2014-05-06T07:46:27-07:00 2013-09-30 990 2012-10-01 042103581 HENRY HEYWOOD MEMORIAL HOSPITAL HENR 9786323420 242 Green Street Gardner MA 01440 Robert Crosby 9786306157 2014-04-25 2012 2015-11-30 17:44:51Z Robert Crosby 242 Green Street Gardner MA 01440 120212006 0 X www.heywood.org X 1907 MA To be our communities' trusted choice for exceptional patient-centered care. 21 19 1037 281 0 0 3474560 908638 100862323 107379169 1034227 495533 967815 1341743 106338925 110125083 118567 120000 0 0 52430754 55829163 12925 6744 220956 49513662 51288346 102075908 107244253 4263017 2880830 91777100 95467985 46158901 45613375 45618199 49854610 X 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 2013" filed with the MA Attorney General's Office. 0 1 101233786 120000 107379169 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 2012" filed with the MA Attorney Generals Office. 0 0 0 101233786 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 1037 1 0 0 0 0 0 0 X 21 19 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 0 0 X 0 0 0 Michael Azzoni 0 0 X 0 0 0 James Garrison 0 0 X 0 0 0 John Kerney 0 0 X 0 0 0 Roy Lake 0 0 X 0 0 0 Michele Parker 0 0 X 0 0 0 JoAnne Parks 0 0 X 0 0 0 Kenneth J Pierce 0 0 X 0 0 0 Glenn A Hunt 0 0 X 0 0 0 Rebecca Bialecki 0 0 X 0 0 0 Cheney Castine 0 0 X 0 0 0 Tina Sbrega 0 0 X 0 0 0 Winfield Brown 40 0 X X 526138 0 50699 Robert Chauvin 0 0 X 0 0 0 Joyce Fletcher 0 0 X 0 0 0 John Flick 0 0 X 0 0 0 James Meehan 0 40 X 0 33400 3247 Donald Mruk 0 0 X 0 0 0 Moshen Noreldin 0 0 X 0 0 0 John Skrzypczak 0 0 X 0 0 0 Douglas Starrett 0 0 X 0 0 0 Robert Crosby 40 0 X 268605 0 48958 Michael Grimmer 40 0 X 228187 0 43961 Tina Santos 40 0 X 221225 0 29541 Thomas Cady 40 0 X 175347 0 45927 Rose Kavalchuck 40 0 X 201940 0 42668 Carol Roosa 40 0 X 7558 0 1800 Dawn Casavant 40 0 X 15603 0 2457 David Gill 40 0 X 255824 0 28343 Faith Pinkerton 40 0 X 192560 0 18332 Sheila Ebert 24 0 X 196069 0 14653 Ellen Ray 40 0 X 182261 0 18130 Alice Vaine 40 0 X 174778 0 13937 James Mullen 40 0 X 101328 0 7819 2747423 33400 370472 45 1 1 0 Quartulli and Associates Inc PO Box 423 Gardner MA 01440 Physical Therapy 3099625 Bay State Emergency Medical Inc 44 Crosby Road Ashburnham MA 01430 Emergency Room Physicians 1455524 Alliance Healthcare Services 100 Bay View Circle Newport Beach CA 92660 MRI 1308445 UMass Memorial Medical Group 3654 Plantation St Worcester MA 01605 Physician Services 1104301 Quest Diagnostics Inc 5763 Collection Center Drive Chicago IL 60693 Lab Contracted Services 796422 27 0 0 55350 0 566103 287185 0 908638 Ancillary O/P Service 621110 60367903 60367903 0 0 Ancillary I/P & Routine 621110 45117072 45117072 0 0 Contracted Services 900099 1357235 1357235 0 0 HMG Patient Revenue (Net) 621111 400582 400582 0 0 Lifeline 624120 54033 54033 0 0 82344 82344 0 0 107379169 301252 0 0 301252 0 0 0 0 0 0 0 0 178929 0 0 0 178929 0 178929 0 0 178929 10236398 1966 10042117 1966 194281 0 194281 0 0 194281 28025 55350 42840 -14815 0 -14815 Meal Revenue 722310 685913 0 0 685913 Purchase Discounts 900099 175857 0 0 175857 Pharmacy Misc Revenue 900099 197516 0 0 197516 118343 0 0 118343 1177629 110125083 107379169 0 1837276 120000 120000 0 0 0 0 0 0 1964485 443411 1399898 121176 0 0 0 0 44372423 43741246 604852 26325 822765 713429 95684 13652 5163413 4845622 291590 26201 3506077 3329057 166695 10325 0 0 0 0 698750 11301 687449 0 106640 0 106640 0 0 0 0 0 6744 6744 0 0 0 0 10576756 10545400 31356 0 99582 89919 9663 0 14983097 14739854 239450 3793 1360901 1298747 62154 0 0 0 0 0 1701811 1678956 22855 0 95509 78890 16619 0 0 0 0 0 84335 63505 19681 1149 708193 708193 0 0 0 0 0 0 4587648 4572888 14760 0 578508 509673 68835 0 Bad Debt 5502302 5502302 0 0 Free Care 2847338 2847338 0 0 Professional Fees 5056562 3681459 1365486 9617 Subscriptions & Dues 714935 225100 487861 1974 1585479 1487496 97983 0 107244253 101233786 5789511 220956 2438924 4168080 0 0 2398884 2264477 10258616 12802618 0 0 0 0 72338 171515 1371294 1413035 1080396 1057751 104097688 51408268 54706913 52689420 17190937 18185573 489451 437650 129347 134526 0 0 1640000 2143340 91777100 95467985 13297762 14314680 0 0 0 258468 26312766 24679160 0 0 0 0 729023 294782 0 0 5819350 6066285 46158901 45613375 X 40274861 44503392 4337245 4345057 1006093 1006161 45618199 49854610 91777100 95467985 X 2880830 2705947 0 0 0 -1350366 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 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 18164728 5250 -686973 0 696267 0 16786738 0.85 0.06 0.09 0 0 0 125271 125271 0 65922189 22700335 43221854 0 0 0 0 0 37252134 28707933 8544201 0 798094 0 798094 52689420 0 Est Settlement with 3rd Party 4205784 Est Insurance Claims 1860501 6066285 X SchD_P05_S00_L04 Schedule D, Part V, Line 4 Perm Endow 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 Endow funds are established by the governing body to fund capital projects and/or improvements of the organization. Temp Restricted funds are established by donor restricted gifts that maintain a source of income for a specific period of time. SchD_P10_S00_L02 Schedule D, Part X, Line 2 The Hospital and HMGI (as of April 2006) have been determined to be not-for-profit corporations as described in Section 501(c)(3), and the Realty Corp has been determined to be a not-for-profit corporation as described in Section 501(c)(2) of the Internal Revenue Code (the "Code") and are exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. The IRS has also previously determined that the Hospital is not a private foundation because it is an organization described under the IRC section 170(i)(A)(iii). Any income not substantially related to these Organizations' exempt purposes may be considered unrelated business income under IRC Section 511 and, as such, subject to tax at normal corporate rates. In accordance with generally accepted accounting principles, the Organization annually evaluates its tax status and tax positions taken with respect to its operations and financial position. Tax years from 2008 through the current year remain open for examination by federal and state taxing authorities. Golf Classic 83375 55350 28025 0 5277 14017 17158 400 5988 0 0 83375 55350 28025 0 5277 14017 17158 400 5988 42840 -14815 1 1 X 1 X 1 X 1 1 1 0 1 1 1882213 506134 1376079 0.0135 17041326 14859011 2182315 0.0214 0 0 0 0 0 0 18923539 15365145 3558394 0.0349 982953 113321 869632 0.0085 239160 616 238544 0.0023 0 0 0 0 0 0 0 0 44743 0 44743 0.0004 0 0 1266856 113937 1152919 0.0112 0 0 20190395 15479082 4711313 0.0461 0 0 0 0 0 0 0 0 0 0 0 0 240 0 240 0 0 0 0 0 126353 0 126353 0.0012 0 0 0 0 110701 0 110701 0.0011 0 0 0 0 0 0 237294 0 237294 0.0023 1 2255163 92236 32944291 28809621 4134670 X 1 1 1 1 Henry Heywood Memorial Hospital

242 Green Street Gardner MA 01440

X X X Henry Heywood Memorial Hospital 1 1 X X X X X X X X X 11 1 1 1 X 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 SchH_P01_S00_L06a Schedule H, Part I, Line 6a The Organization makes it's annual Community Benefit Report available to the public by transmitting the report electronically to the Attorney General's Community Benefit office which then makes it public on their website. SchH_P01_S00_L07 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. The costs for lines 7e through 7i were actual costs incurred. SchH_P02_S00_L00 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". SchH_P02_S00_L04 Schedule H, Part II, Line 4 This year's expenses were related to Heywood Hospital's Green Team and their sponsorship of Earth Day events which included a recycling day and plant sales. SchH_P02_S00_L06 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, Montachusetts 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 Dpt of Public Health, AHEC and others. At his 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. SchH_P02_S00_L08 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. SchH_P03_S0A_L02 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 sch H instructions. SchH_P03_S0A_L03 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 2013. This amounted to approximately 4.09% which was applied against the number on line2.. It is our belief that the $92,236 amount of bad debt should be included as a community benefit. As a ax 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 devts as a community benefit. SchH_P03_S0A_L04 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". SchH_P03_S0B_L06 Schedule H, Part III, Section B, Line 6 The allowable costs on line 6 were obtained from our FY 2013 Medicare Cost Report, Worksheet D schedules. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 There is no shortfall. SchH_P03_S0C_L09b 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, Commoneealth 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 if the patient is eligible to apply for certain health insurance programs. If the patient or guarantor is unable to provide the necessary information Heywood Hospital may make reasonable efforts to obtain any additional information from other sources. Information that Heywood obtains will be maintained in accordance with applicable federal and state privacy and security laws. The screening and application process for a 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. Heywod 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 Commonweatlh 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 the determination of program eligibility made by the Commonwealth, but at the patient's request may take a direct role in appealing or 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. SchH_P05_S0B_L03 Schedule H, Part V, Section B, Line 3 The 2011 Community Health Needs Assessment of North Cental Massachusetts was a joint effort between MA Dept 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 areals 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 Dept of Public Health, the US Census Bureau, the MA Dept of Workforce Development, the MA Dept of Elementary and Secondary Education and the Massachusetts Behavorial 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, Montachusestt Opportunity Council, in addition to other area agencies. SchH_P05_S0B_L04 Schedule H, Part V, Section B, Line 4 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. SchH_P05_S0B_L12 Schedule H, Part V, Section B, Line 12 12h:Medical Hardship, wherein the patient's medical expenses exceed the patient's income SchH_P05_S0B_L18 Schedule H, Part V, Section B, Line 18 18e: The Hospital posts general notices throughout the hospital about the financial assistance policy. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 Heywood Hospital assesses the health needs of the communities it serves in a variety of ways in addition to the CHNA. The Patient and Family Advisory Council which meets every other month includes 14 patients and two hospital representatives. This council, comprised of former patients and their families, provides general input on community needs, as well as input on hospital-specific services and opportunities for improvement. In addition, the hospital works closely throughout the year with area social service agencies obtaining input on community health needs including, Gardner Board of Health, the Joint Coalition on Healthcare, the Minority Coalition of North Central MA, Gardner CDC, the Massachusetts Department of Public Health, more than 100 agencies belonging to the Suicide Prevention Taskforce, Gardner Public Schools, Ashburnham Public Schools, Winchendon Public Schools, Gardner Area Interagency Team, Mount Wachusett Community College, Alzheimer Association, Montachusett Veterans Outreach, Gardner Area Seniors, Gardner VNA and the Greater Gardner Religious Council. The hospital solicits feedback from social service and nursing staff, as well as physicians regarding patient feedback. The hospital also provides space for/and facilitates support groups which provide feedback on community interests and needs. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 General Principles: For those patients who are uninsured or under-insured, Heywood Hospital will work with them to assist with applying for available financial assistance programs that may cover some or all of their unpaid hospital bills. In order to help uninsured and under-insured patients find available and appropriate financial assistance programs, Heywood Hospital will provide all patients with a general notice of the availability of programs in both the bills that are sent to patients as well as in general notices that are posted throughout the hospital. 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, Heywood Hospital may also assist patients in applying for coverage of services as a Medical Hardship based on the patients who are low income through Heywood Hospital's own internal financial assistance program. Heywood Hospital will also notify the patient about available payment plans that may available to them based on their family size and income. Role of Hospital Patient Financial Counselors and other Finance staff: Heywood Hospital will try to identify available coverage options for patients who may be uninsured or under-insured with their current insurance program when the patient is scheduling their services, while the patient is in Heywood Hospital, upon discharge, and for a reasonable time following discharge from the hospital. The hospital registration and admission staff will direct all patients seeking available coverage options or financial assistance to the hospital's patient financial counseling office to determine if they are eligible and then o screen for eligibility in an appropriate coverage option. Heywood Hospital will then assist the patient in applying for the appropriate coverage options that are available or notify them of the availability of financial assistance through the hospital's own internal financial assistance program. Heywood Hospital will also provide information on how to contact the appropriate staff within the hospital's finance office to verify the accuracy of the hospital bill or to dispute certain charges. Notification Practices: Heywood Hospital will post a notice of availability of financial assistance in the following locations; 1) Service Delivery Areas such as Inpatient, Clinic and Emergency Department admissions and registration areas. 2) Patient Financial Counselor areas. 3) Central Admission and Registration areas. and 4) Business office areas that are open to patients. Posted signs will be clearly visible and legible to patients visiting these areas. Heywood Hospital will also include a notice about the availability of financial assistance in all initial bills. When the patient contacts Heywood Hospital, the hospital finance staff will attempt to identify if a patient qualifies for a public financial assistance program or a payment plan... A patient who is enrolled in a public financial assistance program may qualify for certain plans. Patients may also qualify for additional assistance based on Heywood 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. For cases where Heywood Hospital is using the Virtual Gateway application, the hospital will assist the patient in completing the application for MassHealth, Commonwealth Care, Children's Medical Security Plan, Healthy Start, Health Safety Net or other forms of financial assistance programs, as they become part of the Virtual Gateway program. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 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 over 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. SchH_P06_S00_L05 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 over 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. SchH_P06_S00_L06 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 CHNA. Financial counselors help uninsured populations, ncluding 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 at the school, providing nearly 1000 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 health equity. 1 Montachusett Home Care Corp 680 Mechanic St Leominster MA 01453 042551175 501(c)(3) 76800 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. Montachusett Opportunity Council 133 Pritchard St Fitchburg MA 01420 042401111 501(c)(3) 43200 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 SchI_P01_S00_L02 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 0 0 X X X X X 1 0 0 0 0 1 0 0 0 Winfield Brown 383569 0 133569 0 9000 0 19261 0 31438 0 576837 0 0 0 Robert Crosby 225978 0 41469 0 1158 0 21255 0 27703 0 317563 0 0 0 Michael Grimmer 190066 0 25621 0 12500 0 17000 0 26961 0 272148 0 0 0 Tina Santos 195816 0 25233 0 176 0 17780 0 11761 0 250766 0 0 0 Thomas Cady 153094 0 21352 0 901 0 20283 0 25643 0 221273 0 0 0 Rose Kavalchuck 177031 0 23938 0 971 0 20675 0 21993 0 244608 0 0 0 David Gill 253233 0 0 0 2591 0 5326 0 23017 0 284167 0 0 0 Faith Pinkerton 182352 0 10000 0 208 0 0 0 18332 0 210892 0 0 0 Sheila Ebert 195570 0 0 0 499 0 3901 0 10752 0 210722 0 0 0 Ellen Ray 171937 0 10000 0 324 0 0 0 18130 0 200391 0 0 0 Alice Vaine 174279 0 0 0 499 0 3601 0 10335 0 188714 0 0 0 James Mullen 0 0 0 0 101328 0 0 0 7819 0 109147 0 0 0 SchJ_P01_S00_L01a Schedule J, Part I, Line 1a Housing allowance provided to Michael Grimmer, VP of Support Services, per contract. Paid through his weekly salary. SchJ_P01_S00_L01b Schedule J, Part I, Line 1b Housing allowance was part of his employment contract. SchJ_P01_S00_L04 Schedule J, Part I, Line 4 James Mullen, former CNO received severance payments in CY 2012. Total severance paid in 2012 was $101,328. SchJ_P01_S00_L06 Schedule J, Part I, Line 6 Heywood Hospital accrues 15% of the executive team's salary for a bonus payment that is based on the financial condition of the hospital and other quality based criteria. 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 SchK_P04_S00_L02c Schedule K, Part IV, Line 2c Rebate computation was performed October 8, 2013. F990_P03_S00_L03 Form 990, Part III, Line 3 In August 2013, Heywood Hospital closed its Transitional Care Unit and reduced the number of beds in its Pediatric unit. F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b The Senior Accountant at Heywood Hospital prepares the form 900 and provides to the controller for review. The form is then sent to the CFO for final review. Once review, 990 is placed on Hospital Cyber Board for Board of Trustee review. The 990 is then approved by the board and submitted by the accounting department. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c Annually, a Conflict of Interest form is sent out to the managers, trustees and employees with broad discretionary authority. These forms are required to be signed and are monitored by the Corporate Compliance office for completion. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 The CEO and Officer's salary is determined by the market data provided to the search committee by a search firm, an independent third party. This data supplemented the first hand knowledge of other comparable facilities in New England and that search firm had based on prior searches. Sources such as the Massachusetts Hospital Salary Survey and intimate knowledge of the going salaries for senior executives in healthcare also played a major role in determining salaries F990_P06_S0C_L19 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. F990_P11_S00_L09 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 inter-corporate and inter-corporate transfers to 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 0 1 1 1 0 Heywood Hospital Realty Corporation q 229571 Actual Cost. Extension was granted.