2011-05-13T15:21:52-05:00 2010-06-30 ParenteBeard LLC 1650 Market Street Suite 4500 Philadelphia PA 19103 990 2009-07-01 231352159 JC BLAIR MEMORIAL HOSPITAL JCBL 8146432290 1225 WARM SPRINGS AVENUE HUNTINGDON PA 16652 NANCY GLIDDEN 8146432290 2011-05-12 1 2159720701 2009 2016-02-24 21:20:13Z JOSEPH J PELUSO 1225 WARM SPRINGS AVENUE HUNTINGDON PA 16652 44153018 0 X WWW.JCBLAIR.ORG X 1909 PA HEALTHCARE PROVIDER - NOT-FOR-PROFIT ACUTE CARE HOSPITAL 16 12 565 86 1051849 -385468 1012920 611861 36683834 37233365 661060 2253424 1286768 1213211 39644582 41311861 710500 539466 0 20776501 22527897 0 8629 18246837 17800937 39733838 40868300 -89256 443561 34981712 36298447 17405214 18263218 17576498 18035229 Mission: J.C. Blair Health System is committed to being the premier health resource for the residents of Huntingdon County and nearby communities and strives to deliver the best outcome for every patient. Vision: To be a model of excellence for the provision of a comprehensive range of healthcare and wellness services designed to continually improve the health status and quality of life for the residents of Huntingdon County and nearby communities. 1 0 31543477 539266 37295436 J.C. Blair Memorial Hospital provides inpatient, outpatient, and emergency care services to further the health and wellness of Huntingdon, Pennsylvania and surrounding communities in Huntingdon County, Pennsylvania. In fiscal year 2010, J.C. Blair Memorial Hospital provided the community with charity services amounting to $642,431, the cost of which is estimated at $244,751. Patients receive medically necessary services regardless of ability to pay. Please see attached summary of activities and programs provided for or supported by J.C. Blair Memorial Hospital and its staff for the benefit of the community. The Hospital admitted 2,361 adult and pediatric patients, delivered 299 newborns, provided outpatient services to 100,762 patients, and provided emergency services to 16,245 patients. Services provided included 397,854 laboratory tests and procedures, 37,458 radiologic procedures, and 4,313 surgical procedures. In addition to general surgery, J.C. Blair Memorial Hospital provides urological, ENT, ophthalmology, podiatry, and outpatient orthopedic surgical services.During the year, the hospital continued its path to improved customer service and quality of care, participating in all required quality of care reporting programs and a voluntary pay for performance program under agreement with its largest commercial payer. 31543477 1 1 0 1 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 38 0 1 565 1 1 1 0 0 0 0 0 0 0 0 16 12 1 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 PA X Nancy Glidden - CFO 8146438445 1225 WARM SPRINGS AVENUE HUNTINGDON PA 16652 JOHN D COURSEN 1.00 X X 0 0 0 FRANCES V VAUGHN 1.00 X X 0 0 0 GARRY L POTE 1.00 X X 0 0 0 JOSEPH A MASCIANGELO 1.00 X X 0 0 0 ELLEN SLOAN 1.00 X X 0 0 0 FRANK DEMAR 1.00 X 0 0 0 ARTHUR DECAMP 1.00 X 0 0 0 KEITH BLACK 1.00 X 0 0 0 FRED PRICE 1.00 X 0 0 0 CHARLES CRUIKSHANK 1.00 X 0 0 0 JAMES E SCHALL MD 1.00 X 24000 0 0 JAMES LAKSO PHD 1.00 X 0 0 0 BARBARA EASTMAN 1.00 X 0 0 0 Alfred K Sutton 40.00 X X 227940 0 58307 MARIA PETTINGER 80.00 X 0 0 0 JOSEPH PELUSO 40.00 X X 176171 0 42176 Nancy Glidden 40.00 X 127633 0 30690 john d roth 40.00 X 262321 0 67102 david finch 40.00 X 223554 0 57185 Glenn G Williams 40.00 X 217055 0 55523 brent acker 40.00 X 234245 0 59920 1492919 0 370903 11 0 1 0 QUORUM HEALTH RESOURCES 105 CONTINENTAL PLACE BRENTWOOD TX 37027 MANAGEMENT SERVICES 759858 QUEST DIAGNOSTICS 2769 COLLECTION CENTER DRIVE CHICAGO IL 60693 OUTSIDE LAB TESTING 415392 Revenue Cycle Solutions Inc 4524 SOUTHLAKE PARKWAY SUITE 15 HOOVER AL 35244 Cash Retrievers 265415 rasik lal 1225 WARM SPRINGS AVENUE HUNTINGDON PA 16652 Psychiatrist 261850 ALLIANCE HEALTHCARE SYSTEMS 100 BAYVIEW CIRCLE SUITE 400 NEWPORT BEACH CA 92660 MRI AND PET SCAN SERVICES 175567 9 321325 94327 196209 611861 NET PATIENT SERVICE RE 621110 37233365 37233365 37233365 295731 295731 182905 535365 -352460 -352460 -352460 4262585 900 2305158 634 1957427 266 1957693 1957693 DIETARY SVCS REVENUE 812900 833341 833341 PLANT OPERATIONS SVCS 541610 218508 218508 CAFETERIA REVENUE 722210 205019 205019 308803 62071 246732 1565671 41311861 37295436 1051849 2352715 503466 503466 36000 36000 17089952 13035734 4045589 8629 1476061 1125898 350163 2748593 2096549 652044 1213291 904538 308753 109063 109063 354372 354372 92524 92524 3485148 1790209 1694939 101413 101413 6683055 5574044 1109011 9055 9055 597952 597952 49736 28735 21001 138564 138564 1789557 1789557 453744 453744 BAD DEBT 2816647 2816647 FOOD 646385 603024 43361 PHYSICIAN RECRUITMENT 367452 367452 ADMINISTRATIVE EXPENSES 38225 38225 ANESTHESIOLOGY EXPENSES 25000 25000 43045 23816 19229 40868300 31543477 9316194 8629 300 300 1572042 749485 5024949 4971280 27070 495543 525120 432275 413374 54179249 43079201 12188794 11100048 12506274 14547103 83500 83500 2650965 3908237 34981712 36298447 3262772 4405552 3470000 3185000 2947000 2567000 7725442 8105666 17405214 18263218 X 15356091 15827252 690496 636469 1529911 1571508 17576498 18035229 34981712 36298447 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 6228 6228 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: THE HOSPITAL IS A MEMBER OF THE HOSPITAL ASSOCIATION OF PENNSYLVANIA, Hospital Council of Western PA AND THE AMERICAN HOSPITAL ASSOCIATION. AS SUCH, A PERCENTAGE OF DUES IS EXPENDED BY THOSE ORGANIZATIONS ON LOBBYING ACTIVITIES. IT IS ESTIMATED THAT $6,228 OF THE DUES PAID WAS USED BY THOSE ORGANIZATIONS FOR LOBBYING ACTIVITIES. 14901804 442718 2438363 703555 17079330 17238317 -1536513 800000 14901804 0.87000 0.09000 0.04000 0 1 1 518428 518428 22914657 17270182 5644475 29834898 25032018 4802880 911266 777001 134265 11100048 DUE FROM AFFILIATES 1557386 BENEFICIAL INTEREST IN PERPETUAL TRUSTS 1457558 ASSETS RECEIVED UNDER REVOCABLE TRUST 77436 DEFERRED FINANCING COSTS, NET 177089 INTEREST IN NET ASSETS OF AFFILIATE 344849 ACCRUED INTEREST AND OTHER RECEIVABLES 293919 3908237 ESTIMATED MEDICAL MALPRACTICE CLAIMS LIABILITY 528807 ACCRUED PENSION COST 6357277 REFUNDABLE ADVANCE 77436 OBLIGATIONS UNDER CAPITAL LEASE 186180 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 732461 Due to Affiliates 223505 8105666 41311861 40868300 443561 226517 -218934 7587 15170 458731 42081330 226517 7587 234104 41847226 -535365 -535365 41311861 41403665 535365 535365 40868300 0 40868300 Part V, Line 4: Description of Intended Use of Endowment Funds: J.C. Blair Memorial Hospital has recorded on its balance sheet its interest in the net assets of the J.C. Blair Memorial Hospital Foundation. That amount is reported above and categorized as a term endowment. The Foundation transfers funds raised to the hospital for the purchase of equipment and building improvements. Funds raised and not yet transferred are reported as interest in net assets of the Foundation Part X: Description of Uncertain Tax Positions Under FIN 48: 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 has been met. Management has determined that there were no tax uncertainties that met the recognition threshold in 2010 and 2009. Part XI, Line 8 - Other Adjustments: MINIMUM PENSION LIABILITY ADJUSTMENT: 37408. VALUATION Gain, BENEFICIAL INTEREST IN PERPETUAL TRUST: 41597. CHANGE IN NET ASSETS OF AFFILIATE: -71418. Part XII, Line 2d - Other Adjustments: VALUATION GAIN, BENEFICIAL INTEREST IN PERPETUAL TRUST: 41597. MINIMUM PENSION LIABILITY ADJUSTMENT: 37408. CHANGE IN NET ASSETS OF AFFILIATES: -71418. Part XII, Line 4b - Other Adjustments: RENTAL EXPENSE: -535365. Part XIII, Line 2d - Other Adjustments: RENTAL EXPENSE: 535365. 1 1 0 0 0 1 1 0 1 1 1 779 244751 154497 90254 0.00240 1 15166 5845514 3386349 2459165 0.06460 2 15945 6090265 3540846 2549419 0.06700 236 2479 104118 42660 61458 0.00160 89 411 278598 278598 0.00730 7 27072 617489 617489 0.01620 102 1591 91942 91942 0.00240 434 31553 1092147 42660 1049487 0.02750 436 47498 7182412 3583506 3598906 0.09450 41 2150 2150 0.00010 30 27063 27063 0.00070 2 175 175 0.00000 11 975 975 0.00000 6 1225 1225 0.00000 12 1575 1575 0.00000 1 25 25 0.00000 1 75 75 0.00000 104 33263 33263 0.00080 1 1101309 12864845 14986426 -2121581 X 1 0 JC Blair Memorial Hospital

1225 Warm Springs Avenue Huntingdon PA 16652

X X X Inpatient Psychiatric Unit Part I, Line 3c: In addition to the 200% FPG applied to charity care, the organization offers a 20% discount for prompt payment regardless of income. Part I, Line 6a: J.C. Blair Health Systems, Inc., parent of J.C. Blair Memorial Hospital, produces an annual report which includes a report of community benefit. The report highlights the cost of charity care and the shortfall between Medical Assistance payments and the cost of care, and the value of the community benefit programs categorized as required in the 990 tax return. It also provides a narrative section listing examples of the events hospital leadership, board members, medical staff and employees participate in or sponsor. The annual report is distributed at an annual public meeting, through the mail, and throughout the organization. Part I, Line 7f: 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 $2,816,647. Part III, Line 4: Cost to charge ratio from the 2009 cost report was used to estimaTE COSTS. Discounts and payments on patients accounts are not included in bad debt expense. Payments made after an account has been written off to bad debt are treated as recoveries of bad debt and are netted against bad debts. Part III, Line 8: The value of the cost of unreimbursed Medicare bad debts related to Medicaid crossovers is $42,800, which should be treated as community benefit. This number was calculated by taking the 30% of unreimbursed Medicare bad debts in the 2010 Medicare cost report and applying the cost to charge ratio to that number. line 6 costs were estimated Using ratio of costs to charges as per 2010 cost report, applied to total Medicare revenues including HMO and Part B which are not reported in the cost report. Line 5 revenues reported includes all net revenues for Medicare, including HMO and Part B. Part VI, Line 2: The Community Relations staff at J.C. Blair facilitates the Huntingdon County Healthy PartnerSHIP, a health improvement partnership designated and recognized by the PA Department of Health, which monitors county health status indicators, prioritizes need, and develops initiatives to address those needs. Reports monitored include the Huntingdon County Health Profile, Behavioral Health Risk Factors for PA and Huntingdon County, County Health Rankings, CDC Healthy People 2020, Injuries in PA County Profiles, and others. The PartnerSHIP is comprised of nearly 90 health and human services agencies who network via a listserve and an estimated 20 active members who work together to develop action plans to address priority issues. These active members include representatives from the United Way, PA State Police, drug & alcohol agencies, the American Cancer Society, Home Nursing Agency, tobacco cessation consultant, retirement communities and nursing homes, state health center, Juniata College and others. Part VI, Line 3: In order to be eligible for charity care, a patient who does not have health insurance must complete an application for Medical Assistance and be denied coverage. Such patients, designated as self-pay, are offered assistance by our self-pay financial counselors in completing applications for Medical Assistance. Counselors follow up with patients if applications are not completed or information is not returned. The Hospital also has access to limited funds (the income from a trust which has been designated to be used for charity care). Applicants for charity care are screened for eligibility for this program. In addition, a restricted donation from a community member has provided for payment for health care services which are not eligible for any other programs or insurance coverages. While the amount of that grant was only $10,000, it has already provided coverage for costs of care for several patients for needed services. Patient brochures are provided to explain the availability of assistance and charity care programs.The federal poverty level guidelines with our 200% multiplier are posted in locations frequented by patients, such as the Emergency Department and registration areas. If a patient is Self Pay at the time of registration, the registration clerk notifies a patient financial counselor and provides the patient with a Financial Assistance Program Letter. The Program letter offers a 20% Self Pay Discount Program and Charity Care Program outline. Patient Counselor advises and assists with application process. To apply for Charity Care is the patient must first apply for Medical Assistance. This process can take up to 30 days for Medical Assistance approval or denial. If Medical Assistance coverage is denied, the patient is asked to contact the patient counselor for assistance with completing the Charity Care Application, or to have the application mailed out to the patient. Once the patient is determined to be eligible, the patient is issued an identification card, which they may present at future visits to validate they have been determined to be eligible for Charity Care. Eligibility must be renewed every six months. The hospital is currently developing a new brochure which describes the charity program along with other financial policies, such as prompt payment discounts and eligibility for payment plans and grant funded care. Part VI, Line 4: The Hospital serves the residents of Huntingdon County, being the only hospital in the county. The population in the county is approximately 45,000, spread across many small boroughs and villages. There are a number of Amish and Mennonite settlements in the region. The communities in the primary service area are Huntingdon, Smithfield, Mount Union, Alexandria, Orbisonia, Petersburg, Three Springs, Mapleton Depot, James Creek, Mill Creek. A number of small communities make up the secondary service area. The area is rural. Huntingdon County is in the 'ridge and valley' section of Pennsylvania, which makes for small communities connected by winding and hilly secondary roads. Dairy and other farming is also prevalent in the valleys. About 13% of the population lives below the federal poverty level. Average per capita income is approximately $15,400 and median household income is about $41,500. 11.6% of the population is uninsured. A few of the communities served by the hospital are designated as medically underserved or health professional service areas, but the Borough of Huntingdon, where the hospital is located, is not. Part VI, Line 5: Much of the benefit to the community comes from participation in collaborative efforts that help to assess community need and to address health issues in Huntingdon County. Some of the direct service activities include free breast health and heart health screenings for women, supported by two grants, free diabetes self-management classes, educational programs, mentoring future health care professionals through internships and student practicums, participation in health fairs, patient advocacy and promotion of healthy lifestyles. Indirect support of these activities include hospital staff and medical staff members serving in leadership and working roles on boards and committees that impact the health status and well-being of community members. Part VI, Line 6: The governing body is representative of the communities in the primary and secondary service areas of the hospital. The Chief and Vice Chief of the Medical Staff are voting members of the board. Employees are generally not allowed to serve as voting members of the Board, however, one employed physician serves as vice chief of the medical staff and is a voting member by virtue of that position. members of the medical staff who serve on the board may have contractual relationships with the hospital or its affiliates, which they are asked to disclose in conflict of interest statements. any conflicts that meet the reporting thresholds of the 990 are duly reported. Medical staff privileges are granted through an application and credentialing process and are granted in accordance with bylaws and rules and regulations of the medical staff and board of directors. J.C. Blair Memorial Hospital is a small, rural hospital that is not engaged in research, but it does allocate funds annually for the upgrade of patient care equipment and for expenditures in tecnology or facilites to improve the safety and care of patients. Recent examples of purchases and upgrades are a new MRI scanner, a new echocardiogram machine, new patient beds and a new maternity and fetal monitoring system. Recent technology investments include nursing documentation, electronic medication administration record and bedside medication verification. Part VI, Line 7: J.C. Blair Memorial Hosital is part of J.C. Blair Health System, Inc. The Health System also includes a Foundation, which raises funds through donations and grants to help the hospital acquire needed equipment and provide health and prevention programming, J.C Blair Rehabilitative Services, Inc. which participates in a joint venture to provide outpatient physical and occupational therapy, and J.C. Blair Medical Services, Inc. which has grown quickly over the past few years operating physician practices, allowing for a turn key set up that enhances recruitment of new providers. The companies work together under the parent company umbrella to deliver health care services and accomplish the vision of the Health System: To be a model of excellence for the provision of a comprehensive range of healthcare and wellness services designed to continually improve the health status and quality of life for the residents of Huntingdon County and nearby communities. PA 1 jc blair memorial hospital foundation inc 935 14th street HUNTINGDON PA 16652 251881377 501(c)(3) 503466 cash n/a provide financial support for affiliates 1 NURSING LOAN EDUCATIONAL ASSISTANCE 6 36000 0 CASH N/A Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: FUNDS ARE TRANSFERRED TO AN AFFILIATED ORGANIZATION WITH CONSISTENT MANAGEMENT AND USED TO FINANCIALLY SUPPORT THE FURTHERING OF THEIR EXEMPT PURPOSE. X 1 1 X X X 0 0 0 0 0 0 0 0 0 Alfred K Sutton 227940 0 0 0 0 0 0 0 58307 0 286247 0 0 0 JOSEPH PELUSO 170000 0 0 0 6171 0 0 0 42176 0 218347 0 0 0 Nancy Glidden 127633 0 0 0 0 0 0 0 30690 0 158323 0 0 0 john d roth 262321 0 0 0 0 0 0 0 67102 0 329423 0 0 0 david finch 223554 0 0 0 0 0 0 0 57185 0 280739 0 0 0 Glenn G Williams 217055 0 0 0 0 0 0 0 55523 0 272578 0 0 0 brent acker 234245 0 0 0 0 0 0 0 59920 0 294165 0 0 0 Part I, Line 1a Hospital provided temporary housing to the current CEO, Joseph Peluso, as part of his relocation. This benefit ($5,125) was not included in his taxable compensation. PA ECONOMIC DEVELOPMENT FINANCING AUTHORITY 236003102 708693AD8 2007-03-08 4000000 Plant infrastructure upgrades and equipment replacement. 0 0 4000000 80000 60995 3859005 2010 0 0 1 1 0 0 0 0 1 0.00000 0.00000 0.00000 1 0 1 0 0 0 0 FRED PRICE BOARD OF DIRECTORS - MEMBER 32185 SISTER-IN-LAW IS EMPLOYED BY J.C. BLAIR MEDICAL SERVICES 0 Form 990, Part III, line 2 New Program Services Outpatient echocardiograms were added to the hospital's cardiopulmonary department activities. Occupational medicine program was approved in spring 2010 but was not implemented by fiscal year end. Form 990, Part VI, Section A, line 2 JOHN COURSEN AND FRANCES VAUGHN ARE EMPLOYED BY THE SAME EMPLOYER, MUTUAL BENEFIT GROUP INSURANCE. Form 990, Part VI, Section A, line 3 The Hospital contracts with Quorum Health Resources (QHR) for management services. Executives (CEO and CFO) are provided through the contract, along with on-site support from a regional team at QHR and consulting services. The CEO and CFO provide leadership in strategic and business planning, operational improvements, and follow the policy set forth by the board to accomplish organizational objectives and ensure financial viability. Form 990, Part VI, Section B, line 11 The 990 was provided in draft form to the Board before filing. the cfo also presented key points of the 990 to the board at a meeting prior to filing. Form 990, Part VI, Section B, line 12c The Board members complete a conflict of interest statement annually and return to Executive Assistant who reviews and monitors compliance with the policy. Board members are required to abstain from voting on matters that involve conflicts. Form 990, Part VI, Section B, line 15 The CEO and CFO are employeed by Quorum Health Resources ("QHR") but compensation is determined through a collaborative effort between QHR regional staff and the Executive Committee of the Board of Directors. QHR regional staff research salary market data and provide the Executive Committee with recommendation for a base salary both at hire and upon annual review. If the executive is eligible for a performance bonus, the criteria for determination of the bonus is developed by establishing objectives and measurements that will indicate the degree to which objectives have been accomplished. The Executive Committee of the Board must approve the compensation level including potential performance bonuses. Form 990, Part VI, Section C, line 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. JC BLAIR HEALTH SYSTEMS INC 1225 WARM SPRINGS AVENUE HUNTINGDON PA 16652 251881383 PROVIDE SUPPORT TO RELATED ORGANIZATIONS PA 501(C)(3) 11 TYPE 1 N/A JC BLAIR MEDICAL SERVICES INC 1225 WARM SPRINGS AVENUE HUNTINGDON PA 16652 251881378 PROVIDER OF HOSPITALIST SERVICES AND OPERATIONS OF PHYSICAN PRACTICES PA 501(C)(3) 3 N/A JC BLAIR MEMORIAL HOSPITAL FOUNDATION 935 14th STREET HUNTINGDON PA 16652 231352159 TO SUPPORT HEALTH CARE PROGRAMS OF THE HOSPTIAL PA 501(C)(3) 11 TYPE 1 N/A JC BLAIR REAL ESTATE HOLDINGS 1226 WARM SPRINGS AVENUE HUNTINGDON PA 16652 251881380 REAL ESTATE HOLDING PA N/A C JC BLAIR REHABILITATION SERVICES INC 1226 WARM SPRINGS AVENUE HUNTINGDON PA 16652 251881385 REHABILITATION SERVICES PA N/A C 0 1 1 1 0 0 0 0 0 0 1 1 1 0 0 0 0 0