2017-08-14T10:05:36-05:00 2016-09-30 010494526 BAKER NEWMAN & NOYES LLC 650 ELM STREET SUITE 302 MANCHESTER NH 03101 990 2015-10-01 020222791 Alice Peck Day Memorial Hospital ALIC 6034483121 10 Alice Peck Day Drive Lebanon NH 03766 Susan E Mooney MD MS President & CEO 6034483121 2017-08-09 1 Nicholas E Porto P01310283 8002447444 2015 2021-01-29 14:40:06Z Susan E Mooney MD MS 10 Alice Peck Day Drive Lebanon NH 03766 63056908 0 X www.alicepeckday.org X 1943 NH Critical Access Hospital 21 12 602 35 0 0 618614 1152108 63447169 61540202 198040 -770893 19 0 64263842 61921417 35150 27500 0 0 36019107 35770947 0 0 163254 26816337 26285377 62870594 62083824 1393248 -162407 47766765 45079639 28468893 26473105 19297872 18606534 X The mission of Alice Peck Day Health Systems is to provide personalized, highest quality, patient-focused healthcare services which are responsive to community needs, promote wellness, and continually improve the quality of healthcare in the community. 0 0 58887892 27500 61540202 Alice Peck Day Memorial Hospital is a community-based critical access hospital operating in Lebanon, NH. The Hospital began as a small cottage hospital in 1932. From its humble beginnings, Alice Peck Day has continually demonstrated its commitment to provide patient-focused health care services which improve the quality of life within its community and promote wellness for all. Alice Peck Day Memorial Hospital is a charitable health care organization which is dedicated to serving its community. This commitment includes granting credit to patients, substantially all of whom are local residents. The Hospital provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than the established rates. Collections are not pursued for amounts determined to qualify as charity care. The Hospital maintains records to identify and monitor the level of charity care it provides. These records include the amount of charges foregone for services and supplies furnished under its charity care policy, the established costs of the services and supplies provided, and equivalent service statistics. For the fiscal year ended September 30, 2016, charity care at a cost of $374,682 was provided to eligible patients. Estimated costs incurred in excess of payment for inpatient and outpatient services for Medicaid patients in the fiscal year ended September 30, 2016 were $3,475,083. In addition to the charity care services described above, the Hospital provided a number of other services for which little or no payment was received. These included: community flu clinics, the Upper Valley Smiles Dental Program (free oral health education, screenings, and preventive treatment offered to low-income children in ten local elementary schools), assistance with enrollment into prescription assistance and state health insurance programs, health professional education, emergency pharmacy vouchers for uninsured patients, and childbirth education classes.As a local hospital, Alice Peck Day works closely with community organizations to address community needs. Organizations that were beneficiaries of hospital staff time, meeting space, cash and/or materials include: Alcoholics Anonymous, American Heart Association GO RED campaign, American Red Cross, Geisel School of Medicine at Dartmouth, Good Neighbor Health Clinic, Grafton County Senior Citizens' Council, Hartford School District, Headrest, Healthy Eating, Active Living (HEAL) partnership, Lebanon School District, Mascoma School District, NH March of Dimes, Richards School in Newport, SPARK Community Center, Town of Dorchester, Upper Valley Aquatic Center, Upper Valley Oral Health Coalition and the Upper Valley Public Health Council. In certain instances, assistance was provided to the community for which no value can be placed. This assistance included leadership in identifying community needs, staff commitment to volunteer for community organizations, advocacy and support for the socially and physically disadvantaged, and support for local public safety organizations. Alice Peck Day considers caring for our community a special responsibility that we are honored to fulfill. Through our many programs, dedicated staff and unwavering commitment to quality care, Alice Peck Day works to exceed these expectations and make a real difference in our community. 58887892 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 X 73 0 1 602 1 0 0 0 0 0 0 0 0 0 0 X 21 12 0 1 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X X Todd Roberts 6034483121 10 Alice Peck Day Drive Lebanon NH 03766 X Robert J Bauman Trustee 1.00 1.00 X 0 0 0 George T Blike Trustee 1.00 40.00 X 0 449299 210887 Claudia C Gibson Trustee 1.00 0.00 X 0 0 0 Edward T Kerrigan Trustee 1.00 3.00 X 0 0 0 Gay L Landstrom Trustee (part year) 1.00 60.00 X 0 597242 44071 George W Lange Trustee 1.00 0.00 X 0 0 0 Anne D MacEwan Trustee 1.00 2.00 X 0 0 0 Mark E Melendy Trustee 1.00 3.00 X 0 0 0 Edward J Merrens MD Trustee 1.00 40.00 X 0 469611 67751 Tina E Naimie Trustee 1.00 41.50 X 0 234879 23643 Mary M Oseid Trustee 1.00 40.00 X 0 263800 189207 Brett C Peltzer Trustee 1.00 1.00 X 0 0 0 Brenan Riehl Trustee 1.00 0.00 X 0 0 0 Roderic O Young Trustee 1.00 40.00 X 0 311382 45595 Richard S Jennings Trustee (part year) 1.00 3.00 X 0 0 0 Wendell M Smith Trustee (part year) 1.00 2.00 X 0 0 0 Judson T Pierson Trustee (part year) 2.00 2.00 X 0 0 0 Karen G Kayen Trustee (part year) 1.00 2.00 X 0 0 0 Michael F Long Chair 2.00 1.00 X X 0 0 0 Rev Dr Guy J D Collins Vice Chair 2.00 3.00 X X 0 0 0 Bruce N Johnstone Treasurer 2.00 2.00 X X 0 0 0 Martha P Candon Secretary 2.00 1.00 X X 0 0 0 Susan E Mooney MD MS President & CEO 50.00 11.00 X X 381958 20103 54693 Kathryn M Vargo MD Medical Staff President 30.00 1.00 X X 220829 0 55399 Beverley A Rankin RN BSN VP Patient Care, CNO 60.00 0.00 X X 214527 0 54131 Randall D Lea MD MPH VP & Chief Medical Officer 28.00 1.00 X X 202429 0 39383 Evalie M Crosby CPA FHFMA VP of Finance & CFO (end 2/16) 40.00 20.00 X 195080 48771 41452 Michael P Connelly CPA Interim CFO (2/16 - 10/16) 40.00 20.00 X 0 0 0 J Todd Miller MS VP & COO 40.00 20.00 X 165067 41267 33548 Diane C Riley MD CAQSH Orthopaedic Surgeon 40.00 0.00 X 437040 0 40905 Paul Sansone MD Pain Management MD 40.00 0.00 X 436762 0 51871 Leonard M Rudolf MD Orthopaedic Surgeon 40.00 0.00 X 490599 0 57249 John P Houde MD Orthopaedic Surgeon 40.00 0.00 X 512554 0 57281 Ivan Tomek MD Orthopaedic Surgeon 40.00 0.00 X 554693 0 53779 3811538 2436354 1120845 43 0 1 0 Upper Valley Neurology 106 Hanover Street Lebanon NH 03766 Professional Services 2966819 Navin Haffty & Associates LLC 1900 W Park Drive Westborough MA 01581 Temp Employee Services 400954 GE Medical Systems Information Technolog 8200 W Tower Avenue Milwaukee WI 53223 Medical Imaging Services 174635 Combined Services LLC 2 Delta Drive 301 Concord NH 03301 Payroll Services 165264 4 18667 26000 1107441 7918 1152108 Patient services 621400 63488761 63488761 Other operating 621400 688856 688856 Nutritional services 722210 87290 87290 Provision for Bad Debt 621400 -2724705 -2724705 61540202 127744 127744 24072 24072 0 212782 91357 1020062 121425 -1020062 -898637 -898637 61921417 61540202 0 -770893 X 27500 27500 1640760 866467 774293 29075816 28409752 560540 105524 484449 476848 5485 2116 2605342 2504050 89885 11407 1964580 1892223 64208 8149 80370 80370 63177 63177 84499 84499 16118 16118 7382040 7044831 330152 7057 68164 68164 1041173 850853 184820 5500 109646 103768 5850 28 1117719 1044425 67303 5991 169319 161016 8187 116 447426 447426 1611011 1473668 128893 8450 804699 801023 3450 226 Medical supplies/equipm 9603423 9596629 6410 384 Medicaid Enhancement ta 2501113 2501113 Equipment rental/mainte 664205 646696 17491 18 MRI Expenses 418405 418405 102870 68625 25957 8288 62083824 58887892 3032678 163254 68440 368891 8434054 9814339 537081 114301 10563099 9980697 1162166 1148993 434276 456436 45715994 29414254 17158840 16301740 4334795 4676212 8500 8500 104978 266872 4960536 1942658 47766765 45079639 11322921 8873731 16016656 16191501 682735 640411 446581 767462 28468893 26473105 X 18890082 18251337 377522 323352 30268 31845 19297872 18606534 47766765 45079639 X -162407 265642 -794573 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 9743 0 0 1 6375 16118 0 Part II-B, Line 1: The Organization pays dues to the New Hampshire Hospital Association and the American Hospital Association, a portion of which are attributable to lobbying activities. Also, APD belongs to the 10 Mile CAH Coalition which engaged Strategic Health Resources (SHR) for purposes of furthering lobbying efforts with regards to attempts to eliminate CAH status. The CEO participates in periodic telephone calls with this group in attempts to keep the issue of rural healthcare and the key role that CAHs play in rural healthcare in front of the various legislative delegations 30268 1577 31845 30883 -615 30268 30452 431 30883 27686 2766 30452 25840 1846 27686 0.00000 1.00000 0.00000 0 0 927577 927577 20245809 11496350 8749459 255968 192306 63662 22337556 17725598 4611958 1949084 1949084 16301740 Current Portion of Deferred Annuities 17645 Medical Liability Payable 490000 Longterm Deferred Annuity 32347 Estimated Third-Party Payor Settlements 227470 767462 X 61416558 265642 24072 289714 61126844 794573 794573 61921417 62107896 24072 24072 62083824 0 62083824 Part V, Line 4: The Organization uses the income from its endowment funds for use in operations. Part X, Line 2: Under the State of New Hampshire's tax code, the State imposes a Medicaid enhancement tax (MET) equal to 5.4% of Hospital net patient service revenues in State fiscal year 2016 and 5.5% in State fiscal year 2015, with certain exclusions. The amount of tax incurred by the Obligated Group for 2016 successor period, 2016 predecessor period and fiscal 2015 predecessor period was $1,458,983, $1,042,130 and $2,383,887, respectively. In the fall of 2010, in order to remain in compliance with stated federal regulations, the State of New Hampshire adopted a new approach related to Medicaid disproportionate share funding retroactive to July 1, 2010. Unlike the former funding method, the State's approach led to a payment that was not directly based on, and did not equate to, the level of tax imposed. As a result, the legislation created some level of losses at certain New Hampshire hospitals, while other hospitals realized gains. In the 2016 successor period, 2016 predecessor period, and fiscal 2015 predecessor period, the Obligated Group recognized disproportionate share funding (net of related reserves and changes in estimates) totaling $(215,725), $702,168, and $4,373,676, respectively. Currently the State makes disproportionate share hospital payments to support up to 75% of the actual uncompensated care costs for New Hampshire's hospitals with critical access designation. The Centers for Medicare and Medicaid Services (CMS) has completed audits of the State's program and the disproportionate share payments made by the State in 2011 and 2012, the first years that those payments reflected the amount of uncompensated care provided by New Hampshire hospitals. It is possible that subsequent years will also be audited by CMS. The Hospital records changes in accounting estimates relative to established reserves in the period additional information such as indications of adjustments, are received. A contingency currently exists relative to the treatment of provider taxes in New Hampshire for Hospital fiscal years 2011 through 2015. Although the Medicare Administrative Contractor has issued the 2011 Notice of Program Reimbursement with the New Hampshire tax included as a reimbursable expense, a concurrent Reopening Notice was issued in the event CMS changes its policy on the reimbursement of provider taxes. Management estimates a maximum potential negative impact of $3,754,000 as a result of the treatment of provider taxes in New Hampshire for fiscal years 2011 through 2015. As of the date of these financial statements, management has not provided a specific reserve for the potential reopening of 2011 or final settlement of 2012 through 2015. An unfavorable outcome or likelihood cannot be currently assessed. The Obligated Group consists of not-for-profit corporations as described in Section 501(c)(3) of the Internal Revenue Code, all of which are exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. Management evaluated the Obligated Group's tax positions and concluded the Obligated Group 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 the combined financial statements, other than the contingency discussed in the Medicaid Enhancement Tax, Medicaid Disproportionate Share, and Certain Contingencies section above. Part XI, Line 2d - Other Adjustments: Rental Expenses 24,072. Part XI, Line 4b - Other Adjustments: Application of Push Down Accounting 794,573. Part XII, Line 2d - Other Adjustments: Rental Expenses 24,072. 1 1 1 X 275.000000000000 1 X 275.000000000000 1 1 1 0 1 1 335965 335965 0.00540 8583725 4858244 3725481 0.06000 8919690 4858244 4061446 0.06540 178222 178222 0.00290 49647 49647 0.00080 18492388 5640358 12852030 0.20700 18720257 5640358 13079899 0.21070 27639947 10498602 17141345 0.27610 6046 6046 0.00010 17393 17393 0.00030 23439 23439 0.00040 1 1585118 100000 19526319 19854531 -328212 X 1 1 1 1 Alice Peck Day Memorial Hospital 10 Alice Peck Day Drive Lebanon NH 03766 www.alicepeckday.org 00016 X X X X Physician Clinics Alice Peck Day Memorial Hospital 1 0 0 1 X X X X X X X X 15 1 1 1 1 X see Part V, Section C X See Part V, Section C X 1 15 1 see Part V, Section C 1 0 1 X 275.000000000000 275.000000000000 X X X X X X 1 1 X X X X 1 X see Part V, Section C X see Part V, Section C X see Part V, Section C X X X X X X 1 0 X X X X 1 X 0 0 Alice Peck Day Memorial Hospital Part V, Section B, Line 5: With a shared Hospital Service Area, Alice Peck Day Memorial Hospital collaborated with Dartmouth-Hitchcock in conducting the 2016 Community Health Needs Assessment. Technical expertise was provided by Community Health Institute, the NH affiliate of JSI, a nation-wide public health management consulting and research organization. Input from the joint hospital service area, in an effort to hear from community residents and key stakeholders was gathered using a multi-pronged strategy: 1) a community survey was completed by 1,566 individuals. These surveys were available through town listings, at primary care clinics, a homeless shelter, free community dinners, senior housing projects and other community locations. 2) An online key stakeholder survey was completed by 69 community leaders and service providers, representing the following sections: Human Service/Social Service, Education/Youth Services, Municipal/County Government, Mental/Behavioral Health, Home Health Care, Primary Health Care, Medical Subspecialty, Public Safety/Fire, Public Health, Community Members, Dental Health Care, Emergency Medical Service and the Business Sector. 3) In an effort to get input and community-level context on health issues that matter to the community, four discussion groups were convened representing a variety of key community sectors: business leaders, teenage mothers, low income families and the United Valley Interfaith Project. Alice Peck Day Memorial Hospital Part V, Section B, Line 6a: Alice Peck Day Memorial HospitalDartmouth-Hitchcock Medical CenterNew London Hospital Valley Regional Hospital Mt. Ascutney Hospital and Health Center Alice Peck Day Memorial Hospital Part V, Section B, Line 6b: Technical assistance for the Hospital's 2015 CHNA was provided by Community Health Institute. Alice Peck Day Memorial Hospital Part V, Section B, Line 11: Please see attached Implementation Plan. Alice Peck Day Memorial Hospital Part V, Section B, Line 13h: Alice Peck Day Memorial Hospital offers financial assistance to patients demonstrating need. In making the need determination, APD participates with and honors the founding principles and guidelines of the New Hampshire Health Access Network (NHHAN). Accordingly, decisions regarding the granting of financial assistance will be based primarily on a patient and his or her household income and assets. There will be minimal consideration of expenses except when they identify areas for further investigation or incomplete or inaccurate information. The value of a patient's principal residence is not considered in qualifying a patient for in-house assistance. APD requires exhaustion of other payment methodologies, including but not limited to, Worker's Compensation, Veterans Benefits, Medicaid, liability (auto accidents), victims of crime, and COBRA. When applicable, proof of determination may be required prior to consideration for financial assistance. Alice Peck Day Memorial Hospital Part V, Section B, Line 16i: Please see Part V, Line 3 for a description of the financial assistance program and the efforts made to publicize and promote the program. Alice Peck Day Memorial Hospital Part V, Section B, Line 22d: The hospital facility provides uninsured patients with a 35% discount. At the time the discount was established, the discount approximated the average of the three lowest negotiated commercial insurance rates for services at the hospital facility. The average of the three lowest commercial insurance rates was approximately 87.5%; the rate applied to uninsured patients was lower than that rate, at 65%, representing a 35% discount. Part V, Line 7a & 7b: CHNA can be found on the Hospital's homepage at:http://www.alicepeckday.org/assets/FY2016_APDH_Community_Health_Needs_Assessment.pdfOther websites:http://www.mtascutneyhospital.org/community-services/community-resources/community-health-needshttp://www.dartmouth-hitchcock.org/documents/pdf/FY16-18%20CHNA.pdf Part V, Line 10a: Implementation Plan can be found at: http://www.alicepeckday.org/assets/APDMH_CH_Implementation_Plan_2017.pdf 8 1 - RAM Center for Community Care 5 Alice Peck Day Drive Lebanon NH 03766 Primary Care Physician Clinic 2 - Women's Care Center 141 Mascoma Street Lebanon NH 03766 OB/GYN Physician Clinic 3 - APD Orthopaedic Clinic 17 Alice Peck Day Drive Lebanon NH 03766 Orthopaedic Physician Clinic 4 - General Surgery Clinic 10 Alice Peck Day Drive 12 Mascoma St Lebanon NH 03766 General Surgeon Clinic 5 - Pain Management Clinic 17 Alice Peck Day Drive B Lebanon NH 03766 Pain Management Clinic 6 - APD Hand & Upper Extremity Clinic 205 Billings Farm Road Unit 3A White River Junction NH 05001 Hand & Upper Extremity Orthopaedic Physician Clinic 7 - Occuptational Health Services 127 Mascoma Street 2nd Floor Lebanon NH 03766 Occupational Health Physician Clinic 8 - Neurosurgery Services at APD (NSAPD) 106 Hanover Street Lebanon NH 03766 Neurosurgery Physician Clinic Part I, Line 3c: Family income limit for eligibility for discounted care ranges from 200%-275% of FPG. Part I, Line 7: The costs of charity care and means-tested programs are calculated using the facility-wide cost to charge ratio as calculated in Worksheet 2. Subsidized health services are calculated using the cost to charge ratios per service area, using a step-down cost allocation methodology consistent with Medicare cost report methodology. The cost of financial assistance and other community benefits at cost are 27.60% of total expenditures on Form 990, Part IX, Column A, Line 25, excluding bad debt expense. Part II, Community Building Activities: Alice Peck Day actively promotes community-based leadership development. Staff members participate in the Lebanon Chamber of Commerce, Foundation for Healthy Communities, the Rural Health Coalition, and the Advocacy Task Force. As an active member of the community, APD works to be proactive concerning disaster readiness. Staff have participated in onsite training for disaster preparedness as well as off-site training with other regional hospitals. Collaborative efforts include all hazard regional training, emergency response training, and a regional mass casualty response program to help facilitate cooperative efforts if such needs arise. Part III, Line 2: Bad debt cost is calculated using a cost to charge ratio using a step-down cost allocation methodology consistent with Medicare cost reporting. In FY16, accounts written off to bad debt included gross charges being written off less any payments received against those charges. Any cash collected on accounts previously written off is included as an offset to bad debt expense as recoveries of bad debt. We estimated the amount of charity care in bad debt expense based on the number of applications for charity care. We believe the amount is minimal based on our extensive efforts to educate our patients and staff about our various payment plans and charity care to ensure that patients who qualify for any of our programs utilize them. Depending on the specific circumstances, a patient may be eligible for charity care, discounted care, time-payment programs, or a combination of the above. Due to these efforts, we feel that amounts written off to bad debt that could qualify as charity care are minimal. Footnote 2 of the audited combined financial statements includes the following to address bad debt: Accounts receivable are stated at the amount management expects to collect on outstanding balances. Management provides for possible uncollectible amounts through a charge to operations and a credit to the valuation allowance based on its assessment of individual accounts and historical adjustments. Accounts deemed uncollectible are written off through a charge against the established allowance. Part III, Line 3: See narrative for Schedule H, Part III, Line 2 and Line 4. Part III, Line 4: See Footnote 2 on Page 11 of the attached audited financial statements. Part III, Line 8: Medicare allowable costs for the Medicare Cost Report are reported in accordance with CMS guidelines using the cost to charge ratio methodology. Part III, Line 9b: Our bad debts collection policy applies to all patient accounts in a consistent manner. The policy specifically indicates that, after a second statement is sent with no payment received, a patient accounts representative will contact the patient by phone to determine if a financial assistance application or payment plan is appropriate. This is completed to avoid further escalation of past due account(s) if the patient may qualify for full or partial relief under the charity care policy. If the application is successful, then the qualifying balance or balances are classified as charity care and no longer pursued for collections. Once a patient balance is classified as charity care, it is not subject to collection activities. Alice Peck Day is committed to helping our patients obtain quality healthcare, regardless of ability to pay. Our financial assistance programs encourage and enable our patients to make healthcare decisions free of financial barriers. We educate our patients about our programs and provide assistance prior to their receiving services, at registration for services, and during our billing process to ensure that any and all patients in need of assistance are provided with the help they qualify for under APD programs. Brochures and signs are placed in high traffic areas such as the ER and registration. Our staff is trained to identify patients during registration, provide information, and offer assistance in completing the necessary forms. During our billing process, calls are made to patients with outstanding balances. APD staff work with patients to identify problems they are facing in dealing with outstanding balances. Patients are notified again of the many types of financial assistance available for which they may qualify. Programs are explained and assistance is offered, if needed, in completing the applications. Due to this multi-level approach and staff that is trained to identify clients who may need financial assistance, very few qualifying patients reach the point of bad debt. Our collection policies and procedures, in conjunction with our small size, allow our organization to place great emphasis on helping all patients who may be in need to apply for, and obtain, the appropriate level of financial assistance. Schedule H, Part V, Section B, Line 16a-16c: Financial Assistance Policy, Financial Assistance Policy Application, and Plain Languange Summary can be found at: www.alicepeckday.org/patients/financial_services/financial_assistance/ Part VI, Line 2: In addition to completing a comprehensive needs assessment every three years, the organization's Community Health Director serves on the Steering Committee of the Public Health Council of the Upper Valley, one of the State of New Hampshire's 13 regional health networks, which also serves 22 communities in Vermont. The PHC is comprised of community leaders and representatives from multiple community sectors, working together to set regional health priorities, provide guidance to regional public health activities, and ensure coordination of health improvement projects. In 2014, the PHC created the Upper Valley Agenda for Public Health, and the following year, the 2015-2017 Upper Valley Community Health Improvement Plan. The Public Health Council provides a "finger on the pulse" of the community, and by serving in a leadership role, Alice Peck Day Memorial Hospital is able to stay abreast of the health care needs of our local service area. Part VI, Line 3: Alice Peck Day believes that quality health care should be available to all, regardless of ability to pay. Our financial assistance programs and staff are dedicated to helping people obtain the care they need. We reach out to our patients in many different ways to ensure that they are aware that help is available and to help guide them through the process. Brochures and signage are posted in high traffic areas such as the emergency room, registration, and the lobby. Registration staff are trained to identify patients who may be in need of financial assistance. Once identified, staff notify the patient that APD has various forms of financial assistance and explain that assistance is available for anyone who might require help or guidance in completing any necessary paperwork. In addition to the above, our billing staff are trained to help identify and offer assistance to anyone who might require financial assistance. Patients with outstanding claims are contacted by our credit coordinator who works with them to clear up balances through the variety of programs we offer. Assistance is also provided in applying for federal/state programs to those who qualify. Specially trained staff guide applicants through the process to ensure forms are filled out correctly, all required documentation is attached, and the applicants understand what they can expect to happen along the way. Part VI, Line 4: Alice Peck Day Memorial Hospital is part of the Lebanon Health Care service area. The Lebanon service area comprises cities and towns in New Hampshire and Vermont. APD's service area in NH comprises 15 towns in addition to the city of Lebanon, including Canaan, Cornish, Croydon, Dorchester, Enfield, Grafton, Grantham, Hanover, Lyme, Newport, Orange, Orford, Piermont, Plainfield and Warren. Vermont towns include East Thetford, Fairlee, Hartford, Hartland, North Hartland, North Thetford, Post Mills, Quechee, Sharon, South Strafford, Strafford, Thetford, Thetford Center, Vershire, West Vershire, West Fairlee, West Hartford, White River Junction and Woodstock.Alice Peck Day Memorial Hospital is part of the Lebanon Health Care service area. The Lebanon service area comprises cities and towns in New Hampshire and Vermont. APD's service area in NH comprises 15 towns in addition to the city of Lebanon, including Canaan, Cornish, Croydon, Dorchester, Enfield, Grafton, Grantham, Hanover, Lyme, Newport, Orange, Orford, Piermont, Plainfield and Warren. Vermont towns include East Thetford, Fairlee, Hartford, Hartland, North Hartland, North Thetford, Post Mills, Quechee, Sharon, South Strafford, Strafford, Thetford, Thetford Center, Vershire, West Vershire, West Fairlee, West Hartford, White River Junction and Woodstock.Demographics: Age: According to the 2013 American Community Survey, the population of the APD Service Area is slightly older on average than the New Hampshire and Vermont populations. 15.6% of the service area is over age 65, compared with 14.2% in New Hampshire and 15.2% in Vermont.Income, poverty and unemployment: 9.7% of children in the hospital service area live at or below 100% FPL, with 27.0% living below 200%FPL. The unemployment rate of 6.8% for the region is equal to the statewide rate for Vermont, and slightly lower than the statewide rate of 7.0% for New Hampshire.Education: A higher proportion of the hospital service area (93.9) have earned at least a high school diploma or equivalent compared to New Hampshire (91.8) and Vermont (91.4) overall.Language: The percent of the hospital service area, ages 5 or higher, who report speaking English "less than very well" is 1.6, compared with a statewide rate of 2.5% in New Hampshire and 1.5% in Vermont. Part VI, Line 5: In addition to initiatives to deliver affordable care to our under and uninsured patients through our Financial Assistance programs, the organization provides a wide variety of no-cost or low-cost programs and services for the community. We work in partnership with local and state agencies, including (but not limited to) the Lebanon, Mascoma, Hartford, Hartland and Newport school districts, the NH Division of Health and Human Services, NH Oral Health Coalition, the Public Health Council of the Upper Valley, and the Vermont Dept of Health. Among the free programs and services APD offers in response to demonstrated community need are: Cash support and an in-kind donation of space for the Good Neighbor Health Clinic; vouchers for emergency prescription assistance, and one-on-one assistance with applying for prescription assistance programs offered through drug companies; flu vaccinations for the community; health professions education to medical, nursing and allied health students; cash support to the Grafton County Senior Citizens Council, for transportation; cash donations to human service agencies; subsidized health education programs including Childbirth Education and Breastfeeding Support.APD's Community Health Department is well known in the region for Upper Valley Smiles, a unique school-based oral health program for low-income elementary school children enrolled in ten schools across the Upper Valley. The APD dental team visits each school annually, providing classroom oral health education, dental screenings, fluoride varnish, sealants and (in NH only) decay-stopping fluoride treatments and interim therapeutic restorations, all at little or no cost to parents. Part VI, Line 6: Alice Peck Day Memorial Hospital is a critical access hospital located in Lebanon, NH. The Hospital is served by a board of trustees consisting of local citizens active in community activities and organizations. The majority of board members are not employed by the hospital, and include local government and business representatives as well as practicing independent physicians. Despite its small size, APD is committed to giving back to the community to the greatest extent possible. During FY16, cash donations were given to organizations to help those in need. Local financial contributions helped support free primary care clinics for the uninsured, provided transportation for the elderly and disabled to receive medical care, and provided local nonprofit organizations with meeting space and refreshments. Alice Peck Day supported community flu clinics, provided emergency prescription drug vouchers, and bicycle safety rodeos for local children. Alice Peck Day Memorial Hospital's Department of Community Health is best known and celebrated locally for Upper Valley Smiles, a free school-based dental program that provides a critical safety net for low-income children in the Lebanon, Mascoma, Hartford, and Hartland school districts. During FY '16, the Upper Valley Smiles program of oral health education, dental screenings, preventive treatment, and referrals to dental offices was offered in ten elementary schools. 2,484 children received classroom oral health education, 755 children had a dental screening, 632 children received preventive care (5,142 sealants were placed), and 169 children were referred to a dental office for restorative treatment. To promote health professional education, APD provided clinical undergraduate/graduate training to students from the Geisel School of Medicine at Dartmouth, George Washington University, River Valley Community College, and Yale University. APD annually sponsors district-wide professional development for school nurses in our local area and for others within our region. These initiatives and ongoing efforts continue to address several of the most pressing community needs as identified in our community needs assessment.In 2014, the Board of Alice Peck Day Memorial Hospital, Inc. accompanied by the Board of Dartmouth-Hitchcock Health, Inc. (D-HH), approved an affiliation agreement between the Hospital and D-HH. This affiliation became effective on March 2, 2016 and for financial reporting purposes was deemed effective on March 1, 2016. As a result, the sole corporate member of the Hospital became D-HH. This agreement is intended to improve, integrate, and streamline patient care between the Hospital and D-HH, as well as other efficiencies that may be achieved through the affiliation. Part VI, Line 7, Reports Filed With States NH 1 Good Neighbor Health Clinic 70 North Main Street White River Junction VT 05001 030346949 501(c)(3) 7500 Support for free medical/dental care for uninsured. Grafton County Senior Citizens Council PO Box 433 Lebanon NH 03766 237248316 501(c)(3) 20000 Operational support for transportation services for area senior citizens. The Council provides lift-assisted buses with priority on medical transport for hospital or clinical appointments. 2 Part I, Line 2: As part of APD's Access Improvement Plan developed in 2003, Hospital staff and Board members identified the Grafton County Senior Citizens Council and the Good Neighbor Health Clinic (which also includes the Red Logan Dental Clinic) as essential to providing access to health care in the Upper Valley NH and White River VT areas. Based on the needed services provided, the Board approved on-going monetary support for these organizations. The annual amount to be contributed by APD to these organizations is approved annually through the annual budget process. APD receives and reviews each year the organizations' published annual reports and also maintains informal contacts throughout the year to monitor the organizations' operations and services. 0 1 0 0 0 0 0 1 0 George T Blike Trustee 0 408955 0 0 0 40344 0 190750 0 20137 0 660186 0 0 Gay L Landstrom Trustee (part year) 0 544531 0 50000 0 2711 0 26823 0 17248 0 641313 0 0 Edward J Merrens MD Trustee 0 453422 0 0 0 16189 0 56876 0 10875 0 537362 0 0 Tina E Naimie Trustee 0 234308 0 100 0 471 0 21824 0 1819 0 258522 0 0 Mary M Oseid Trustee 0 251570 0 0 0 12230 0 177906 0 11301 0 453007 0 0 Roderic O Young Trustee 0 306032 0 0 0 5350 0 25544 0 20051 0 356977 0 0 Susan E Mooney MD MS President & CEO 304560 15764 60298 3174 17100 1165 5035 265 46923 2470 433916 22838 0 0 Kathryn M Vargo MD Medical Staff President 220829 0 0 0 0 0 4605 0 50794 0 276228 0 0 0 Beverley A Rankin RN BSN VP Patient Care, CNO 209527 0 5000 0 0 0 4537 0 49594 0 268658 0 0 0 Randall D Lea MD MPH VP & Chief Medical Officer 202429 0 0 0 0 0 4194 0 35189 0 241812 0 0 0 Evalie M Crosby CPA FHFMA VP of Finance & CFO (end 2/16) 150280 37571 44800 11200 0 0 4042 1011 29119 7280 228241 57062 0 0 J Todd Miller MS VP & COO 146509 36627 11135 2784 7423 1856 3262 816 23576 5894 191905 47977 0 0 Diane C Riley MD CAQSH Orthopaedic Surgeon 437040 0 0 0 0 0 5300 0 35605 0 477945 0 0 0 Paul Sansone MD Pain Management MD 436762 0 0 0 0 0 0 0 51871 0 488633 0 0 0 Leonard M Rudolf MD Orthopaedic Surgeon 446599 0 44000 0 0 0 5300 0 51949 0 547848 0 0 0 John P Houde MD Orthopaedic Surgeon 512554 0 0 0 0 0 5300 0 51981 0 569835 0 0 0 Ivan Tomek MD Orthopaedic Surgeon 554693 0 0 0 0 0 0 0 53779 0 608472 0 0 0 Part I, Line 3 The compensation of the Organization's CEO/President is determined through a related party, APD Health Systems, Corp. APD Health Systems used its Compensation Committee, an independent compensation consultant, a compensation survey/study, and approval by its Board's Compensation Committee to establish the CEO/President's compensation and benefits. Part I, Line 4b The following individuals received Dartmouth-Hitchcock Supplemental Retirement Plan Terms and Conditions: Various individuals listed in Form 990, Part VII and Schedule J, Part II are compensated as full-time employees of Dartmouth-Hitchcock Health, or Mary Hitchcock Memorial Hospital, the sole-corporate member of the Organization and a related organization, respectively. The following individuals participated in and received payments from a supplemental nonqualified deferred retirement plan sponsored by Dartmouth-Hitchcock Health. Amounts reported in Schedule J, Part II, Column C as follows: Edward J. Merrens, MD - $23,225 Gay Landstrom - $20,575 Roderic Young - $20,575 Tina Naimie - $17,679 The following individuals had an actuarial change in pension value during the year reported in Schedule J, Part II, Column C: Edward J. Merrens, MD - $14,637 George Blike - $171,533 Mary Oseid - $158,689 All amounts reported in Column C will be included as part of taxable wages in the employees' Form W-2 when paid out. An eligible employee is a participant in the Dartmouth-Hitchcock retirement plan and/or any prior pension arrangements sponsored by Dartmouth-Hitchcock (including a qualified defined benefit plan) who would be entitled to additional contributions or benefit accruals under the terms of the plans for the plan year, but are limited by IRC Section 401(a)(17) and/or 415. For eligible employees, the employer will pay the eligible employee an amount determined by the employer each year to offset the amount of the reduction in the benefit accrual or contributions as a result of limitations imposed by IRC Sections 401(a)(17) and/or 415. Schedule J, Part II, Column B, Parts i, ii, and iii represent actual amounts paid to employees by Alice Peck Day Memorial Hospital, APD Health Systems Corp, or Dartmouth-Hitchcock Health. These amounts are reported to employees on their annual Form W-2 as compensation. Columns C and D represent items earned, however, not paid directly to the employee as cash payments during the calendar year. Column C includes retirement benefits as well as any changes in pension actuarial value (if applicable) in a calendar year. Column D represents nontaxable benefits such as the cost of healthcare coverage sponsored by the Organization or a related organization. Part I, Line 7 A portion of compensation to certain employees is at-risk and variable, and payment depends on the quality of job performance. A Business Finance Authority of the State of NH 521304598 2010-11-30 12282000 Current Refund Existing Bond 0 0 0 A 12282000 12237068 44932 2010 1 0 1 1 A 0 0 0 0 0 0 1 A 0 0 0 1 1 1 TD Banknorth NA 5.000000000000 0 1 0 0 1 A 1 Date Rebate Computation Performed Issuer Name: Business Finance Authority of the State of NH Date the Rebate Computation was Performed: 01/03/2011 Form 990, Part V, Line 2a: For administrative purposes, Alice Peck Day Memorial Hospital acts as the common paymaster for both Alice Peck Day Health Systems, Corp. and Alice Peck Day Lifecare Center, Inc. Form 990, Part VI, Section A, line 3 From the period of February 2016 through May 2016, the Hospital paid a consulting firm, Leaders For Today, which provides interim management staffing to hospitals, for the services of its interim-CFO, Michael P. Connelly. Mr. Connelly was not paid directly by the Hospital for his services rendered as interim CFO. Total amounts paid to Leaders For Today for Mr. Connelly's services were $80,370. Form 990, Part VI, Section A, line 4 In 2014, the Board of Alice Peck Day Memorial Hospital, Inc. accompanied by the Board of Dartmouth-Hitchcock Health, Inc. (D-HH), approved an affiliation agreement between the Hospital and D-HH. This affiliation became effective on March 2, 2016 and for financial reporting purposes was deemed effective on March 1, 2016. As a result, the sole corporate member of the Hospital became D-HH. Alice Peck Day Health Systems Corp. and Alice Peck Day Lifecare Center, Inc. did not affiliate with and become subsidiaries of D-HH. This agreement is intended to improve, integrate, and streamline patient care between the Hospital and D-HH, as well as other efficiencies that may be achieved through the affiliation. As a result of this affiliation, the Organization amended its bylaws to reflect the following significant changes: 1. The sole-corporate member changed from Alice Peck Day Health Systems (APDHS), Inc. to Dartmouth-Hitchcock Health (D-HH). All of the previous rights and powers of APDHS was assumed by D-HH. See narrative for Form 990, Part VI, Line 6, 7a, and 7b. 2. The Board shall nominate two-thirds (2/3) of the Board subject to ratification by the Member in accordance with its bylaws. 3. The Member will retain certain reserved powers over the Hospital, which, except as otherwise required, will be exercised by the D-HH Board of Trustees or the D-HH CEO, as determined by the D-HH Board of Trustees. See narrative for Form 990, Part VI, Line 6, 7a, and 7b. 4. The composition of the board is to be made up of the following: A. Voting Trustees 1. Up to 11 APD appointed trustees 2. Up to 5 Member appointed trustees 3. APD President and CEO 4. D-HH CEO or designee 5. President of the APD Medical Staff B. Non-Voting Trustees 1. APD Chief Medical Officer 2. President of the Friends of APD Form 990, Part VI, Section A, line 6 The Membership of the Corporation shall consist of Dartmouth-Hitchcock Health (D-HH) as the sole member. Form 990, Part VI, Section A, line 7a The Member will retain the reserved power to appoint without limitation one-third of the Trustees (which appointees, before final appointment by Member, will be discussed with the Board Chair and other Trustees selected by the Chair for their input). The D-H/D-HH CEO or designee will serve on the Board ex officio, with full voting rights, and will count toward the one-third membership appointed by Member. Form 990, Part VI, Section A, line 7b The Member will retain the following reserved powers over APD, which, except as otherwise required below, will be exercised by the D-HH Board of Trustees or the D-HH CEO, as determined by the D-HH Board of Trustees: 1. To initiate and/or to approve or disapprove all material governance, programmatic, and financial decisions of the Board of Trustees, including without limitation the elimination or addition of any material health/health care services or programs; 2. To appoint without limitation one-third of the Trustees (which appointees, before final appointment by Member, will be discussed with the Board Chair and other Trustees selected by the Chair for their input). The D-H/D-HH CEO or designee will serve on the Board ex officio, with full voting rights, and will count toward the one-third membership appointed by Member; 3. To ratify those trustee candidates nominated by the Board in accordance with Section 2.04 of the Corporation's bylaws (meaning the ability of Member to approve or disapprove, based on a good faith and reasonableness standard, each trustee candidate nominated by the Board of Trustees and upon such approval, the ability to install such approved candidate to the Board); 4. To remove by a vote of two-thirds of the D-HH Board of Trustees any Trustee if the Member determines in its reasonable good faith discretion that such removal is in the best interests of the D-H System which will include APD and taking into consideration the impact on APD and the community it serves, following prior consultation with the Board Chair; 5. To approve of borrowings (debt) and dispositions of material assets by APD; 6. To approve any key strategic relationship(s) between APD and another organization(s) (key strategic relationships defined as the ownership or contractual participation in a network, system, affiliation, joint venture, alliance or similar arrangement with an organization that is not part of the D-H System or which is not addressed in a Member approved APD strategic plan); 7. To initiate and/or to approve all operating and capital budgets as well as all strategic plans of APD; 8. To approve all policies relating to academic and research programs and affiliations; 9. To allocate the non-donor restricted assets and resources of APD and D-H/D-HH as appropriate to serve the overall best interests of the D-H System (which will include APD), taking into consideration the impact on APD and the community it serves; while Member will retain this reserved power, Member will exercise this reserved power only after consulting with and providing reasonable time and opportunity for the Board of Trustees to provide meaningful input and recommendations which shall be considered in good faith. For one (1) year following the effective date of its bylaws any material reallocation of assets or resources will also require an affirmative vote by a majority of the Board of Trustees. 10. Except as limited by the affiliation agreement, to appoint, evaluate the performance of, and terminate the APD President and CEO, subject to prior consultation with the Board of Trustees and a reasonable time and opportunity for the Board to provide meaningful input and recommendations which shall be considered in good faith. 11. To approve any proposed amendment or repeal of the APD articles of agreement or bylaws which proposed amendment or repeal would (i) impact the powers reserved to Member in its bylaws, or (ii) reasonably be expected to have any material strategic, competitive or financial impact on the D-H System. No change in the provisions of APD's bylaws shall be binding on D-H/D-HH or APD unless such change(s) is/are approved by way of amendment to APD's governing documents approved by Member. 12. To approve the dissolution or liquidation of APD, following such approval by the Board. Form 990, Part VI, Section B, line 11 The completed Form 990 is provided to the Chair of the Board and a designated member of the finance committee in advance of the filing deadline to enable a detailed and conscientious review to bring to the rest of the members of the committee to address any questions or changes. The completed Form 990 is also distributed to all members of the full Board for review no later than the final regularly scheduled Board meeting prior to the filing deadline. All questions and concerns are addressed by the Chief Executive Officer and incorporated into the Form 990 as deemed appropriate. After all input from the Chair of the Board, the designated member of the finance committee and the full Board has been appropriately addressed and incorporated into the final Form 990, a vote of acceptance of the final document is required. The vote is recorded in the minutes of the Board of Trustees prior to the filing of the Form 990. Once approved, senior management files the final Form 990 with the Internal Revenue Service as required. Form 990, Part VI, Section B, line 12c Alice Peck Day has a multi-faceted conflict of interest policy. Members of the Board of Trustees complete conflict of interest questionnaires on an annual basis and any new members complete the questionnaire upon joining the Board. As part of our ongoing monitoring process, our Executive Assistant reviews all Board questionnaires and disclosures to identify any potential conflicts before they arise. In addition, our Executive Assistant attends all Board meetings to ensure that if any conflicts arise, they are handled appropriately. If such conflicts arise, the Organization complies with the New Hampshire and federal requirements for disclosures of such events. The Organization is committed to conducting its business in a manner that is both ethical and legal. As part of this commitment, a standard of conduct form is required of all employees of the organization. This is reviewed with all employees upon hire and on an annual basis thereafter. The standard of conduct covers conflict of interest and other vital matters to ensure all business activity is conducted in a manner that is consistent with the highest standards of honesty, integrity, and fairness. Form 990, Part VI, Section B, line 15 The Human Resources Committee of the Alice Peck Day Memorial Hospital Board of Trustees is responsible for determining the compensation of the Chief Executive Officer/President. The Chief Administrative Officer or her designee provides compensation data of comparable organizations with approximately the same size staff and spending in a location of similar size. The committee determines the appropriate compensation and approves an amount that is then communicated to Human Resources for adjustment. This process is completed annually. The CEO/President is responsible for reviewing the performance of senior management staff. The information is brought to the Human Resource Committee of the Board of Trustees along with a recommendation for the salary of each individual. The compensation is determined through a variety of analysis of salary data and performance. Individual salary increases are then based on overall performance, within budgeted increases for the organization. The Human Resources committee approves the base compensation and salary increase amount. Form 990, Part VI, Section C, line 19 The Organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Form 990, Part VII, Section A, Column D: Dr. Susan E. Mooney is a practicing physician in addition to being the Chief Executive Officer. She worked an average of 61 hours per week, of which a majority of time is spent on executive matters. Approximately 8 hours per month is spent as a physician. Form 990, Part VII: Effective February 2016, the Hospital's VP of Finance & CFO, Evalie M. Crosby, resigned to take a position at another healthcare institution. Alice Peck Day Memorial Hospital subsequently named Michael P. Connelly as interim CFO. Mr. Connelly served in this position through the end of the fiscal year. Effective in October 2016, the Hospital named Timothy Graham as its fulltime CFO. IRS instructions stipulate that anyone who served as a board member or officer of the filing organization during the fiscal year is to be listed in Form 990, Part VII with their compensation disclosed for the calendar year ending within the filing organization's fiscal year. In accordance with these instructions, Ms. Crosby is being listed in Part VII along with her 2015 compensation as she served as an officer of the organization during the fiscal year covered by this return. Mr. Connelly is also being listed; but, as he did not begin his tenure with the organization until 2016. He did not receive any W-2 compensation in the calendar year ending in 2015, no compensation information is being disclosed for him in Part VII. The Hospital's next Form 990 filing will disclose the compensation paid to Mr. Connelly and will list Mr. Graham as an officer in Part VII. Form 990, Part IX, line 11g Purchased Physician Services: Program service expenses 7,044,831. Management and general expenses 330,152. Fundraising expenses 7,057. Total expenses 7,382,040. Form 990, Part XI, line 9: Application of Push Down Accounting -794,573. Form 990, Part XII, Line 2c: The finance committee acts as the audit committee and oversees the audit process for the Alice Peck Day entities. 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, Part XII, Line 3a: Alice Peck Day Memorial Hospital was included in the consolidated audited financial statements of the Dartmouth-Hitchcock Health System. During fiscal year 2016, Mary Hitchcock Memorial Hospital expended federal funding which met the minimum threshold set forth in the single audit act and OMB Circular A-133. Due to the nature of the consolidated financial statements, the audit was performed on the financial information of all organizations, including Alice Peck Day Memorial Hospital. Form 990, Part IV, Line 34: Dartmouth-Hitchcock Health, Inc. is the direct controlling parent of Alice Peck Day Memorial Hospital (02-0222791). Alice Peck Day Health Systems, Corp. is the direct controlling parent company of Alice Peck Day Lifecare Center, Inc. (02-0479094). Alice Peck Day Health Systems, Corp. is also the direct controlling parent company of Alice Peck Day Realty Corp. (02-0485369) and Alice Peck Day Health Management Corp. (02-0485370). Both entities are inactive and hold no assets. Alice Peck Day Health Systems Corp 10 Alice Peck Day Drive Lebanon NH 03766 020479095 Promote Health NH 501(c)(3) Line 11b, II N/A 0 Alice Peck Day Lifecare Center Inc 10 Alice Peck Day Drive Lebanon NH 03766 020479094 Independent & Assisted Living NH 501(c)(3) Line 9 APD Health Systems 0 Alice Peck Day Realty Corp 10 Alice Peck Day Drive Lebanon NH 03766 020485369 Inactive NH 501(c)(2) APD Health Systems 0 Dartmouth-Hitchcock Health One Medical Center Drive Lebanon NH 03756 264812335 Govern Integrated Health System NH 501(c)(3) Line 7 N/A 0 Dartmouth-Hitchcock Clinic One Medical Center Drive Lebanon NH 03756 222519596 Physician Services NH 501(c)(3) Line 9 Dartmouth-Hitchcock Health 0 Mary Hitchcock Memorial Hospital One Medical Center Drive Lebanon NH 03756 020222140 Hospital NH 501(c)(3) Line 3 Dartmouth-Hitchcock Health 0 The New London Hospital Association Inc 273 County Road New London NH 03257 020222171 Hospital NH 501(c)(3) Line 3 Dartmouth-Hitchcock Health 0 Windsor Hospital Corporation 289 Country Road Windsor VT 05089 030183721 Hospital VT 501(c)(3) Line 3 Dartmouth-Hitchcock Health 0 Cheshire Medical Center 580 Court Street Keene NH 03431 020354549 Hospital NH 501(c)(3) Line 3 Dartmouth-Hitchcock Health 0 OneCare VT ACO LLC 111 Colchester Avenue Burlington VT 05401 455399218 Shared Saving VT N/A Alice Peck Day Health Management Corp 10 Alice Peck Day Drive Lebanon NH 03766 020485370 Inactive NH N/A C 0 Hitchcock Health Connect One Medical Center Drive Lebanon NH 03756 800908979 Telehealth DE N/A C 0 Imaginecare Inc One Medical Center Drive Lebanon NH 03756 813105071 Software Tech NH N/A C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0