2012-05-15T07:53:39-05:00 2011-06-30 CARBIS WALKER LLP 5700 CORPORATE DRIVE STE 650 PITTSBURGH PA 15237 990 2010-07-01 240701920 BUCKTAIL MEDICAL CENTER BUCK 5709231000 1001 PINE STREET RENOVO PA 17764 MICHELE C BRAGUE NHA MHA 5709231000 2012-05-11 1 JEFFREY J PETRELL CPA 4126356270 2012-05-11 2010 2016-02-24 21:20:13Z ORPHA S KING NHA 1001 PINE STREET RENOVO PA 17764 6079721 0 X N/A X 1909 PA BUCKTAIL MEDICAL CENTER IS A NON-PROFIT CORPORATION SERVING THE HEALTHCARE NEEDS OF WESTERN CLINTON COUNTY, PA THROUGH A 21-BED HOSPITAL, 43-BED NURSING HOME, AND AN OUTPATIENT COMMUNITY HEALTH CLINIC. 11 9 119 45 0 0 160988 60944 5961916 5805748 106 -19037 205251 212945 6328261 6060600 0 0 0 0 3106906 3182172 0 0 0 3019774 2968270 6126680 6150442 201581 -89842 3318967 2708948 2819046 2313725 499921 395223 BUCKTAIL MEDICAL CENTER IS A NON-PROFIT CORPORATION SERVING THE HEALTHCARE NEEDS OF WESTERN CLINTON COUNTY, PA THROUGH A 21-BED HOSPITAL, 43-BED NURSING HOME, AND AN OUTPATIENT COMMUNITY HEALTH CLINIC. 0 0 1749530 1901312 BUCKTAIL MEDICAL CENTER PROVIDED NURSING HOME SERVICES TO OVER 28 DIFFERENT RESIDENTS FOR A TOTAL OF 11,263 RESIDENT DAYS. SERVICES INCLUDED PHYSICAL THERAPY, SPEECH THERAPY, AND OCCUPATIONAL THERAPY AND ACTIVITIES. 3552075 3904436 BUCKTAIL MEDICAL CENTER PROVIDES HOSPITAL INPATIENT AND OUTPATIENT SERVICES. THE INPATIENT SERVICE ADMISSIONS TOTALED 126 IN FISCAL YEAR 2011 FOR A TOTAL OF 1,071 INPATIENT AND SWING BED DAYS. BUCKTAIL'S OUTPATIENT SERVICES TOTALED 10,342 OUTPATIENT VISITS, WHICH INCLUDE 4,236 LABORATORY VISITS, 3,132 BMC COMMUNITY CLINIC VISITS, 2,109 EMERGENCY ROOM VISITS, 427 RADIOLOGY VISITS, AND 293 AMBULANCE TRIPS. 5301605 1 1 0 1 0 0 1 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 25 0 1 119 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 PA X THE ORGANIZATION 5709231000 1001 PINE STREET RENOVO PA 17764 LENNEA BROWN 1.00 X 0 0 0 GEORGE CRIGHTON 1.00 X X 0 0 0 ANNA KNAUFF 1.00 X X 0 0 0 PAUL FANTASKEY 1.00 X 0 0 0 JOHN BRUNO 1.00 X 0 0 0 JOHN KURUTZ 1.00 X 0 0 0 HARRIET NUSS 1.00 X 0 0 0 MARTHA SYKES 1.00 X 0 0 0 ROBERT PICKERING 1.00 X 0 0 0 ALVIN BERLOT DO 72.00 X 267815 0 0 ELEANOR KEPLER 1.00 X 0 0 0 ROY SCHOONOVER 1.00 X 0 0 0 ORPHA S KING NHA 40.00 X 30433 0 2328 ANITA RATHGEBER 40.00 X 45604 0 13849 GEORGE K HALAMA 40.00 X 55805 0 9977 WENDY D JANERELLA 40.00 X 3837 0 294 403494 0 26448 1 0 1 0 JAMES P HERBERG MD 2475 UPPER BRUSH VALLEY ROAD CENTRE HALL PA 16828 PHYSICIAN 268042 ALVIN J BERLOT DO RR 4 BOX 4479 MOSCOW PA 18444 PHYSICIAN 267815 JERSEY SHORE HOSPITAL 1020 THOMPSON STREET JERSEY SHORE PA 17740 LAB, PHYSICAL THERAPY, RADIOLOGY 104733 3 15405 45539 60944 OUTPATIENT REVENUE 900099 2743459 2743459 LONG-TERM CARE 623000 1901312 1901312 INPATIENT REVENUE 900099 1160977 1160977 5805748 84 84 19121 -19121 -19121 -19121 MISCELLANEOUS REVENUE 900099 194207 194207 CAFETERIA INCOME 900099 18738 18738 212945 6060600 5805748 0 193908 429942 267815 162127 2166669 1915946 250723 391816 355524 36292 193745 164683 29062 12834 12834 298767 189657 109110 676328 650443 25885 86396 86396 173855 173855 113968 96873 17095 227288 193195 34093 112473 95602 16871 PROFESSIONAL FEES 691491 587767 103724 BAD DEBT EXPENSE 279126 279126 AGENCY EXPENSE 149196 149196 MISCELLANEOUS EXPENSE 93943 50813 43130 MAINTENANCE EXPENSE 52605 44714 7891 6150442 5301605 848837 0 187188 31152 962299 745769 73440 88878 93254 39096 6477146 4704165 1969279 1772981 5877 6426 27630 24646 3318967 2708948 790178 602658 2017404 1643535 11464 67532 2819046 2313725 X 415628 326335 84293 68888 499921 395223 3318967 2708948 X -89842 -14856 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 108 108 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: DUES TO THE HOSPITAL AND HEALTH SYSTEM ASSOCIATION OF PENNSYLVANIA (HAP) X X 3 570.71 0 0 1 0 85487 85487 3120037 2015669 1104368 2848970 2408702 440268 422652 279794 142858 1772981 OTHER LIABILITIES 20106 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 47426 67532 6060600 6150442 -89842 549 -15405 -14856 -104698 6056015 0 6056015 4585 4585 6060600 6150442 0 6150442 0 6150442 DESCRIPTION OF HOW ORGANIZATION REPORTS CONSERVATION EASEMENTS: PART II, LINE 9: IN OCTOBER 2008 BUCKTAIL MEDICAL CENTER RECEIVED APPROVAL OF TWO APPLICATIONS, "APPLICATION OF USE VALUE ASSESSMENT OF LAND FOR REAL ESTATE TAX PURPOSES UNDER ACT 319, 156" AND "TITLE 7 PA CODE, CHAPTER 137B, CLEAN & GREEN." UNDER THESE PROGRAMS, BMC IS NOT ALLOWED TO DEVELOP 570.71 ACRES OF LAND COVERED BY THESE APPLICATIONS. DUE TO THE NATURE OF THE LAND INVOLVED AND THE IMMATERIAL COST BASIS, THE ORGANIZATION DOES NOT REPORT THE EASEMENTS ON THE FINANCIAL STATEMENTS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE CENTER FOLLOWS THE GUIDANCE FOR ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ORGANIZATION'S FINANCIAL STATEMENTS THAT PRESCRIBES 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 HAS BEEN MET. THE GUIDANCE ALSO ADDRESSES DERECOGNITION, CLASSIFICATION, INTEREST AND PENALTIES, ACCOUNTING IN INTERIM PERIODS, AND DISCLOSURE. THE CENTER'S POLICY IS TO RECOGNIZE INTEREST RELATED TO UNRECOGNIZED TAX BENEFITS IN INTEREST EXPENSE AND PENALTIES IN OPERATING EXPENSES. THERE WERE NO INTEREST OR PENALTIES RECOGNIZED ON THE STATEMENTS OF OPERATIONS AS A RESULT OF THIS GUIDANCE. GENERALLY, TAX RETURNS FOR YEARS ENDED JUNE 30, 2008, AND THEREAFTER REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. PART XI, LINE 8 - OTHER ADJUSTMENTS: TEMPORARILY RESTRICTED - NET ASSETS RELEASED FROM RESTRICTIONS -15,405. PART XII, LINE 4B - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTIONS 4,585. 1 1 1 X 1 X 1 1 0 0 17096 17096 0.00290 2163789 1983000 180789 0.03080 2180885 1983000 197885 0.03370 1501 1501 0.00030 909 909 0.00020 7038 7038 0.00120 9448 9448 0.00170 2190333 1983000 207333 0.03540 121 121 0.00000 171 171 0.00000 292 292 0 182425 63828 1623122 815549 807573 X 1 1 1 1 BUCKTAIL MEDICAL CENTER

1001 PINE STREET RENOVO PA 17764

X X X X OUTPATIENT CLINIC BUCKTAIL MEDICAL CENTER 1 1 BUCKTAIL MEDICAL CENTER

1001 PINE STREET RENOVO PA 17764

SKILLED NURSING FACILITY PART I, LINE 7: A COST-TO-CHARGE RATIO CALCULATED FROM WORKSHEET 2, RATIO OF PATIENT CARE COSTS-TO-CHARGES IS THE COSTING METHODOLOGY USED TO DETERMINE THE AMOUNTS REPORTED ON PART I, LINE 7. PART I, LINE 7G: THE HOSPITAL'S CLINIC, LONG-TERM CARE AND EMERGENCY DEPARTMENT OPERATED AT A LOSS. IF DEPARTMENTS WERE CLOSED, PATIENTS WOULD HAVE TO TRAVEL 28 MILES THROUGH MOUNTAINOUS TERRAIN TO THE NEAREST HOSPITAL FOR THESE SERVICES. THIS WOULD CREATE A HARDSHIP FOR MANY TO HAVE TO TRAVEL THAT DISTANCE. PART I, L7 COL(F): THE BAD DEBT EXPENSE OF 279,126 INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN A WAS SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE OF TOTAL EXPENSES. PART III, LINE 4: BUCKTAIL MEDICAL CENTER'S FINANCIAL STATEMENTS DO NOT INCLUDE A BAD DEBT FOOTNOTE. THE BAD DEBT EXPENSE CONSISTS OF BALANCES THAT ARE SENT TO COLLECTIONS AS WELL AS AN ADDITIONAL AMOUNT ASSESSED BY MANAGEMENT. EVERY MONTH MANAGEMENT REVIEWS THE ACCOUNTS RECEIVABLE BALANCE AND WRITES OFF ADDITIONAL AMOUNTS BASED ON MANAGEMENT'S ASSESSMENT OF HISTORICAL COLLECTIONS AND ECONOMIC CONDITIONS.A COST-TO-CHARGE RATIO CALCULATED FROM WORKSHEET 2, RATIO OF PATIENT CARE COSTS-TO-CHARGES IS THE COSTING METHODOLOGY USED TO DETERMINE THE AMOUNTS REPORTED ON LINES 2 AND 3 OF PART III. PART III, LINE 8: A COST-TO-CHARGE RATIO CALCULATED FROM WORKSHEET 2, RATIO OF PATIENT CARE COSTS-TO-CHARGES IS THE COSTING METHODOLOGY USED TO DETERMINE THE AMOUNTS REPORTED ON PART III, LINE 6. PART III, LINE 9B: IT IS THE POLICY OF BUCKTAIL MEDICAL CENTER TO ALLOW DISCOUNTS AND ALLOWANCES FROM STATED CHARGES WHEN HOSPITAL SERVICES ARE PROVIDED TO SELF-PAY INDIVIDUALS WHOSE SUBSTANTIATED INCOME FALLS BELOW CERTAIN PREDETERMINED LEVELS. PART VI, LINE 2: BUCKTAIL MEDICAL CENTER IS CURRENTLY WORKING WITH THE SUSQUEHANNA VALLEY RURAL HEALTH PARTNERSHIP TO DEVELOP AND IMPLEMENT A COMMUNITY HEALTH NEEDS ASSESSMENT. BUCKTAIL MEDICAL CENTER IS ALSO WORKING WITH OUR LOCAL UNITED WAY, WEST BRANCH VALLEY DRUG AND ALCOHOL AND THE CLINTON COUNTY COLLABORATIVE BOARD. WE ESTIMATE THE ASSESSMENT WILL BE READY FOR USE IN LATE 2012 OR EARLY 2013. PART VI, LINE 3: HILL-BURTON NOTICES WERE DISPLAYED AT EACH AREA OF SERVICE, INCLUDING: MAIN REGISTRATION; EMERGENCY ROOM; OUTPATIENT AREAS (LABORATORY/X-RAY) AND BUSINESS/BILLING OFFICE. HILL-BURTON "PACKETS" ARE MADE AVAILABLE TO EVERY PATIENT AT EACH OF THESE LOCATIONS AS WELL. FOR INPATIENT, SWING BED AND SKILLED NURSING SERVICES, THE HILL-BURTON "PACKET" WITH NOTICE WAS INCLUDED WITH EACH INPATIENT RELATED ADMISSION PACKET. THESE MATERIALS ARE REVIEWED BY THE PERSON PROVIDING THE ADMISSION PAPERWORK (E.G. SOCIAL SERVICES; NURSING).DURING THE BILLING PROCESS, IF ANY PATIENT APPEARS TO BE HAVING DIFFICULTY PAYING A BILL, BUCKTAIL MEDICAL CENTER BILLING STAFF WILL INCLUDE A HILL-BURTON PACKET WITH THE BILLING STATEMENT. BUCKTAIL MEDICAL CENTER ALSO PROVIDES A HILL-BURTON PACKET TO ANYONE REQUESTING ASSISTANCE AT ANY TIME BEFORE, DURING OR AFTER SERVICES ARE PROVIDED, INCLUDING ACCOUNTS IN COLLECTION.THE HILL-BURTON PACKET PROVIDED BY BUCKTAIL MEDICAL CENTER INCLUDES:-COVER LETTER DESCRIBING STEPS NEEDED IN ORDER TO APPLY-INDIVIDUAL NOTICE-APPLICATION-ITEMS REQUIRED FOR ELIGIBILITYHILL-BURTON INDIVIDUAL NOTICES ARE PUBLISHED THREE (3) TIMES IN A LOCAL NEWSPAPER OF GENERAL CIRCULATION TO ALL OF CLINTON COUNTY, PA AND CERTAIN AREAS OF POTTER COUNTY, PA. PART VI, LINE 4: THE MEDICAL CENTER IS NESTLED IN A SCENIC VALLEY ALONG THE WEST BRANCH OF THE SUSQUEHANNA RIVER IN THE TOWN OF RENOVO. THE TOWN AND OUTLYING COMMUNITIES HAVE A POPULATION OF APPROXIMATELY 3,600 AND ARE SURROUNDED BY THE LARGEST STATE FOREST LAND IN PENNSYLVANIA; LENDING ITS BEAUTY TO RESIDENTS AND VISITORS THROUGHOUT THE YEAR. THE 2009 ESTIMATED MEDIAN HOUSEHOLD INCOME WAS $20,277 WHICH IS WELL BELOW THE PENNSYLVANIA ESTIMATED HOUSEHOLD INCOME OF $49,520. APPROXIMATELY 35% OF RESIDENTS LIVE IN POVERTY. PART VI, LINE 6: THE MEDICAL CENTER IS A 64 BED FACILITY COMPRISED OF TWENTY-ONE (21) CRITICAL ACCESS HOSPITAL/SWING BEDS AND FORTY-THREE (43) SKILLED NURSING BEDS. THE CENTER PROVIDES A FULL-SERVICE EMERGENCY DEPARTMENT AND A COMMUNITY CLINIC, STAFFED WITH A BOARD CERTIFIED FAMILY PRACTICE PHYSICIAN AND CERTIFIED PHYSICIAN'S ASSISTANT. IN ADDITION, BUCKTAIL MEDICAL CENTER PROVIDES LABORATORY, RADIOLOGY, AMBULANCE, OCCUPATIONAL THERAPY, PHYSICAL THERAPY AND SPEECH THERAPY SERVICES. THE BOARD OF TRUSTEES IS MADE UP OF INDIVIDUALS WHO LIVE AND WORK IN THE COMMUNITY WHO VOLUNTEER THEIR TIME AND SERVICES TO ASSIST IN THE GOVERNANCE OF THE ORGANIZATION. THE ORGANIZATION USES SURPLUS FUNDS TO PROVIDE THE LATEST IN TECHNOLOGY TO IMPROVE PATIENT CARE. X X 0 0 0 0 0 0 0 0 0 ALVIN BERLOT DO 267815 0 0 0 0 0 0 0 0 0 267815 0 0 0 0 DAVID KNAUFF FAMILY MEMBER OF ANNA KNAUFF, BOARD MEMBER 26465 EMPLOYEE OF BUCKTAIL MEDICAL CENTER 0 JOANN KNAUFF FAMILY MEMBER OF ANNA KNAUFF, BOARD MEMBER 20078 EMPLOYEE OF BUCKTAIL MEDICAL CENTER 0 FORM 990, PART VI, SECTION A, LINE 6 BUCKTAIL MEDICAL CENTER HAS TWO TYPES OF CORPORATE MEMBERS. THE FIRST TYPE OF CORPORATE MEMBER ARE THOSE INDIVIDUALS WHO LIVE WITHIN THE BMC SERVICE AREA AND PAY AN ANNUAL MEMBERSHIP FEE OF $15, WHICH IS SET BY THE BOARD OF DIRECTORS. THE SECOND TYPE OF CORPORATE MEMBER ARE THOSE INDIVIDUALS WHO WANT A LIFELONG MEMBERSHIP AND PAY A ONE TIME FEE OF $500. THESE INDIVIDUALS DO NOT NEED TO LIVE IN THE BMC SERVICE AREA. EACH CORPORATE MEMBER HAS THE RESPONSIBILITY TO VOTE FOR BOARD MEMBERS AT THE ANNUAL MEETING HELD IN APRIL OF EACH YEAR. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS OF THE ORGANIZATION HAVE THE RESPONSIBLITY TO VOTE FOR ANY OPEN SEATS ON THE BOARD. THIS ANNUAL MEETING IS HELD EACH YEAR IN APRIL. FORM 990, PART VI, SECTION B, LINE 11 BUCKTAIL MEDICAL CENTER HAS A CPA FIRM PREPARE ITS 990. THE RETURN IS COMPLETED IN DRAFT FORM AND REVIEWED BY MANAGEMENT OF THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 12C BUCKTAIL MEDICAL CENTER ANNUALLY REQUIRES ITS BOARD MEMBERS AND OFFICERS TO FILL OUT A CONFLICTS OF INTEREST FORM. DURING BOARD MEETINGS, IF AN INTERESTED PARTY HAS A CONFLICT OF INTEREST, HE OR SHE RECUSES THEMSELVES FROM VOTING. FORM 990, PART VI, SECTION B, LINE 15 BUCKTAIL MEDICAL CENTER'S BOARD OF DIRECTORS DETERMINES THE COMPENSATION OF THE TOP MANAGEMENT OFFICIAL, OFFICERS, AND KEY EMPLOYEES OF THE ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 18 BUCKTAIL MEDICAL CENTER MAKES ITS FORM 990 AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 AT THIS TIME, BUCKTAIL MEDICAL CENTER DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES, AND FINANCIAL STATEMENTS AVAILABLE TO THE GENERAL PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 549. TEMPORARILY RESTRICTED - NET ASSETS RELEASED FROM RESTRICTIONS -15,405. TOTAL TO FORM 990, PART XI, LINE 5: -14,856. FORM 990, PART XII, LINE 2C THE BOARD OF DIRECTORS OF BUCKTAIL MEDICAL CENTER ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND SELECTION OF THE INDEPENDENT ACCOUNTANT. THE PROCESS IS CONSISTENT WITH PRIOR YEARS AND HAS NOT CHANGED. FORM 990, PART VI, SECTION A, LINE 1A LENNEA BROWN, BOARD PRESIDENT DOES NOT VOTE ON GENERAL ISSUES EXCEPT IN CASE OF A TIE.