2019-05-15T07:17:22-05:00 2018-06-30 010494526 BAKER NEWMAN & NOYES LLC 650 ELM STREET SUITE 302 MANCHESTER NH 03101 990 2017-07-01 020222791 Alice Peck Day Memorial Hospital ALIC 6034483121 10 Alice Peck Day Drive Lebanon NH 03766 Susan E Mooney MD MS President & CEO 6034483121 2019-05-13 1 Nicholas E Porto P01310283 8002447444 208.105.168.164 2019-05-13 10:26:38 ED P 98DE52733C2B26E898897C723B4DD0B631253A03 86AD5A998A217BD7885303F5109AB5202568ED7D 2017 2019-02-21 02:37:17Z Susan E Mooney MD MS 10 Alice Peck Day Drive Lebanon NH 03766 71825729 0 X www.alicepeckday.org X 1943 NH Critical Access Hospital 16 8 571 70 0 729 360135 1105059 48706952 70526144 22398 -58871 0 29303 49089485 71601635 40590 41972 0 0 26352582 36709910 0 0 182275 22343930 32554938 48737102 69306820 352383 2294815 53279410 60180132 34015801 38514635 19263609 21665497 X The mission of Alice Peck Day Health Systems is to provide personalized, highest quality, patient-focused healthcare services which are responsive to community needs, promote wellness, and continually improve the quality of healthcare in the community. 0 0 65027551 41972 70526144 Alice Peck Day Memorial Hospital is a community-based critical access hospital operating in Lebanon, NH. The Hospital began as a small cottage hospital in 1932. From its humble beginnings, Alice Peck Day has continually demonstrated its commitment to provide patient-focused health care services which improve the quality of life within its community and promote wellness for all. Alice Peck Day Memorial Hospital is a charitable health care organization which is dedicated to serving its community. This commitment includes granting credit to patients, substantially all of whom are local residents. The Hospital provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than the established rates. Collections are not pursued for amounts determined to qualify as charity care. The Hospital maintains records to identify and monitor the level of charity care it provides. These records include the amount of charges foregone for services and supplies furnished under its charity care policy, the established costs of the services and supplies provided, and equivalent service statistics. For the fiscal year ended June 30, 2018, charity care at a cost of $571,229 was provided to eligible patients. Estimated costs incurred in excess of payment for inpatient and outpatient services for Medicaid patients in fiscal year ended June 30, 2018 were $1,771,848. In addition to the charity care services described above, the Hospital provided a number of other services for which little or no payment was received. These included: the Upper Valley Smiles dental program of free oral health education, screenings, and preventive treatment offered to low-income children in ten local elementary schools; nursing support for community flu clinics; Canaan Elementary School morning activity program; Elder Friends, a program matching volunteers one-on-one with isolated, home-bound seniors; assistance with enrollment into prescription assistance and state health insurance programs and scholarships for health professions workforce training.As a local hospital, Alice Peck Day worked closely with community organizations to address community needs. Organizations that were beneficiaries of hospital staff time, meeting space, cash and/or materials included: Alcoholics Anonymous, American Heart Association GO RED campaign, American Red Cross, Child and Family Services, Daniel Webster Council, Good Neighbor Health Clinic, Grafton County Senior Citizens' Council, Headrest, Lebanon Lunch Friends (free summer lunch program for low-income children), Lebanon Chamber of Commerce, Lebanon School District, Mascoma Savings Bank, Mascoma School District, Richards School in Newport, Turning Point, Upper Valley Music Center, and the Upper Valley Public Health Council. In certain instances, assistance was provided to the community for which no value can be placed. This assistance included leadership in identifying community needs, staff commitment to volunteer for community organizations, advocacy and support for the socially and physically disadvantaged, and support for local public safety organizations. Alice Peck Day considers caring for our community a special responsibility that we are honored to fulfill. Through our many programs, dedicated staff and unwavering commitment to quality care, Alice Peck Day works to exceed these expectations and make a real difference in our community. 65027551 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 1 0 0 0 1 X 99 0 1 571 1 1 1 0 0 0 0 0 0 0 0 0 X 16 8 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X X Todd Roberts 6034483121 10 Alice Peck Day Drive Lebanon NH 03766 X Robert J Bauman Trustee (end 12/17) 1.00 1.00 X 0 0 0 George T Blike Trustee 1.00 40.00 X 0 479654 354998 Claudia C Gibson Trustee 1.00 0.00 X 0 0 0 Anne D MacEwan Trustee 1.00 2.00 X 0 0 0 Mark E Melendy Trustee 1.00 4.00 X 0 0 0 Edward J Merrens Trustee 1.00 40.00 X 0 672063 66216 Tina E Naimie Trustee 1.00 40.00 X 0 252623 21009 Mary M Oseid Trustee 1.00 40.00 X 0 259439 362997 Jennifer Sage Schiffman Trustee 1.00 0.00 X 0 0 0 Roderic O Young Trustee 1.00 40.00 X 0 273470 24181 Michael F Long Chair (end 12/17); Vice Chair (beg 1/18) 2.00 1.00 X X 0 0 0 Rev Dr Guy J D Collins Vice Chair (end 12/17) 2.00 3.00 X X 0 0 0 Brett C Peltzer Treasurer 2.00 2.00 X X 0 0 0 Bruce N Johnstone Treasurer (end 4/18) 2.00 2.00 X X 0 0 0 Brenan Riehl Secretary 2.00 0.00 X X 0 0 0 Martha P Candon Secretary (end 12/17) 2.00 1.00 X X 0 0 0 Susan E Mooney MD MS President & CEO 53.00 8.00 X X 381858 57059 61242 Kathryn M Vargo MD Medical Staff President 30.00 1.00 X X 223173 0 38167 Randall D Lea MD MPH VP & Chief Medical Officer 28.00 1.00 X X 219643 0 35398 Greg W Lange Chair (beg 1/18) 2.00 0.00 X X 0 0 0 Barbra Brown RN Interim CNO (begin 10/17) 60.00 0.00 X 48748 0 0 Timothy Graham MBA FHFMA CPA Interim CFO 40.00 20.00 X 189950 47488 0 J Todd Miller MS VP & COO 32.00 29.00 X 71803 63674 41236 Dale C Vidal MD MS Executive Director, Multi-Specialty Clinic 40.00 0.00 X 518155 0 44261 Paul Sansone MD Pain Management MD 40.00 0.00 X 440252 0 40705 Leonard M Rudolf MD Orthopaedic Surgeon 40.00 0.00 X 503071 0 29361 John P Houde MD Orthopaedic Surgeon 40.00 0.00 X 515354 0 42115 Ivan Tomek MD Orthopaedic Surgeon 40.00 0.00 X 559950 0 57237 3671957 2105470 1219123 37 0 1 0 Upper Valley Neurology 106 Hanover Street Lebanon NH 03766 Neurology Physician Practice Services 3357940 EmCare Physician Services Inc 7032 Collection Center Drive Chicago IL 60693 Emergency Room/ Hospitalist Services 1811932 Conifer Revenue Cycle Solutions LLC PO Box 655025 Dallas TX 75265 Coding Operations 686632 The Chappelle Group LLC 7500 Greenway Center Drive Suite 4 Greenbelt MD 20770 Revenue Cycle/ Financial Services 646361 American Healthcare Services Associates PO Box 945 Traverse MI 49685 Agency/Temp Employee Services 462928 15 77731 1027328 30224 1105059 Patient services 621400 67979275 67979275 NH DSH Payment 962140 3478463 3478463 Other operating 621400 670518 670518 Nutritional services 722210 77901 77901 Provision for Bad Debt 621400 -1680013 -1680013 70526144 69065 69065 29303 0 29303 29303 29303 96158 0 224094 96158 -224094 -127936 -127936 71601635 70526144 0 -29568 X 17500 17500 24472 24472 1283876 632260 651616 28168267 26871893 1185721 110653 622825 610731 9589 2505 4703663 4481097 204238 18328 1931279 1824479 99451 7349 57900 57900 76478 76478 13269171 12468356 783976 16839 85790 85790 1132331 767660 360777 3894 116593 112544 4011 38 1040636 951922 83261 5453 158352 156379 1852 121 974764 891665 77991 5108 1831419 1675290 146532 9597 951421 943776 7175 470 Medical Supplies/Equipm 9290523 9283439 6709 375 Medicaid Enhancement Ta 2175745 2175745 Equipment Rental/Mainte 678351 661023 17133 195 MRI Expenses 425072 425072 290392 52248 236794 1350 69306820 65027551 4096994 182275 657704 1247096 10729206 4698217 67463 158696 8878043 7996791 1214330 1322780 1041417 892831 57544969 31959673 23445990 25585296 5107061 15841735 8500 8500 139333 139333 1990363 2288857 53279410 60180132 7158192 8894447 99676 15805409 15408101 430570 399825 10621630 13712586 34015801 38514635 X 18965454 21030940 264615 415262 33540 219295 19263609 21665497 53279410 60180132 2294815 107073 0 X X 0 1 X 1 1 1 X 0 0 0 0 0 1 11200 0 0 1 4500 15700 0 Part II-B, Line 1: The Organization pays dues to the New Hampshire Hospital Association and the American Hospital Association, a portion of which are attributable to lobbying activities. Also, APD belongs to the 10 Mile CAH Coalition which engaged Strategic Health Resources (SHR) for purposes of furthering lobbying efforts with regards to attempts to eliminate CAH status. The CEO participates in periodic telephone calls with this group in attempts to keep the issue of rural healthcare and the key role that CAHs play in rural healthcare in front of the various legislative delegations. 33230 185160 218390 31845 1385 33230 30268 1577 31845 30883 -615 30268 30452 431 30883 0.00000 1.00000 0.00000 0 0 927577 927577 20165601 12372850 7792751 212775 210856 1919 23069572 19375967 3693605 13169444 13169444 25585296 Medical Liability Payable 513000 Deferred Annuity 29626 Estimated Third-Party Payor Settlements 2448274 Accrued Construction Costs for Building Under Development 10721686 13712586 X Part V, Line 4: The Organization uses the income from its endowment funds for use in operations. Part X, Line 2: Dartmouth-Hitchcock Health (D-HH) serves as the sole corporate member of the following entities: Dartmouth-Hitchcock Clinic and Subsidiaries (DHC), Mary Hitchcock Memorial Hospital and Subsidiaries (MHMH), (DHC and MHMH together are referred to as D-H), The New London Hospital Association and Subsidiaries (NLH), Windsor Hospital Corporation (d/b/a MT. Ascutney Hospital and Health Center) and Subsidiaries (MAHHC), Cheshire Medical Center and Subsidiaries (Cheshire), Alice Peck Day Memorial Hospital (APD), and the Visiting Nurse and Hospice of NH and VT and Subsidiaries (VNH). The "Health System" consists of D-HH, its affiliates and their subsidiaries. The Health System currently operates one tertiary, one community and three acute care (critical access) hospitals in New Hampshire (NH) and Vermont (VT). One facility provides inpatient and outpatient rehabilitation medicine and long-term care. The Health System also operates multiple physician practices, a nursing home and a home health and hospice service. The Health System operates a graduate level program for health professions and is the principal teaching affiliate of the Geisel School of Medicine (Geisel), a component of Dartmouth College. D-HH, MHMH, DHC, NLH, Cheshire, and APD are NH not-for-profit corporations exempt from federal income taxes under Section 501(c)(3) of the Internal Revenue Code (IRC). MAHHC and VNH are VT not-for-profit corporations exempt from federal income taxes under Section 501(c)(3) of the IRC. 1 1 1 X 1 X 275.000000000000 1 1 0 1 1 546099 546099 0.00790 6404183 5206254 1197929 0.01730 6950282 5206254 1744028 0.02520 138188 138188 0.00200 20993 20993 0.00030 5022877 4265909 756968 0.01090 58289 58289 0.00080 5240347 4265909 974438 0.01400 12190629 9472163 2718466 0.03920 7068 7068 0.00010 15203 15203 0.00020 22271 22271 0.00030 1 1696009 100000 21082029 21999557 -917528 X 1 1 1 1 Alice Peck Day Memorial Hospital 10 Alice Peck Day Drive Lebanon NH 03766 www.alicepeckday.org 00016 X X X X Physician Clinics Alice Peck Day Memorial Hospital 1 0 0 1 X X X X X X X X 15 1 1 1 1 X see Part V, Section C X See Part V, Section C X 1 16 1 see Part V, Section C 1 0 1 X 200.000000000000 275.000000000000 X X X X X X 1 1 X X X X 1 X see Part V, Section C X see Part V, Section C X see Part V, Section C X X X X X X X 1 X 0 X X X X 1 X 0 0 Alice Peck Day Memorial Hospital Part V, Section B, Line 5: With a shared Hospital Service Area, Alice Peck Day Memorial Hospital collaborated with Dartmouth-Hitchcock in conducting the 2016 Community Health Needs Assessment. Technical expertise was provided by Community Health Institute, the NH affiliate of JSI, a nation-wide public health management consulting and research organization. Input from the joint hospital service area, in an effort to hear from community residents and key stakeholders was gathered using a multi-pronged strategy: 1) a community survey was completed by 1,566 individuals. These surveys were available through town listings, at primary care clinics, a homeless shelter, free community dinners, senior housing projects and other community locations. 2) An online key stakeholder survey was completed by 69 community leaders and service providers, representing the following sections: Human Service/Social Service, Education/Youth Services, Municipal/County Government, Mental/Behavioral Health, Home Health Care, Primary Health Care, Medical Subspecialty, Public Safety/Fire, Public Health, Community Members, Dental Health Care, Emergency Medical Service and the Business Sector. 3) In an effort to get input and community-level context on health issues that matter to the community, four discussion groups were convened representing a variety of key community sectors: business leaders, teenage mothers, low income families and the United Valley Interfaith Project. Alice Peck Day Memorial Hospital Part V, Section B, Line 6a: Alice Peck Day Memorial HospitalDartmouth-Hitchcock Medical CenterNew London Hospital Valley Regional Hospital Mt. Ascutney Hospital and Health Center Alice Peck Day Memorial Hospital Part V, Section B, Line 6b: Technical assistance for the Hospital's 2015 CHNA was provided by Community Health Institute. Alice Peck Day Memorial Hospital Part V, Section B, Line 11: Please see attached Implementation Plan. Alice Peck Day Memorial Hospital Part V, Section B, Line 13h: Alice Peck Day Memorial Hospital offers financial assistance to patients demonstrating need. In making the need determination, APD participates with and honors the founding principles and guidelines of the New Hampshire Health Access Network (NHHAN). Accordingly, decisions regarding the granting of financial assistance will be based primarily on a patient and their household income and assets. There will be minimal consideration of expenses except when they identify areas for further investigation or incomplete or inaccurate information. The value of a patient's principal residence is not considered in qualifying a patient for in-house assistance. APD requires exhaustion of other payment methodologies, including but not limited to, worker's compensation, veterans benefits, Medicaid, liability insurance, victims of crime, and COBRA. When applicable, proof of determination may be required prior to consideration for financial assistance. Alice Peck Day Memorial Hospital Part V, Section B, Line 16j: Please see Part V, Line 3 for a description of the financial assistance program and the efforts made to publicize and promote the program.Alice Peck Day Memorial Hospital prints and distributes its financial assistance application in Spanish when requested. Part V, Line 7a & 7b: CHNA can be found on the Hospital's website at:https://www.alicepeckday.org/assets/FY2016_APDH_Community_Health_Needs_Assessment.pdf Other websites:www.mtascutneyhospital.org/community-services/community-resources/community-health-needs www.dartmouth-hitchcock.org/documents/pdf/FY16-18%20CHNA.pdf Part V, Line 10a: Implementation Plan can be found at: https://www.alicepeckday.org/assets/APDCommunityHealthNeedsImplementation2017.pdf 7 1 - Neurosurgery Services at APD (NSAPD) 106 Hanover Street Lebanon NH 03766 Neurosurgery Physician Clinic 2 - RAM Center for Community Care 10 Alice Peck Day Drive Lebanon NH 03766 Primary Care Physician Clinic 3 - APD Orthopaedic Clinic 10 Alice Peck Day Drive Lebanon NH 03766 Orthopaedic Physician Clinic 4 - Women's Care Center 10 Alice Peck Day Drive Lebanon NH 03766 OB/GYN Physician Clinic 5 - General Surgery Clinic 10 Alice Peck Day Drive Lebanon NH 03766 General Surgeon Clinic 6 - Pain Management Clinic 10 Alice Peck Day Drive Lebanon NH 03766 Pain Management Clinic 7 - Occuptational Health Services 10 Alice Peck Day Drive Lebanon NH 03766 Occupational Health Physician Clinic Part I, Line 3c: Alice Peck Day provides sliding scale coverage with 100% coverage for those with household income below 200% of the Federal Poverty Limit (FPL) and partial coverage for those with household income between 200% and 275% of FPL. The coverage tiers are maintained on the APD website, and are available from all financial counselors or by mail upon request. Part I, Line 7: The costs of charity care and means-tested programs are calculated using the facility-wide cost to charge ratio as calculated in Worksheet 2. Subsidized health services are calculated using the cost to charge ratios per service area, using a step-down cost allocation methodology consistent with Medicare cost report methodology. Part II, Community Building Activities: Alice Peck Day actively promotes community-based leadership development. Staff members participate in the Lebanon Chamber of Commerce, Mascoma Savings Bank Board of Directors, Foundation for Healthy Communities, the Rural Health Coalition, and the Advocacy Task Force. As an active member of the community, APD works to be proactive concerning disaster readiness. Staff have participated in onsite training for disaster preparedness as well as off-site training with other regional hospitals. Collaborative efforts include all hazard regional training, emergency response training, and a regional mass casualty response program to help facilitate cooperative efforts if such needs arise. Part III, Line 2: Bad debt cost is calculated using a cost to charge ratio using a step-down cost allocation methodology consistent with Medicare cost reporting. In FY18, accounts written off to bad debt included gross charges being written off less any payments received against those charges. Any cash collected on accounts previously written off is included as an offset to bad debt expense as recoveries of bad debt. We estimated the amount of charity care in bad debt expense based on the number of applications for charity care. We believe the amount is minimal based on our extensive efforts to educate our patients and staff about our various payment plans and charity care to ensure that patients who qualify for any of our programs utilize them. Depending on the specific circumstances, a patient may be eligible for charity care, discounted care, time-payment programs, or a combination of the above. Due to these efforts, the amounts written off to bad debt that could qualify as charity care are minimal. Footnote 3 of the audited combined financial statements includes the following to address bad debt: Accounts receivable are reduced by an allowance for estimated uncollectibles. In evaluating the collectibility of accounts receivable, the Health System analyzes past collection history and identifies trends for several categories of self-pay accounts (uninsured, residual balances, pre-collection accounts and charity) to estimate the appropriate allowance percentages in establishing the allowance for bad debt expense. Management performs collection rate look-back analyses on a quarterly basis to evaluate the sufficiency of the allowance for estimated uncollectibles. Throughout the year, after all reasonable collection efforts have been exhausted, the difference between the standard rates and the amounts actually collected, including contractual adjustments and uninsured discounts, will be written off against the allowance for estimated uncollectibles. In addition to the review of the categories of revenue, management monitors the write offs against established allowances as of a point in time to determine the appropriateness of the underlying assumptions used in estimating the allowance for estimated uncollectibles. Part III, Line 3: See narrative for Schedule H, Part III, Line 2 and Line 4. Part III, Line 4: See Footnote 3 on Page 14 of the attached audited financial statements. Part III, Line 8: Medicare allowable costs for the Medicare Cost Report are reported in accordance with CMS guidelines using the cost to charge ratio methodology. Part III, Line 9b: Our bad debts collection policy applies to all patient accounts in a consistent manner. The policy specifically indicates that, after a second statement is sent with no payment received, a patient accounts representative will contact the patient by phone to determine if a financial assistance application or payment plan is appropriate. This is completed to avoid further escalation of past due account(s) if the patient may qualify for full or partial relief under the charity care policy. If the application is successful, then the qualifying balance or balances are classified as charity care and no longer pursued for collections. Once a patient balance is classified as charity care, it is not subject to collection activities. Alice Peck Day is committed to helping our patients obtain quality healthcare, regardless of ability to pay. Our financial assistance programs encourage and enable our patients to make healthcare decisions free of financial barriers. We educate our patients about our programs and provide assistance prior to their receiving services, at registration for services, and during our billing process to ensure that any and all patients in need of assistance are provided with the help they qualify for under APD programs. Brochures and signs are placed in high traffic areas such as the ER and registration. Our staff is trained to identify patients during registration, provide information, and offer assistance in completing the necessary forms. During our billing process, calls are made to patients with outstanding balances. APD staff work with patients to identify problems they are facing in dealing with outstanding balances. Patients are notified again of the many types of financial assistance available for which they may qualify. Programs are explained and assistance is offered, if needed, in completing the applications. Due to this multi-level approach and staff that is trained to identify clients who may need financial assistance, very few qualifying patients reach the point of bad debt. Our collection policies and procedures, in conjunction with our small size, allow our organization to place great emphasis on helping all patients who may be in need to apply for, and obtain, the appropriate level of financial assistance. Schedule H, Part V, Section B, Line 16a-16c: Financial Assistance Policy, Financial Assistance Policy Application, and Plain Languange Summary can be found at: www.alicepeckday.org/patients/financial_services/financial_assistance/ Part VI, Line 2: In addition to completing a comprehensive needs assessment every three years, the organization's Community Health Director serves on the Steering Committee of the Public Health Council of the Upper Valley, one of the State of New Hampshire's 13 regional health networks, which also serves 22 communities in Vermont. The PHC is comprised of community leaders and representatives from multiple community sectors, working together to set regional health priorities, provide guidance to regional public health activities, and ensure coordination of health improvement projects. In 2014, the PHC created the Upper Valley Agenda for Public Health, and the following year, the 2015-2017 Upper Valley Community Health Improvement Plan. This plan will be updated in the summer of 2019 with input from APD's Community Health Director. The Public Health Council provides a "finger on the pulse" of the community, and by serving in a leadership role, Alice Peck Day Memorial Hospital is able to stay abreast of the health care needs of our local service area. Part VI, Line 3: Alice Peck Day believes that quality health care should be available to all, regardless of ability to pay. Our financial assistance programs and staff are dedicated to helping people obtain the care they need. We reach out to our patients in many different ways to ensure that they are aware that help is available and to help guide them through the process. Brochures and signage are posted in high traffic areas such as the emergency room, registration, and the lobby. Registration staff are trained to identify patients who may be in need of financial assistance. Once identified, staff notify the patient that APD has various forms of financial assistance and explain that assistance is available for anyone who might require help or guidance in completing any necessary paperwork. In addition to the above, our billing staff are trained to help identify and offer assistance to anyone who might require financial assistance. Patients with outstanding claims are contacted by our credit coordinator who works with them to clear up balances through the variety of programs we offer. Assistance is also provided in applying for federal/state programs to those who qualify. Specially trained staff guide applicants through the process to ensure forms are filled out correctly, all required documentation is attached, and the applicants understand what they can expect to happen along the way. Part VI, Line 4: Alice Peck Day Memorial Hospital is part of the Lebanon Health Care service area. The Lebanon service area comprises cities and towns in New Hampshire and Vermont. APD's service area in NH comprises 15 towns in addition to the city of Lebanon, including Canaan, Cornish, Croydon, Dorchester, Enfield, Grafton, Grantham, Hanover, Lyme, Newport, Orange, Orford, Piermont, Plainfield and Warren. Vermont towns include East Thetford, Fairlee, Hartford, Hartland, North Hartland, North Thetford, Post Mills, Quechee, Sharon, South Strafford, Strafford, Thetford, Thetford Center, Vershire, West Vershire, West Fairlee, West Hartford, White River Junction and Woodstock.Demographics: Age: According to the 2013 American Community Survey, the population of the APD Service Area is slightly older on average than the New Hampshire and Vermont populations. 15.6% of the service area is over age 65, compared with 14.2% in New Hampshire and 15.2% in Vermont.Income, poverty and unemployment: 9.7% of children in the hospital service area live at or below 100% FPL, with 27.0% living below 200%FPL. The unemployment rate of 6.8% for the region is equal to the statewide rate for Vermont, and slightly lower than the statewide rate of 7.0% for New Hampshire.Education: A higher proportion of the hospital service area (93.9) have earned at least a high school diploma or equivalent compared to New Hampshire (91.8) and Vermont (91.4) overall.Language: The percent of the hospital service area, ages 5 or higher, who report speaking English "less than very well" is 1.6, compared with a statewide rate of 2.5% in New Hampshire and 1.5% in Vermont. Part VI, Line 5: In addition to initiatives to deliver affordable care to our under and uninsured patients through our Financial Assistance programs, the organization provides a wide variety of no-cost or low-cost programs and services for the community. We work in partnership with local and state agencies, including but not limited to: the Lebanon, Mascoma, Hartford, Hartland and Newport school districts; the Good Neighbor Health Clinic; Grafton County Senior Citizens Council; NH Division of Health and Human Services; NH Oral Health Coalition; Vermont Oral Health Coalition; the Public Health Council of the Upper Valley; and the Vermont Department of Health. Among the free programs and services APD offers in response to demonstrated community need are: cash support and an in-kind donation of space for the Good Neighbor Health Clinic; vouchers for emergency prescription assistance and one-on-one assistance with applying for prescription assistance programs offered through drug companies; cash support to the Grafton County Senior Citizens Council for transportation; cash donations to human service agencies; and administrative support for "Elder Friends," a companionship program for frail, isolated elders in the community who are matched with a volunteer.APD's Community Health Department is well known in the region for Upper Valley Smiles, a unique school-based oral health program for low-income elementary school children enrolled in ten schools across the Upper Valley. The APD dental team visits each school annually, providing classroom oral health education, dental screenings, fluoride varnish, sealants and (in NH only) decay-stopping fluoride treatments and interim therapeutic restorations, all at little or no cost to parents. During fiscal year 2018, the Upper Valley Smiles program of oral health education, dental screenings, preventive treatment, and referrals to dental offices was offered in ten elementary schools. 2,721 children received classroom oral health education, 700 children had a dental screening, 953 children received preventive care (fluoride varnish, sealants, and in NH schools, temporary fillings and decay-stopping fluoride), and 192 children were referred to a dental office for restorative treatment. Part VI, Line 6: Alice Peck Day Memorial Hospital is a critical access hospital located in Lebanon, NH. The Hospital is served by a board of trustees consisting of local citizens active in community activities and organizations. The majority of board members are not employed by the hospital, and include local government and business representatives as well as practicing independent physicians. Despite its small size, APD is committed to giving back to the community to the greatest extent possible. During fiscal year 2018, cash donations were given to organizations to help those in need. Local financial contributions helped support free primary care clinics for the uninsured, provided transportation for the elderly and disabled to receive medical care, and provided local nonprofit organizations with meeting space and refreshments. Alice Peck Day also supported: community flu clinics, the West Central Behavioral Health agency, a free summer lunch program for low-income school-age children in Lebanon public housing sites, emergency prescription drug vouchers for uninsured patients, and a pilot "before school" morning activity program for children in the Canaan Elementary School. To promote health professional education, APD provided tuition reimbursement for students in the Surgical Tech Training Program and hosted a Nurse Residency Program. These initiatives and ongoing efforts continue to address several of the most pressing community needs as identified in our community needs assessment.Alice Peck Day Memorial Hospital became affiliated with Dartmouth-Hitchcock Health, Inc. (D-HH), on March 2, 2016. As a result, the sole corporate member of APD is D-HH. This agreement is intended to improve, integrate, and streamline patient care between the Hospital and D-HH, as well as take advantage of other efficiencies that may be achieved through the affiliation. Part VI, Line 7, Reports Filed With States NH 1 Grafton County Senior Citizens Council PO Box 433 Lebanon NH 03766 237248316 501(c)(3) 12000 0 Support for services that enable seniors to age-in-place Good Neighbor Health Clinic 70 North Main Street White River Junction VT 05001 030346949 501(c)(3) 5000 0 Support for free medical and dental care for patients in need 2 0 Tuition Assistance 12 24472 Part I, Line 2: APD provides support for selected community organizations that address needs identified in the Community Health Needs Assessment and are part of APD's Community Health Improvement plan. For this reporting period, hospital staff identified the Grafton County Senior Citizens Council and Good Neighbor Health Clinic. The annual amount to be contributed by APD to these organizations is approved annually through the annual budget process. APD receives and reviews each year the organizations' published annual reports and also maintains informal contacts throughout the year to monitor the organizations' operations and services. Additionally, the Hospital provides tuition reimbursement for some health professional employees. The employees must have been employed by the Hospital or a related entity for at least one year and be in good standing. X X X X 1 1 0 0 0 0 0 1 0 George T Blike Trustee 0 437202 0 0 0 42452 0 333250 0 21748 0 834652 0 0 Edward J Merrens Trustee 0 637949 0 0 0 34114 0 53885 0 12331 0 738279 0 0 Tina E Naimie Trustee 0 252087 0 0 0 536 0 19147 0 1862 0 273632 0 0 Mary M Oseid Trustee 0 258929 0 0 0 510 0 343760 0 19237 0 622436 0 0 Roderic O Young Trustee 0 187436 0 0 0 86034 0 13044 0 11137 0 297651 0 0 Susan E Mooney MD MS President & CEO 291196 43512 75002 11207 15660 2340 20358 3042 32923 4919 435139 65020 0 0 Kathryn M Vargo MD Medical Staff President 212254 0 10919 0 0 0 4162 0 34005 0 261340 0 0 0 Randall D Lea MD MPH VP & Chief Medical Officer 205046 0 14597 0 0 0 4651 0 30747 0 255041 0 0 0 Barbra Brown RN Interim CNO (begin 10/17) 45500 0 0 0 3248 0 0 0 0 0 48748 0 0 0 Timothy Graham MBA FHFMA CPA Interim CFO 161500 40375 0 0 28450 7113 0 0 0 0 189950 47488 0 0 J Todd Miller MS VP & COO 66787 59226 0 0 5016 4448 6466 5734 15389 13647 93658 83055 0 0 Dale C Vidal MD MS Executive Director, Multi-Specialty 505743 0 12412 0 0 0 5400 0 38861 0 562416 0 0 0 Paul Sansone MD Pain Management MD 440252 0 0 0 0 0 5400 0 35305 0 480957 0 0 0 Leonard M Rudolf MD Orthopaedic Surgeon 503071 0 0 0 0 0 5400 0 23961 0 532432 0 0 0 John P Houde MD Orthopaedic Surgeon 515354 0 0 0 0 0 5400 0 36715 0 557469 0 0 0 Ivan Tomek MD Orthopaedic Surgeon 542450 0 0 0 17500 0 22900 0 34337 0 617187 0 0 0 Part I, Lines 4a-b Roderic Young, who served as a Trustee during the year, received $80,324 in severance payments from Dartmouth-Hitchcock Health, a related organization. The following individuals received Dartmouth-Hitchcock Supplemental Retirement Plan Terms and Conditions: Various individuals listed in Form 990, Part VII and Schedule J, Part II are compensated as full-time employees of Dartmouth-Hitchcock Health, or Mary Hitchcock Memorial Hospital, the sole-corporate member of the Organization and a related organization, respectively. The following individuals participated in and received payments from a supplemental nonqualified deferred retirement plan sponsored by Dartmouth-Hitchcock Health. Amounts reported in Schedule J, Part II, Column C as follows: Edward J. Merrens, MD - $33,700 George Blike - $40,874 Roderic Young - $5,293 Gay Landstrom - $29,011 The following individuals had an actuarial change in pension value during the year reported in Schedule J, Part II, Column C: Edward J. Merrens, MD - $25,145 George Blike - $333,250 Mary Oseid - $343,760 All amounts reported in Column C will be included as part of taxable wages in the employees' Form W-2 when paid out. An eligible employee is a participant in the Dartmouth-Hitchcock retirement plan and/or any prior pension arrangements sponsored by Dartmouth-Hitchcock (including a qualified defined benefit plan) who would be entitled to additional contributions or benefit accruals under the terms of the plans for the plan year, but are limited by IRC Section 401(a)(17) and/or 415. For eligible employees, the employer will pay the eligible employee an amount determined by the employer each year to offset the amount of the reduction in the benefit accrual or contributions as a result of limitations imposed by IRC Sections 401(a)(17) and/or 415. Schedule J, Part II, Column B, Parts (i), (ii), and (iii) represent actual amounts paid to employees by Alice Peck Day Memorial Hospital, APD Health Systems Corp, or Dartmouth-Hitchcock Health. These amounts are reported to employees on their annual Form W-2 as compensation. Columns C and D represent items earned, however, not paid directly to the employee as cash payments during the calendar year. Column C includes retirement benefits as well as any changes in pension actuarial value (if applicable) in a calendar year. Column D represents nontaxable benefits such as the cost of healthcare coverage sponsored by the Organization or a related organization. Part I, Line 7 A portion of compensation to certain employees is at-risk and variable, and payment depends on the quality of job performance. Form 990, Part VII-A, Line 5: During the fiscal year, Alice Peck Day Memorial Hospital had an interim CFO, Timothy Graham. Mr. Graham was compensated through a consulting firm, Healthcare RESQ, LLC, during the calendar year. The total amount paid to Healthcare RESQ, LLC for his services was $201,875. Mr. Graham was directly compensated an additional $35,563 to cover travel expenses. Healthcare RESQ, LLC is unrelated to Alice Peck Day Memorial Hospital and its affiliates. The amounts allocated as specific to the filing organization are broken out in Form 990, Part VII. Beginning in October 2017, Alice Peck Day Memorial Hospital also had an interim CNO, Barbra Brown, who was compensated through a consulting firm called Leaders for Today. Pursuant to IRS instructions, Ms. Brown's 2017 1099-MISC compensation is reported on Schedule J since she was compensated from an unrelated organization for her work with the hospital. A Business Finance Authority of the State of NH 521304598 2010-11-30 12282000 Current Refund Existing Bond 0 0 0 A 2622966 12282000 44932 12237068 2010 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 1 1 TD Banknorth NA 5.000000000000 0 1 0 0 1 A 1 Date Rebate Computation Performed Issuer Name: Business Finance Authority of the State of NH Date the Rebate Computation was Performed: 01/03/2011 Timothy Graham MBA FHFMA CPA Chief Financial Officer 201875 During the fiscal year, Alice Peck Day Memorial Hospital had an interim CFO, Timothy Graham. Mr. Graham was compensated through a consulting firm, Healthcare RESQ, LLC. Mr. Graham is 100% owner of Healthcare RESQ, LLC. The total amount paid to Healthcare RESQ, LLC for his services during calendar year 2017 was $201,875, and Mr. Graham was directly compensated an additional $35,563 to cover travel expenses. These totals represent payment for services to Alice Peck Day Memorial Hospital, Alice Peck Day Lifecare Center, and Alice Peck Day Health Systems, Inc. All transactions were at arm's length. The amounts allocated as specific to the filing organization are broken out in Form 990, Part VII. The total amount paid to Healthcare RESQ, LLC for Mr. Graham's services to the entire APD system has been reported in Schedule L, Part IV, Column (c). 0 X 6 30224 Stock Exchange Price 0 0 1 Part I, Line 32b: The organization uses a third party broker to sell gifts of stock when received. Form 990, Part V, Line 1a & 2a: For administrative purposes, Alice Peck Day Memorial Hospital acts as the common paymaster for both Alice Peck Day Health Systems, Corp. and Alice Peck Day Lifecare Center, Inc. Form 990, Part VI, Section A, line 3 During the fiscal year, Alice Peck Day Memorial Hospital had an interim CFO, Timothy Graham. Mr. Graham was compensated through a consulting firm, Healthcare RESQ, LLC, during the calendar year. The total amount paid to Healthcare RESQ, LLC for his services was $201,875. Mr. Graham was directly compensated an additional $35,563 to cover travel expenses. The amounts allocated as specific to the filing organization are broken out in Form 990, Part VII. The total amounts allocated to each related organization are also codified in Part VII. Form 990, Part VI, Section A, line 6 The Membership of the Corporation shall consist of Dartmouth-Hitchcock Health (D-HH) as the sole member. Form 990, Part VI, Section A, line 7a The Member will retain the reserved power to appoint without limitation one-third of the Trustees (which appointees, before final appointment by Member, will be discussed with the Board Chair and other Trustees selected by the Chair for their input). The D-H/D-HH CEO or designee will serve on the Board ex officio, with full voting rights, and will count toward the one-third membership appointed by Member. Form 990, Part VI, Section A, line 7b The Member will retain the following reserved powers over APD, which, except as otherwise required below, will be exercised by the D-HH Board of Trustees or the D-HH CEO, as determined by the D-HH Board of Trustees: 1. To initiate and/or to approve or disapprove all material governance, programmatic, and financial decisions of the Board of Trustees, including without limitation the elimination or addition of any material health/health care services or programs; 2. To appoint without limitation one-third of the Trustees (which appointees, before final appointment by Member, will be discussed with the Board Chair and other Trustees selected by the Chair for their input). The D-H/D-HH CEO or designee will serve on the Board ex officio, with full voting rights, and will count toward the one-third membership appointed by Member; 3. To ratify those trustee candidates nominated by the Board in accordance with Section 2.04 of the Corporation's bylaws (meaning the ability of Member to approve or disapprove, based on a good faith and reasonableness standard, each trustee candidate nominated by the Board of Trustees and upon such approval, the ability to install such approved candidate to the Board); 4. To remove by a vote of two-thirds of the D-HH Board of Trustees any Trustee if the Member determines in its reasonable good faith discretion that such removal is in the best interests of the D-H System which will include APD and taking into consideration the impact on APD and the community it serves, following prior consultation with the Board Chair; 5. To approve of borrowings (debt) and dispositions of material assets by APD; 6. To approve any key strategic relationship(s) between APD and another organization(s) (key strategic relationships defined as the ownership or contractual participation in a network, system, affiliation, joint venture, alliance or similar arrangement with an organization that is not part of the D-H System or which is not addressed in a Member approved APD strategic plan); 7. To initiate and/or to approve all operating and capital budgets as well as all strategic plans of APD; 8. To approve all policies relating to academic and research programs and affiliations; 9. To allocate the non-donor restricted assets and resources of APD and D-H/D-HH as appropriate to serve the overall best interests of the D-H System (which will include APD), taking into consideration the impact on APD and the community it serves; while Member will retain this reserved power, Member will exercise this reserved power only after consulting with and providing reasonable time and opportunity for the Board of Trustees to provide meaningful input and recommendations which shall be considered in good faith. For one (1) year following the effective date of its bylaws any material reallocation of assets or resources will also require an affirmative vote by a majority of the Board of Trustees. 10. Except as limited by the affiliation agreement, to appoint, evaluate the performance of, and terminate the APD President and CEO, subject to prior consultation with the Board of Trustees and a reasonable time and opportunity for the Board to provide meaningful input and recommendations which shall be considered in good faith. 11. To approve any proposed amendment or repeal of the APD articles of agreement or bylaws which proposed amendment or repeal would (i) impact the powers reserved to Member in its bylaws, or (ii) reasonably be expected to have any material strategic, competitive or financial impact on the D-H System. No change in the provisions of APD's bylaws shall be binding on D-H/D-HH or APD unless such change(s) is/are approved by way of amendment to APD's governing documents approved by Member. 12. To approve the dissolution or liquidation of APD, following such approval by the Board. Form 990, Part VI, Section B, line 11b Management provides a notice that the completed Form 990 is available to the Finance Committee at the May meeting. Management advises the Finance Committee that the completed Form 990 is available on a secure website that requires an assigned user name and password. The Chair of the Finance Committee advises the Financial Committee members to review the Form 990 for content and raise any issues with Board Leadership or Management. The Chair of the Finance Committee advises the Chair of the Board and the full Board that the Form 990 is available for review. That notice is in advance of the filing deadline to enable a detailed and conscientious review by the Board. All questions and concerns are addressed by the Chief Executive Officer and are incorporated into the Form 990 as deemed appropriate. Management files the final Form 990 with the Internal Revenue Service, as required after the above review is concluded. Form 990, Part VI, Section B, line 12c Alice Peck Day has a multi-faceted conflict of interest policy. Members of the Board of Trustees complete conflict of interest questionnaires on an annual basis and any new members complete the questionnaire upon joining the Board. As part of our ongoing monitoring process, our Executive Assistant reviews all Board questionnaires and disclosures to identify any potential conflicts before they arise. In addition, our Executive Assistant attends all Board meetings to ensure that if any conflicts arise, they are handled appropriately. If such conflicts arise, the Organization complies with the New Hampshire and federal requirements for disclosures of such events. The Organization is committed to conducting its business in a manner that is both ethical and legal. As part of this commitment, a standard of conduct form is required of all employees of the organization. This is reviewed with all employees upon hire and on an annual basis thereafter. The standard of conduct covers conflict of interest and other vital matters to ensure all business activity is conducted in a manner that is consistent with the highest standards of honesty, integrity, and fairness. Form 990, Part VI, Section B, line 15 The Human Resources Committee of the Alice Peck Day Memorial Hospital Board of Trustees is responsible for determining the compensation of the Chief Executive Officer/President. The Chief Administrative Officer or her designee provides compensation data of comparable organizations with approximately the same size staff and spending in a location of similar size. The committee determines the appropriate compensation and approves an amount that is then communicated to Human Resources for adjustment. Dartmouth-Hitchcock Health reviews the compensation of the CEO/President in addition to the process described above. The CEO/President is responsible for reviewing the performance of senior management staff. The information is brought to the Human Resource Committee of the Board of Trustees along with a recommendation for the salary of each individual. The compensation is determined through a variety of analysis of salary data and performance. Individual salary increases are then based on overall performance, within budgeted increases for the organization. The Human Resources committee approves the base compensation and salary increase amount. Form 990, Part VI, Section C, line 19 The Organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Form 990, Part VII, Section A, Column D: Dr. Susan E. Mooney is a practicing physician in addition to being the Chief Executive Officer. She worked an average of 61 hours per week, of which a majority of time is spent on executive matters. Approximately 8 hours per month is spent as a physician. Form 990, Part IX, line 11g Physician Service Fees: Program service expenses 7,354,498. Management and general expenses 0. Fundraising expenses 0. Total expenses 7,354,498. Consulting Service Fees: Program service expenses 3,273,978. Management and general expenses 732,560. Fundraising expenses 13,768. Total expenses 4,020,306. Maintenance Service Agreements: Program service expenses 1,839,880. Management and general expenses 51,416. Fundraising expenses 3,071. Total expenses 1,894,367. Form 990, Part XII, Line 2c: The finance committee acts as the audit committee and oversees the audit process for the Alice Peck Day entities. Independent accountants performed the audit for the fiscal year ended 6/30/17. For the fiscal year ended 6/30/18 the Hospital was included in the Dartmouth Hitchcock Health System consolidated audited statements. Form 990, Part XII, Line 3a: Alice Peck Day Memorial Hospital was included in the consolidated audited financial statements of the Dartmouth-Hitchcock Health System. During fiscal year 2018, Mary Hitchcock Memorial Hospital expended federal funding which met the minimum threshold set forth in the single audit act and OMB Circular A-133. Due to the nature of the consolidated financial statements, the audit was performed on the financial information of all organizations, including Alice Peck Day Memorial Hospital. Alice Peck Day Health Systems Corp 10 Alice Peck Day Drive Lebanon NH 03766 020479095 Promote Health NH 501(c)(3) Line 12b, II N/A 0 Alice Peck Day Lifecare Center Inc 10 Alice Peck Day Drive Lebanon NH 03766 020479094 Independent & Assisted Living NH 501(c)(3) Line 10 APD Health Systems 0 Alice Peck Day Realty Corp 10 Alice Peck Day Drive Lebanon NH 03766 020485369 Inactive NH 501(c)(2) APD Health Systems 0 Dartmouth-Hitchcock Health One Medical Center Drive Lebanon NH 03756 264812335 Govern Integrated Health System NH 501(c)(3) Line 7 N/A 0 Dartmouth-Hitchcock Clinic One Medical Center Drive Lebanon NH 03756 222519596 Physician Services NH 501(c)(3) Line 10 Dartmouth-Hitchcock Health 0 Mary Hitchcock Memorial Hospital One Medical Center Drive Lebanon NH 03756 020222140 Hospital NH 501(c)(3) Line 3 Dartmouth-Hitchcock Health 0 The New London Hospital Association Inc 273 County Road New London NH 03257 020222171 Hospital NH 501(c)(3) Line 3 Dartmouth-Hitchcock Health 0 Windsor Hospital Corporation 289 Country Road Windsor VT 05089 030183721 Hospital VT 501(c)(3) Line 3 Dartmouth-Hitchcock Health 0 Cheshire Medical Center 580 Court Street Keene NH 03431 020354549 Hospital NH 501(c)(3) Line 3 Dartmouth-Hitchcock Health 0 OneCare VT ACO LLC 111 Colchester Avenue Burlington VT 05401 455399218 Shared Saving VT N/A Alice Peck Day Health Management Corp 10 Alice Peck Day Drive Lebanon NH 03766 020485370 Inactive NH N/A C 0 Hitchcock Health Connect One Medical Center Drive Lebanon NH 03756 800908979 Telehealth DE N/A C 0 Imaginecare Inc One Medical Center Drive Lebanon NH 03756 813105071 Software Tech NH N/A C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0