2014-05-13T10:38:03-05:00 2013-06-30 BKD LLP 910 E St Louis St Springfield MO 658062523 990 2012-07-01 232751183 Susquehanna Health System SUSQ 5703207900 1205 Grampian Blvd 2nd Floor Williamsport PA 17701 Charles J Santangelo 5703213171 2014-05-13 1 Brian D Todd P00422601 4178658701 2012 2015-11-30 17:44:51Z Steven P Johnson 700 High Street Williamsport PA 17701 201465443 0 X www.susquehannahealth.org X 1994 PA SHS provides management services for the delivery of healthcare through its affiliated entities. 24 14 0 15 0 0 57000 37844569 15444 14769 2117617 2067773 0 0 2190061 39927111 36088 20720 0 0 0 554961 0 0 0 254647 1550768 290735 2126449 1899326 37800662 46869129 89980840 54722 2061725 46814407 87919115 X The mission of SHS and affiliates is as follows: Our Mission - to extend God's healing love by improving the health of those we serve. Our Vision - to create a world-class health system. Our Values - putting patients first, sharing ownership and being servant leaders. 1 0 1351100 20720 14769 SHS is organized and operated to coordinate the activities of the Supported Organizations as they pursue their charitable, educational, benevolent, and other purposes related to health care, health education and training, health facilities, and scientific research and health. The Supported Organizations include: The Williamsport Hospital & Medical Center, Divine Providence Hospital of the Sisters of Christian Charity, Muncy Valley Hospital, and Susquehanna Physician Services. Other supported entities include the Laurel Entities provided that each such Laurel Health Entity is an organization described in Section 501(c)(3) of the Code as a public charity under either Section 509(a)(1) or Section 509(a)(2) of the Code. SHS also is operated to establish, sponsor, and develop, directly or indirectly, facilities and programs for the accommodation, care and treatment of individuals suffering from illness, injury, disease, disability or infirmity, including but not limited to hospitals, nursing homes, residential facilities for the elderly, life care centers, ambulatory medical treatment facilities, clinics, rehabilitation centers, aloholism treatment centers, home health programs, mental health centers, hospice programs, pharmacies, laboratories, and training and research facilities. 1351100 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 1 0 0 1 0 0 0 0 0 0 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 X 310 0 1 0 0 1 CJ 0 0 0 0 0 0 0 0 X 24 14 0 0 1 0 0 1 0 1 1 0 0 0 1 1 1 1 1 0 0 0 PA X Susquehanna Health Finance Department 5703207900 1205 Grampian Blvd 2nd Floor Williamsport PA 17701 X Ronald V DeFeo Jr 1.00 1.00 X X 0 0 0 Ann S Pepperman Esquire 1.00 1.00 X X 0 0 0 Davie Jane Gilmour PhD 1.00 1.00 X X 0 0 0 Sister Teresa Ann Jacobs 1.00 2.00 X 0 0 0 John M Burks MD 1.00 40.00 X 0 423058 29130 Leonard R Collins MD 1.00 42.00 X 0 260644 24456 Ronald E DiSimone MD 1.00 40.00 X 0 971504 30107 James E Douthat EdD 1.00 0.00 X 0 0 0 Timothy M Gage 1.00 1.00 X 0 0 0 Daniel J Glunk MD 1.00 40.00 X 0 201627 6578 Sister Joan Daniel Healy 1.00 0.00 X 0 0 0 Steven P Johnson 1.00 43.00 X X 0 962143 32509 Daniel A Klingerman 1.00 1.00 X 0 0 0 Lynda Livingston 1.00 2.00 X 0 0 0 Philip H Johnson 1.00 1.00 X 0 0 0 James E Mothersbaugh 1.00 1.00 X X 0 0 0 Alexander R Nesbitt MD 1.00 42.00 X 0 186910 29074 Melissa E Welch Esq 1.00 3.00 X 0 0 0 Kevin Kist MD 1.00 43.00 X 0 351380 33016 Stephen F Weber MD 1.00 40.00 X 0 300370 25535 Robert DeCamp 1.00 3.00 X 0 0 0 Dr Walter Laibinis 1.00 43.00 X 0 235052 12795 Dr J Dennis Murray 1.00 3.00 X 0 0 0 Glenn Poirier 1.00 3.00 X 0 0 0 Charles J Santangelo 0.00 40.00 X 0 358326 29369 Jan E Fisher 0.00 40.00 X 0 333591 22798 William C McCauley MD 0.00 40.00 X 0 403160 31423 Ronald J Butler 0.00 40.00 X 0 367109 19857 Neil G Armstrong 0.00 40.00 X 0 293762 27670 0 5648636 354317 0 0 1 0 Stevens & Lee 111 North Sixth Street Reading PA 19603 Legal services 287760 Infor (US) Inc NW 7418 PO Box 1450 Minneapolis MN 55485 IT services 165813 2 37819569 25000 37844569 Interest on Note Receivable 525990 12791 12791 Support allocation income 900003 1347 1347 Misc other income 900003 631 631 14769 821863 821863 162725510 58732 161382752 155580 1342758 -96848 1245910 1245910 39927111 14769 0 2067773 20720 20720 439215 439215 85538 85538 30208 30208 281196 281196 287760 287760 201842 201842 4551 4551 173983 173983 476 476 635 635 1347 1347 595372 595372 Use of Funds-Misc Expen 3606 3606 2126449 1351100 775349 0 71392 110085 262941 247264 0 223 806309 797554 10102 8755 46508630 51778254 16064 37836259 46869129 89980840 34100 36000 20622 2025725 54722 2061725 X 46207453 83710294 574545 1072292 32409 3136529 46814407 87919115 46869129 89980840 37800662 3304046 0 X X 0 1 X 1 0 X X X 0 0 0 The Williamsport Hospital & Medical Center 240795508 3 1 16455 Divine Providence Hospital 240799343 3 1 4265 Muncy Valley Hospital 240806023 3 1 0 Susquehanna Physician Services 232449454 3 1 0 Soldiers & Sailors Memorial Hospital 232176963 3 1 0 5 20720 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 38043 100 1776 1000 38919 36722 1596 725 1000 38043 35555 2167 1000 36722 33758 1797 35555 34177 -419 33758 0.83530 0.16470 0 0 762929 754174 8755 43380 43380 0 8755 Cash Value of Life Insurance 16659 Other Assets 31 Interest in Net Affiliate 37819569 37836259 Deferred Annuity 9515 Due to Affiliates 2016210 2025725 X 39608570 3304046 3353 3307399 36301171 3625940 3625940 39927111 2105729 0 2105729 20720 20720 2126449 Description of Intended Use of Endowment Funds: Part V, Line 4: The Arthur R. Taylor, M.D. Endowment Fund for Continuing Medical Education will provide financial support for continuing medical education programs at Susquehanna Health System with a focus on primary care. These educational programs will be for the benefit of the physicians of Susquehanna Health and surrounding regions. Part XI, Line 2d - Other Adjustments: Assets released from restriction 3,353. Part XI, Line 4b - Other Adjustments: Restricted net assets 3,625,940. Part XII, Line 4b - Other Adjustments: Restricted grants 20,720. Part X, Line 2 Management has evaluated their income tax positions under the guidance included in ASC 740. Based on their review, management has not identified any material uncertain tax positions to be recorded or disclosed in the financial statements. Central America 0 1 Program services Captive insurance company-Total investment 30117295 0 1 0 0 0 1 30117295 0 30117295 0 0 1 0 0 0 1 The Williamsport Hospital 700 High Street Williamsport PA 17701 240795508 501(c)(3) 16455 Used for Medical Halo system and equipment for inpatient rehab. 1 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: Grantees are related organizations and part of the Susquehanna Health System with consistent management oversight ensuring the use of funds for charitable purposes. 0 0 0 0 0 1 1 0 0 John M Burks MD 0 396285 0 0 0 26773 0 9500 0 19630 0 452188 0 0 Leonard R Collins MD 0 244600 0 0 0 16044 0 9500 0 14956 0 285100 0 0 Ronald E DiSimone MD 0 845483 0 114684 0 11337 0 9500 0 20607 0 1001611 0 0 Daniel J Glunk MD 0 183217 0 16693 0 1717 0 2899 0 3679 0 208205 0 0 Steven P Johnson 0 511232 0 139282 0 311629 0 13250 0 19259 0 994652 0 0 Alexander R Nesbitt MD 0 174228 0 0 0 12682 0 10532 0 18542 0 215984 0 0 Kevin Kist MD 0 350414 0 0 0 966 0 9500 0 23516 0 384396 0 0 Stephen F Weber MD 0 277854 0 18660 0 3856 0 12000 0 13535 0 325905 0 0 Dr Walter Laibinis 0 178483 0 56569 0 0 0 5641 0 7154 0 247847 0 0 Charles J Santangelo 0 331316 0 19112 0 7898 0 9500 0 19869 0 387695 0 0 Jan E Fisher 0 283326 0 49437 0 828 0 10346 0 12452 0 356389 0 0 William C McCauley MD 0 376235 0 23425 0 3500 0 9500 0 21923 0 434583 0 0 Ronald J Butler 0 293922 0 72441 0 746 0 13971 0 5886 0 386966 0 0 Neil G Armstrong 0 276505 0 14286 0 2971 0 15750 0 11920 0 321432 0 0 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. 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 acheived 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. Danko Holdings IncDaniel Klingerman Pres (board member) President of Danko is a board member of SHS Danko has an agreement to pay Community Basket a note at 5% interest X 300000 247264 0 1 1 247264 New Program Services Form 990, Part III, line 2 On September 1, 2012, Susquehanna Health System #23-2751183 executed an affiliation agreement with Laurel Health System and its related entities. As a result of the acquisition SHS will expand its service area to include several counties adjacent to those it currently serves. Form 990, Part VI, Section A, line 4 On September 1, 2012, Susquehanna Health System (SHS) EIN #23-2751183 executed an affiliation agreement with Laurel Health System (LHS) and related entities. Related entities include Laurel Health Foundation (LHF), Soldiers and Sailors Memorial Hospital (SSMH), North Penn Comprehensive Health Services, Inc. (North Penn), The Green Home (TGH), Tioga Health Care Providers, Inc. (THCP), Tyoga Carenet (TCN), Tioga Management Services Organization, Inc. (TMSO), Laurel Realty, Inc. (LRI) and Laurel Management Services Inc. (LMS). As part of the agreement, SHS became the sole member of Laurel Health System and related entities, with the exception of North Penn and LHF. Collectively, Laurel Health System and the related entities (excluding North Penn) are referred to as the Tioga Affiliates. The affiliation was treated as an acquisition of the Tioga Affiliates by SHS. There was no consideration transferred as part of the agreement. Accordingly, an implied contribution to SHS from the Tioga Affiliates was recorded totaling $37,819,569. As a result of the acquisition, SHS will have an opportunity to expand its service area to include several counties adjacent to those it currently serves. Form 990, Part VI, Section A, line 7a Two members of the board of directors shall be appointed by the Sisters of Christian Charity Health Care Corporation. These directors shall have all of the powers provided to the other directors except they shall not have the power to vote to appoint the President of the Corporation and they shall not participate in the discussions of, or vote on any matters contrary to the Directives. Form 990, Part VI, Section B, line 11 A high-level overview of Forms 990 is presented to the parent Board of Directors (Susquehanna Health System EIN #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 All members of the Board of Directors are required to submit a statement annually disclosing any conflict of interest that may arise. Requests for the annual form are distributed individually to each Board Member by the Office of the President and CEO. The CEO's executive assistant ensures that she receives a completed form from every Board Member. All Board Members agree to abstain when any issue involving the parties with conflicting interest is called to motion. Form 990, Part VI, Section B, Line 15a&b: All top management is employed by The Williamsport Hospital EIN #24-0795508. The following paragraph describes the process they use. The Board of Directors, through the Executive Compensation Committee, retains an independent outside consultant to provide guidance with respect to the annual establishment of the rebuttable presumptive or reasonableness relative to executive compensation and benefits. The consultant annually provides detailed market information from its annual Executive Compensation Survey for Health Systems. In addition, other regional survey data is provided in order to supply the health system with a "national" picture of compensation. With this process established, the Executive Compensation Committee takes the proper steps to educate the Board of Directors to understand all of the above-mentioned oversight and to appropriately prepare them for community or media inquiry. In addition, the Board is made aware of the Form 990 and its role in the communication of information to the public. Form 990, Part VI, Section C, line 19 These documents are available to members of the public who request them. They would be produced by the corporate office. Form 990, Part XII, Line 2c The organization did not change its oversight process or selection process. Number reported in Box 3 of Form 1096 Form 990, Part V, Line 1a All 1099's are issued by Susquehanna Health System EIN #23-2751183. All expenses are then allocated back to all related entities. Number of employees reported on Form W-3 Form 990, Part V, Line 2a & 2b Susquehanna Health System EIN #23-2751183 utilizes a common paymaster which includes the following entities: Divine Providence Hospital #24-0799343 Muncy Valley Hospital #24-0806023 The Williamsport Hospital #24-0795508 Susquehanna Health Foundation #23-2743470 Susquehanna Physician Services #23-2449454 Williamsport Area Ambulance Service Cooperative #23-2416166 The total number of employees reported on Form W-3 would be 3482 for Susquehanna Health System #23-2751183. The only payroll expenses that were recorded by Susquehanna Health System was the time spent on the merger of the Laurel Health System and related entities. Divine Providence Hospital 1100 Grampian Blvd Williamsport PA 17701 240799343 Hospital PA 501(c)(3) Line 3 Susquehanna Health System 1 Muncy Valley Hospital 215 E Water St Muncy PA 17756 240806023 Hospital PA 501(c)(3) Line 3 Susquehanna Health System 1 The Williamsport Hospital 700 High Street Williamsport PA 17701 240795508 Hospital PA 501(c)(3) Line 3 Susquehanna Health System 1 Susquehanna Health Foundation 1100 Grampian Blvd Williamsport PA 17701 232743470 Fundraising for affiliated entities PA 501(c)(3) Line 11a, I Susquehanna Health System 1 Susquehanna Physician Services 1201 Grampian Blvd Williamsport PA 17701 232449454 Physician services & MRI services PA 501(c)(3) Line 3 Susquehanna Health System 1 Williamsport Area Ambulance Service Cooperative 700 High Street Williamsport PA 17701 232416166 Ambulance transports PA 501(c)(3) Line 9 N/A 0 Soldiers & Sailors Memorial Hospital 32-36 Central Ave Wellsboro PA 16901 232176963 Hospital PA 501(c)(3) Line 3 Susquehanna Health System 1 The Green Home 37 Central Ave Wellsboro PA 16901 240804365 Skilled nursing & assisted living PA 501(c)(3) Line 9 Susquehanna Health System 1 Tioga Health Care Providers 15 Meade Street Wellsboro PA 16901 251765538 Physician services PA 501(c)(3) Line 11b, II Susquehanna Health System 1 Laurel Management Services 15 Meade Street Wellsboro PA 16901 251644910 Mgmt consulting & supervisory svcs PA 501(c)(3) Line 11b, II Susquehanna Health System 1 Laurel Realty 15 Meade Street Wellsboro PA 16901 231403678 Own & manage real estate PA 501(c)(2) N/A Susquehanna Health System 1 Laurel Health System 15 Meade Street Wellsboro PA 16901 240795488 Coordinate & manage the delivery of healthcare PA 501(c)(3) Line 11b, II Susquehanna Health System 1 Laurel Health Foundation 15 Meade Street Wellsboro PA 16901 251810488 Fundraising for affiliated entities PA 501(c)(3) Line 11a, I Laurel Health System 1 Community Basket LLC 1205 Grampian Blvd Williamsport PA 17701 201195739 Rents real estate PA Susquehanna Health System & Susquehanna Health Foundation Excluded from tax 0 0 0.50000 Susquehanna Ventures Inc 1201 Grampian Blvd Williamsport PA 17701 232470263 Pharmacy & Infusion services PA Susquehanna Health System C 1858139 2304288 1.00000 1 Susquehanna Health System Insurance Network LTD PO Box 1159 Grand Caymans CJ KY1-1102 980458722 Captive Insurance Company CJ Susquehanna Health System 3384374 30117295 1.00000 0 Tyoga Carenet 15 Meade Street Wellsboro PA 16901 251810967 Integrate Health Care PA Susquehanna Health System C 151535 323421 1.00000 1 Tioga Management Services Org 15 Meade Street Wellsboro PA 16901 232886336 Manage Physician Practices PA Susquehanna Health System C 29850 1.00000 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 Laurel Health SystemTioga Affiliates C 37819569 Implied contribution 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 has been granted an exemption until September 2022 for any such taxes that might be introduced. SHSIN's sole shareholder, Susquehanna Health System 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.