TY 2015 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) JOHN SUTIKA...................................................................... DIRECTOR/DRMC PRESIDENT/CEO	3.0 ................. 40.0	X			0	416,199	59,641
(2) RONALD E KING...................................................................... CHAIRMAN	3.0 ................. 0.0	X	X		0	0	0
(3) WILLIAM YOUNG...................................................................... VICE CHAIRMAN	3.0 ................. 0.0	X	X		0	0	0
(4) JUDITH GROMLEY...................................................................... TREASURER	3.0 ................. 0.0	X	X		0	0	0
(5) GENE HOAK...................................................................... SECRETARY	3.0 ................. 0.0	X	X		0	0	0
(6) TODD P STOLTZ...................................................................... DIRECTOR	3.0 ................. 0.0	X			0	0	0
(7) MELANIE HATCH...................................................................... DIRECTOR	3.0 ................. 0.0	X			0	0	0
(8) DR BARRY SNYDER MD...................................................................... DIR/MED STAFF PRES END 12/15	40.0 ................. 0.0	X			176,396	0	19,539
(9) JULIANNE PEER...................................................................... PRESIDENT	40.0 ................. 0.0	X	X		128,695	85,021	26,587
(10) DR KUMARESAN GANABATHI MD...................................................................... PRES OF MED STAFF BEG 01/2016	40.0 ................. 0.0	X			578,489	0	25,100
(11) DAVID GARADI...................................................................... PHYSICIAN	37.5 ................. 0.0			X	466,690	0	24,690
(12) TANIS PENDLETON...................................................................... PHYSICIAN	37.5 ................. 0.0			X	311,546	0	5,248
(13) CYRIL GAMIS...................................................................... PHYSICIAN	37.5 ................. 0.0			X	266,671	0	11,386
(14) EMERSON TURNBULL...................................................................... CRNA	37.5 ................. 0.0			X	155,222	0	22,812
(15) ALAN CORNMAN...................................................................... PHARMACIST	37.5 ................. 0.0			X	149,606	0	22,874

(A) Name and business address	(B) Description of services	(C) Compensation
NORTHFORK, REHAB BROOKVILLE,PA15825	PHYSICAL THERAPY	1,043,175
MEDICUS,	LOCUM STAFFING	414,965
BROOKVILLE ER, GROUP LAYFAYETTE,LA70508	PHYSICIAN STAFFING	230,674
ALLIED, RESOURCES EXTON,PA19341	LOCUM STAFFING	1,775,589
THE EXECUSEARCH, GROUP NEW YORK,NY10017	LOCUM STAFFING	112,630
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 5

- TIN:

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

Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public
Inspection

Name of the organization

BROOKVILLE HOSPITAL

Employer identification number

25-0984595

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.)

A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E (Form 990 or 990-EZ))

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross 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.)

An organization organized and operated exclusively to test for public safety. See section 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box in lines 11a through 11d that describes the type of supporting organization and complete lines 11e, 11f, and 11g.

Type I. A supporting organization operated, supervised, or controlled by its supported organization(s), typically by giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B.

Type II. A supporting organization supervised or controlled in connection with its supported organization(s), by having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C.

Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E.

Type III non-functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distribution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V.

Check this box if the organization received a written determination from the IRS that it is a Type I, Type II, Type III functionally integrated, or Type III non-functionally integrated supporting organization.

Enter the number of supported organizations ..............

Provide the following information about the supported organization(s).

(i)Name of supported organization	(ii) EIN	(iv) Is the organization listed in your governing document?		(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)
(i)Name of supported organization	(ii) EIN	Yes	No	(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)


Total

For Paperwork Reduction Act Notice, see the Instructions for
Form 990 or 990-EZ.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2015

Page 2

Part II

Support Schedule for Organizations Described in Sections 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) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(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) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(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. Do not include gain or loss from the sale of capital assets (Explain in Part VI.)..
11	Total support. Add lines 7 through 10.

Gross receipts from related activities, etc. (see instructions) ..................

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2015 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2014 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2015. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ....................... right arrow

33 1/3% support test—2014. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2015. If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the facts-and-circumstances test, check this box and stop here. Explain
in Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2014. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2015

Page 3

Part III

Support Schedule for Organizations Described in Section 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) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(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) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(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 VI.) ..
13	Total support. (Add lines 9, 10c, 11, and 12.)..

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2015 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2014 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2015 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2014 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2015. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ....... right arrow

33 1/3% support tests—2014. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .... right arrow

Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions .... right arrow

Schedule A (Form 990 or 990-EZ) 2015

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 11 of Part I. If you checked 11a of Part I, complete Sections A and B. If you checked 11b of Part I, complete Sections A and C. If you checked 11c of Part I, complete Sections A, D, and E. If you checked 11d of Part I, complete Sections A and D, and complete Part V.)

Section A. All Supporting Organizations

Yes

Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.

Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).

Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below.

Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.

Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.

Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked 11a or 11b in Part I, answer (b) and (c) below.

Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations.

Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.

Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer (b) and (c) below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document).

Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?

Substitutions only. Was the substitution the result of an event beyond the organization's control?

Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.

Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ) .

Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ).

Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.

Did one or more disqualified persons (as defined in line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.

Did a disqualified person (as defined in line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.

10a

Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer line 10b below.

10a

Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).

10b

Schedule A (Form 990 or 990-EZ) 2015

Page 5

Part IV

Supporting Organizations (continued)

Yes

Has the organization accepted a gift or contribution from any of the following persons?

A person who directly or indirectly controls, either alone or together with persons described in (b) and (c) below, the governing body of a supported organization?

11a

A family member of a person described in (a) above?

11b

A 35% controlled entity of a person described in (a) or (b) above? If “Yes” to a, b, or c, provide detail in Part VI.

11c

Section B. Type I Supporting Organizations

Yes

Did the directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.

Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.

Section C. Type II Supporting Organizations

Yes

Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).

Section D. All Type III Supporting Organizations

Yes

Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?

Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).

By reason of the relationship described in (2), did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.

Section E. Type III Functionally-Integrated Supporting Organizations

Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):

The organization satisfied the Activities Test. Complete line 2 below.

The organization is the parent of each of its supported organizations. Complete line 3 below.

The organization supported a governmental entity. Describe in Part VI how you supported a government entity (see instructions)

Activities Test. Answer (a) and (b) below.

Yes

Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.

Did the activities described in (a) constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.

Parent of Supported Organizations. Answer (a) and (b) below.

Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? Provide details in Part VI.

Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI. the role played by the organization in this regard.

Schedule A (Form 990 or 990-EZ) 2015

Page 6

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations

Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970. See instructions. All other Type III non-functionally integrated supporting organizations must complete Sections A through E.

	Section A - Adjusted Net Income		(A) Prior Year	(B) Current Year (optional)
1	Net short-term capital gain	1
2	Recoveries of prior-year distributions	2
3	Other gross income (see instructions)	3
4	Add lines 1 through 3	4
5	Depreciation and depletion	5
6	Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions)	6
7	Other expenses (see instructions)	7
8	Adjusted Net Income (subtract lines 5, 6 and 7 from line 4)	8

	Section B - Minimum Asset Amount		(A) Prior Year	(B) Current Year (optional)
1	Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year):	1
a	Average monthly value of securities	1a
b	Average monthly cash balances	1b
c	Fair market value of other non-exempt-use assets	1c
d	Total (add lines 1a, 1b, and 1c)	1d
e	Discount claimed for blockage or other factors (explain in detail in Part VI):
2	Acquisition indebtedness applicable to non-exempt use assets	2
3	Subtract line 2 from line 1d	3
4	Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions).	4
5	Net value of non-exempt-use assets (subtract line 4 from line 3)	5
6	Multiply line 5 by .035	6
7	Recoveries of prior-year distributions	7
8	Minimum Asset Amount (add line 7 to line 6)	8

	Section C - Distributable Amount		Current Year
1	Adjusted net income for prior year (from Section A, line 8, Column A)	1
2	Enter 85% of line 1	2
3	Minimum asset amount for prior year (from Section B, line 8, Column A)	3
4	Enter greater of line 2 or line 3	4
5	Income tax imposed in prior year	5
6	Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions)	6

Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions)

Schedule A (Form 990 or 990-EZ) 2015

Page 7

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations (continued)

Section D - Distributions		Current Year
1 Amounts paid to supported organizations to accomplish exempt purposes
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity
3 Administrative expenses paid to accomplish exempt purposes of supported organizations
4 Amounts paid to acquire exempt-use assets
5 Qualified set-aside amounts (prior IRS approval required)
6 Other distributions (describe in Part VI). See instructions
7Total annual distributions. Add lines 1 through 6.
8 Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions
9 Distributable amount for 2015 from Section C, line 6
10 Line 8 amount divided by Line 9 amount

Section E - Distribution Allocations (see instructions)		(i) Excess Distributions	(ii) Underdistributions Pre-2015	(iii) Distributable Amount for 2015
1 Distributable amount for 2015 from Section C, line 6
2 Underdistributions, if any, for years prior to 2015 (reasonable cause required--see instructions)
3 Excess distributions carryover, if any, to 2015:
a
b
c
d From 2013.......
e From 2014.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2015 distributable amount
i Carryover from 2010 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.
4Distributions for 2015 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2015 distributable amount
c Remainder. Subtract lines 4a and 4b from 4.
5 Remaining underdistributions for years prior to 2015, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions)
6 Remaining underdistributions for 2015. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions)
7 Excess distributions carryover to 2016. Add lines 3j and 4c.
8 Breakdown of line 7:
a
b
c Excess from 2013.......
d From 2014.......
e From 2015.......

Schedule A (Form 990 or 990-EZ) (2015)

Schedule A (Form 990 or 990-EZ) 2015

Page 8

Part VI

Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Return Reference	Explanation

Schedule A (Form 990 or 990-EZ) 2015

Additional Data

Software ID:
Software Version:

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

Information about Schedule B (Form 990, 990-EZ, or 990-PF) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Name of the organization

BROOKVILLE HOSPITAL

Employer identification number

25-0984595

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

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

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, contributions totaling $5,000 or more (in money or other property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.

Special Rules

For an organization described in section 501(c)(3) filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions of the greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 exclusively for religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions exclusively for religious, charitable, etc., purposes, but no such contributions totaled more than $1,000. If this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule applies to this organization because it received nonexclusively religious, charitable, etc., contributions totaling $5,000 or more during the year ......... 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 its Form 990PF, Part I, line 2, 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) (2015)

Schedule B (Form 990, 990-EZ, or 990-PF) (2015) Page 2

Name of organization BROOKVILLE HOSPITAL

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	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

Page 3

Name of organization BROOKVILLE HOSPITAL		Employer identification number 25-0984595

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) (2015)

Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

Page 4


Name of organization BROOKVILLE HOSPITAL			Employer identification number 25-0984595
Part III Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. 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.) $ Use duplicate copies of Part III if additional space is needed.

(a)
No.from Part I

(b) Purpose 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

(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

(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

(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) (2015)

Additional Data

Software ID:
Software Version:

- TIN:

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

Information about Schedule C (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public
Inspection

If the organization answered "Yes" on 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" on 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" on Form 990, Part IV, Line 5 (Proxy Tax) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

BROOKVILLE HOSPITAL

Employer identification number

25-0984595

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV.

Political expenditures ...................................................................................................................... SchCMd Bullet

Volunteer hours .............................................................................................................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ................................ SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ....................... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? .........................................

Yes No

Was a correction made? ......................................................................................................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c), except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities ..... SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ............................................................................................................................ SchCMd Bullet

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

Did the filing organization file Form 1120-POL for this year? ...................................................................

Yes No

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-.
1
2
3
4
5
6

For Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2015

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 SchCMd Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(b) Affiliated group totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ...............................................
b	Total lobbying expenditures to influence a legislative body (direct lobbying) ...........................................
c	Total lobbying expenditures (add lines 1a and 1b) .......................................................................
d	Other exempt purpose expenditures .........................................................................................
e	Total exempt purpose expenditures (add lines 1c and 1d) ....................................................................
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	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) ..........................................................................
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? ..............................................................................................................	Yes No

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 separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2012	(b) 2013	(c) 2014	(d) 2015	(e) Total

2a	Lobbying nontaxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots nontaxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2015

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 on lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes

(b)

Amount

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:

Volunteers? ...........................................................................................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ........

Media advertisements? ...................................................................................................

Mailings to members, legislators, or the public? .............................................................................

Publications, or published or broadcast statements? ...........................................................

Grants to other organizations for lobbying purposes? ..........................................................

Direct contact with legislators, their staffs, government officials, or a legislative body? .......................

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ..................

Other activities? ...................................................................................................................

Yes

1,800

Total. Add lines 1c through 1i ....................................................................................................

1,800

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 ...........................................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 ...................

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

Were substantially all (90% or more) dues received nondeductible by members? ...............................................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ............................................

Did the organization agree to carry over lobbying and political expenditures from the prior year? .................................

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."

Dues, assessments and similar amounts from members ......................................................................

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political expenses for which the section 527(f) tax was paid).

Current year .............................................................................................................................

Carryover from last year ............................................................................................................

Total ...........................................................................................................................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

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? ......................................................................................................................

Taxable amount of lobbying and political expenditures (see instructions) .........................................

Part IV

Supplemental Information

Provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.

Return Reference	Explanation
SCHEDULE C, PART II-B, LINE 1(I)	OTHER LOBBYING ACTIVITIES: THE ORGANIZATION PAYS DUES TO HOSPITAL COUNCIL OF WESTERN PENNSYLVANIA. A PORTION OF THESE DUES ARE ATTRIBUTABLE TO LOBBYING.

Schedule C (Form 990 or 990EZ) 2015

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," on 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.
Information about Schedule D (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

BROOKVILLE HOSPITAL

Employer identification number

25-0984595

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" on Form 990, Part IV, line 6.

			(a) Donor advised funds	(b) Funds and other accounts

1	Total number at end of year ....
2	Aggregate value of contributions to (during year)
3	Aggregate value of grants from (during year)
4	Aggregate value at end of year ....

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? ...........

Yes No

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? ............................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" on Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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.


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

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the
tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holds? ............

Yes No

Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .............................

Yes No

In Part XIII, 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" on Form 990, Part IV, line 8.

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 XIII, the text of the footnote to its financial statements that describes these items.

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)

Revenue included on Form 990, Part VIII, line 1 ......................... SchDMd Bullet

(ii)

Assets included in Form 990, Part X ............................... SchDMd Bullet

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:

Revenue included on Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 52283D

Schedule D (Form 990) 2015

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.

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?...

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" on Form 990, Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No


b	If "Yes," explain the arrangement in Part XIII 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

Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability?

Yes No

If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........

Part V

Endowment Funds. Complete if the organization answered "Yes" on 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 ....
b	Contributions ...
c	Net investment earnings, gains, and losses
d	Grants or scholarships ...
e	Other expenditures for facilities and programs ...
f	Administrative expenses ....
g	End of year balance ......

Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

The percentages on lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) unrelated organizations .................

3a(i)

(ii) related organizations .................

3a(ii)

If "Yes" on 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIII the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11a. 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 ...	205,546		205,546
b	Buildings	8,503,715	7,104,731	1,398,984
c	Leasehold improvements	204,286	204,286
d	Equipment ...	29,482,327	26,820,459	2,661,868
e	Other ...	2,026,592	1,413,168	613,424
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				4,879,822

Schedule D (Form 990) 2015

Page 3

Part VII

InvestmentsOther Securities. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11b. 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
(3)Other
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

InvestmentsProgram Related. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11c. See Form 990, Part X, line 13.

(a) Description of investment	(b) Book value	(c) Method of valuation: Cost or end-of-year market value

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value
(1) BEN INT IN PERPETUAL TRUST				192,288
(2) OTHER ASSETS				67,222
(3) DUE FROM AFFILIATES				1,479,407
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				1,738,917

Part X

Other Liabilities. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability	(b) Book value
(1) Federal income taxes	0
EST AMT DUE TO THIRD PARTIES	642,404
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	642,404
2. Liability for uncertain tax positions. In Part XIII, 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 (ASC 740). Check here if the text of the footnote has been provided in Part XIII

Schedule D (Form 990) 2015

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total revenue, gains, and other support per audited financial statements .......			1	27,158,465
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains (losses) on investments ....	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d	-1,537,642
e	Add lines 2a through 2d .....................			2e	-1,537,642
3	Subtract line 2e from line 1..................			3	28,696,107
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 XIII.) ...........	4b	11,854
c	Add lines 4a and 4b....................			4c	11,854
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......			5	28,707,961

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total expenses and losses per audited financial statements ...........			1	26,780,894
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 XIII.) ............	2d	8,119
e	Add lines 2a through 2d....................			2e	8,119
3	Subtract line 2e from line 1...................			3	26,772,775
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 XIII.) ............	4b	1,537,642
c	Add lines 4a and 4b.....................			4c	1,537,642
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......			5	28,310,417

Part XIII

Supplemental Information

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, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Return Reference	Explanation
SCHEDULE D, PART X, LINE 2	UNCERTAIN TAX POSITIONS: MANAGEMENT HAS EVALUATED THEIR INCOME TAX POSITIONS UNDER THE GUIDANCE INCLUDED IN ASC 740. BASED ON THEIR REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE RECORDED OR DISCLOSED IN THE FINANCIAL STATEMENTS.
SCHEDULE D, PART XI, LINE 2D	OTHER REVENUE ON LINE 1, BUT NOT ON FORM 990, PART VIII, LINE 12: $(1,537,642) BAD DEBT EXPENSE
SCHEDULE D, PART XI, LINE 4B	OTHER REVENUE ON FORM 990, PART VIII, LINE 12, BUT NOT ON LINE 1: $ ( 8,119) SPECIAL EVENT EXPENSE 19,973 TEMPORARILY RESTRICTED CONTRIBUTIONS ------------ $ 11,854
SCHEDULE D, PART XII, LINE 2D	OTHER EXPENSE ON LINE 1, BUT NOT ON FORM 990, PART IX, LINE 25: $ 8,119 SPECIAL EVENT EXPENSE
SCHEDULE D, PART XII, LINE 4B	OTHER EXPENSE ON FORM 990, PART IX, LINE 25 BUT NOT ON LINE 1: $ 1,537,642 BAD DEBT EXPENSE

Schedule D (Form 990) 2015

Additional Data

Software ID:
Software Version:

- TIN:

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" on 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 arrow

Attach to Form 990 or Form 990-EZ.
right arrow

Information about Schedule G (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization
BROOKVILLE HOSPITAL

Employer identification number

25-0984595

Part I

Fundraising Activities. Complete if the organization answered "Yes" on Form 990, Part IV, line 17.

Form 990-EZ filers are not required to complete this part.

Indicate whether the organization raised funds through any of the following activities. Check all that apply.

a	Mail solicitations	e	Solicitation of non-government grants
b	Internet and email solicitations	f	Solicitation of government grants
c	Phone solicitations	g	Special fundraising events
d	In-person solicitations

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?

YesNo

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.

(i) Name and address of individual or entity (fundraiser)	(iii) Did fundraiser have custody or control of contributions?
	Yes	No










Total . . . . . . . . . . . . . . . . . . . .

List all states in which the organization is registered or licensed to solicit contributions or has been notified it is exempt from registration or licensing.

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 50083H

Schedule G (Form 990 or 990-EZ) 2015

Page 2

Part II

Fundraising Events. Complete if the organization answered "Yes" on Form 990, Part IV, line 18, or reported more than $15,000 of fundraising event contributions and gross income on Form 990-EZ, lines 1 and 6b. List events with gross receipts greater than $5,000.

		(a) Event #1 1 IN 100 EVENT (event type)	(d) Total events (add col. (a) through col. (c))
1	Gross receipts . . . . .	17,390	17,390
2	Less: Contributions . . . .	5,899	5,899
3	Gross income (line 1 minus line 2) . . . . . .	11,491	11,491

4	Cash prizes . . . . .	3,600	3,600
5	Noncash prizes . . . .	102	102
6	Rent/facility costs . . . .	445	445
7	Food and beverages . . .	3,169	3,169
8	Entertainment . . . .
9	Other direct expenses . . .	803	803
10	Direct expense summary. Add lines 4 through 9 in column (d) . . . . . . . . . .		8,119
11	Net income summary. Subtract line 10 from line 3, column (d). . . . . . . . . .		3,372

Part III

Gaming. Complete if the organization answered "Yes" on Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.

		(a) Bingo	(b) Pull tabs/Instant bingo/progressive bingo	(c) Other gaming	(d) Total gaming (add col.(a) through col.(c))
1	Gross revenue . . . . .

2	Cash prizes . . . . .
3	Noncash prizes . . . .
4	Rent/facility costs . . . .
5	Other direct expenses . . .	803	803

Volunteer labor . . . .

	Yes %
	No

	Yes %
	No

	Yes %
	No

Direct expense summary. Add lines 2 through 5 in column (d) . . . . . . . . . . right arrow

Net gaming income summary. Subtract line 7 from line 1, column (d). . . . . . . . . right arrow

Enter the state(s) in which the organization conducts gaming activities:

Is the organization licensed to conduct gaming activities in each of these states? . . . . . . . .

YesNo

If "No," explain:

10a

Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? . . .

YesNo

If "Yes," explain:

Schedule G (Form 990 or 990-EZ) 2015

Page 3

Does the organization conduct gaming activities with nonmembers? . . . . . . . . . . .

YesNo

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? . . . . . . . . . . . . . . . . .

YesNo

Indicate the percentage of gaming activity conducted in:

The organization's facility . . . . . . . . . . . . . . . . . .

13a

An outside facility . . . . . . . . . . . . . . . . . . . .

13b

Enter the name and address of the person who prepares the organization's gaming/special events books and records:

Name

Address

15a

Does the organization have a contract with a third party from whom the organization receives gaming

revenue? . . . . . . . . . . . . . . . . . . . . . . . .

YesNo

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

$ .

If "Yes," enter name and address of the third party:

Name

Address

Gaming manager information:

Name

Gaming manager compensation right arrow

Description of services provided right arrow

Director/officer Employee Independent contractor

Mandatory distributions:

Is the organization required under state law to make charitable distributions from the gaming proceeds to

retain the state gaming license? . . . . . . . . . . . . . . . . . . .

YesNo

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

Supplemental Information. Provide the explanations required by Part I, line 2b, columns (iii) and (v); and Part III, lines 9, 9b, 10b, 15b, 15c, 16, and 17b, as applicable. Also complete this part to provide any additional information (see instructions).

Return Reference	Explanation

Schedule G (Form 990 or 990-EZ) 2015

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

Complete if the organization answered "Yes" on Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990.
MediumBullet

Information about Schedule H (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

BROOKVILLE HOSPITAL

Employer identification number

25-0984595

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a . . . .

Yes

If "Yes," was it a written policy? ......................

Yes

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.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

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.

Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?

If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:

Yes

100% 150% 200% Other %

Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate

which of the following was the family income limit for eligibility for discounted care: . . . . . . . .

Yes

200% 250% 300% 350% 400% Other %

If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used 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, as a factor in determining eligibility for free or discounted care.

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"? . . . . . . . . . . . . .

Yes

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

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? . . . . . .

Yes

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? . . . . . . . . . . . . .

Did the organization prepare a community benefit report during the tax year? . . . . . . . . .

If "Yes," did the organization make it available to the public? . . . . . . . . . . . . .

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(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) . . .	81,076		81,076	0.300 %
b	Medicaid (from Worksheet 3, column a) . . . . .	2,926,963	1,219,817	1,707,146	6.380 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	3,008,039	1,219,817	1,788,222	6.680 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	3,147		3,147	0.010 %
f	Health professions education (from Worksheet 5) . . .	14,258		14,258	0.050 %
g	Subsidized health services (from Worksheet 6) . . . .
h	Research (from Worksheet 7) .
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .	6,132		6,132	0.020 %
j	Total. Other Benefits . .	23,537		23,537	0.080 %
k	Total. Add lines 7d and 7j .	3,031,576	1,219,817	1,811,759	6.760 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2015

Schedule H (Form 990) 2015

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
7	Community health improvement advocacy
8	Workforce development
9	Other
10	Total

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................

Yes

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

1,537,642

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

224,496

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.

Section B. Medicare

Enter total revenue received from Medicare (including DSH and IME).....

9,901,913

Enter Medicare allowable costs of care relating to payments on line 5.....

10,173,145

Subtract line 6 from line 5. This is the surplus (or shortfall)........

-271,232

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:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Did the organization have a written debt collection policy during the tax year? ..........

Yes

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 .........................

Part IV

Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—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) 2015

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?1 Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)
1	BROOKVILLE HOSPITAL 100 HOSPITAL ROAD BROOKVILLE,PA15825 WWW.PHHEALTHCARE.ORG 28050101	X	X	X	X

Schedule H (Form 990) 2015

Page 4

Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)

	BROOKVILLE HOSPITAL
Name of hospital facility or letter of facility reporting group

Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):

Yes

Community Health Needs Assessment

Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................

Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C...............

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12......................

Yes

If "Yes," indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The significant health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

Information gaps that limit the hospital facility’s ability to assess the community’s health needs

Other (describe in Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 14

In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted .................

Yes

6 a

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C..................................

Yes

Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................

Did the hospital facility make its CHNA report widely available to the public?..............

Yes

If "Yes," indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website (list url): SEE PART V, SECTION C

Other website (list url):

Made a paper copy available for public inspection without charge at the hospital facility

Other (describe in Section C)

Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. ..............

Yes

Indicate the tax year the hospital facility last adopted an implementation strategy: 20 14

Is the hospital facility's most recently adopted implementation strategy posted on a website?.........

Yes

If "Yes" (list url): SEE PART V, SECTION C

If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ......

10b

Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.

12a

Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?...............................

12a

If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........

12b

If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2015

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	BROOKVILLE HOSPITAL
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility have in place during the tax year a written financial assistance policy that:

Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care?

Yes

If “Yes,” indicate the eligibility criteria explained in the FAP:

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 200.% and FPG family income limit for eligibility for discounted care of 300.%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

Explained the basis for calculating amounts charged to patients?.................

Yes

Explained the method for applying for financial assistance?...................

Yes

If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):

Described the information the hospital facility may require an individual to provide as part of his or her application

Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application

Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process

Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications

Other (describe in Section C)

Included measures to publicize the policy within the community served by the hospital facility?........

Yes

If "Yes," indicate how the hospital facility publicized the policy (check all that apply):

The FAP was widely available on a website (list url):

SEE PART V, SECTION C

The FAP application form was widely available on a website (list url):

SEE PART V, SECTION C

A plain language summary of the FAP was widely available on a website (list url):
SEE PART V, SECTION C

The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)

The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)

A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)

Notice of availability of the FAP was conspicuously displayed throughout the hospital facility

Notified members of the community who are most likely to require financial assistance about availability of the FAP

Other (describe in Section C)

Billing and Collections

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 all of the actions the hospital facility or other authorized party may take upon non-payment?..................................

Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

Schedule H (Form 990) 2015

Page 6

Part VFacility Information (continued)

	BROOKVILLE HOSPITAL
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............

If "Yes," check all actions in which the hospital facility or a third party engaged:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

Notified individuals of the financial assistance policy in communications with the individuals regarding the individuals’ bills

Documented its determination of whether individuals were eligible for financial assistance under the hospital facility’s financial assistance policy

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required 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?..................

Yes

If "No," indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Section C)

Other (describe in Section C)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)

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.

The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that
can be charged

The hospital facility used the average of its three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged

The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged

Other (describe in Section C)

During the tax year, did the hospital facility charge any FAP-eligible individual 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? ...............................

If "Yes," explain in Section C.

During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ...........................

If "Yes," explain in Section C.

Schedule H (Form 990) 2015

Page 7

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16i, 18d, 19d, 20e, 21c, 21d, 22d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation
SCHEDULE H, PART V, SECTION B, LINE 5	COMMUNITY INPUT: THE CHNA ASSESSMENT CONDUCTED BY TRIPP UMBACH FOR BROOKVILLE HOSPITAL INCLUDED PRIMARY AND SECONDARY DATA COLLECTION, INTERVIEWS WITH COMMUNITY STAKEHOLDERS, FOCUS GROUPS WITH KEY AUDIENCES, AND A COMMUNITY PLANNING RETREAT. THE CHNA REPRESENTED A COMPREHENSIVE COMMUNITY-WIDE PROCESS WHERE ELK REGIONAL HEALTH CENTER CONNECTED WITH A WIDE RANGE OF PUBLIC AND PRIVATE ORGANIZATIONS SUCH AS EDUCATIONAL INSTITUTIONS, HEALTH-RELATED PROFESSIONALS, LOCAL GOVERNMENT OFFICIALS, HUMAN SERVICE ORGANIZATIONS, AND FAITH-BASED ORGANIZATIONS TO EVALUATE THE COMMUNITY'S HEALTH AND SOCIAL NEEDS.
SCHEDULE H, PART V, SECTION B, LINE 6A	CHNA CONDUCTED WITH OTHER HOSPITAL FACILITIES: THE CHNA WAS CONDUCTED ALONG WITH DUBOIS REGIONAL MEDICAL CENTER, CLEARFIELD HOSPITAL, AND ELK REGIONAL HEALTH CENTER, RELATED ORGANIZATIONS.
SCHEDULE H, PART V, SECTION B, LINE 7	WEBSITE WHERE CHNA IS AVAILABLE: https://www.phhealthcare.org/community-health/community-health-needs-asses sment/page.aspx?id=2021
SCHEDULE H, PART V, SECTION B, LINE 10A	WEBSITE WHERE IMPLEMENTATION STRATEGY IS AVAILABLE: https://www.phhealthcare.org/community-health/community-health-needs-asses sment/page.aspx?id=2021
SCHEDULE H, PART V, SECTION B, LINE 11	ADDRESSING IDENTIFIED NEEDS: Penn Highlands Brookville, Penn Highlands DuBois, Penn Highlands Clearfield and Penn Highlands Elk also partnered with various local organizations in a collaborative manner during 2016 in order to carry out the intended goals and outcomes of our previous CHNA strategy. PENN HIGHLANDS BROOKVILLE LISTENS TO COMMUNITY CONCERNS, ANALYZES HEALTHCARE UTILIZATION AND COSTS, EXPLORES ACCESS ISSUES, COLLABORATES WITH AND DEVELOPS EFFECTIVE PROGRAMS TO IMPROVE THE HEALTH OF THOSE IN THIS PORTION OF WEST CENTRAL PENNSYLVANIA. BASED ON THE COMMUNITY HEALTH NEEDS ASSESSMENT FINDINGS AND THE PRIORITIZED NEEDS, THREE COMMUNITY NEEDS WILL BE ADDRESSED AND FURTHER EXPLORED. DESPITE MANY CHALLENGES FACING A RURAL, CRITICAL ACCESS HOSPITAL, PENN HIGHLANDS BROOKVILLE, IN COLLABORATION WITH OTHER PARTNERS IN OUR REGION, MADE STRIDES TO MEET MANY OF THE COMMUNITY NEEDS. OF THE IDENTIFIED CHNA AND PRIORITIZED HEALTH NEEDS, PENN HIGHLANDS BROOKVILLE FOCUSED ON FOUR OF THE COMMUNITY REQUIREMENTS: -PROVIDER WORKFORCE -ACCESS TO CARE -DENTAL CARE PROVIDER WORKFORCE AND ACCESS TO CARE WHILE OUR STUDY NOTES THAT THOSE IN NEED OF HEALTHCARE OFTEN CITE THE LACK OF INSURANCE AS THE MAIN BARRIER, PENN HIGHLANDS BROOKVILLE TOOK ON THIS ISSUE IN ORDER TO ADDRESS THE PERCEPTION THAT THERE ARE NOT ENOUGH PROVIDERS TO SERVE COMMUNITY RESIDENTS. TACKLING THE LACK OF AVAILABLE PHYSICIANS AND ALLIED HEALTH PROFESSIONALS IN THE AREA WAS ALSO DONE TO HELP AND IMPROVE COMMUNITY RESIDENTS' ABILITY TO ACCESS AFFORDABLE HEALTHCARE SERVICES AND INFORMATION. ACCESS TO AFFORDABLE HEALTHCARE AND PREVENTIVE HEALTHCARE AND WELLNESS WERE IDENTIFIED AS DIRECT NEEDS FROM THE COMMUNITY HEALTH NEEDS ASSESSMENT. DURING THE FISCAL YEAR, THE SYSTEM PHYSICIAN RECRUITERS USED THE FOLLOWING TOOLS TO ENGAGE POTENTIAL CANDIDATES: CONTINGENCY FIRMS; ADVERTISING JOB BOARDS (PRACTICE LINK, CAREER MD, JOURNAL OF FAMILY PRACTICE, HEALTHECAREERS); CAREER FAIRS (PITTSBURGH, GREENSBURG, PHILADELPHIA); COMMUNICATION WITH RESIDENCY PROGRAM DIRECTORS IN SURROUNDING STATES; AND COMMUNICATION WITH COLLEAGUES TO POOL CANDIDATES. PENN HIGHLANDS BROOKVILLE ALSO ENGAGED AN EMERGENCY MEDICINE PHYSICIAN STAFFING GROUP TO PROVIDE PHYSICIANS FOR ITS EMERGENCY DEPARTMENT. THE HOSPITAL HAS THREE RURAL HEALTH CLINICS, ONE IN BROOKVILLE, ONE IN MARIENVILLE AND ONE IN NEW BETHLEHEM. THERE ARE THREE PHYSICIANS AND FOUR ADVANCED PRACTICE PROVIDERS WORKING IN THOSE THREE CLINICS. THE RECENT ADDITION OF THE FOURTH ALLIED HEALTH PROFESSIONAL ALSO INCREASED THE BROOKVILLE REGION'S ACCESS TO PRIMARY CARE. PENN HIGHLANDS BROOKVILLE WAS ALSO ABLE TO REESTABLISH ACCESS TO A FELLOWSHIP-TRAINED CARDIOLOGIST BY PARTNERING WITH DUBOIS REGIONAL CARDIOLOGY ASSOCIATES TO STAFF A LOCAL OFFICE AND PROVIDE CONSULTATIONS IN THE HOSPITAL TWO DAYS PER WEEK. THOSE SEEKING LOCAL ACCESS TO OUTPATIENT OBSTETRICAL AND GYNECOLOGICAL CARE ARE ALSO NOW ABLE TO SEE A PHYSICIAN IN BROOKVILLE THANKS TO THE ADDITION OF A NEW OFFICE OF PENN HIGHLANDS WOMEN'S CARE. IN ADDITION TO PLACING QUALIFIED PROVIDERS IN PRACTICES AROUND OUR SERVICE AREA, PENN HIGHLANDS BROOKVILLE IS WORKING ON A PLAN TO INCLUDE AS QCARE PROGRAM IN THE REGION. THIS WILL FOCUS ON ACCESS AND AFFORDABILITY FOR THOSE SEEKING CARE FOR URGENT NEEDS THAT ARE NOT EMERGENCIES. IN 2016, PENN HIGHLANDS BROOKVILLE WORKED WITH LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE TO PROVIDE CLINICAL SETTINGS FOR MEDICAL STUDENTS TO GET HANDS-ON OPPORTUNITIES TO EXPAND THEIR MEDICAL EDUCATION. A GENERAL MEDICAL EDUCATION PROGRAM WILL BE PART OF A SYSTEM-WIDE INITIATIVE THAT WILL BRING MEDICAL RESIDENTS IN THE FIELDS OF FAMILY MEDICINE, INTERNAL MEDICINE AND EMERGENCY MEDICINE TO PENN HIGHLANDS BROOKVILLE IN 2017. ADDITIONAL PARTNERSHIPS WILL ALSO INCLUDE A PHYSICIAN ASSISTANT TRAINING PROGRAM WITH LOCK HAVEN UNIVERSITY AND AN EDUCATIONAL/TRAINING PROGRAM FOR MID-LEVEL PROVIDERS WITH THE UNIVERSITY OF PITTSBURGH MEDICAL CENTER. DENTAL CARE MANY AVENUES FOR EXPANDING ACCESS TO DENTAL CARE IN OUR COMMUNITIES WERE EXPLORED WITH PARTNERS THROUGHOUT OUR HEALTH SYSTEM. DISCUSSIONS WITH CURRENT PROVIDERS ABOUT PLANS FOR ADDITIONAL STAFFING, THE REVIEW OF A MOBILE DENTAL UNIT FOR THE REGION AND DISCUSSIONS WITH OTHER STAKE-HOLDERS TO GENERATE NEW OPTIONS FOR DENTAL CARE WERE ALL INCLUDED IN THE PROCESS. THIS PRIORITY PROVED VERY CHALLENGING. NO NEW PROVIDERS OR PARTNERS COULD BE IDENTIFIED FOR OUR REGION FOR ANY INITIATIVES THAT WERE REVIEWED. MUCH TIME WAS DEVOTED TO STUDYING HOW MOBILE DENTAL UNITS WORK IN RURAL COMMUNITIES AND DEMONSTRATIONS OF MOBILE UNITS WERE CONDUCTED. FOLLOWING EXTENSIVE REVIEW AND DISCUSSION, OFFICIALS DETERMINED THAT PURCHASING A MOBILE UNIT WAS NOT FEASIBLE FOR OUR SYSTEM. THE TWO MAJOR FACTORS INCLUDED COST AND THE LACK OF A QUALIFIED PROVIDER TO RUN THE UNIT. EACH OF THE HEALTH NEEDS IDENTIFIED WITHIN THE CHNA ARE IMPORTANT AND ARE BEING ADDRESSED TO SOME DEGREE BY ORGANIZATIONS, PROGRAMS/INITIATIVES OPERATED BY REGIONAL AND LOCAL COMMUNITY-BASED ORGANIZATIONS OR BY BROOKVILLE HOSPITAL AND/OR DRMC. THROUGH ANALYSIS AND DISCUSSIONS RESULTING FROM A WORK SESSION HELD WITH REPRESENTATIVES FROM BROOKVILLE HOSPITAL AND DRMC, THE FOLLOWING NEEDS IDENTIFIED IN THE CHNA THAT WILL NOT BE ADDRESSED ARE: 1. ACCESSING HEALTH INFORMATION / LACK OF ACCESS (BRIDGING GAP BETWEEN SERVICE PROVIDERS AND END-USERS) 2. DRUG/ALCOHOL PREVENTION 3. HEALTH EDUCATION AND COMMUNICATION
SCHEDULE H, PART V, SECTION B, LINES 16A, 16B, 16C	FINANCIAL ASSISTANCE POLICY: https://www.phhealthcare.org/patients-visitors/financial-assistance-progra m/page.aspx?id=3112
SCHEDULE H, PART V, SECTION B, LINE 22D	MAXIMUM AMOUNTS CHARGED TO FAP-ELIGIBLE INDIVIDUALS: AMOUNTS GENERALLY BILLED WILL BE CALCULATED UTILIZING THE LOOK BACK METHOD WHICH REFLECTS THE AVERAGE PAYMENT OVER A RECENT 12 MONTH PERIOD OF PAYMENTS MADE TO PHH/PHPN BY MEDICARE AND ALL PRIVATE INSURERS.

Schedule H (Form 990) 2015

Page 8

Part VFacility Information (continued)

Section D. 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?5
Name and address		Type of Facility (describe)
1	PHYSICAL THERAPY BUILDING 88 INDUSTRIAL PARK RD BROOKVILLE,PA15825	OUTPATIENT PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY
2	CHARLES PROFESSIONAL BUILDING 240 ALLEGHENY BLVD BROOKVILLE,PA15825	PHYSICIAN OFFICES, HOME HEALTH
3	DAVID L MILLER MEDICAL CENTER BROOKVILLE STREET FAIRMOUNT,PA16224	RADIOLOGY, LAB, PHYSICAL AND OCCUPATIONAL THERAPY, AND RURAL HEALTH CLINIC
4	ALLEGHENY HEALTH CENTER 22 INDUSTRIAL PARK RD BROOKVILLE,PA15825	RURAL HEALTH CLINIC
5	MARIENVILLE FAMILY HEALTH 125 CHESTNUT ST MARIENVILLE,PA16239	RURAL HEALTH CLINIC
6
7
8
9
10

Schedule H (Form 990) 2015

Page 9

Part VI

Supplemental Information

Provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs 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.

Form and Line Reference	Explanation
SCHEDULE H, PART I, LINE 7, COLUMN F	PERCENT OF TOTAL EXPENSE: TO ARRIVE AT THE PERCENT OF TOTAL EXPENSES, THE DENOMINATOR WHICH EQUALS TOTAL OPERATING EXPENSES PER PART OF IX, LINE 25 OF THE FORM 990, WAS REDUCED BY BAD DEBT EXPENSE OF $ 1,537,642.
SCHEDULE H, PART I, LINE 7	COSTING METHODOLOGY: THE COST TO CHARGE RATIO COMPUTED ON IRS WORKSHEET 2 WAS USED IN THE CALCULATIONS OF IRS WORKSHEETS 1 AND 3.
SCHEDULE H, PART III, SECTION A, LINE 2	BAD DEBT EXPENSE: THE ORGANIZATION CALCULATED BAD DEBT USING THE BAD DEBT ATTRIBUTABLE TO PATIENT ACCOUNTS PER THE AUDITED FINANCIAL STATEMENTS.
SCHEDULE H, PART III, SECTION A, LINE 3	BAD DEBT EXPENSE ATTRIBUTABLE TO CHARITY CARE: BAD DEBT ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY WAS DETERMINED USING POVERTY LIMIT DEMOGRAPHIC INFORMATION OBTAINED THROUGH THE U.S. CENSUS BUREAU. THE MOST RECENT US CENSUS BUREAU INDICATES THAT 14.6 PERCENT OF JEFFERSON COUNTY WAS CONSIDERED TO LIVE IN POVERTY.
SCHEDULE H, PART III, SECTION A, LINE 4	BAD DEBT EXPENSE FOOTNOTE: THE AUDITED FINANCIAL STATEMENTS DO NOT CONTAIN A FOOTNOTE THAT DESCRIBES BAD DEBT EXPENSE. THEY DO, HOWEVER, CONTAIN A FOOTNOTE THAT DESCRIBES PATIENT ACCOUNTS RECEIVABLE: ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE SYSTEM ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR UNCOLLECTIBLE ACCOUNTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE SYSTEM ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR UNCOLLECTIBLE ACCOUNTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYER HAS NOT YET PAID, OR FOR PAYERS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE SYSTEM RECORDS A SIGNIFICANT PROVISION FOR UNCOLLECTIBLE ACCOUNTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED OR PROVIDED BY POLICY) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS.
SCHEDULE H, PART III, SECTION B, LINE 8	COMMUNITY BENEFIT: SERVING PATIENTS WITH GOVERNMENT HEALTH BENEFITS, SUCH AS MEDICARE, IS A COMPONENT OF THE COMMUNITY BENEFIT STANDARD THAT TAX-EXEMPT HOSPITALS ARE HELD TO. THIS IMPLIES THAT SERVING MEDICARE PATIENTS IS A COMMUNITY BENEFIT AND THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY.
SCHEDULE H, PART III, SECTION C, LINE 9B	COLLECTION POLICY: A CHARITY CARE APPLICATION IS GOOD FOR SIX MONTHS ONCE APPROVED. ALSO PATIENTS ARE SENT THREE STATEMENTS BEFORE BEING SENT TO COLLECTION AGENCY, SO THEY HAVE TIME TO CONTACT THE BILLING OFFICE FOR CHARITY CARE.
SCHEDULE H, PART VI, LINE 2	NEEDS ASSESSMENT: The hospital collects data on an ongoing basis regarding patients who travel to outlying areas for services not offered by Penn Highlands Brookville. Based on this data, services are added and improved upon in order to serve the needs of the community as effectively and efficiently as possible. PH Brookville routinely sends patient satisfaction surveys to those receiving medical services. These surveys allow patients to offer suggestions regarding how the hospital could better serve patients and the community as a whole. PH Brookville offers a variety of education programs that allow employees to interact on a one-on-one basis with the residents of the community as a whole. In addition, the medical staff of the hospital consistently participates in research and continuing education. This knowledge allows the hospital to remain updated on the latest medical news and techniques in order to offer patients the highest and most innovative levels of care. Penn Highlands hired an outside firm to assist with conducting a Community Health Needs Assessment. The contractor gathered secondary data in Jefferson and surrounding counties, conducted various focus groups with key audiences and users of healthcare and social services to identify areas for perspective improvement within the community. The contractor has developed a master plan of initiatives for PH Brookville which has been posted on the hospitals website.
SCHEDULE H, PART VI, LINE 3	PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE: INFORMATION IS POSTED AT REGISTRATION AREA AND IN WAITING AREAS. SELF PAY PATIENTS ARE GIVEN INFORMATION WITH THE FIRST BILL. THE CARE MANAGEMENT DEPARTMENT WORKS WITH ALL INPATIENTS AND WITH OUTPATIENTS AS NEEDED/REQUESTED.
SCHEDULE H, PART VI, LINE 4	COMMUNITY INFORMATION: BROOKVILLE HOSPITAL SERVES BROOKVILLE AND THE SURROUNDING COMMUNITIES. THE SERVICE AREA EXTENDS NORTH TO MARIENVILLE AND SOUTH TO NEW BETHLEHEM, AND INCLUDES JEFFERSON COUNTY, FOREST COUNTY AND CLARION COUNTY. THIS SERVICE AREA IS IN A RURAL PART OF WESTERN PENNSYLVANIA, WITH MANY RESIDENTS LIVING BELOW OR WELL BELOW THE NATIONAL AND STATE INCOME AVERAGE. ACCORDING TO THE US CENSUS BUREAU'S MOST RECENT DATA, APPROXIMATELY 15 PERCENT OF INDIVIDUALS LIVING IN THIS AREA WERE CONSIDERED TO LIVE IN POVERTY. THE MEDIAN HOUSEHOLD INCOME IN THE SERVICE AREA IS APPROXIMATELY $38,500. FROM THE RECENTLY COMPLETED COMMUNITY HEALTH NEEDS ASSESSMENT, THE SERVICE AREA INCLUDES 22% OF UNINSURED ADULTS, 7.8% OF CHILDREN WHO ARE UNINSURED. UNEMPLOYMENT RATES FOR CLEARFIELD AND JEFFERSON COUNTY WERE JUST OVER 8%. THE MEDIAN AGE OF THE POPULATION IS ABOUT 42, WITH ABOUT 18% 65 AND OVER. CLEARFIELD COUNTY HAS A 45.9% URBAN POPULATION, WHILE JEFFERSON HAS A 33.8% URBAN POPULATION.
SCHEDULE H, PART VI, LINE 5	PROMOTION OF COMMUNITY HEALTH: BROOKVILLE HOSPITAL PARTICIPATES IN AND PROVIDES MANY HEALTH FAIR AND COUNSELING OPPORTUNITIES THROUGHOUT THE YEAR, INCLUDING THOSE ASSOCIATED WITH MENTAL HEALTH, DIABETES, NUTRITION AND WEIGHT MANAGEMENT. ALSO, THE ORGANIZATION WORKS TO PROMOTE LEARNING THROUGH THE MEDICAL EXPLORERS PROGRAM AND LOCAL CAREER DAYS.
SCHEDULE H, PART VI, LINE 6	AFFILIATED HEALTH CARE SYSTEM: BROOKVILLE HOSPITAL IS A SUBSIDIARY OF DUBOIS REGIONAL MEDICAL CENTER (DRMC). DRMC HAS AN AFFILIATION AGREEMENT WITH CLEARFIELD HOSPITAL, CREATING PENN HIGHLANDS HEALTHCARE, WHICH BECAME THE PARENT AND SOLE MEMBER OF DRMC AND CLEARFIELD.

Schedule H (Form 990) 2015

Additional Data

Software ID:
Software Version:

- TIN:

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" on Form 990, Part IV, line 23.
SchJMediumBullet

Attach to Form 990.
SchJMediumBullet

Information about Schedule J (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

BROOKVILLE HOSPITAL

Employer identification number

25-0984595

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed on Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

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 of the expenses described above? If "No," complete Part III to explain .........

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked in line 1a? ..

Indicate which, if any, of the following the filing organization used 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.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed on Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? ................

Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........

Yes

Participate in, or receive payment from, an equity-based compensation arrangement? .........

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), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ...........................

Any related organization?

If "Yes," on line 5a or 5b, describe in Part III.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization?

Any related organization? .........................

If "Yes," on line 6a or 6b, describe in Part III.

For persons listed on 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 ............

Were any amounts reported on 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 .............................

If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50053T

Schedule J (Form 990) 2015

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 on 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 (E) amounts for that individual.

(A) Name and Title		(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 in column(B) reported as deferred on prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
1JOHN SUTIKADIRECTOR/DRMC PRESIDENT/CEO	(i) (ii)	0 ------------- 330,506	0 ------------- 50,589	0 ------------- 35,104	0 ------------- 43,651	0 ------------- 15,990	0 ------------- 475,840	0 ------------- 0
2DR BARRY SNYDER MDDIR/MED STAFF PRES END 12/15	(i) (ii)	155,783 ------------- 0	20,613 ------------- 0	0 ------------- 0	6,001 ------------- 0	13,538 ------------- 0	195,935 ------------- 0	0 ------------- 0
3DAVID GARADIPHYSICIAN	(i) (ii)	202,500 ------------- 0	264,190 ------------- 0	0 ------------- 0	7,800 ------------- 0	16,890 ------------- 0	491,380 ------------- 0	0 ------------- 0
4TANIS PENDLETONPHYSICIAN	(i) (ii)	311,546 ------------- 0	0 ------------- 0	0 ------------- 0	0 ------------- 0	5,248 ------------- 0	316,794 ------------- 0	0 ------------- 0
5CYRIL GAMISPHYSICIAN	(i) (ii)	254,421 ------------- 0	12,250 ------------- 0	0 ------------- 0	0 ------------- 0	11,386 ------------- 0	278,057 ------------- 0	0 ------------- 0
6EMERSON TURNBULLCRNA	(i) (ii)	149,722 ------------- 0	5,500 ------------- 0	0 ------------- 0	5,922 ------------- 0	16,890 ------------- 0	178,034 ------------- 0	0 ------------- 0
7JULIANNE PEERPRESIDENT	(i) (ii)	95,337 ------------- 63,594	551 ------------- 19,398	32,807 ------------- 2,029	3,813 ------------- 5,723	10,557 ------------- 6,494	143,065 ------------- 97,238	0 ------------- 0
8DR KUMARESAN GANABATHI MDPRES OF MED STAFF BEG 01/2016	(i) (ii)	533,939 ------------- 0	0 ------------- 0	44,550 ------------- 0	10,600 ------------- 0	14,500 ------------- 0	603,589 ------------- 0	0 ------------- 0
9ALAN CORNMANPHARMACIST	(i) (ii)	149,606 ------------- 0	0 ------------- 0	0 ------------- 0	5,984 ------------- 0	16,890 ------------- 0	172,480 ------------- 0	0 ------------- 0

Schedule J (Form 990) 2015

Page 3

Part III

Supplemental Information

Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.

Return Reference	Explanation
SCHEDULE J, PART I, LINE 4B	NONQUALIFIED RETIREMENT PLAN: PENN HIGHLANDS DUBOIS EMPLOYEES WHO PARTICIPATED IN A 457(F) PLAN: JOHN SUTIKA 2015 CONTRIBUTIONS $15,051
SCHEDULE J, PART I, LINE 3	CEO COMPENSATION DETERMINATION: PENN HIGHLANDS HEALTHCARE (PHH), A RELATED ORGANIZATION, COMPLETES THE REVIEW OF THE CEO'S COMPENSATION, USING THE FOLLOWING METHODS: -COMPENSATION COMMITTEE -INDEPENDENT COMPENSATION CONSULTANT -COMPENSATION SURVEY OR STUDY -APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE -WRITTEN EMPLOYMENT CONTRACT
SCHEDULE J, PART I, LINE 7	NON-FIXED PAYMENTS: A PORTION OF JOHN SUTIKA'S BONUS, PAID BY A RELATED ORGANIZATION, WAS BASED ON BOARD DISCRETION, WHILE THE MAJORITY WAS BASED ON FORMULAS USING INFORMATION BASED ON FINANCE, GROWTH, QUALITY/SAFETY, PEOPLE, AND SERVICE.

Schedule J (Form 990) 2015

Additional Data

Software ID:
Software Version:

- TIN:

Schedule L
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Transactions with Interested Persons

Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V, line 38a or 40b.
MediumBullet

Attach to Form 990 or Form 990-EZ.
MediumBullet

Information about Schedule L (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

BROOKVILLE HOSPITAL

Employer identification number

25-0984595

Part I

Excess Benefit Transactions (section 501(c)(3), section 501(c)(4), and 501(c)(29) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.

1(a) Name of disqualified person	(c) Description of transaction	(d) Corrected?
1(a) Name of disqualified person	(c) Description of transaction	Yes	No

Enter the amount of tax incurred by organization managers or disqualified persons during the year under section 4958. ........................... Bullet Image

Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ........ Bullet Image

Part II

Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22

(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	(d) Loan to or from the organization?		(e)Original principal amount	(f)Balance due	(g) In default?		(h) Approved by board or committee?		(i)Written agreement?
(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	To	From	(e)Original principal amount	(f)Balance due	Yes	No	Yes	No	Yes	No
(1) JULIANNE PEER	PRESIDENT	EDUC. REIMB.		X	20,000	4,924		No		No	Yes









Total ............... $						4,924

Part III

Grants or Assistance Benefiting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of assistance	(d) Type of assistance	(e) Purpose of assistance

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 50056A

Schedule L (Form 990 or 990-EZ) 2015

Page 2

Part IV

Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of transaction	(d) Description of transaction	(e) Sharing of organization's revenues?
(a) Name of interested person		(c) Amount of transaction	(d) Description of transaction	Yes	No
(1) LINDA GRINDER	SISTER OF RON KING	53,528	EMPLOYEE OF HOSPITAL		No

Part V

Supplemental Information
Provide additional information for responses to questions on Schedule L (see instructions).

Return Reference	Explanation

Schedule L (Form 990 or 990-EZ) 2015

Additional Data

Software ID:
Software Version:

- TIN:

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 990-EZ or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public
Inspection

Name of the organization

BROOKVILLE HOSPITAL

Employer identification number

25-0984595

Return Reference	Explanation
FORM 990, PART III, LINE 1	ORGANIZATION'S MISSION: MISSION STATEMENT OUR MISSION IS TO PROVIDE QUALITY HEALTHCARE SERVICES TO THE COMMUNITIES THAT WE SERVE IN A COST EFFECTIVE MANNER. VISION STATEMENT OUR VISION IS TO BE THE PROVIDER OF CHOICE IN PROMOTING HEALTHCARE FOR THE COMMUNITIES THAT WE SERVE. VALUE STATEMENT -SERVICE EXCELLENCE THAT IS RESPONSIVE TO THE NEEDS OF THOSE WE SERVE. -DIGNITY & COMPASSION IN CARING FOR PATIENTS AND THEIR FAMILIES. -RESPECT TREATING EACH OTHER WITH FAIRNESS, HONESTY, AND TRUST. -TEAMWORK CHARACTERIZED BY UNITY OF PURPOSE, FLEXIBILITY AND EMPOWERMENT OF PEOPLE. -PLANNING BUILDING ON THE PAST AND ANTICIPATING THE FUTURE TO MEET OUR GOALS. -FINANCIAL HEALTH TO ENSURE THE CONTINUATION OF OUR MISSION. -ACTIVE PARTICIPATION BY PATIENTS AND FAMILIES IN THEIR HEALTHCARE.
FORM 990, PART III, LINE 4A	PROGRAM SERVICE: BROOKVILLE HOSPITAL ESTIMATED VALUE OF FREE CARE, COMMUNITY SERVICE, CHARITABLE CONTRIBUTIONS, AND PROFESSIONAL AND COMMUNITY EDUCATION. UNCOMPENSATED CHARITY CARE UNCOMPENSATED CHARITY CARE CHARGES WRITTEN OFF WERE $215,000. THE TOTAL DOES NOT INCLUDE BAD DEBT. THE HOSPITAL'S DETERMINATION OF INABILITY TO PAY DIFFERENTIATES CHARITY CARE FROM BAD DEBT, WHICH IS DETERMINED BY ABILITY TO PAY BUT UNWILLINGNESS TO DO SO. BAD DEBT THE HOSPITAL'S BAD DEBT AMOUNT WRITTEN OFF WAS $1,537,642 IN FY 2016. CHARITY CARE SERVICE THE HOSPITAL OWNS AND OPERATES THE ALLEGHENY, NEW BETHLEHEM, AND MARIENVILLE HEALTH CENTERS. THESE ARE RURAL HEALTH CLINICS THAT ARE AVAILABLE TO THE COMMUNITY. CHARITY CARE IS OFFERED TO PATIENTS OF THESE CLINICS. COMMUNITY VOLUNTEER ASSISTANCE APPROXIMATELY 25 ACTIVE HOSPITAL VOLUNTEERS ASSISTED WITH THE PROVISION OF SERVICES BY THE HOSPITAL. THE AUXILIARY HAS ABOUT 28 MEMBERS THAT HOLD FUND RAISING EVENTS THROUGHOUT THE YEAR. THE FUNDS FROM THESE EVENTS ARE GIVEN BACK TO THE HOSPITAL FOR VARIOUS PROJECTS. PASTORAL CARE THE HOSPITAL HAS VOLUNTEER PASTORS THAT PERFORM MINISTRY TO THE HOSPITAL'S PATIENTS, PATIENTS' FAMILIES, AND STAFF. THIS SERVICE IS AVAILABLE 24 HOURS A DAY/7 DAYS A WEEK. PATIENT COMMENT SURVEYS THE HOSPITAL DISTRIBUTES SURVEYS TO INPATIENT, OUTPATIENTS, AMBULATORY SURGERY, EMERGENCY ROOM, AND HOME CARE PATIENTS TO ASSESS THE NEEDS OF THE PATIENTS IN OUR COMMUNITY REGARDING CARE AND OPPORTUNITIES TO IMPROVE THAT CARE. RESULTS ARE RECEIVED QUARTERLY AND COMPARED TO PRIOR RESULTS. TIME IS SPENT BY HOSPITAL STAFF I EVALUATING RESULTS, WITH DEPARTMENTAL AND CONSUMER FOLLOW-UP AND WORK PROCESS REDESIGN TO IMPROVE CARE AND SATISFACTION. FOREIGN LANGUAGE & SIGN LANGUAGE INTERPRETING SERVICE THE HOSPITAL PROVIDES INTERPRETING SERVICES AT NO CHARGE TO FOREIGN LANGUAGE AND SIGN LANGUAGE SPEAKING PATIENTS AND PATIENT FAMILY MEMBERS. THESE SERVICES ARE PERFORMED ON AN ON-CALL BASIS. HOSPITAL EMPLOYEES WHO SPEAK A FOREIGN LANGUAGE OR ARE TRAINED IN SIGN LANGUAGE CAN BE USED TO TRANSLATE. THE HOSPITAL ALSO SUBSCRIBES TO AN ON-LINE INTERPRETING SERVICE, LANGUAGE LINE SERVICES. COMMUNITY EDUCATION / PUBLIC AFFAIRS ACTIVITIES IN OUR ROLES AS A LEADING PROVIDER OF HEALTH AND HEALTH-RELATED SERVICES TO JEFFERSON AND SURROUNDING COUNTIES, BROOKVILLE HOSPITAL RECOGNIZES OUR RESPONSIBILITY TO HELP THE PEOPLE OF OUR SERVICE AREA ACHIEVE AND MAINTAIN OPTIMUM HEALTH STATUS. THE ADMINISTRATION AND EDUCATION DEPARTMENT AND THE HEALTHY COMMUNITY COMMITTEE, OFFERS A SERIES OF PROGRAMS THROUGHOUT THE YEAR TO ACHIEVE THIS ROLE. BROOKVILLE HOSPITAL'S EDUCATIONAL EFFORTS ARE HEALTH-RELATED TO HELP FULFILL OUR MISSION OF HELPING PEOPLE IN OUR SERVICE AREA ACHIEVE AND MAINTAIN OPTIMUM HEALTH STATUS. EFFORTS IN THIS AREA INCLUDE FREE COMMUNITY HEALTH AND PATIENT EDUCATION PUBLICATIONS, MATERIALS TO PROMOTE HEALTH-RELATED ACTIVITIES, A PHYSICIAN REFERRAL LINE, AND PARTICIPATION IN LOCAL HEALTH FAIRS. PATIENT SUPPORT AND EDUCATION NUTRITIONAL COUNSELING A REGISTERED DIETITIAN IS AVAILABLE TO MEET WITH PATIENTS AND FAMILIES TO ASSESS NUTRITIONAL NEEDS AND DETERMINE APPROPRIATE NUTRITIONAL GOALS AND STRATEGIES. IN ADDITION, CLASSES ARE OFFERED THROUGHOUT THE YEAR TO THE COMMUNITY ON HEALTHY COOKING, LOW FAT DIET, DIABETES, CARDIOVASCULAR HEALTH. MAMMOGRAMS IN COOPERATION WITH AREA PHYSICIANS, THE HOSPITAL PROVIDES REDUCED FEE MAMMOGRAMS WITH INTERPRETATIONS ON AN ANNUAL BASIS FOR HIGH RISK WOMEN WHO ARE LOW INCOME AND GENERALLY UNINSURED. COMMUNITY CLASSES THE HOSPITAL OFFERS A VARIETY OF COMMUNITY EDUCATION CLASSES THAT INCLUDES CPR, DIABETES EDUCATION, AND A NEW WAY OF LIFE. PATIENT EDUCATION PUBLICATIONS INCLUDES A VARIETY OF PUBLICATIONS SUCH AS THE PATIENT VISITOR GUIDE, THE PATIENT RIGHTS & RESPONSIBILITIES BOOKLET, ADVANCE DIRECTIVES, ETC. MATERIALS TO PROMOTE HEALTH-RELATED ACTIVITIES MATERIALS INCLUDE PROMOTING A VARIETY OF ACTIVITIES INCLUDING HEALTH SCREENING ADS, CANCER ASSESSMENT AND BREAST HEALTH AWARENESS MATERIALS, AND DIABETES EDUCATION CLASSES. VOLUNTARISM BROOKVILLE HOSPITAL'S WORK FORCE, ONE OF THE LARGEST IN THE REGION, IS COMPRISED OF MANY INDIVIDUALS WHO ENGAGE IN PERSONAL COMMUNITY SERVICE. THESE INDIVIDUALS GIVE OF THEIR TIME, TALENT, AND RESOURCES TO MAKE OUR COMMUNITY A BETTER PLACE TO LIVE AND WORK. PHYSICIANS AND EMPLOYEES VOLUNTEER THEIR TIME INDIVIDUALLY, BENEFITING COMMUNITY ORGANIZATIONS AND CAUSES. DURING THE YEAR. EMPLOYEES SPEND TIME PROVIDING CARE, EDUCATING THE COMMUNITY, AND SERVING ON BOARDS OF SOCIAL SERVICE AGENCIES. EMPLOYEES ALS VOLUNTEER THEIR TIME FOR ADOPT A HIGHWAY, MARCH OF DIMES WALK AMERICA, THE M/S WALK, AND SIT ON VARIOUS COMMUNITY BOARDS. CONTRIBUTIONS EACH YEAR, BROOKVILLE HOSPITAL RECEIVES REQUESTS FOR FINANCIAL SUPPORT FROM NUMEROUS ORGANIZATIONS PROVIDING VALUABLE SERVICES TO OUR COMMUNITY. WHILE WE ARE A NOT-FOR-PROFIT ORGANIZATION, WE DO PROVIDE SUPPORT ON A LIMITED BASIS. UNITED FUND CAMPAIGN BROOKVILLE HOSPITAL EMPLOYEES CONTRIBUTE FUNDS TO THE COMMUNITY THROUGH THE UNITED FUND CAMPAIGN. INFECTION CONTROL COMMUNITY SERVICE THE INFECTION CONTROL DEPARTMENT SHARES POLICIES, PROCEDURES, AND EXPERTISE WITH OTHER HOSPITALS NURSING HOMES, AND HEALTH CARE PROVIDERS. IN SOLVING INFECTION-RELATED PROBLEMS, HELPING TO DEVELOP PROGRAMS, ETC., AS REQUESTED. THE INFECTION CONTROL DEPARTMENT ALSO PROVIDES FOLLOW-UP TO BLOOD/BODY FLUID EXPOSURES EXPERIENCED BY HOSPITAL PERSONNEL. FOLLOW-UP IS GENERALLY COMPLICATED AND INVOLVES BLOOD WORK FOR EMPLOYEES AND PATIENTS AND COUNSELING AS PROVIDED AFTER EACH EXPOSURE. INFECTION CONTROL COMMUNICATE REGULARLY WITH ALL AREA HEALTH BUREAUS REPORTING COMMUNICABLE DISEASES, THUS AFFORDING CONTINUITY OF FOLLOW-UP INVESTIGATION FOR POTENTIALLY EXPOSED PATIENTS AND STAFF. COMMUNITY EDUCATION WE WORK WITH HIGH SCHOOL STUDENTS TO EDUCATE THEM ABOUT HEALTHCARE CAREERS THROUGH JOB FAIRS AT THE SCHOOL AND BY OFFERING JOB SHADOWING OPPORTUNITIES IN BOTH CLINICAL AND NON-CLINICAL AREAS.
FORM 990, PART IV, LINE 24A	TAX EXEMPT BOND ISSUE: A REFINANCING BOND ISSUE WAS NEGOTIATED BY THE PARENT COMPANY OF BROOKVILLE HOSPITAL, PENN HIGHLANDS HEALTHCARE, INC., TO BENEFIT THE HOSPITALS WITHIN THE PENN HIGHLANDS SYSTEM. PENN HIGHLANDS HEALTHCARE, INC. REPORTED THIS BOND ISSUE ON SCHEDULE K OF ITS FORM 990. PENN HIGHLANDS HEALTHCARE, INC. DOES NOT CARRY THIS LIABILITY ON ITS BALANCE SHEET. RATHER, BROOKVILLE HOSPITAL IS LEGALLY RESPONSIBLE FOR ITS PORTION OF THE LIABILITY AND THUS, REPORTS ITS SHARE ON ITS BALANCE SHEET.
FORM 990, PART VI, SECTION A, LINE 6	MEMBERS/STOCKHOLDERS: DUBOIS REGIONAL MEDICAL CENTER (DRMC) IS THE SOLE MEMBER OF BROOKVILLE HOSPITAL.
FORM 990, PART VI, SECTION A, LINE 7A	ELECTION OF DIRECTORS: AS THE SOLE MEMBER OF BROOKVILLE HOSPITAL, DRMC'S RESERVED POWERS INCLUDE THE RIGHT TO ELECT THE BOARD OF DIRECTORS OF BROOKVILLE HOSPITAL. CANDIDATES ARE SUBMITTED TO DRMC THROUGH A NOMINATING PROCESS THAT INVOLVES THE APPROVAL OF BROOKVILLE HOSPITAL'S BOARD. AS THE OTHER BODY OF DRMC, PHH HAS THE AUTHORITY TO APPROVE DRMC'S ELECTION OF BROOKVILLE HOSPITAL'S BOARD OF DIRECTORS.
FORM 990, PART VI, SECTION A, LINE 7B	DECISION APPROVALS: AS THE SOLE MEMBER OF BROOKVILLE HOSPITAL, DRMC'S RESERVED POWERS INCLUDE: -APPROVAL OF ALL FUNDAMENTAL TRANSACTIONS; -APPROVAL OF ALL STRATEGIC PLANS, BUDGETS, AND FEASIBILITY PLANS; -APPROVAL OF THE INCURRENCE, RE-FINANCING OR PREPAYMENT OF ALL INDEBTEDNESS IN EXCESS OF $10,000; -WITH SOME EXCEPTIONS, THE APPROVAL OF THE SECURING OF ANY ENCUMBRANCE OF ASSETS; -WITH SOME EXCEPTIONS, APPROVAL OF THE MAKING OF ANY CAPITAL EXPENDITURES OR ANY CAPITAL ADDITIONS OR IMPROVEMENTS GREATER THAN $10,000; -APPROVAL OF ANY AND ALL AMENDMENTS OF THE ARTICLES AND/OR BYLAWS; -APPROVAL OF ANY CHANGE IN MISSION OR DIRECTION; -APPROVAL OF THE ESTABLISHMENT OF, OR TERMINATION OR WITHDRAWAL FROM, ANY SUBSIDIARY, JOINT VENTURE, OR OTHER PARTNERSHIP OR SHARED GOVERNANCE ARRANGEMENT; -APPROVAL OF AGREEMENTS OF $50,000 OR MORE; AND -APPROVAL OF THIRD PARTY PAYOR AGREEMENTS, COLLECTIVE BARGAINING AGREEMENTS AND AGREEMENTS BETWEEN BROOKVILLE HOSPITAL AND DRMC. AS THE OTHER BODY OF DRMC, PHH HAS THE POWER TO REVIEW AND APPROVE ANY ACTION TAKEN BY DRMC IN EXERCISING THE RESERVED POWERS LISTED ABOVE.
FORM 990, PART VI, SECTION B, LINE 11B	990 REVIEW PROCESS: THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM BASED ON THE AUDITED FINANCIAL STATEMENTS AND INFORMATION PROVIDED BY THE ACCOUNTING DEPARTMENT OF THE ORGANIZATION. THE FORM 990 IS REVIEWED BY THE CEO PRIOR TO BEING FILED. IN ADDITION, THE REVIEW AND APPROVAL OF THE FORM 990 WILL BE ON THE AGENDA FOR THE NEXT BOARD MEETING AFTER FILING OF THE FORM 990. IF THERE ARE NECESSARY SIGNIFICANT CHANGES IDENTIFIED DURING THIS PROCESS, THE ORGANIZATION WILL CONSIDER AMENDING TO REFLECT THESE CHANGES.
FORM 990, PART VI, SECTION B, LINE 12C	CONFLICT OF INTEREST POLICY: THE CONFLICT OF INTEREST STATEMENTS ARE REVIEWED BY THE CEO. ANY BOARD MEMBER WITH A CONFLICT OR POTENTIAL CONFLICT WOULD ABSTAIN FROM VOTING ON ANY MATTER RELATED TO THAT CONFLICT. ADDITIONALLY, THE BOARD MEMBERS ARE GIVEN A QUESTIONNAIRE TO COMPLETE TO ASSIST THE ORGANIZATION IN PROPERLY ANSWERING THE QUESTIONS FOR THE NEW FORM 990. CORPORATE OFFICERS AND KEY EMPLOYEES ARE ALSO REQUIRED TO ANNUALLY DISCLOSE CONFLICTS OF INTEREST.
FORM 990, PART VI, SECTION B, LINE 15A	CEO COMPENSATION REVIEW: PHH COMPLETES A REVIEW OF EXECUTIVE SALARIES USING AN INDEPENDENT CONSULTANT AND A COMPENSATION COMMITTEE. THE INDEPENDENT CONSULTANT USES COMPARABILITY DATA IN THE REVIEW AND THE DECISION IS DOCUMENTED IN THE BOARD MINUTES.
FORM 990, PART VI, SECTION C, LINE 19	DOCUMENT DISCLOSURE: A FINANCIAL SUMMARY IS PUBLISHED IN THE PAPER EACH YEAR WITH THE ANNUAL REPORT TO THE COMMUNITY. THIS FINANCIAL SUMMARY AND ANNUAL REPORT CAN ALSO BE REVIEWED IN THE HOSPITAL ADMINISTRATIVE OFFICES. THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC.
FORM 990, PART VII	DIRECTOR COMPENSATION: NO DIRECTORS RECEIVE COMPENSATION FOR THEIR ROLES AS DIRECTORS. JULIANNE PEER, JOHN SUTIKA, KUMARESAN GANABATHI AND BARRY SNYDER RECEIVE COMPENSATION FROM RELATED ORGANIZATIONS FOR THEIR ROLES AS MANAGEMENT AND/OR PHYSICIANS.
FORM 990, PART IX, LINE 11G, COLUMN A	OTHER FEES FOR SERVICES: $ 1,254,934 OUTSIDE SERVICES 2,400,787 PROFESSIONAL FEES 564,453 MAINTENANCE CONTRACTS 32,358 SERVICE CONTRACTS ----------- $ 4,252,532
FORM 990, PART XI, LINE 9	OTHER CHANGES IN NET ASSETS: $ ( 26,241) CHANGE IN BENEFICIAL INTEREST IN TRUST 146,905 TRANSFER FROM AFFILIATES ----------- $ 120,664

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2015

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBullet

Attach to Form 990.
MediumBullet

Information about Schedule R (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

BROOKVILLE HOSPITAL

Employer identification number

25-0984595

Part I

Identification of Disregarded Entities Complete if the organization answered "Yes" on Form 990, Part IV, line 33.

(a) Name, address, and EIN (if applicable) 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 entity?
(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	Yes	No
(1)PENN HIGHLANDS HEALTHCARE 100 HOSPITAL AVENUE DUBOIS,PA15801 32-0345810	MGMT SERVICES	PA	501(C)(3)	11 C III-FI	NA		No
(2)DUBOIS REGIONAL MEDICAL CENTER 100 HOSPITAL AVENUE DUBOIS,PA15801 25-1490707	HEALTHCARE	PA	501(C)(3)	3	PHH		No
(3)ELCO HOUSING 759 JOHNSONBURG ROAD ST MARYS,PA15857 25-1639115	HOUSING	PA	501(C)(3)	7	PHH		No
(4)ELK REGIONAL PROFESSIONAL GROUP INC 763 JOHNSONBURG ROAD ST MARYS,PA15857 25-1875183	HEALTH CARE	PA	501(C)(3)	3	PHH		No
(5)COMMUNITY NURSES HOME HEALTH AND HOSPICE 757 JOHNSONBURG ROAD STE 200 ST MARYS,PA15857 25-0996070	HEALTH CARE	PA	501(C)(3)	9	CNI		No
(6)COMMUNITY NURSES HOME SUPPORT SERVICES 757 JOHNSONBURG ROAD STE 200 ST MARYS,PA15857 25-1623601	HEALTH CARE	PA	501(C)(3)	9	CNI		No
(7)COMMUNITY NURSES INC 757 JOHNSONBURG ROAD STE 200 ST MARYS,PA15857 25-1623598	HEALTH CARE	PA	501(C)(3)	7	PHH		No
(8)CLEARFIELD HOSPITAL 809 TURNPIKE DR CLEARFIELD,PA16830 25-0979346	HOSPITAL	PA	501(C)(3)	3	PHH		No
(9)ELK REGIONAL HEALTH CENTER 763 JOHNSONBURG ROAD ST MARYS,PA15857 25-0585280	HOSPITAL	PA	501(C)(3)	3	PHH		No
(10)NATHANIEL D YINGLING CANCER CENTER 815 DOCTORS DR CLEARFIELD,PA16830 20-5114093	RADIATION ONC	PA	501(C)(3)	3	PHH		No
(11)CLEAR-MED PROVIDER CORPORATION PO BOX 1260 CLEARFIELD,PA16830 25-1657668	OUTPAT. PHYS.	PA	501(C)(3)	3	PHH		No
(12)DRMC EMPLOYEE BENEFITS PLAN TRUST 100 HOSPITAL AVE DUBOIS,PA15801 25-6332829	DRMC EMP BENE	PA	501(C)(9)		PHH		No

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2015

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	(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?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	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	(i) Section 512(b)(13) controlled entity?
(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		Yes	No
(1) BROOKCARE II INC 100 HOSPITAL ROAD BROOKVILLE,PA15825 27-1573910	OFFICE SPACE	PA	BROOKVILLE	C CORP	234,883	946,194	100.000 %	Yes
(2) CHARITABLE TRUST 25-6171730	TRUST	PA	BROOKVILLE	TRUST		192,364	100.000 %	Yes

Schedule R (Form 990) 2015

Page 3

Part V

Transactions With Related Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.

Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.

Yes

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, or (iv) rent from a controlled entity .....................

b Gift, grant, or capital contribution to related organization(s) ............................

c Gift, grant, or capital contribution from related organization(s) ............................

Yes

d Loans or loan guarantees to or for related organization(s) ............................

e Loans or loan guarantees by related organization(s) ............................

f Dividends from related organization(s) ............................

g Sale of assets to related organization(s) ............................

h Purchase of assets from related organization(s) ............................

i Exchange of assets with related organization(s) ............................

j Lease of facilities, equipment, or other assets to related organization(s) .......................

Yes

k Lease of facilities, equipment, or other assets from related organization(s) ......................

Yes

l Performance of services or membership or fundraising solicitations for related organization(s) .....................

m Performance of services or membership or fundraising solicitations by related organization(s) .................

Yes

n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) ...................

Yes

o Sharing of paid employees with related organization(s) ............................

Yes

p Reimbursement paid to related organization(s) for expenses ............................

Yes

q Reimbursement paid by related organization(s) for expenses ............................

Yes

r Other transfer of cash or property to related organization(s) ............................

s Other transfer of cash or property from related organization(s) ............................

Yes

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 related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) BROOKCARE II INC	K	83,164	FMV

Schedule R (Form 990) 2015

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)	(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?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2015

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R (see instructions).

Return Reference	Explanation

Schedule R (Form 990) 2015

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: BROOKVILLE HOSPITAL IS A 35 BED CRITICAL ACCESS HOSPITAL THAT PROVIDES QUALITY HEALTHCARE SERVICES. OUTPATIENT SERVICES INCLUDE RADIOLOGY, LAB, REHABILITATION, AND HOME HEALTH.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	9
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	5
5	Total number of individuals employed in calendar year 2015 (Part V, line 2a) ......	5	259
6	Total number of volunteers (estimate if necessary) .............	6	25
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	0

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	1,086,319	416,973
9	Program service revenue (Part VIII, line 2g) .........	27,620,097	28,185,611
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	18,986	20,711
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	56,267	84,666
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	28,781,669	28,707,961
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	6,395	6,132
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)	15,374,226	15,991,336
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	11,866,894	12,312,949
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	27,247,515	28,310,417
19	Revenue less expenses. Subtract line 18 from line 12.......	1,534,154	397,544
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	17,607,357	17,942,514
21	Total liabilities (Part X, line 26).............	7,561,834	7,378,783
22	Net assets or fund balances. Subtract line 21 from line 20.....	10,045,523	10,563,731

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 17,729,141 including grants of $ 6,132 ) (Revenue $ 20,011,784 )
	BROOKVILLE HOSPITAL PROVIDES A WIDE VARIETY OF OUTPATIENT SERVICES TO THE COMMUNITY. WE HAVE A PHYSICIAN STAFFED 24 HOUR EMERGENCY DEPARTMENT THAT PROVIDED OVER 9,000 VISITS THIS YEAR AND 3 FAMILY PRACTICE CLINICS AND AN URGENT CARE CLINIC THAT HAD OVER 27,000 VISITS. WE ALSO PROVIDE OUTPATIENT PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY, GENERAL RADIOLOGY, CAT SCAN, MRI, PET, ULTRASOUND, NUCLEAR MEDICINE, CARDIOLOGY, LABORATORY SERVICES, PAIN CLINIC, AND OUTPATIENT PSYCH SERVICES. OUR SURGEONS PERFORMED 1,200 SURGERIES AND OUR HOME HEALTH AGENCY PROVIDED OVER 6,000 VISITS. SEE SCHEDULE O FOR ADDITIONAL INFORMATION.

4b	(Code: ) (Expenses $ 7,241,480 including grants of $ ) (Revenue $ 8,173,827 )
	BROOKVILLE HOSPITAL IS A 35 BED HOSPITAL THAT PROVIDED INPATIENT SERVICES TO OVER 1,100 PATIENTS THIS YEAR. INPATIENT SERVICES INCLUDED TREATMENTS FOR BOTH MEDICAL AND SURGICAL PATIENTS. MANY OF OUR PATIENTS WERE TREATED IN THE GERO-PSYCHIATRIC UNIT OF THE HOSPITAL. THIS UNIT SPECIALIZES IN PSYCHIATRIC DISORDERS FOR PATIENTS OVER THE AGE OF 55.

4c	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses24,970,621

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	2,233,315	501,220	217,877

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c	5,899
d	Related organizations		1d
e	Government grants (contributions)		1e

f	All other contributions, gifts, grants, and similar amounts not included above		1f	411,074

g	Noncash contributions included in lines 1a-1f:$
h Total.Add lines 1a-1f.......		416,973

			Business Code
2a	NET PATIENT SERVICE REVENUE	621110	27,600,065	27,600,065
b	MEAL TICKETS	722210	64,319	64,319
c	OTHER REVENUE	900099	118,272	118,272
d	PHARMACY REVENUE	446110	402,955	402,955
e
f	All other program service revenue.
g Total.Add lines 2a–2f.....			28,185,611

3 Investment income (including dividends, interest, and othersimilar amounts) ..........			19,138			19,138
4 Income from investment of tax-exempt bond proceeds			0
5 Royalties...........			0
		(ii) Personal	(i) Real
6a	Gross rents		53,426
b	Less: rental expenses
c	Rental income or (loss)	0	53,426
d	Net rental income or (loss)......			53,426			53,426
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory	1,573
b	Less: cost or other basis and sales expenses
c	Gain or (loss)	1,573
d	Net gain or (loss).....			1,573			1,573
8a	Gross income from fundraising events (not including $ 5,899of contributions reported on line 1c). See Part IV, line 18 ....
	a		11,491
b	Less: direct expenses ...b		8,119
c	Net income or (loss) from fundraising events..			3,372			3,372
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities..			0
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..			0
Business Code			Miscellaneous Revenue
11a	INCOME FROM EQUITY INVESTEE		900099	27,868			27,868
b
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......			27,868
12	Total revenue. See Instructions......			28,707,961	28,185,611		105,377

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21	4,132	4,132
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	2,000	2,000
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 ....	942,589	799,524	143,065
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	53,528	53,528
7	Other salaries and wages	12,184,060	11,431,511	752,549
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	223,333	210,775	12,558
9	Other employee benefits .......	1,895,729	1,776,373	119,356
10	Payroll taxes ...........	692,097	645,614	46,483
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	4,969		4,969
c	Accounting ...........	58,500		58,500
d	Lobbying ...........	0
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	4,252,532	2,751,081	1,501,451
12	Advertising and promotion ....	7,413		7,413
13	Office expenses .......	1,290,959	989,327	301,632
14	Information technology ......	0
15	Royalties ..	0
16	Occupancy ...........	567,487	502,965	64,522
17	Travel ............	100,748	63,828	36,920
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .	0
19	Conferences, conventions, and meetings ....	17,498	15,224	2,274
20	Interest ...........	107,185	90,423	16,762
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization ..	1,395,087	1,176,913	218,174
23	Insurance ...	433,713	403,402	30,311
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	MEDICAL SUPPLIES & DRUGS	2,468,702	2,468,702
b	BAD DEBT	1,537,642	1,537,642
c	LICENSES, DUES, SUBSCRIPTIONS	70,514	47,657	22,857
d
e	All other expenses
25	Total functional expenses. Add lines 1 through 24e	28,310,417	24,970,621	3,339,796	0
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 if following SOP 98-2 (ASC 958-720).

1	Cash–non-interest-bearing ........			112,445	1	898,008
2	Savings and temporary cash investments .........			5,338,346	2	5,562,296
3	Pledges and grants receivable, net ......			0	3	0
4	Accounts receivable, net .............			3,257,797	4	3,869,348
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L
				19,685	5	4,924
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
				0	6	0
7	Notes and loans receivable, net ....			0	7	0
8	Inventories for sale or use ........			664,353	8	633,087
9	Prepaid expenses and deferred charges ......			330,535	9	320,145
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	40,422,466
b	Less: accumulated depreciation	10b	35,542,644	6,124,798	10c	4,879,822
11	Investments—publicly traded securities .			0	11	0
12	Investments—other securities. See Part IV, line 11 .....			23,473	12	23,473
13	Investments—program-related. See Part IV, line 11 ..			0	13	0
14	Intangible assets ...............			24,998	14	12,494
15	Other assets. See Part IV, line 11 ...........			1,710,927	15	1,738,917
16	Total assets. Add lines 1 through 15 (must equal line 34)...			17,607,357	16	17,942,514

17	Accounts payable and accrued expenses .....	3,458,863	17	2,944,864
18	Grants payable ...	0	18	0
19	Deferred revenue .........	0	19	0
20	Tax-exempt bond liabilities .........	3,518,749	20	3,344,066
21	Escrow or custodial account liability. Complete Part IV of Schedule D	0	21	0
22	Loans and other 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 ..	584,222	23	447,449
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	0	25	642,404
26	Total liabilities. Add lines 17 through 25..	7,561,834	26	7,378,783

	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets	9,814,111	27	10,338,587
28	Temporarily restricted net assets ...........	12,883	28	32,856
29	Permanently restricted net assets	218,529	29	192,288
	Organizations that do not follow SFAS 117 (ASC 958), check here 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 ...........	10,045,523	33	10,563,731
34	Total liabilities and net assets/fund balances ........	17,607,357	34	17,942,514