2015-05-05T12:08:26-07:00 2014-09-30 990 2013-10-01 042103581 HENRY HEYWOOD MEMORIAL HOSPITAL HENR 9786323420 242 Green Street Gardner MA 01440 Robert Crosby Sr VP of Finance, Treasurer, CFO 9786306157 2015-04-17 2013 2016-02-25 16:41:14Z Robert Crosby 242 Green Street Gardner MA 01440 114734426 0 X www.heywood.org X 1907 MA To be our communities' trusted choice for exceptional patient-centered care. 21 20 1097 166 0 0 908638 2425672 107379169 104118171 495533 761780 1341743 1252666 110125083 108558289 120000 125000 0 0 55829163 54557727 6744 0 248020 51288346 50617334 107244253 105300061 2880830 3258228 95467985 97123339 45613375 44445106 49854610 52678233 To be the community's trusted choice for patient-centered care. 0 0 99156370 125000 104118171 Heywood Hospital is dedicated to the community benefit goals of improving the health status of our community, addressing the specific health care needs of the under-served and collaborating with others to enhance quality and contain the growth of community health care costs. Details to this are published in "The Community Benefit Report of Heywood Hospital - Fiscal Year 2014" filed with the MA Attorney Generals Office. 0 0 0 99156370 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 1 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 1 148 0 1 1097 1 0 0 0 0 0 1 1 0 0 0 0 X 21 20 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 MA X Robert Crosby 9786306157 242 Green Street Gardner MA 01440 Daniel M Asquino Trustee 0 0 X 0 0 0 Michael Azzoni Trustee 0 0 X 0 0 0 James Garrison Trustee 0 0 X 0 0 0 John Kerney Trustee 0 0 X 0 0 0 Roy Lake Trustee 0 0 X 0 0 0 Michele Parker Trustee 0 0 X 0 0 0 JoAnne Parks Trustee 0 0 X 0 0 0 Kenneth J Pierce Chairman-Trustee 0 0 X 0 0 0 Glenn A Hunt Vice Chairman -Trustee 0 0 X 0 0 0 Rebecca Bialecki 2nd Vice Chairman - Trustee 0 0 X 0 0 0 Cheney Castine Treasurer - Trustee 0 0 X 0 0 0 Tina Sbrega Trustee 0 0 X 0 0 0 Winfield Brown President /CEO 40 0 X X 762263 0 68064 Robert Chauvin Trustee 0 0 X 0 0 0 Joyce Fletcher Trustee 0 0 X 0 0 0 John Flick Trustee 0 0 X 0 0 0 James Meehan Trustee 0 0 X 0 1400 110 Donald Mruk Trustee 0 0 X 0 0 0 Moshen Noreldin Trustee 0 0 X 0 32390 0 John Skrzypczak Trustee 0 0 X 0 0 0 Douglas Starrett Trustee 0 0 X 0 0 0 Robert Crosby Sr VP of Finance / CFO 40 0 X 240032 0 49292 Michael Grimmer VP of Support Services 40 0 X 244898 0 47239 Tina Santos VP of Patient Care Srvcs/CNO 40 0 X 237097 0 33773 Rose Kavalchuck VP of Quality Services 40 0 X 217554 0 43701 Carol Roosa VP of Information Services/CIO 40 0 X 141086 0 42326 Dawn Casavant VP of Philanthropy 40 0 X 156441 0 42638 Karen McArdle-Coggins HMG President/VP of Physician Recruiting 32 8 X 17001 8462 2096 Bruce Bertrand Chief Medical Officer 32 0 X 45255 0 3965 Steven Yerid Chief of Emergency Medicine 40 0 X 462954 0 40167 Ellen Ray Emergency Physician 40 0 X 337138 0 30715 Faith Pinkerton Emergency Physician 40 0 X 294751 0 26575 David Gill Staff Phychologist 40 0 X 250600 0 28102 Robert Shepard Emergency Physician 40 0 X 216803 0 26365 Thomas Cady VP of Human Resources 40 0 X 186165 0 46665 3810038 42252 531793 73 1 1 0 Quartulli and Associates Inc PO Box 423 Gardner MA 01440 Physical Therapy 2988109 Alliance Healthcare Services 100 Bay View Circle Newport Beach CA 92660 MRI 1302455 Diversified Clinical Services PO Box 636981 Cincinatti OH 45201 Wound Care Services 854088 Quest Diagnostics Inc 5763 Collection Center Drive Chicago IL 60693 Lab Contracted Services 849345 New England Inpatient Specialists 120 Waters Street North Andover MA 01845 Inpatient Support 667500 34 0 0 103125 0 1929734 392813 0 2425672 Ancillary O/P Services 622110 61036334 61036334 0 0 Ancillary I/P & Routine 622110 39603810 39603810 0 0 Contracted Service Revenue 900099 2340909 2340909 0 0 HMG Patient Revenue (Net) 621111 1019651 1019651 0 0 Lifeline 624120 47363 47363 0 0 70104 70104 0 0 104118171 297513 0 0 297513 0 0 0 0 0 0 0 0 257469 0 0 0 257469 0 257469 0 0 257469 6460421 84860 6072880 8134 387541 76726 464267 0 0 464267 30280 30280 95123 -64843 0 -64843 0 0 0 0 0 0 0 0 0 0 0 0 Meal Revenue 722310 671992 0 0 671992 Purchase Discounts 900099 151527 0 0 151527 Pharmacy Misc Revenue 900099 142704 0 0 142704 93817 0 0 93817 1060040 108558289 104118171 0 2014446 X 125000 125000 0 0 0 0 0 0 2301238 775397 1387825 138016 0 0 0 0 42885566 41596049 1260263 29254 835094 731701 86637 16756 4923357 4614947 283037 25373 3612472 3463827 137512 11133 0 0 0 0 369325 14705 354620 0 105292 0 105292 0 0 0 0 0 0 0 0 0 0 11623227 11623227 0 0 147462 141976 5324 162 14451357 14290757 155326 5274 1601685 1601685 0 0 0 0 0 0 2148500 2121746 26754 0 100967 72183 27537 1247 0 0 0 0 137803 91824 45979 0 728416 728416 0 0 0 0 0 0 4345728 4319963 25718 47 762021 678550 83471 0 Professional Fees 5718308 4376077 1326147 16084 Bad Debt 4876447 4876447 0 0 Free Care 1409381 1409381 0 0 Subscriptions & Dues 729875 251274 476737 1864 1361540 1251238 107492 2810 105300061 99156370 5895671 248020 4168080 4790919 0 0 2264477 2183922 12802618 12412717 0 0 0 0 171515 141938 1413035 1293977 1057751 1136493 107149255 55313590 52689420 51835665 18185573 20325016 437650 502992 134526 139610 0 0 2143340 2360090 95467985 97123339 14314680 14129444 0 0 258468 601026 24679160 23948559 0 0 0 0 294782 109342 0 0 6066285 5656735 45613375 44445106 X 44503392 47224241 4345057 4447768 1006161 1006224 49854610 52678233 95467985 97123339 X 3258228 1298967 0 0 0 -1733572 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 18078764 100 1729112 0 -362690 0 20170666 17128384 2200 2044839 0 1096659 0 18078764 11897431 5683 1966503 0 -3258767 0 17128384 17367013 5000 -128702 0 5345880 0 11897431 16786738 4875 958017 0 382617 0 17367013 0.86 0.05 0.09 0 0 0 125271 125271 0 66804460 24483585 42320875 0 0 0 0 0 38261543 30830005 7431538 0 1957981 0 1957981 51835665 0 Est. Settlement w/3rd Party 3355109 Est. Insurance Claims 1751001 Deferred Comp 550625 5656735 X Schedule D, Part V, Line 4 Permanent Endowment funds are established by donor restricted gifts and maintained to provide a permanent source of income. The principal of which is kept in perpetuity. Board Designated Endowment funds are established by the governing body to fund capital projects and/or improvements of the organization. Temporary Restricted funds are established by donor restricted gifts that maintain a source of income for a specific period of time. Schedule D, Part X, Line 2 Heywood Healthcare, Heywood Hospital, Athol and HMGI Have been determined to be not-for-profit corporations as described in Section 501(c)(3) of the Internal Revenue Code (the "Code"), and the Realty Corp. has been determined to be a not-for-profit corporation as described in Section 501(c)(2) of the Code. All of the entities are exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. Any income not substantially related to these Organizations' exempt purposes may be considered unrelated business income under Internal Revenue Code Section 511 and, as such, be subject to tax at normal corporate rates. In accordance with generally accepted accounting principles ("GAAP"), the Organization annually evaluates its tax status and tax positions taken with respect to its operations and financial position. Tax years from 2010 through the current year remain open for examination by federal and state taxing authorities. Golf Classic 89110 58830 30280 0 11097 13944 18974 400 6350 Winter Affair 25245 25245 0 0 1154 4552 14426 1800 7000 2 19050 19050 0 0 2326 865 541 0 11694 133405 103125 30280 0 14577 19361 33941 2200 25044 95123 -64843 1 1 1 X 1 X 1 1 0 1 1 0 0 1442301 1446797 -4496 0.00 0 0 19254293 17398110 1856183 0.0176 0 0 0 0 0 0 0 0 20696594 18844907 1851687 0.0176 0 0 1347073 32894 1314179 0.0125 0 0 398748 113 398635 0.0038 0 0 0 0 0 0 0 0 0 0 0 0 0 0 53616 0 53616 0.0005 0 0 1799437 33007 1766430 0.0168 0 0 22496031 18877914 3618117 0.0344 0 0 219 0 219 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1006 0 1006 0 0 0 148871 0 148871 0.0014 0 0 0 0 0 0 0 0 198241 0 198241 0.0019 0 0 0 0 0 0 0 0 348337 0 348337 0.0033 1 1884554 62567 25739033 23502373 2236660 X 1 1 1 1 Henry Heywood Memorial Hospital 242 Green Street Gardner MA 01440 www.heywood.org X Henry Heywood Memorial Hospital 1 1 X X X X X X X X X 11 1 1 1 X www.heywood.org X X X X X X X X X 1 0 1 1 100 1 400 1 X X X X 1 1 X X X X X X 1 X 1 X X X X X X 1 X 0 0 Schedule H, Part V, Section B, Line 3-Henry Heywood Memorial Hospital The 2011 Community Health Needs Assessment of North Central Massachusetts was a joint effort between MA Department of Public Health's Community Health Network Area of North Central Massachusetts (CHNA 9) and the Joint Coalition on Health. The assessment is designed to provide information and analyses relative to the health status, issues, concerns and assets of the North Central Region of Massachusetts. The assessment includes 27 cities and towns covered by CHNA 9 of which Gardner, Ashburnham, Westminster, Winchendon, Templeton, and Hubbardston are primary service areas of Heywood Hospital, and are included within the reporting region of Gardner. Comparisons are made to Massachusetts as a whole and to Healthy People 2010 goals. All data was gathered systematically utilizing standards which guided the methodologies. The quantitative data collected came from the Massachusetts Community Health Information Profile, the Massachusetts Department of Public Health, the US Census Bureau, the MA Department of Workforce Development, the MA Department of Elementary and Secondary Education and the Massachusetts Behavioral Health Partnership. Qualitative data was gathered using focus groups and interviews that were conducted in cooperation with the Minority Coalition of North Central Beautiful Gate Church, Twin Cities CDC, Gardner CDC, Memorial Congregational Church, New Hope Community Church, Montachusett Opportunity Council, in addition to other area agencies. Schedule H, Part V, Section B, Line 4-Henry Heywood Memorial Hospital Hospitals included in the development of the 2012 Community Health Needs Assessment are Heywood Hospital, Gardner, MA; HealthAlliance Hospital, Leominster, MA; and Clinton Hospital, Clinton, MA. Schedule H, Part V, Section B, Line 12-Henry Heywood Memorial Hospital Medical Hardship, wherein the patient's medical expenses exceed the patient's income. Schedule H, Part V, Section B, Line 18-Henry Heywood Memorial Hospital The Hospital posts general notices throughout the hospital about the financial assistance policy. Schedule H, Part I, Line 7 The costing methodology used to calculate the amounts reported in the table in Part I, for lines 7a through 7c was based on the cost to charge ratio derived from the supplied Worksheet 2, in the IRS schedule H instructions. Schedule H, Part II The Heywood Hospital's Community Benefits Mission Statement is "Heywood Hospital is dedicated to the community benefit goals of improving the health status of our community, addressing the specific health needs of the under-served and collaborating with others to enhance quality and contain the growth of community healthcare costs." Schedule H, Part II, Line 1 Heywood donated plants and beverages toward community wellness paths and gardens to promote a healthier community. Schedule H, Part II, Line 5 Heywood staff provided training to members of the community for early suicide prevention, education and training certification at no cost to the community members. Schedule H, Part II, Line 6 Heywood's approach to Community Benefits has been to collaborate with others through the Joint Coalition on Health and other coalitions to develop our plan, goals and strategies. Partners include the Joint Coalition on Health, Gardner Interagency Team, the CHNA, The Minority Coalition, Montachusett Opportunity Council, Mount Wachusett Community College, the Community Health Connections Health Centers, North Central Human Services, Luc, Inc., Community Health Link, Gardner, VNA, the Gardner Public Schools, the Winchendon Public Schools, the Health Foundation of Central MA, Kresge Foundation, the Department of Public Health, AHEC, and others. At this time we continue to focus our efforts on mental health and substance abuse, insuring those without jobs and/or insurance, addressing the needs of under-served populations, focusing on the needs of youth and children, and targeting adults and children with overweight and obesity issues which lead to chronic diseases and diabetes. Schedule H, Part II, Line 8 Heywood Hospital serves a medically underserved population area, because of this, the Hospital is constantly working to recruit and search for physicians to serve our community. Schedule H, Part III, Section A, Line 2 The costing methodology used for line 2 was based on the cost charge ratio derived from the supplied worksheet 2 in the IRS Schedule H instructions. Schedule H, Part III, Section A, Line 3 The methodology used for line 3 was to take the percentage of financial assistance applications that were due to inadequate documentation divided by the total applications received for FY 2014. This amounted to approximately 3.32% which was applied against the number on line 2. It is our belief that the $62,567 amount of bad debt should be included as a community benefit. As a tax exempt hospital, we must provide necessary services regardless of the patient's ability to pay for the service provided. As a not for profit, patient care is provided to all, regardless of ability to pay for that care, making quality patient care available to all in our community, regardless of their economic means, qualifies bad debts as community benefit. Schedule H, Part III, Section A, Line 4 The footnote can be found on Page 8 of the financial statements - footnote #2 under "Allowance of Doubtful Accounts". Schedule H, Part III, Section B, Line 6 The allowable costs on line 6 were obtained from our FY 2014 Medicare Cost Report, Worksheet D schedules. Schedule H, Part III, Section B, Line 8 There is no shortfall. Schedule H, Part III, Section C, Line 9b Heywood Hospital provides patients with information about financial assistance programs that are available through the Commonwealth of MA or through Heywood Hospital's own financial assistance program, which may cover all or some of their unpaid hospital bills. For those patients that request such assistance, Heywood Hospital assists patients by screening them for eligibility in an available public program and assisting them in applying for the program. These programs include but are not limited to MassHealth, Commonwealth Care, Children's Medical Security Plan, Healthy Start, Health Safety Net and others. It is the patient's obligation to provide Heywood Hospital with accurate and timely information to determine of the patient is eligible to apply for certain health insurance programs. If the patient of guarantor is unable to provide the necessary information Heywood Hospital may make reasonable efforts to obtain any additional information from other sources. Information the Heywood obtains will be maintained in accordance with applicable federal and state privacy and security laws. The screening and application process for public health insurance program is done through Virtual Gateway, which is an internet portal designed by the MA Executive Office of Health and Human Services. The Virtual Gateway manages the application process from the programs listed above, which is available for children, adults, seniors, veterans, homeless and disabled individuals. Heywood specifically assists the patient in completing the application and secure the necessary documentation required by the applicable financial assistance program. Heywood Hospital will then submit this document to the Commonwealth Office of Medicaid and assist the patient in any additional documentation if such is required by the Commonwealth after completing the application. All Virtual Gateway applications are reviewed and processed by the Commonwealth of MA, Office of Medicaid. Special circumstance applications are reviewed and approved by the MA Division of Health Care Finance and Policy. Hospitals have no role in determination of program eligibility made by the Commonwealth, but at the patient's request may take a direct role in appealing decisions made by the Commonwealth to ensure accurate and timely adjudication of all hospital bills. If the patient does not comply with the request for documentation, then our standard collection procedures apply. Schedule H, Part VI, Line 2 Heywood Hospital collaborates with many local and state agencies and organizations to assess community health needs in the North Central region of MA. We work with representatives from more than 100 local and state organizations and state legislators on our Suicide Prevention Taskforces. We work with the Massachusetts Department of Public Health, GVNA Healthcare, Gardner Area Interagency Team, Gardner, Winchendon, Ashburnham, and Westminster Public Schools, Gardner Police Dept, area Boards of Health, local legislators, Patient Family Advisory Council and direct outreach to community and schools. Schedule H, Part VI, Line 3 Role of Hospital Certified Financial Counselors and other Finance Staff: The hospital will try to identify available coverage options for patients who may be uninsured or underinsured with their current insurance program when the patient is scheduling their services, while the patient is in the hospital, upon discharge, and for a reasonable time following discharge from the hospital. The hospital will direct all patients seeking available coverage options, or those that the hospital determines may be eligible, to the hospital's patient financial counseling to screen for eligibility in an appropriate coverage option. The hospital will then assist the patient in applying for the appropriate coverage options that are available or notify them of availability of financial assistance through the hospital's own internal financial assistance program, if available. Notification Practices: Individual printed notices are available by contacting a Financial Counselor or through the Patient Accounts Office. Notices indicate the criteria used to determine eligibility for MassHealth and the Health Safety Net Trust Fund and where or how patients may apply. The goal of these notices is to assist patients in applying for coverage within a financial assistance program such as MassHealth, Commonwealth Care, Children's Medical Security Plan, Healthy Start, and Health Safety Net. When applicable, the hospital may also assist patients in applying for coverage of services as a Medical Hardship based on the patient's documented income and allowable medical expenses. When a patient contacts the hospital, Patient Accounting, Financial Counseling or Social Service Staff will attempt to identify if a patient qualifies for a public financial assistance program or payment plan. Patients who are already enrolled in a public financial assistance program, such as MassHealth or Health Safety Net, may qualify for certain federal, state and private assistance agencies. Patients may also qualify for additional assistance based on the hospital's own internal criteria for financial assistance, or qualify for coverage of services as a Medical Hardship based on the patient's documented income and allowable medical expenses. The following items outline more specifically the notification process, criteria, and availability of information beyond the signs that are posted in the hospital. 1. The hospital will provide an individual notice of the availability of financial assistance programs and other programs of public assistance to a patient expected to incur charges for which he/she will be personally responsible, exclusive of personal convenience items or services that may not be paid in full by third party coverage. 2. The hospital or its agents will include a notice or statement about Eligible Services to Low Income Patients and other programs of public assistance in its initial bill and subsequent correspondence with the patient. All correspondence will direct the patient where and how they can receive more information or additional assistance and will inform the patient that they may apply or reapply for financial and public assistance before, during or after care, or after collection agency assignment if their situation changes. 3. The hospital will include a notice regarding the availability of financial assistance and other programs of public assistance to Low Income Patients in all written collection actions. The hospital will notify the patient that it offers a payment plan if the patient is determined to be eligible for MassHealth or free care/uncompensated care through the Health Safety Net Trust Fund as a low income patient or due to Medical Hardship. These payment plans are consistent with 1016 CMR 6613.08 (1)(f)(4). The hospital will also offer payment plan options for those individuals who do not qualify for Low Income Patient status. 4. Heywood Hospital will include language on its written notices that reads: "You may be eligible for assistance through our Financial Assistance Program. For eligibility information, please contact our Customer Services Department at 1-800-305-6757." Verbiage may change to accommodate changes of department information. 5. There is no primary language other than English that is spoken by 5% or more of the hospital's service area. Signage and other documentation will be provided in English. The hospital provides translator services for several other languages and this service may be accessed for those individuals whose primary language is not English or Spanish. 6. For cases where the hospital continues to determine eligibility for free care/uncompensated care through the Health Safety Net Trust Fund application, then MassHealth will provide written notice of determination that the patient is or is not eligible within 30 days of receiving a completed application and the required supporting documentation. The vast majority of patients will however be screened via the common intake process and processed through the Virtual Gateway and MA-21 system. 7. Whether the hospital is using the MassHealth application process through the Virtual Gateway or submitting a MassHealth application directly, the hospital will assist the patient in completing the application or intake process for enrollment and eligibility screening. Schedule H, Part VI, Line 4 The Assessment includes 27 cities and towns covered by CHNA9, of which Gardner, Ashburnham, Westminster, Winchendon, Templeton and Hubbardston are primary service areas for Heywood Hospital. 33% of Gardner population made up of age 65+ living alone, 10% single females with children, 9.6% of population living below 100% of poverty level, with Suicide Mortality rates at 12.3%-state average is 7%. Schedule H, Part VI, Line 5 The Greater Gardner area, comprised of the City of Gardner, and five surrounding towns, has a population of 60,000 people, a median income below the state average and an unemployment rate above the state average. The community has been affected by the loss of the furniture industry of the past few decades, and by the current economic downturn. Mental health and substance abuse are significant challenges for many residents of the area. The Hospital is the largest employer in the area, with around 1,000 employees. The community is largely white, non-Hispanic, but has a growing Hispanic population. Gardner is one of three cities in the region; the others are Fitchburg and Leominster, which frequently collaborates for the betterment of the region. Heywood Hospital collaborates with the competing hospital in the Fitchburg/Leominster area, HealthAlliance, on the community health improvement activities. Schedule H, Part VI, Line 6 Heywood Hospital works closely with the community to promote health in areas identified by the 2011 Community Health Needs Assessment (CHNA) through a variety of means. The hospital works with area school systems to address childhood obesity and onset of adult diabetes through nutrition/fitness programs targeting young students K-2, in order to help develop healthy habits which may result in a reduction of chronic illness and obesity as indicated in the 2011 CNHA. Financial counselors help uninsured populations, including those recently unemployed and those experiencing financial hardship to enroll in appropriate programs to ensure healthcare coverage, an identified barrier to obtaining health care, as indicated in the 2011 CHNA. Community programs targeting nutrition and fitness are offered free and at reduced rates focusing on nutrition, healthy cooking and consistent exercise, focusing on the reduction of chronic disease including diabetes and cardiovascular disease in adults as indicated in the 2011 CHNA. Operation of a school-based health center which enrolls an average of 79% of all students in the school, providing nearly 1,000 behavioral health visits annually, addressing higher than normal suicide and substance abuse rate, as indicated in the 2011 CHNA. The Suicide Prevention Taskforce, which partners with approximately 100 area social service agencies, provides educational tools, and raises community and legislative awareness of significant area mental health and substance abuse issues, resulting in a Gardner suicide rate approximately twice the state average. Continue to work with the Minority Coalition, Joint Coalition of Health and other community agencies to raise awareness and skills among health providers to reduce disparities and strive for equal health. Schedule H, Part VI, Line 7 Community Benefit Report is filed with Attorney General's Office, State of Massachusetts. 1 Montachusett Home Care Corp 680 Mechanic Street Leominster MA 01453 042551175 501(c)(3) 80000 0 n/a n/a The funds will be used by the Community Health Network of North Central MA as support and collaborative community health assessment work. MOC Inc 133 Pritchard Street Fitchburg MA 01420 042401111 501(c)(3) 45000 0 n/a n/a The funds will be used by Joint Coalition on Health as support of operations to provide Community Health grants in conjunction with identified priorities of the JCOH service area, and to support the Gardner Area InterAgency Team. 2 0 Schedule I, Part I, Line 2 Montachusett Home Care Corp and the Community Health Network of MA file an annual report with the Office of Healthy Communities that contains a summary of how the funds are allocated. X X 0 0 X X X X X X 0 0 0 0 0 1 0 0 0 Winfield Brown President /CEO 399129 0 111540 0 251595 0 22600 0 45463 0 830327 0 0 0 Robert Crosby Sr VP of Finance / CFO 238806 0 0 0 1226 0 22455 0 26837 0 289324 0 0 0 Michael Grimmer VP of Support Services 197484 0 32432 0 14983 0 20589 0 26649 0 292137 0 0 0 Tina Santos VP of Patient Care Srvcs/CNO 204903 0 31941 0 253 0 21229 0 12544 0 270870 0 0 0 Rose Kavalchuck VP of Quality Services 186024 0 30011 0 1519 0 21368 0 22333 0 261255 0 0 0 Carol Roosa VP of Information Services/CIO 135697 0 5000 0 389 0 17500 0 24826 0 183412 0 0 0 Dawn Casavant VP of Philanthropy 134236 0 22051 0 154 0 17500 0 25138 0 199079 0 0 0 Steven Yerid Chief of Emergency Medicine 378552 0 77000 0 7402 0 18789 0 21378 0 503121 0 0 0 Ellen Ray Emergency Physician 336490 0 0 0 649 0 2412 0 28302 0 367853 0 0 0 Faith Pinkerton Emergency Physician 294751 0 0 0 0 0 0 0 26575 0 321326 0 0 0 David Gill Staff Phychologist 248009 0 0 0 2591 0 5100 0 23002 0 278702 0 0 0 Robert Shepard Emergency Physician 215632 0 0 0 1171 0 0 0 26365 0 243168 0 0 0 Thomas Cady VP of Human Resources 158222 0 26768 0 1175 0 20923 0 25742 0 232830 0 0 0 Schedule J, Part I, Line 1a Housing allowance provided to Michael Grimmer, VP of Support Services, per contract. This is paid through his weekly salary. Social Club Membership dues provided to Mr. Brown, CEO, per contract. Schedule J, Part I, Line 1b There was no written policy for the housing allowance provided to Michael Grimmer; it was part of his employment contract. There was no written policy for the Social Club Membership dues; it was part of his employment contract. Schedule J, Part I, Line 6 Heywood Hospital accrues 15% of the executive team's salary as part of an incentive compensation program, and service goals are set by the Hospital's trustees annually. A MA Health and Educational Facilitiy Authority 042456011 57586EGT2 2009-03-31 17785000 Funds used for new Watkins Bldg project 0 0 0 B MA Health and Educational Facility Authority 042456011 57586C7E9 2008-06-19 6715000 Refunding and new Watkins Bldg project 0 0 0 A 0 0 66235 0 0 0 281690 0 0 17569545 0 0 2010 0 0 1 1 B 0 0 19154 0 0 0 329467 0 3597891 2806796 0 0 2008 1 0 1 1 A 0 0 0 0 0 0 0 1 0 1 B 0 0 0 0 0 0 0 1 0 1 A 0 0 0 1 1 1 TD Bank 18.7 0 0 0 0 1 B 0 0 0 1 1 1 Piper Jaffrey 18.7 0 0 0 0 1 A 0 B 0 Schedule K, Part IV, Line 2c-03/31/2009 17,785,000 MA Health and Educational Facilitiy Authority Rebate computation was performed on October 8, 2013. Schedule K, Part IV, Line 2c-06/19/2008 6,715,000 MA Health and Educational Facility Authority Rebate computation was performed on October 8, 2013. Form 990, Part VI, Section B, Line 11b The accountant at Heywood Hospital prepares the Form 990 and provides to the controller for review. The form is then sent to the CFO for final review. Once reviewed, the 990 is received by the Board of Trustees. The 990 is then approved by the board, and submitted by the accounting department. Form 990, Part VI, Section B, Line 12c Annually, a Conflict of Interest Form is sent out to the manager, trustees, and employees with broad discretionary authority. These forms are required to be signed and are monitored by the Corporate Compliance office for completion. Form 990, Part VI, Section B, Line 15 The CEO and Executive Staff's compensation is determined by market data and analysis provided to the Hospital's Compensation Committee and Board of Trustees by an independent compensation consultant engaged by the Board of Trustees annually. Mr. Brown, CEO, also receives an annual contribution as payment for deferred compensation which is subject to a multi-year vesting schedule that is incumbent upon his ongoing employment. Form 990, Part VI, Section C, Line 19 The organization makes the governing documents, conflict of interest policy, and financial statements available to the public by providing completed copies to the Administrative Assistant, who provides copies upon request. Form 990, Part IX, Line 11g Included in Fees for services (non-employees) other expenses are: Physician Fees: $6,367,621 Outside Clinical Fees: $4,980,534 Temporary Employees: $259,038 Medical Staff: $16,034 Form 990, Part XI, Line 9 The amount that makes up the other changes in net assets or fund balance is from discounts on pledge receivables and transfers to inter-corporate related organizations to support their operations. Heywood Affiliated Medical Group 242 Green Street Gardner MA 01440 043163589 employ physicians MA 501(c)(3) 9 Heywood Healthcare 0 Heywood Hospital Realty Corporation 242 Green Street Gardner MA 01440 043327447 property holding company MA 501(c)(2) Heywood Healthcare 0 Athol Memorial Hospital 2033 Main Street Athol MA 01331 042126583 Hospital MA 501(c)(3) 3 Heywood Healthcare 0 Heywood Healthcare Inc 242 Green Street Gardner MA 01440 222720658 Parent Corp MA 501(c)(3) 7 N/A 0 Heywood Healthcare Charitable Foundation 242 Green Street Gardner MA 01440 222720562 Charitable Foundation MA 501(c)(3) 7 Heywood Healthcare 0 HHMH Aid Association 242 Green Street Gardner MA 01440 042198019 raise funds for the Hospital MA 501(c)(3) 9 N/A 0 Winchendon Health Foundation 87 Central Street Winchendon MA 01475 042113276 supporting organization MA 501(c)(3) PF N/A 0 Heywood Physician Hospital Organization 242 Green Street Gardner MA 01440 043153119 Managed care contracted physicians MA 501(c)(3) 9 N/A 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 1 1 1 0 Heywood Hospital Realty Corporation j 85815 Actual Cost Heywood Hospital Realty Corporation q 218321 Actual Cost Extension granted.