2017-08-10T12:42:39-05:00 2016-09-30 010494526 BAKER NEWMAN & NOYES BOX 507 PORTLAND ME 04112 990 2015-10-01 020222157 Monadnock Community Hospital MONA 6039247191 452 Old Street Road Peterborough NH 03458 Richard D Scheinblum VP of Finance/CFO 6039247191 2017-08-04 1 Nicholas E Porto P01310283 2078792100 2017-08-04 2015 2021-01-29 14:40:06Z Cynthia K McGuire 452 Old Street Road Peterborough NH 03458 83412150 0 X www.monadnockcommunityhospital.com X 1919 NH Critical access hospital serving the Monadnock region of the State of New Hampshire 17 13 775 140 0 0 1299530 712030 76857288 81749052 1605715 866929 4390 2719 79766923 83330730 21000 24000 0 0 39259408 39878040 0 0 435135 41027368 43272466 80307776 83174506 -540853 156224 107855800 112294272 48663461 50782612 59192339 61511660 X Monadnock Community Hospital is committed to improving the health and well-being of our community. We will elevate the health of our community by providing accessible, high quality and value based care. 0 0 73510930 24000 81749052 The primary purpose of Monadnock Community Hospital (MCH) is to ensure access to quality health care for patients in our community, regardless of their ability to pay. The following is a summary of the services MCH provides in an effort to fulfill its mission, together with key program statistics for fiscal year 2016.Inpatient Services - Includes: intensive care unit, adult stays, pediatric stays, maternity/births, and skilled nursing. During the fiscal year, the Hospital admitted 1,490 patients and recorded 4,952 patient days. Emergency Services - MCH offers health services 24 hours per day, 7 days per week. Responsible for the immediate treatment of any medical or surgical emergency; for initiating lifesaving procedures in all types of emergency situations; and for providing emergency and initial evaluations and treatment for other conditions including minor illnesses and injuries, and sub-acute medical problems. During the year, there were 14,584 visits to the ER. Physician Practices - Family health services, programs, and education are integral components of healthcare at MCH. Inpatient and outpatient primary care includes: medical, surgical, psychological and specialist services, provided by physicians and mid-level practitioners. These are located at the Hospital and its four satellite practices located in Antrim, Jaffrey, New Ipswich, and Rindge. During the year, 70,045 primary care office visits were recorded. Surgical Services - Includes same day and short-term inpatient surgery. MCH provides surgery in the areas of orthopaedics, general surgery, OB/GYN, ophthalmology, urology, ENT, and podiatry. In addition, the Hospital offers some non-surgical procedures including colonoscopies, gastroscopies, and pain management injections. During the fiscal year, 3,148 procedures were performed. Radiology and Diagnostics - MCH provides advanced radiological technology and extensive imaging services including: bone density, MRI, CT, nuclear medicine, ultrasound, mammography, and other diagnostic procedures, both inpatient and outpatient. During the fiscal year, 30,399 exams were performed. Rehabilitation Services - Additionally, MCH serves the people of the Monadnock Region through its medical rehabilitation services. MCH offers rehabilitation programs for cardiac, pulmonary and diabetic rehabilitation which feature educational and exercise components. We also provide physical and occupational therapy, as well as speech rehabilitation. During the fiscal year 47,856 procedures were recorded for these services. Wellness Services - Community members wanting to improve and maintain their health have access to an award-winning, medically-based fitness facility. During the fiscal year, 18,851 member months were recorded.Monadnock Community Hospital's Financial Grant Program provides assistance with hospital and/or physician bills for qualifying patients. In fiscal year 2016, the Organization recorded $1,682,000 in charges foregone based on established rates. The estimated cost incurred to provide these services was $865,345. In addition, Monadnock Community Hospital provided other services to the community at no cost or reduced cost, such as screenings and clinics. The cost of providing these services was approximately $2,914,000 in 2016. 73510930 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 1 1 1 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 1 1 0 0 0 1 135 0 1 775 1 0 0 0 0 0 1 1 0 0 0 0 X 17 13 0 0 1 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X Nicole Humphrey 6039247191 452 Old Street Road Peterborough NH 03458 X Anne Baddour Trustee 3.00 0.00 X 0 0 0 Thomas S Bates CPA PC Trustee 3.00 0.00 X 0 0 0 Robert Boyd Trustee 3.00 0.00 X 0 0 0 Barbara R Duckett RN Trustee 3.00 0.00 X 0 0 0 Robert L Edwards Trustee 3.00 0.00 X 0 0 0 Peter L Forssell MD Trustee 3.00 0.00 X 0 0 0 Richard Frechette MD Ex-Officio w/voting rights (part yr) 3.00 0.00 X 224090 0 32424 William James Jr Trustee 3.00 0.00 X 0 0 0 Gregory Kriebel MD Ex-Officio w/voting rights 50.00 0.00 X 237516 0 22300 Leslie Lewis Trustee 3.00 0.00 X 0 0 0 Terrence McNamara DO Ex-Officio w/voting rights 50.00 0.00 X 477329 0 22369 Fay Migotsky MD Medical Staff President 3.00 0.00 X 132311 0 19325 Michael Shea Trustee 3.00 0.00 X 0 0 0 Thomas Ward Ex-Officio w/voting rights (part yr) 3.00 0.00 X 0 0 0 Steven H Reynolds Chair 8.00 0.00 X X 0 0 0 Carole Monroe Chair (part yr) 3.00 0.00 X X 0 0 0 Marcia Ober Vice Chair 3.00 0.00 X X 0 0 0 Jamie Trowbridge Treasurer 3.00 0.00 X X 0 0 0 Norman A Makechnie Esq Secretary 3.00 0.00 X X 0 0 0 Cynthia McGuire Chief Executive Officer 55.00 0.00 X X 244254 0 39705 Richard D Scheinblum VP Finance/CFO 50.00 0.00 X 176888 0 9693 Philip Vuocolo MD Physician 50.00 0.00 X 400984 0 33600 Ronald Michalak MD Physician 50.00 0.00 X 478389 0 22011 Douglas Weiss MD Physician 50.00 0.00 X 470615 0 11700 Shawn Harrington MD Physician 50.00 0.00 X 403518 0 22525 Robert C Knowles MD Physician 50.00 0.00 X 402566 0 23328 3648460 0 258980 43 0 1 0 Hutter Construction Corporation PO Box 257 New Ipswich NH 03071 General Contractor 2266057 Monadnock Region Emergency Physicians PL 380 Lafayette Road Hampton NH 03842 Contract Emergency Physician Group 2022583 Catholic Medical Center 195 McGregor Street Manchester NH 03102 Contract Hospital Physician and Laborato 1701273 Monadnock Anesthesia Associates C/O Surgical Suite Peterborough NH 03458 Contract Anesthesia Group 1521329 McKesson PO Box 98347 Chicago IL 60693 IS Vendor 955118 21 43446 15635 652949 26806 712030 Net Patient Service Revenue 621400 75009060 75009060 Other Operating Revenue 621400 4200123 4200123 Disproportionate Share Funding 621400 2100000 2100000 Cafeteria/Vending Machine 722210 308997 308997 Employee Pharmacy Sales 446110 130872 130872 81749052 667421 667421 261397 57756 4133 203641 -4133 199508 199508 22250 43446 19531 2719 2719 83330730 81749052 0 869648 18000 18000 6000 6000 1757717 1235155 522562 31213087 27898434 3070019 244634 419689 355993 61808 1888 4384126 3793482 560953 29691 2103421 1855264 230901 17256 78695 78695 54000 54000 181228 181228 5783740 5387064 395211 1465 78949 78949 2288635 1042403 1224124 22108 1162020 1009899 152121 2727622 2466479 261143 52899 42991 7928 1980 140041 58726 53036 28279 1139533 28708 1110825 4589694 4392276 197418 564344 386562 177782 Med & Pharm Supplies 10380306 10378592 1714 Med Exp/Service Contrac 5196168 4708149 415334 72685 Provision for Bad Debt 4469090 4469090 NH Medicaid Enhancement 3367222 3367222 1018280 531492 471639 15149 83174506 73510930 9228441 435135 5732 5092 18080723 17996186 681106 676322 6954225 7965431 92838 57777 171396 332284 1199012 1162728 1159462 762457 89031907 51294959 39028498 37736948 35550447 40332117 3887633 4179974 126451 918277 1086956 107855800 112294272 7372803 7673889 25971797 25374399 643132 632304 14675729 17102020 48663461 50782612 X 48138603 49771713 2946661 3340531 8107075 8399416 59192339 61511660 107855800 112294272 X 156224 2204216 -41119 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 10885 1 369 0 0 11254 0 Part II-B, Line 1: Monadnock Community Hospital is a member of the NH Hospital Association and the American Hospital Association. A portion of the dues paid to these organizations is available for lobbying expenditures on behalf of Monadnock Community Hospital in furtherance of its exempt purpose. The Hospital does not directly perform any lobbying activities related to these dues. NHHA, Portion of dues available for lobbying: $7,642 AHA, Portion of dues available for lobbying: $3,243 In addition, MCH hosts an annual legislative breakfast, which is a bipartisan event to which legislators, local politicians, and other public officials are invited to discuss health care issues in New Hampshire. Discussion topics for the 2016 breakfast focused on the current and proposed healthcare legislation, its impact on MCH, and collaboration to advocate for the growing health needs of the Monadnock region. The cost of this forum was $369. 11053734 498812 708687 521286 11739947 11410548 1026702 489797 1873313 11053734 10304146 526809 924772 345179 11410548 8591510 1127458 819722 234544 10304146 8314205 486841 948400 1157936 8591510 0.00000 0.71550 0.28450 1 0 964622 964622 34541380 18549796 15991584 842848 513565 329283 51443400 32231598 19211802 1239657 1239657 37736948 Interest Rate Swap Agreements 3178663 Estimated Third-Party Settlements 13923357 17102020 X 84877464 2204216 2204216 82673248 181228 476254 657482 83330730 82558143 0 82558143 181228 435135 616363 83174506 Part V, Line 4: Temporarily restricted assets are available for health care services, including the purchase of equipment and providing health education and programs. The income and dividends on permanently restricted net assets are generally used to support health care services and for capital purchases of property and equipment. Part X, Line 2: The Hospital is a not-for-profit corporation as described in Section 501(c)(3) of the Internal Revenue Code (the Code) and is exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. Management evaluated the Hospital's tax positions and concluded the Hospital has maintained its tax-exempt status, does not have any significant unrelated business income and had taken no uncertain tax positions that require adjustment to or disclosure in the accompanying financial statements. Part XI, Line 4b - Other Adjustments: Fundraising Expenses 435,135. Decrease in fair value of interest rate swap agreement 41,119. Part XII, Line 4b - Other Adjustments: Fundraising Expenses 435,135. MCH Golf Classic 65696 43446 22250 600 6608 6150 4268 1905 65696 43446 22250 600 6608 6150 4268 1905 19531 2719 1 1 1 X 1 X 1 1 1 0 1 1 865345 865345 0.01100 8545796 5442067 3103729 0.03940 9411141 5442067 3969074 0.05040 959982 959982 0.01220 5740 5740 0.00010 1748292 1748292 0.02220 200139 200139 0.00250 2914153 2914153 0.03700 12325294 5442067 6883227 0.08740 1 2298995 112654 24597730 24439068 158662 X 1 1 1 1 Monadnock Community Hospital 452 Old Street Road Peterborough NH 03458 02507 X X X X Monadnock Community Hospital 1 0 0 1 X X X X X X X X 15 1 0 0 1 X see Part V, Section C X 1 12 1 See Part V, Section C 1 0 1 X 200.000000000000 400.000000000000 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 1 X 0 X X X X 1 X 0 0 Monadnock Community Hospital Part V, Section B, Line 5: Monadnock Community Hospital (MCH) used a multi-phased methodology to achieve the objectives of the assessment. The methodology included the following stages: establishing a leadership team to provide project guidance and insight regarding local health resources and perspectives of community needs; strategic secondary research; conducting qualitative research through group discussions and surveying community stakeholders representing high-risk populations in the service area; needs prioritization process. Establishing a Leadership Team - The objective of the Leadership Group was to engage a broad cross-section of the community that could reasonably represent the very diverse consumers who comprise the MCH service area. MCH reached out to an expansive and highly diverse group of individuals to participate in its CHNA leadership team and to contribute insight from community service organizations. Each member provided project insight, feedback regarding perceptions of area health needs, data evaluation, and other guidance during the CHNA process. These individuals had a breadth of community health vision, knowledge, and power to impact the well-being of the service area. The steering committee also offered critical feedback on quantitative data, refined the list of community needs, helped develop the database of available resources, and participated in quantitative and qualitative research methods to build the prioritized list of community needs identified in the report. Qualitative Research - Qualitative research was conducted with MCH leaders, leadership team members, other community service providers, and healthcare consumers in the service area. The qualitative research methods included the following: a discussion group and/or individual interviews with a diverse set of participants who represented a span of healthcare consumers in the service area, and qualitative feedback provided by 60 community leaders via an electronic survey, and select interviews with key stakeholders. The discussion group included leaders from community service providers who represent at-risk groups such as (but not limited to) adults and children suffering from behavioral health problems, chronic disease patients and those at-risk of acquiring a chronic condition, economically challenged populations including children living in poverty and/or near-poverty, homeless individuals and families, individual and families engaging in risky lifestyles, populations requiring integrated care service, senior citizens, and other frequent users of the healthcare system. Monadnock Community Hospital Part V, Section B, Line 11: Please see attached implementation plan for how the Hospital is addressing (or any needs it is not addressing and why) the significant needs of the community in which it serves. Monadnock Community Hospital Part V, Section B, Line 20e: The Hospital Patient Financial Services (PFS) Department shall develop and implement billing and collection procedures designed to maintain an adequate cash flow, keep accounts receivable at an acceptable level, and identify and write-off bad debts in a timely fashion. Monadnock Community Hospital contracts with an agency to process all self-pay accounts and self-pay after insurance balance statements/letters. I. Self-pay accounts and self-pay balances remaining after insurance adjudication shall be transferred to the agency on a weekly basis. The cycle for collections is three (3) statements and/or letters and two phone call series spaced approximately thirty (30) days apart. The statements shall include: a. Previous balance (unless this is the first statement). b. Activity since last statement (except those accounts that went to a $0.00 balance). c. Current balance due. d. Telephone number(s) for inquiries concerning the statement. e. Status or reminder message where appropriate. f. Availability for the use of a credit card for payment. g. Information regarding Financial Assistance and Medication Bridge Programs. h. Return envelope.II. In the event that statements or letters are returned by the postal service as undeliverable for reasons such as "moved, left no forwarding address," "forwarding order expired, or "no such address" the agency will indicate on the daily report "mail returned." PFS staff will review system for the correct address and will make corrections within the computer system and correspondence will be re-mailed. If no correct or current information can be obtained, the specific account(s) shall be flagged for referral to an outside collection agency equipped to handle this type of situation (see bad debt processing footnote).In addition, on a weekly basis, the FAP staff run system reports to identify emergency room visits classified as self-pay. Based on the information in these reports, the guarantor of each visit is sent a financial assistance application in the mail. Determination of eligibility is contingent upon receiving a completed application and required documentation from the patient and/or guarantor. Schedule H, Part V, Section B, Line 7a & 10a: The CHNA is available at the Hospital facility's website: http://www.monadnockcommunityhospital.com/pdf/community-matters/CHNA_2015.pdfThe Hospital's Implementation Strategy is available at:http://monadnockcommunityhospital.com/pdf/community-matters/MCH_Implementation_Plan-2016.pdf Schedule H, Part V, Section B, Line 16b: The Hospital's Financial Assistance Policy is available on the Hospital's website at:http://www.monadnockcommunityhospital.com/services/financial/FinancialAssistance1.phpThe Hospital's Financial Assistance Policy Application is available at:http://www.monadnockcommunityhospital.com/pdf/MCH_FAP_Application.pdfThe Hospital's Financial Assistance Policy Plain Language Summary is available at:http://www.monadnockcommunityhospital.com/services/financial/FinancialAssistance1.php Schedule H, Part V, Section B, Line 8: In conjunction with its most recent CHNA, which was made widely available to the public in December of 2015, the Hospital created an implementation strategy to meet the significant needs identified in that CHNA. Due to delays related to the pending affiliation with Catholic Medical Center and Huggins Hospital (see Schedule O for additional information), the implementation strategy was not formally presented to the Board of Trustees for approval until after the deadline identified in the Regulations of February 15, 2017. However, as soon as this administrative delay was identified, immediate action was taken to have the Hospital's Board approve the implementation strategy. Formal approval and adoption of the implementation strategy was conducted prior to the filing of this return. The approved and adopted strategy has been posted on the Hospital's website (see hyperlink in narrative for Schedule H, Part V, Section B, Line 10a) and has also been attached to this return. 12 1 - Monadnock Orthopaedic Associates 458 Old Street Road Wellness Center Peterborough NH 03458 Physician practice 2 - Bond Wellness Center 458 Old Street Road Wellness Center Peterborough NH 03458 Fitness center and rehabilitation services 3 - Monadnock Regional Pediatrics 454 Old Street Road MAB Building Peterborough NH 03458 Physician practice 4 - Jaffrey Family MedicinePT Satellite 82 Peterborough Road Jaffrey NH 03452 Physician practice with PT services 5 - Monadnock Internal Medicine 454 Old Street Road MAB Building Peterborough NH 03458 Physician practice 6 - Monadnock Family Care 454 Old Street Road MAB Building Peterborough NH 03458 Physician practice 7 - Rindge Family Practice 145 US Route 202 Rindge NH 03461 Physician practice 8 - Monadnock Behavioral Health 458 Old Street Road Wellness Center Peterborough NH 03458 Physician practice 9 - Antrim Medical Group 12 Elm Street Antrim NH 03440 Physician practice 10 - Monadnock Surgical Associates 454 Old Street Road MAB Building Peterborough NH 03458 Physician practice 11 - New Ipswich Family Medicine 821 Turnpike Road New Ipswich NH 03071 Physician practice 12 - Neurology Center 458 Old Street Road Wellness Center Peterborough NH 03458 Physician practice Part I, Line 3c: N/A Part I, Line 6a: N/A Part I, Line 7: Charity care and means tested programs use the cost to charge ratio as their methodology. This Hospital calculates the ratio in a manner consistent with worksheet 2, patient care charges to patient care expenses, to arrive at the ratio of cost to charges. Part I, Line 7g: Included in the subsidized health services activities reported for FY 2016 are unreimbursed costs of $461,139 attributed to an outpatient behavioral health practice and $1,210,726 related to emergency and trauma services. 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 $ 4,469,090. Part II, Community Building Activities: See previous footnotes. Part III, Line 2: The amount reported on Part III, Line 2 was derived by applying the cost to charge ratio against the amount of bad debt expense reported on Form 990, Part IX, Line 25, Column (A) ($4,469,090). Accounts written off to bad debt include 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. The Hospital calculates the ratio in a manner consistent with Worksheet 2, patient care charges to patient care expenses, to arrive at the ratio of costs to charges. Part III, Line 3: The estimated amount of charity care included in bad debt expense is based on the number of applications for charity care denied due to lack of complete documentation against the average charity care write off at cost per qualified patient. We believe the amount is minimal based on our extensive efforts to educate patients and staff about our various payment plans and financial grant programs 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, payment programs, or a combination of the above. Due to these efforts, we believe that amounts written off to bad debt that could qualify as charity care is minimal. Part III, Line 4: See page 7 of the attached 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: As of 9/30/2011 Monadnock Community Hospital has a written credit and collection policy. Described within that policy are the collection practices and bad debt processes that are followed for patients who are known to qualify for charity care or financial assistance. The Organization maintains a Financial Assistance Program (FAP) database which is maintained by the Social Services Department of MCH. The Patient Financial Services (PFS) staff reference this database for approval status and eligibility amounts, identifying any account(s) where the discount will apply. Internal FAP insurance plans are applied to those accounts and related discount amounts are adjusted in the billing system. Remaining balances are expected to be paid in full by the patient. Payment plans may be requested by the patient and are established by the Financial Grant Coordinator based on the patient's available income and assets. Accounts are annotated to reflect payment arrangements. During bad debt processing, designated staff evaluate accounts listed as collection review for potential bad debt write off. This process includes an examination of account history for indication of FAP application. Part VI, Line 2: The State of NH, under RSA 7:32-f, requires every healthcare charitable trust, either alone or in conjunction with other healthcare charitable trusts in its community, to conduct a Community Health Needs Assessment to assist in determining the activities to be included in its community benefits plan. The needs assessment process includes consultation with members of the public, community organizations, service providers, and local government officials in the entity's service area to identify and prioritize the community needs that the health care entity can address directly or in collaboration with others. The Community Health Needs Assessment is updated at least every 5 years, most recently in 2015. In 2007, the Regional Community Benefits Steering Committee was first formed to prepare a single Community Benefits Needs Assessment for the Monadnock Region. The work group consisted of representatives from multiple organizations, including Monadnock Community Hospital. Based on the needs assessment and community engagement process, the priority needs and health concerns of the community MCH serves include access to care - driven by financial barriers and/or availability of primary care, availability of behavioral health care, general socioeconomic issues, and transportation services. Monadnock Community Hospital used this information to help focus its community benefit efforts to meet the priority needs identified in the community benefit plan. In addition, other needs or services not specifically identified in the community needs assessment, but addressed under the Organization's community benefit plan include availability of dental or oral health care (via the Organization's Monadnock Healthy Teeth to Toes program which focuses on dental hygiene and care, nutrition, and daily physical activity for children ages kindergarten to third grade) and availability of prescription medication (via the Organization's Medication Bridge program designed to help eligible patients apply for assistance programs that provide free or discounted prescription medications). Part VI, Line 3: MCH is committed to providing quality healthcare to anyone in need of services, regardless of ability to pay. We understand patients may not have the finances to pay for their healthcare services and medications, and do not want this to prevent anyone from receiving necessary treatment. As part of the Hospital's mission to the communities we serve, we have developed programs to help meet the needs of our patients who meet income eligibility. Through our Financial Assistance and Medication Bridge Programs, we have been providing financial assistance to those qualifying for many years. We reach out to our patients in many different ways to ensure they are aware that help is available and to guide them through the process. Brochures and signage are posted in high traffic areas and all employees of MCH are informed about the Financial Assistance Program during orientation. When a patient goes through the registration process at the Hospital the staff are trained to inform uninsured or underinsured patients about the Monadnock Community Hospital Financial Assistance and the New Hampshire Health Access programs and that there is assistance available within the Hospital to help with the application process. In addition, any time a patient calls customer service, the representative is trained to help identify and offer support to patients who may require financial assistance. Patients may qualify for free care, discounted care, payment plans or a combination of the above. Assistance is also provided in applying to federal and state programs for those who qualify. Part VI, Line 4: The Hospital's primary service area consists of 13 towns, including Antrim, Bennington, Dublin, Francestown, Greenfield, Greenville, Hancock, Jaffrey, New Ipswich, Peterborough, Rindge, Sharon, and Temple. The Hospital serves the general population of the primary service area referenced above. Part VI, Line 5: Monadnock Community Hospital is a critical access hospital located in the Monadnock Region of NH. Our mission is to improve the health and well-being of our community. The Hospital is served by a board of trustees consisting of local citizens active in their community and its organizations. The majority of the board is not employed by the Hospital and consists of local community and business representatives as well as medical staff. The Hospital is committed to giving back to the community to the greatest extent possible. Monadnock Community Hospital supports thousands of individuals and families with free or reduced-fee services and programs. Our Financial Assistance Program administered by the Social Services Department helps families and individuals in need with access to health care and other available community services such as catastrophic care, fuel assistance, meals on wheels, food banks, and visiting nurses. Other examples of the Hospital's effort to reach our patients beyond traditional hospital services include access to free or reduced cost medications through our Medication Bridge program; educating children on the importance of good oral hygiene, eating health, and daily physical activity through our Monadnock Healthy Teeth to Toes program; training for community agencies such as local volunteer fire and rescue personnel; prevention and wellness education including nutrition, smoking cessation and dealing with stress; providing regular community seminars regarding timely health topics; and screenings for important health issues such as breast cancer. These are just a few of the many areas where we are reaching out to others to assure they are cared for well. Part VI, Line 6: N/A Part VI, Line 7, Reports Filed With States NH 1 Town of Peterborough 1 Grove Street Peterborough NH 03458 Government 15000 Cash contribution for the benefit of the Peterborough Ambulance. 1 Scholarships awarded in order to provide financial support to MCH employees who would like to further their careers in health care through educational advancement. 5 6000 Part I, Line 2: During the fiscal year ending September 30, 2016, the Hospital made contributions to a governmental entity, the Town of Peterborough, additional monitoring is not deemed necessary with respect to this grant. Additionally, during the fiscal year, the Hospital established the Peter L. Gosline Employee Education Scholarship to support professional growth of Hospital employees. Both full and part-time employees are eligible to submit an application. The applicant must be a current Hospital employee in good standing who has been employed at MCH for at least 12 months. The applicant must also be currently enrolled in a degree or certificate program, provide a letter of recommendation from their current Hospital manager, as well provide a copy of their current college transcript. X X X X 0 1 0 0 0 0 0 1 0 Richard Frechette MD Ex-Officio w/voting rights (part yr) 221988 0 0 0 2102 0 4245 0 28179 0 256514 0 0 0 Gregory Kriebel MD Ex-Officio w/voting rights 236678 0 0 0 838 0 4772 0 17528 0 259816 0 0 0 Terrence McNamara DO Ex-Officio w/voting rights 402626 0 60644 0 14059 0 5300 0 17069 0 499698 0 0 0 Fay Migotsky MD Medical Staff President 130663 0 0 0 1648 0 2580 0 16745 0 151636 0 0 0 Cynthia McGuire Chief Executive Officer 242964 0 0 0 1290 0 17500 0 22205 0 283959 0 0 0 Richard D Scheinblum VP Finance/CFO 176438 0 0 0 450 0 3580 0 6113 0 186581 0 0 0 Philip Vuocolo MD Physician 399615 0 0 0 1369 0 5300 0 28300 0 434584 0 0 0 Ronald Michalak MD Physician 477911 0 0 0 478 0 5300 0 16711 0 500400 0 0 0 Douglas Weiss MD Physician 458312 0 0 0 12303 0 5300 0 6400 0 482315 0 0 0 Shawn Harrington MD Physician 400196 0 2844 0 478 0 5300 0 17225 0 426043 0 0 0 Robert C Knowles MD Physician 388093 0 0 0 14473 0 5300 0 18028 0 425894 0 0 0 Part I, Line 4b Cynthia McGuire, President & CEO, participates in a 457(f) plan with Monadnock Community Hospital. After a three-year vesting period which began in 2014, there will be a 457(f) amount included in W-2 wages for Ms. McGuire reported on Schedule J, Part II, Column B(iii). This amount will be comprised of interest and deferred compensation that was previously included in Schedule J, Part II, Column C. On June 21, 2016, $17,500 was deposited into Ms. McGuire's 457(f) plan account for calendar 2015 which will be reported on the Hospital's 2016 Form 990, Schedule J, Part II, Column C for the fiscal year ending September 30, 2017. The 457(f) amount that will be included in W-2 wages after the three-year vesting period properly accounts for the elimination of substantial risk of forfeiture. Part I, Line 7 MCH compensates physicians utilizing productivity targets based on RVU (relative value units). In addition, the Compensation Committee recommends to the full board, annually, the variable pay award that may be issued to the Hospital's CEO. The payment of the award is discretionary and is subject to meeting the pre-determined goals of the Organization. A NHBFA Revenue Bonds Series 2013 021304598 2013-01-01 27240000 refinance existing Series 2007 and 2009 bonds 0 0 0 A 27240000 27057466 182534 2013 0 1 1 1 A 0 1 1 1 1 1 0.00000 0.00000 0.00000 0 0 0 A 0 0 1 0 1 0 0 0 0 A 0 Schedule K, Part III, Line 9, Part IV, line 7 and Part V: Although formal policies are not in place in regards to the remediation of our bond, the monitoring requirements of section 148, and procedures to ensure that violations are timely identified and corrected, Mondanock Community Hospital has compliance checks in place that substantiate these requirements. Below is a list of all compliance checks that Monadnock Community Hospital has in place to monitor the 2013 Bond Issue: 1. Covenant calculations performed monthly as part of the Financial Scorecard preparation which is reviewed by the MCH Board of Trustees; 2. Covenant calculations are performed for each quarter and reported to the bond issuer, TD Bank; 3. Covenant certificate is signed each quarter by the CFO and reported to the bond issuer, TD Bank; 4. Financial statements and statistical reports are sent to the bond issuer, TD Bank, on a quarterly basis; 5. Annual Operating and Capital budgets are reported to the bond issuer, TD Bank; 6. A No Event of Default certificate is signed by the CFO annually and reported to the bond issuer, TD Bank; 6. Annual Audited Financial statements are reported to the bond issuer, TD Bank. Each of these items that are reported to TD Bank has a specific deadline for completion as outlined in the bond documents. Terrence McNamara DO Trustee Assistance to repay student loans X 60000 12347 0 1 1 Douglas Weiss MD Highest Compensated EE Assistance to repay student loans X 50000 20650 0 1 1 Robert C Knowles MD FACS Highest Compensated EE Malpractice Tail Coverage X 60000 24780 0 1 1 57777 Peter L Forssell MD Board Member 20040 The Hospital rents a medical office space from Dr. Forssell at a fair market rate. Though the transaction amount is below the threshold for disclosure, the Hospital is reporting it on Schedule L, Part IV for transparency purposes. 0 Schedule L, Part II: The Hospital has entered into loan agreements with several physician employees. Three physicians listed in Form 990, Part VII have been involved in the loan program, though the Hospital has loans with other physician employees as well. In all instances, the loans were a part of a written policy that was pursuant to a written contract and approved by the board. The board also reviews on an annual basis the status of all physician loans not more than 180 days after the fiscal year end. Each loan will accrue interest at a rate of prime plus 1% or 2%. The loans will be forgiven over the terms of the notes. The amount of loan forgiveness, along with imputed interest, will be included in the recipients' IRS Form W-2 or IRS Form 1099-MISC as taxable compensation in the year forgiven. The details of the loan forgiveness which is reported on Schedule J, Part II, Column B(iii) for the respective recipients as follows:Dr. McNamara - $13,560 (inclusive of $1,560 of interest)Dr. Weiss - $11,300 (inclusive of $1,300 of interest)Dr. Knowles - $13,560 (inclusive of $1,560 of interest) X 4 26806 Fair Market Value 0 0 1 Part I, Line 32b: The Hospital uses its third party investment broker to sell gifts of publicly traded securities. Donations of such securities are sold as soon as administratively possible. Form 990, Part VI, Section A, line 4 The maximum number of Trustees allowable per the organization's bylaws was increased from fifteen to sixteen. The article allowing the Board of Trustees to delegate the approval of Medical Staff Clinical Department Chairs to the Medical Staff Executive Committee was removed from the bylaws. Form 990, Part VI, Section B, line 11 The Hospital's Form 990 is prepared with assistance by an independent public accounting firm. A draft of the Form 990 is initially reviewed in detail by key finance employees. Thereafter, the final draft is made available to the full board prior to filing with the IRS. Form 990, Part VI, Section B, line 12c On an annual basis, the Organization provides all administrators/directors/ managers, Board Members, and medical staff members with the conflict of interest policy. Said individuals are required to complete a new conflict of interest disclosure on an annual basis. Any conflicts of interest noted are reviewed by the Chair of the Board in conjunction with the Corporate Compliance Officer. If the conflict of interest appears to meet the policy definitions requiring full Board review, the President of the Board takes this to the full Board meeting, it is discussed, and appropriate action is taken (in compliance with state and federal requirements). The conflict of interest statement requires signatories to inform the Hospital of any conflict of interest that occurs at any time throughout the year. If a conflict of interest arises during the year, it is reviewed by the Compliance Officer, and if necessary, is taken to the Board President/Board. The Compliance Officer confers with legal counsel with regard to conflicts of interest, if there is any question regarding the potential conflict. Form 990, Part VI, Section B, line 15 The Organization has a written executive compensation policy and procedure. Under this policy, the Compensation Committee, comprised of delegated representatives of the Board of Trustees, has the power and responsibility to determine the Hospital's approach to executive compensation and review of the performance of the CEO. The Compensation Committee has the responsibility to set, monitor and review the base salary of the CEO. The Committee maintains minutes of sessions and final recommendations and determinations in accordance with the Board of Trustee guidelines. Annually, market data is reviewed by the Committee to determine the appropriate salary for the Hospital's CEO based upon identified standards. At the end of the time period, the Committee reviews to what extent stated goals were met and recommends an amount for the variable pay award to be approved by the full board. Form 990, Part VI, Section C, line 19 Monadnock Community Hospital files audited financial statements annually with the New Hampshire Attorney General's Charitable Trust Unit and informs the Director of Charitable Trusts of pecuniary benefit transactions that have occurred between MCH and a board member or officer. Notices of such transactions of $5,000 or more are also published in the local newspaper in accordance with NH RSA 7:19-A, II(D). Current copies of the bylaws, conflict of interest Policy and Form 990 are on file with the Charitable Trust Unit. The Hospital also 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: Director Compensation The 2015 compensation reported for Dr. Kriebel, Dr. Frechette, Dr. Migotsky, and Dr. McNamara was paid by Monadnock Community Hospital for their services as physicians. No part of their compensation was remuneration for their services as an ex-officio voting members of MCH's Board of Trustees. Form 990, Part XI, line 9: Change in fair value of interest rate swap agreements -41,119. Form 990, Part XI, Line 2c: Audit Review Process The Audit Committee oversees the audit process for Monadnock Hospital. The audit process for the financial statements did not change from the prior year. Independent accountants performed the audit for the fiscal years ended 9/30/15 and 9/30/16. Form 990: During the fiscal year covered by this return, Monadnock Community Hospital began engaging in negotiations to become affiliated with Huggins Hospital of Wolfeboro, New Hampshire and Catholic Medical Center of Manchester, New Hampshire. An Affiliation Agreement was fully executed on June 29, 2016. Huggins Hospital, Monadnock Community Hospital, and Catholic Medical Center each submitted the required notice to the Charitable Trust Unit in the Office of the New Hampshire Attorney General on July 7, 2016. Each hospital submitted a joint request for approval to the Attorney General's Consumer Protection and Antitrust Bureau on July 7, 2016. The Director of Charitable Trust Unit issued its report of approval on November 3, 2016. The New Hampshire antitrust bureau approved the affiliation on December 9, 2016 and was effective on December 30, 2016. As this affiliation was formally effectuated after September 30, 2016 it will be disclosed in greater detail in Monadnock Community Hospital's Form 990 for the fiscal year ended September 30, 2017. For more information, see Footnote 1 in the attached audited financial statements. Monadnock Health Services - INACTIVE 452 Old Street Road Peterborough NH 03458 020420789 Inactive NH 501(c)(3) Line 11a, I Monadnock Community Hospital 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0