2015-08-14T14:16:13-05:00 2014-09-30 010494526 BAKER NEWMAN & NOYES BOX 507 PORTLAND ME 04112 990 2013-10-01 020222157 Monadnock Community Hospital MONA 6039247191 452 Old Street Road Peterborough NH 03458 Richard D Scheinblum VP of Finance/CFO 6039247191 2015-08-13 1 Nicholas E Porto P01310283 2078792100 2015-08-13 2013 2016-02-25 16:41:14Z Cynthia K McGuire 452 Old Street Road Peterborough NH 03458 82165613 0 X www.monadnockcommunityhospital.com X 1919 NH Critical access hospital serving the Monadnock region of the State of New Hampshire 15 12 776 144 0 0 1420503 916625 76958001 79776991 341552 1205315 369213 6419 79089269 81905350 0 15000 0 0 39544302 40760738 0 0 440639 37630255 38619692 77174557 79395430 1914712 2509920 99482264 104528486 45471971 45153660 54010293 59374826 X Monadnock Community Hospital is committed to improving the health and well-being of our community. We will elevate the health of our community by providing accessible, high quality and value based care. 0 0 69619735 15000 79776991 The primary purpose of Monadnock Community Hospital (MCH) is to ensure access to quality health care for patients in our community, regardless of their ability to pay. The following is a summary of the services MCH provides in an effort to fulfill its mission, together with key program statistics for fiscal year 2014.Inpatient Services - Includes: intensive care unit, adult stays, pediatric stays, maternity/births, and skilled nursing. During the fiscal year, the Hospital admitted 1,422 patients and recorded 5,249 patient days. Emergency Services - MCH offers health services 24 hours per day, 7 days per week. Responsible for the immediate treatment of any medical or surgical emergency; for initiating life saving procedures in all types of emergency situations; and for providing emergency and initial evaluations and treatment for other conditions including minor illnesses and injuries, and sub-acute medical problems. During the year, there were 14,765 visits to the ER. Physician Practices - Family health services, programs, and education are integral components of healthcare at MCH. Inpatient and outpatient primary care includes: medical, surgical, psychological and specialist services, provided by physicians and mid-level practitioners. These are located at the Hospital and its five satellite practices located in Antrim, Jaffrey, New Ipswich, Peterborough, and Rindge. During the year, 72,515 primary care office visits were recorded. Surgical Services - Includes same day and short-term inpatient surgery. MCH provides surgery in the areas of orthopaedics, general surgery, OB/GYN, opthamology, urology, ENT, and podiatry. In addition, the Hospital offers some non-surgical procedures including colonoscopies, gastrocopies, and pain management injections. During the fiscal year, 3,416 procedures were performed. Radiology and Diagnostics - MCH provides advanced radiological technology and extensive imaging services including: bone density, MRI, CT, nuclear medicine, ultrasound, mammography, and other diagnostic procedures, both inpatient and outpatient. During the fiscal year, 30,288 exams were performed. Rehabilitation Services - Additionally, MCH serves the people of the Monadnock Region through its medical rehabilitation services. MCH offers rehabilitation programs for cardiac, pulmonary and diabetic rehabilitation which feature educational and exercise components. We also provide physical and occupational therapy, as well as speech rehabilitation. During the fiscal year 51,079 procedures were recorded for these services. Wellness Services - Community members wanting to improve and maintain their health have access to an award-winning, medically-based fitness facility. During the fiscal year, 92,281 member visits were recorded.Monadnock Community Hospital's Financial Grant Program provides assistance with hospital and/or physician bills for qualifying patients. In FY 2014, the Organization recorded $3,785,000 in charges foregone based on established rates. The estimated cost incurred to provide these services was $2,017,000. In addition, Monadnock Community Hospital provided other services to the community at no cost or reduced cost, such as screenings and clinics. The cost of providing these services was approximately $2,081,000 in 2014. 69619735 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 1 0 1 1 1 0 1 1 0 0 0 0 0 0 0 1 1 0 1 0 0 0 0 1 1 0 0 0 1 120 0 1 776 1 0 0 0 0 0 1 1 0 0 0 0 X 15 12 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X Nicole Humphrey 6039247191 452 Old Street Road Peterborough NH 03458 X Cyndy Burgess Trustee 9.00 X 0 0 0 Diane Cherwin Ex-Officio w/voting rights 2.00 X 0 0 0 Robert J Condon Jr Trustee (part yr) 3.00 X 0 0 0 Barbara R Duckett Trustee 2.00 X 0 0 0 Peter L Forssell MD Trustee 1.00 X 0 0 0 Richard Frechette MD Ex-Officio w/voting rights (part yr) 2.00 X 204389 0 31141 David A Hedstrom DDS Trustee 4.00 X 0 0 0 Gregory Kriebel MD Ex-Officio w/voting rights 50.00 X 223166 0 26625 Marcia Ober Trustee 1.00 X 0 0 0 James D Potter MD Ex-Officio w/voting rights (part yr) 25.00 X 108880 0 21793 Fletcher R Wilson MD Ex-Officio w/voting rights 3.00 X 0 0 0 Carole Monroe Chair 8.00 X X 0 0 0 Robert L Edwards Immediate Past Chair 1.50 X X 0 0 0 Steven H Reynolds Vice Chair 2.00 X X 0 0 0 Jamie Trowbridge Treasurer 1.50 X X 0 0 0 Norman H Makechnie Esq Secretary 1.00 X X 0 0 0 Cynthia McGuire Chief Executive Officer (eff. 2/14) 60.00 X X 0 0 0 Peter L Gosline Chief Executive Officer (thru 4/14) 55.00 X X 295107 0 23234 Richard D Scheinblum VP Finance/CFO 50.00 X 167730 0 12207 Terrence McNamara DO Physician 50.00 X 555557 0 19881 Ronald Michalak MD Physician 50.00 X 471931 0 25689 Douglas Weiss MD Physician 50.00 X 491623 0 8173 Shawn Harrington MD Physician 50.00 X 398044 0 25454 Robert C Knowles MD FACS Physician 50.00 X 378807 0 20147 3295234 0 214344 41 0 1 0 Monadnock Region Emergency Physicians PL 380 Lafayette Road Hampton NH 03842 Contract Emergency Physician Group 1855300 Monadnock Anesthesia Associates C/O Surgical Suite Peterborough NH 03458 Contract Anesthesiologist Group 1383376 Catholic Medical Center 100 McGregor Street Manchester NH 03102 Contract Hospitalist Group 1244299 McKesson PO Box 98347 Chicago IL 60693 IS Vendor 698885 American Health Centers Inc 100 Griffin Road Suite C Portsmouth NH 03801 MRI Services 608226 20 34595 882030 63400 916625 Net Patient Service Revenue 621400 70322689 70322689 Other Operating Revenue 621400 5365112 5365112 Disproportionate Share Funding 621400 3573806 3573806 Cafeteria/Vending Machine 722210 348552 348552 Employee Pharmacy Sales 446110 166832 166832 79776991 470949 470949 976803 233069 9368 743734 -9368 734366 734366 24245 34595 17826 6419 6419 81905350 79776991 0 1211734 15000 15000 1253275 615910 637365 31810640 28471837 3073596 265207 489852 422851 67001 5017948 4348527 636783 32638 2189023 1907948 262376 18699 128937 6624 122313 54000 54000 1345 1345 5122716 4592382 530334 73219 73219 2168936 1098964 1026328 43644 1143989 979718 164271 3046758 2775703 271055 79543 53379 25204 960 56004 38490 13921 3593 1181275 1181275 4521689 4350749 170940 562555 422694 139861 Med & Pharm Supplies 7633626 7628398 5228 Provision for Bad Debt 4465396 4465396 Other Med Exp/Service C 4234345 3796586 396372 41387 NH Medicaid Enhancement 3402383 3402383 742976 152977 556833 33166 79395430 69619735 9335056 440639 5064 5064 17594099 18904373 793082 677841 5773955 6513721 240184 158767 1242787 1257506 867448 682936 84573811 46136620 38076116 38437191 29923690 33316218 3407090 3735792 197606 160168 1361143 678909 99482264 104528486 6773500 7100470 26909344 26450980 535451 835553 11253676 10766657 45471971 45153660 X 43706147 47964278 2677614 3455314 7626532 7955234 54010293 59374826 99482264 104528486 X 2509920 2737553 117060 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 13592 1 231 0 0 13823 0 Part II-B, Line 1: Monadnock Community Hospital is a member of the NH Hospital Association and the American Hospital Association. A portion of the dues paid to these organizations is available for lobbying expenditures on behalf of Monadnock Hospital in furtherance of its exempt purpose. Monadnock Hospital does not directly perform any lobbying activities. NHHA, Portion of dues available for lobbying: $10,305 AHA, Portion of dues available for lobbying: $3,287 In addition, MCH hosts an annual legislative breakfast, which is a bipartisan event to which legislators, local politicians, and other public officials are invited to discuss health care issues in New Hampshire. Topics for the 2014 breakfast included how the Affordable Care Act will affect the Monadnock region, the priorities of Monadnock Community Hospital as the primary healthcare provider and one of the largest employers in the region, and the Hospital's response to the community needs identified in its CHNA. The cost of this forum was $231. 10304146 526809 924772 345179 11410548 8591510 1127458 819722 234544 10304146 8314205 486841 948400 1157936 8591510 10031251 884501 93759 2695306 8314205 10623404 1266761 200900 2059814 10031251 0.30280 0.69720 0.00000 1 0 966127 966127 34541380 16944183 17597197 964272 503856 460416 47027943 28688581 18339362 1074089 1074089 38437191 Interest Rate Swap Agreements 2961591 Estimated Third-Party Settlements 7805066 10766657 X 84319324 2737553 117060 2854613 81464711 440639 440639 81905350 78954791 0 78954791 440639 440639 79395430 Part V, Line 4: Temporarily restricted assets are available for health care services, including the purchase of equipment and providing health education and programs. The income and dividends on permanently restricted net assets are generally used to support health care services and for capital purchases of property and equipment. Part X, Line 2: The Hospital is a not-for-profit corporation as described in Section 501(c)(3) of the Internal Revenue Code (the Code) and is exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. Management evaluated the Hospital's tax positions and concluded the Hospital has maintained its tax-exempt status, does not have any significant unrelated business income and had taken no uncertain tax positions that require adjustment to or disclosure in the accompanying financial statements. With few exceptions, the Hospital is no longer subject to tax examination by the U.S. federal or state tax authorities for years prior to 2011. Part XI, Line 2d - Other Adjustments: Increase in fair value of interest rate swap agreement 117,060. Part XI, Line 4b - Other Adjustments: Fundraising Expenses 440,639. Part XII, Line 4b - Other Adjustments: Fundraising Expenses 440,639. MCH Golf Classic 58840 34595 24245 5547 5440 4660 2179 58840 34595 24245 5547 5440 4660 2179 17826 6419 1 1 1 X 1 X 1 1 1 0 1 1 2017035 2017035 0.02690 7128871 5907092 1221779 0.01630 9145906 5907092 3238814 0.04320 868628 868628 0.01160 9529 9529 0.00010 1066064 1066064 0.01420 136355 136355 0.00180 2080576 2080576 0.02770 11226482 5907092 5319390 0.07090 1 2379632 246442 20693852 20571430 122422 X 1 1 1 1 Monadnock Community Hospital 452 Old Street Road Peterborough NH 03458 02507 X X X X Monadnock Community Hospital 1 1 X X X X X X X 12 1 0 1 X see Part V, Section C X X X X X X X 0 0 1 1 200.000000000000 1 400.000000000000 1 X X X X 1 1 X X X X X X X 1 0 X X X X 1 X 0 1 Monadnock Community Hospital Part V, Section B, Line 3: Monadnock Community Hospital (MCH) used a multi-phased methodology to achieve the objectives of the assessment. The methodology included the following stages: establishing a leadership team to provide project guidance and insight regarding local health resources and perspectives of community needs; strategic secondary research; four qualitative discussion groups with healthcare consumers, service providers, and other community opinion leaders; needs prioritization process. Establishing a Leadership Team - The MCH Leadership Group was established early in the project process in order to develop communication channels with, and to learn about the insights of, a diverse set of community stakeholders. In order to generate the information, MCH incorporated input from persons who represent the broad interest of the community served by the hospital facility, including those with special knowledge of our expertise in public health. Group members were selected based upon their perceived community health vision, knowledge, and power to impact the well-being of the community. The steering committee also offered critical feedback on quantitative data, refined the list of community needs, helped develop the database of available resources, and participated in quantitative and qualitative research methods to build the prioritized list of community needs identified in the report. Qualitative Discussion Groups - MCH conducted five discussion groups with individuals from a breadth of community groups regarding their perception of healthcare service gaps. The groups included in-depth discussion about topics such as community strengths, service gaps, needs prioritization, and ways that MCH may be able to help address community needs. The information gleaned was used to help triangulate statistical data and qualitative information collected through the other research modalities. The discussion groups included the following community segments: leadership group members (executives from a diverse range of organizations that have direct contact with healthcare consumers and/or provide affiliated services), healthcare consumers (consumer sectors included the homeless, people from diverse age groups and economic strata, and individuals with varying degrees of chronic illness), and community opinion leaders (healthcare consumers living in the MCH service area and also providing community services such as faith-based networking and in-school nursing). Monadnock Community Hospital Part V, Section B, Line 7: The Hospital will not directly address all the needs identified in the CHNA at the time of this filing. The community needs not addressed in the Hospital's implementation plan scored lower on the prioritization rationale, were determined as not being in the purview of the Hospital, and/or are better addressed by other community organizations. The needs not included in the Hospital's implementation plan include: parenting classes, lower insurance rates, and dental health services for adults and seniors. Monadnock Community Hospital Part V, Section B, Line 14g: The complete financial assistance policy is available upon request and in the waiting rooms. Instructions on how to find out more about financial assistance are posted on the Hospital's website, on the back of all billing invoices, and published in a brochure that is available around the Hospital and in the admissions office.Additionally, the financial assistance program is communicated to all employees during the orientation process. Monadnock Community Hospital Part V, Section B, Line 18e: Line E: Description from Credit and Collections Policy:The Hospital Patient Financial Services (PFS) Department shall develop and implement billing and collection procedures designed to maintain an adequate cash flow, keep accounts receivable at an acceptable level, and identify and write-off bad debts in a timely fashion. Monadnock Community Hospital contracts with an agency to process all self-pay accounts and self-pay after insurance balance statements/letters. I. Self-pay accounts and self-pay balances remaining after insurance adjudication shall be transferred to the agency on a weekly basis. The cycle for collections is three statements and/or letters and two phone call series spaced approximately thirty (30) days apart. The statements shall include:a. Previous balance (unless this is the first statement).b. Activity since last statement (except those accounts that went to a $0.00 balance).c. Current balance due.d. Telephone number(s) for inquiries concerning the statement.e. Status or reminder message where appropriate.f. Availability for the use of a credit card for payment.g. Information regarding Financial Assistance and Medication Bridge Programs.h. Return envelope.II. In the event that statements or letters are returned by the postal service as undeliverable for reasons such as "moved, left no forwarding address," "forwarding order expired," or "no such address" the agency will indicate on the daily report "mail returned." PFS staff will review system for the correct address and will make corrections within the computer system and correspondence will be re-mailed. If no correct or current information can be obtained, the specific account(s) shall be flagged for referral to an outside collection agency equipped to handle this type of situation (see bad debt processing footnote).In addition, on a weekly basis, the FAP staff run system reports to identify outpatient visits classified as self-pay. Based on the information in these reports, the guarantor of each visit is sent a financial assistance application in the mail. Determination of eligibility is contingent upon receiving a completed application and required documentation from the patient and/or guarantor. Monadnock Community Hospital Part V, Section B, Line 22: The State of NH does not allow healthcare providers to bill auto insurance companies directly in regards to a motor vehicle accident. The patient, when treated, has the choice to either be billed directly and they will then bill their auto insurance company or we can bill their health insurance company directly. Schedule H, Part V, Section B, line 5a: The CHNA is available at the Hospital facility's website: http://monadnockcommunityhospital.com/pdf/community-matters/Community%20Assessment%20Report%20-%20Monadnock%20Community-Hospital-Final-Version-with-Guide.pdf 14 Bond Wellness Center 458 Old Street Road Wellness Center Peterborough NH 03458 Fitness center and rehabilitation services Monadnock Orthopaedic Associates 458 Old Street Road Wellness Center Peterborough NH 03458 Physician practice Monadnock Regional Pediatrics 454 Old Street Road MAB Building Peterborough NH 03458 Physician practice Jaffrey Family MedicinePT Satellite 82 Peterborough Road Jaffrey NH 03452 Physician practice Monadnock Family Care 454 Old Street Road MAB Building Peterborough NH 03458 Physician practice North Meadow 154 Hancock Road Peterborough NH 03458 Physician practice Monadnock Behavioral Health 458 Old Street Road Wellness Center Peterborough NH 03458 Physician practice Monadnock Internists 454 Old Street Road MAB Building Peterborough NH 03458 Physician practice Monadnock Surgical Associates 454 Old Street Road MAB Building Peterborough NH 03458 Physician practice Peterborough Internal Medicine 454 Old Street Road MAB Building Peterborough NH 03458 Physician practice Rindge Family Practice 145 US Route 202 Rindge NH 03461 Physician practice New Ipswich Family Medicine 821 Turnpike Road New Ipswich NH 03071 Physician practice Antrim Medical Group 12 Elm Street Antrim NH 03440 Physician practice Neurology Center 458 Old Street Road Wellness Center Peterborough NH 03458 Physician practice Part I, Line 3c: N/A Part I, Line 6a: N/A Part I, Line 7: Charity care and means tested programs use the cost to charge ratio as their methodology. This Hospital calculates the ratio in a manner consistent with worksheet 2, patient care charges to patient care expenses, to arrive at the ratio of cost to charges. Part I, Line 7g: Included in the subsidized health services activities reported for FY 2014 are unreimbursed costs of $479,784 attributed to an outpatient behavioral health practice and $533,538 related to emergency and trauma services. Part I, Line 7, Column (f): The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 4,465,396. Part II, Community Building Activities: See previous footnotes. Part III, Line 2: The amount reported on Part III line 2 was derived by applying the cost to charge ratio against the amount of bad debt expense reported on Form 990, Part IX, line 25, column (A) ($4,465,396). Accounts written off to bad debt include gross charges being written off less any payments received against those charges. Any cash collected on accounts previously written off is included as an offset to bad debt expense as recoveries of bad debt. The Hospital calculates the ratio in a manner consistent with worksheet 2, patient care charges to patient care expenses, to arrive at the ratio of costs to charges. Part III, Line 3: The estimated amount of charity care included in bad debt expense is based on the number of applications for charity care denied due to lack of complete documentation against the average charity care write off at cost per qualified patient. We believe the amount is minimal based on our extensive efforts to educate patients and staff about our various payment plans and financial grant programs to ensure that patients who qualify for any of our programs utilize them. Depending on the specific circumstances, a patient may be eligible for charity care, discounted care, payment programs, or a combination of the above. Due to these efforts, we believe that amounts written off to bad debt that could qualify as charity care is minimal. Part III, Line 4: See page 7 of the attached financial statements. Part III, Line 8: Medicare allowable costs for the Medicare cost report are reported in accordance with CMS guidelines using the cost to charge ratio methodology. Part III, Line 9b: As of 9/30/2011 Monadnock Community Hospital has a written credit and collection policy. Described within that policy are the collection practices and bad debt processes that are followed for patients who are known to qualify for charity care or financial assistance. The Organization maintains a Financial Assistance Program (FAP) database which is maintained by the Social Services Department of MCH. The Patient Financial Services (PFS) staff reference this database for approval status and eligibility amounts, identifying any account(s) where the discount will apply. Internal FAP insurance plans are applied to those accounts and related discount amounts are adjusted in the billing system. Remaining balances are expected to be paid in full by the patient. Payment plans may be requested by the patient and are established by the Financial Grant Coordinator based on the patient's available income and assets. Accounts are annotated to reflect payment arrangements. During bad debt processing, designated staff evaluate accounts listed as collection review for potential bad debt write off. This process includes an examination of account history for indication of FAP application. Part VI, Line 2: The State of NH, under RSA 7:32-f, requires every healthcare charitable trust, either alone or in conjunction with other healthcare charitable trusts in its community, to conduct a Community Health Needs Assessment to assist in determining the activities to be included in its community benefits plan. The needs assessment process includes consultation with members of the public, community organizations, service providers, and local government officials in the entity's service area to identify and prioritize the community needs that the health care entity can address directly or in collaboration with others. The Community Health Needs Assessment is updated at least every 5 years, most recently in 2012. In 2007, the Regional Community Benefits Steering Committee was first formed to prepare a single Community Benefits Needs Assessment for the Monadnock Region. The work group consisted of representatives from multiple organizations, including Monadnock Community Hospital. Based on the needs assessment and community engagement process, the priority needs and health concerns of the community MCH serves include access to care - driven by financial barriers and/or availability of primary care, availability of behavioral health care, general socioeconomic issues, and transportation services. Monadnock Community Hospital used this information to help focus its community benefit efforts to meet the priority needs identified in the community benefit plan. In addition, other needs or services not specifically identified in the community needs assessment, but addressed under the Organization's community benefit plan include availability of dental or oral health care (via the Organization's Monadnock Healthy Teeth to Toes program which focuses on dental hygiene and care, nutrition, and daily physical activity for children ages kindergarten to third grade) and availability of prescription medication (via the Organization's Medication Bridge program designed to help eligible patients apply for assistance programs that provide free or discounted prescription medications). Part VI, Line 3: MCH is committed to providing quality healthcare to anyone in need of services, regardless of ability to pay. We understand patients may not have the finances to pay for their healthcare services and medications, and do not want this to prevent anyone from receiving necessary treatment. As part of the Hospital's mission to the communities we serve, we have developed programs to help meet the needs of our patients who meet income eligibility. Through our Financial Assistance and Medication Bridge Programs, we have been providing financial assistance to those qualifying for many years. We reach out to our patients in many different ways to ensure they are aware that help is available and to guide them through the process. Brochures and signage are posted in high traffic areas and all employees of MCH are informed about the Financial Assistance Program during orientation. When a patient goes through the registration process at the Hospital the staff are trained to inform uninsured or underinsured patients about the Monadnock Community Hospital Financial Assistance and the New Hampshire Health Access programs and that there is assistance available within the Hospital to help with the application process. In addition, any time a patient calls customer service, the representative is trained to help identify and offer support to patients who may require financial assistance. Patients may qualify for free care, discounted care, payment plans or a combination of the above. Assistance is also provided in applying to federal and state programs for those who qualify. Part VI, Line 4: The Hospital's primary service area consists of 14 towns, including Antrim, Bennington, Dublin, Francestown, Greenfield, Greenville, Hancock, Jaffrey, Mason, New Ipswich, Peterborough, Rindge, Sharon, and Temple. The Hospital serves the general population of the primary service area referenced above. Part VI, Line 5: Monadnock Community Hospital is a critical access hospital located in the Monadnock Region of NH. Our mission is to improve the health and well-being of our community. The Hospital is served by a board of trustees consisting of local citizens active in their community and its organizations. The majority of the board is not employed by the Hospital and consists of local community and business representatives as well as medical staff. The Hospital is committed to giving back to the community to the greatest extent possible. Monadnock Community Hospital supports thousands of individuals and families with free or reduced-fee services and programs. Our Financial Assistance Program administered by the Social Services Department helps families and individuals in need with access to health care and other available community services such as catastrophic care, fuel assistance, meals on wheels, food banks, and visiting nurses. Other examples of the Hospital's effort to reach our patients beyond traditional hospital services include access to free or reduced cost medications through our Medication Bridge program; educating children on the importance of good oral hygiene, eating health, and daily physical activity through our Monadnock Healthy Teeth to Toes program; training for community agencies such as local volunteer fire and rescue personnel; prevention and wellness education including nutrition, smoking cessation and dealing with stress; providing regular community seminars regarding timely health topics; and screenings for important health issues such as breast cancer. These are just a few of the many areas where we are reaching out to others to assure they are cared for well. Part VI, Line 6: N/A Part VI, Line 7, Reports Filed With States NH 1 Town of Peterborough 1 Grove Street Peterborough NH 03458 Governmental 15000 Cash contribution for the benefit of the Peterborough Ambulance. 1 Part I, Line 2: During the tax year ending September 30, 2014, the Hospital only made contributions to governmental entities or other 501(c)(3) public charities, additional monitoring is not deemed necessary. X X X X 1 1 0 0 0 0 0 1 0 Richard Frechette MD Ex-Officio w/voting rights (part yr) 202593 0 0 0 1796 0 5184 0 25957 0 235530 0 0 0 Gregory Kriebel MD Ex-Officio w/voting rights 222386 0 0 0 780 0 5533 0 21092 0 249791 0 0 0 Peter L Gosline Chief Executive Officer (thru 4/14) 266478 0 6238 0 22391 0 6314 0 16920 0 318341 0 0 0 Richard D Scheinblum VP Finance/CFO 166930 0 0 0 800 0 4195 0 8012 0 179937 0 0 0 Terrence McNamara DO Physician 406121 0 133958 0 15478 0 0 0 19881 0 575438 0 0 0 Ronald Michalak MD Physician 468953 0 2058 0 920 0 0 0 25689 0 497620 0 0 0 Douglas Weiss MD Physician 474847 0 0 0 16776 0 0 0 8173 0 499796 0 0 0 Shawn Harrington MD Physician 390148 0 6976 0 920 0 0 0 25454 0 423498 0 0 0 Robert C Knowles MD FACS Physician 352638 0 0 0 26169 0 0 0 20147 0 398954 0 0 0 Part I, Lines 4a-b Peter L. Gosline served as Chief Executive Officer of the Hospital until April 2014. In the fiscal year covered by this filing, Mr. Gosline received severance payments totaling $113,379. Mr. Gosline received severance through mid-April, 2015. MCH sponsors a split-dollar life insurance employee benefit program for certain officers and key employees. Split-dollar life insurance is an arrangement in which the employee is the owner of the life insurance policy and the premiums are paid by both the employer and employee. Pursuant to MCH's split-dollar agreement, and the collateral assignment therein, the employer's share of the policy premiums paid is recovered either upon termination of the policy or at the death of the participant. Note that the split-dollar arrangement is part of an employee benefit program and economically not a direct extension of credit. Furthermore, the reportable compensation of the respective employees includes the annual value of the life insurance coverage. The policy was surrendered and contract terminated upon Mr. Gosline's retirement. As a result, no values are attributed to the split-dollar arrangement as of 9/30/14. Under the terms of his transition agreement with the Hospital, Mr. Gosline paid back $542,000 of cumulative premiums paid since 2001. Cynthia McGuire, President & CEO, participates in a 457(f) plan with Monadnock Community Hospital. Ms. McGuire began her tenure with the Hospital after calendar year 2013. Therefore, no compensation or benefits will be reported for her on this Schedule J, Part II. After a three-year vesting period, there will be a 457(f) amount included in W-2 wages for Ms. McGuire reported on Schedule J, Part II, Column B(iii). This amount will be comprised of interest and deferred compensation that was included in Schedule J, Part II, Column C. On May 19, 2015 $17,500 was deposited into Ms. McGuire's 457(f) plan account for calendar 2014. The 457(f) amount that will be included in W-2 wages properly accounts for the elimination of substantial risk of forfeiture. Part I, Line 7 MCH compensates physicians utilizing productivity targets based on RVU (relative value units). In addition, the Compensation Committee recommends to the full board, annually, the variable pay award that may be issued to the Hospital's CEO. The payment of the award is discretionary and is subject to meeting the pre-determined goals of the Organization. Schedule J, Part II Cynthia McGuire, CEO began her tenure with Monadnock Community Hospital in February 2014. Peter L. Gosline remained with the Hospital in an advisory capacity until his resignation effective April 2014. Because IRS instructions require that compensation and benefit information be reported on Form 990, Part VII on a calendar year basis, no compensation and benefits are reported on this Form 990 for Ms. McGuire. The Organization's 2014 Form 990 will reflect Ms. McGuire's compensation information, accordingly, she has not been included as an independent board member on this return. A NHBFA Revenue Bonds Series 2013 021304598 2013-01-01 27240000 refinance existing Series 2007 and 2009 bonds 0 0 0 A 27240000 27057466 182534 2013 0 1 1 1 A 0 0 0 0 0 0 0 A 0 0 1 0 1 0 0 0 0 A 0 Schedule K, Part III, Line 9, Part IV, line 7 and Part V: Although formal policies are not in place in regards to the remediation of our bond, the monitoring requirements of section 148, and procedures to ensure that violations are timely identified and corrected, Mondanock Community Hospital has compliance checks in place that substantiate these requirements. Below is a list of all compliance checks that Monadnock Community Hospital has in place to monitor the 2013 Bond Issue: 1. Covenant calculations performed monthly as part of the Financial Scorecard preparation which is reviewed by the MCH Board of Trustees 2. Covenant calculations are performed for each quarter and reported to the bond issuer, TD Bank 3. Covenant certificate is signed each quarter by the CFO and reported to the bond issuer, TD Bank 4. Financial statements and statistical reports are sent to the bond issuer, TD Bank, on a quarterly basis 5. Annual Operating and Capital budgets are reported to the bond issuer, TD Bank 6. A No Event of Default certificate is signed by the CFO annually and reported to the bond issuer, TD Bank 6. Annual Audited Financial statements are reported to the bond issuer, TD Bank Each of these items that are reported to TD Bank has a specific deadline for completion as outlined in the bond documents. Patti Potter Spouse to Trustee 20181 Mrs. Patti Potter is the spouse of Dr. James Potter, who was a trustee on MCH's Board for part of the year and listed in Part VII. Mrs. Potter is compensated as an employee of MCH. The W-2 compensation paid is in accordance with MCH's standard employment practices and policies. 0 Peter L Forssell MD Board Member 20040 The Hospital rents a medical office space from Dr. Forssell. Though the transaction amount is below the threshold for disclosure, the Hospital is reporting it on Schedule L, Part IV for transparency purposes. 0 X 6 63400 0 0 1 Part I, Line 32b: The Hospital uses its third party investment broker to sell gifts of publicly traded securities. Donations of such securities are sold as soon as administratively possible. Form 990, Part VI, Section B, line 11 The Hospital's Form 990 is prepared with assistance by an independent public accounting firm. A draft of the Form 990 is initially reviewed in detail by key finance employees. Thereafter, the final draft is made available to the full board prior to filing with the IRS. Form 990, Part VI, Section B, line 12c On an annual basis, the Organization provides all administrators/directors/managers, Board Members, and medical staff members with the conflict of interest policy. Said individuals are required to complete a new conflict of interest disclosure on an annual basis. Any conflicts of interest noted are reviewed by the Chair of the Board, in conjunction with the Corporate Compliance Officer. If the conflict of interest appears to meet the policy definitions requiring full Board review, the President of the Board takes this to the full Board meeting, and it is discussed, and appropriate action is taken (in compliance with state and federal requirements). The conflict of interest statement requires signatories to inform the Hospital of any conflict of interest that occurs at any time throughout the year. If a conflict of interest arises during the year, it is reviewed by the Compliance Officer, and if necessary, is taken to the Board President/Board. The Compliance Officer confers with legal counsel with regard to conflicts of interest, if there is any question regarding the potential conflict. Form 990, Part VI, Section B, line 15 The Organization has a written executive compensation policy and procedure. Under this policy, the Compensation Committee, comprised of delegated representatives of the Board of Trustees, has the power and responsibility to determine the Hospital's approach to executive compensation and review the performance of the CEO. The Compensation Committee has the responsibility to set, monitor and review the base salary of the CEO. The Committee maintains minutes of sessions and final recommendations and determinations in accordance with the Board of Trustee guidelines. Annually, market data is reviewed by the Committee to determine the appropriate salary for the Hospital's CEO based upon identified standards. At the end of the time period, the Committee reviews to what extent stated goals were met and recommends an amount for the variable pay award to be approved by the full board. Form 990, Part VI, Section C, line 19 Monadnock Community Hospital files audited financial statements annually with the New Hampshire Attorney General's Charitable Trust Unit and informs the Director of Charitable Trusts of pecuniary benefit transactions that have occurred between MCH and a board member or officer. Notices of such transactions of $5,000 or more are also published in the local newspaper in accordance with NH RSA 7:19-A, II(D). Current copies of the bylaws, conflict of interest Policy and Form 990 are on file with the Charitable Trust Unit. The Hospital also makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Form 990, Part VII, Section A, Column D: Director Compensation The 2013 compensation reported for Dr. Kriebel, Dr. Frechette, and Dr. Potter was paid by Monadnock Community Hospital for their services as physicians. Neither was compensated for their services as an ex-officio voting members of MCH's Board of Trustees. Form 990, Part VII, Section A, Column D: CEO Compensation Cynthia McGuire, CEO began her tenure with Monadnock Community Hospital in February 2014. Peter L. Gosline remained with the Hospital in an advisory capacity until his resignation effective April 2014. Because IRS instructions require that compensation and benefit information be reported on Form 990, Part VII on a calendar year basis, no compensation and benefits are reported on this Form 990 for Ms. McGuire. The Organization's 2014 Form 990 will reflect Ms. McGuire's compensation information, accordingly, she has not been included as an independent board member on this return. Form 990, Part XI, line 9: Change in fair value of interest rate swap agreements 117,060. Form 990, Part XI, Line 2c: Audit Review Process The Audit Committee oversees the audit process for Monadnock Hospital. The audit process for the financial statements did not change from the prior year. Independent accountants performed the audit for the fiscal years ended 9/30/13 and 9/30/14. Monadnock Health Services - INACTIVE 452 Old Street Road Peterborough NH 03458 020420789 Inactive NH 501(c)(3) Line 11a, I Monadnock Community Hospital 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0