2015-06-30T10:36:27-05:00 2014-09-30 061533253 SASLOW LUFKIN & BUGGY LLP 175 POWDER FOREST DRIVE SIMSBURY CT 06089 990 2013-10-01 060646678 THE CHARLOTTE HUNGERFORD HOSPITAL CHAR 8604966728 540 LITCHFIELD STREET PO BOX 988 TORRINGTON CT 067900988 SUSAN M SCHAPP VP FINANCE/TREASURER 8604966728 2015-06-30 1 KRISTIN ANDERSON P01231300 8606789200 2013 2016-04-25 22:37:26Z SUSAN M SCHAPP 540 LITCHFIELD STREET PO BOX 988 TORRINGTON CT 067900988 134126705 0 X WWW.CHARLOTTEHUNGERFORD.ORG X 1917 CT TO PROVIDE QUALITY, COMPASSIONATE AND COST EFFECTIVE HEALTHCARE TO THE COMMUNITY OF NORTHWESTERN CONNECTICUT. 16 14 1253 185 980924 0 3015379 3170907 122017519 118627892 2463648 3182192 381719 479250 127878265 125460241 12000 12000 0 0 75560164 73040987 0 0 345306 49401846 49026972 124974010 122079959 2904255 3380282 132607623 137043425 47910218 52361370 84697405 84682055 X THE CHARLOTTE HUNGERFORD HOSPITAL PROVIDES QUALITY MEDICAL HEALTHCARE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR ABILITY TO PAY. OUR MISSION IS TO SERVE THE COMMUNITY WITH RESPECT TO PROVIDING HEALTHCARE SERVICES AND HEALTHCARE EDUCATION. IN KEEPING WITH THE HOSPITAL'S COMMITMENT TO SERVE ALL MEMBERS OF THE COMMUNITY, FREE CARE AND/OR SUBSIDIZED CARE, CARE PROVIDED TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT BELOW COST, HEALTH ACTIVITIES AND PROGRAMS TO SUPPORT THE COMMUNITY WILL BE CONSIDERED WHERE THE NEED AND/OR AN INDIVIDUAL'S INABILITY TO PAY COEXIST. THESE ACTIVITIES INCLUDE WELLNESS PROGRAMS, COMMUNITY EDUCATION PROGRAMS, SPECIAL PROGAMS FOR THE ELDERLY, HANDICAPPED, THE MEDICALLY UNDERSERVED AND A VARIETY OF BROAD COMMUNITY SUPPORT ACTIVITIES. 0 0 107818668 12000 117870688 DURING FY 2014 THE HOSPITAL CONTRIBUTED OVER 15,000 HOURS TOWARD THE COMMON PURPOSE OF SERVICING THE HEALTHCARE NEEDS OF THE COMMUNITY. THE VALUE OF THIS CONTRIBUTION IS APPROXIMATELY $125,000, WHICH IS GIVEN BACK TO THE COMMUNITY THROUGH LOWER COSTS IN BOTH PATIENT SERVICES AND OTHER "WELLNESS" PROGRAMS. IN ADDITION THE HOSPITAL GRANTED CHARITY CARE IN THE AMOUNT OF $1,349,407 DURING FISCAL YEAR 2014. THE CHARLOTTE HUNGERFORD HOSPITAL RENDERED THE FOLLOWING SERVICES DURING FY 2014:INPATIENT SERVICES:DISCHARGES 6,106PATIENT DAYS 25,604 SPECIAL SERVICES: OPERATING ROOM CASES 4,011 AMBULATORY SURGERY CASES 3,245 ENDOSCOPY CASES 981 AMBULATORY MEDICAL CASES 2,808WOUND CARE CASES 6,522POST ANESTHESIA CARE UNIT CASES 2,401 DELIVERY ROOM DELIVERIES 444RESPIRATORY THERAPY TREATMENTS 35,824 PULMONARY REHAB TESTS 5,691PULMONARY FUNCTION LAB TESTS 1,434 CARDIO DIAGNOSTIC EXAMS 13,415EEG EXAMS 186PHYSICAL THERAPY TREATMENTS 35,268 CARDIAC REHAB TREATMENTS 3,298 SPEECH THERAPY TREATMENTS 765 OCCUPATIONAL THERAPY TREATMENTS 3,759 SLEEP STUDY TESTS 516 DIAGNOSTIC RADIOLOGY EXAMS 25,786MAMMOGRAPHY EXAMS 8,923 NUCLEAR MEDICINE EXAMS 801ULTRASOUND EXAMS 9,028C.A.T. SCAN EXAMS 12,932P.E.T. SCAN EXAMS 276M.R.I. EXAMS 1,359SPECIAL PROCEDURES (RADIOLOGY) EXAMS 1,243RADIATION THERAPY TREATMENTS 8,266LABORATORY TESTS 571,488 PSYCHIATRIC CLINIC VISITS 34,954 PHP-ADULT/ADOLESCENT VISITS 4,677 RENAL DIALYSIS VISITS 302 EMERGENCY DEPARTMENT VISITS 34,363OUTPATIENT DIABETES PROGRAM VISITS 1,699WALK IN CENTER VISITS 11,890PROFESSIONAL SERVICE CONSULTS 126,787HUNGERFORD EMERGENCY MEDICAL CENTER: CARDIAC REHAB TREATMENTS 1,551DIAGNOSTIC RADIOLOGY EXAMS 3,741 LABORATORY TESTS 17,877EMERGENCY DEPARTMENT VISITS 6,361PULMONARY REHAB TESTS 2,246 107818668 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 1 0 1 1 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 1 216 0 1 1253 1 1 1 0 0 0 0 0 0 0 0 0 X 16 14 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 CT X X SUSAN M SCHAPP 8604966728 540 LITCHFIELD STREET TORRINGTON CT 06790 EDWARD ARUM GOVERNOR 2.50 X 0 0 0 RICHARD DUTTON MD GOVERNOR 1.00 X 0 0 0 GLADYS CERRUTO GOVERNOR 1.00 X 0 0 0 DAVID J FRAUENHOFER SECRETARY 1.00 X X 0 0 0 JAMIE GREG GOVERNOR 1.00 X 0 0 0 KENDRICK HOM MD GOVERNOR 40.00 X 275710 0 33960 JOHN JANCO CHAIRMAN 2.50 X X 0 0 0 JOHN LAVIERI GOVERNOR 2.50 X 0 0 0 DIANE LIBBY CPA VICE CHAIRMAN 1.00 X 0 0 0 JAMES O'LEARY GOVERNOR 1.00 X 0 0 0 EDWIN G BOOTH JR GOVERNOR 1.00 X 0 0 0 FRANK BUONOCORE JR GOVERNOR 1.00 X 0 0 0 STEPHANIE FOWLER MD GOVERNOR 1.00 X 0 0 0 MICHAEL PATTERSON GOVERNOR 1.00 X 0 0 0 CHARLES W RORABACK GOVERNOR 1.00 X 0 0 0 ANDREW SZCZEPENSKI MD GOVERNOR 10.00 X 43045 0 4108 DANIEL J MCINTYRE CEO/PRESIDENT 60.00 X 446903 0 83619 SUSAN M SCHAPP VP FINANCE/ TREASURER 60.00 X 269327 0 50496 JOHN J CAPOBIANCO VP OUT PATIENT SERVICES 60.00 X 241956 0 44778 MARK PRETE MD VP MEDICAL AFFAIRS 60.00 X 311896 0 59231 RAYMOND J ELLIOTT VP FACILITIES 60.00 X 165636 0 40397 BRIAN MATTIELLO VP HUMAN RESOURCES 60.00 X 188193 0 21961 ELZBIETA LACH-PASKO MD PATHOLOGIST 60.00 X 393156 0 53166 MUSTAFA UGURLU MD PHYSICIAN 60.00 X 490960 0 55528 TIMOTHY GOSTKOWSKI MD PHYSICIAN 60.00 X 612210 0 68166 WILLIAM MCGEEHIN MD PHYSICIAN 60.00 X 584900 0 65973 DAVID FRECCERO MD PHYSICIAN 60.00 X 532006 0 52663 4555898 0 634046 50 0 1 0 ADULT & PEDIATRIC UROLOGY OF NW CONNECTI 538 LITCHFIELD STREET SUITE 102 TORRINGTON CT 06790 MEDICAL 1454570 BUILDING ONE FACILITY SERVICES 57 OZICK DRIVE SUITE A DURHAM CT 06422 CLEANING SERVICES 1290327 MAYO COLLABORATIVE SERVICES PO BOX 9146 MINEAPOLIS MN 554809146 LABORATORY TESTS 943485 NEW MILFORD LAUNDRY 40 COMMONS COURT WATERBURY CT 06704 LAUNDRY/LINEN SERVICES 507855 PROGRESSIVE PAVING & CONSTRUCTION LLC PO BOX 160 GOSHEN CT 06756 PAVING / CONSTRUCTION 503410 28 19933 2047945 1103029 3170907 NET PATIENT REVENUE 900099 104184584 104184584 LABORATORY SERVICES 621500 10437466 9465157 972309 OTHER HOSPITAL SERVICES 900099 4005842 4005842 118627892 1587620 1587620 573597 358492 215105 215105 215105 7755404 2006529 6460129 1707232 1295275 299297 1594572 1594572 123545 19933 44242 79303 79303 206597 96369 110228 110228 GAIN FROM EQUITY METHOD 900001 65999 65999 MEDCONN 561499 8615 8615 74614 125460241 117870688 980924 3437722 12000 12000 2322016 1741512 580504 56934381 50878266 5882224 173891 3417762 3034978 372754 10030 6517466 5787520 710820 19126 3849362 3418240 419826 11296 7099731 6304572 774324 20835 350198 310976 38194 1028 119200 105850 13000 350 7248543 6436718 790554 21271 524329 465605 57185 1539 366847 325760 40010 1077 1656884 1471316 180706 4862 3364241 2987451 366917 9873 29278 25999 3193 86 15651 13898 1707 46 5899420 5238695 643413 17312 1997755 1774009 217883 5863 SUPPLIES 15955239 14168279 1740139 46821 PHYSICIAN FEES 4330528 3247896 1082632 0 HOSPITAL AUXILIARY EXPE 69128 69128 122079959 107818668 13915985 345306 64643 110649 9014949 7236836 36857 14891 13504471 13152579 2119166 1999800 1512549 1264076 155625189 116385088 36869779 39240101 66334495 69582179 3150714 4442314 132607623 137043425 11483194 11740332 298993 516546 3219468 0 32908563 40104492 47910218 52361370 X 61261338 59513314 3334379 3526938 20101688 21641803 84697405 84682055 132607623 137043425 X 3380282 4658208 -8053840 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 22332 22332 0 PART II-B, LINE 1: THE HOSPITAL IS A MEMBER OF THE CONNECTICUT HOSPITAL ASSOCIATION. $22,332 REPRESENTS THE PORTION OF DUES PAID TO THE ASSOCIATION WHICH WERE USED FOR LOBBYING PURPOSES. 60160777 253117 5411408 3269043 62556259 53165045 243732 7106906 354906 60160777 46929816 239485 6103897 108153 53165045 49273746 186977 -2264127 266780 46929816 45533758 690138 3824302 774452 49273746 0.59800 0.34600 0.05600 0 0 155467 155467 82924326 57153527 25770799 65768005 54733312 11034693 6777391 4498249 2279142 39240101 ESTIMATED AMOUNTS DUE TO THIRD PARTY REIMBURSEMENT AGENCIES 4348984 MISCELLANEOUS CURRENT LIABILITIES 198980 ESTIMATED SELF-INSURANCE LIABILITIES 3971340 ACCRUED PENSION LIABILITY 27865188 PENSION CONTRIBUTION - CURRENT YEAR 3720000 40104492 X 125021877 0 125021877 438364 438364 125460241 121998831 0 121998831 81128 81128 122079959 PART V, LINE 4: THE ENDOWMENT FUNDS WILL BE USED PRIMARILY FOR CAPITAL PURCHASES, INDIGENT CARE AND OTHER USES AS APPROVED BY THE BOARD IN ACCORDANCE WITH DONOR RESTRICTIONS. PART X, LINE 2: THE HOSPITAL ACCOUNTS FOR UNCERTAIN TAX POSITIONS WITH PROVISIONS OF FASB ASC 740, "INCOME TAXES" WHICH PROVIDES A FRAMEWORK FOR HOW COMPANIES SHOULD RECOGNIZE, MEASURE, PRESENT AND DISCLOSE UNCERTAIN TAX POSITIONS IN THEIR FINANCIAL STATEMENTS. THE HOSPITAL MAY RECOGNIZE THE TAX BENEFIT FROM AN UNCERTAIN TAX POSITION ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITION WILL BE SUSTAINED ON EXAMINATION BY THE TAXING AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. THE HOSPITAL DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS AS OF SEPTEMBER 30, 2014 AND 2013. AS OF SEPTEMBER 30, 2014 AND 2013, THE HOSPITAL DID NOT RECORD ANY PENALTIES OR INTEREST ASSOCIATED WITH UNCERTAIN TAX POSITIONS. THE HOSPITAL'S PRIOR THREE TAX YEARS ARE OPEN AND SUBJECT TO EXAMINATION. PART XI, LINE 4B - OTHER ADJUSTMENTS: TEMPORARY RESTRICTED ACTIVITY 335,640. AUXILIARY REVENUE 102,724. PART XII, LINE 4B - OTHER ADJUSTMENTS: AUXILIARY EXPENSES 81,128. GOLF TOURNAMENT 95680 95680 5436 25252 DINNER DANCE 27865 27865 13554 6 19933 19933 143478 19933 123545 5436 38806 44242 79303 1 1 1 X 1 X 1 1 0 1 1 1736 1311527 0 1311527 0.01070 46250 28577031 21909855 6667176 0.05460 595 276706 111323 165383 0.00140 48581 30165264 22021178 8144086 0.06670 11 6264 269597 0 269597 0.00220 2 413 3985 0 3985 0.00000 74408 29371764 26682171 2689593 0.02200 2 1492 9933 9933 0.00010 15 82577 29655279 26682171 2973108 0.02430 15 131158 59820543 48703349 11117194 0.09100 1 2699503 0 43633893 48228139 -4594246 X 1 1 1 ADVANCED MEDICAL IMAGING OF NORTHWEST CT LLC IMAGING CENTER 0.50000 0.00000 0.50000 2 MEDCONN COLLECTION AGENCY LLC PATIENT COLLECTION AGENCY 0.33370 0.00000 0.00000 3 UROLOGY CENTER OF NW CT UROLOGY CENTER 0.62500 0.00000 0.37500 4 LITCHFIELD COUNTY HEALTHCARE SERVICE CORP PHYSICIANS PRACTICE 1.00000 0.00000 0.00000 1 1 CHARLOTTE HUNGERFORD HOSPITAL 540 LITCHFIELD STRRET TORRINGTON CT 06790 WWW.CHARLOTTEHUNGERFORD.ORG 0042 X X X X CHARLOTTE HUNGERFORD HOSPITAL 1 1 X X X X X X X X 12 1 0 1 X WWW.CHARLOTTEHUNGERFORD.ORG X X X X X X X X 0 0 1 1 200.000000000000 1 400.000000000000 1 X X 1 1 X X X X X 1 X X 1 X X X X X 1 X 0 0 CHARLOTTE HUNGERFORD HOSPITAL PART V, SECTION B, LINE 3: THE STUDY WAS CONDUCTED BY THE CENTER FOR HEALTHY SCHOOLS AND COMMUNITIES AT EDUCATION CONNECTION IN LITCHFIELD, CT. THE STEERING COMMITTEE INCLUDED THE FOLLOWING INDIVIDUALS AND ORGANIZATIONS: JIM ROKOS, DIRECTOR OF HEALTH, TORRINGTON AREA HEALTH DISTRICT; LESLIE POLITO, ASSISTANT DIRECTOR OF HEALTH, TORRINGTON AREA HEALTH DISTRICT; SHARON MCCOY, PROJECT DIRECTOR, TORRINGTON AREA HEALTH DISTRICT; STEPHANIE BARKSDALE, EXECUTIVE DIRECTOR, UNITED WAY OF NORTHWEST CONNECTICUT; GREG BRISCO, CHIEF EXECUTIVE OFFICER, NORTHWEST CONNECTICUT YMCA; BRIAN MATTIELLO, V.P. FOR ORGANIZATIONAL DEVELOPMENT, CHARLOTTE HUNGERFORD HOSPITAL; DANIEL BAROODY, DIRECTOR OF HEALTH, TOWN OF SHARON; MIKE CRESPAN, DIRECTOR OF HEALTH, NEW MILFORD HEALTH DEPARTMENT; DONNA CULBERT, DIRECTOR OF HEALTH, NEWTOWN HEALTH DISTRICT; JENNIFER KERTANIS, DIRECTOR OF HEALTH, FARMINGTON VALLEY HEALTH DISTRICT; NEAL LUSTIG, DIRECTOR OF HEALTH, POMPERAUG HEALTH DISTRICT; MARY BEVAN, DIRECTOR, CENTER FOR HEALTHY SCHOOLS AND COMMUNITIES EDUCATION CONNECTION; JIM HUTCHISON, COMMUNITY HEALTH COORDINATOR, SHARON HOSPITAL; ANDREA RYNN, DIRECTOR OF PUBLIC AND GOVERNMENT RELATIONS, WESTERN CT HEALTH NETWORK; MARY WINAR, PROJECTS COORDINATOR, CONNECTICUT OFFICE OF RURAL HEALTH. CHARLOTTE HUNGERFORD HOSPITAL PART V, SECTION B, LINE 7: NOT ALL NEEDS HAVE BEEN ADDRESSED SINCE THE ASSESSMENT WAS IN YEAR TWO OF A FIVE YEAR PLAN WITH A CONTINUED EFFORT TO REFINE ASSESSMENTS. CHARLOTTE HUNGERFORD HOSPITAL PART V, SECTION B, LINE 20D: CONNECTICUT STATE LAW (LOONEY BILL) REQUIRES THE HOSPITAL TO ADJUST THE PATIENT'S BALANCE EQUAL TO THE COST OF PROVIDING THE CARE. 13 NORTHWEST CONNECTICUT MEDICAL WALK IN 1598 EAST MAIN STREET TORRINGTON CT 06790 WALK IN MEDICAL CLINIC THE HUNGERFORD CENTER 780 LITCHFIELD STREET TORRINGTON CT 06790 CARDIAC AND PULMONARY REHAB SERVICES THE CENTER FOR CANCER CARE 200 KENNEDY DRIVE TORRINGTON CT 06790 CANCER TREATMENT CENTER HUNGERFORD DIAGNOSTIC CENTER 220 KENNEDY DRIVE TORRINGTON CT 06790 RADIOLOGY SERVICES THE CENTER FOR YOUTH AND FAMILIES 50 LITCHFIELD STREET TORRINGTON CT 06790 PSYCH SERVICES FOR CHILDREN AND FAMILIES WINSTED BEHAVIORAL HEALTH CENTER 294 MAIN STREET WINSTED CT 06098 PSYCH SERVICES SURGICAL ASSOCIATES OF CHH 538 LITCHFIELD STREET TORRINGTON CT 06790 SURGICAL PHYSICIANS PRACTICE NEUROLOGY PBC 780 LITCHFIELD STREET TORRINGTON CT 06790 NEUROLOGY PHYSICIANS PRACTICE CHH PRIMARY CARE 780 LITCHFIELD STREET TORRINGTON CT 06790 PRIMARY CARE PHYSICIANS PRACTICE CHH CARDIOVASCULAR MEDICINE SERVICE 1215 NEW LITCHFIELD STREET TORRINGTON CT 06790 CARDIOVASCULAR PHYSICIANS PRACTICE CHH WOUND CARE AND HYPERBARIC MEDICINE 7 FELICITY LANE TORRINGTON CT 06790 WOUND CARE PHYSICIANS PRACTICE CHH UROLOGY MEDICINE 538 LITCHFIELD STREET TORRINGTON CT 06790 ADULT AND PEDIATRIC UROLOGY PHYSICIANS PRACTICE HUNGERFORD EMERGENCY AND MEDICAL CARE 115 SPENCER STREET WINSTED CT 06098 EMERGENCY SERVICES PART I, LINE 3C: CARE WILL BE PROVIDED FREE FOR THOSE WHO QUALIFY AS UNINSURED AND VERIFICATION HAS DETERMINED THAT THEIR ANNUAL INCOME IS LESS THAN 200% OF THE FEDERAL INCOME POVERTY LEVEL. CARE WILL BE PROVIDED AT HOSPITAL COST, AS ESTABLISHED BY THE OFFICE OF HEALTH CARE ACCESS (OCHA), FOR THOSE UNINSURED PATIENTS WHO REQUEST ASSISTANCE AND VERIFICATION HAS DETERMINED THAT THEIR ANNUAL INCOME IS BETWEEN 200% AND 250% OF THE FPL. CARE WILL BE DISCOUNTED BY 30% FOR THOSE UNISURED PATIENTS WHO REQUEST ASSISTANCE AND VERIFICATION HAS DETERMINED THAT THEIR ANNUAL INCOME IS BETWEEN 250% AND 400% OF THE FPL. THE HOSPITAL WILL ALSO CONSIDER THE TOTAL MEDICAL EXPENSES FACED BY THE FAMILY AND THE FAMILY'S ABILITY TO PAY FOR THOSE EXPENSES, AND WILL CONSIDER OFFERING GREATER ASSISTANCE WHEN POSSIBLE TO THOSE FAMILIES FACING CATASTROPHIC MEDICAL EXPENSES. PART I, LINE 7: A COST TO CHARGE RATIO BASED ON CHARITY CARE CHARGES AND EXPENSES. PART III, LINE 4: IN JULY 2011, THE FASB ISSUED ASU 2011-07, "HEALTH CARE ENTITIES (TOPIC 954): PRESENTATION AND DISCLOSURE OF PATIENT SERVICE REVENUE, PROVISION OF BAD DEBTS, AND THE ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR CERTAIN HEALTH CARE ENTITIES." THIS GUIDANCE ESTABLISHES ACCOUNTING AND DISCLOSURE REQUIREMENTS FOR HEALTH CARE ENTITIES THAT RECOGNIZE SIGNIFICANT AMOUNTS OF PATIENT SERVICE REVENUES AT THE TIME SERVICES ARE RENDERED EVEN THOUGH THE ENTITY DOES NOT ASSESS A PATIENT'S ABILITY TO PAY. SPECIFICALLY, THE GUIDANCE REQUIRES THAT HEALTH CARE ENTITIES PRESENT BAD DEBT EXPENSE ASSOCIATED WITH NET PATIENT SERVICE REVENUES AS AN OFFSET TO NET PATIENT SERVICE REVENUES WITHIN THE STATEMENTS OF OPERATIONS AND CHANGES IN NET ASSETS. ADDITIONALLY, THE GUIDANCE REQUIRES ENHANCED DISCLOSURE OF THE POLICIES FOR RECOGNIZING REVENUE AND ASSESSING BAD DEBTS, AS WELL AS QUALITATIVE AND QUANTITATIVE INFORMATION ABOUT CHANGES IN THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE GUIDANCE REQUIRES RETROSPECTIVE APPLICATION TO ALL PRIOR PERIODS PRESENTED. THIS GUIDANCE BECAME EFFECTIVE FOR THE HOSPITAL BEGINNING ON OCTOBER 1, 2012. THE ADOPTION OF THIS GUIDANCE HAD NO IMPACT ON THE HOSPITAL'S OPERATING INCOME IN THE STATEMENTS OF OPERATIONS AND CHANGES IN NET ASSETS, BUT RESULTED IN ADDITIONAL DISCLOSURES IN NOTE 3. ALL PERIODS INCLUDED HAVE BEEN PRESENTED IN ACCORDANCE WITH THE PROVISIONS OF ASU 2011-07.IT IS AN INHERENT PART OF THE HOSPITAL'S MISSION TO PROVIDE NECESSARY MEDICAL CARE FREE OF CHARGE, OR AT A DISCOUNT, TO INDIVIDUALS WITHOUT INSURANCE OR OTHER MEANS OF PAYING FOR SUCH CARE. AS THE AMOUNTS DETERMINED TO QUALIFY FOR CHARITY CARE ARE NOT PURSUED FOR COLLECTION, THEY ARE NOT REPORTED AS NET PATIENT SERVICE REVENUE. PATIENTS WHO WOULD OTHERWISE QUALIFY FOR CHARITY CARE BUT WHO DO NOT PROVIDE ADEQUATE INFORMATION WOULD BE CHARACTERIZED AS BAD DEBT AND INCLUDED IN THE PROVISION FOR BAD DEBTS.PART III, LINE 2: COSTING METHODOLOGY USED - THE HOSPITAL USES A MODEL CONSISTING OF OUR ACCOUNTS RECEIVABLE BALANCE DIVIDED INTO EIGHT AGING CATEGORIES AS FOLLOWS: 0-30 DAYS, 31-60 DAYS, 61-90 DAYS, 91-120 DAYS, 121-210 DAYS, 211-365 DAYS, AND GREATER THAN 365 DAYS. A PERCENTAGE IS THEN ASSIGNED TO EACH AGING BUCKET BASED ON AGE, WITH A HIGHER PERCENTAGE ASSIGNED AS THE DAYS OUTSTANDING INCREASES. THE RESULTING CALCULATION IS USED TO COMPARE WITH THE RESERVE AND A MONTHLY ADJUSTMENT IS MADE TO DETERMINE THE EXPENSE. ANNUALLY, THIS CALCULATION IS COMPARED TO AN AUDIT OF THE BAD DEBT RESERVES TO DETERMINE IF ANY ADJUSTMENTS ARE REQUIRED. PART III, LINE 8: THE MEDICARE SHORTFALL IS NOT TREATED AS COMMUNITY BENEFIT. THE MEDICARE ALLLOWABLE COSTS OF CARE ARE DERIVED DIRECTLY FROM THE MEDICARE COST REPORT. PART III, LINE 9B: THE HOSPITAL ATTEMPTS TO HAVE INDIVIDUALS FILL OUT ALL PAPER WORK REQUIRED FOR CHARITY CARE. IF THE PERSON IS NOT CAPABLE OF DOING THIS OR IS KNOWN TO BE UNABLE TO DO THIS (SUCH AS A KNOWN HOMELESS PERSON), THEN THE FINANCIAL ASSISTANCE COMMITTEE WILL ADJUST THE ACCOUNT TO CHARITY CARE AND IT WILL NOT BE REPORTED AS BAD DEBT. IF THE ACCOUNT HAS BEEN REPORTED AS BAD DEBT AND INFORMATION COMES FORTH INDICATING AN INABILITY TO PAY, THEN THE ACCOUNT WOULD BE REMOVED FROM BAD DEBT AND MOVED TO CHARITY CARE. PART VI, LINE 2: THE HOSPITAL OFFERS FREE HEALTH SCREENINGS, FREE HEALTH EDUCATION AND LECTURES AT VARIOUS COMMUNITY EVENTS INCLUDING FAIRS, EXPOS, PRIVATE COMPANIES, PUBLIC MUNICIPALITIES, AND PUBLIC GATHERINGS. THESE EVENTS PROVIDE A FORUM FOR RECEIVING INFORMATION AND INPUT FROM THE COMMUNITY. PART VI, LINE 3: THE HOSPITAL COUNSELS ALL SELF PAY PATIENTS BY PROVIDING A MEETING WITH A FINANCIAL COUNSELOR OR SOCIAL WORKER. ALL STATEMENTS DISTRIBUTED TO PATIENTS INCLUDE FINANCIAL COUNSELING INFORMATION. SIGNS ARE POSTED THROUGHOUT THE HOSPITAL, INCLUDING THE EMERGENCY ROOM, WHICH STATE CHARITY CARE POLICIES AND FINANCIAL ASSISTANCE INFORMATION. PART VI, LINE 4: THE CHARLOTTE HUNGERFORD HOSPITAL IS LOCATED IN TORRINGTON, CONNECTICUT, AND SERVES AS A REGIONAL HEALTH CARE RESOURCE FOR 100,000 RESIDENTS OF LITCHFIELD COUNTY AND NORTHWEST CONNECTICUT. RECENT ASSESSMENTS FROM THE AREA THAT THE HOSPITAL SERVES HAS FOUND THE FOLLOWING: - THE COUNTY HAS BECOME MORE RACIALLY AND ETHNICALLY DIVERSE. - THE COUNTY HAS THE HIGHEST PROPORTION OF RESIDENTS AGES 50+ IN THE STATE. - AREA RATES OF OBESITY AND CURRENT SMOKING EXCEED THE STATE AVERAGE. - STUDENTS IN NEARLY HALF OF THE AREA'S SCHOOL DISTRICTS SCORED BELOW THE STATE AVERAGE IN STANDARDIZED PHYSICAL FITNESS TESTS. - NEARLY ONE IN FOUR COUNTY RESIDENTS HAS HYPERTENSION. - NEARLY 40% HAVE BEEN TOLD BY THEIR HEALTH PROFESSIONAL THAT THEY HAVE HIGH CHOLESTEROL. - THE COUNTY HAS A RATIO OF ONE PRIMARY CARE PHYSICIAN TO EVERY 1,123 RESIDENTS. THIS WELL BELOW BOTH STATE AND NATIONAL BENCHMARKS. PART VI, LINE 5: ALL BOARD OF DIRECTORS MEMBERS RESIDE IN THE COMMUNITY SERVED BY THE CHARLOTTE HUNGERFORD HOSPITAL. THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS WHO APPLY FOR SUCH PRIVILEGES. THE HOSPITAL ESTABLISHES AN ANNUAL CAPITAL BUDGET TO ADD OR REPLACE PATIENT CARE EQUIPMENT AND FACILITIES. MEDICAL EDUCATION IS PROVIDED TO PHYSICIANS THROUGH CONFERENCES ON A MONTHLY BASIS. PART VI, LINE 7, REPORTS FILED WITH STATES CT 1 HEALTHCARE SCHOLARSHIPS 12 12000 PART IV THE CHARLOTTE HUNGERFORD HOSPITAL AUXILIARY AWARDS SCHOLARSHIPS IN THE AMOUNT OF $1,000 EACH TO STUDENTS PURSUING HEALTHCARE EDUCATION. THE STUDENTS MUST LIVE IN THE AREA SERVED BY THE HOSPITAL. THEY MUST ALSO PROVIDE EVIDENCE OF ACCEPTANCE INTO A COLLEGE PROGRAM OR THEIR CURRENT GRADES IN COLLEGE. APPLICANTS MUST SUBMIT LETTERS OF RECOMMENDATION FROM THEIR TEACHERS AND ALSO FROM NON-FAMILY PERSONS. X X X X 0 0 0 0 0 0 0 0 0 KENDRICK HOM MD GOVERNOR 275710 0 0 0 0 0 7650 0 26310 0 309670 0 0 0 DANIEL J MCINTYRE CEO/PRESIDENT 446903 0 0 0 0 0 40973 0 42646 0 530522 0 0 0 SUSAN M SCHAPP VP FINANCE/ TREASURER 269327 0 0 0 0 0 24795 0 25701 0 319823 0 0 0 JOHN J CAPOBIANCO VP OUT PATIENT SERVICES 241956 0 0 0 0 0 21689 0 23089 0 286734 0 0 0 MARK PRETE MD VP MEDICAL AFFAIRS 311896 0 0 0 0 0 29468 0 29763 0 371127 0 0 0 RAYMOND J ELLIOTT VP FACILITIES 165636 0 0 0 0 0 24591 0 15806 0 206033 0 0 0 BRIAN MATTIELLO VP HUMAN RESOURCES 188193 0 0 0 0 0 4003 0 17958 0 210154 0 0 0 ELZBIETA LACH-PASKO MD PATHOLOGIST 393156 0 0 0 0 0 15649 0 37517 0 446322 0 0 0 MUSTAFA UGURLU MD PHYSICIAN 490960 0 0 0 0 0 8678 0 46850 0 546488 0 0 0 TIMOTHY GOSTKOWSKI MD PHYSICIAN 612210 0 0 0 0 0 9745 0 58421 0 680376 0 0 0 WILLIAM MCGEEHIN MD PHYSICIAN 584900 0 0 0 0 0 10159 0 55814 0 650873 0 0 0 DAVID FRECCERO MD PHYSICIAN 532006 0 0 0 0 0 1896 0 50767 0 584669 0 0 0 MARK PRETE MD KEY EMPLOYEE 543761 PARTNER IN NWCT EMERGENCY MEDICINE P.C. WHICH PROVIDES EMERGENCY ROOM SERVICES TO THE HOSPITAL. 0 DIANE LIBBY CPA GOVERNOR 6100 PARTNER IN ADAMS SAMARTINO & CO, P.C. WHICH PROVIDES ACCOUNTING SERVICES TO CHARLOTTE HUNGERFORD HOSPITAL. 0 FORM 990, PART VI, SECTION B, LINE 11 A COPY OF FORM 990 IS DISTRIBUTED TO THE BOARD OF DIRECTORS BEFORE IT IS FILED WITH THE IRS. THIS ENABLES THE BOARD TO ASK QUESTIONS, AND TO APPROVE THE DISCLOSURES MADE IN THE RETURN. FORM 990, PART VI, SECTION B, LINE 12C THE HOSPITAL DISTRIBUTES A CONFLICT OF INTEREST QUESTIONNAIRE ANNUALLY TO ITS BOARD OF DIRECTORS, ALL MANAGEMENT PERSONNEL, AND PURCHASING AGENTS. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION FOR SENIOR STAFF IS DETERMINED USING THE FOLLOWING STEPS: - A MARKET SURVEY BASED ON CT HOSPITAL ASSOCIATION IS USED AS A STARTING POINT. - ADJUSTMENTS ARE THEN MADE BASED ON THE CANDIDATE'S CURRENT SALARY AND PRIOR EXPERIENCE. - THE COMPENSATION FIGURE IS THEN PRESENTED TO THE BOARD OF DIRECTORS FOR APPROVAL. THE LAST COMPENSATION REVIEW OCCURRED IN AUGUST 2014. FORM 990, PART VI, SECTION C, LINE 19 THE HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND ANNUAL REPORT AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: PENSION RELATED CHANGES OTHER THAN NET PERIODIC PENSION COSTS -7,784,797. NET ASSETS RELEASED FROM RESTRICTIONS -269,043. FORM 990, PART XI, LINE 2C: THE HOSPITAL'S AUDIT COMMITTEE ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND THE SELECTION OF AN INDEPENDENT ACCOUNTANT. THESE FUNCTIONS AND PROCESSES HAVE NOT CHANGED FROM THE PRIOR YEAR. 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