2012-05-14T13:25:17-05:00 2011-06-30 PARENTEBEARD LLC 400 MARKET STREET WILLIAMSPORT PA 17701 990 2010-07-01 231352202 SCHUYLKILL MEDICAL CTR - SOUTH JACKSON ST F/K/A POTTSVILLE HOSP & WARNE CLINIC SCHU 5706215000 MAUCH CHUNK AND JACKSON STREETS POTTSVILLE PA 17901 JOHN E SIMODEJKA PRESIDENTCEO 5706215000 2012-05-14 1 JULIUS C GREEN CPA JD 5703236023 2010 2016-02-24 21:20:13Z JOHN E SIMODEJKA MAUCH CHUNK AND JACKSON STREETS POTTSVILLE PA 17901 93049464 0 X WWW.SCHUYLKILLHEALTH.COM X 2008 PA TO MAKE A POSITIVE DIFFERENCE IN THE SCOPE AND QUALITY OF HEALTHCARE FOR THE SCHUYLKILL COMMUNITY. 14 14 1015 41 0 0 544967 754767 83501318 88312632 437375 146522 984080 3778843 85467740 92992764 1500 8891 0 0 50309031 50186039 0 0 0 44776149 42979128 95086680 93174058 -9618940 -181294 58009848 53301818 82936836 64218346 -24926988 -10916528 X SCHUYLKILL MEDICAL CENTER - SOUTH JACKSON STREET'S MISSION IS TO MAKE A POSITIVE DIFFERENCE IN THE SCOPE AND QUALITY OF HEALTHCARE AVAILABLE FOR THE SCHUYLKILL COUNTY COMMUNITY. 0 0 77031055 8891 88478088 IN FISCAL YEAR 2011, SCHUYLKILL MEDICAL CENTER - SOUTH JACKSON STREET ADMITTED 8,730 INPATIENTS, PROVIDED EMERGENCY CARE FOR 30,675 PEOPLE, DELIVERED MORE THAN 1,030 BABIES, DID MORE THAN 13,600 HOME HEALTH CARE VISITS AND PROVIDED MORE THAN 92,200 OUTPATIENT TESTS AND PROCEDURES.THE SCHUYLKILL HEALTH SYSTEM HAS A COMPREHENSIVE CHARITY CARE PROGRAM. CHARGES FOREGONE FOR SERVICES RENDERED AND SUPPLIES FURNISHED UNDER THIS PROGRAM AMOUNTED TO $1,800,000 DURING FISCAL YEAR 2011.SCHUYLKILL HEALTH IS COMMITTED TO THE PHYSICAL, MENTAL, AND EMOTIONAL HEALTH OF OUR ENTIRE COMMUNITY. AS A HEALTHCARE FACILITY, WE ARE CONCERNED WITH THE HEALTH AWARENESS OF OUR NEIGHBORS, FAMILY, AND FRIENDS.OUR COMMUNITY LOOKS TO US TO HELP EDUCATE THEM ON CURRENT HEALTH CARE TOPICS AS WELL AS THE EVERYDAY HEALTH ISSUES THAT CONCERN EVERYONE. THROUGH OUR INITIATIVES WE CAN REACH OUT AND HELP OTHERS UNDERSTAND WHERE TO GO, WHAT TO ASK, AND WHO TO SEE FOR THEIR HEALTHCARE NEEDS. WE CAN GIVE OUR COMMUNITY THE CONFIDENCE THEY NEED WHEN MAKING WISE CHOICES. SCHUYLKILL MEDICAL CENTER HOSTS APPROXIMATELY TWELVE (12) COMMUNITY HEALTH AWARENESS TALKS ("CHAT") A YEAR. MONTHLY PROGRAMS ARE HELD ON CAMPUS OR CHAT ON THE ROADS. CHAT TOPICS HAVE INCLUDED, BUT ARE NOT LIMITED TO NUTRITION, PHYSICAL FITNESS, DIABETES AWARENESS, BREAST CANCER AWARENESS, CANCER, ARTHRITIS, SEIZURE TREATMENTS, AND HEART HEALTH TO NAME A FEW.SCHUYLKILL HEALTH ALSO SPONSORS AN ANNUAL "WOMEN'S DAY"; WOMEN HAVE GATHERED OVER THE PAST SEVEN YEARS TO ATTEND A FREE EVENT. ALL GENERATIONS ENJOY BEING EDUCATED, HAVING THE ABILITY TO ASK QUESTIONS IN A COMFORTABLE SETTING WHILE SPENDING TIME WITH OLD AND NEW FRIENDS, AND SIPPING ON THAT GREAT CUP OF COFFEE. WE EXPLORE THE "WHOLE" PERSON - BODY, MIND, AND SPIRIT AND ENABLE THEM TO CAPTURE INFORMATION TO SHARE WITH OTHERS AT HOME, WORK, OR IN THEIR NEIGHBORHOOD.SCHUYLKILL MEDICAL CENTER HOSTS A CANCER SUPPORT GROUP FOR CANCER SURVIVORS, FAMILY AND CARE GIVERS. EACH MONTH, A GROUP OF SURVIVORS GATHER TO TALK ABOUT RECENT TREATMENT, HOW THEY ARE FEELING AND TO CELEBRATE LIFE. WE ALSO HOST A GENTLE YOGA WELLNESS PROGRAM FOR SURVIVORS AND CARE GIVERS. THOSE IN ATTENDANCE HAVE SLEPT BETTER, THEIR "HOT FLASHES" HAVE CEASED, AND THEY ARE ABLE TO RELAX. WE HOLD A FREE SKIN CANCER SCREENING TO THE GENERAL PUBLIC. WE SCREEN APPROXIMATELY 125 PEOPLE AND REFER APPROXIMATELY 50 PEOPLE. THIS SCREENING SAVES LIVES. DIABETES NUMBERS CONTINUE TO RISE, ESPECIALLY IN SCHUYLKILL COUNTY. WE OFFER FREE DIABETES EDUCATION ALONG WITH A DIABETES SUPPORT GROUP.WE ALSO HOLD A 5K WALK/RUN FOR DIABETES, THE GOAL IS TO INCREASE THE AWARENESS AND RISKS ASSOCIATED WITH DIABETES. APPROXIMATELY 150 RUNNERS AND 200 WALKERS PARTICIPATE AS WELL AS NUMEROUS FRIENDS AND FAMILY TAKE ADVANTAGE OF INFORMATION PRESENTATIONS.FREE HEALTH SCREENINGS AND WELLNESS PROGRAMS ARE HELD THROUGHOUT THE YEAR AT VARIOUS LOCATIONS IN OUR COMMUNITY. BLOOD PRESSURES, BODY FAT, BONE DENSITY SCREENINGS ARE JUST A FEW OF THE SERVICES WE PROVIDE AT NO COST TO OUR COMMUNITY. 77031055 1 1 0 1 0 0 0 0 0 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 39 0 1 1015 1 0 0 0 0 0 0 0 0 0 0 X 14 14 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 PA X BERNIE KOSKULITZ DIRECTOR FINANCE 5706215142 420 SOUTH JACKSON STREET POTTSVILLE PA 17901 X JESSE ACHENBACH 1.00 X 0 0 0 ANTHONY BARAN 1.00 X 0 0 0 DEBRA BLASCHAK 1.00 X 0 0 0 SARAH CASEY 1.00 X 0 0 0 JAMES GALLAGHER EDD 1.00 X 0 0 0 WILLIAM L JONES III 1.00 X 0 0 0 ALLEN E KIEFER 1.00 X 0 0 0 FRANKLIN K SCHOENEMAN 1.00 X 0 0 0 SYED SHAH MD 1.00 X 0 0 0 ROBERT M ZIMMERMAN JRD 1.00 X 0 0 0 JUDGE JOSEPH F MCCLOSKEY 1.00 X X 0 0 0 JUDGE WILLIAM BALDWIN 1.00 X X 0 0 0 JAY M LINARD 1.00 X X 0 0 0 WILLIAM KIRWAN CPA ESQ 1.00 X X 0 0 0 JOHN E SIMODEJKA 14.00 X 401645 0 15152 DIANE BORIS 16.00 X 0 107241 19293 DANIEL KOCHIE 20.00 X 0 169330 17206 DARNELL FURER 20.10 X 0 170991 5777 RICHARD BINDIE 37.50 X 275009 0 13228 LYNDA L JAKUBCO 37.50 X 219665 0 13205 JULIANNE M TIDMORE 37.50 X 230511 0 14195 MARY R TUNNESSEN 37.50 X 217322 0 13205 SHERRY L BURINSKY BOTTOR 37.50 X 248586 0 14195 1592738 447562 125456 24 0 1 0 SODEXHO INC & AFFILIATES PO BOX 360170 PITTSBURGH PA 15251 DIETARY 1114492 QUEST DIAGNOSTICS INC 12436 COLLECTIONS CENTER DRIVE CHICAGO IL 60693 REFERENCE LAB SERVICE 915187 ARAMARK 450 WASHINGTON STREET POTTSVILLE PA 17901 CLINICAL ENGINEERING AND ENVIRONMENTAL 636743 CAPITAL REGION SLEEP DISORDERS 3450 W CENTRAL AVE SUITE 118 TOLEDO OH 43606 SLEEP LAB 439600 GEISINGER MEDICAL CENTER 100 NORTH ACADEMY AVENUE DANVILLE PA 17822 REFERENCE LAB SERVICE 413940 15 101030 653737 754767 NET PATIENT SERVICE RE 621400 87760183 87760183 SCHOOL OF NURSING 621400 552449 552449 88312632 155280 155280 38594 32685 5909 5909 5909 15257 24015 -8758 -8758 -8758 MEANINGFUL USE REVENUE 561439 2292640 2292640 TOBACCO SETTLEMENT FUN 561439 581022 581022 CAFETERIA & VENDING 561439 329195 329195 570077 165456 404621 3772934 92992764 88478088 0 3759909 6156 6156 2735 2735 39457063 32545599 6911464 2446128 2017654 428474 5451399 5404716 46683 2831449 2353987 477462 120800 120800 136560 136560 23245 23245 10074432 6307465 3766967 74259 74259 11403581 10329832 1073749 1425993 16358 1409635 103136 87020 16116 45660 17429 28231 1727400 1727400 4678100 4678100 921924 921924 BAD DEBT EXPENSE 6837337 6837337 DRUGS 3129883 3129883 COLLECTION FEES 1057341 1057341 FOOD 561883 561883 DATA PROCESSING 385573 6220 379353 272021 56112 215909 93174058 77031055 16143003 0 1501 1500 7261412 5035733 11117885 9154975 1172916 1092255 337106 464788 77315938 52625761 27892032 24690177 1114845 842343 4757060 4996659 4355091 7023388 58009848 53301818 46816945 31535205 463750 393750 27982666 26744238 1500000 1500000 6173475 4045153 82936836 64218346 X -28705281 -15269200 24001 34724 3754292 4317948 -24926988 -10916528 58009848 53301818 X -181294 14191754 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 11995 1 11250 0 0 23245 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: A PORTION OF THE HOSPITAL'S DUES PAID TO THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE HOSPITAL ASSOCIATION OF PENNSYLVANIA (HAP) ARE USED FOR LOBBYING PURPOSES. BOB ALLEN WORKED ON BEHALF OF THE HOSPITAL WITH GOVERNMENTAL OFFICIALS AND REPRESENTATIVES OF AND CONSULTANTS TO STATE AND LOCAL GOVERNMENTAL AGENCIES, BOARDS, COMMITTEES AND COMMISSIONS, INCLUDING WITHOUT LIMITATION MEETINGS WITH SUCH OFFICIALS, REPRESENTATIVES AND CONSULTANTS, REGARDING LEGISLATIVE, REGULATORY AND OTHER ISSUES THAT AFFECT THE INTERESTS AND AFFAIRS OF THE HOSPITAL AS MAY BE ASSIGNED BY THE HOSPITAL FROM TIME TO TIME. BOB ALLEN ALSO ATTENDS AND REPORTS AT HOSPITAL BOARD MEETINGS AND STAFF MEETINGS, IF REQUIRED. BOB ALLEN ALSO PERFORMS SUCH OTHER TASKS AND ACTIVITIES OF A GENERAL GOVERNMENTAL RELATIONS NATURE AS MAY BE ASSIGNED BY THE HOSPITAL FROM TIME TO TIME. 745633 745633 48616444 32992633 15623811 26800871 19481591 7319280 1152990 151537 1001453 24690177 FEDERAL AGENCY OBLIGATIONS 1754635 F ACCRUED INVESTMENT INCOME 14132 F INVESTMENT IN PENNSYLVANIA COMMUNITY HOSPITAL ASSOCIATION 3227892 C 4996659 BENEFICIAL INTEREST IN PERPETUAL TRUST 3926067 DEFERRED FINANCING COSTS, NET 71760 BENEFICIAL INTEREST IN ASSETS HELD BY FOUNDATION 68899 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 2956662 7023388 OBLIGATION UNDER CAPITAL LEASE 2646624 BLUE CROSS CURRENT FINANCING ADVANCE 479000 ESTIMATED MEDICAL MALPRACTICE CLAIMS LIABILITY 639467 DUE TO AFFILIATES 280062 4045153 92992764 93174058 -181294 14191754 14191754 14010460 107217203 14191754 14191754 93025449 -32685 -32685 92992764 93206743 32685 32685 93174058 0 93174058 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE CORPORATION PRESCRIBES A RECOGNITION THRESHOLD OF MORE-LIKELY-THAN-NOT TO BE SUSTAINED UPON EXAMINATION BY THE APPROPRIATE TAXING AUTHORITY IN RECORDING TAX LIABILITIES IN THE FINANCIAL STATEMENTS. MEASUREMENT AND RECOGNITION OF THE TAX INCERTAINTY OCCURS IF THE RECOGNITION THRESHOLD HAS BEEN MET. FEDERAL EXEMPT ORGANIZATION BUSINESS INCOME TAX RETURNS FOR THE MEDICAL CENTERS, THE FOUNDATION, SMG, AND THE CENTERS FOR 2010, 2009, AND 2008 REMAIN SUBJECT TO EXAMINATION BY THE IRS. PART XI, LINE 8 - OTHER ADJUSTMENTS: PENSION LIABILITY ADJUSTMENT 13,658,726. POSTRETIREMENT BENEFIT LIABILITY ADJUSTMENT -136,818. INCREASE IN NET ASSETS OF AFFILIATE 106,190. VALUATION GAIN 563,656. PART XII, LINE 2D - OTHER ADJUSTMENTS: POST RETIREMENT BENEFIT LIABILITY ADJUSTMENT -136,818. INCREASE IN INTEREST IN NET ASSETS OF AFFILIATE 106,190. VALUATION GAIN 563,656. PENSION LIABILITY ADJUSTMENT 13,658,726. PART XII, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -32,685. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 32,685. 1 1 1 X 250.000000000000 1 X 1 1 0 0 446060 446060 0.00520 12600568 9387544 3213024 0.03720 13046628 9387544 3659084 0.04240 124877 124877 0.00140 33696 1750 31946 0.00040 4574141 3047481 1526660 0.01770 4732714 3049231 1683483 0.01950 17779342 12436775 5342567 0.06190 1232 1232 0.00000 50 50 0.00000 246 246 0.00000 423 423 0.00000 26092 26092 0.00030 28043 28043 0.00030 1 6837337 2780847 28189782 29836249 -1646467 X 1 1 1 1 SCHUYLKILL MEDICAL CENTER SOUTH JACKSON

420 SOUTH JACKSON STREET POTTSVILLE PA 17901

X X X NOT REQUIRED 1 PART I, LINE 7: SCHUYLKILL MEDICAL CENTER - SOUTH COMPUTED A COST TO CHARGE RATIO USING INFORMATION FROM THE MOST RECENTLY FILED MEDICARE COST REPORT (FYE 6/30/11) FOR THE CALCULATION OF COSTS FOR CHARITY CARE AND MEDICAID. DIRECT COSTS ARE OBTAINED FROM THE HOSPITAL COMPUTER SYSTEM FOR EACH COST CENTER FOR ALL OTHER BENEFITS. INDIRECT COSTS ARE COMPUTED UTILIZING THE MOST RECENTLY FILED MEDICARE COST REPORT (FYE 6/30/11). PART I, LINE 7G: THERE ARE NO PHYSICIAN CLINICAL SERVICES INCLUDED. PART I, L7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25 COLUMN (A) BUT SUBTRACTED OUT FOR PURPOSES OF CALCULATING THE PERCENTAGE ON SCH H, PART I, LINE 7, COLUMN (F) IS $6,837,337. PART II: ECONOMIC DEVELOPMENT - SCHUYLKILL COUNTY CHILD DEVELOPMENT POLICY COUNCIL, CHILD DEVELOPMENT IS A DAY CARE PROGRAM IN SCHUYLKILL COUNTY THAT IS PROVIDED TO ANYONE BUT IS FOCUSED ON CHILDREN OF PARENTS WHO CANNOT AFFORD TO PAY THE FULL COST OF DAYCARE. IF THIS SERVICE WAS NOT AVAILABLE FOR THESE PARENTS, THEY WOULD NOT BE ABLE TO WORK BECAUSE THEY WOULD HAVE TO STAY HOME TO TAKE CARE OF THEIR CHILDREN. WE HAVE A CLINICAL RN CHARGE NURSE WHO ATTENDS THE MEETINGS AND IS A MEMBER OF THIS POLICY COUNCIL.COMMUNITY SUPPORT - BRIDGE HOUSE OF SCHUYLKILL COUNTY - THE BRIDGE HOUSING PROGRAM IS A TRANSITIONAL HOUSING SERVICE LOCATED ON THE GROUNDS OF THE POTTSVILLE HOUSING AUTHORITY AT LAUREL TERRACE, POTTSVILLE, PENNSYLVANIA. BRIDGE HOUSING PROVIDES COMPREHENSIVE SERVICES TO PERSONS FACING LONG-TERM HOMELESSNESS AND PROVIDES A SUPPORTIVE, SAFE ENVIRONMENT FOR ADULTS AND CHILDREN. STUDENTS FROM THE SCHOOL OF NURSING PROVIDE TALKS TO RESIDENTS ABOUT SEVERAL DIFFERENT HEALTH TALKS INCLUDING PARENTING AND HEALTH PREVENTION.COALITION BUILDING - SCHUYLKILL COUNTY CHILD DEVELOPMENT HEALTH ADVISORY - FOR THIS WE HAVE ONE OF OUR SCHOOL OF NURSING INSTRUCTORS ADVISE CHILD DEVELOPMENT ON CERTAIN HEALTH MATTERS. THIS HELPS FORM A PARTNERSHIP OR COALITION WITH SCHUYLKILL COUNTY CHILD DEVELOPMENT.WORKFORCE DEVELOPMENT - SCHUYLKILL TRAINING AND TECHNOLOGY CENTER PROVIDES ASSISTANCE AND GUIDANCE TO THE LPN PROGRAM AT THE TRAINING & TECHNOLOGY CENTER AND ALSO KEEPS THE ADMINISTRATION AND LPN PROGRAM FACULTY UP TO DATE ON HEALTH CARE RELATED INFORMATION. THIS HELPS TO ENSURE THE LPN PROGRAM HAS A BACKGROUND THAT IS UP TO DATE TO PROVIDE THE STUDENTS TO ENTER THE WORKFORCE RIGHT AFTER GRADUATION. PART III, LINE 4: ACCOUNTS RECEIVABLE, OTHER 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 INDIVIDUAL ACCOUNTS.ALL APPROPRIATE DISCOUNTS AND PAYMENTS ARE REFLECTED ON EACH PATIENTS' ACCOUNT. ONCE A PATIENT IS IDENTIFIED AS BAD DEBT, THE BALANCE THAT IS BAD DEBT WOULD BE CHARGES NET OF ANY PAYMENTS OR ADJUSTMENTS. THE COST OF BAD DEBT EXPENSE IS CALCULATED BY USING THE COST TO CHARGE RATIO FROM THE MOST RECENTLY FILE MEDICARE COST REPORT AND APPLYING THAT TO THE CHARGE.WE BELIEVE THAT A PORTION OF OUR BAD DEBTS RESULTS FROM SERVICES PROVIDED TO PATIENTS WHO MEET THE CHARITY CARE GUIDELINES BUT WERE UNABLE OR UNWILLING TO PROVIDE THE APPROPRIATE DOCUMENTATION TO ALLOW THAT CLASSIFICATION. THESE WOULD BE CLASSIFIED AS BAD DEBT EXPENSE TIMES THE COST TO CHARGE RATIO TO ARRIVE AT THE COST. PART III, LINE 8: THE HOSPITAL CONTINUES TO PROVIDE CARE TO ALL PRESENTING AND ADMITTED PATIENTS, REGARDLESS OF ABILITY OR PAY. NOTWITHSTANDING THE COSTS TO PROVIDE CARE, RECEIVING "LESS" THAN WHAT IT COSTS TO PROVIDE ADEQUATE CARE TO MEDICARE COVERED LIVES DOES THE HOSPITAL A DISSERVICE. THIS SHORTFALL SHOULD COUNT AS A COMMUNITY BENEFIT. THE HOSPITAL USES THE COST-TO-CHARGE RATIO TO DETERMINE THE MEDICARE ALLOWABLE COSTS. PART III, LINE 9B: THE ORGANIZATION DOES HAVE A WRITTEN DEBT COLLECTION POLICY. ALL STAFF INVOLVED IN DEBT COLLECTION (EMPLOYEES OF THE MEDICAL CENTER AND ANY THIRD PARTY AGENCIES) ARE TRAINED ON THE POLICY AS WELL AS THE CHARITY CARE POLICY. IN DEALING WITH PATIENTS IN DEBT COLLECTION, STAFF WILL INFORM PATIENTS OF THE CHARITY CARE POLICY THAT IS AVAILABLE AND ALSO ANY OTHER FINANCIAL ASSISTANCE POLICIES OF THE MEDICAL CENTER THAT MAY BE APPLICABLE TO THE PATIENT. THE STAFF WILL INSTRUCT PATIENTS ON APPROPRIATE PAPERWORK THAT NEEDS TO BE COMPLETED IN REGARDS TO CHARITY CARE OR FINANCIAL ASSISTANCE. PART VI, LINE 2: SCHUYLKILL MEDICAL CENTER - SOUTH JACKSON STREET (SMS-SJS) WORKS WITH SCHUYLKILL MEDICAL CENTER - EAST NORWEGIAN STREET (SMS-ENS) IN ASSESSING THE HEALTH NEEDS OF THE COMMUNITY IT IS LOCATED IN AND SERVES; SCHUYLKILL COUNTY IN PENNSYLVANIA. BOTH MEDICAL CENTERS ALSO WORK WITH VARIOUS CITY, COUNTY AND STATE AGENCIES TO SPECIFICALLY IDENTIFY THE HEALTH NEEDS OF THE RESIDENTS OF SCHUYLKILL COUNTY.SMC-SJS IS LOCATED IN POTTSVILLE, WHICH IS THE COUNTY SEAT FOR SCHUYLKILL COUNTY. SCHUYLKILL COUNTY IS A RURAL COUNTY. THE COUNTY HAS AN UNEMPLOYMENT RATE OF OVER 11%, 19% OF THE RESIDENTS ARE COVERED BY MEDICAID, AND 18% OF THE RESIDENTS ARE OVER THE AGE OF 65.SMC-SJS IS A 180 BED ACUTE CARE FACILITY THAT PROVIDES ACUTE MEDICAL SURGICAL CARE, ADOLESCENT AND ADULT BEHAVIORAL HEALTH SERVICES, AND TRANSITIONAL REHAB CARE AND NURSERY SERVICES TO THE COMMUNITY.SMC-SJS WORKS WITH THE SOCIAL SERVICE AGENCIES, LOCAL DEPARTMENT OF HEALTH, THE CHAMBER OF COMMERCE, UNITED WAY, AMERICAN CANCER SOCIETY, LOCAL SCHOOLS, LOCAL SUPPORT GROUPS, PHYSICIAN OFFICES AND OTHER HEALTHCARE ORGANIZATIONS IN IDENTIFYING THE HEALTHCARE NEEDS OF THE LOCAL COMMUNITIES AND THE SERVICES THAT ARE NEEDED. AFTER A NEED HAS BEEN IDENTIFIED, THE MEDICAL CENTER WORKS WITH THESE ORGANIZATIONS TO HELP PROVIDE THE SERVICE TO RESIDENTS.THE MEDICAL CENTER ALSO WORKS WITH HEALTHCARE ORGANIZATIONS OUTSIDE SCHUYLKILL COUNTY TO HELP BRING HEALTHCARE SERVICES TO THE COUNTY. THIS ALLOWS COUNTY RESIDENTS TO OBTAIN NECESSARY SERVICES CONVENIENTLY WITHIN THE COUNTY.THE MEDICAL CENTER ALSO REVIEWS INTERNAL DATA ON ADMISSIONS, EMERGENCY ROOM VISITS, CLINIC VISITS AND DIAGNOSIS TO HELP IDENTIFY COMMUNITY NEEDS. THIS INFORMATION IS REVIEWED ANNUALLY AS PART OF THE BUDGET AND STRATEGIC PLANNING PROCESS.THE BOARD OF THE MEDICAL CENTER IS COMPRISED OF INDIVIDUALS FROM THE COMMUNITY REPRESENTING SOCIAL SERVICE AGENCIES, EDUCATION, ASSISTED LIVING/LONG TERM CARE, PHYSICIANS, MATERNAL/CHILD HEALTH AND LOCAL BUSINESSES. THESE INDIVIDUALS ALSO PROVIDE INPUT ON THE NEEDS OF THE COMMUNITY IN MEETING HEALTHCARE NEEDS. PART VI, LINE 3: EACH PATIENT IS REGISTERED INTO THE HOSPITAL COMPUTER SYSTEM WHEN THEY ARRIVE FOR SERVICES. AS PART OF THE REGISTRATION, INFORMATION IS OBTAINED ON ANY HEALTH INSURANCE THEY HAVE. INDIVIDUALS WITHOUT HEALTH INSURANCE ARE INFORMED AT THAT TIME OF THE MEDICAL CENTER'S CHARITY CARE POLICY. PATIENTS ARE GIVEN INFORMATION ON CONTACTING STAFF WITHIN THE HOSPITAL PATIENT ACCOUNTING DEPARTMENT TO DISCUSS APPLYING FOR THE HOSPITAL CHARITY CARE PROGRAM. SPECIFIC STAFF HAVE BEEN TRAINED AND ARE RESPONSIBLE FOR ADMINISTERING THE CHARITY CARE PROGRAM FOR THE HOSPITAL. HOSPITAL STAFF CONTACT PATIENTS WITHOUT INSURANCE AND EXPLAIN THE POLICY AND THE INFORMATION NEEDED TO APPLY. HOSPITAL STAFF WILL ALSO ASSIST PATIENTS IN APPLYING FOR MEDICAL ASSISTANCE. THEY WILL ALSO ASSIST PATIENTS IN COMPLETING THE APPLICATION AND GATHERING THE NECESSARY FINANCIAL DOCUMENTS.THE MEDICAL CENTER ALSO POSTS INFORMATION WITHIN THE ADMISSION AND EMERGENCY ROOM AREAS INFORMING PATIENTS THAT THERE IS A CHARITY CARE POLICY AVAILABLE. ALL REGISTRATION PERSONNEL ARE TRAINED ON THE POLICY SO THAT THEY ARE ABLE TO INFORM PATIENTS WHEN THEY ARE REGISTERED.OTHER HOSPITAL STAFF MEMBERS THAT MAY COME IN CONTACT WITH PATIENTS ARE ALSO EDUCATED REGARDING THE CHARITY CARE POLICY. THIS WOULD INCLUDE SOCIAL WORKERS, CARE MANAGERS, NURSING STAFF AND ALL DEPARTMENT DIRECTORS. THE CHARITY CARE POLICY IS AVAILABLE ON THE HOSPITAL INTRANET WHICH IS ACCESSIBLE BY ALL EMPLOYEES. THE HOSPITAL IS ALSO IN THE PROCESS OF PLACING THE POLICY ON THE HOSPITAL WEBSITE.ALL PATIENT ACCOUNTING, CASHIERING AND COLLECTION STAFF ARE ALSO EDUCATED ON THE CHARITY CARE POLICY AND CAN ASSIST PATIENTS IN APPLYING FOR CHARITY CARE. ALSO ALL THIRD PARTY ORGANIZATIONS THAT WORK ON BEHALF OF THE MEDICAL CENTER IN PERFORMING COLLECTIONS HAVE ALSO BEEN EDUCATED ON THE CHARITY CARE POLICY AND CAN ALSO ADVISE PATIENTS ON APPLYING FOR THIS BENEFIT. PART VI, LINE 4: SMC-SJS IS LOCATED IN POTTSVILLE, PENNSYLVANIA. THE MEDICAL CENTER SERVES ALL OF SCHUYLKILL COUNTY. SCHUYLKILL COUNTY IS A RURAL COUNTY IN PENNSYLVANIA. POTTSVILLE IS THE LARGEST POPULATION CENTER OF SCHUYLKILL COUNTY AND IS ALSO THE COUNTY SEAT. THE COUNTY IS COMPRISED OF SMALL TOWNS, BOROUGHS AND TOWNSHIPS.THE POPULATION OF THE COUNTY IS APPROXIMATELY 147,000. APPROXIMATELY 25% OF THE POPULATION IS UNDER THE AGE OF 18 AND 18% IS OVER THE AGE OF 65. THE POPULATION IS 49% FEMALE AND 96% WHITE. APPROXIMATELY 11% OF THE POPULATION HAS A BACHELOR'S DEGREE OR HIGHER. 12.4% OF THE POPULATION IS BELOW THE POVERTY LEVEL. THE UNEMPLOYMENT RATE IS 11.2%.19% OF THE POPULATION IS INSURED BY MEDICAID. 42% OF THAT NUMBER ARE UNDER THE AGE OF 18, 13% ARE OVER THE AGE OF 65 AND 18 % ARE DISABLED. 50% OF THE BIRTHS ARE COVERED BY THE MEDICAID PROGRAM.IN A RECENT REPORT RELEASED BY THE ROBERT WOOD JOHNSON FOUNDATION AND THE UNIVERSITY OF WISCONSIN'S POPULATION HEALTH INSTITUTE, SCHUYLKILL COUNTY WAS RANKED THE 56TH HEALTHIEST OF THE 67 COUNTIES IN PENNSYLVANIA. SCHUYLKILL COUNTY HAD HIGHER THAN THE STATE AND NATIONAL RATES FOR SMOKING, OBESITY, EXCESSIVE DRINKING AND MOTOR VEHICLE CRASH DEATH RATES. THIS REPORT ALSO SHOWED THAT THE COUNTY HAD ACCESS TO FEWER PRIMARY CARE PHYSICIANS.THE DEMOGRAPHICS OF THE PATIENTS ADMITTED TO SMC-SJS ARE 41 % MEDICARE, 24% MEDICAID AND 3% SELF PAY. EMERGENCY PATIENTS AT SMC-SJS ARE 14% MEDICARE, 25% MEDICAID AND 11% SELF PAY.SCHUYLKILL COUNTY HAS FOUR HOSPITALS SERVING THE COUNTY. SMC-SJS AND SCHUYLKILL MEDICAL CENTER - EAST NORWEGIAN STREET ARE BOTH LOCATED IN POTTSVILLE AND SERVE THE MAJORITY OF THE COUNTY RESIDENTS. SAINT CATHERINE MEDICAL CENTER IS LOCATED IN ASHLAND IN NORTHERN SCHUYLKILL COUNTY AND ST. LUKE'S MINERS MEMORIAL HOSPITAL IS LOCATED IN COALDALE NEAR THE CARBON COUNTY BORDER. PART VI, LINE 6: THE BOARD OF SMC - SJS IS COMPRISED OF TWELVE INDIVIDUALS FROM THE SCHUYLKILL COUNTY COMMUNITY. THESE INDIVIDUALS ARE NOT EMPLOYED BY THE MEDICAL CENTER. THEY ARE INVOLVED IN EDUCATION, SOCIAL SERVICES, GERIATRIC SERVICES, MATERNAL/CHILD SERVICES, PRIMARY MEDICAL CARE, CRIMINAL JUSTICE, SMALL BUSINESS AND MANUFACTURING. ALL PHYSICIANS ARE ENCOURAGED TO APPLY FOR MEDICAL STAFF PRIVILEGES FOR THE MEDICAL CENTER.SMC-SJS ALSO WORKS WITH VARIOUS COMMUNITY ORGANIZATIONS TO HELP IDENTIFY COMMUNITY NEEDS AND WORK TOGETHER TO MEET THOSE NEEDS. THE MEDICAL CENTER HAS INPATIENT ADOLESCENT AND ADULT BEHAVIORAL HEALTH SERVICES AVAILABLE TO THE RESIDENTS OF SCHUYLKILL COUNTY. THIS ALLOWS COUNTY RESIDENTS TO OBTAIN NECESSARY INPATIENT CARE WITHIN THE COUNTY WITHOUT REQUIRING FAMILIES TO TRAVEL OUTSIDE OF THE COUNTY. THE MEDICAL CENTER ALSO HAS A CERTIFIED DIABETES EDUCATOR AVAILABLE TO CONSULT WITH PATIENTS AND ALSO WITH PHYSICIANS WHEN THEY HAVE A PATIENT THAT IS NEWLY DIAGNOSED WITH DIABETES. THE MEDICAL CENTER IS ALSO THE ONLY FACILITY IN THE COUNTY WITH A MATERNITY DEPARTMENT AND NEWBORN NURSERY. THIS ALLOWS COUNTY RESIDENTS TO REMAIN IN THE COUNTY FOR MATERNITY CARE. MORE THAN 50% OF THE BIRTHS EACH YEAR ARE MEDICAID.THE EMERGENCY DEPARTMENT OF SMC-SJS IS A 24 HOUR EMERGENCY ROOM AVAILABLE TO ALL REGARDLESS OF THEIR ABILITY TO PAY. THE MEDICAL CENTER PARTICIPATES IN MANY INSURANCE PROGRAMS SUCH AS MEDICARE, MEDICAID, CHAMPUS AND VA. THE MEDICAL CENTER ALSO HAS A CHARITY CARE POLICY THAT PROVIDES ASSISTANCE TO ELIGIBLE INDIVIDUALS IN PROVIDING FREE OR DISCOUNTED CARE BASED ON THEIR ABILITY TO PAY AND THE FEDERAL POVERTY GUIDELINES.SMC-ENS ALSO PROVIDES OPPORTUNITIES TO STUDENTS IN HEALTHCARE FIELDS TO GAIN EXPERIENCE WORKING IN THE HEALTH CARE ENVIRONMENT SUCH AS NURSING STUDENTS (RN AND LPN), PHARMACY STUDENTS, PHYSICIAN ASSISTANT STUDENTS, PHYSICAL THERAPY STUDENTS, RADIOLOGY TECHNICIANS AND MEDICAL ASSISTANTS. THE MEDICAL CENTER ALSO PROVIDES A VOLUNTEER PROGRAM FOR JUNIOR HIGH AND HIGH SCHOOL STUDENTS TO BECOME FAMILIAR WITH THE MEDICAL SERVICES OFFERED AND THE EDUCATIONAL OPPORTUNITIES AVAILABLE WITHIN THE HEALTHCARE ENVIRONMENT.THE MEDICAL CENTER ALSO SPONSORS AND PARTICIPATES IN HEALTH FAIRS AT COMMUNITY EVENTS SUCH AS THE COUNTY FAIR, EVENTS AT THE LOCAL MALL, HEALTH SCREENINGS, BLOOD PRESSURE SCREENINGS, VETERAN'S BREAKFAST EVENT, MEALS ON WHEELS, SKIN CANCER SCREENINGS, MAMMOGRAPHY SCREENINGS, BLOOD PRESSURE CLINICS, SUPPORT GROUPS AND LOCAL AMERICAN CANCER SOCIETY RELAY FOR LIFE.ANY EXCESS FUNDS THAT ARE GENERATED FROM OPERATIONS ARE INVESTED BACK INTO THE MEDICAL CENTER BY PURCHASING NECESSARY CAPITAL EQUIPMENT, FUNDING CAPITAL IMPROVEMENT PROJECTS, FUNDING NEW SERVICES, IMPROVING AND EXPANDING EXISTING SERVICES AND ANY OTHER GENERAL IMPROVEMENTS TO PATIENT CARE. PART VI, LINE 7: ON AUGUST 1, 2008, SMC-SJS AND SMC-ENS AFFILIATED UNDER THE CONTROL OF SCHUYLKILL HEALTH SYSTEM, THE PRIMARY SERVICE AREA IS POTTSVILLE AND THE SURROUNDING COMMUNITIES IN SCHUYLKILL COUNTY. THE PURPOSE OF BOTH MEDICAL CENTERS IS TO ENGAGE IN ACTIVITIES RELATED TO THE PROMOTION OF HEALTH OF THE PEOPLE IN THE SERVICE AREA, WORK CHARITABLY TO PROMOTE COMMUNITY HEALTH EDUCATION, PREVENTION OF ILLNESS AND INJURY AND PROVISION OF MEDICAL SERVICES TO THE DIVERSE POPULATION OF THE SERVICE AREA AND ENGAGE IN ANY AND ALL ACTIVITIES CONSISTENT WITH OR IN FURTHERANCE OF THESE PURPOSES.EACH MEDICAL CENTER OPERATES INDEPENDENTLY OF EACH OTHER BUT WORKS IN SYNC WITH EACH OTHER IN PROVIDING HEALTHCARE SERVICES TO THE RESIDENTS OF SCHUYLKILL COUNTY. BOTH MEDICAL CENTERS HAVE WORKED TO PROVIDE A CONTINUUM OF CARE SO THAT HEALTHCARE IS AVAILABLE WITHIN THE COUNTY AND RESIDENTS DO NOT HAVE TO TRAVEL OUTSIDE OF THE COUNTY FOR CARE. THE FOLLOWING SERVICES ARE AVAILABLE AT EITHER SMC-SJS OR SMC-ENS: - ACUTE CARE /MEDICAL SURGICAL SERVICES- INTENSIVE CARE SERVICES- MATERNITY SERVICES- NEWBORN SERVICES- PEDIATRICS SERVICES- ADOLESCENT, ADULT AND GERIATRIC BEHAVIORAL SERVICES- ACUTE REHAB AND TRANSITIONAL REHAB SERVICES- INPATIENT AND OUTPATIENT PHYSICAL THERAPY- INPATIENT AND OUTPATIENT DIAGNOSTIC SERVICES- HOME HEALTH SERVICES- OUTPATIENT DRUG AND ALCOHOL SERVICES- OUTPATIENT BEHAVIORAL HEALTH SERVICES- 24 HOUR EMERGENCY ROOM SERVICES- OUTPATIENT DENTAL CLINIC- INPATIENT AND OUTPATIENT SURGICAL SERVICES- COMMUNITY BENEFIT/CHARITY CARE SERVICES- ADVANCE WOUND CARE - OUTPATIENT SURGERY CENTERPART VI, LINE 7: N/A 0 X X X 0 0 0 0 0 0 0 0 0 JOHN E SIMODEJKA 401645 0 0 0 0 0 0 0 15152 0 416797 0 0 0 DANIEL KOCHIE 0 131830 0 0 0 37500 0 0 0 17206 0 186536 0 0 DARNELL FURER 0 170991 0 0 0 0 0 3427 0 2350 0 176768 0 0 RICHARD BINDIE 275009 0 0 0 0 0 0 0 13228 0 288237 0 0 0 LYNDA L JAKUBCO 219665 0 0 0 0 0 0 0 13205 0 232870 0 0 0 JULIANNE M TIDMORE 230511 0 0 0 0 0 0 0 14195 0 244706 0 0 0 MARY R TUNNESSEN 217322 0 0 0 0 0 0 0 13205 0 230527 0 0 0 SHERRY L BURINSKY BOTTOR 248586 0 0 0 0 0 0 0 14195 0 262781 0 0 0 FORM 990, PART VI, SECTION A, LINE 3 THE HOSPITAL HAS DELEGATED MANAGEMENT DUTIES OVER ITS DIETARY SERVICES TO SODEXHO INC. AND AFFILIATES. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED BY MANAGEMENT PRIOR TO ITS FILING WITH THE INTERNAL REVENUE SERVICE. SELECTED MEMBERS OF THE BOARD REVIEWED THE 990 WITH THE TAX RETURN PREPARER AND MANAGEMENT ON BEHALF OF THE BOARD. FORM 990, PART VI, SECTION B, LINE 12C EACH OFFICER, KEY EMPLOYEE, DIRECTOR OR TRUSTEE WITH BOARD DELEGATED AUTHORITY IS REQUIRED TO ANNUALLY SIGN A CONFLICT OF INTEREST DISCLOSURE STATEMENT. THESE STATEMENTS ARE REVIEWED BY THE PRESIDENT/CEO'S ADMINISTRTIVE ASSISTANT AND ANY CONFLICTS ARE REPORTED TO THE PRESIDENT/CEO. THE STATEMENTS ARE KEPT ON FILE IN THE PRESIDENT/CEO'S OFFICE AFTER REVIEW. BOARD MEMBERS ARE EXPECTED TO EXCUSE THEMSELVES FROM TAKING ANY ACTION OR EVEN DISCUSSING ISSUES OF RELATED PARTIES. IF THEY VIOLATE THESE RULES THEY ARE REMOVED FROM THE BOARD. FORM 990, PART VI, SECTION B, LINE 15 ANNUALLY, THE ORGANIZATION CONTRACTS WITH JAFFE AND COMPANY, AN INDEPENDENT CONSULTANT, TO MAKE RECOMMENDATIONS TO THE COMPENSATION COMMITTEE, A SUB COMMITTEE OF THE BOARD, BASED ON MARKET AND INDUSTRY DATA TO ENSURE COMPENSATION DOES NOT EXCEED FAIR MARKET VALUE. THIS PROCESS IS USED FOR THE FOLLOWING POSITIONS PRESIDENT/CEO, VICE PRESIDENT OF OPERATIONS/COO, VICE PRESIDENT OF NURSING/CNO AND THE VICE PRESIDENT OF FINANCE/CFO. THIS REVIEW AND APPROVAL PROCESS IS DOCUMENTED VIA COMMITTEE MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VII, SECTION A: THE FOLLOWING INDIVIDUALS WORK AN AVERAGE OF 40 HOURS PER WEEK FOR ALL SCHUYLKILL RELATED ENTITIES: DARNELL FURER DANIEL KOCHIE JOHN SIMODEJKA DIANE BORIS CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: PENSION LIABILITY ADJUSTMENT 13,658,726. POSTRETIREMENT BENEFIT LIABILITY ADJUSTMENT -136,818. INCREASE IN NET ASSETS OF AFFILIATE 106,190. VALUATION GAIN 563,656. TOTAL TO FORM 990, PART XI, LINE 5: 14,191,754. STATEMENT PURSUANT TO SECTION 1.351-3(A) STATEMENT PURSUANT TO SECTION 1.351-3(A) BY SCHUYLKILL MEDICAL CENTER - SOUTH JACKSON STREET 23-1352202 (1) NAME AND EMPLOYER IDENTIFICATION NUMBER OF THE TRANSFEREE CORPORATION: NAME: SCHUYLKILL MEDICAL CENTER - SOUTH JACKSON STREET EIN: 23-1352202 (2) DATE(S) OF TRANSFER(S) OF ASSETS: TRANSFER DATE(S): 9/22/2010 AND 03/04/2011 (3) AGGREGATE FAIR MARKET VALUE AND BASIS OF PROPERTY TRANSFERRED: FAIR MARKET VALUE: $237,125 AND $150,000 BASIS: $237,125 AND $150,000 (4) DATE AND CONTROL NUMBER OF PRIVATE LETTER RULING(S) ISSUED BY THE IRS IN CONNECTION WITH THE EXCHANGE: DATE(S) AND CONTROL NUMBER(S): NONE SCHUYLKILL REHABILITATION CENTER INC 420 SOUTH JACKSON STREET POTTSVILLE PA 17901 232440891 OPERATES A COMPREHENSIVE REHABILITATION FACILITY PA 501(C)(3) 3 SCHUYLKILL HEALTH SYSTEM 0 SCHUYLKILL HEALTH SYSTEM FOUNDATION EAST NORWEGIAN TREMONT STREETS POTTSVILLE PA 17901 222793805 SOLICIT, RECEIVE, MAINTAIN AND INVEST MONEY FOR CHARITABLE PURPOSES PA 501(C)(3) 7 SCHUYLKILL HEALTH SYSTEM 0 SCHUYLKILL MEDICAL CENTER - EAST NORWEGIAN STREET 700 EAST NORWEGIAN STREET POTTSVILLE PA 17901 230880420 OPERATES A HOSPITAL PROVIDING INPATIENT, OUTPATIENT & EMERGENCY SVCS PA 501(C)(3) 3 SCHUYLKILL HEALTH SYSTEM 0 SCHUYLKILL HEALTH SYSTEM MEDICAL GROUP INC 700 EAST NORWEGIAN STREET POTTSVILLE PA 17901 232866006 TO SUPPORT AND PROMOTE THE PURPOSES OF AFFILIATED ENTITIES PA 501(C)(3) 9 SCHUYLKILL HEALTH SYSTEM 0 SCHUYLKILL HEALTH SYSTEM 420 SOUTH JACKSON STREET POTTSVILLE PA 17901 262990543 TO SUPPORT, PROMOTE, ADVANCE & ENHANCE QUALITY OF LIFE OF SCHUYLKILL CNTY PA 501(C)(3) 11B N/A 0 SCHUYLKILL COMMUNITY HEALTH SERVICES INC 420 SOUTH JACKSON STREET POTTSVILLE PA 17901 232410904 INACTIVE PA 501(C)(3) SCHUYLKILL HEALTH SYSTEM 0 SCHUYLKILL HEALTH SYSTEM MEDICAL MALL LP EAST NORWEGIAN TREMONT STREETS POTTSVILLE PA 17901 232514813 RENTAL PA N/A SCHUYLKILL HEALTH SYSTEM DEVELOPMENT CORPORATION 700 EAST NORWEGIAN STREET POTTSVILLE PA 17901 232432417 PURSUES, IMPLEMENTS & FURTHERS THE ACTVTIES & PURPOSES OF THE SYS PA N/A C SCHUYLKILL MEDICAL PLAZA - CONDOMINIUM ASSOCIATION 420 SOUTH JACKSON STREET POTTSVILLE PA 17901 232931821 CONDOMINIUM ASSOCIATION PA N/A C 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1