2011-05-12T16:04:38-05:00 2010-06-30 PARENTEBEARD LLC 400 MARKET STREET WILLIAMSPORT PA 17701 990 2009-07-01 240792115 JERSEY SHORE HOSPITAL JERS 5703980100 1020 THOMPSON STREET JERSEY SHORE PA 17740 CAREY W PLUMMER 5703980100 2011-05-12 1 5703236023 2009 2016-02-24 21:20:13Z CAREY W PLUMMER 1020 Thompson Street Jersey Shore PA 17740 29672321 0 X www.jsh.org X 1922 PA PROVIDE INPATIENT, OUTPATIENT, AND EMERGENCY CARE SERVICES FOR RESIDENTS OF JERSEY SHORE AREA. 13 10 344 10 0 0 182298 448563 51137846 28901185 10921 21130 260162 255384 51591227 29626262 0 0 10908284 11801828 0 204024 39133789 15481101 50042073 27282929 1549154 2343333 27479924 29001096 21961655 22153378 5518269 6847718 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 24418429 28903513 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 $492,633 DURING THE YEAR ENDED JUNE 30, 2010. 24418429 1 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 110 0 1 344 1 0 0 0 0 0 1 1 0 0 0 13 10 1 1 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 PA X THE CORPORATION 5703980100 1020 THOMPSON STREET JERSEY SHORE PA 17740 CAREY PLUMMER 40.00 X X 194295 0 67150 HUBERT VALENICK 1.00 X 0 0 0 LEROY KEILOR III 1.00 X X 0 0 0 WILLIAM CAMERER III 1.00 X X 0 0 0 CARMEN SPINNEY MD 1.00 X X 0 160903 25751 GILBERT MATON 1.00 X 0 0 0 DONALD GREENE MD 1.00 X 0 0 0 JOHN A HUNTER DDS 1.00 X 30000 0 0 JAMES REESER 1.00 X 0 0 0 RICHARD BEATTY DMD 1.00 X X 0 0 0 Paul Dempsey 1.00 X 0 0 0 Walter Eisenhauer 1.00 X 0 0 0 James Ely 1.00 X 0 0 0 STEVEN KATZ MD 1.00 X 0 388476 37932 KURT WILLIAMS 40.00 X 89356 0 11877 AARON KOLB MD 40.00 X 225112 0 34887 THOMAS FORKER MD 40.00 X 175753 0 24162 THOMAS BURGE 40.00 X 149715 0 24162 Ronald Eister 40.00 X 214604 0 31956 JERRY CROSBY 40.00 X 111659 0 27368 1190494 549379 285245 9 0 1 0 SUSQUEHANNA HEALTH SYSTEM 1205 GRAMPIAN BOULEVARD WILLIAMSPORT PA 17701 IT SUPPORT/LAB TEST INTERPRETATION 696850 QUORUM HEALTH SYSTEM 105 CONTINENTAL PLACE BRENTWOOD TN 370275014 MANAGEMENT FEES 518992 Quest Diagnostics 315 Boulevard NE Ste 240 Atlanta GA 30312 Lab Services 208450 STAFF CARE PO BOX 281923 ATLANTA GA 303841923 ER PHYSICIAN LOCUMS 107543 Williamsport Pathology Assoc 777 Rural Avenue WILLIAMSPORT PA 17701 Lab TEST INTERPRETATION 106994 6 19520 266044 162999 448563 GROSS PATIENT SVC REV 621110 28901185 28901185 28901185 20002 20002 101686 27224 74462 74462 74462 1507 379 1128 1128 1128 14062 19520 18456 -4394 -4394 CAFETERIA/VENDING REV 722210 108224 108224 REBATES/REFUNDS 900099 41838 41838 RADIOLOGY ADMIN FEES 900099 25000 25000 10254 2328 7926 185316 29626262 28903513 0 274186 362651 362651 9042559 8166946 808801 66812 301276 263827 35291 2158 1282993 1192695 80541 9757 812349 711373 95157 5819 282906 282906 42477 42477 58724 58724 5183908 4459801 713237 10870 98082 5451 92631 3942734 3465189 463597 13948 594161 594161 26793 25143 1650 39138 38964 174 949407 949407 1937480 1937480 513624 513624 Bad Debt Expense 1630000 1630000 Dues & Books 68450 68340 110 Miscellaneous expenses 59883 59788 95 EmPLOYEE RECOGNITION 53334 53334 27282929 24418429 2660476 204024 1305 1425 2446714 3423909 316751 217292 2586744 2858519 280519 286343 314915 367252 349860 32863090 14994281 19270625 17868809 1923671 3966367 27479924 29001096 2043074 2182949 15000000 14838199 4918581 5132230 21961655 22153378 X 5027326 6079759 490943 767959 5518269 6847718 27479924 29001096 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2419 2419 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: 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 ($2,419 DURING THE YEAR ENDED JUNE 30, 2010) WAS USED FOR LOBBYING PURPOSES. 147956 147956 17344838 3330723 14014115 14806013 11500980 3305033 564283 162578 401705 17868809 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 57560 DEFERRED FINANCING COSTS, NET 127296 DUE FROM AFFILIATES 2081511 Funded depreciation 1700000 3966367 OBLIGATIONS UNDER CAPITAL LEASES 1409252 DUE TO AFFILIATES 816091 PATIENT REFUNDS PAYABLE 49169 BLUE CROSS CURRENT FINANCING ADVANCE 158704 ESTIMATED MEDICAL MALPRACTICE CLAIMS LIABILITY 125000 Fair Value of Derivative Instrument 373900 Accrued Pension Cost 2200114 5132230 29626262 27282929 2343333 -1013884 -1013884 1329449 28639601 -1013884 -1013884 29653485 -27223 -27223 29626262 27310152 27223 27223 27282929 0 27282929 Part X: Description of Uncertain Tax Positions Under FIN 48: The corporation 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 has been met. Management determined there were no tax uncertainties that met the recognition threshold in 2010. Part XI, Line 8 - Other Adjustments: PENSION LIABILITY ADJUSTMENT: -675255. Change in Fair Value of Derivative Instrument: -338629. Part XII, Line 2d - Other Adjustments: Change in Fair value of Derivative Instrument: -338629. PENSION LIABILITY ADJUSTMENT: -675255. Part XII, Line 4b - Other Adjustments: RENTAL EXPENSE: -27223. Part XIII, Line 2d - Other Adjustments: RENTAL EXPENSES: 27223. Golf Tounament 22881 14063 8818 1200 2001 7600 Crab Fest 10701 5457 5244 4598 3057 33582 19520 14062 1200 6599 10657 18456 -4394 1 1 1 X 1 X 1 0 0 0 492633 492633 0.01920 2380817 1543858 836959 0.03260 2873450 1543858 1329592 0.05180 199164 11824 187340 0.00730 199164 11824 187340 0.00730 3072614 1555682 1516932 0.05910 1 1630000 0 5883131 4804279 1078852 X 1 1 Jersey SHore Hospital

1020 Thompson Street Jersey Shore PA 17740

X X X X Part I, Line 7g: THERE ARE NO PHYSICIAN CLINICAL SERVICES INCLUDED. Part I, Line 7f: 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 $1,630,000. Part III, Line 4: 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.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. Part III, Line 8: N/A - as a CAH, we are reimbursed at 101% of cost from Medicare. Part III, Line 9b: Any remaining balance after charity care guidelines, falls under our general collection 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. Part VI, Line 4: Jersey Shore Hospital's Primary service area covers much of Clinton County and Lycoming County - an area with a population of approximately 40,000. 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.Seventy-nine point four percent (79.4%) of Jersey Shore Hospital inpatients live in the primary service area (PSA) which is in Lycoming County and Clinton County, Pennsylvania. The Primary Service Area (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 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 and from which 17% of hospitalized patients originate. These zip codes are to the west and northeast of the PSA.The total Service Area for Jersey Shore Hospital has a population of 103,102 and is expected to decrease in population by 1.2% by 2012 to 101,890.A major demographic issue affecting Jersey Shore Hospital is the aging population.The percent of the population over the age of 65 in the PSA is 16% and 16.6% in the SSA. This compares to the over 65 population for the U.S. of 12%. The senior population is expected to increase by 5.8% in the PSA and by 4% in the SSA by 2012.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 Service Area is $35,956, compared to PA ($45,038) and the U.S. ($48,250). By 2012 the PSA is anticipated to have a median household income of $41,006. This is 82% of the Pennsylvania state average household income and considerably below the national average.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 2010 reflected a slight decrease in Medicare, Blue Cross, HMO and Self Pay and a slight increase in Commercial. This is the first time in over five years that HMO has decreased. Our Medical Assistance business continued to have a significant impact on JSH as a Critical Access Hospital. Medical Assistance payments make up 9.35% of our payers, which is up over 6% from 2009. Part VI, Line 6: 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 suplus 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 7: The hospital is part of Jersey Shore Healthcare, Inc. This affiliation includes a non-profit physician practice with family practice physicians and surgeons.PART VI, LINE 8: N/A X X 0 0 0 0 0 0 0 0 0 CAREY PLUMMER 194295 0 0 0 0 0 0 0 67150 0 261445 0 0 0 CARMEN SPINNEY MD 0 160903 0 0 0 0 0 0 0 25751 0 186654 0 0 STEVEN KATZ MD 0 388476 0 0 0 0 0 0 0 37932 0 426408 0 0 AARON KOLB MD 225112 0 0 0 0 0 0 0 34887 0 259999 0 0 0 THOMAS FORKER MD 175753 0 0 0 0 0 0 0 24162 0 199915 0 0 0 THOMAS BURGE 149715 0 0 0 0 0 0 0 24162 0 173877 0 0 0 Ronald Eister 214604 0 0 0 0 0 0 0 31956 0 246560 0 0 0 Form 990, Part VI, Section A, line 2 Hubert Valencik and Leroy H. Keilor,III, board members, are both on the board of Jersey Shore State Bank. Form 990, Part VI, Section A, line 3 THE ORGANIZATION UTILIZES THE MANAGEMENT SERVICES OF QUORUM HEALTH SYSTEM. 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 after filing with the IRS. Form 990, Part VI, Section B, line 12c ALL BOARD MEMBERS AND EMPLOYEES ARE REQUIRED TO ANNUALLY COMPLETE A CONFLICT OF INTEREST STATEMENT. THESE 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 The Personnel Salary committee and Quorum (management company) reviews an executive compensation study performed by Yaffee, an independent third party who is employed by HAP to conduct a compensation study. HR 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 and 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 I, LINES 9 AND 17: Contractual Allowances are reported in the current year as net of patient service revenue as is typically done with hospital organizations. Prior year presentation reflected Gross patient service revenue on the Statement of Revenues (line 9 of Part I) and contractual allowances on the Statement of Functional Expenses (line 17 of Part I). JERSEY SHORE HEALTH CARE INC 1020 THOMPSON STREET JERSEY SHORE PA 17740 232480603 HEALTHCARE PA 501(C)(3) 3 N/A SHORE PROPERTIES CORPORATION 1020 THOMPSON STREET JERSEY SHORE PA 17740 231280605 SUPPORT JERSEY SHORE HEALTH CARE INC. THROUGH RENTAL INCOME PA 501(C)(3) 11A JERSEY SHORE HEALTH CARE INC JERSEY SHORE AREA HEALTH SERVICES CORPORATION 1020 THOMPSON STREET JERSEY SHORE PA 17740 232192826 LABORATORY SERVICES PA JERSEY SHORE HEALTH CARE INC C 1 0 0 1 0 0 0 0 1 1 0 0 1 1 1 1 1 1