Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2011
Open to Public Inspection
A For the calendar year, or tax year beginning 07-01-2011 and ending 06-30-2012
BCheck if applicable:
CName of organization
Canonsburg General Hospital
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
C/O Tax Dept Two Alleghney Center
 
Room/suite
City or town, state or country, and ZIP + 4
Pittsburgh, PA15212
D Employer identification number

25-1737079
E Telephone number

G Gross receipts $ 49,368,600
F Name and address of principal officer:
Matthew Peterson
Two Allegheny Center 11th Fl
Pittsburgh,PA15212
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.wpahs.org
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1994
M State of legal domicile: PA
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: See Form 990, Page 2, Part III, Line 1
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a)..... 3 13
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 11
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ... 5 567
6 Total number of volunteers (estimate if necessary) .... 6 168
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 164,236
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b -40,789
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 484,851 108,639
9 Program service revenue (Part VIII, line 2g) ......... 49,070,470 47,651,284
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 4,527 -3,944
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 1,998,489 1,575,044
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 51,558,337 49,331,023
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 11,754 950
14 Benefits paid to or for members (Part IX, column (A), line 4)..... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 22,278,461 23,268,857
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet96,892    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 29,153,027 30,346,263
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 51,443,242 53,616,070
19 Revenue less expenses. Subtract line 18 from line 12....... 115,095 -4,285,047
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 27,520,106 27,946,630
21 Total liabilities (Part X, line 26)............. 45,155,974 52,826,694
22 Net assets or fund balances. Subtract line 21 from line 20..... -17,635,868 -24,880,064
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title.
Paid preparer use only
Print/type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name Right pointing arrowhead image

Firm's EIN Right pointing arrowhead image
Firm's address Right pointing arrowhead image



Phone no.
May the IRS discuss this return with the preparer shown above? See instructions .........bullet
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2011)
Form 990 (2011)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III .........
1
Briefly describe the organization’s mission: CANONSBURG GENERAL HOSPITAL IS AN ORGANIZATION DEFINED BY OUR TALENTED PEOPLE. AN ORGANIZATION COMMITTED TO EXCELLENCE; AN ORGANIZATION WITH ONE PURPOSE AND ONE MISSION. OUR ONE PURPOSE IS TO IMPROVE THE HEALTH OF THE PEOPLE IN THE WESTERN PENNSYLVANIA REGION. OUR ONE MISSION IS TO PRACTICE MEDICINE, EDUCATE AND CONDUCT RESEARCH AS AN INTEGRATED TEAM OF PHYSICIANS, NURSES AND SUPPORT PROFESSIONALS WHO ARE COMMITTED TO IMPROVING THE HEALTH OF OUR PATIENTS.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ....................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ..........................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 7,409,650 including grants of $ 0 ) (Revenue $ 7,360,177 )
The purpose of Canonsburg General Hospital is to improve the health of the people in Western Pennsylvania. In order to accomplish this mission, Canonsburg General Hospital provides orthopaedic services to individuals in need of medical attention.
4b (Code:   ) (Expenses $ 5,416,583 including grants of $ 0 ) (Revenue $ 4,970,989 )
The purpose of Canonsburg General Hospital is to improve the health of the people in Western Pennsylvania. In order to accomplish this mission, Canonsburg General Hospital provides cardiovascular services to individuals in need of medical attention.
4c (Code:   ) (Expenses $ 3,952,440 including grants of $ 0 ) (Revenue $ 3,739,852 )
The purpose of Canonsburg General Hospital is to improve the health of the people in Western Pennsylvania. In order to accomplish this mission, Canonsburg General Hospital provides rehabilitation services to those individuals in need of medical attention.
(Code:   ) (Expenses $ 31,078,101 including grants of $ 950 ) (Revenue $ 31,580,266 )
Other Medical Services Provided To Patients
4d Other program services (Describe in Schedule O.)
(Expenses $ 31,078,101 including grants of $ 950 ) (Revenue $ 31,580,266 )
4e Total program service expensesMediumBullet$ 47,856,774
Form 990 (2011)
Form 990 (2011)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? Click to see attachment........
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part IClick to see attachment..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part IIClick to see attachment.........................
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C, Part III........................
5
 
 
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part IClick to see attachment....................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,”
complete Schedule D, Part IVClick to see attachment...................
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment
10
Yes
 
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10? If “Yes,” complete Schedule D, Part VI.Click to see attachment
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII.Click to see attachment
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.Click to see attachment
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX.Click to see attachment
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part X.Click to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X.Click to see attachment
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI, XII, and XIII Click to see attachment
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered ‘No’ to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Part I.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.? If “Yes,” complete Schedule F, Part II..
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.? If “Yes,” complete Schedule F, Part III..
16
 
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part IClick to see attachment
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II.......... Click to see attachment
18
Yes
 
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III................... Click to see attachment
19
 
No
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H..... Click to see attachment
20a
Yes
 
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statement to this return? Note. All Form 990 filers that operated one or more hospitals must attach audited financial statements. Click to see list of attachments
20b
Yes
 
Form 990 (2011)
Form 990 (2011)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II..
21
 
No
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III.....
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, questions 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J................ Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer questions 24b–24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I......
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II.........................
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III.........
27
 
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV .........................
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV...................
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner? If “Yes,” complete Schedule L, Part IV..
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II.......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Parts II, III, IV, and V, line 1..................... Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
 
No
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
35b
 
No
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2........... Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2011)
Form 990 (2011)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V .........
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable. .......
1a
88
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements filed for the calendar year ending with or within the year covered by this return .....................
2a
567
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
Yes
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?.......................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T? ........
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?..........
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
Yes
 
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
Yes
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?...............
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?................
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?.........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them) ........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
 
 
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
 
c
Enter the aggregate amount of reserves on hand.
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
 
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2011)
Form 990 (2011)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI .........
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year
If the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
1a
13
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
11
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
Yes
 
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
 
No
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? .................
7a
 
No
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ............
7b
 
No
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ..........
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O .....
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal
Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes? ....
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form?
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review the Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done ....................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes," to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
PA
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
MATTHEW PETERSON
TWO ALLEGHENY CENTER 11TH FLOOR
Pittsburgh,PA15212
(412) 330-6005
Form 990 (2011)
Form 990 (2011)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII .........
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and current key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) Joseph Macerelli
Chair of the Board
 1.0 X   X       0 0 0
(2) William Burt
Director
 1.0 X           0 0 0
(3) Carol Pankas
Director
 1.0 X           0 0 0
(4) William Thomeier MD
Director
 1.0 X           0 0 0
(5) Charles LaBelle
Director
 1.0 X           0 0 0
(6) Michael Alterio
Director
 1.0 X           0 0 0
(7) David Celko MD
Director
 1.0 X           0 0 0
(8) David Burkey MD
Director
 1.0 X           0 0 0
(9) John Isherwood
Ex Officio Director
 1.0 X           0 0 0
(10) Joseph Cerenzia
Director
 1.0 X           0 0 0
(11) Kimberly Malinky
Hospital President & CEO
 40.0 X   X       0 134,548 0
(12) Theodore Neighbors
Ex Officio Director
 1.0 X           0 0 0
(13) Diane Dismukes
Health System President & CEO
 1.0 X   X       0 739,638 0
(14) Terry Wiltrout
Hospital President and CEO
 40.0 X   X       42,641 107,873 0
(15) Jeffrey Gretz MD
Ex Officio Director
 1.0 X           0 335,954 0
(16) Roy Santarella
Treasurer
 1.0     X       0 971,890 0
(17) Deborah Olszewski
Assistant Secretary
 1.0     X       0 236,608 0
Form 990 (2011)
Form 990 (2011)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) Matthew Peterson
Treasurer
 1.0     X       0 177,970 0
(19) David Kiehn
Assistant Treasurer
 1.0     X       0 543,218 0
(20) Robert Brandfass
Secretary
 1.0     X       0 436,568 0
(21) Eugene Trout
VP of Finance
 40.0       X     0 138,644 0
(22) Thomas Corkery MD
Hospital Chief Medical Officer
 40.0       X     0 247,786 0
(23) Susan Manzi MD
Chair - System Dept. of Med.
 1.0       X     0 486,014 0
(24) Pamela Gallagher
VP of Finance
 40.0       X     0 264,367 0
(25) Teresa Gordon
CRNA
 40.0         X   202,176 0 0
(26) Denise Westwood
VP - Patient Care Services
 40.0         X   142,348 0 0
(27) Laurie Molinda MD
Physician
 40.0         X   144,340 0 0
(28) Cathleen Allinder
CRNA
 40.0         X   153,473 0 0
(29) Barbara Gorby
CRNA
 40.0         X   155,471 0 0
(30) Christopher Olivia MD
Health System President & CEO
             X 0 4,107,961 0
(31) Dawn Gideon
Ex Officio Director
             X 0 520,867 0
(32) Thomas Albanesi
Assistant Treasurer
             X 0 317,580 0
(33) Judy Hlafcsak
Secretary
             X 0 258,918 0
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 840,449 10,026,404 0
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet8
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual .............
3
Yes
 
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person .....
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
Allegheny Chesapeake Physical The
3053 New Germany Road
EBENSBURG,PA15931 		Physical Therapy 1,221,871
Astorino Development Company
235 Fort Pitt Boulevard
PITTSBURGH,PA15222 		Construct. & Design 3,400,473
Astorino Associates Ltd
227 Fort Pitt Boulevard
PITTSBURGH,PA15222 		Architecture Service 1,913,866
VEBH Architects PC
470 Washington Road
PITTSBURGH,PA15228 		Architecture Service 205,768
Clean Care
PO Box 40330
PITTSBURGH,PA15201 		Linen Services 220,745
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet7
Form 990 (2011)
Form 990 (2011)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c 27,612
d Related organizations...1d 8,800
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		72,227
g Noncash contributions included in lines 1a-1f:$  
h Total. Add lines 1a-1f.......MediumBullet 108,639
Program Service Revenue Business Code
2a PATIENT SERVICE REVENUE 621,500 47,651,284 47,521,426 129,858  
b
c
d
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 47,651,284
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 1,297     1,297
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties............MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents 305,961  
b Less: rental expenses    
c Rental income or (loss) 305,961  
d Net rental income or (loss).......MediumBullet 305,961   5,235 300,726
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 2,150  
b Less: cost or other basis and sales expenses 2,123 5,268
c Gain or (loss) 27 -5,268
d Net gain or (loss)..........MediumBullet -5,241     -5,241
8a Gross income from fundraising events (not including
$ 27,612
of contributions reported on line 1c). See Part IV, line 18 ...
a 42,306
b Less: direct expenses ...b 30,186
c Net income or (loss) from fundraising events..MediumBullet 12,120    
9a Gross income from gaming activities.
See Part IV, line 19 ...
a 4,552
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 4,552      
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet 0      
Miscellaneous Revenue Business Code
11a SCHOOL DISTRICT NURSING SERVICES 621,110 356,733 356,733    
b HIGHMARK QUALITY AWARD 621,110 291,000 291,000    
c OFFSETTING GRANT REVENUE 621,110 245,902 245,902    
d All other revenue .... 358,776 329,633 29,143  
e Total. Add lines 11a–11d ......MediumBullet 1,252,411
12 Total revenue. See Instructions....MediumBullet 49,331,023 48,744,694 164,236 296,782
Form 990 (2011)
Form 990 (2011)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
Check if Schedule O contains a response to any question in this Part IX. .........
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the United States. See Part IV, line 21 550 550
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 400 400
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16 0  
4 Benefits paid to or for members 0  
5 Compensation of current officers, directors, trustees, and key employees .... 50,730   50,730  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 0      
7 Other salaries and wages 19,039,451 16,098,911 2,855,918 84,622
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 752,614 639,722 112,892  
9 Other employee benefits ....... 2,072,720 1,761,812 310,908  
10 Payroll taxes ........... 1,353,342 1,144,097 203,001 6,244
11 Fees for services (non-employees):        
a Management ...... 233,593   233,593  
b Legal ......... 43,659 39,293 4,366  
c Accounting ........... 0      
d Lobbying ........... 0      
e Professional fundraising. See Part IV, line 17.. 0  
f Investment management fees ...... 128   128  
g Other .......... 3,477,091 3,127,418 347,709 1,964
12 Advertising and promotion .... 2,600     2,600
13 Office expenses ....... 209,604 188,529 20,960 115
14 Information technology ...... 0      
15 Royalties .. 0      
16 Occupancy ........... 1,184,922 1,066,430 118,492  
17 Travel ............ 30,546 27,066 3,055 425
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 10,200 9,180 1,020  
20 Interest ........... 1,314,101 1,182,691 131,410  
21 Payments to affiliates ....... 6,551,806 5,896,625 655,181  
22 Depreciation, depletion, and amortization ..... 2,842,798 2,558,518 284,280  
23 Insurance .............. 800,375 800,375    
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24f. If line 24f amount exceeds 10% of line 25, column (A) amount, list line 24f expenses on Schedule O.)
a PATIENT CARE COSTS 6,482,228 6,482,228    
b BAD DEBT 3,075,456 3,075,456    
c REPAIR AND MAINTENANCE 2,161,273 1,945,146 216,127  
d PA ACT 49 - QUALITY CARE 770,448 770,448    
e
f All other expenses 1,155,435 1,041,879 112,634 922
25 Total functional expenses. Add lines 1 through 24f 53,616,070 47,856,774 5,662,404 96,892
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2011)
Form 990 (2011)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing .......... 870 1 935
2 Savings and temporary cash investments ....... 3,513,780 2 5,119,356
3 Pledges and grants receivable, net ......... 266,687 3 168,064
4 Accounts receivable, net ......... 3,975,214 4 4,931,181
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L .......... 0 5 0
6 Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
Schedule L .......... 0 6 0
7 Notes and loans receivable, net ............. 0 7 0
8 Inventories for sale or use .............. 941,356 8 819,464
9 Prepaid expenses and deferred charges ............ 960,229 9 773,924
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 50,724,529
b Less: accumulated depreciation. ..... 10b 34,855,040 17,558,502 10c 15,869,489
11 Investments—publicly traded securities .......... 194,001 11 208,018
12 Investments—other securities. See Part IV, line 11 ...... 18,017 12 13,848
13 Investments—program-related. See Part IV, line 11 .. 0 13 0
14 Intangible assets ......... 0 14 0
15 Other assets. See Part IV, line 11 ........... 91,450 15 42,351
16 Total assets. Add lines 1 through 15 (must equal line 34)... 27,520,106 16 27,946,630
Liabilities 17 Accounts payable and accrued expenses . 6,360,093 17 3,738,262
18 Grants payable .......... 0 18 0
19 Deferred revenue .......... 2,860,051 19 3,117,042
20 Tax-exempt bond liabilities .......... 26,554,171 20 26,142,473
21 Escrow or custodial account liability. Complete Part IV of Schedule D.. 0 21 0
22 Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L.......... 0 22 0
23 Secured mortgages and notes payable to unrelated third parties .. 0 23 0
24 Unsecured notes and loans payable to unrelated third parties .... 0 24 0
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D..... 9,381,659 25 19,828,917
26 Total liabilities. Add lines 17 through 25..... 45,155,974 26 52,826,694
Net Assets or Fund Balance Organizations that follow SFAS 117, check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets ..... -18,000,103 27 -25,247,734
28 Temporarily restricted net assets ..... 280,774 28 288,498
29 Permanently restricted net assets ..... 83,461 29 79,172
Organizations that do not follow SFAS 117, check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds .....   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ..... -17,635,868 33 -24,880,064
34 Total liabilities and net assets/fund balances ..... 27,520,106 34 27,946,630
Form 990 (2011)
Form 990 (2011)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI .........
1
Total revenue (must equal Part VIII, column (A), line 12) ...
1
49,331,023
2
Total expenses (must equal Part IX, column (A), line 25) ....
2
53,616,070
3
Revenue less expenses. Subtract line 2 from line 1 ...
3
-4,285,047
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
-17,635,868
5
Other changes in net assets or fund balances (explain in Schedule O) ...
5
-2,959,149
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B)) ....
6
-24,880,064
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII .........
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?....
2a
 
No
b
Were the organization’s financial statements audited by an independent accountant?........
2b
Yes
 
c
If “Yes,” to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant? If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O. ...........................
2c
Yes
 
d
If “Yes” to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? ................
3a
Yes
 
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. ..
3b
Yes
 
Form 990 (2011)
Additional Data


Software ID:  
Software Version:  
Form 990, Special Condition Description:
Special Condition Description
SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service
Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
Canonsburg General Hospital
 
Employer identification number

25-1737079
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization? ................
11g(i)
 
 
(ii) a family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
(i)
Name of supported organization 		(ii)
EIN 		(iii)
Type of organization (described on lines 1- 9 above or IRC section (see instructions)) 		(iv)
Is the organization in col. (i) listed in your governing document? 		(v)
Did you notify the organization in col. (i) of your support? 		(vi)
Is the organization in col. (i) organized in the U.S.? 		(vii)
Amount of support?
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....            
2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......            
3 The value of services or facilities furnished by a governmental unit to the organization without charge..            
4 Total. Add lines 1 through 3..            
5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..            
6 Public Support. Subtract line 5 from line 4.            
Section B. Total Support
Calendar year(or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
7 Amounts from line 4..            
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
9 Net income from unrelated business activities, whether or not the business is regularly carried on..            
10 Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..            
11 Total support (Add lines 7 through 10).            
12
12
 
13
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .            
2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......            
3 Gross receipts from activities that are not an unrelated trade or business under section 513..            
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...            
5 The value of services or facilities furnished by a governmental unit to the organization without charge..            
6 Total. Add lines 1 through 5.            
7a Amounts included on lines 1, 2, and 3 received from disqualified persons...            
b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.            
c Add lines 7a and 7b..            
8 Public Support (Subtract line 7c from line 6.)            
Section B. Total Support
Calendar year (or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.            
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)            
13 Total support (Add lines 9, 10c, 11 and 12.).            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 4
Part IV
Supplemental Information. Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2011

Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2011
Name of organization
Canonsburg General Hospital
 
Employer identification number

25-1737079
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule
Special Rules
......................... Arrow Bullet   $    
Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its
Form 990-EZ or on Part I, line 2, of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 2
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
Canonsburg General Hospital
  		Employer identification number

25-1737079
Part I
Contributors (see Instructions). Use duplicate copies of Part I if additional space is needed.
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 3
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
Canonsburg General Hospital
  		Employer identification number

25-1737079
Part II
Noncash Property (see Instructions). Use duplicate copies of Part II if additional space is needed.
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 4
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
Canonsburg General Hospital
  		Employer identification number

25-1737079
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet $  
Use duplicate copies of Part III if additional space is needed
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Additional Data


Software ID:  
Software Version:  
SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet Complete if the organization is described below.
SchCMd Bullet Attach to Form 990 or Form 990-EZ. SchCMd Bullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public
Inspection
If the organization answered “Yes” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)) Complete Part II-A. Do not complete Part II-B.
Round Bullet Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, line 35c (Proxy Tax), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
Canonsburg General Hospital
 
Employer identification number

25-1737079
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization’s direct and indirect political campaign activities in Part IV.
2
Political expenditures ....................................SchCMd Bullet
$  
3
Volunteer hours ........................................
 

Part I-B
Complete if the organization is exempt under section 501(c)(3).
1
Enter the amount of any excise tax incurred by the organization under section 4955 .........SchCMd Bullet
$  
2
Enter the amount of any excise tax incurred by organization managers under section 4955 ......SchCMd Bullet
$  
3
If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............
4a
Was a correction made? .........................................
b
If "Yes," describe in Part IV.
Part I-C
Complete if the organization is exempt under section 501(c) except section 501(c)(3).
1
Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet
$  
2
Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ...................................SchCMd Bullet

$  
3
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b..SchCMd Bullet

$  
4
Did the filing organization file Form 1120-POL for this year? ..........................
5
Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.
(a) Name (b) Address (c) EIN (d) Amount paid from filing organization's funds. If none, enter -0-. (e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.










For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990.
Cat. No. 50084S
Schedule C (Form 990 or 990-EZ) 2011

Schedule C (Form 990 or 990-EZ) 2011
Page 2
Part II-A
Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).
A Check expenses, and share of excess lobbying expenditures).
B Check
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
organization's
totals 		(b) Affiliated group
totals
1a Total lobbying expenditures to influence public opinion (grass roots lobbying) ...... 0 0
b Total lobbying expenditures to influence a legislative body (direct lobbying) ....... 7,055 225,684
c Total lobbying expenditures (add lines 1a and 1b) ................... 7,055 225,684
d Other exempt purpose expenditures ........................ 53,609,015 1,698,163,316
e Total exempt purpose expenditures (add lines 1c and 1d) ............... 53,616,070 1,698,389,000
f Lobbying nontaxable amount. Enter the amount from the following table in both
columns.		 1,000,000 1,000,000
  If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:    
  Not over $500,00020% of the amount on line 1e.    
  Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.    
  Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.    
  Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.    
  Over $17,000,000$1,000,000.    
       
g Grassroots nontaxable amount (enter 25% of line 1f) ................. 250,000 250,000
h Subtract line 1g from line 1a. If zero or less, enter -0-. ................    
i Subtract line 1f from line 1c. If zero or less, enter -0-. ................    
j If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting
section 4911 tax for this year? ......................................

4-Year Averaging Period Under Section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five
columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
  Calendar year (or fiscal year
beginning in) 		(a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) Total
             
2a Lobbying non-taxable amount 1,000,000 1,000,000 1,000,000 1,000,000 4,000,000
             
b Lobbying ceiling amount
(150% of line 2a, column(e)) 		        6,000,000
             
c Total lobbying expenditures 585,102 418,483 424,588 225,684 1,653,857
             
d Grassroots nontaxable amount 250,000 250,000 250,000 250,000 1,000,000
             
e Grassroots ceiling amount
(150% of line 2d, column (e))		         1,500,000
             
f Grassroots lobbying expenditures 0 0 0 0 0
Schedule C (Form 990 or 990-EZ) 2011


Schedule C (Form 990 or 990-EZ) 2011
Page 3
Part II-B
Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).
For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.
(a)
Yes
No
(b)
Amount
1
During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:
a
Volunteers? .........................................
 
 
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
 
 
c
Media advertisements? ....................................
 
 
 
d
Mailings to members, legislators, or the public? .........................
 
 
 
e
Publications, or published or broadcast statements? .......................
 
 
 
f
Grants to other organizations for lobbying purposes? .......................
 
 
 
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
 
 
 
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
 
 
i
Other activities? ..........................
 
 
 
j
Total. Add lines 1c through 1i ...............................
 
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
 
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......
 
 
Part III-A
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).
Yes
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........
3
 
 
Part III-B
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2 are answered “No” OR (b) Part III-A, line 3 is answered “Yes”.
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ...........................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
Part IV
Supplemental Information
Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, Part II-A; line 5; and Part ll-B, line 1.
Also, complete this part for any additional information.
Identifier Return Reference Explanation
Lobbying Expenditures Form 990, Schedule C, Page 2, Part II-A, Line 1b, Column A Canonsburg General Hospital (CGH) has made the IRC Section 501(h) election. CGH has not made any political expenditure and no direct lobbying expenditures. CGH is a member of the West Penn Allegheny Health System (WPAHS). WPAHS employs an Executive Vice President for external affairs to lobby issues of importance to WPAHS and all of its members. WPAHS also elected to engage the services of outside consultants to assist us in lobbying issues of importance. The lobbying expenditures of $7,055 attributed to CGH on Schedule C, Page 2, Part II-A reflect expenditures allocated to CGH from WPAHS and do not reflect direct expenditures made by CGH.
Schedule C (Form 990 or 990EZ) 2011

Additional Data


Software ID:  
Software Version:  

SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Canonsburg General Hospital
 
Employer identification number

25-1737079
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .......    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) ...    
4 Aggregate value at end of year .......    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................
9
In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958), relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 52283D
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIV and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIV.
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current Year (b)Prior Year (c)Two Years Back (d)Three Years Back (e)Four Years Back
1a Beginning of year balance .... 364,235 776,418 469,207 290,085
b Contributions ........ 121,900 278,567 460,881 183,331
c Net investment earnings, gains, and losses ... 936 12,775 10,255 -1,398
d Grants or scholarships .....        
e Other expenditures for facilities
and programs ........ 		119,274 703,464 163,880 2,624
f Administrative expenses .... 127 61 45 187
g End of year balance ...... 367,670 364,235 776,418 469,207
2
Provide the estimated percentage of the year end balance (line 1g) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet22.000 %
c
Temporarily restricted endowment SchDMd Bullet78.000 %
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
Yes
 
(ii) related organizations ........................
3a(ii)
 
No
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIV the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   244,925 244,925
b Buildings ................   27,975,602 18,133,659 9,841,943
c Leasehold improvements ............   279,707 279,707 0
d Equipment ................   18,870,714 13,923,268 4,947,446
e Other .................   3,353,581 2,518,406 835,175
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 15,869,489
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet  
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of Liability (b) Book value
Federal Income Taxes 0
ACCRUED PENSION COST 8,166,884
INSURANCE LIABILITIES 661,054
DUE TO AFFILIATED ORGANIZATION 11,000,979






Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 19,828,917
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 4
Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1 Total revenue (Form 990, Part VIII, column (A), line 12) .................... 1  
2 Total expenses (Form 990, Part IX, column (A), line 25) ..................... 2  
3 Excess or (deficit) for the year. Subtract line 2 from line 1 ............. 3  
4 Net unrealized gains (losses) on investments .......................... 4  
5 Donated services and use of facilities ............................. 5  
6 Investment expenses ................................... 6  
7 Prior period adjustments .................................. 7  
8 Other (Describe in Part XIV.) ................................. 8  
9 Total adjustments (net). Add lines 4 through 8 ......................... 9  
10 Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 ......... 10  
Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIV.) ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIV.) ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total Revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5  
Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ............. 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIV.) ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIV.) ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5  
Part XIV
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
CGH Inclusion In The Consolidated Audit of WPAHS Form 990, Schedule D, Part X, Question 2, Part XII and XIII Canonsburg General Hospital does not receive its own independent audit. It is a member of a regional healthcare system named West Penn Allegheny Health System. West Penn Allegheny Health System receives a consolidated audit that includes the operations of Canonsburg General Hospital. The following analysis represents the reconciliation between the Canonsburg General Hospital financial statement net income and the net income as reported on Form 990, Page 1, line 19: Net loss per financial statements $(4,292,690) Plus: Income and expense reclassified from restricted net assets on the financial statements to unrestricted income and expense on Form 990 8,742 Less: Unrealized Gain on the Financial Statements reclassified to Net Assets (1,099) ___________ Net loss per Form 990 $(4,285,047) The following is the footnote to the audited consolidated financial statements of the West Penn Allegheny Health System for FASB ASC 740: WPAHS adopted Financial Accounting Standards Board (FASB) Accounting Standards Codification (ASC) 740, Income Taxes, which clarifies the accounting for uncertainty in income taxes recognized in an enterprise's financial statements. FASB ASC 740 prescribes a more-likely than-not recognition threshold and measurement attribute for the financial statement recognition and measurement of a tax position taken or expected to be taken. Under FASB ASC 740, tax positions will be evaluated for recognition, derecognition, and measurement using consistent criteria and will provide more information about the uncertainty in income tax assets and liabilities. Based on an analysis prepared by WPAHS, it was determined that the application of FASB ASC 740 had no material effect on the recorded assets and liabilities of WPAHS.
Intended Use of the Organization Endowment Fund Schedule D, Page 2, Part V, Line 4 The intended use of the Canonsburg General Hospital permanent and term endowments are for, but not exclusive to: capital improvements, research, education, departmental needs, operating efficiencies, and overall patient care. The earnings off of the permanent amount are expendable, based on the specific use of the fund.
Schedule D (Form 990) 2011

Additional Data


Software ID:  
Software Version:  




SCHEDULE G (Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Supplemental Information Regarding
Fundraising or Gaming Activities
Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19,or if the organization entered more than $15,000 on Form 990-EZ, line 6a.right arrowAttach to Form 990 or Form 990-EZ. right arrowSee separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Canonsburg General Hospital
 
Employer identification number

25-1737079
Part I
Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.
1
Indicate whether the organization raised funds through any of the following activities. Check all that apply.
a e
b f
c g
d
2a
Did the organization have a written or oral agreement with any individual (including officers, directors, trustees
or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?
b
If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization. Form 990-EZ filers are not required to complete this table.
(i) Name and address of individual
or entity (fundraiser) 		(ii) Activity (iii) Did fundraiser have custody or control of contributions? (iv) Gross receipts
from activity 		(v) Amount paid to
(or retained by)
fundraiser listed in
col. (i) 		(vi) Amount paid to
(or retained by)
organization
Yes No
Total .................right arrow      
3
List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50083H
Schedule G (Form 990 or 990-EZ) 2011
Schedule G (Form 990 or 990-EZ) 2011
Page 2
Part II
Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 on Form 990-EZ, line 6a. List events with gross receipts greater than $5,000.
(a) Event #1

GOLF TOURNAMENT
(event type) 		(b) Event #2

 
(event type) 		(c) Other Events

0
(total number) 		(d) Total Events
(Add col. (a) through col. (c))
VerticalRevenue 1 Gross receipts . . . 74,470     74,470
2 Less: Charitable
contributions . . . 		27,612     27,612
3 Gross income (line 1
minus line 2) . . . 		46,858     46,858
VerticalDirectExpenses 4 Cash prizes . . .        
5 Non-cash prizes . .        
6 Rent/facility costs . . 23,877     23,877
7 Food and beverages . .        
8 Entertainment . . .        
9 Other direct expenses . 6,309     6,309
10 Direct expense summary. Add lines 4 through 9 in column (d) ........... right arrow 30,186
11 Net income summary. Combine lines 3 and 10 in column (d)............ right arrow 16,672
Part III
Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.
VerticalRevenue (a) Bingo (b) Pull tabs/Instant
bingo/progressive bingo 		(c) Other gaming (d) Total gaming (Add col. (a) through col. (c))
1 Gross revenue . . . .        
VerticalDirectExpenses 2 Cash prizes . . . .        
3 Non-cash prizes . . .        
4 Rent/facility costs . . .        
5 Other direct expenses . .        
6 Volunteer labor . . .
 
 
 
7 Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow  
8 Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow  
9
Enter the state(s) in which the organization operates gaming activities:
a
Is the organization licensed to operate gaming activities in each of these states? ............
b
If "No," Explain:
 
10a
Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....
b
If "Yes," Explain:
 
11
Does the organization operate gaming activities with nonmembers? .................
12
Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity
formed to administer charitable gaming? ..........................
Schedule G (Form 990 or 990-EZ) 2011
Schedule G (Form 990 or 990-EZ) 2011
Page 3
13
Indicate the percentage of gaming activity operated in:
a
The organization's facility ......................
13a
 
b
An outside facility ........................
13b
 
14
Provide the name and address of the person who prepares the organization's gaming/special events books and records:
Name right arrow
Address right arrow
15a
Does the organization have a contract with a third party from whom the organization receives gaming
revenue? ......................................
b
If "Yes," enter the amount of gaming revenue received by the organization right arrow $   and the
amount of gaming revenue retained by the third party right arrow $   .
c
If "Yes," enter name and address:
Name right arrow
Address right arrow
 
 
16
Gaming manager information:
Name right arrow
Gaming manager compensation right arrow $  
Description of services provided right arrow
 
17
Mandatory distributions:
a
Is the organization required under state law to make charitable distributions from the gaming proceeds to
retain the state gaming license? ............................
b
Enter the amount of distributions required under state law distributed to other exempt organizations or spent
in the organization's own exempt activities during the tax year right arrow$  
Part IV
Complete this part to provide additional information for responses to quuestion on Schedule G (see instructions.)
Identifier ReturnReference Explanation
Schedule G (Form 990 or 990-EZ) 2011
Additional Data


Software ID:  
Software Version:  
SCHEDULE H (Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet Attach to Form 990. MediumBullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Canonsburg General Hospital
 
Employer identification number

25-1737079
Part I
Charity Care and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a....
1a
Yes
 
b
If "Yes," was it a written policy? .......................
1b
Yes
 
2
If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.
3
Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.
a
Did the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Did the organization use FPG to determine eligibility for providing discounted care? If "Yes," indicate which of the
following was the family income limit for eligibility for discounted care: ............
3b
Yes
 
c
If the organization did not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.
4
Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

4

Yes

 
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount?......
5b
 
No
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care?...............
5c
 
 
6a
Did the organization prepare a community benefit report during the tax year?...........
6a
Yes
 
b
If "Yes," did the organization make it available to the public? ...............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance
and Means-Tested Government Programs		 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) .. 		    194,773   194,773 0.360 %
b Medicaid (from Worksheet 3, column a) .....     3,450,859 1,667,992 1,782,867 3.330 %
c Costs of other means-tested government programs (from Worksheet 3, column b) .            
dTotal Financial Assistance and
Means-Tested Government Programs ..... 		    3,645,632 1,667,992 1,977,640 3.690 %
Other Benefits
e Community health improvement
services and community
benefit operations (from
(Worksheet 4) .... 		    112,418   112,418 0.210 %
f Health professions education
(from Worksheet 5) .. 		    176,058   176,058 0.330 %
g Subsidized health services
(from Worksheet 6) .. 		    23,048,553 21,479,075 1,569,478 2.930 %
h Research (from Worksheet 7)            
i Cash and in-kind contributions for community benefit (from Worksheet 8) ....     39,083   39,083 0.070 %
jTotal Other Benefits ...     23,376,112 21,479,075 1,897,037 3.540 %
kTotal. Add lines 7d and 7j. ..     27,021,744 23,147,067 3,874,677 7.230 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development            
3 Community support            
4 Environmental improvements            
5 Leadership development and training for community members            
6 Coalition building     34,277   34,277 0.060 %
7 Community health improvement advocacy     72,180   72,180 0.130 %
8 Workforce development            
9 Other            
10 Total     106,457   106,457 0.190 %
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense........
2
973,689
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy .....
3
234,284
4
Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense. In addition, describe the costing methodology used in determining the amounts reported on lines 2 and 3, and rationale for including a portion of bad debt amounts as community benefit.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
9,472,178
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
11,533,727
7
Subtract line 6 from line 5. This is the surplus or (shortfall)........
7
-2,061,549
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

9b

Yes

 
Part IV
Management Companies and Joint Ventures
(see instructions)
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership% 		(e) Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest)
How many hospital facilities did the organization operate during the tax year?1
Name and address 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe)
1 Canonsburg General Hospital
100 Medical Boulevard
Canonsburg,PA15317 		X X         X    
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)
Canonsburg General Hospital
Name of Hospital Facility:  
Line Number of Hospital Facility (from Schedule H, Part V, Section A):1

Yes No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2011)
1 During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. ..................... 1    
If “Yes,” indicate what the Needs Assessment describes (check all that apply):
a A definition of the community served by the hospital facility
b Demographics of the community
c Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d How data was obtained
e The health needs of the community
f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g The process for identifying and prioritizing community health needs and services to meet the community health needs
h The process for consulting with persons representing the community’s interests
i Information gaps that limit the hospital facility’s ability to assess the community’s health needs
j Other (describe in Part VI)
2 Indicate the tax year the hospital facility last conducted a Needs Assessment: 20  
3 In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted. 3    
4 Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................ 4    
5 Did the hospital facility make its Needs Assessment widely available to the public? ........... 5    
If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
a Hospital facility’s website
b Available upon request from the hospital facility
c Other (describe in Part VI)
6 If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
a Adoption of an implementation strategy to address the health needs of the hospital facility’s community
b Execution of the implementation strategy
c Participation in the development of a community-wide community benefit plan
d Participation in the execution of a community-wide community benefit plan
e Inclusion of a community benefit section in operational plans
f Adoption of a budget for provision of services that address the needs identified in the Needs Assessment
g Prioritization of health needs in the community
h Prioritization of services that the hospital facility will undertake to meet health needs in its community
i Other (describe in Part VI)
7 Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs. .... 7    
Financial Assistance Policy
Did the hospital facility have in place during the tax year a written financial assistance policy that:
8 Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 8 Yes  
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care?........... 9 Yes  
If "Yes," indicate the FPG family income limit for eligibility for free care: 200.%
If "No," explain in Part VI the criteria the hospital facility used.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Yes No
10 Used FPG to determine eligibility for providing discounted care?................. 10 Yes  
If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 400.%
If "No," explain in Part VI the criteria the hospital facility used.
11 Explained the basis for calculating amounts charged to patients?................. 11 Yes  
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a Income level
b Asset level
c Medical indigency
d Insurance status
e Uninsured discount
f Medicaid/Medicare
g State regulation
h Other (describe in Part VI)
12 Explained the method for applying for financial assistance?................... 12 Yes  
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13 Yes  
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a The policy was posted on the hospital facility’s web site
b The policy was attached to all billing invoices
c The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d The policy was posted in the hospital facility’s admissions offices
e The policy was provided, in writing, to patients upon admission to the hospital facility
f The policy was available upon request
g Other (describe in Part VI)
Billing and Collections
14 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?....... 14 Yes  
15 Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other similar actions (describe in Part VI)
16 Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?.......... 16 Yes  
If “Yes,” check all actions in which the hospital facility or a third party engaged:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other similar actions (describe in Part VI)
17 Indicate which efforts the hospital facility made before initiating any of the actions checked in line 16 (check all that apply):
a Notified patients of the financial assistance policy upon admission
b Notified patients of the financial assistance policy prior to discharge
c Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
d Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy
e Other (describe in Part VI)
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
Yes No
18 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.......... 18 Yes  
If “No,” indicate why:
a The hospital facility did not provide care for any emergency medical conditions
b The hospital facility’s policy was not in writing
c The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
d Other (describe in Part VI)
Individuals Eligible for Financial Assistance
19 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
b The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
c The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
d Other (describe in Part VI)
20 Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?......... 20   No
If “Yes,” explain in Part VI.
21 Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?............................... 21 Yes  
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, from largest to smallest)
How many non-hospital health care facilities did the organization operate during the tax year?3
Name and address Type of Facility (describe)
1 Peters Township Outpatient Care Center
160 Gallery Drive
McMurray,PA15317 		Outpatient Care Center
2 Canonsburg Community Health Care
36 East Pike Street
Canonsburg,PA15317 		Community Health Care
3 CGH - Physician Offices
Southpoint Plaza 1 Ste 235
Canonsburg,PA15317 		Physician Offices
4
5
6
7
8
9
10
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VI
Supplemental Information
Complete this part to provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 9, 10, 11h, 13g, 15e, 16e, 17e, 18d, 19d, 20, and 21.
2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Identifier ReturnReference Explanation
Bad Debt Expense Financial Statement Footnote and Costing Methodology Schedule H, Part III, Question 4 Canonsburg General Hospital does not issue a separate audited financial statement and therefore a footnote does not exist. Bad debt is accounted for on a charge basis in our internal financial statements. A cost to charge ratio is applied to the internal figures to convert the charge to cost. It is the opinion of Canonsburg General Hospital management that because patients are often reluctant to complete the required charity care paperwork that an significant amount of charity care results in bad debt. Thus, it is our opinion that bad debt expense should be considered a justifiable component of charity care.
Medicare Costing Methodology Schedule H, Part III, Question 8 Canonsburg General Hospital receives overall reimbursement from Medicare less than the cost of the services provided. As such, we consider the shortfall a community benefit. The source used to determine the amount reported on line 6 is the medicare cost report.
Collection Practices For Patients Who Qualify For Financial Assistance Schedule H, Part III, Question 9b Patients that qualify for charity care or financial assistance are provided with an approval letter with the effective dates for the assistance. At any time the individual presents for services within a 90 day span of approval, they show the letter and will be registered as a charity care case. Charity care cases are designated in the internal computerized systems with unique plan codes that prevent billing to the patient. Reports are run to capture the patient accounts registered with the charity care plan codes so they can be written off to charity care.
Charges For Medical Care Schedule H, Part V, Line 19 Canonsburg General Hospital offers uninsured patients a fifty percent (50%) discount on total gross charges to all hospital charges. The intent of the discount is to standardize charging practices for covered and non covered patients. The discount is offered during patient contact for elective/ urgent (non cosmetic) procedures during the financial counseling process, as well as during the patient statement cycle process for services provided (including Emergency services.) Patient statements are clearly marked with the uninsured discount, reducing the 'amount owed' of the gross charges. An uninsured discount of 50% is applied to the patient account either at the time of payment or prior to transferring the account to bad debt upon conclusion of the routine four statement cycle, for any unpaid balances.
Charges Equal to Gross Charges for Patient Services Schedule H, Part V, Line 21 The hospital offers a variety of procedures. For elective/non medically emergent procedures not covered by health plans, individual fee schedules are published and communicated prior to services. Patients are contacted in advance of the procedure by financial counselors and are required to pay for services in full based on the fee schedule. The patient is required to pay the hospital fee schedule for the technical component and the physician for the professional services rendered.
Health Needs Assessment Schedule H, Part VI, Line 2 Canonsburg General Hospital management and staff utilize multiple strategies to continually monitor and assess the health care needs of the communities it serves. One approach to assessing needs involves surveying community members about health needs related to national and state health goals. Canonsburg General Hospital also acts on expressed community needs by responding to direct community requests for health screenings, outreach events and other health-related activities and by maintaining longstanding programs that are well attended and positively evaluated by community participants. In addition, Canonsburg General Hospital gathers community input through participation in area rotaries, chambers of commerce, through partnerships with community organizations and other community engagement activities. Another means is through reviewing and taking appropriate actions on feedback gathered from the following sources: routine market assessments; patient and family satisfaction surveys; Press Ganey surveys; patient, patient family and staffs' suggestions for improving patient safety; medical staff input and physician surveys. In addition to the ongoing community health monitoring and assessment, Canonsburg General Hospital is actively working towards a formal community health needs assessment (CHNA) that will be completed for the year ending June 30, 2013. This formal needs assessment will have the findings published and available to the general public as well as an implementation strategy adopted by the Board of Directors. The needs assessment will involve systematically analyzing demographic and other health-related data, considering local, state and national health goals, understanding existing community health resources and programs, as well as engaging and actively soliciting input from community partners and community members with special knowledge of public health. It is expected that the CGH Board of Directors will approve and implement the CHNA plan prior to June 30, 2013.
Patient Education For Eligibility For Assistance Schedule H, Part VI, Line 3 Canonsburg General Hospital displays signage in various patient Admission, Registration and Emergency Department areas that alerts that patient to Account Assistance program availability and contact information. During the preservice process, patients are evaluated to determine financial assistance options. Canonsburg General Hospital offers the "Account Assistance Program" which consists of application assistance for governmental eligibility, Charity Care application completion and submission support, as well as uninsured provisions. Account Assistance summaries are available on the West Penn Allegheny Health System website www.wpahs.org under the link titled, "Care for Uninsured" are available to the public. The Charity Care application, as well as, a Medical Assistance check list is available for patients who wish to self-apply. In addition to the documents, toll free telephone numbers regarding Account Assistance, charity and/or other financial inquiries are available. The website also contains a copy of the brochure that summarizes the Account Assistance program, as well as provides various governmental and internal numbers to patients seeking additional support. Canonsburg General Hospital also provides on-site support through Financial Counselor staff who are available to work with patient walk in's. Financial Counselors work directly with the patients as well as designated agency support regarding qualifying patients for Medical Assistance. Both week day and weekend coverage is available to the patients, as well as field support needed for post discharge follow up needed for application submission. The above support is available at no charge to the patient.
Community Served Information Schedule H, Part VI, Line 4 Canonsburg General Hospital, located in Canonsburg Pennsylvania, provides health care services to residents of Allegheny and Washington Counties. Located approximately 20 miles outside of Pittsburgh, Canonsburg has approximately 9,000 residents. Allegheny County consists of approximately 1,227,000 residents living in a land area of approximately 730 square miles. The median housing value in Allegheny County is $118,700. Washington County consists of approximately 209,000 residents living in a land area of approximately 857 square miles. The median housing value in Washington County is $136,400.
Promotion of Community Health Schedule H, Part VI, Line 5 The Canonsburg General Hospital Emergency Department cares for the community by operating 24 hours a day, 7 days a week with highly skilled and trained emergency medicine physicians and nurses. The Emergency Department is open to all individuals regardless of their ability to pay. The voting members of the Canonsburg General Hospital Board of Directors consist of a majority of independent community members without personal financial ties to the hospital or any of its affiliated organizations.
Affiliated Healthcare System Schedule H, Part VI, Line 6 West Penn Allegheny Health System (WPAHS) is comprised of some of the oldest and best-known names in health care in western Pennsylvania. From their inception, the system's hospitals have been in the vanguard of patient care, medical research and health sciences education. Comprised of two tertiary and three community hospitals, WPAHS includes Allegheny General Hospital and The Western Pennsylvania Hospital, both in Pittsburgh; Alle-Kiski Medical Center in Natrona Heights; Canonsburg General Hospital in Canonsburg; and Forbes Regional Campus in Monroeville. Offering a comprehensive range of medical and surgical services, the hospitals serve Pittsburgh and the surrounding five-state area, house approximately 1,600 beds and employ more than 11,000 people. Together, the WPAHS hospitals admit nearly 56,000 patients, log over 164,000 emergency visits and deliver more than 3,800 newborns each year. Combined, the hospitals are among the leaders in percentages of total surgeries, cardiac surgeries, neurosurgeries and cardiac catheterization procedures performed throughout the region. Through the West Penn Allegheny Health System, Canonsburg General Hospital (CGH) is able to ensure that area residents have access to a complete continuum of health care services. And through appropriate integration across the system, both clinically and operationally, the hospital is able to remain a high-quality, low-cost provider with linkages to the latest medical research and advanced technology. Canonsburg General Hospital provides a wide range of medical and surgical services, with advanced diagnostic and treatment services accessible on both an inpatient and outpatient basis. The Hospital has an active ambulatory care center available to serve the needs of the community.
State Filing of Community Benefit Report Schedule H, Part VI, Line 7 Canonsburg General Hospital files the community benefit report with the state of Pennsylvania as part of our obligation to furnish the state of Pennsylvania with a copy of the IRS Form 990 and related schedules.
Schedule H (Form 990) 2011
Additional Data


Software ID:  
Software Version:  
Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Canonsburg General Hospital
 
Employer identification number

25-1737079
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all the expenses described above? If "No," complete Part III to explain....
1b
 
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....
2
 
 
3
Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ...............
4a
Yes
 
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........
4b
 
No
c
Participate in, or receive payment from, an equity-based compensation arrangement? ........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 50053T
Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and column (E) for that individual.
(A) Name (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) Christopher Olivia MD (i)
(ii)		 0
677,905 		0
2,500,000 		0
930,056 		0
1,884,800 		0
10,553 		0
6,003,314 		0
3,507,618
(2) Roy Santarella (i)
(ii)		 0
605,727 		0
171,437 		0
194,726 		0
1,301,114 		0
11,650 		0
2,284,654 		0
117,174
(3) Thomas Albanesi (i)
(ii)		 0
50,974 		0
0 		0
266,606 		0
43,578 		0
6,445 		0
367,603 		0
239,282
(4) Judy Hlafcsak (i)
(ii)		 0
0 		0
0 		0
258,918 		0
17,210 		0
240 		0
276,368 		0
258,918
(5) Deborah Olszewski (i)
(ii)		 0
176,869 		0
58,723 		0
1,016 		0
14,195 		0
1,658 		0
252,461 		0
0
(6) Matthew Peterson (i)
(ii)		 0
165,051 		0
12,862 		0
57 		0
7,748 		0
5,141 		0
190,859 		0
0
(7) Diane Dismukes (i)
(ii)		 0
413,921 		0
100,000 		0
225,717 		0
833,367 		0
10,967 		0
1,583,972 		0
0
(8) Thomas Corkery MD (i)
(ii)		 0
236,057 		0
11,221 		0
508 		0
9,800 		0
8,841 		0
266,427 		0
0
(9) Terry Wiltrout (i)
(ii)		 34,904
90,458 		7,713
17,361 		24
54 		1,916
4,313 		6,172
1,992 		50,729
114,178 		0
0
(10) Teresa Gordon (i)
(ii)		 161,607
0 		40,279
0 		290
0 		8,189
0 		8,364
0 		218,729
0 		0
0
(11) Cathleen Allinder (i)
(ii)		 153,058
0 		0
0 		415
0 		7,806
0 		3,551
0 		164,830
0 		0
0
(12) Barbara Gorby (i)
(ii)		 155,217
0 		0
0 		254
0 		6,410
0 		7,662
0 		169,543
0 		0
0
(13) Jeffrey Gretz MD (i)
(ii)		 0
247,744 		0
87,983 		0
227 		0
7,963 		0
11,262 		0
355,179 		0
0
(14) David Kiehn (i)
(ii)		 0
451,544 		0
90,090 		0
1,584 		0
579,119 		0
12,145 		0
1,134,482 		0
0
(15) Susan Manzi MD (i)
(ii)		 0
421,712 		0
63,750 		0
552 		0
9,800 		0
11,065 		0
506,879 		0
0
(16) Robert Brandfass (i)
(ii)		 0
364,311 		0
60,764 		0
11,493 		0
9,800 		0
19,628 		0
465,996 		0
0
(17) Pamela Gallagher (i)
(ii)		 0
235,714 		0
28,137 		0
516 		0
9,800 		0
8,104 		0
282,271 		0
0
(18) Dawn Gideon (i)
(ii)		 0
0 		0
0 		0
520,867 		0
0 		0
0 		0
520,867 		0
520,867
Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.
Identifier Return Reference Explanation
Additional Compensation Disclosure Form 990, Schedule J, Page 1, Part I, Question 4a The following represents additional disclosure for Schedule J, line 4a pertaining to officers and key employees listed in Form 990, Part VII, Section A, Line 1a receiving severance pay during the calendar year ending within the June 30, 2012 fiscal year end: Judy Hlafcsak $259,157 Dawn Gideon $520,867 Christopher Olivia, MD $625,000 Diane Dismukes $166,673 Roy Santarella $117,174 Thomas Albanesi $228,782 The following list represents Officers, Directors or Key Employees of Canonsburg General Hospital listed on Form 990, Part VII who did not serve a full consecutive twelve month tenure for the year ended June 30, 2012 along with the dates served: Kimberly Malinky 07-01-2011 - 08-05-2011 Diane Dismukes 07-01-2011 - 10-31-2011 Roy Santarella 07-01-2011 - 11-01-2011 David Kiehn 07-01-2011 - 12-30-2011 Eugene Trout 07-01-2011 - 04-02-2012 Deborah Olszewski 01-31-2012 - 06-30-2012 Matthew Peterson 01-31-2012 - 06-30-2012 Pamela Gallagher 04-03-2012 - 06-30-2012
Deferred Compensation Schedule J, Part II, Column C Retirement and other deferred compensation reflect amounts accrued to the benefit of the applicable individuals related to qualified pension and severance plans. In this regard, the following individuals have amounts accrued related to future severance payments to be made: Christopher Olivia, MD Roy Santarella Diane Dismukes Thomas Albanesi David Kiehn Judy Hlafcsak
Schedule J (Form 990) 2011

Additional Data


Software ID:  
Software Version:  
SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
Canonsburg General Hospital
 
Employer identification number

25-1737079
Identifier Return Reference Explanation
Subsequent Event - Corporate Affiliation Form 990 - General Information West Penn Allegheny Health System, Inc., the sole member of Canonsburg General Hospital has consummated a formal affiliation on April 29, 2013 to establish a regional integrated health care services delivery system. The details of the affiliation will be documented in the footnotes to the Audited Financial Statements. Due to the considerable complexities associated with this affiliation, the audited financial statements have not been issued at the date of the filing of this tax return. Upon issuance, we will amend this tax return to include a copy of the audited financial statements.
Statement of Program Service Accomplishments Form 990, Page 2, Part III, Line 4a INTRODUCTION TO CANONSBURG GENERAL HOSPITAL Canonsburg General Hospital (CGH), founded in 1904, is a 104-bed community hospital located 25 miles southwest of Pittsburgh. The hospital's primary service areas are northern Washington and southern Allegheny counties. CGH is part of the West Penn Allegheny Health System (WPAHS). Organized in 2000, WPAHS (www.wpahs.org) is comprised of West Penn Allegheny Health System, Inc. (WPAHS, Inc.), Alle-Kiski Medical Center (AKMC), Allegheny Medical Practice Network (AMPN), Allegheny Specialty Practice Network (ASPN) Allegheny-Singer Research Institute (ASRI), West Penn Allegheny Oncology Network (WPAON), West Penn Physician Practice Network (WPPPN), Canonsburg General Hospital Ambulance Service (CGH Ambulance), the Western Pennsylvania Hospital Foundation (WPHF), Forbes Health Foundation (FHF), Suburban Health Foundation (SHF) and the Alle-Kiski Medical Center Trust (AKMC Trust) as well as CGH. Through its affiliation with the West Penn Allegheny Health System, CGH area residents have access to a complete continuum of health care services. Through appropriate integration across the System both clinically and operationally, the Hospital is able to remain a high quality, low-cost provider with linkages to the latest medical research and advanced technology. The Hospital received various accreditations in Fiscal 2012 from sources that include the state Department of Health and the American College of Radiology. CGH has also maintained The Joint Commission's Gold Seal of Approval by demonstrating compliance with The Joint Commission's national standards for health care quality and safety. CGH participated in the Quality Blue program sponsored by Highmark that measured quality initiatives and indicators that included Emergency Department Throughput, Readmissions, Surgical Safety, and Venous Thromboembolism Care and Coordination. The Hospital achieved the maximum level of incentive for the Highmark Quality Blue initiative as a result of our infection prevention initiatives, and process changes to improve patient care and patient safety. CGH provides a wide range of medical and surgical services, with diagnostic and treatment services easily accessible on both an inpatient and outpatient basis. The hospital offers specialized services in acute inpatient rehabilitation, as well as having a strong focus on health education and preventive care programs that reflect its commitment to wellness and health improvement. CGH's ambulatory care center offers a full complement of outpatient services including same-day surgery, gastrointestinal (GI) procedures, computed tomography (CT) scans, pain management and sleep labs. Other specific departments and services available at CGH include medical imaging; laboratory testing and analysis, acute care and intensive care units, and rehabilitation services. The Outpatient Care Center - Peters Township offers medical services and physician offices, allowing cancer care, diagnostic testing, laboratory services, primary care physician offices, specialists, and same-day surgery. For the 12 months ended June 30, 2012, CGH served 3,283 inpatients, registered 72,608 outpatient visits, treated 21,381 patients in the emergency department and performed 1,919 surgeries. CGH employs a workforce of 567 employees and has 267 physicians on its medical staff. PURPOSE AND MISSION Canonsburg General Hospital is an organization defined by our talented people. We are an organization committed to excellence, an organization with one purpose and one mission. Our purpose is to improve the health of the people in the Western Pennsylvania region. Our mission is to practice medicine, educate and conduct research as an integrated team of physicians, nurses and support professionals who are committed to improving the health of our patients. UNCOMPENSATED CARE To enhance the health status of the community in which it operates and consistent with its tax-exempt status, CGH provides needed health care services to individuals regardless of their ability to pay for all or part of the services rendered. These services include both inpatient and outpatient services as well as an emergency room that is available 24 hours a day. Consistent with the filing of Schedule H, the components of uncompensated care include charity care and unreimbursed Medicaid costs. CGH provided uncompensated care at a cost of $1,977,640 in Fiscal 2012. COMMUNITY BENEFIT Community Health Improvement Services and Community Benefit Operations Community health improvement services and community benefit operations include activities carried out to improve community health. They extend beyond patient care to include activities subsidized by the Hospital. The activities range from community health clinics and screenings to health education programs designed to raise community awareness of various healthcare topics and issues. Consistent with the filing of Schedule H, CGH provided these services at a cost of $112,418 in Fiscal 2012. Flu Vaccinations - Flu vaccinations were provided free of charge at local community clinics. In addition, the Hospital provided free vaccinations to local fire, police and ambulance personnel of Canonsburg, Fort Cherry, North Strabane and Houston borough. Medivan Service - CGH provided a free transportation service to area residents who require testing or surgery at the hospital. The Hospital provides this program to enhance access to healthcare for those members of the community who cannot find adequate transportation. During Fiscal 2012, the medivan service made 2,722 trips. Health Fairs and Screenings - CGH sponsored various free health fairs throughout the year. Medical professionals provided cholesterol, glucose, body composition, bone density, lung capacity and blood pressure screenings. In addition, the Hospital provided first aid supplies and written materials containing various items of health information to individuals attending the health fairs. Community Health Fairs - Peters Township - The Hospital outpatient center at Peters Township held a health fair open to everyone in the community. The fair was staffed with two registered nurses, a dietician, medical imaging technologists, staff from medical and radiation oncology as well as athletic trainers and therapists from our orthopaedic institute. Health Education Classes - The Hospital provides the community with the opportunity to attend various programs and classes throughout the year at no cost. The programs include adult and child CPR, First Aid, automated external defibrillator as well as informational sessions on joint replacement and pain management.
Statement of Program Service Accomplishments (continued) Ask The Doctor Show - CGH, in collaboration with local cable television, produced a monthly health education program during which a CGH surgeon hosts the 30-minute live show. Physician guests answer questions regarding a variety of topics. Pharmacist Question and Answer - A CGH registered pharmacist is available by phone to answer questions from the public on over-the-counter and prescription medications. The availability is Monday through Friday from 10 am to 2 pm. Pastoral Care - CGH, in association with Canonsburg Ministerial Association, contracts with a Hospital Chaplain to provide spiritual guidance and healing to CGH patients and their respective families in times of loss and need. This care includes a bereavement series held three times a year for a total of six weeks to help individuals through the emotional process of grief. The Hospital also provides a grief and loss support dinner monthly for families coping with the loss of a loved one. Diabetes Awareness and Education - A registered pharmacist conducts quarterly presentations to the public on diabetes related topics such as oral and insulin medications and the side effects of those medications. In addition, CGH sponsors a four-week course designed to promote diabetes awareness and education three times a year. The course provides education on diabetes, diet, eye care, insulin pumps, foot care and coping skills. Hospital Tours - Children from local pre-schools and elementary schools were provided tours of the Hospital. The event promotes awareness and comfort by teaching children about the hospital and it allows the schools to learn about the services the hospital provides in the case of an emergency. Summer Camp Splash Program - This program targets to educate children attending summer camp about basic first aid, summer safety tips, hazardous weather emergencies and water safety concerns. Poison Presentations - CGH staff gave two presentations during the year in an effort to educate young children about various types of poisons. The children were taught how to identify and avoid poisonous substances. Glo-Germ Presentations - Hospital personnel made eight presentations to pre-school and K-2 grades about how to properly wash hands. An educational lesson was given to the children in conjunction with a photosynthesized gel. Safe Sitter Classes - CGH held numerous classes during the year designed to teach boys and girls how to handle emergencies when caring for young children. Children's Expo - Hospital medical staff attended a children's health exposition to offer presentations on poison and germs, as well as provide free blood pressure screenings for adults. Health Professions Education CGH provides aspiring health professionals with many educational opportunities to further their career in healthcare. Consistent with the filing of Schedule H, CGH provided these services at a cost of $176,058 in Fiscal 2012. Technicians Training - CGH offers an opportunity for students in Radiology and Nuclear Medicine to complete their student externships within the Hospital's Medical Imaging Department. Radiology students work directly with a Registered Radiology Technologist throughout the training. Physical Therapy - Physical therapy students receive mentoring and training by CGH therapists. The training takes place during regular clinical rotations. Emergency Medical and Paramedic Training - CGH's pre-hospital care department provides continuing education training to emergency medical technicians and paramedics from local ambulance departments. Information Technology - Two students from Pittsburgh Technical Institute did their unpaid internships with a CGH Microcomputer Specialist which provided them with education in all aspects of hospital information technology. Medical Imaging - Students from local colleges and universities trained with CGH health care professionals to learn more about practices in the Medical Imaging Department, working a total of 361.5 hours. Pharmacy Training - A pharmacy student received required rotation hours through the CGH Pharmacy Department. Health Professions Job Shadowing - Three students from local high schools shadow CGH health care professionals to learn more about a particular specialty. Phlebotomy Training - Twenty-six students trained with the CGH health care professionals to learn more about phlebotomy and laboratory activities over a nine-month period. In Kind Donations - Financial Contributions This category includes funds and in-kind services donated to individuals and the community at large. In-kind services include hours donated by staff to the community during hospital work hours, overhead expenses of meeting space donated to not-for-profit community groups and the free provision of food, equipment, supplies as well as monetary donations. Consistent with the filing of Schedule H, CGH provided these contributions at a cost of $39,083 in Fiscal 2012. Cash Donations - CGH supports the community through cash contributions made at the discretion of the Hospital and its directors, benefiting not only the non-profit recipient but also ultimately the community as a whole. In-kind Donations - In addition to the cash contributions, CGH also made in-kind donations of time and resources to help support various community functions. The Hospital donated space for community food drives, blood drives, girl scouts, boy scouts, clothing drives, ministerial associations, United Way, Rotary International, elderly functions, local EMS and Fire departments. In addition, the Hospital donated products and equipment to various local charitable organizations including Brother's Brother Foundation, the humane society and local youth sports teams. Subsidized Health Services Subsidized health services represent those programs provided to the community by CGH despite the fact the Hospital incurs a financial loss to do so. CGH recognizes the need of its community and voluntarily subsidizes these programs in support of its charitable mission. Among the subsidized health services provided by CGH are the treatment of drug and alcohol abuse, mental health treatment, burn care and the operation of the emergency department. Consistent with the filing of Schedule H, CGH provided subsidized health services at a cost of $1,569,478 in Fiscal 2012. Community Building Activities Community Building Activities include activities engaged in for the purpose of improving or protecting the health, future and wellbeing of the community. Consistent with the filing of Schedule H, CGH provided these services at a cost of $106,457 in Fiscal 2012. Representation on Community Boards, Committees and Partnerships - Several leaders at CGH reside on community boards, committees and partnerships. These organizations included the American Association of Physician Liaisons, American Heart Association, Greater Canonsburg Economic Development Committee, Hospital Council of Western PA, McMurray and Canonsburg Rotaries, Peters Township Chamber of Commerce, Washington County Chamber of Commerce and the Western Area Career and Technical Advisory Board. Social Work Services - The services of a professionally trained medical social worker is available to all patients and families for crisis intervention, counseling and discharge planning. The social worker handles problems that may arise during hospitalization or at the time of discharge. The social worker also provides counseling, emotional support and information regarding community services and programs. Thanksgiving Essay Contest: The Hospital Children Services Department sponsors a Thanksgiving essay contest for elementary age students. The essays are intended to promote healthy themes to children. Each essay is focused on a healthy topic and the reasons why the child is thankful. Each child completes an essay to be judged by the community with winners receiving a U.S. Savings Bond. Halloween Trail: The Hospital sponsors the annual Halloween Trail to provide a fun and safe way for children to celebrate Halloween. Treats were provided free of charge. Approximately 1,000 children attended the free event held at the hospital. Fourth of July Celebration - The borough of Canonsburg hosts a large Fourth of July Celebration in which the hospital participates by making the medical staff available as well as donations to support the event. Washington County Business Expo - As one of fifty businesses participating in this Chamber of Commerce event, CGH was able to reach out to the approximately 500 attendees, networking and forming partnerships with local businesses. Community Meals - Supporting Peters Township and Canonsburg-Houston as they host holiday meals for the community by providing napkins, plates, and cups for a children's holiday party, turkey for a Senior Citizen luncheon, and yams and cranberry sauce for a Thanksgiving event.
Operational Oversight By A Third Party Management Company Form 990, Page 6, Part VI, Line 3 Canonsburg General Hospital (CGH) is a member of the West Penn Allegheny Health System (System). The System consists of thirteen operational IRC Section 501(c)(3) organizations. The parent organization for CGH and the other eleven operational IRC Section 501(c)(3) organizations is West Penn Allegheny Health System, Inc. (WPAHS, Inc.). The board of directors of WPAHS, Inc. is comprised of a majority of independent members. Effective November 7, 2011 (Effective Date), the board of directors of WPAHS, Inc. engaged Alvarez & Marsal Healthcare Industry Group, LLC (A&M) to assign an Interim Chief Executive Officer of the System, Interim Chief Operating Officer of the System and Interim Chief Financial Officer of the System. All individuals appointed to their respective positions are under the employment of A&M and have daily oversight of all matters pertinent to the operation of the System as a whole and all organizations on an independent basis. All interim management personnel under the employment of A&M are responsible to and report to the WPAHS, Inc. board of directors. The term of the engagement is to last one year from the effective date with the option to renew the engagement beyond the initial one year term. During the course of the engagement, the WPAHS, Inc. board of directors upon written notice may cause any individual employed by A&M to be removed from their respective position and replaced by another similarly qualified individual. CGH did not directly compensate A&M for their management services. WPAHS, Inc. compensates A&M directly for these services. The decision was made to allocate a portion of the expenditures of WPAHS, Inc. to CGH. Thus, the portion of management expense allocated from WPAHS, Inc. to CGH is reflected on Form 990, Page 10, Line 11a. As of the date of the filing of this tax return, A&M continues to provide management oversight to CGH and the System under the supervision of the WPAHS, Inc. board of directors.
Form 990 Review Process Form 990, Page 6, Part VI, Section B, Question 11a Form 990 is prepared internally by an employee of the West Penn Allegheny Health System, Inc. (Health System) Tax Department who is a certified public accountant. The document is then reviewed internally by top management officials of the Health System. A detailed external review is conducted by Health System external tax advisors, who sign the return as preparer. The Chair of the organization's Board of Directors, or another Board Member otherwise designated by the Chair, along with members of the Audit and Compliance committee of the Health System Board review the Form 990 and recommend changes or accept the document as presented. A copy of the Form 990 is made available to every board member for review prior to filing the document with the Internal Revenue Service.
Monitoring and Enforcement of the Conflict of Interest Policy Form 990, Page 6, Part VI, Section B, Question 12c Canonsburg General Hospital (CGH) is a member of the West Penn Allegheny Health System (WPAHS). WPAHS has a corporate compliance department that monitors and oversees compliance with the conflict of interest policy of all organizations in the health system. The following describes the manner in which the corporate compliance department monitors and oversees compliance with the conflict of interest policy for CGH as well as the other WPAHS affiliates: Conflict of Interest disclosure forms are completed on an annual basis by all board members, officers, employees who have a title of Manager and above, physicians in leadership roles, Pharmacy and Therapeutic Committee members, all employees of the System's Compliance and Internal Audit Departments as well as personnel involved with contracting in the Corporate Purchasing Department. Upon completion of the above disclosure statement by all applicable individuals, a report is generated listing all individuals that have reported a conflict. The System Compliance Officer and General Counsel review the conflicts disclosed. Those that require additional information or clarification receive a letter from the Compliance Officer requesting such. Once received, all additional information is added to the report and again reviewed by the Compliance Officer and General Counsel. Those conflicts that require a mitigation plan are sent to the respective organization's senior management for development of the mitigation plan. The organization's senior management is responsible to discuss the mitigation plan with the individual as needed and monitor compliance with the mitigation plan. Once mitigation is received, a final report is reviewed with the System Executive Compliance Council and finally the Audit & Compliance Committee of the Board.
Process Used To Determine Executive Compensation Form 990, Page 6, Part VI, Section B, Line 15b The West Penn Allegheny Health Systems (WPAHS) process for determining compensation for executive positions (including officers, key employees and other management positions) within Canonsburg General Hospital is covered by the WPAHS Executive Compensation Policy. This policy was approved by the West Penn Allegheny Health System, Inc. Board of Directors. It is the policy of WPAHS and its Board of Directors to compensate its executives in accordance with the market and in relation to the experience, service and accomplishments of the individual both prior to and during their service with WPAHS. The Compensation Committee of the West Penn Allegheny Health System, Inc. Board of Directors approves the compensation for WPAHS senior executives. The Compensation Committee approves the initial compensation for newly hired senior executives, which shall include all compensation components, including without limitation, base compensation, incentive compensation, deferred compensation, fringe and other benefits, as well as the total compensation. It shall also approve all base compensation adjustments and all incentive compensation awards, as well as material changes to deferred compensation, fringe, or other benefits. The Compensation Committee uses comparability data provided by the System Human Resources Department, which may include industry surveys, expert compensation studies, documented compensation of persons holding similar positions, or other comparable data in approving any executive compensation. The Compensation Committee shall periodically retain the services of an independent compensation consultant to provide an expert opinion report as to the reasonableness of total compensation of Canonsburg General Hospital officers and key employees. Each Compensation Committee member voting on a senior executive's compensation arrangement ensures that he or she has no conflict of interest, including that he or she (a) does not economically benefit from the proposed employment; (b) does not receive compensation subject to the approval of the proposed employee; and (c) has no material financial interest affected by the transaction. The Compensation Committee consists of five independent Board Members of West Penn Allegheny Health System, Inc. All decisions of the Compensation Committee regarding executive compensation matters are documented.
Public Availability of Organizational Documents Form 990, Page 6, Part VI, Section C, Question 19 Canonsburg General Hospital (CGH) does not make its governing documents available to the public. CGH is a member of the West Penn Allegheny Health System (WPAHS). The WPAHS makes available their annual and quarterly financial statements through the use of a dissemination agent. These financial statements are on a consolidated basis with CGH being one of the consolidated entities. In addition, the WPAHS annual report and quarterly financial results are available on the WPAHS website. WPAHS has adopted a conflict of interest policy that is uniformly applied to all organizations of the health system, including CGH. A condensed version of this conflict of interest policy is available on the WPAHS website.
Average Hours Per Week Reported for Officers, Directors and Key Employees Form 990, Page 7, Part VII, Column B Canonsburg General Hospital (CGH) is part of an integrated healthcare delivery system named West Penn Allegheny Health System. Individuals employed by one organization may be assigned to provide management for an affiliated organization. As such, many individuals play key roles or serve as officers or directors on multiple affiliated organizations. Each individual will be assigned forty hours to the organization of their actual employment. If the individual is employed by one organization and appointed as an officer, director or key employee of affiliated organizations the hour allocation on Form 990, Part VII, Page 7, Column (B) takes various factors into account when attempting to assign hours in a reasonable manner. Thus, it is possible for a single individual to have hours assigned in excess of forty hours per week if all affiliated organization IRS Forms 990 is taken into account. Directors who are not employed and volunteer their services are assigned one hour of service. The actual time served for all individuals disclosed in IRS Form 990 can vary based upon the need of the organization.
Rental Expense Form 990, Page 9, Part VIII, Line 6b Canonsburg General Hospital does not account for rental expense in a manner that would allow for a direct offset of rental income on Form 990, Page 9, Line 6b(i). The components of rental expense are reflected on Form 990, Page 10, Statement of Functional Expense.
Purpose of Tax Exempt Bond Issue Form 990, Page 11, Part X, Line 20 Canonsburg General Hospital is a member of the West Penn Allegheny Health System obligated group in regards to 2007 Allegheny County Hospital Development Authority tax-exempt bonds. Accordingly, Schedule K has been inserted into this Form 990 for full disclosure purposes. The purpose of the issue of the Allegheny County Hospital Development Authority (ACHDA) Hospital Revenue Bonds, Series 2007 A is to refund the outstanding ACHDA Series 2000A and B Bond Issues, refund the Dauphin County General Authority (DCGA) Series 1992A and B Hospital Bonds, the Pennsylvania Higher Education Facility Authority (PHEFA) Series 1991A Revenue Bonds, the Monroeville Hospital Authority (MHA) Series 1992 and 1995 Revenue Bonds, the funding of a project fund for certain prior and future capital expenditures and to pay the cost of issuing Series 2007A Debt. The amount of $26,142,473 reflected on Form 990, Page 11, Line 20 represents the internal allocation of debt to Canonsburg General Hospital by the parent organization, West Penn Allegheny Health System, Inc. The IRS Form 990 filed by West Penn Allegheny Health System, Inc., EIN: 25-0969492 has completed Schedule K in its entirety. Please refer to the Form 990 filed by West Penn Allegheny Health System, Inc., EIN: 25-0969492 to review Schedule K with regard to this bond issue.
Other Changes In Net Assets Form 990, Page 12, Part XI, Line 5 The following is a reconciliation of Other Changes in Net Assets of Canonsburg General Hospital for the year ended June 30, 2012: Change in Minimum Pension Liability $(2,954,940) Unrealized Gain on Marketable Securities 15 Transfer to Balance Sheet Investment Account (4,224) __________ Other Changes in Net Assets $(2,959,149)
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2011

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SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Canonsburg General Hospital
 
Employer identification number

25-1737079
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)
(a)
Name, address, and EIN of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income
(e)
End-of-year assets


 		(f)
Direct controlling
entity

















Part II
Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)
(a)
Name, address, and EIN of related organization


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section
(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled organization
Yes No
(1) West Penn Allegheny Health System Inc

4800 Friendship Avenue

Pittsburgh,PA15224
25-0969492 		Healthcare PA 501(c)(3) 3 NA
 
 
No
(2) Alle-Kiski Medical Center

1301 Carlisle Street

Natrona Heights,PA15065
25-1875178 		Healthcare PA 501(c)(3) 3 NA
 
 
No
(3) Allegheny Singer Research Institute

320 East North Avenue

Pittsburgh,PA15212
25-1320493 		Sci. Research PA 501(c)(3) 4 NA
 
 
No
(4) Allegheny Medical Practice Network

4800 Friendship Avenue

Pittsburgh,PA15224
25-1838457 		Healthcare PA 501(c)(3) 3 NA
 
 
No
(5) Allegheny Specialty Practice Network

320 East North Avenue

Pittsburgh,PA15212
25-1838458 		Healthcare PA 501(c)(3) 3 NA
 
 
No
(6) West Penn Allegheny Oncology Network

4800 Friendship Avenue

Pittsburgh,PA15224
11-3683376 		Healthcare PA 501(c)(3) 11-III FL NA
 
 
No
(7) West Penn Physician Practice Network

4800 Friendship Avenue

Pittsburgh,PA15224
25-1494317 		Healthcare PA 501(c)(3) 9 NA
 
 
No
(8) CGH Ambulance Service Inc

100 Medical Boulevard

Canonsburg,PA15317
23-2939715 		Emer Response PA 501(c)(3) 9 NA
 
 
No
(9) Alle-Kiski Medical Center Trust

1301 Carlisle Street

Natrona Heights,PA15065
20-5855753 		Fundraising PA 501(c)(3) 11-I NA
 
 
No
(10) Forbes Health Foundation

2570 Haymaker Road

Monroeville,PA15146
25-1798379 		Fundraising PA 501(c)(3) 7 NA
 
 
No
(11) Suburban Health Foundation

100 South Jackson Avenue

Pittsburgh,PA15202
25-1472073 		Fundraising PA 501(c)(3) 11-I NA
 
 
No
(12) Western Pennsylvania Hospital Foundation

4800 Friendship Avenue

Pittsburgh,PA15224
25-1470766 		Fundraising PA 501(c)(3) 11-I NA
 
 
No
(13) West Allegheny Hospital

100 Medical Boulevard

Canonsburg,PA15317
25-1054206 		Inactive PA 501(c)(3) 3 NA
 
 
No
(14) Greater Canonsburg Health System

100 Medical Boulevard

Canonsburg,PA15317
25-1488089 		Inactive PA 501(c)(3) 11-I NA
 
 
No
(15) Canonsburg HealthHospital Foundation

100 Medical Boulevard

Canonsburg,PA15317
25-1818505 		Inactive PA 501(c)(3) 11-I NA
 
 
No
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No












Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of related organization



 		(b)
Primary activity



 		(c)
Legal domicile
(state or
foreign
country)
 		(d)
Direct controlling
entity


 		(e)
Type of entity
(C corp, S corp,
or trust)

 		(f)
Share of total income



 		(g)
Share of
end-of-year
assets

 		(h)
Percentage
ownership
(1) Burn Care Associates
4800 Friendship Avenue
Pittsburgh,PA15224
23-2899534 		Healthcare PA NA
  		C Corporation 0 0 0 %
(2) Medical Center Clinic
4800 Friendship Avenue
Pittsburgh,PA15224
23-2894939 		Healthcare PA NA
  		C Corporation 0 0 0 %
(3) West Penn Corporate Medical Services Inc
4800 Friendship Avenue
Pittsburgh,PA15224
25-1437405 		Healthcare PA NA
  		C Corporation 0 0 0 %
(4) West Penn Neurosurgery
4800 Friendship Avenue
Pittsburgh,PA15224
25-1630719 		Healthcare PA NA
  		C Corporation 0 0 0 %
(5) Friendship Insurance Company Ltd
 
 
98-0116952 		Insurance CJ NA
  		C Corporation 0 0 0 %




Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III or IV.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
 
No
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
Yes
 
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1m
 
No
n Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1n
 
No
o Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
Yes
 
p Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
q Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type(a-r) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1)
(2)
(3)
(4)
(5)
(6)
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(e)
Are all
partners
section
501(c)(3)
organizations? 		(f)
Share of total income




 		(g)
Share of
end-of-year
assets 		(h)
Disproprtionate allocations? 		(i)
Code V—UBI
amount in box
20 of Schedule K-1
(Form 1065) 		(j)
General or
managing
partner? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation
Transactions With Affiliated Organizations Schedule R, Part V, Line 2 Canonsburg General Hospital has chosen not to complete Schedule R, Part V, line 2. The disclosure of this information is only required for organizations listed in Schedule R, Part V, line 2 that are controlled entities within the meaning of section 512(b)(13). No organization listed in Schedule R, Part V, line 2 is a controlled entity within the meaning of section 512(b)(13) for Canonsburg General Hospital.
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