2015-02-16T12:59:31-06:00 2014-06-30 020476956 TYLER SIMMS & STSAUVEUR CPAS PC 19 MORGAN DRIVE LEBANON NH 03766 990 2013-07-01 020226774 SPEARE MEMORIAL HOSPITAL SPEA 6032382231 16 HOSPITAL ROAD PLYMOUTH NH 03264 MICHELLE MCEWEN PRESIDENT/CEO 6035361120 2015-02-09 1 JAMES N GODFREY CPA P00913422 6036530044 2015-02-09 2013 2016-02-25 16:41:14Z MICHELLE MCEWEN 16 HOSPITAL ROAD PLYMOUTH NH 03264 61624241 0 X SPEAREHOSPITAL.COM X 1899 NH TO PROVIDE INPATIENT, OUTPATIENT AND PHYSICIAN HEALTH CARE SERVICES 15 14 445 75 0 0 870980 950824 57976992 57812917 754004 567762 263714 269960 59865690 59601463 228000 278000 0 0 22543915 23393776 0 0 126821 30003704 34617178 52775619 58288954 7090071 1312509 75507185 78560598 31554594 31785630 43952591 46774968 X TO MAINTAIN A HOSPITAL AND OTHER SUCH INSTITUTIONS WITHIN THE STATE OF NEW HAMPSHIRE, WITH FACILITIES THAT INCLUDE MEDICAL SERVICES TO PROVIDE FOR THE DIAGNOSIS AND TREATMENT OF PATIENTS THAT MAY REQUIRE INPATIENT, OUTPATIENT, EMERGENCY CARE AND OTHER PURSUITS DESIGNED TO PROMOTE THE GENERAL HEALTH OF THE COMMUNITY. SMH DOES NOT DISCRIMINATE RELATIVE TO RACE, RELIGION OR NATIONAL ORIGIN, ABILITY TO PAY AND WILL ASSURE THAT ALL PATIENTS RECEIVE THE SAME LEVEL OF CARE THROUGH QUALITY ASSESSMENT MONITORING AND IMPROVEMENT ACTIVITIES. 0 0 52983736 278000 57812917 SMH IS A 25-BED ACUTE-CARE HOSPITAL THAT PROVIDES INPATIENT AND OUTPATIENT SERVICES TO THE SURROUNDING COMMUNITY. 52983736 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 0 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 55 0 1 445 1 0 0 0 0 0 1 1 0 0 0 0 X 15 14 1 1 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 0 1 1 NH X X FINANCE DIRECTOR 6032382160 SMH 16 HOSPITAL ROAD PLYMOUTH NH 03264 MICHELLE MCEWEN HOSPITAL PRESIDENT/CEO 40.00 X X 238234 0 40421 CLINT HUTCHINS CHAIR 1.00 X X 0 0 0 STANLEY LEE FREEMAN TREASURER 1.00 X X 0 0 0 ELDWIN WIXSON MEMBER 1.00 X 0 0 0 NANCY PUGLISI MEMBER 1.00 X 0 0 0 QUINTIN BLAINE SECRETARY 1.00 X 0 0 0 SAM BRICKLEY II MEMBER 1.00 X 0 0 0 LINDA CRAWFORD MD MEMBER 1.00 X 0 0 0 JILL DUNCAN MEMBER 1.00 X 0 0 0 WILLIAM LARSEN VICE CHAIR 1.00 X X 0 0 0 ROBERT MALONEY MEMBER 1.00 X 0 0 0 ALISON RITZ MEMBER 1.00 X 0 0 0 MARILYN SANDERSON MEMBER 1.00 X 0 0 0 DANA MERRITHEW MD MEMBER 1.00 X 0 0 0 STEVE TAKSAR ASST TREASURER 1.00 X X 0 0 0 THOMAS LENKOWSKI PART-YEAR CFO 40.00 X X 0 0 0 RICHARD WERKOWSKI PART-YEAR CFO 40.00 X 157229 0 21320 JOSEPH EBNER CHIEF MEDICAL OFFICER 40.00 X 216783 0 37750 STEVE DANOSI MD PHYSICIAN 40.00 X 453355 0 44153 RALPH BROADWATER MD PHYSICIAN 40.00 X 357421 0 42459 MICHAEL GIOVAN MD PHYSICIAN 40.00 X 401382 0 43841 JOSEPH CASEY MD PHYSICIAN 40.00 X 350420 0 43913 VICTOR GENNARO MD PHYSICIAN 40.00 X 409501 0 44888 2584325 0 318745 30 0 1 0 PLYMOUTH REGIONAL REHAB SERVICES 60 LYME STREET OLD LYME CT 06371 PT/OT THERAPISTS 902262 MMODAL SERVICES LTD PO BOX 538504 ATLANTA GA 30353 TRANSCRIPTION 264562 MEDICAL REIMBURSEMENT SPECIALISTS PO BOX 486 BRISTOL NH 03222 BILLING OVERSIGHT 176265 STIVERS MANAGEMENT CONSULTING 3 DRURY LANE LYNFIELD MA 01940 IT CONSULTING 130902 PPR LLC DRAWER 1587 PO BOX 5935 TROY NY 48007 CONTRACT LABOR 111559 5 950 548619 401255 5052 950824 NET PATIENT REVENUE 624100 56370816 56370816 OTHER OPERATING REVENU 900099 1442101 1442101 57812917 411628 411628 59571 50355 9216 9216 9216 2091121 10839 1529743 416083 561378 -405244 156134 156134 56452 950 26597 29855 29855 CAFETERIA INCOME 722210 130299 130299 PHARMACY INCOME 446110 100590 100590 230889 59601463 57812917 0 837722 278000 278000 774080 774080 16742063 14709915 1954215 77933 1028762 903125 120852 4785 3452559 2954054 482854 15651 1396312 1178566 211502 6244 43094 43094 75233 75233 96001 96001 128026 128026 5541984 5114247 408179 19558 1312121 1204209 107912 84118 75565 6183 2370 881 881 346878 346878 3081175 3081175 BAD DEBT 7381680 7381680 PURCHASED SERVICES 5380001 5305744 74257 PHYSICIAN FEES & WAGES 5360443 5360443 PROVIDER TAX STATE OF N 2357603 2357603 3427940 2603625 824035 280 58288954 52983736 5178397 126821 12652016 14868353 1470060 1224621 7717508 7831545 2534011 2424629 864005 884947 455790 425088 49678022 25576295 24417933 24101727 16406439 18687132 6603676 5598529 999011 983243 1386736 1530784 75507185 78560598 2176809 2768878 20868086 20160113 230652 118052 8279047 8738587 31554594 31785630 X 43101817 45988510 288948 197122 561826 589336 43952591 46774968 75507185 78560598 X 1312509 1436724 73144 X 0 1 X 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 10937 10937 0 PART II-B, LINE 1: SPEARE MEMORIAL HOSPITAL IS A MEMBER OF THE NEW HAMPSHIRE HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. A PORTION OF THE DUES PAID TO THESE ORGANIZATIONS IS AVAILABLE FOR LOBBYING EXPENDITURES ON BEHALF OF SPEARE MEMORIAL HOSPITAL AND THE OTHER MEMBER ORGANIZATIONS IN FURTHERANCE OF THEIR EXEMPT PURPOSE. SPEARE MEMORIAL HOSPITAL DOES NOT DIRECTLY PERFORM ANY LOBBYING ACTIVITES. 270204 8 -5 270207 270198 6 270204 271045 7 -854 270198 248354 25000 5 2314 271045 223344 25000 10 248354 0.98830 0.01170 1 0 549583 549583 29467146 12376004 17091142 922885 554492 368393 18626617 12645799 5980818 111791 111791 24101727 BOND FUNDS 5598529 F 5598529 OTHER CURRENT LIABILITIES 2354118 EST. THIRD-PARTY PAYER SETTLEMENTS 4480995 INVESTMENT IN SUB-BOULDER 1890232 CURRENT PORTION OF LONG-TERM LEASE 13242 8738587 53328140 1436724 -7381680 -5944956 59273096 96001 232366 328367 59601463 50533273 0 50533273 96001 7659680 7755681 58288954 PART V, LINE 4: THE ENDOWMENT FUND IS USED TO SUPPORT OPERATIONS OF THE HOSPITAL. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE -7,381,680. PART XI, LINE 4B - OTHER ADJUSTMENTS: GRANT EXPENSE 278,000. BAD DEBT EXPENSE ON MSHC RECEIVABLE 4,722. RENTAL EXPENSES -50,355. ROUNDING -1. PART XII, LINE 4B - OTHER ADJUSTMENTS: GRANT EXPENSE 278,000. BAD DEBT EXPENSE 7,381,680. GOLF TOURNAMENT 57402 950 56452 22 3175 12380 11020 57402 950 56452 22 3175 12380 11020 26597 29855 1 1 1 X 125.000000000000 1 X 225.000000000000 1 1 0 1 1 3133586 899352 2234234 0.03830 5761055 5684460 76595 0.00130 8894641 6583812 2310829 0.03960 59821 59821 0.00100 11500 11500 0.00020 177260 177260 0.00300 293377 293377 0.00500 541958 541958 0.00920 9436599 6583812 2852787 0.04880 1 3363218 107623 16441471 18617559 -2176088 X 1 1 1 PLYMOUTH REGIONAL REHABILITATION SERVICES PHYSICAL THERAPY, OCCUPATIONAL THERAPY & MEDICAL FITNESS 0.50000 1 1 SPEARE MEMORIAL HOSPITAL 16 HOSPITAL ROAD PLYMOUTH NH 03264 X X X X SPEARE MEMORIAL HOSPITAL 1 1 X X X X X X X X X X 11 1 0 1 X SPEAREHOSPITAL.COM X X X X X X X X X 1 0 1 1 225.000000000000 1 225.000000000000 1 X X X X X X X 1 1 X X X X 1 X 1 X X X X 1 X 0 0 SPEARE MEMORIAL HOSPITAL PART V, SECTION B, LINE 1J: SPEARE MEMORIAL HOSPITAL CONDUCTED A COMMUNITY WIDE PUBLIC PRESENTATION OF THE NEEDS ASSESSMENT REPORT IN OCTOBER 2011. PART III, LINE 4: SMH HAS NO APPROPRIATE FOOTNOTE IN THE APPLICABLE AUDITED FINANCIAL STATEMENT. SMH HAS USED A RATIO OF COSTS TO CHARGES OF 48% IN DETERMINING THE COST OF BAD DEBT EXPENSE. PART III, LINE 8: 100% OF THE SHORTFALL FROM MEDICARE SHOULD BE CONSIDERED A COMMUNITY BENEFIT. THE SOURCE USED TO DETERMINE THIS AMOUNT IS THE MEDICARE CHARGES LESS THE MEDICARE PAYMENTS MADE TO SPEARE MEMORIAL HOSPITAL. SERVICES THAT INCUR SUCH COSTS ARE PROVIDED BY THE HOSPITAL TO PROMOTE THE WELL-BEING OF THE COMMUNITY. THE SERVICES ARE RENDERED IN CONJUNCTION WITH THE HOSPITAL'S CHARITABLE TAX EXEMPT PURPOSE. TREATING THE SHORTFALL AS A COMMUNITY BENEFIT RELIEVES THE BURDEN ON LOCAL SOCIAL SERVICES AND GOVERNMENT SUPPORTED PROGRAMS. PART III, LINE 9B: SPEARE MEMORIAL HOSPITAL HAS BOTH A COLLECTIONS POLICY, AND A CHARITY CARE POLICY THAT DESCRIBES CHARITY ELIGIBILITY AND THE STEPS TO BE COMPLETED BEFORE A PATIENT'S ACCOUNT IS WRITTEN OFF TO BAD DEBT. PART VI, LINE 2: INFORMATION GATHERING THROUGH SURVEYS, FOCUS GROUPS, COMMUNITY REPRESENTATION, PUBLIC FORUMS, INPUT FROM HEALTH CARE PROVIDERS, INDUSTRY LEADERS, OUTSIDE CONSULTANTS,AND ANALYSIS OF INTERNAL DATA AND EXTERNAL DATA PROVIDED BY HOSPITAL ASSOCIATIONS, PAYERS, ETC. PART VI, LINE 3: PATIENTS ARE EDUCATED AT TIME OF REGISTRATION OR THROUGH EDUCATIONAL MATERIALS THAT ARE DISTRIBUTED THROUGH THE HOSPITAL'S WEBSITE OR BY COMMUNITY OUTREACH. SPEARE MEMORIAL HOSPITAL IS A MEMBER OF A STATE-WIDE COMMUNITY HEALTH NETWORK THAT PROVIDES ASSISTANCE, SUPPORT,AND EDUCATION RELATING TO ELIGIBILITY ASSISTANCE. PART VI, LINE 4: SPEARE MEMORIAL HOSPITAL IS LOCATED IN THE MOUNTAIN AND LAKES REGION OF NEW HAMPSHIRE AND PRIMARLY SERVES CONSTITUENTS IN GRAFTON COUNTY. GRAFTON COUNTY POPULATION SIZE IS APPROXIMATELY 86,000 WITHIN ITS 40 DISTINCT MUNICIPALITIES. ITS SERVICE AREA INCLUDES 17 TOWNS WITH AN APPROXIMATE TOTAL POPULATION OF 30,000. PART VI, LINE 5: SPEARE MEMORIAL HOSPITAL PROVIDES PRESCRIPTION MEDICATION ASSISTANCE, PRIMARY-CARE CLINCS, MULTIPLE SUPPORT GROUPS, COMMUNITY EDUCATION PROGRAMS, SCHOOL DENTAL PROGRAM, ETC. AND HAS AFFLIATIONS AND PARTNERSHIPS WITH MANY COMMUNITY ORGANIZATIONS; AN OPEN MEDICAL STAFF AND COMMUNITY BOARD. OPERATING FUNDS ARE USED FOR ONGOING CAPITAL EXPENDITURES. PART VI, LINE 7, REPORTS FILED WITH STATES NH 1 MID-STATE HEALTH CENTER 101 BOULDER POINT DRIVE NO 1 PLYMOUTH NH 03264 020487172 501 (C)(3) 278000 FMV COMMUNITY BENEFIT GRANT 1 X X X X X 0 0 0 0 0 0 0 0 0 MICHELLE MCEWEN HOSPITAL PRESIDENT/CEO 238234 0 0 0 0 0 20026 0 20395 0 278655 0 0 0 RICHARD WERKOWSKI PART-YEAR CFO 157229 0 0 0 0 0 13066 0 8254 0 178549 0 0 0 JOSEPH EBNER CHIEF MEDICAL OFFICER 216783 0 0 0 0 0 17526 0 20224 0 254533 0 0 0 STEVE DANOSI MD PHYSICIAN 453355 0 0 0 0 0 23759 0 20394 0 497508 0 0 0 RALPH BROADWATER MD PHYSICIAN 357421 0 0 0 0 0 22065 0 20394 0 399880 0 0 0 MICHAEL GIOVAN MD PHYSICIAN 401382 0 0 0 0 0 23759 0 20082 0 445223 0 0 0 JOSEPH CASEY MD PHYSICIAN 350420 0 0 0 0 0 23518 0 20395 0 394333 0 0 0 VICTOR GENNARO MD PHYSICIAN 409501 0 0 0 0 0 24331 0 20557 0 454389 0 0 0 A NEW HAMPSHIRE HEALTH AND EDUCATION FACILITIES AUTHORITY 020279866 2012-12-07 21100000 TO PAY OFF AND PROVIDE ADVANCED REFUNDING FOR 2010 AND 2004 BONDS 0 0 0 A 16323208 21100000 12612773 209815 4566977 1 1 1 1 A 0 0 0 0 0 0 0 A 1 0 0 0 0 0 A 0 FORM 990, PART VI, SECTION A, LINE 2 THE COMMUNITY RELATIONS DIRECTOR IS THE SPOUSE OF A BOARD MEMBER. FORM 990, PART VI, SECTION A, LINE 3 THE REHABILITATION DEPARTMENT IS NOW MANAGED BY ORTHOPEDIC HEALTH SERVICES. INC. FORM 990, PART VI, SECTION A, LINE 6 THE PROVISIONS OF SMH GOVERNING DOCUMENTS PROVIDE THE BOARD OF DIRECTORS AND IS COMPRISED OF ASSOCIATION MEMBERS. FORM 990, PART VI, SECTION A, LINE 7A THE ASSOCIATION MEMBERS ELECT THE BOARD MEMBERS FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED BY THE HOSPITAL CFO AND THE PRESIDENT/CEO AND THE FINANCE COMMITTEE. THE TAX FORM 990 IS MADE AVAILABLE FOR REVIEW TO THE BOARD OF DIRECTORS. THE FORM 990 IS THEN SIGNED AND FILED. FORM 990, PART VI, SECTION B, LINE 12C ANNUAL COMPLIANCE FORM COMPLETED BY EACH MEMBER OF THE BOARD FORM 990, PART VI, SECTION B, LINE 15A COMPENSATION FOR THE CEO IS DETERMINED VIA A COMPENSATION COMMITTEE, COMPENSATION SURVEY OR STUDY, COMPARISON OF OTHER ORGANIZATIONS 990 INFORMATION, BOARD APPROVAL AND WRITTEN EMPLOYMENT CONTACT. FORM 990, PART VI, SECTION C, LINE 19 UPON REQUEST FORM 990, PART XI, LINE 9: BAD DEBT EXPENSE ON MSHC RECEIVABLE -4,722. RENTAL EXPENSES 50,355. CHANGE IN BENEFICIAL INTEREST IN PERPETUAL TRUSTS 27,510. ROUNDING 1. SPEARE MEMORIAL AT BOULDER POINT BOULDER POINT DR PLYMOUTH NH 03264 263888977 REAL ESTATE NH 501(C)(3) LINE 9 SPEARE MEMORIAL HOSPITAL 0 SPEARE HEALTH VENTURE 16 HOSPITAL ROAD PLYMOUTH NH 03264 020366565 HEALTHCARE SERVICES NH C 1.00000 0 SPEARE HEALTH NETWORK LLC 16 HOSPITAL ROAD PLYMOUTH NH 03264 043372339 PHYSICIAN/HOSPITAL ORGANIZATION NH C 0.50000 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 SPEARE MEMORIAL AT BOULDER POINT-LEASES ALL OF ITS SPACE TO SMH K 502582 ACTUAL SPEARE HEALTH VENTURE D 254315 FAIR MARKET VALUE SPEARE MEMORIAL AT BOULDER POINT D 2040520 FAIR MARKET VALUE SPEARE MEMORIAL AT BOULDER POINT Q 7925 ACTUAL