2019-01-14T13:53:29-06:00 2018-02-28 111986323 MARCUM LLP 185 ASYLUM STREET HARTFORD CT 06103 990 2017-03-01 060655139 SILVER HILL HOSPITAL INC SILV 2039661380 208 VALLEY ROAD NEW CANAAN CT 06840 DENNIS DOLAN CFO 2039661380 2019-01-10 1 DOUGLAS FARRINGTON P00370668 8607600600 47.19.127.190 2019-01-10 13:19:50 ES P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 DD44AF68ECC090A8110D92EA04805F7936D9C986 2017 2019-02-21 02:37:17Z PETER ORTHWEIN 208 VALLEY ROAD NEW CANAAN CT 06840 47061661 0 X WWW.SILVERHILLHOSPITAL.ORG X 1934 CT THE MISSION OF SILVER HILL HOSPITAL IS TO PROVIDE OUR PATIENTS WITH THE BEST AVAILABLE TREATMENT OF MENTAL ILLNESS AND ADDICTION; AND TO OFFER CONTINUING SUPPORT, COUNSELING AND EDUCATION TO OUR PATIENTS AND FAMILIES IN EVERY PHASE OF ILLNESS AND RECOVERY. 18 17 410 250 -107983 -107807 3324071 2010014 41596630 41718721 383244 569754 -1192112 -185345 44111833 44113144 81650 25500 0 0 25341956 27054139 0 0 613212 14333474 15316503 39757080 42396142 4354753 1717002 65132411 68443375 11709333 12415127 53423078 56028248 X THE MISSION OF SILVER HILL HOSPITAL IS TO PROVIDE OUR PATIENTS WITH THE BEST AVAILABLE TREATMENT OF MENTAL ILLNESS AND ADDICTION; AND TO OFFER CONTINUING SUPPORT, COUNSELING AND EDUCATION TO OUR PATIENTS AND THEIR FAMILIES IN EVERY PHASE OF ILLNESS AND RECOVERY. 0 0 16422549 15356358 INPATIENT TREATMENT IS THE MOST INTENSIVE FORM OF CARE, INDICATED FOR A PHASE OF ILLNESS THAT REQUIRES A GREAT DEAL OF NURSING AND MEDICAL INTERVENTION. BECAUSE PATIENTS ARE USUALLY ACUTELY ILL DURING THIS PHASE OF CARE, OUR INPATIENT TREATMENT PLANS EMPHASIZE DIAGNOSTIC ASSESSMENT, SYMPTOM REDUCTION, AND STABILIZATION. THE HOSPITAL TREATED APPROXIMATELY 1,273 INPATIENTS DURING FISCAL YEAR 2018. 16613173 25500 24788628 SILVER HILL HOSPITAL'S TRANSITIONAL LIVING PROGRAMS PROVIDE HIGHLY STRUCTURED INTENSIVE TREATMENT FOR PATIENTS WHO ARE READY FOR MORE PSYCHOLOGICAL AND BEHAVIORAL INTERVENTIONS. SET IN RESIDENTIAL, HOME-LIKE SETTINGS, THE TRANSITIONAL PROGRAMS HELP PATIENTS CONTINUE THEIR RECOVERY PROCESS UNTIL THEY ARE READY TO RETURN HOME FOR FURTHER COMMUNITY-BASED TREATMENTS. PATIENTS FOCUS ON DEVELOPING A PSYCHOLOGICAL UNDERSTANDING OF THEIR ILLNESS, OBTAINING INFORMATION ABOUT THEIR ILLNESS, AND DEVELOPING NEW BEHAVIORAL SKILLS TO MANAGE THEIR RECOVERY PROCESS. THE HOSPITAL TREATED APPROXIMATELY 729 TRANSITIONAL LIVING PATIENTS DURING FISCAL YEAR 2018. 1151389 1670348 INTENSIVE OUTPATIENT PROGRAMS (IOPS) TYPICALLY MEET FOR THREE HOURS A DAY, THREE DAYS PER WEEK. THE HOSPITAL PROVIDES TWO DIALECTICAL BEHAVIOR THERAPY IOPS FOR PATIENTS EXPERIENCING DIFFICULTY REGULATING INTENSE EMOTIONS, IMPULSIVITY AND HARMFUL BEHAVIORS. THESE PROGRAMS TEACH PATIENTS THE CORE DBT SKILLS OF MINDFULNESS, EMOTION REGULATION, INTERPERSONAL EFFECTIVENESS SKILLS AND DISTRESS TOLERANCE. THE HOSPITAL ALSO PROVIDES A WOMEN'S DBT AND SAFE RELATIONSHIPS IOP FOR WOMEN WHO STRUGGLE WITH ADDICTION TO LEARN SAFE COPING SKILLS TO MAINTAIN SOBRIETY, AS WELL AS TO EXPLORE UNDERLYING INTERPERSONAL ISSUES INCLUDING RELATIONSHIP DIFFICULTIES, ABUSE, CODEPENDENCY AND BOUNDARIES. IN ADDITION, THE HOSPITAL PROVIDES AN ADDICTION/DUAL DIAGNOSIS IOP WHICH IS APPROPRIATE FOR PATIENTS DIAGNOSED WITH EITHER AN ADDICTION AND/OR CO-OCCURING DISORDER. GROUPS INCLUDE RELAPSE PREVENTION, FAMILY DISEASE AND RELAPSE WARNING SIGNS, UNDERSTANDING EMOTIONS, AND SELF-ESTEEM. THIS PROGRAM ALSO TEACHES PATIENTS DIALECTICAL BEHAVIOR THERAPY SKILLS SUCH AS DISTRESS TOLERANCE. THE HOSPITAL OFFERS A SIX-WEEK OUTPATIENT ADDICTION PROGRAM TO HELP THOSE WHO STRUGGLE WITH ADDICTION TO BREAK THE CYCLE OF RELAPSE AND MAINTAIN THEIR SOBRIETY. 34187111 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 193 0 1 410 1 1 1 0 0 0 0 1 1 0 0 0 0 X 18 17 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 CT NY X HEIDI A LEATHERMAN 2038012268 208 VALLEY ROAD NEW CANAAN CT 06840 PETER ORTHWEIN CHAIRMAN 5.00 X X 0 0 0 DEANN E MURPHY CHAIR EMERITUS & DIRECTOR 2.00 X 0 0 0 WARD F CLEARY ESQ CHAIR EMERITUS & DIRECTOR 1.00 X 0 0 0 RICHARD GANNON TREASURER & DIRECTOR 1.00 X X 0 0 0 SPERRY DECEW ESQ DIRECTOR 1.00 X 0 0 0 LINDA AUTORE SECRETARY & DIRECTOR 1.00 X X 0 0 0 RICHARD CANNING DIRECTOR 1.00 X 0 0 0 FREDERICK FEINER MD DIRECTOR 1.00 X 0 0 0 HANK J HARTONG JR DIRECTOR 1.00 X 0 0 0 THEODORE HERMAN DIRECTOR 1.00 X 0 0 0 TODD HOLLANDER DIRECTOR 1.00 X 0 0 0 DAVID HUNT DIRECTOR 1.00 X 0 0 0 CLAUDETTE H KUNKES PHD DIRECTOR 1.00 X 0 0 0 PAUL LAMBDIN DIRECTOR 1.00 X 0 0 0 LANCE LUNDBERG DIRECTOR 1.00 X 0 0 0 JIM PERAKIS DIRECTOR 1.00 X 0 0 0 CHERYL WIESENFELD DIRECTOR 1.00 X 0 0 0 SIGURD H ACKERMAN MD PRES/MED DIR TO 8/17 & PRES EMERITUS FROM 9/17 40.00 X X 600253 0 41912 ERIC D COLLINS MD PHYSICIAN-IN-CHIEF 40.00 X X 401505 0 35535 ELIZABETH E MOORE COO (THROUGH 11/3/17) 40.00 X X 406734 0 30534 JOHN SANTOPIETRO MD PRESIDENT & MEDICAL DIRECTOR 40.00 X X 237977 0 11423 DENNIS DOLAN CHIEF FINANCIAL OFFICER 40.00 X 59868 0 2087 HOWARD WEINER MD PHYSICIAN 40.00 X 267769 0 24465 ANRI KISSILENKO MD PHYSICIAN 40.00 X 238448 0 47082 MARK CERBONE MD PHYSICIAN 40.00 X 269413 0 13250 ROCCO MAROTTA MD PHYSICIAN 40.00 X 231517 0 39985 SARAH NIEGO MD PHYSICIAN 40.00 X 255725 0 3038 2969209 0 249311 31 0 1 0 UNIDINE ONE GATEWAY CENTER SUITE 751 NEWTON MA 02458 FOOD SERVICES 1691017 TURLINGTON ARCHITECTS 244 MAPLE STREET NEW HAVEN CT 06511 ARCHITECT 659879 PHARAMACY & THERAPEUTICS CONS 300 CHURCH STREET WALLINGFORD CT 06492 PHARMACY MANAGEMENT 508606 PAC GROUP LLC 126 SOUTH MAIN STREET SUITE 200 TORRINGTON CT 06790 GENERAL CONTRACTOR 415956 YALE NEW HAVEN HEALTH - GREENWICH HOSPIT 5 PERRYRIDGE RD GREENWICH CT 06830 LAB SERVICES 286710 18 924152 1085862 60239 2010014 TRANSITIONAL LIVING PROGRAM 623000 24703182 24703182 INPATIENT PROGRAM 623000 15345191 15345191 INTENSIVE OUTPATIENT SERVICES 623000 1670348 1670348 41718721 508739 508739 146690 225118 -78428 -78428 -107983 29555 2342000 2280985 61015 61015 61015 128455 924152 424158 -295703 -295703 23098 18256 4842 4842 GUEST MEALS 900099 86349 86349 TUTORING 900099 50646 50646 WELLNESS 900099 33517 33517 13432 13432 183944 44113144 41816316 -107983 394797 X 25500 25500 2212291 1326821 763932 121538 19950277 18010693 1616946 322638 774229 617936 148558 7735 2687502 2203424 435157 48921 1429840 1212340 198200 19300 153513 67833 85680 546103 109717 436386 103904 103904 30000 30000 82546 82546 4709639 4136323 563182 10134 837583 817449 15337 4797 1467691 1216130 203689 47872 201742 167543 30203 3996 994658 639818 351392 3448 221463 173929 42385 5149 63082 27996 35086 17396 17396 2827102 2453980 368742 4380 1054388 1054388 ASSET IMPAIRMENT 380050 380050 DRUGS 312965 312965 BAD DEBT EXPENSE 140913 140913 1171765 286664 871797 13304 42396142 34187111 7595819 613212 1900 1900 5544794 4623532 1459757 1290926 3145909 2906557 95589 97995 1584691 616063 73552335 29555785 39931202 43996550 12412219 14129863 956350 779989 65132411 68443375 7612409 3347249 3875758 3763658 221166 5304220 11709333 12415127 X 49946047 52432631 3264031 3382617 213000 213000 53423078 56028248 65132411 68443375 1717002 888168 0 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 30000 30000 0 PART II-B, LINE 1: HIRED A LOBBYIST CONSULTANT TO REPRESENT THE HOSPITAL AGAINST THE PROPOSED REPEAL OF PROPERTY TAX EXEMPTION AT THE TOWN LEVEL. 237557 8002 245559 213000 24557 237557 213000 213000 213000 6903 -6903 213000 213000 1690 -1690 213000 0.87000 0.13000 0 0 1766706 1766706 46792815 19515364 27277451 11101335 7041973 4059362 13891479 2998448 10893031 43996550 CAPITAL LEASES 293696 DUE TO PATIENTS AND THIRD PARTIES 1779325 PROFESSIONAL LIABILITY RESERVE 1626776 OTHER CURRENT LIABILITIES 1604423 5304220 X 45424867 888168 -82546 805622 44619245 -506101 -506101 44113144 42819697 506101 506101 42313596 82546 82546 42396142 PART V, LINE 4: DONORS HAVE STIPULTED THAT ANY INCOME FROM THE ENDOWMENT FUNDS IS TO BE USED FOR ADOLESCENT AND CHEMICAL DEPENDENCY PROGRAMS. PART X, LINE 2: THE HOSPITAL IS QUALIFIED AS A TAX-EXEMPT ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE CODE), AND AS SUCH, NO PROVISION FOR INCOME TAXES HAS BEEN RECORDED. THE INTERNAL REVENUE SERVICE INFORMED THE HOSPITAL BY A LETTER DATED JUNE 23, 1937 THAT THE HOSPITAL'S OPERATIONS ARE DESIGNED IN ACCORDANCE WITH SUCH SECTION OF THE CODE. CERTAIN TRANSACTIONS COULD BE DEEMED "UNRELATED BUSINESS INCOME AND WOULD RESULT IN A TAX LIABILITY. MANAGEMENT REVIEWS TRANSACTIONS TO ESTIMATE POTENTIAL TAX LIABILITIES. THE HOSPITAL RECOGNIZES INCOME TAX POSITIONS WHEN IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINABLE BASED ON THE MERITS OF THE POSITION. MANAGEMENT HAS CONCLUDED THAT THERE ARE NO UNCERTAIN TAX POSITIONS THAT NEEDED TO BE RECORDED AT FEBRUARY 28, 2018 AND 2017. THE HOSPITAL RECOGNIZES INTEREST AND/OR PENALTIES RELATED TO INCOME TAX MATTERS WITHIN INTEREST. AS OF FEBRUARY 28, 2018 AND 2017, THE HOSPITAL DID NOT RECORD ANY PENALTIES OR INTEREST ASSOCIATED WITH UNCERTAIN TAX POSITIONS. THE HOSPITAL'S PRIOR THREE TAX YEARS ARE OPEN AND SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. THE HOSPITAL IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. PART XI, LINE 2D - OTHER ADJUSTMENTS: INVESTMENT EXPENSES -82,546. PART XI, LINE 4B - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES -295,703. GIFT SHOP COGS -18,256. RENTAL EXPENSES -225,118. REVENUE / EXPENSE RECLASS 32,976. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES 295,703. GIFT SHOP COGS 18,256. RENTAL EXPENSES 225,118. REVENUE / EXPENSE RECLASS -32,976. GALA FUNDRAISER 1052607 924152 128455 146475 48786 228897 1052607 924152 128455 146475 48786 228897 424158 -295703 1 1 1 X 600.000000000000 1 X 900.000000000000 0 1 0 0 690400 690400 690400 690400 0 0.00000 139195 225 138970 0.00330 17459 17459 0.00040 16736901 15115185 1621716 0.03840 25500 25500 0.00060 16919055 15115410 1803645 0.04270 17609455 15805810 1803645 0.04270 1 109109 0 256478 70021 186457 X 1 1 1 1 SILVER HILL HOSPITAL 208 VALLEY ROAD NEW CANAAN CT 06840 WWW.SILVERHILLHOSPITAL.ORG H-0006 X SILVER HILL HOSPITAL 1 0 0 1 X X X X X X X X X 17 1 0 0 1 X WWW.SILVERHILLHOSPITAL.ORG 1 17 1 WWW.SILVERHILLHOSPITAL.ORG 0 1 X 600.000000000000 900.000000000000 X X 1 1 X 1 X WWW.SILVERHILLHOSPITAL.ORG X WWW.SILVERHILLHOSPITAL.ORG X WWW.SILVERHILLHOSPITAL.ORG X X X X 1 X 0 1 X 0 0 SILVER HILL HOSPITAL PART V, SECTION B, LINE 5: COMMUNITY ENGAGEMENT AND FEEDBACK WERE AN INTEGRAL PART OF THE CHNA PROCESS. SILVER HILL HOSPITAL SOUGHT COMMUNITY INPUT THROUGH KEY INFORMANT INTERVIEWS WITH COMMUNITY LEADERS AND PARTNERS. PUBLIC HEALTH AND HEALTH CARE PROFESSIONALS AS WELL AS LEADERS AND REPRESENTATIVES OF NON-PROFIT AND COMMUNITY-BASED ORGANIZATIONS SHARED KNOWLEDGE ABOUT MENTAL HEALTH AND SUBSTANCE ABUSE AND PROVIDED INSIGHT ON THE COMMUNITY, INCLUDING UNDERSERVED POPULATIONS. SEE APPENDIX B OF THE COMMUNITY NEEDS ASSESSMENT FOR A LIST OF KEY INFORMANTS. SILVER HILL HOSPITAL PART V, SECTION B, LINE 11: THE HOSPITAL IS ADDRESSING SUBSTANCE ABUSE ISSUES, WITH A FOCUS ON ALCOHOL ABUSE, UNDERAGE DRINKING, MARIJUANA USE, AND MISUSE OF PRESCRIPTION MEDICATION, AS WELL AS MENTAL HEALTH ISSUES, WITH A FOCUS ON ANXIETY, DEPRESSION, SUICIDE RISK AND THE EFFECTS OF TRAUMA, THROUGH: (1) ITS WORK WITH COMMUNITY ORGANIZATIONS TO PROVIDE EDUCATION EVENTS (2) PARTICIPATION IN THE DIVERSIONARY PROGRAMS FOR AT RISK YOUTH (3) PARTICIPATION IN COMMUNITY FORUMS FOR SUICIDE PREVENTION (4) TRAININGS ON THE ADMINISTRATION OF NARCAN AND FREE NARCAN TO THOSE TRAINED IN ITS USE AND (5) THROUGH ITS EXISTING PROGRAMS FOR INPATIENTS, RESIDENTIAL AND OUTPATIENT TREATMENT.THE HOSPITAL HAS IDENTIFIED A LACK OF MENTAL HEALTH RESOURCES/SERVICES FOR CERTAIN POPULATIONS, SUCH AS TEENS, AS WELL AS A LACK OF SUPPORT FOR FINDING RESOURCES AND NAVIGATING THE MENTAL HEALTH SYSTEM. THEY INTRODUCED A FAMILY RESOURCE PROGRAM IN ORDER TO PROVIDE SUPPORT IN NAVIGATING THE MENTAL HEALTH SYSTEM. IN ADDITION, THE HOSPITAL EXPANDED ITS RESIDENTIAL EATING DISORDERS PROGRAM TO INCLUDE ADOLESCENT PATIENTS. SILVER HILL HOSPITAL PART V, SECTION B, LINE 13H: SILVER HILL HOSPITAL, INC. OFFERS FINANCIAL ASSISTANCE, IN THE FORM OF REDUCED RATES, TO QUALIFYING PATIENTS RECEIVING EMERGENCY OR MEDICALLY NECESSARY SERVICES (I.E. INPATIENT LEVEL OF CARE). THE POLICY APPLIES TO PATIENTS THAT HAVE NO INSURANCE OR HAVE EXHAUSTED THEIR INSURANCE BENEFITS, AND HAVE INCOME OF LESS THAN 300% OF THE FEDERAL POVERTY GUIDELINES. COINSURANCE, COPAYMENTS AND DEDUCTIBLES ARE EXCLUDED FROM THE POLICY.THE HOSPITAL ALSO OFFERS SCHOLARSHIPS TO PATIENTS RECEIVING TREATMENT IN ITS TRANSITIONAL LIVING PROGRAMS. TRANSITIONAL LIVING PATIENTS ARE ELIGIBLE FOR DISCOUNTED OR FREE CARE IF THEY ARE CLINICALLY APPROPRIATE AND MOTIVATED FOR TREATMENT AND HAVE INCOME LEVELS EQUAL TO OR LESS THAN 900% OF THE FEDERAL POVERTY GUIDELINES. SILVER HILL HOSPITAL PART V, SECTION B, LINE 16J: THE HOSPITAL MAINTAINS A FORMAL, WRITTEN SCHOLARSHIP POLICY FOR ITS TRANSITIONAL LIVING PROGRAM. THE POLICY IS AVAILABLE UPON REQUEST. PATIENTS WHO DO NOT HAVE THE FINANCIAL ABILITY TO PAY FOR SERVICES, MAY APPLY FOR SCHOLARSHIPS ASSISTANCE UPON ADMISSION INTO THE PROGRAM. PART I, LINE 3C: THE HOSPITAL USED A FPG OF 300% AS A FACTOR FOR DETERMINING ELIGIBILITY FOR PROVIDING DISCOUNTED CARE FOR MEDICALLY NECESSARY SERVICES. MEDICALLY NECESSARY SERVICES ARE DEFINED BY THE HOSPITAL AS INPATIENT SERVICES.THE HOSPITAL USED A FPG OF 600% AS A FACTOR FOR DETERMINING ELIGIBILITY FOR PROVIDING FREE CARE FOR TRANSITIONAL LIVING SERVICES AND A FPG OF 900% FOR DETERMINING ELIGIBILITY FOR PROVIDING DISCOUNTED CARE FOR TRANSITIONAL LIVING SERVICES. PART I, LINE 6A: DURING FY 2018, THE HOSPITAL WAS NOT REQUIRED TO FILE A COMMUNITY BENEFIT REPORT WITH THE STATE OF CONNECTICUT. PART I, LINE 7: A COST TO CHARGE RATIO, DERIVED FROM WORKSHEET 2 RATIO OF PATIENT CARE COST TO CHARGES, WAS USED TO DETERMINE FINANCE ASSISTANCE COSTS REPORTED. A COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 WAS USED TO DETERMINE THE AMOUNT OF INPATIENT CARE THAT WAS SUBSIDIZED IN FISCAL 2018. ALL OTHER EXPENSES REPORTED ARE ACTUAL COSTS. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 140,913. PART III, LINE 2: BAD DEBT EXPENSE IS ESTIMATED BASED ON HISTORICAL AND EXPECTED WRITE-OFFS AND NET COLLECTIONS, AS WELL AS AGING STATUS. A COST TO CHARGE RATIO FROM WORKSHEET 2 WAS APPLIED TO BAD DEBT EXPENSE REPORTED IN THE AUDITED FINANCIAL STATEMENTS IN ORDER TO DETERMINE THE BAD DEBT EXPENSE REPORTED ON PART III, LINE 2. PART III, LINE 4: EXCERPT FROM THE AUDITED FINANCIAL STATEMENT, FOOTNOTE 2 - NET PATIENT SERVICE REVENUE AND ACCOUNTS RECEIVABLE; AUDITED FINANCIAL STATEMENTS PAGE 17.PATIENT SERVICE REVENUE, NET OF CONTRACTUAL ALLOWANCES, IS REDUCED BY THE PROVISION FOR BAD DEBTS, AND PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. THESE AMOUNTS ARE BASED ON HISTORICAL AND EXPECTED WRITE-OFFS AND NET COLLECTIONS AS WELL AS AGING STATUS. BASED ON HISTORICAL EXPERIENCE, A PORTION OF THE HOSPITAL'S SELF-PAY PATIENTS WHO DO NOT QUALIFY FOR CHARITY CARE WILL BE UNABLE OR UNWILLING TO PAY FOR SERVICES PROVIDED. THUS, THE HOSPITAL RECORDS A PROVISION FOR BAD DEBTS RELATED TO THESE PATIENTS IN THE PERIOD THE SERVICES ARE PROVIDED. THE HOSPITAL WROTE OFF $266,920 AND $284,632 IN BAD DEBTS, NET OF RECOVERIES, IN FISCAL YEARS 2018 AND 2017, RESPECTIVELY. PART III, LINE 8: N/A PART III, LINE 9B: THE HOSPITAL'S COLLECTION POLICY STATES THE FOLLOWING: PATIENT ACCOUNTS WILL WORK WITH PATIENTS THAT QUALIFY FOR FINANCIAL ASSISTANCE TO DEVELOP A REASONABLE BUDGET/PAYMENT PLAN. DELINQUENT SELF-PAY BALANCES FOR PATIENTS THAT QUALIFY FOR FINANCIAL ASSISTANCE MAY BE SENT TO OUTSIDE COLLECTION AGENCIES; HOWEVER THE HOSPITAL WILL NOT PURSUE EXTRAORDINARY COLLECTION ACTIONS (ECA) AGAINST THESE PATIENTS. PART VI, LINE 2: IN ADDITION TO THE CHNA, THE SILVER HILL HOSPITAL STAFF ASSESSES THE NEED FOR ADDITIONAL PROGRAMMING BASED ON SERVICE AVAILABILITY FOR OUR DISCHARGING PATIENT POPULATION. THE HOSPITAL ALSO RECEIVES INPUT FROM COMMUNITY-BASED CLINICIANS TO IDENTIFY NEEDS WITHIN THE COMMUNITY. PART VI, LINE 3: SOCIAL WORKERS HAVE A COMPREHENSIVE VIEW OF A PATIENT'S FINANCIAL AND SOCIAL SITUATION AND ARE KNOWLEDGEABLE ABOUT THE ELIGIBILITY CRITERIA FOR ENTITLEMENT PROGRAMS. IT IS THE ASSIGNED RESPONSIBILITY OF THE SOCIAL WORKER TO INFORM PATIENTS AND THEIR FAMILIES ABOUT ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS.PATIENTS WHO DO NOT HAVE THE FINANCIAL ABILITY TO PAY FOR SERVICES, ARE EDUCATED ABOUT SILVER HILL HOSPITAL'S FINANCIAL ASSISTANCE AND SCHOLARSHIP PROGRAMS BY A SPECIALLY TRAINED STAFF MEMBER. THE STAFF MEMBER PROVIDES PATIENTS AND THEIR FAMILIES WITH THE FINANCIAL GUIDELINES AND SUPPORTING DOCUMENTATION REQUIRED FOR OBTAINING FINANCIAL ASSISTANCE/ SCHOLARSHIPS. PART VI, LINE 4: APPROXIMATELY 38% OF THE PATIENT POPULATION IS FROM CONNECTICUT, 41% FROM NEW YORK, 21% FROM OTHER AREAS INCLUDING NEW JERSEY AND MASSACHUSETTS. PART VI, LINE 5: SILVER HILL HOSPITAL FURTHERS ITS EXEMPT PURPOSE OF PROMOTING HEALTH OF THE COMMUNITY THROUGH A DIVERSE BOARD OF DIRECTORS WHOSE MEMBERS CONTRIBUTE THROUGH THEIR UNIQUE TALENTS AND RESOURCES TOWARD THE HOSPITAL'S MISSION OF HEALING AND THE CARE OF ITS PATIENTS. PART VI, LINE 6: N/A 1 NEW CANAAN POLICE DEPARTMENT 174 SOUTH AVE NEW CANAAN CT 06840 066002043 N/A 10000 DONATION NEW CANNAAN VOLUNTEER AMBULANCE CORPORATION 182 SOUTH AVE NEW CANAAN CT 06840 237300265 501C(3) 10000 DONATION 2 0 PART I, LINE 2: THE AMOUNTS REPORTED ON SCHEDULE I ARE ASSISTANCE TO SUPPORT THE MISSION OF THE TAX EXEMPT ORGANIZATIONS. X 0 1 X X X X 1 0 0 0 0 0 0 1 0 SIGURD H ACKERMAN MD PRES/MED DIR TO 8/17 & PRES EMERITUS 441060 0 150000 0 9193 0 19875 0 22037 0 642165 0 0 0 ERIC D COLLINS MD PHYSICIAN-IN-CHIEF 338797 0 62192 0 516 0 6625 0 28910 0 437040 0 0 0 ELIZABETH E MOORE COO (THROUGH 11/3/17) 263316 0 75000 0 68418 0 19875 0 10659 0 437268 0 0 0 JOHN SANTOPIETRO MD PRESIDENT & MEDICAL DIRECTOR 150303 0 85000 0 2674 0 0 0 11423 0 249400 0 0 0 HOWARD WEINER MD PHYSICIAN 264170 0 3121 0 478 0 0 0 24465 0 292234 0 0 0 ANRI KISSILENKO MD PHYSICIAN 227186 0 10896 0 366 0 18172 0 28910 0 285530 0 0 0 MARK CERBONE MD PHYSICIAN 256495 0 12095 0 823 0 13250 0 0 0 282663 0 0 0 ROCCO MAROTTA MD PHYSICIAN 219029 0 10319 0 2169 0 11951 0 28034 0 271502 0 0 0 SARAH NIEGO MD PHYSICIAN 249166 0 6317 0 242 0 3013 0 25 0 258763 0 0 0 PART I, LINE 1B THE HOSPITAL GROSSED UP TAXES ON A BONUS PAYMENT PURSUANT TO AN EMPLOYMENT AGREEMENT FOR ONE OFFICER. SEE SCHEDULE O FOR DETAILS REGARDING THE ORGANIZATION'S COMPENSATION "POLICIES AND OVERSIGHT PROCEDURES". PART I, LINE 4A ELIZABETH E. MOORE RECEIVED A SEVERANCE PAYMENT OF $65,471. PART I, LINE 7 THE CHIEF EXECUTIVE OFFICER, CHIEF OPERATING OFFICER, AND PHYSICIAN-IN-CHIEF WERE ELIGIBLE FOR INCENTIVE COMPENSATION BASED ON THE ACHIEVEMENT OF PERFORMANCE GOALS ESTABLISHED AND APPROVED BY THE BOARD OF DIRECTORS. IN CALENDAR YEAR 2017, THE AFOREMENTIONED INDIVIDUALS RECEIVED COMPENSATION FOR ACHIEVEMENT OF INCENTIVE GOALS RELATED TO THE FISCAL YEAR ENDING FEBRUARY 28, 2017. THESE AMOUNTS ARE REPORTED IN SCHEDULE J, PART II, COLUMN (B)(II). X 2 10329 FMV X GALA AUCTION 3 49910 VALUE OF AUCTION ITE 0 1 0 FORM 990, PART VI, SECTION B, LINE 11B REVIEW BY ORGANIZATION THE FORM 990 OF THE ORGANIZATION IS PREPARED BY THE FINANCE DEPARTMENT OF SILVER HILL HOSPITAL BASED ON THE BOOKS AND RECORDS OF THE ORGANIZATION. THE DRAFT RETURN AND ALL SUPPORTING DOCUMENTATION ARE PROVIDED TO THE ORGANIZATION'S INDEPENDENT ACCOUNTANTS FOR REVIEW AND FINAL PREPARATION OF THE RETURN. THE FINAL VERSION OF THE FORM 990 IS THEN REVIEWED BY THE CONTROLLER, CFO, AND PRESIDENT & MEDICAL DIRECTOR. THE FINAL VERSION OF THE FORM 990 IS PROVIDED TO ALL MEMBERS OF THE GOVERNING BODY FOR THEIR REVIEW AND COMMENTS BEFORE FILING THE FORM WITH THE INTERNAL REVENUE SERVICES. FORM 990, PART VI, SECTION B, LINE 12C COMPLIANCE WITH CONFLICT OF INTEREST POLICY THE HOSPITAL REQUIRES THE BOARD OF DIRECTORS AND OFFICERS TO COMPLETE A NOTIFICATION OF COMPLIANCE QUESTIONNAIRE AT THE END OF EACH FISCAL YEAR. THE FINANCE DEPARTMENT REVIEWS THE QUESTIONNAIRES FOR DETERMINATION OF POTENTIAL CONFLICTS OF INTEREST. ANY POTENTIAL CONFLICTS OF INTEREST ARE MADE KNOWN TO THE BOARD FOR RESOLUTION. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION DETERMINATION EACH YEAR, OR WHEN OTHERWISE REQUIRED, THE BOARD OF DIRECTORS APPOINTS A COMPENSATION SUB-COMMITTEE OF INDEPENDENT DIRECTORS TO REVIEW THE COMPENSATION OF THE PRESIDENT AND MEDICAL DIRECTOR, CHIEF OPERATING OFFICER, CHIEF FINANCIAL OFFICER, PHYSICIAN IN CHIEF, AND KEY EMPLOYEES. THE SUB-COMMITTEE REVIEWS THE FORM 990'S OF SIMILAR ORGANIZATIONS AS WELL AS AMERICAN HOSPITAL ASSOCIATION SURVEYS, AND MAKES RECOMMENDATIONS TO THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS. ANY DELIBERATIONS AND DECISIONS OF THE COMPENSATION SUB-COMMITTEE ARE DOCUMENTED IN THE MEETING MINUTES OF THE COMPENSATION SUB COMMITTEE. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS AVAILABILITY THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC ON REQUEST. FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 2,798,062. MANAGEMENT AND GENERAL EXPENSES 563,182. FUNDRAISING EXPENSES 10,134. TOTAL EXPENSES 3,371,378. PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 1,338,261. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,338,261. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.