2018-01-15T12:09:41-06:00 2017-02-28 111986323 Marcum LLP 53 State Street Boston MA 02109 990 2016-03-01 060655139 Silver Hill Hospital Inc SILV 2039661380 208 Valley Road New Canaan CT 06840 Dennis Dolan cfo 2039661380 2018-01-12 1 DOUGLAS FARRINGTON P00370668 6178075000 2018-01-12 47.19.127.190 2018-01-12 15:22:42 ES P 3447139BC9A15B5A3A12F6ABCC6B1291F2E269E0 8F3D8A7E117716E042E5BC9D47685EF3938B73D4 2016 2021-01-29 14:40:06Z Peter Orthwein 208 Valley Road New Canaan CT 06840 47694688 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. 20 17 404 240 -1253210 -135715 1735934 3324071 40363349 41596630 413695 383244 -220957 -1192112 42292021 44111833 27150 81650 0 0 25039444 25341956 0 0 659307 13732233 14333474 38798827 39757080 3493194 4354753 58734143 65132411 10984697 11709333 47749446 53423078 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 15307691 15166076 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 1,276 INPATIENTS DURING FISCAL YEAR 2017. 15740395 81650 24347992 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 722 TRANSITIONAL LIVING PATIENTS DURING FISCAL YEAR 2017. 1156007 2275302 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 HEALTHY 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 OR DUAL 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. 32204093 1 1 0 0 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 1 1 0 0 0 0 0 0 0 0 1 204 0 404 1 1 1 0 0 0 0 1 1 0 0 0 0 X 20 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 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 0 0 0 Sperry Decew Esq Secretary & Director 1.00 X 0 0 0 Linda Autore Director 1.00 X 0 0 0 Richard Canning Director 1.00 X 0 0 0 Frederick Feiner MD Director 3.00 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 President, Medical Director & Director 40.00 X X 600655 0 42741 Eric D Collins MD Physician-in-Chief & Director 40.00 X X 419346 0 36713 Elizabeth E Moore Chief Operating Officer & Director 40.00 X X 372032 0 31929 Mark Cerbone MD physician 40.00 X 277554 0 13250 John Meyers MD physician 40.00 X 238201 0 5947 Anri Kissilenko MD physician 40.00 X 231879 0 48260 Rocco Marotta MD Physician 40.00 X 231072 0 40563 John Douglas MD Physician 40.00 X 229089 0 16103 2599828 0 235506 31 1 1 0 Unidine One Gateway Center Suite 751 Newton MA 02458 FOOD SERVICES 1687421 Richard Turlington Architects 244 Maple Street New Haven CT 06511 ARCHITECT 1175332 Pharamacy Therapeutics Cons 300 Church Street Wallingford CT 06492 PHARMACY MANAGEMENT 406155 Pac Group llc 126 South Main Street Suite 200 Torrington CT 06790 GENERAL CONTRACTOR 294641 David Tine 56 Green Lane Durham CT 06422 CONSULTANT 216215 9 1047377 2276694 53154 3324071 Transitional Living program 623000 24206143 24206143 Inpatient program 623000 15115185 15115185 Intensive Outpatient services 623000 2275302 2275302 41596630 397197 397197 116179 1278389 -1162210 -1162210 -1253210 91000 1794687 1808640 -13953 -13953 -13953 167800 1047377 481558 -313758 -313758 26339 14268 12071 12071 all other revenue 900099 116959 116959 Guest Meals 900099 82885 3840 79045 Tutoring 900099 71941 71941 271785 44111833 41789370 -1253210 251602 X 81650 81650 1495766 807592 553432 134742 18885264 17029870 1526593 328801 715292 544601 164789 5902 2901207 2418481 424554 58172 1344427 1156266 169950 18211 229221 79551 149670 121793 121793 65540 65540 4817781 4118165 649405 50211 614451 607588 1786 5077 1279215 1080247 169269 29699 158175 131285 23726 3164 1194220 772327 417771 4122 124582 110639 10014 3929 93417 90890 2452 75 17051 17051 2553687 2273867 276385 3435 950491 950491 Miscellaneous 1372020 590966 767287 13767 Bad Debt Expense 431722 431722 Pharmacy 310108 310108 39757080 32204093 6893680 659307 1900 1900 4800237 5544794 39950 1459757 2884200 3145909 97508 95589 1588676 1584691 66689433 26758231 38518499 39931202 9753556 12412219 1049617 956350 58734143 65132411 6796610 7612409 3982243 3875758 205844 221166 10984697 11709333 X 46302472 49946047 1233974 3264031 213000 213000 47749446 53423078 58734143 65132411 4354753 1318879 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED SCHEDULE C PART II-B In FY 2017, the hospital did not engage in any lobbying activities. 213000 24557 237557 213000 213000 213000 6903 -6903 213000 213000 1690 -1690 213000 213000 3158 -3158 213000 0.90000 0.10000 0 0 673731 1092996 1766727 926269 44363280 17811715 27477834 10637263 6797854 3839409 9986 8985908 2148662 6847232 39931202 Employee F.S.A. Payable 204248 Unclaimed Property 16117 Other Personal Services 801 221166 X 46524133 1318879 313757 1632636 44891497 65541 -845205 -779664 44111833 40850501 1590684 1590684 39259817 65541 431722 497263 39757080 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. THERE ARE CERTAIN TRANSACTIONS THAT COULD BE DEEMED "UNRELATED BUSINESS INCOME AND WOULD RESULT IN A TAX LIABILITY. MANAGEMENT REVIEWS TRANSACTONS 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, 2017 and FEBRUARY 29, 2016. Part XI, Line 2d - Other Adjustments: Special event expenses 313,757. Part XI, Line 4b - Other Adjustments: Bad Debt Expense 431,722. Gift Shop COGS -14,268. Realized losses from investment -13,953. Rental expenses -1,278,389. Other Gains 29,683. Part XII, Line 2d - Other Adjustments: Special event expenses 313,757. Gift Shop COGS 14,268. Realized losses from investment 13,953. Rental expenses 1,278,389. Other Gains -29,683. Part XII, Line 4b - Other Adjustments: Bad Debt Expense 431,722. SCHEDULE D, PART V, LINE 4 INTENDED USE OF ENDOWMENT FUNDS DONORS HAVE STIPULATED THAT ANY INCOME FROM THE ENDOWMENT FUNDS IS TO BE USED FOR ADOLESCENT AND CHEMICAL DEPENDENCY PROGRAMS. Gala Fundraiser 1215177 1047377 167800 187325 47630 246603 1215177 1047377 167800 187325 47630 246603 481558 -313758 1 1 1 X 600.000000000000 1 X 900.000000000000 0 1 0 0 769320 769320 769320 769320 0 0.00000 173046 225 172821 0.00430 47336 47336 0.00120 16512253 15115185 1397068 0.03510 80500 80500 0.00200 16813135 15115410 1697725 0.04260 17582455 15884730 1697725 0.04260 1 325997 0 195497 59926 135571 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 16 1 0 0 1 X www.SilverHillHospital.org 1 16 1 www.SilverHillHospital.org 0 1 X 600.000000000000 900.000000000000 X X 1 1 X X X 1 X www.SilverHillHospital.org X www.SilverHillHospital.org X www.SilverHillHospital.org X 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. TRANSITION LIVING PROGRAM SERVICES ARE NOT CONSIDERED AN INPATIENT LEVEL OF CARE. 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: IN ADDITION TO MAINTAINING A FORMAL FINANCIAL ASSISTANCE POLICY FOR INPATIENT CARE, 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 3a, b, c 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 (NON-INPATIENT SERVICES), AND A FPG OF 900% FOR DETERMINING ELIGIBILITY FOR PROVIDING DISCOUNTED CARE FOR TRANSITIONAL LIVING SERVICES (NON-INPATIENT SERVICES). Part I, Line 6a DURING FY 2017, 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 FOR INPATIENT SERVICES WAS USED TO DETERMINE THE AMOUNT OF INPATIENT CARE THAT WAS SUBSIDIZED IN FISCAL 2017. ALL OTHER EXPENSES REPORTED ARE ACTUAL COSTS. Part I, Line 7 Column F TOTAL EXPENSES FROM PART IX, LINE 25 WERE REDUCED BY BAD DEBT EXPENSE OF $431,732 IN CALCULATING TOTAL EXPENSES FOR COLUMN (F). Part II, 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 16.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 $284,632 AND $387,155 IN BAD DEBTS, NET OF RECOVERIES, IN FISCAL YEARS 2017 AND 2016, RESPECTIVELY. 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 III, Line 8 N/A Part VI 2. NEEDS ASSESSMENTIN 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.3. PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE: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.4. COMMUNITY INFORMATION:APPROXIMATELY 39% OF THE PATIENT POPULATION IS FROM CONNECTICUT, 38% FROM NEW YORK, 23% FROM OTHER AREAS INCLUDING NEW JERSEY AND MASSACHUSETTS.5. PROMOTION OF COMMUNITY HEALTH: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. 1 New Canaan Community Foundation 111 Cherry Street New Canaan CT 06840 060970466 501c(3) 50000 Donation New Canaan Police Department 174 South Ave New Canaan CT 06840 066002043 New Canaan 10000 Donation New Cannaan Volunteer Ambulance Corporation 182 South Ave New Canaan CT 06840 237300265 501c(3) 10000 Donation 3 Schedule I, Part I, Line 2 THE AMOUNTS REPORTED ON SCHEDULE I ARE CONTRIBUTIONS TO SUPPORT THE EXEMPT PURPOSE OF THE 501(3) ORGANIZATIONS. THEY DO NOT REPRESENT GRANTS. X 0 1 X X X X 0 0 0 0 0 0 0 1 0 Sigurd H Ackerman MD President, Medical Director & Direct 441462 0 150000 0 9193 0 19875 0 22866 0 643396 0 0 0 Eric D Collins MD Physician-in-Chief & Director 339257 0 79813 0 276 0 6625 0 30088 0 456059 0 0 0 Elizabeth E Moore Chief Operating Officer & Director 294560 0 75000 0 2472 0 19875 0 12054 0 403961 0 0 0 Mark Cerbone MD physician 264261 0 12688 0 605 0 13250 0 0 0 290804 0 0 0 John Meyers MD physician 227626 0 10251 0 324 0 5947 0 0 0 244148 0 0 0 Anri Kissilenko MD physician 220995 0 10560 0 324 0 18172 0 30088 0 280139 0 0 0 Rocco Marotta MD Physician 218932 0 10352 0 1788 0 11951 0 28612 0 271635 0 0 0 John Douglas MD Physician 220851 0 8111 0 127 0 5816 0 10287 0 245192 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 7 THE CHIEF EXECUTIVE OFFICER, CHIEF OPERATING OFFICER, AND PHYSICIAN-IN-CHIEF ARE ELIGIBLE FOR INCENTIVE COMPENSATION BASED ON THE ACHIEVEMENT OF PERFORMANCE GOALS ESTABLISHED AND APPROVED BY THE BOARD OF DIRECTORS. IN CALENDAR YEAR 2016, THE AFOREMENTIONED INDIVIDUALS RECEIVED COMPENSATION FOR ACHIEVEMENT OF INCENTIVE GOALS RELATED TO THE FISCAL YEAR ENDING FEBRUARY 29, 2016. THESE AMOUNTS ARE REPORTED IN SCHEDULE J, PART II, COLUMN (B)(II). contributor 10 Substantial Contributor 2749984 GENERAL CONTRACTOR/CONSTR 0 contributor 33 Substantial Contributor 1175332 Architect 0 contributor 23 Substantial Contributor 290138 Medical Record Software V 0 X 1 25154 Stock Market Value X Gala Auction Items 2 28000 Value of Auction Bid 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, COO, 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 2,648,438. Management and general expenses 649,405. Fundraising expenses 50,211. Total expenses 3,348,054. Other Professional Services: Program service expenses 1,469,727. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,469,727.