2018-06-20T08:15:57-05:00 2017-09-30 020476956 Tyler Simms & St Sauveur CPAs PC 19 Morgan Drive Lebanon NH 03766 990 2016-10-01 030183721 windsor hospital corporation WIND 8026746711 289 County Road Windsor VT 05089 David Sanville CFO 8026746711 2018-06-18 1 W Jay Simms P00435321 6036530044 2018-05-03 216.107.201.226 2018-06-18 15:06:33 ED P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 E125F4664CA59E986E126FDFBB4724C3AED932BF 2016 2018-06-14 16:35:46Z MTASCUTNEY HOSPITAL & HEALTH CENTER David Sanville 289 County Road Windsor VT 05089 52886516 0 X mtascutneyhospital.org X 1933 VT To improve the lives of those we serve. Our activities include providing healthcare. 15 8 550 174 -3029 -3029 1048528 906396 48955981 51135484 1763248 624393 221132 159577 51988889 52825850 0 0 0 0 29253933 30149034 0 0 223218 20352611 20347045 49606544 50496079 2382345 2329771 46763552 50695886 26988956 25152463 19774596 25543423 X Mount Ascutney Hospital and Health Center's mission is to improve the lives of those we serve. 0 0 41020721 51246093 Mt. Ascutney Hospital and Health Center (MAHHC) operates a not-for-profit critical access hospital which provides primary and secondary health care. MAHHC's primary service area includes Windsor, Claremont, Woodstock, Hartland, Springfield, and Brownsville. The hospital provides essential healthcare services including emergency department, med/surg inpatient, and ancillary diagnostic tests, imaging/radiology procedures, and wellness/prevention services. MAHHC staffs a total of 25 acute med/surg beds and 10 acute rehabilitation beds. During the year, there were 1,016 discharges, 1,507 surgeries, 58,953 lab tests, and 11,238 imaging procedures. MAHHC identified access to primary care as a central community need and is committed to providing the physician services of family practice, internal medicine and pediatrics in Windsor and Woodstock. MAHHC provides free care to patients who meet certain criteria. Foregone charges furnished under MAHHC's free care policy amounted to $733,410 in FY17. 41020721 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 62 0 1 550 1 1 1 0 0 0 0 0 0 0 0 0 X 15 8 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X David Sanville 8026746711 289 County Road Windsor VT 05089 John Gilman Trustee 1.00 X 0 0 0 Michael Newbold Trustee 1.00 X 0 0 0 Lynn Peterson MD Trustee 1.00 X 0 0 0 Hon Donna Sweaney vice-chair 1.00 X X 0 0 0 Steven Smith MD Trustee 1.00 40.00 X 0 177772 96013 Donna VanFleet chair 1.00 X X 0 0 0 maria padin md dh Representative 1.00 40.00 X 0 409356 197804 William Palmer MD Trustee 1.00 40.00 X 0 191066 170950 Vincent Fusca III trustee 1.00 40.00 X 0 330998 24833 Deanna S Howard DH Representative 1.00 40.00 X 0 165139 28397 Matthew S Houde Dh Representative 1.00 40.00 X 0 139190 29402 Stephen D Surgenor MD Dh Representative 1.00 40.00 X 0 527655 65123 Alan Keiller treasurer/DH Representative 1.00 40.00 X X 0 0 0 John Tansey secretary 1.00 X X 0 0 0 gay landstrom interim CEO (effective through 1/17) 40.00 1.00 X X 0 579445 39835 joseph perras president & CEO (from 1/17) 40.00 1.00 X X 291241 0 11341 Patty O'Neill Treasurer (effective through 12/16) 1.00 X X 0 0 0 david sanville cfo 32.00 X 160554 0 18521 mary joyce physician 40.00 X 247222 0 18521 christopher connor physician 40.00 X 304416 0 8947 andrew robinson physician 40.00 X 259787 0 24157 dennis heibein physician 40.00 X 238491 0 8947 Peter rauert physician 40.00 X 334066 0 12231 kevin donovan CEO (former CEO) 0.00 40.00 X 0 174811 40569 1835777 2695432 795591 38 1 1 0 mary hitchcock memorial hospital one medical drive lebanon NH 03756 professional and Physician Services 2040902 Emergency Services of New England po box 12 chester VT 05143 Physician Asst for Emergency Room 1391997 Dartmouth-Hitchcock Clinic one medical drive lebanon NH 03756 Professional and Physician Services 874672 Sodexo Inc & Affiliates po box 360170 pittsburgh PA 15251 Mngmt & Support Staff - Envmmntl Srvs 780558 cerner po box 959156 st louis MO 63195 support for emr 587464 14 7900 598994 299502 3279 906396 Patient Services 621110 88433431 88433431 Program & Misc Other 621110 2882459 2882459 DSH/VAHHS Revenue 621110 541427 541427 Provision for Doubtful Accounts 621110 -1725743 -1725743 Contractual Allowances 621110 -38996090 -38996090 51135484 192143 -3029 195172 30647 0 30647 30647 30647 479715 0 47465 479715 -47465 432250 432250 31522 7900 13201 18321 18321 Equity in income of subsidiaries 621110 110609 110609 110609 52825850 51246093 -3029 676390 532851 34681 498170 23508248 20190926 3180104 137218 977250 828637 142995 5618 3501714 3178886 314099 8729 1628971 1370453 249233 9285 54237 54237 86662 86662 3971223 2158701 1797473 15049 105489 14803 75756 14930 63943 49369 13539 1035 312914 183511 124515 4888 728508 701104 27404 67980 42722 25152 106 219414 219414 2104831 2104831 965929 530061 433681 2187 purchased services 4738865 4203222 535643 Supplies 3286479 3089350 185260 11869 Dues/Fees/Taxes 2083534 1787531 292801 3202 Utilities 651853 29924 621929 905184 522009 374073 9102 50496079 41020721 9252140 223218 3472557 6094896 171778 172467 993244 603278 5368536 5888667 549408 478194 325675 581355 41974310 24839100 17732576 17135210 13735024 15281709 1830928 1856051 2583826 2604059 46763552 50695886 4180684 4820536 278460 753948 22529812 19577979 26988956 25152463 X 12429466 18320180 1495059 1345233 5850071 5878010 19774596 25543423 46763552 50695886 X 2329771 996397 2442659 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 11073 11073 0 Part II-B, Line 1: The Hospital paid $10,392 in the form of dues to the Vermont Association of Hospitals and Health Systems (VAHHS). VAHHS is a member-owned organization devoted to improving the health status of communities throughout Vermont through activities which include advocacy, policy development, education and research. The Hospital also paid $681 in the form of dues to the American Hospital Association (AHA). 0 4667571 475456 184785 4958242 4431980 420076 184485 4667571 4759330 -30485 296865 4431980 4645093 312380 198143 4759330 4536888 298805 190600 4645093 0.85080 0.14920 0 0 410000 410000 16584668 8197775 8386893 12528575 10023287 2505288 12451067 6618038 5833029 17135210 Rental Deposits 5560 Equity in Subsidiary 2396799 Other Receivables 201700 2604059 dartmouth-hitchcock clinic (related) accounts payable 543956 Est. Settlements W/ 3rd party payors 1133202 mary hitchcock memorial hospital & neah (related) accounts payable 58698 mary hitchcock memorial hospital (related) note payable 10838163 Other Liabilities 1316626 Post Retirement Benefit Obligation 5687334 19577979 X 56191447 996397 2442661 3439058 52752389 86662 -13201 73461 52825850 50422620 13203 13203 50409417 86662 86662 50496079 Part V, Line 4: In general, the amount of the original gift and any required accumulations by the donor are not expendable. However, the market value of the fund may fall below that amount depending on current financial conditions in the underlying investments. Under the policy of the Hospital, the endowment assets are invested moderately with the intent of providing a predictable stream of funding to the hospital. The Hospital invests in equity funds, bond funds and money market investments to achieve its long-term return objectives within limited risk constraints. Actual returns in any year may vary from budgeted amounts due to market fluctuations. Part X, Line 2: ASC Subtopic 740-10, Accounting for Uncertainty in Income Taxes, addresses the accounting uncertainty of income taxes recognized in an enterprise's financial statements and prescribes a threshold of "more-likely-than-not" for recognition and derecognition of tax positions taken or expected to be taken in a tax return. Subtopic 740-10 also provides guidance on measurement classification, interest and penalties and disclosure. The Organization has determined that the provisions of Subtopic 740-10 do not have a material effect on the Organization's financial statements. The Organization believes it is no longer subject to examinations for fiscal years prior to 2014. Part XI, Line 2d - Other Adjustments: Other components of net periodic benefit cost 141,188. Change in net assets to recognize funded status of post-retirement plans 986,472. rounding 1. transfer of net assets from dartmouth hitchcock-health 1,315,000. Part XI, Line 4b - Other Adjustments: Fundraising Expenses -13,201. Part XII, Line 2d - Other Adjustments: Rounding 2. Fundraising Expenses 13,201. Golf Tournament 39422 7900 31522 1262 2560 7033 2346 39422 7900 31522 1262 2560 7033 2346 13201 18321 1 1 1 X 225.000000000000 1 X 1 1 1 0 1 1 347526 347526 0.00690 6120610 2501408 3619202 0.07170 6468136 2501408 3966728 0.07860 258286 258286 0.00510 168726 168726 0.00330 16089517 9844453 6245064 0.12370 6500 6500 0.00010 16523029 9844453 6678576 0.13220 22991165 12345861 10645304 0.21080 1 733410 20320670 21134724 -814054 X 1 1 1 1 Windsor Hospital Corporation 289 County Road Windsor VT 05089 X X X X Distinct Part Rehab Unit Windsor Hospital Corporation 1 0 0 1 X X X X X X X X X 15 1 1 0 1 X See Schedule O X X 1 15 1 See Schedule O 0 1 X 225.000000000000 300.000000000000 X X X X X X X 1 1 X X X 1 X see schedule O X See schedule o X SEE SCHEDULE O X X X 1 X 0 X X X X 1 X 0 0 Windsor Hospital Corporation Part V, Section B, Line 5: Methods employed in the assessment included a survey of area residents made available through direct mail and website links, a survey of key community stakeholders who are agency, municipal or community leaders, a series of community discussion groups convened in the Mt. Ascutney Hospital service area, and a review of available population demographics and health status indicators. At the beginning of the survey, respondents were asked to indicate the region they primarily serve or are most familiar with. A total of 33 key stakeholder respondents indicated that their responses were reflective of the Greater Windsor service area. Respondents represented the following sectors:Human service/Social Service 21%Mental /Behavioral Health 3%Home Health Care 6%Primary Health Care 12%Medical subspecialty 6%Public safety/Fire 3%Emergency Medical Services 3%Education/Youth Services 6%Municipal/County Government 6%Community Member/Volunteer 6% Windsor Hospital Corporation Part V, Section B, Line 6a: Other facilities were Dartmouth Hitchcock Medical Center, Alice Peck Day Memorial Hospital, New London Hospital and Valley Regional Hospital. Windsor Hospital Corporation Part V, Section B, Line 7d: A benefit report was prepared and made available and distributed through 5 Community Presentations, conducted by the Community Benefit Staff, as well as a thorough presentation made to the Hospital's Board of Trustees. The Mt. Ascutney Community Health Foundation and Committee, as well as the Windsor Area Community Partnership, participated in the distribution of the report. The CHNA and all information in the Needs Assessment is available for stakeholders. The CHNA is also available via paper copy for public inspection upon request at the Hospital's main information desk. It is also available prominently on the following website, http://www.mtascutneyhospital.org/sites/default/files/content/documents/MTA%202015%20CHNA%20report.pdf. Windsor Hospital Corporation Part V, Section B, Line 11: The hospital is addressing the significant needs identified in the most recently conducted CHNA in an implementation plan that mirrors best practices in each of the areas of need. This implementation plan was accomplished through efforts of the hospital and working in partnership with community organizations, as indicated. The outcomes of the implementation plan have been presented to the hospital Board of Trustees, community groups and posted on the hospital website. An effectiveness evaluation has also been accomplished and presented to the aforementioned groups. The accomplishments of the 2015 CHNA implementation plan during fiscal year ended Septemebr 30, 2017 are as follows: Served as Integrator for Community Infrastructure, Networking, and Partnership Windsor HSA Community Collaborative Community Health Subcommittee of Board of Trustees Blueprint for Health CHT, Interagency Care Management, Spoke/MAT Windsor Area Community Partnership PATCH Windsor Area Drug Task Force Mt. Ascutney Prevention Partnership1. Alcohol and drug misuse including heroin and use of pain medications -Completed extensive revisions to the Consumer Guide for Substance Use Treatment subsequent liberal distribution throughout the Hospital, community partners and community -Delineated and publicized a community based access to treatment services protocol -Medication Assisted Therapy, counseling, support and case management through Spoke services in pediatrics, primary care, Connecticut Valley Recovery Services, Bradford Psychiatric Associates; led quality improvement projects within each site -Partnership with Blue Cross Blue Shield and Department of Health Office of Alcohol and Drug Abuse to implement a systematic and ongoing Screening, Brief Intervention and Referral to Treatment (SBIRT) protocol for substance use within the clinics and ED -SBIRT/Motivational Interviewing for substance misuse community trainings to SASH, spoke staff, Turning Point recovery coaches, HCRS, Court Diversion, White River Family Practice, school staff -Organized and delivered provider education regarding marijuana -Participated in Gov. Summit for Substance Misuse Workforce and Workgroup -Multidisciplinary Functional Recovery Consult Team for patients with chronic pain -Interagency Care Management through CHT -A plethora of education and prevention initiatives including "Be Aware Don't Share," "Most Dangerous Leftovers," "Drug Take Back," prom and grad season education, retailer compliance recognition, work with Vermont league of cities and towns and regional planning boards regarding education on the impact of marijuana legalization -Monitored, tracked and distributed data from the Vermont Prescription Monitoring System. Distributed data to providers. Outcomes show Windsor area to be the lowest prescribers in the state. -Provider education was provided by UVM and the Vermont medical society on both opioid management and a new state regulations. New regulation protocols have been implemented. -Organized a Regional Youth Summit for Substance Misuse Services involving the court system, law enforcement, school, prevention, early intervention and treatment professionals to share knowledge of existing resources, identify gaps and barriers and propose new solutions. A new partnership was formed to work on new solutions.2. Access to mental health -Distribution brochure of Local Mental Health Counselors in the hospital and throughout the community -3 WRAP workshops delivered for skill building and self-management support for anxiety, depression and general mental health -Expansion of a HCRS embedded clinician/LADAC to four days a week in Patient Centered Medical Home supported by SBIRT grant -Hired and supported a psychiatrist within our Patient Centered Medical Home -Partnership in interagency care management with HCRS and other partners -Provided Mental Health First Aid training to hospital staff and community partners X2 -336 mental health counseling sessions were provided through the Windsor Connection Resource Center3. Access to dental care -Application of fluoride in pediatric clinics -Outreach to recruit a local dentist work with Springfield Medical Services and Deputy Commissioner Of Health -Services and Managed Care -Dental vouchers for care through Windsor Community Health Clinic -Dental clinic in the school, provided education to 252 children and their parents, provided dental screening and sealant applications to 60 children in 2017 -Community Health Team, Spoke Staff and staff of the Windsor Community Health Clinic assist patients to find dental homes, care and financing4. Access to affordable health insurance, cost of prescription drugs -Windsor Community Health Clinic assists community members with Vermont Health Connect, and Medicare and Medicaid applications -Medicare Boot Camp - March 31, 2017 and July 24, 2017 -Medication Voucher Program is offered through the Windsor Community Health Clinic5. Nutrition/access to affordable food -Membership in the Upper Valley Hunger Council -Work with the school, three local churches, recreation department, low-income housing, Windsor Connection Resource Center and Windsor Food Shelf to provide Summer Food Program, 1070 meals served -Food Drive for the Food shelf working with schools, town government and churches -Implementation of 3-4-50 reaching over 1,000 people through outreach to towns, schools, businesses, day cares and Health and Human Services agencies -Recognized at the Gold Level for 3-4-50 Worksite Wellness -Creating a family friendly version of Eat Well on $4/day-Good and Cheap Cook Book created by pediatric staff, AHEC and illustrated by local students. -Working with Vermont Housing Association, MAHHC and SASH to organize a cooking matters class for residents at Union Square Apartments -Nurse in pediatric clinic created a farmers market flyer to distribute to families -Implemented VeggieVanGo working with the Vermont Food Bank as a monthly community resource. Served 90 -130 families each month. Physicians are writing prescriptions for vegetables to families in need.6. Lack of physical activity, need for recreational opportunities and active living -Readiness Assessment for Health and Wellness Committees in Windsor, Weathersfield and Woodstock -Implementation of 3-4-50 reaching over 1,000 people through outreach to towns, schools, businesses, day cares and Health and Human Services agencies -Registered and recognized at the Gold Level for 3-4-50 Worksite Wellness activities7. Income, poverty and family stress -PATCH services at the Windsor Connection Resource Center from October 2016 through September 2017 include visits for economic services and for mental health counseling -Ten Parent-to-Parent Collaborative Problem-Solving Programs -A Family Wellness Program with wellness coaching has been embedded in the pediatric clinic based on the research effective Vermont Family-Based Approach Program after receipt of grant funding and consultation and training with Dr. Hudziak and his staff. 111 family wellness visits from Sept. 2016 through Aug. 2017 -Promise Community to promote kindergarten readiness and emotional and social competence of children and families through a five prong strategy -Provided interagency care planning, coordination and management to high risk pediatric and complex chronic care patients using a best practice model and tools8. Access to transportation -Participating in Regional Transportation Coalition -Volunteers in Action provision of rides -Use of transportation vouchers -Work with VTrans, The Current and local community partners on Rides to Wellness grant initiative -Developed and distributed 2 transportation algorithms to maximize use of existing resources 9. Access to primary health care -Achievement of NCQA re-designation as a Level III Patient Centered Medical Home -Implementation of Annual Wellness visits by the Collaborative Care Nurse -Recruitment of primary care providers10. Health care for seniors -Interagency care management in partnership with Senior Solutions -Woodstock Area Adult Day Services -Aging in Place Initiatives by VIA new group formed in Weathersfield -SASH Wellness Nurse -HASS at Olde Windsor Village11. Tobacco use/smoking -Regular cessation groups and 1:1 counseling has been provided -Prevention activities to decrease tobacco advertising and use -Implementation of 3-4-50 and non-smoking pledge cards -Community education about the impact of vaping provided -Recognized at the Gold Level for 3-4-50 Worksite Wellness Windsor Hospital Corporation Part V, Section B, Line 13b: patients whose family income exceeds 300% of FPL may be eligible to receive a discount based on the self-pay balance. Discounts will be granted such that the total self-pay bill does not exceed 10% of 2 years gross income, plus 10% of assets in excess of the sheltered asset calculation described earlier in the Policy. Any discounts other than those described above must be approved by the Financial Assistance Appeals Committee based on a written appeal from the patient or responsible party. Windsor Hospital Corporation Part V, Section B, Line 13h: MAHHC applies a discount to the FAP eligible patient's gross charges to all balances where there is no insurance, or to medically necessary services processed by insurance carriers resulting in a balance, which the patient is expected to pay. Part I, Line 7: A cost accounting system was used to calculate the amounts reported in the table. A cost accounting system addresses all patients segments. A cost-to-charge ratio was used. Part I, Line 7g: Physician Clinic costs included within Subsidized Health Services are $6,245,064 of the total Community Benefit Expenses and $9,844,453 of the Direct Offsetting Revenue. Part III, Line 2: Bad debt expense is derived from the write off of patient accounts after they have been sent 4 statements over a course of 120 days. Also, Bad debt expense contains estimates for future write-offs based on management's judgements and financial models. Part III, Line 4: Patient accounts receivable are stated at the amount management expects to collect from outstanding balances. Management provides for probable uncollectible amounts through a charge to operations and a credit to a valuation allowance based on its assessment of individual accounts and historical adjustments. Balances still outstanding after management has used reasonable collection efforts are written off through a charge to the provision for doubtful accounts and a credit to accounts receivable.In evaluating the collectability of accounts receivable, the Hospital analyzes past results and identifies trends for each major payor source of revenue for the purposes of estimating the appropriate amounts of the allowance for doubtful accounts and the provision for doubtful accounts. Data in each major payor source are regularly reviewed to evaluate the adequacy of the allowance for doubtful accounts. Specifically, for receivables relating to services provided to patients having third-party coverage, an allowance for doubtful accounts and a corresponding provision for doubtful accounts are established at varying levels based on the age of the receivables and payor source. For receivables relating to self-pay patients, a provision for doubtful accounts is made in the period services are rendered based on experience indicating the inability or unwillingness of patients to pay amounts for which they are financially responsible. Actual write-offs are charged against the provision for doubtful accounts. Part III, Line 8: The shortfall represents the PPS reimbursement difference on the Rehab units. Since the reimbursement does not cover the costs of these units, a subsidy is created. Because the Hospital determined that these services are important to our service area, the Hospital covers the subsidy. The costing methodology used above was the cost to charge ratio. Part III, Line 9b: MAHHC's collection policy and charitable care policies are consistently applied to all patients. Our collection policy applies to any balance owed by the patient whether it is a balance after insurance, a balance with no insurance, or a balance after an adjustment for partial charitable care. Statements, credit reporting, collection efforts, and write-off criteria are the same for all like balances, regardless of the reason for the balance and regardless of whether it is a balance after charitable care or not. Patients who qualify for financial assistance receive the appropriate adjustment on their bill. If a balance remains after that adjustment, they are billed according to the collection policy, for the remainder. Part VI, Line 2: In addition to the Community Health Needs Assessment, the needs of the community are assessed through ongoing review of health indicators such as the youth risk behavior survey, BRFSS, quality indicators from both the hospital and external evaluations such as One Care Vermont and the That practice profiles. Community health needs are also assessed through patient satisfaction surveys and the patient complaint process. The hospital also has a community health team embedded in our patient centered medical home who respond to the needs of patients with complex chronic care needs. Part VI, Line 3: Windsor Community Health Clinic (A department within the Hospital) provides information and one-on-one assistance with any individual that is identified without insurance. This begins at the time that a patient presents for their health care appointment; the registration staff make the introduction and provide information to the patient on the services. Also, a referral from the physician/provider may direct a patient to this department. The staff of this department assist patients in applying for health insurance, whether on the commercial "exchange", or in governmental insurers. They also provide information on and the application for Financial Assistance; often time, assisting patients with completing the application. This is a dedicated staff that is on site during the normal business hours when the majority of patients would be seeking care. Part VI, Line 4: MAHHC's primary service area includes Windsor, Hartland, Woodstock, Springfield, Weathersfield, Brownsville, VT and Cornish, and Claremont, NH. MAHHC is the largest employer in the town of Windsor, with many of its residents having lower than average paying jobs and struggle with financial stability; including transportation difficulties. Part VI, Line 5: The hospital has established A Director of Community Health, a Prevention Education and Health Promotion Department and a Community Health Committee which is a subcommittee of the Board of Trustees. Our staff organize, lead and implement health promotion and prevention programs for high risk behaviors such as alcohol, tobacco and drug misuse. We promote exercise and nutrition programs in a well-established campaign working with the Vermont Department of Health in the 3-4-50 campaign. This campaign involves outreach and engagement to and with the community to decrease the three behaviors of tobacco use, lack of exercise and poor nutrition that are related to the four conditions of heart disease and stroke, diabetes, cancer and respiratory diseases that account for over 50% of the deaths in Vermont. This year our outreach impacted over 1000 people. We serve as an integrator and leader of community health by chairing and leading the following community partnerships; Windsor area community partnership, Windsor PA TCH team, blueprint for health extended team, Windsor HSA community collaborative and Windsor drug task force. Mission statements and minutes are available per request. Part VI, Line 6: The Hospital Community Benefit staff is an active participant in Regional Community Health committee, which is lead and organized by Dartmouth-Hitchcock. The Hospital is affiliated, formally, with Dartmouth-Hitchcock. As are other local hospitals, Alice Peck Day Memorial Hospital and New London Hospital. Valley Regional Hospital is also part of the Regional Community Health committee. The participants collaborate, compare solutions and offer support to each other as all are serving overlapping service areas. Part VI, Line 7 There are no requirements to file a community benefits report in the state of Vermont. X 0 1 0 0 0 0 0 1 0 Steven Smith MD Trustee 0 176998 0 0 0 774 0 76703 0 19310 0 273785 0 0 maria padin md dh Representative 0 398748 0 0 0 10608 0 177879 0 19925 0 607160 0 0 William Palmer MD Trustee 0 189878 0 0 0 1188 0 158353 0 12597 0 362016 0 0 Vincent Fusca III trustee 0 319753 0 0 0 11245 0 23344 0 1489 0 355831 0 0 Deanna S Howard DH Representative 0 163908 0 0 0 1231 0 23344 0 5053 0 193536 0 0 Matthew S Houde Dh Representative 0 139190 0 0 0 0 0 8890 0 20512 0 168592 0 0 Stephen D Surgenor MD Dh Representative 0 455683 0 47500 0 24472 0 42733 0 22390 0 592778 0 0 gay landstrom interim CEO (effective through 1/17) 0 544439 0 0 0 35006 0 20575 0 19260 0 619280 0 0 joseph perras president & CEO (from 1/17) 291241 0 0 0 0 0 0 0 11341 0 302582 0 0 0 david sanville cfo 160554 0 0 0 0 0 0 0 18521 0 179075 0 0 0 mary joyce physician 247222 0 0 0 0 0 0 0 18521 0 265743 0 0 0 christopher connor physician 304416 0 0 0 0 0 0 0 8947 0 313363 0 0 0 andrew robinson physician 259787 0 0 0 0 0 0 0 24157 0 283944 0 0 0 dennis heibein physician 238491 0 0 0 0 0 0 0 8947 0 247438 0 0 0 Peter rauert physician 334066 0 0 0 0 0 0 0 12231 0 346297 0 0 0 kevin donovan CEO (former CEO) 0 170076 0 0 0 4735 0 29444 0 11125 0 215380 0 0 Part I, Line 3 THE former CEO and interim CEO were PAID BY MARY HITCHCOCK MEMORIAL HOSPITAL, A RELATED ORGANIZATION, WHICH USES A COMPENSATION COMMITTEE, AN INDEPENDENT CONSULTANT, A COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE TO ESTABLISH THE CEO'S COMPENSATION. Part I, Line 4b THE FOLLOWING INDIVIDUALS RECEIVED PAYMENTS FROM A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN (WHICH ARE REFLECTED IN SCHEDULE J, PART II, COLUMN B (III)): MARY HITCHCOCK MEMORIAL HOSPITAL, A RELATED ORGANIZATION, PAID GAY LANDSTROM $33,499, KEVIN DONOVAN $4,712 AND VINCENT FUSCA $6,601. DARTMOUTH-HITCHCOCK CLINIC, A RELATED ORGANIZATION, PAID MARIA PADIN $10,074 AND STEPHEN D SURGENOR $24,010. Part I, Line 7 SMITH, CONNOR AND HEIBEIN RECEIVED BONUSES. THE BONUSES WERE AWARDED EITHER DUE TO MEETING RVU GOALS OR BASED ON QUALITY AND CITIZENSHIP. Form 990, Part VI, Section A, line 2 MOUNT ASCUTNEY HOSPITAL & HEALTH CENTER IS A PART OF THE DARTMOUTH-HITCHCOCK HEALTH SYSTEM, WHICH OWNS FOR-PROFIT SUBSIDIARIES THAT PROVIDE SERVICES AND SUPPORT THE MISSION OF THE ORGANIZATION. AS A RESULT, SOME OFFICERS OF THE MAHHC ALSO MAY BE OFFICERS OF FOR-PROFIT ENTITIES WITHIN THE HEALTHCARE SYSTEM. Form 990, Part VI, Section A, line 6 DARTMOUTH-HITCHCOCK HEALTH, A NEW HAMPSHIRE VOLUNTARY CORPORATION, IS THE SOLE CORPORATE MEMBER OF MOUNT ASCUTNEY HOSPITAL & HEALTH CENTER. Form 990, Part VI, Section A, line 7a DARTMOUTH-HITCHCOCK HEALTH HAS THE POWER TO APPOINT 1/3 OF THE MEMBERS OF MAHHC'S BOARD OF TRUSTEES. Form 990, Part VI, Section A, line 7b THE SOLE MEMBER HAS THE RIGHT TO RATIFY MOUNT ASCUTNEY HOSPITAL & HEALTH CENTER'S NOMINATION OF 2/3 OF THE MEMBERS OF THE BOARD OF TRUSTEES; REMOVE TRUSTEES AFTER CONSULTATION WITH THE CHAIRPERSON OF THE BOARD; APPROVE THE DISSOLUTION OR LIQUIDATION OF MAHHC; APPOINT, EVALUATE, TERMINATE, AND APPROVE THE COMPENSATION OF THE PRESIDENT AND CEO; AND OTHER GOVERNANCE DECISIONS. Form 990, Part VI, Section B, line 11b board of trustees reviewed prior to filing, provided multiple days to provide feedback and/or questions and Hospital then filed after there was satisfaction. Form 990, Part VI, Section B, line 12c The finance and audit committee monitor and report to the Board of Directors Form 990, Part VI, Section B, line 15 The Executive Committee of the Board meets annually to review compensation for the CEO, using independent surveys of area compensation for executives of various sized hospitals. Other officers and key employees salaries are determined, by the HR Department using comparable market data. Form 990, Part VI, Section C, line 19 All internal policies, governing documents, and financial statements are made available upon request Form 990, Part XI, line 9: Change in Net Assets to recognize funded status of post retirement plans 986,472. Other components of net periodic benefit cost 141,188. Rounding -1. transfer of net assets from Dartmouth hitchcock-health 1,315,000. Form 990, Part XII, Line 3b: the single audit was performed on the combined financial information of dartmouth-hitchcock Health and subsidiaries including mount ascutney hospital and health center. Schedule H, Part V, Line 7a: http://www.mtascutneyhospital.org/sites/default/files/content/documents/ MTA%202015%20CHNA%20report.pdf Schedule H, Part V, Line 10a: http://www.mtascutneyhospital.org/sites/default/files/content/ documents/CHNA%20Implementation%20Plan%202015-2.pdf schedule H, Part V, Line 16a: http://www.mtascutneyhospital.org/sites/default/files/content/documents/ MAH%20Financial%20Assistance%20Policy_0.pdf schedule H, Part V, Line 16b: http://www.mtascutneyhospital.org/sites/default/files/Financial%20Assist ance%20Application%2010012016.pdf schedule H, Part V, Line 16c: http://www.mtascutneyhospital.org/sites/default/files/content/documents/ MAH17_FinancialAssistancePolicyBrochure_Web.pdf HISTORIC HOMES OF RUNNEMEDE 289 County Road Windsor VT 05089 237396147 providing svcs for the aging VT 501(c)(3) Line 10 WINDSOR HOSPITAL CORPORATION 1 Mount Ascutney Hospital Community Health Foundation Inc 289 County Road Windsor VT 05089 030300481 health education & promotion VT 501(c)(3) Line 3 WINDSOR HOSPITAL CORPORATION 1 Dartmouth-Hitchcock MEDICAL CENTER One Medical Center Drive Lebanon NH 03756 222715483 Supporting Org NH 501(c)(3) Line 12a, I N/A 0 MARY HITCHCOCK MEMORIAL HOSPITAL One Medical Center Drive Lebanon NH 03756 020222140 Hospital NH 501(c)(3) Line 3 Dartmouth-Hitchcock Health 0 Dartmouth-Hitchcock clinic ONe Medical Center Drive Lebanon NH 03756 222519596 Phys Svcs NH 501(c)(3) Line 10 Dartmouth-Hitchcock Health 0 Hitchcock Foundation One Medical Center Drive Lebanon NH 03756 020222139 Hlthcre Rsrch NH 501(c)(3) Line 7 Dartmouth-Hitchcock CLINIC 0 Hamden Risk Retention Group Inc 30 Main Street Suite 330 Burlington VT 05401 208530788 Self Ins VT 501(c)(3) Line 12a, I Dartmouth-Hitchcock Clinic 0 The New London Hospital Assoc Inc 273 County Road New London NH 03257 020222171 Hospital NH 501(c)(3) Line 3 Dartmouth-Hitchcock Health 0 Everwell Inc One Medical Center Drive Lebanon NH 03756 352506275 Supporting Org NH 501(c)(3) Line 12a, I N/A 0 VISITING NURSE ASSOCIATION AND HOSPICE OF VT AND NH INC 205 billings farm rd no 5 wilder VT 05088 036006494 Hospice VT 501(c)(3) Line 10 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 ALICE PECK DAY MEMORIAL HOSPITAL 10 alice peck day dr lebanon NH 03766 020222791 hospital NH 501(c)(3) Line 3 dartmouth-Hitchcock health 0 SURGERY CENTER OF GREATER NASHUA 10 prospect st no 101 nashua NH 03060 461084049 surgery center NH 501(c)(3) Line 3 N/A 0 CHESHIRE HEALTH FOUNDATION 580 COURT STREET keene NH 03431 020202220 supporting org NH 501(c)(3) Line 12a, I cheshire medical center 0 Chesire health services 580 COURT STREET keene NH 03431 473379283 healthcare NH 501(c)(3) Line 3 cheshire medical center 0 dartmouth-hitchcock health one Medical Center Drive lebanon NH 03756 264812335 parent org NH 501(c)(3) Line 7 N/A 0 DH MASTER INVESTMENT PARTNERSHIP one MED CTR DR LEBANON NH 03756 020505863 POOLED INVESTMENT NH mary hitchcock memorial hospital Excluded 1494553 14772295 0 -3029 0 0.02460 new england pharMACY COLLAB one MED CTR DR leBANON NH 03756 263819035 group purchasing NH N/A -5770 0 0 0.04740 imaginecare inc one mediCAL CENTER DRIVE leBANON NH 03756 813105071 software technology DE N/A C 0 HITCHCOCK HEALTH CONNECT INC ONE MEDICAL CENTER DRIVE LEBANON NH 03756 800908979 TELEHEALTH DE N/A C 0 POMPANOOSUC INVESTMENT CORPORATION ONE MEDICAL CENTER DRIVE LEBANON NH 03756 020352330 real estate hldg NH N/A C 0 HAMDEN ASSURANCE COMPANY LIMITED 44 church st HAMILTON BD hm 12 980121409 liability insurance BD N/A C 0 KEARSARGE COMMUNITY SERVICES INC 273 COUNTY RD NEW LONDON NH 03257 020460136 real estate hldg NH N/A C 0 NEW LONDON PHYSICIAN GROUP INC 273 COUNTY RD NEW LONDON NH 03257 020494420 PHYSICIAN GROUP NH N/A C 0 NEW LONDON MEDICAL CENTER EAST INC 273 COUNTY RD NEW LONDON NH 03257 020480857 real estate hldg NH N/A C 0 KEENE HEALTH SERVICES 580 COURT STREET KEENE NH 03431 020374997 real estate hldg NH N/A C 0 KEENE HEALTH REALTY 580 COURT STREET KEENE NH 03431 020374998 real estate hldg NH N/A C 0 KEENE HEALTH ENTERPRISES 580 COURT STREET KEENE NH 03431 020374999 real estate hldg NH N/A C 0 88 Prospect St Condo Owners Assoc 88 prospect street white river junction VT 06002 020480857 real estate hldg VT N/A C 0 CHARITABLE REMAINDER UNITRUSTS (10) 289 COUNTY RD WINDSOR VT 05089 CHARITABLE TRUST VT N/A T 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 Mary Hitchcock Memorial HospitalDartmouth Hitchcock Health E 10838163 Actual Historic Homes of Runnemede Q 152751 actual Dartmouth-hitchcock health S 1315000 actual NEW ENGLAND ALLIANCE FOR HEALTH llc (MHMH) P 666821 ACTUAL DARTMOUTH-HITCHCOCK clinic E 543956 ACTUAL DARTMOUTH-HITCHCOCK clinic O 3214612 ACTUAL MARy Hitchcock Memorial Hospital P 322991 ACTUAL