIENT CARE AND OUTREACH SERVICES. THE HOSPITAL MAXIMIZES THE EFFECTIVENESS OF ITS PROGRAM THROUGH INTEGRATION WITH OTHER HEALTHCARE PROVIDERS TO ASSURE THE COMMUNITY ACCESS TO A BROAD ARRAY OF HEALTH CARE SERVICES. 0 0 26324687 27499242 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 FOR COMPREHENSIVE, MANAGED HEALTH PROGRAMS IN 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 $609,740 DURING THE YEAR ENDED JUNE 30, 2014. 26324687 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 36 0 1 324 1 1 1 0 0 0 0 1 1 0 0 0 0 X 11 8 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 5703983101 1020 THOMPSON STREET JERSEY SHORE PA 17740 X CAREY PLUMMER NONVOTING PRESIDENT & CEO (END 5.1.14) 39.00 1.00 X X 0 0 0 LEROY H KEILER III SECRETARY 1.00 1.00 X X 0 0 0 WILLIAM R CAMERER III MEMBER 1.00 X 0 0 0 CARMEN SPINNEY MD MEMBER 1.00 39.00 X 0 101796 11371 JAMES REESER MEMBER 1.00 X 0 0 0 RICHARD BEATTY DMD CHAIRPERSON 1.00 1.00 X X 0 0 0 WALTER EISENHAUER MEMBER 1.00 X 0 0 0 JAMES ELY TREASURER 1.00 1.00 X X 0 0 0 SEAN SIMCOX VICE CHAIRPERSON 1.00 X X 0 0 0 THOMAS C CONNOLLY MD MEDICAL STAFF PRESIDENT 1.00 39.00 X 0 456290 31124 CRAIG HARRIS MEMBER 1.00 X 0 0 0 STEPHEN P NEUN PHD MEMBER 1.00 X 0 0 0 DAVID A SHANNON NONVOTING PRESIDENT & CEO (BEGIN 5.1.14) 39.00 1.00 X X 0 0 0 LISA STRAWSER DO MEMBER (END 12/2013) 1.00 X 0 0 0 MARK RICE CFO 39.00 1.00 X 95684 0 23281 AARON KOLB MD PHYSICIAN 40.00 X 321383 0 27400 RONALD EISTER PHYSICIAN 40.00 X 242303 0 23110 SHAIRKO MISSOURI ANESTHESIOLOGIST 40.00 X 445625 0 20098 TAMAR BAITEL PHYSICIAN 40.00 X 300353 0 6903 RICHARD CORNISH PHYSICIAN 40.00 X 258213 0 15978 1663561 558086 159265 7 0 1 0 JERSEY SHORE RADIOLOGY 222 DEER TRAIL ROAD SPRING GROVE PA 17362 RADIOLOGY TESTS INTREPRETATIONS 1160469 MEDICAL STAFFING NETWORK PO BOX 202996 DALLAS TX 753202996 ER PHYSICIAN LOCUMS 655570 QUORUM HEALTH RESOURCES 105 CONTINENTAL PLACE BRENTWOOD TN 370271018 MANAGEMENT FEES 296135 LOCUM-TENENSCOM PO BOX 405547 ATLANTA GA 30384 ER PHYSICIAN LOCUMS 237529 SUSQUEHANNA HEALTH SYSTEM 1205 GRAMPIAN BOULEVARD WILLIAMSPORT PA 17701 IT SUPPORT/LAB TEST INTERPRETATION 174354 8 4000 197522 25341 226863 PATIENT SERVICE REV 621110 27263577 26661430 602147 27263577 43060 43060 84256 35654 48602 48602 48602 18191 4000 9037 9154 9154 LHU CLNIC REVENUE 900099 279369 279369 MEANINGFUL USE 622000 235665 235665 CAFETERIA/VENDING REV 722210 106440 106440 58120 58120 679594 28270850 27176464 602147 265376 X 461777 401297 60480 31200 27114 4086 10591831 9204599 1387232 491528 427152 64376 1570182 1364532 205650 871300 757184 114116 596040 517975 78065 83508 83508 68377 68377 2970 2970 4957792 3805110 1152682 46916 46916 470962 266683 204279 544470 355636 188834 568969 525807 43162 64254 54258 9996 24757 7597 17160 827755 827755 2365496 2365496 421252 421252 BAD DEBT EXPENSE 2802969 2802969 MEDICAL SUPPLIES 1013311 1013311 CHARGEABLE SUPPLIES 510487 510487 NONCHARGE SUPPLIES 463965 453393 10572 525332 165194 360138 30377400 26324687 4052713 0 1200 1435 1161073 1288441 11068 6029 3446820 2887474 50000 243070 239137 201690 176371 37719281 21918774 17489053 15800507 6336925 5213908 28890899 25663302 2863811 2947572 14761344 13889676 5065542 4522528 22690697 21359776 X 6056609 4244099 143593 59427 6200202 4303526 28890899 25663302 X -2106550 209874 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2970 2970 0 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 ($2,970 DURING THE YEAR ENDED JUNE 30, 2014) WAS USED FOR LOBBYING PURPOSES. 154956 154956 18170788 7159633 11011155 18685153 14458552 4226601 708384 300589 407795 15800507 DEFERRED FINANCING COSTS, NET 106080 DUE FROM AFFILIATES 4739455 FUNDED DEPRECIATION 234187 OTHER ASSET 134186 5213908 OBLIGATIONS UNDER CAPITAL LEASES 1335625 BLUE CROSS CURRENT FINANCING ADVANCE 79353 ACCRUED PENSION COST 2010204 DEFERRED REVENUE 824826 ESTIMATED THRID-PARTY PAYOR SETTLEMENTS 272520 4522528 X 28525415 209874 209874 28315541 -44691 -44691 28270850 30422091 44691 44691 30377400 0 30377400 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 2014 AND 2013. THE HOSPITAL'S FEDERAL RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX AND EXEMPT ORGANIZATION BUSINESS TAX RETURN FOR THE YEARS ENDED PRIOR TO JUNE 30, 2012 NO LONGER REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN FAIR VALUE OF DERIVATIVE INSTRUMENT 179,803. PENSION LIABILITY ADJUSTMENT 30,071. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSE -35,654. FUNDRAISING EXPENSE -9,037. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 35,654. FUNDRAISING EXPENSE 9,037. GOLF TOURNAMENT 22191 4000 18191 320 1200 4990 656 1871 22191 4000 18191 320 1200 4990 656 1871 9037 9154 1 1 X 1 X 1 X 1 0 0 234422 234422 0.00850 2326996 2134542 192454 0.00700 2561418 2134542 426876 0.01550 253476 20196 233280 0.00850 2800 2800 0.00010 256276 20196 236080 0.00860 2817694 2154738 662956 0.02410 1 1120609 0 4305825 4393699 -87874 X 1 1 1 1 JERSEY SHORE HOSPITAL 1020 THOMPSON STREET JERSEY SHORE PA 17740 HTTP://WWW.JSH.ORG 101401 X X X X JERSEY SHORE HOSPITAL 1 1 X X X X X X X X 12 1 0 1 X HTTP://WWW.JSH.ORG/CHNA-JSH-2012.PDF X X X 0 0 1 1 200.000000000000 1 250.000000000000 1 X X X 1 1 X X X 1 0 X X X X 1 X 0 0 JERSEY SHORE HOSPITAL PART V, SECTION B, LINE 3: TWO FOCUS GROUPS WITH COMMUNITY LEADERS AND STAKEHOLDERS WERE HELD ON AUGUST 15, 2012 AT JERSEY SHORE HOSPITAL. THE PURPOSE OF THE FOCUS GROUPS WAS TO GATHER QUALITATIVE DATA FROM "KEY INFORMANTS" ON LOCAL HEALTH ISSUES. KEY INFORMANTS WERE DEFINED AS AREA HEALTH CARE PROFESSIONALS, SOCIAL SERVICE PROVIDERS, NON-PROFIT LEADERS, BUSINESS LEADERS, FAITH-BASED ORGANIZATIONS AND OTHER AREA AUTHORITIES. EACH SESSION LASTED APPROXIMATELY TWO HOURS. A DISCUSSION GUIDE WAS USED TO PROMPT DISCUSSION AND GUIDE THE FACILITATION. THE GUIDE FOCUSED ON GATHERING QUALITATIVE FEEDBACK REGARDING PERCEPTIONS OF COMMUNITY NEEDS ACCROSS THREE KEY DOMAINS: HEALTH CARE ACCESS, KEY HEALTH ISSUES, AND COMMUNITY ASPIRATIONS & CAPACITY. IN TOTAL, 18 PEOPLE PARTICIPATED IN THE FOCUS GROUPS, REPRESENTING A VARIETY OF SECTORS INCLUDING PUBLIC HEALTH AND MEDICAL SERVICES, NON-PROFIT AND SOCIAL ORGANIZATIONS, CHILDREN AND YOUTH AGENCIES, AND THE BUSINESS COMMUNITY. JERSEY SHORE HOSPITAL PART V, SECTION B, LINE 7: THE COMMUNITY HEALTH NEEDS ASSESSMENT IDENTIFIED 8 OVERALL NEEDS WITHIN THE COMMUNITY. THESE NEEDS IDENTIFIED ARE AS FOLLOWS: ACCESS TO CARE, MENTAL/BEHAVOIRAL HEALTH/SUBSTANCE ABUSE, OVERWIEGHT & OBESITY, RESPIRATORY DISEASE/ASTHMA, DIABETES, HEART DISEASE, LYME DISEASE, AND MATERNAL/INFANT HEALTH. THE TOP FOUR PRIORITIES THAT ARE BEING ADDRESSED ARE: ACCESS TO CARE, MENTAL & BEHAVIORAL HEALTH, OVERWEIGHT & OBESITY, AND RESPIRATORY DISEASE/ASTHMA. BEING OVERWEIGHT OR OBESE HAS AN EFFECT ON DIABETES AND HEART DISEASE, THEREFORE, IT WAS DECIDED TO INCLUDE DIABETES AND HEART DISEASE AS SUBSETS OF THE OVERWEIGHT AND OBESITY PRIORITY. THEREFORE THE ONLY TWO NEEDS IDENTIFIED THAT ARE NOT CURRENTLY BEING ADDRESSED ARE LYME DISEASE AND MATERNAL/INFANT HEALTH. THESE NEEDS WILL BE CONSIDERED AS FUTURE PROJECTS. JERSEY SHORE HOSPITAL PART V, SECTION B, LINE 14G: POLICY WAS REFERENCED ON INVOICES AND VERBALLY DISCUSSED WITH PATIENTS. JERSEY SHORE HOSPITAL PART V, SECTION B, LINE 20D: AS SOON AS THE PATIENT IS DEEMED ELIGIBLE FOR FINANCIAL ASSISTANCE, THE HOSPITAL RECORDS THE DISCOUNT AND BILLS THE PAITENT THE AMOUNT THAT THEY ARE RESPONSIBLE FOR UNDER THEIR FAP POLICY. THE DISCOUNT CHARGED IS IN LINE WITH THE COMMERCIAL PAYOR RATE. PART I, LINE 7: THE HOSPITAL USED THE COST TO CHARGE RATIO. PART I, LN 7 COL(F): AMOUNT OF BAD DEBT EXPENSE FROM PART IX SUBTRACTED IN ORDER TO CALCULATE PERCENT OF TOTAL EXPENSE IN PART I LINE 7 COLUMN F WAS $2,802,969. PART III, LINE 2: 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 CHARGES. PART III, LINE 4: 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 EXPERIENCE, WHICH INDICATES 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 BAD DEBT - THEY ARE INCLUDED IN CONTRACTUAL ADJUSTMENTS. PAYMENTS ON PATIENT ACCOUNTS ARE INCLUDED IN THE ALLOWANCE FOR BAD DEBTS.THE HOSPITAL IS DILIGENT IN THE CLASSIFICATION OF AMOUNTS AS CHARITY CARE OR BAD DEBT. WE BELIEVE NONE OF THE AMOUNTS IN BAD DEBT WOULD BE RECLASSIFIED TO CHARITY CARE GIVEN ADDITIONAL INFORMATION. PART III, LINE 8: THE MEDICARE SHORTFALL NOTED IS NOT CONSIDERED A COMMUNITY BENEFIT BECAUSE IT IS DUE TO SEQUESTRATION.ALLOWABLE COSTS WERE DETERMINED USING THE COST-TO-CHARGE RATIO FROM MEDICARE COST REPORT. PART III, 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. PART VI, LINE 2: JERSEY SHORE HOSPITAL (JSH) LED A COMPREHENSIVE COMMUNITY HEALTH NEEDS ASSESSMENT TO EVALUATE THE HEALTH NEEDS OF INDIVIDUALS LIVING IN THE JERSEY SHORE HOSPITAL SERVICE AREA IN NORTH CENTRAL, PENNSYLVANIA. THE PURPOSE OF THE ASSESSMENT WAS TO GATHER INFORMATION ABOUT LOCAL HEALTH NEEDS AND HEALTH BEHAVIORS. THE ASSESSMENT EXAMINED A VARIETY OF INDICATORS, INCLUDING SOCIAL DETERMINANTS OF HEALTH (POVERTY, HOUSING, EDUCATION), MORTALITY RATES, RISKY BEHAVIORS (ALCOHOL USE, TOBACCO USE) AND CHRONIC HEALTH CONDITIONS (DIABETES, HEART DISEASE). METHODOLOGYJSH DEFINED THEIR SERVICE AREA BASED ON ANALYSIS OF THE GEOGRAPHIC AREA WHERE INDIVIDUALS UTILIZING JSH HEALTH SERVICES RESIDE. BECAUSE JSH'S SERVICE AREA ENCOMPASSES RESIDENTS LIVING IN TWO COUNTIES IN NORTH CENTRAL PENNSYLVANIA, THE CHNA INCLUDES QUANTITATIVE AND QUALITATIVE RESEARCH DATA FOR BOTH CLINTON COUNTY AND LYCOMING COUNTY.THE CHNA WAS COMPRISED OF BOTH QUANTITATIVE AND QUALITATIVE RESEARCH COMPONENTS. THIS MULTI-FACETED APPROACH TOOK INTO ACCOUNT VARIOUS DATA SOURCES AND PERSPECTIVES. QUANTITATIVE DATA INCLUDED A SECONDARY DATA PROFILE DEPICTING POPULATION AND HOUSEHOLD STATISTICS, EDUCATION AND ECONOMIC MEASURES, MORBIDITY AND MORTALITY RATES, INCIDENCE RATES, AND OTHER HEALTH STATISTICS FOR CLINTON AND LYCOMING COUNTIES. QUALITATIVE DATA INCLUDED TWO FOCUS GROUPS HELD ON AUGUST 15, 2012 AT JERSEY SHORE HOSPITAL WITH KEY COMMUNITY LEADERS. JSH CONTRACTED WITH HOLLERAN, AN INDEPENDENT RESEARCH AND CONSULTING FIRM, TO CONDUCT RESEARCH IN SUPPORT OF THE CHNA. THE FIRM PROVIDED THE FOLLOWING ASSISTANCE: 1) COLLECTED AND INTERPRETED SECONDARY DATA, 2) CONDUCTED FOCUS GROUPS WITH COMMUNITY STAKEHOLDERS, AND 3) FACILITATED A PRIORITIZATION AND IMPLEMENTATING PLANNING SESSION. COMMUNITY ENGAGEMENT AND FEEDBACK WAS AN INTEGRAL PART OF THE CHNA PROCESS. JSH SOUGHT COMMUNITY INPUT THROUGH FOCUS GROUPS WITH COMMUNITY STAKEHOLDERS AND THROUGH INCLUSION OF COMMUNITY PARTNERS IN THE PRIORITIZATION AND IMPLEMENTATION PLANNING PROCESS. PUBLIC HEALTH AND HEALTHCARE PROFESSIONALS SHARED KNOWLEDGE AND EXPERTISE ABOUT HEALTH ISSUES, WHILE LEADERS AND REPRESENTATIVES OF NON-PROFIT AND COMMUNITY-BASED ORGANIZATIONS PROVIDED INSIGHT ON THE COMMUNITY SERVED BY JSH INCLUDING MEDICALLY UNDERSERVED, LOW INCOME, AND MINORITY POPULATIONS. JSH AND ITS PARTNERS USED THE RESULTS OF THE FOCUS GROUPS IN CONJUNCTION WITH SECONDARY STATISTICAL DATA TO PRIORITIZE PUBLIC HEALTH ISSUES AND DEVELOP A COMMUNITY HEALTH IMPLEMENTATION PLAN FOCUSED ON MEETING COMMUNITY NEEDS. 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. PATIENT 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 OF WHAT CHARITY CARE IS AND THAT IT EXISTS. IF THE PATIENT IS INTERESTED THE PROCESS IS EXPLAINED. PART VI, LINE 4: JERSEY SHORE HOSPITAL'S PRIMARY SERVICE AREA (PSA) COVERS EASTERN CLINTON COUNTY AND WESTERN LYCOMING COUNTY - AN AREA WITH A 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 IN A MEDICALLY UNDERSERVED AREA (MUA). JERSEY SHORE AND JERSEY SHORE HOSPITAL IS LOCATED IN LYCOMING COUNTY, WHICH HAS AN AREA OF 1,237 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 9 ADDITIONAL ZIP CODES WHICH ARE IMPORTANT TO THE HOSPITAL. THESE ZIP CODES ARE PRIMARILY TO THE WEST AND NORTH OF THE PSA. ABOUT TWO PERCENT (2%) OF INPATIENT STAYS IN THE PSA OCCUR AT JERSEY SHORE HOSPITAL. ABOUT ELEVEN PERCENT (11%) OF OUTPATIENT VISITS IN THE PSA OCCUR AT JERSEY SHORE HOSPITAL.WITHIN THE PSA, THE TOTAL POPULATION IS EXPECTED TO INCREASE BY 1.0% 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 MAKES 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 AT 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 $47,113, COMPARED TO PA ($54,138) AND THE U.S. ($54,889). 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 44% OF THE POPULATION HAS A HIGH SCHOOL EDUCATION AND 7.1% OF THE POPULATION HAS AN ASSOCIATE DEGREE. THE PERCENTAGE ACHIEVING A BACHELOR OR PROFESSIONAL DEGREE 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 US AS A WHOLE.IN TERMS OF PATIENTS SERVED, COMBINED INPATIENT AND OUTPATIENT PAYER MIX IN 2013 REMAINED FAIRLY CONSISTENT. MEDICARE AND MEDICARE ADVANTAGE MAKE UP ABOUT 42% OF OUR PAYERS IN TERMS OF GROSS CHARGES. MEDICAL ASSISTANCE BUSINESS CONTINUED TO HAVE A SIGNIFICANT IMPACT ON JSH AS A CRITICAL ACCESS HOSPITAL. MEDICAL ASSISTANCE CHARGES ACCOUNT FOR ABOUT 10% OF OUR PAYERS. SELF-PAY CHARGES ACCOUNTED FOR ABOUT 5% OF OUR PAYERS. 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 PURCHASES, MAJOR FACILITY IMPROVEMENTS, AND COMMUNITY HEALTH PROGRAMS.THE HOSPITAL PARTICIPATES IN MEDICARE, MEDICAID, CHAMPUS, AND TRICARE. 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. PART VI, LINE 7, REPORTS FILED WITH STATES PA PART VI IN SUPPORT OF THE 2012 COMMUNITY HEALTH NEEDS ASSESSMENT, AND ONGOING COMMUNITY BENEFIT INITIATIVES, JERSEY SHORE HOSPITAL PLANS TO IMPLEMENT THE FOLLOWING STRATEGIES TO IMPACT AND MEASURE COMMUNITY HEALTH IMPROVEMENT.OVERWEIGHT /OBESITY (HEALTHY EATING/PHYSICAL ACTIVITY/CHRONIC CONDITIONS)JERSEY SHORE HOSPITAL STAFF RECOGNIZES THE CONNECTION BETWEEN OVERWEIGHT AND OBESITY TO HEART DISEASE, DIABETES AND OTHER CHRONIC ILLNESSES. THE HOSPITAL WILL SEEK TO REDUCE THE PERCENTAGE OF OUR CLIENTS IDENTIFIED AS BEING EITHER OVERWEIGHT OR OBESE BY FOCUSING EDUCATION AND AWARENESS ON PROMOTING HEALTHY WEIGHT THROUGH DIET AND EXERCISE.GOAL:REDUCE THE PERCENTAGE OF COMMUNITY MEMBERS CONSIDERED OVERWEIGHT OR OBESE THROUGH PROMOTION OF HEALTHY EATING AND PHYSICAL ACTIVITY.OBJECTIVES:1) PARTNER WITH SCHOOL DISTRICTS TO IMPROVE THE EDUCATION AND AWARENESS OF PROPER DIETARY HABITS.STRATEGIES:-PARTNER WITH JERSEY SHORE AND KEYSTONE CENTRAL SCHOOL DISTRICTS TO PROVIDE EDUCATION TO STAFF AND FACULTY ABOUT HEALTHY EATING AND PHYSICAL ACTIVITY.-SUPPORT RESEARCH GRANT FOR STRETCH AND GROW PROGRAM THROUGH AMERICAN HEART ASSOCIATION.2)RAISE AWARENESS TO THE BENEFITS OF AREA TOURISM ATTRACTIONS BUILT AROUND EXERCISE ACTIVITY TO LOCAL RESIDENTS.STRATEGIES:-ORGANIZE 5K WALK WITH NATURALIST.3)PROVIDE COMMUNITY-WIDE EDUCATION EVENTS ON HEALTHY NUTRITION. STRATEGIES:-CONTINUE WITH PORTION DISTORTION PROGRAM TO EDUCATE RESIDENTS ON HEALTHY EATING AND PROPER MEALS PROPORTION.-CONTINUE BI-ANNUAL HEALTH SCREENINGS EVENT TO IDENTIFY HIGH CHL/TRIGLICERIDES AND OTHER HEALTH INDICATORS.-RESEARCH GRANT OPPORTUNITIES FOR SUCH EXERCISE AND HEALTHY EATING PROGRAMS INCLUDING STRETCH N' GROW.ACCESS TO CARE:ACCESS TO CARE INCLUDES PRIMARY CARE PROVIDERS, BEHAVIORAL HEALTH PROVIDERS, AND LOCATION OF SERVICES AS MAY BE IMPACTED BY AVAILABILITY OF TRANSPORTATION.JERSEY SHORE HOSPITAL STAFF BELIEVES THAT IMPROVED HEALTH STATUS IS CONTINGENT ON ACCESS TO PRIMARY CARE SERVICES BY ALL. WE WILL DESIGNATE RESOURCES TO IMPROVING ACCESS TO CARE FOR ALL RESIDENTS AND TO CREATING A STRUCTURE OF PROVIDERS THAT SUPPORTS COORDINATION OF CARE. GOAL:1) INCREASE ACCESS TO QUALITY HEALTH CARE PROVIDERS WITH A FOCUS ON PRIMARY CARE AND BEHAVIORAL SCIENCES.STRATEGY: INCREASE PHYSICIAN/PATIENT RATIO THROUGH RECRUITMENT AND PARTNERSHIP EFFORTS.2)IMPROVE COMMUNITY AWARENESS AND UNDERSTANDING OF CHOOSING BETWEEN EMERGENCY DEPARTMENT, URGENT CARE CENTER AND FAMILY PHYSICIAN WHEN SEEKING NON-EMERGENT CARE.STRATEGIES: -CONDUCT AWARENESS CAMPAIGN TO INCLUDE PRINT MATERIALS, RADIO AND PRINT ADVERTISING, AND SERVICE-EDUCATE INSURANCE CARRIERS ABOUT AVAILABILITY AND COVERAGE OF ALTERNATIVE CARE DELIVERY OPTIONS. X X X 0 0 0 0 0 0 0 0 0 THOMAS C CONNOLLY MD MEDICAL STAFF PRESIDENT 0 456290 0 0 0 0 0 12000 0 19124 0 487414 0 0 AARON KOLB MD PHYSICIAN 321383 0 0 0 0 0 12767 0 14633 0 348783 0 0 0 RONALD EISTER PHYSICIAN 242303 0 0 0 0 0 10243 0 12867 0 265413 0 0 0 SHAIRKO MISSOURI ANESTHESIOLOGIST 445625 0 0 0 0 0 12767 0 7331 0 465723 0 0 0 TAMAR BAITEL PHYSICIAN 300353 0 0 0 0 0 0 0 6903 0 307256 0 0 0 RICHARD CORNISH PHYSICIAN 258213 0 0 0 0 0 0 0 15978 0 274191 0 0 0 LISA STRAWSER MEDICAL STAFF DIRECTOR AND BOARD MEMBER THROUGH DECEMBER 2013 1160469 LISA STRAWSER IS A PART OWNER OF JERSEY SHORE RADIOLOGISTS. JERSEY SHORE RADIOLOGISTS HAS A CONTRACT WITH THE HOSPITAL TO PERFORM RADIOLOGY SERVICES FOR THE HOSPITAL. THE SERVICES ARE PROVIDED AT FMV. IN ACCORDANCE WITH THE CONFLICT OF INTEREST POLICY, LISA STRAWSER ABSTAINS FROM ANY DECISION MAKING AS IT RELATES TO THIS TRANSACTION. 0 JAMES ELY BOARD MEMBER AND BROTHER TO EMPLOYEE 31200 JAMES ELY IS A BOARD MEMBER AND IS ALSO THE BROTHER TO EMPLOYEE MARY HOLLICK. 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 11 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. THERE HAS NEVER BEEN AN 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 PURPOSES. 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: THE PRESIDENT/CEO IS AN EMPLOYEE OF QUORUM (MANAGEMENT COMPANY). THE HOSPITAL PAYS QUORUM FOR THE PRESIDENT/CEO'S SALARY. FOR CALENDAR YEAR 2013 HIS COMPENSATION WAS $299,905. FORM 990, PART IX, LINE 11G LAUNDRY: PROGRAM SERVICE EXPENSES 79,499. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 79,499. OTHER: PROGRAM SERVICE EXPENSES 13,367. MANAGEMENT AND GENERAL EXPENSES 528,279. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 541,646. CONTRACTED SERVICES: PROGRAM SERVICE EXPENSES 243,314. MANAGEMENT AND GENERAL EXPENSES 388,055. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 631,369. MEDICAL: PROGRAM SERVICE EXPENSES 193,652. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 193,652. MEDICAL LABS: PROGRAM SERVICE EXPENSES 235,030. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 235,030. TRANSPORTATION: PROGRAM SERVICE EXPENSES 2,819. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,819. MICROFILM: PROGRAM SERVICE EXPENSES 28,000. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 28,000. COLLECTIONS: PROGRAM SERVICE EXPENSES 50,889. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 50,889. CONSULTING: PROGRAM SERVICE EXPENSES 97,000. MANAGEMENT AND GENERAL EXPENSES 22,701. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 119,701. BIOHAZARDOUS MATERIALS: PROGRAM SERVICE EXPENSES 29,833. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 29,833. MAINTENANCE AND REPAIRS: PROGRAM SERVICE EXPENSES 628,972. MANAGEMENT AND GENERAL EXPENSES 213,647. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 842,619. PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 2,202,735. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,202,735. FORM 990, PART XI, LINE 9: PENSION LIABILITY ADJUSTMENT 30,071. CHANGE IN FAIR VALUE OF DERIVATIVE INSTRUMENT 179,803. JERSEY SHORE HOSPITAL FOUNDATION INC 1020 THOMPSON STREET JERSEY SHORE PA 17740 232480603 HEALTHCARE PA 501(C)(3) 3 N/A 0 0 0 0 1 0 0 0 0 0 1 0 1 1 1 1 1 0 0 0