2013-05-15T09:15:19-05:00 2012-06-30 232932984 PARENTEBEARD LLC 1650 MARKET STREET SUITE 4500 PHILADELPHIA PA 19103 990 2011-07-01 240792115 JERSEY SHORE HOSPITAL JERS 5703980100 1020 THOMPSON STREET JERSEY SHORE PA 17740 CAREY W PLUMMER 5703980100 2013-05-14 1 JULIUS C GREEN CPA JD P00350393 2159720701 2011 2016-02-24 21:20:13Z CAREY W PLUMMER 1020 THOMPSON STREET JERSEY SHORE PA 17740 30497822 0 X WWW.JSH.ORG X 1922 PA PROVIDE INPATIENT, OUTPATIENT, AND EMERGENCY CARE SERVICES FOR RESIDENTS OF JERSEY SHORE AREA. 11 9 352 11 994442 8820 130721 202636 30076603 29702490 -6695 7186 316625 526999 30517254 30439311 0 2971067 0 0 12260092 14393091 0 0 207986 17463238 16767536 29723330 34131694 793924 -3692383 30259484 26311495 20267058 22403553 9992426 3907942 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 31294859 28708521 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 $637,510 DURING THE YEAR ENDED JUNE 30, 2012. 31294859 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 1 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 1 116 0 1 352 1 1 1 0 0 0 0 1 1 0 0 0 0 X 11 9 1 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 PA X CAREY W PLUMMER - PRESIDENTCEO 5703983101 1020 THOMPSON STREET JERSEY SHORE PA 17740 X CAREY PLUMMER 39.00 X X 300374 0 0 LEROY H KEILER III 1.00 X 0 0 0 WILLIAM R CAMERER III 1.00 X X 0 0 0 CARMEN SPINNEY MD 1.00 X X 0 170211 19167 JAMES REESER 1.00 X 0 0 0 RICHARD BEATTY DMD 1.00 X X 0 0 0 WALTER EISENHAUER 1.00 X 0 0 0 JAMES ELY 1.00 X 0 0 0 SEAN SIMCOX 1.00 X X 0 0 0 ROB GLUNK 1.00 X 0 0 0 DOROTHY CHAPPEL PHD 1.00 X 0 0 0 LISA STRAWSER DO 1.00 X 0 0 0 DEAN FLEMING 103111-83112 39.00 X 20925 0 1047 AARON KOLB MD 40.00 X 286179 0 28054 THOMAS BURGE 40.00 X 172639 0 14077 RONALD EISTER 40.00 X 242438 0 26034 SHAIRKO MISSOURI 40.00 X 432128 0 20008 CHRISTINE HAAS 39.00 X 117982 0 13026 1572665 170211 121413 7 0 1 0 SUSQUEHANNA HEALTH SYSTEM 1205 GRAMPIAN BOULEVARD WILLIAMSPORT PA 17701 IT SUPPORT/LAB TEST INTERPRETATION 591729 QUORUM HEALTH SYSTEM 105 CONTINENTAL PLACE BRENTWOOD TN 370275014 MANAGEMENT FEES 563473 STAFF CARE PO BOX 281923 ATLANTA GA 303841923 ER PHYSICIAN LOCUMS 466575 MEDICAL STAFFING NETWORK CO 2300 VALLEY LANE IRVING TX 75062 ER PHYSICIAN LOCUMS 453481 QUEST DIAGNOSTICS 315 BOULEVARD NE STE 240 ATLANTA GA 30312 LAB SERVICES 233847 6 15008 183333 4295 202636 PATIENT SERVICE REV 621110 29702490 28708048 994442 29702490 4724 4724 36198 42040 -5842 -5842 -5842 2462 0 2462 2462 2462 20337 15008 16471 3866 3866 CAFETERIA/VENDING REV 722210 112304 112304 REBATES/REFUNDS 900099 50190 50190 OUTREACH/STAFF DEV REV 611710 2886 2886 363595 473 363122 528975 30439311 28708521 994442 533712 2971067 2971067 390446 390446 11227607 9445475 1692566 89566 391721 320665 68015 3041 1420775 1228181 180948 11646 962542 787942 167128 7472 330374 330374 68459 68459 61287 61287 3054 3054 4893642 4885764 7878 71408 2027 69381 4356713 4341927 14786 576301 576301 72413 69389 3024 68537 68015 522 822877 822877 2017025 2017025 310890 310890 BAD DEBT EXPENSE 2739988 2739988 EMPLOYEE RECOGNITION 166631 166631 DUES & BOOKS 127832 127390 442 BANK SERVICE FEES 24732 24732 55373 55145 228 34131694 31294859 2628849 207986 1427 2175 3340805 1156008 94823 70945 3132916 3798829 309635 277097 515880 329609 37885502 20435527 17198631 17449975 5665367 3226857 30259484 26311495 2691694 3256150 14656196 14417074 2919168 4730329 20267058 22403553 X 9469982 3581965 522444 325977 9992426 3907942 30259484 26311495 X -3692383 -2392101 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3054 3054 0 EXPLANATION OF LOBBYING ACTIVITIES: 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 ($3,054 DURING THE YEAR ENDED JUNE 30, 2012) WAS USED FOR LOBBYING PURPOSES. 154956 154956 17991958 5135874 12856084 17322035 15089332 2232703 2416553 210321 2206232 17449975 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 505836 DEFERRED FINANCING COSTS, NET 116688 DUE FROM AFFILIATES 1689381 FUNDED DEPRECIATION 914952 3226857 OBLIGATIONS UNDER CAPITAL LEASES 805033 PATIENT REFUNDS PAYABLE 51517 BLUE CROSS CURRENT FINANCING ADVANCE 158704 FAIR VALUE OF DERIVATIVE INSTRUMENT 332042 ACCRUED PENSION COST 3383033 4730329 30439311 34131694 -3692383 -2392101 -2392101 -6084484 25134654 -5363168 -5363168 30497822 -58511 -58511 30439311 31219138 58511 58511 31160627 2971067 2971067 34131694 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: 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 2012 AND 2011. THE HOSPITAL'S FEDERAL RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX, EXEMPT ORGANIZATION BUSINESS TAX RETURN, AND CORPORATE INCOME TAX RETURNS FOR THE YEARS ENDED JUNE 2011, 2010, AND 2009 REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 8 - OTHER ADJUSTMENTS: PENSION LIABILITY ADJUSTMENT -2,478,012. CHANGE IN FAIR VALUE OF DERIVATIVE INSTRUMENT 85,911. TOTAL TO SCHEDULE D, PART XI, LINE 8: -2,392,101. PART XII, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN FAIR VALUE OF DERIVATIVE INSTRUMENT 85,911. PENSION LIABILITY ADJUSTMENT -2,478,012. REVENUE OF AFFILIATES CONSOLIDATED ON FINANCIAL STATEMENTS TRANSFER TO AFFILIATE -2,971,067. PART XII, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSE -42,040. FUNDRAISING EXPENSE -16,471. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 42,040. FUNDRAISING EXPENSE 16,471. PART XIII, LINE 4B - OTHER ADJUSTMENTS: TRANSFER TO AFFILIATE 2,971,067. GOLF TOURNAMENT 23411 9941 13470 1632 5411 CRAB FEST 11934 5067 6867 5900 250 3278 35345 15008 20337 7532 250 8689 16471 3866 1 1 1 X 1 X 1 0 1 1 254807 254807 0.00810 2778457 1754453 1024004 0.03260 3033264 1754453 1278811 0.04070 248550 20200 228350 0.00730 3006 3006 0.00010 251556 20200 231356 0.00740 3284820 1774653 1510167 0.04810 1 1095149 6532846 4776789 1756057 X 1 1 1 1 JERSEY SHORE HOSPITAL

1020 THOMPSON STREET JERSEY SHORE PA 17740

X X X X JERSEY SHORE HOSPITAL 1 1 1 200.000000000000 1 250.000000000000 1 X X X 1 1 X X X 0 0 1 X 0 0 PART I, LINE 7: THE HOSPITAL USED THE COST TO CHARGE RATIO. PART I, L7 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 $2,739,988. PART III, LINE 4: ACCOUNTS RECEIVABLE, PATIENTS 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. THE ALLOWANCE FOR DOUBTFUL COLLECTIONS IS ESTIMATED BASED UPON A PERIODIC REVIEW OF THE ACCOUNTS RECEIVABLE AGING, PAYOR CLASSIFICATIONS, AND APPLICATION OF HISTORICAL WRITE-OFF PERCENTAGES.BAD DEBT EXPENSE IS BASED ON A PERCENTAGE OF REVENUE DURING THE YEAR. THE ALLOWANCE IS EVALUATED AT THE END OF THE YEAR AND ANY ADJUSTMENTS ARE MADE TO BAD DEBT EXPENSE.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: THERE IS NO MEDICARE SHORTFALL - AS A CRITICAL ACCESS HOSPITAL, WE ARE REIMBURSED AT 101% OF COST FROM MEDICARE.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. JERSEY SHORE HOSPITAL PART V, SECTION B, LINE 3: DURING FY 2013, THE COMMUNITY NEEDS ASSESSMENT PROCESS WAS BEGUN. A COMMITTEE WAS ESTABLISHED TO REVIEW EXISTING DATA AND COMPLETE THE COMMUNITY ASSESSMENT. THE ASSESSMENT IS COMPLETED, THE HOSPITAL IS CURRENTLY WORKING ON THEIR IMPLEMENTATION PLAN. JERSEY SHORE HOSPITAL PART V, SECTION B, LINE 13G: POLICY WAS REFERENCED ON INVOICES AND VERBALLY DISCUSSED WITH PATIENTS. JERSEY SHORE HOSPITAL PART V, SECTION B, LINE 19D: JERSEY SHORE HOSPITAL DISCOUNTED AMOUNTS CHARGED TO ELIGIBLE PATIENTS ACCORDING TO THE FINANCIAL ASSISTANCE POLICY. PART VI, LINE 2: SEVERAL GROUPS REQUEST HEALTH FAIRS. THE BOARD AND MANAGEMENT CONSIDERED THE HEALTH NEEDS OF THE COMMUNITY. COMMUNITY MEMBERS HAVE REQUESTED THE PROGRAM. 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 IS EXISTS. IF THE PATIENT IS INTERESTED THE PROCESS IS EXPLAINED. PART VI, LINE 4: JERSEY SHORE HOSPITALS PRIMARY SERVICE AREA (PSA) COVERS EASTERN CLINTON COUNTY AND WESTERN LYCOMING COUNTY - AN AREA WITH A POPULATION OF APPROXIMATELY 41,000. THE PSA FOR JERSEY SHORE HOSPITAL CONSISTS OF FOUR ZIP CODES: 17720 - 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 1.8% BY 2017. 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 11.2% BY 2017. THIS AGE GROUP CURRENTLY MAKES UP OVER 16% OF THE POPULATION IN THE PSA COMPARED TO ABOUT 13% 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 $40,477, COMPARED TO PA ($47,478) AND THE U.S. ($47,529). THE MEDIAN HOUSEHOLD INCOME IN THE SSA IS $39,660.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 2012 REMAINED FAIRLY CONSISTENT. MEDICARE AND MEDICARE ADVANTAGE MAKE UP ABOUT 43% 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 OVER 10% OF OUR PAYERS. SELF-PAY CHARGES ACCOUNTED FOR ALMOST 4% 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: N/A 1 JERSEY SHORE HOSPITAL FOUNDATION INC 1020 THOMPSON STREET JERSEY SHORE PA 17740 232480603 501(C)(3) 2971067 0 N/A N/A TO FUND OPERATIONS AT JERSEY SHORE HOSPITAL FOUNDATION, INC. PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: ASSISTANCE IS PROVIDED TO RELATED ENTITIES FOR FINANCIAL SUPPORT. MANAGEMENT OF THE HOSPITAL OVERSEES THE USE OF FUNDS AT THE RELATED ORGANIZATION. X X X 0 0 0 0 0 0 0 0 0 CAREY PLUMMER 223507 0 0 0 76867 0 0 0 0 0 300374 0 0 0 CARMEN SPINNEY MD 0 170211 0 0 0 0 0 8562 0 10605 0 189378 0 0 AARON KOLB MD 286179 0 0 0 0 0 11514 0 16540 0 314233 0 0 0 THOMAS BURGE 172639 0 0 0 0 0 3472 0 10605 0 186716 0 0 0 RONALD EISTER 242438 0 0 0 0 0 10022 0 16012 0 268472 0 0 0 SHAIRKO MISSOURI 432128 0 0 0 0 0 360 0 19648 0 452136 0 0 0 LISA STRAWSER MEDICAL STAFF DIRECTOR AND BOARD MEMBER 1295567 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 FORM 990, PART VI, SECTION A, LINE 1 CAREY W. PLUMMER IS A NON-VOTING MEMBER. FORM 990, PART VI, SECTION A, LINE 2 MEMBERS LEROY KEILER, III, AND ROB GLUNK HAVE A BUSINESS RELATIONSHIP. . 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: CERTAIN INDIVIDUALS LISTED ON 990 PART VII SPENT TIME ON RELATED ORGANIZATIONS ACTIVITIES. THE FOLLOWING SUMMARIZES THOSE INDIVIDUALS AND THE ESTIMATED AVERAGE NUMBER OF HOURS SPENT ON RELATED ORGANIZATIONS' ACTIVITIES: CAREY PLUMMER - 1 HOUR DEAN FLEMING - 1 HOUR CARMEN SPINNEY - 39 HOURS LEROY H. KEILER, III - .5 HOUR RICHARD BEATTY, DMD - .5 HOUR JAMES ELY - .5 HOUR ROB GLUNK - .5 HOUR FORM 990, PART VII, SECTION A: THE PRESIDENT AND CEO IS AN EMPLOYEE OF QUORUM (MANAGEMENT COMPANY). THE HOSPITAL PAYS QUOROM FOR THE PRESIDENT/CEOS SALARY. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: PENSION LIABILITY ADJUSTMENT -2,478,012. CHANGE IN FAIR VALUE OF DERIVATIVE INSTRUMENT 85,911. TOTAL TO FORM 990, PART XI, LINE 5: -2,392,101. 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 0 1 0 0 0 1 0 0 0 1 1 1 0 1 1