2014-05-08T10:27:02-05:00 2013-09-30 010494526 BAKER NEWMAN & NOYES LLC 650 ELM STREET SUITE 302 MANCHESTER NH 03101 990 2012-10-01 020222791 Alice Peck Day Memorial Hospital ALIC 6034483121 10 Alice Peck Day Drive Lebanon NH 037662647 Evalie M Crosby CPA FHFMA 6034483121 2014-04-30 1 Nicholas E Porto P01310283 8002447444 2012 2015-11-30 17:44:51Z Susan E Mooney MD MS 10 Alice Peck Day Drive Lebanon NH 037662647 55778622 0 X www.alicepeckday.org X 1943 NH Critical Access Hospital 20 17 692 50 0 0 2648403 483872 51719846 54164603 284746 150290 39312 13075 54692307 54811840 40000 40150 0 0 30812469 31282308 256600 11502 368956 21328367 22769142 52437436 54103102 2254871 708738 39832951 43973140 23447694 26451784 16385257 17521356 X The mission of Alice Peck Day Health Systems is to provide personalized, high quality, patient-focused healthcare services which are responsive to community needs, promote wellness, and continually improve the quality of healthcare in the community. 0 0 50028636 40150 54164603 Alice Peck Day Memorial Hospital is a community-based critical access hospital operating in Lebanon, NH. The Hospital began as a small cottage hospital in 1932. From its humble beginnings, Alice Peck Day has continually demonstrated its commitment to provide patient-focused health care services which improve the quality of life within its community and promote wellness for all. Alice Peck Day Memorial Hospital is a charitable health care organization which is dedicated to serving its community. This commitment includes granting credit to patients, substantially all of whom are local residents. The Hospital provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than the established rates. Collections are not pursued for amounts determined to qualify as charity care. The Hospital maintains records to identify and monitor the level of charity care it provides. These records include the amount of charges foregone for services and supplies furnished under its charity care policy, the established costs of the services and supplies provided, and equivalent service statistics. For the year ended September 30, 2013, charity care at a cost of $867,713 was provided to eligible patients. Estimated costs incurred in excess of payment for inpatient and outpatient services for Medicaid patients in the year ended September 30, 2013 were $2,083,515. In addition to the charity care services described above, the Hospital provided a number of other services for which little or no payment was received. Services included community health services, health professional education, community building activities, and community benefit programs. Services ranged from community flu clinics, Upper Valley Smiles Dental Program, student and professional education, emergency pharmacy vouchers, and many other programs which contributed to and supported our community. As a local hospital, Alice Peck Day works closely with community organizations to address community needs. Organizations that were beneficiaries of hospital staff time, meeting space, and/or materials include Alcoholics Anonymous, AARP, Arthritis Foundation, Awake Support Group, Childbirth Education and Postpartum Massage, Colby Sawyer College, Community Health Department, Geisel School of Medicine at Dartmouth, Good Neighbor Health Clinic, Grafton County Senior Center, Grafton County Senior Citizens' Council, Lebanon Area Chamber of Commerce, Lebanon College, Lebanon School Bike Rodeo, Lebanon School District, NE Institute of Technology, Over-Eaters Anonymous, River Valley Community College, Savvy Seniors Exercise Program, Upper Valley Interfaith Project, Upper Valley Turning Point, Upper Valley Smiles Dental Program, Vermont Technical College, and Yale University. In certain instances, assistance was provided to the community for which no value can be placed. This assistance included leadership in identifying community needs, staff commitment to volunteer for community organizations, advocacy and support for the socially and physically disadvantaged, and support for local public safety organizations. Alice Peck Day considers caring for our community a special responsibility that we are honored to fulfill. Through our many programs, dedicated staff and unwavering commitment to quality care, Alice Peck Day works to exceed these expectations and make a real difference in our community. 50028636 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 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 X 51 0 1 692 1 0 0 0 0 0 0 0 0 0 0 X 20 17 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X X Evalie M Crosby CPA FHFMA 6034483121 10 Alice Peck Day Drive Lebanon NH 037662647 X Marty P Candon 1.00 1.00 X 0 0 0 Michael J Cryans 1.00 1.00 X 0 0 0 Closey F Dickey 0.00 0.00 X 0 0 0 Terri C Dudley 0.00 0.00 X 0 0 0 Curt A Jacques II 1.00 1.00 X 0 0 0 Richard S Jennings 1.00 2.00 X 0 0 0 Bruce N Johnstone 2.00 4.00 X 0 0 0 Edward T Kerrigan 2.00 4.00 X 0 0 0 Miriam M Maguire 0.50 1.50 X 0 0 0 Mark E Melendy 1.00 2.50 X 0 0 0 Shelly L Moses 1.00 1.00 X 0 0 0 Hildegard Z Ojibway 1.00 1.00 X 0 0 0 Brett C Peltzer 1.00 1.00 X 0 0 0 Wendall M Smith 1.00 1.00 X 0 0 0 Michael R Harris PhD 1.00 1.00 X X 0 0 0 Rev Dr Guy J D Collins 1.00 2.00 X X 0 0 0 Judson T Pierson 2.00 4.00 X X 0 0 0 Karen G Kayen 2.00 1.00 X X 0 0 0 Harry G Dorman III FACHE 43.00 17.00 X X 148298 181253 32248 Susan E Mooney MD MS 50.00 11.00 X X 257562 13556 45062 Deborah A Glazer MD 12.00 1.00 X X 59347 0 0 Randall D Lea MD MPH 2.00 1.00 X X 23857 0 4658 Claudia C Gibson 5.00 X X 0 0 0 Beverley Rankin RN BSN 60.00 0.00 X X 149526 0 42029 Evalie M Crosby CPA FHFMA 40.00 20.00 X 130463 32615 37326 J Todd Miller MS 40.00 20.00 X 157792 0 41306 Brenda L Blair 60.00 X 117393 0 27389 Andrew Best MD 40.00 X 315461 0 33117 Diane C Riley MD 40.00 X 408801 0 35149 Leonard M Rudolf MD 40.00 X 463539 0 29921 Douglas Cedeno MD 40.00 X 286465 0 22024 David R Kroner MD 40.00 X 288406 0 32614 2806910 227424 382843 41 0 1 0 Upper Valley Neurology 106 Hanover Street Lebanon NH 03766 Professional Services 1927991 Engelberth Construction 428 Main Street Keene NH 03431 Construction Services 605525 Carpenter & Costin 289 North Main Street Rutland VT 05701 Landscaping Services 147139 3 483872 483872 Patient services 621400 53729634 53729634 Other operating 621400 343728 343728 Nutritional services 722210 91241 91241 54164603 97095 97095 36958 23883 13075 13075 13075 988215 7879 942899 0 45316 7879 53195 53195 54811840 54164603 0 163365 40150 40150 659091 61564 597527 25964607 24673868 1054380 236359 402759 374806 24248 3705 2501297 2380140 97569 23588 1754554 1632788 105624 16142 26109 3740 22369 47125 47125 11920 11920 11502 11502 5400274 5041985 322292 35997 42405 10587 31697 121 1245305 882409 347320 15576 83622 78320 4407 895 1084965 919583 160810 4572 196149 174557 19183 2409 481043 481043 1955564 1655517 291813 8234 983557 971306 11915 336 Medical supplies/equipm 5620283 5612130 7950 203 Medicaid Enhancement ta 2433571 2433571 Provison for bad debt 2085471 2085471 Equipment rental/mainte 481802 470973 10747 82 589977 525171 55571 9235 54103102 50028636 3705510 368956 49669 382532 2737368 4210783 1833739 1347100 7528117 8282884 0 0 0 0 0 0 1238856 1129039 387557 440197 43240471 24839043 19099897 18401428 3395054 4047095 8500 8500 0 0 122544 116963 3431650 5606619 39832951 43973140 7799569 8372064 0 0 0 0 14807522 14830040 0 0 0 0 837113 0 0 840603 2412567 23447694 26451784 X 15898995 16878683 458576 612221 27686 30452 16385257 17521356 39832951 43973140 X 708738 336654 90707 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 7279 1 495 0 1 4196 11970 0 Explanation of Lobbying Activities: Part II-B, Line 1: The Organization pays dues to the New Hampshire Hospital Association and the American Hospital Association, a portion of which are attributable to lobbying activities. Also, APD joined the 10 Mile CAH Coalition which engaged in strategic health resources (SHA) in lobbying efforts with regards to efforts in trying to eliminate CAH status. The CEO and CFO participated in a gathering in Washington DC that included visits to and discussions with all 4 members of the New Hampshire Legislative delegation. This was a two day event in February 2013. APD signed letters produced by SHA and sent them to members of Congress regarding the protection of the critical access hospital program. The CEO and CFO participated in phone conference calls with SHA and other members of the Coalition for strategic planning purposes. 27686 2766 30452 25840 1846 27686 28065 -2225 25840 26827 1238 28065 26456 371 26827 0.00000 1.00000 0.00000 0 0 927577 927577 19758231 8441352 11316879 250651 209757 40894 20111647 15339583 4772064 2192365 848351 1344014 18401428 Estimated Third-Party Payor Settlements 1831736 Due from Affiliates 2012350 Liability Insurance Receivable 1762533 5606619 Current portion of deferred annuities 17645 Interest rate swap 187124 Liability payable 2157533 Longterm deferred annuity 50265 2412567 X Description of Intended Use of Endowment Funds: Part V, Line 4: The Organization uses the income from its endowment funds for use in operations. Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: The System consists of not-for-profit corporations as described in Section 501(c)(3) of the Internal Revenue Code, all of which are exempt from federal income taxes on related income pursuant to Sections 501(a) of the Code. Management evaluated the System's tax positions and concluded the System 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 the consolidated financial statements. With few exceptions, the System is no longer subject to income tax examinations by the U.S. federal or state tax authorities for years before 2010. 1 1 1 X 275.000000000000 1 X 275.000000000000 1 1 1 0 1 1 867713 867713 0.01670 4165481 2081966 2083515 0.04010 5033194 2081966 2951228 0.05680 141559 141559 0.00270 190934 190934 0.00370 13214767 5689151 7525616 0.14470 0 70523 70523 0.00140 13617783 5689151 7928632 0.15250 18650977 7771117 10879860 0.20930 0 1939 1939 0.00000 12549 12549 0.00020 3736 3736 0.00010 3725 3725 0.00010 1650 1650 0.00000 23599 23599 0.00040 1 1376250 100000 14850900 13849369 1001531 X 1 1 1 1 Alice Peck Day Memorial Hospital

10 Alice Peck Day Drive Lebanon NH 03766

www.alicepeckday.org X X X X Physician Clinics Alice Peck Day Memorial Hospital 1 1 X X X X X X X X 12 1 1 1 X X X X X X X X X X 0 0 1 1 275.000000000000 1 275.000000000000 1 X X X X X X X 1 1 X X X X X X X 1 X X 1 X X X X X 1 X 0 0 8 RAM Center for Community Care

5 Alice Peck Day Drive Lebanon NH 03766

Primary Care Physician Clinic Women's Care Center

141 Mascoma Street Lebanon NH 03766

OB/GYN Physician Clinic APD Orthopaedic Clinic

17 Alice Peck Day Drive Lebanon NH 03766

Orthopaedic Physician Clinic General Surgery Clinic

10 Alice Peck Day Drive 17A Lebanon NH 03766

General Surgeon Clinic Pain Management Clinic

17 Alice Peck Day Drive B Lebanon NH 03766

Pain Management Clinic APD Hand & Upper Extremity Clinic

205 Billings Farm Road Unit 3A White River Junction NH 05001

Hand & Upper Extremity Orthopaedic Physician Clinic Occuptational Health Services

127 Mascoma Street 2nd Floor Lebanon NH 03766

Occupational Health Physician Clinic Neurosurgery Services at APD (NSAPD)

106 Hanover Street Lebanon NH 03766

Neurosurgery Physician Clinic Part I, Line 3c: Family income limit for eligibility for discounted care ranges from 200%-275% of FPG. Part I, Line 7: The costs of charity care and means-tested programs are calculated using the facility-wide cost to charge ratio as calculated in Worksheet 2. Subsidized health services are calculated using the cost to charge ratios per service area, using a step-down cost allocation methodology consistent with Medicare cost report methodology. The cost of financial assistance and other community benefits at cost are 6.19% of total expenditures on Form 990, Part IX, Column A, Line 25, excluding bad debt expense. Part I, L7 Col(f): Bad debt expense reported on Form 990, Part IX, Line 25 was excluded from total expenses for the calculation of net community benefit expenses as a percent of total expense. Part II: Alice Peck Day Memorial Hospital participates in various community building activities to promote and advocate for the health needs of the community. Significant activities include participation in the Upper Valley Interfaith Project, which promotes adequate public transportation in the region, including availability of transportation for hospital and clinic visits for area residents. APD's social services department works with patients who seek assistance with living wills and advance medical directives. APD personnel are actively involved in disaster and emergency preparedness planning and training activities. These activities are designed to promote the health and safety of the community in the event of widespread or large natural or other disaster, or in the event of widespread viral outbreaks, such as influenza. Finally, APD personnel are active participants in the New Hampshire Hospital Association (NHHA). NHHA advocates for the care and protection of NH hospital patients, including making quality health care available, affordable, and accessible to all, regardless of ability to pay. Part III, Line 4: Bad debt cost is calculated using a cost to charge ratio using a step-down cost allocation methodology consistent with Medicare cost reporting. In FY 13, accounts written off to bad debt included 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. We estimated the amount of charity care in bad debt expense based on the number of applications for charity care. We believe the amount is minimal based on our extensive efforts to educate our patients and staff about our various payment plans and charity care 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, time-payment programs, or a combination of the above. Due to these efforts, we feel that amounts written off to bad debt that could qualify as charity care are minimal. Footnote 1 to the audited consolidated financial statements of Alice Peck Day Health Systems, Corp. includes the following to address bad debt: Accounts receivable are stated at the amount management expects to collect on outstanding balances. Management provides for possible uncollectible amounts through a charge to operations and a credit to the valuation allowances based on its assessment of individual accounts and historical adjustments. Accounts deemed uncollectible are written off through a charge against the established allowance. 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: Our bad debts collection policy applies to all patient accounts in a consistent manner. The policy specifically indicates that, after a second statement is sent with no payment received, a patient accounts representative will attempt to contact the patient by phone to determine if a financial assistance application or payment plan is appropriate. This is completed to avoid further escalation of past due account(s) if the patient may qualify for full or partial relief under the charity care policy. If the application is successful, then the qualifying balance or balances are classified as charity care and no longer pursued for collections. Once a patient balance is classified as charity care, it is not subject to collection activities. Alice Peck Day is committed to helping our patients obtain quality healthcare, regardless of ability to pay. Our financial assistance programs encourage and enable our patients to make healthcare decisions free of financial barriers. We educate our patients about our programs and provide assistance prior to their receiving services, at registration for services, and during our billing process to ensure that any and all patients in need of assistance are provided with the help they qualify for under APD programs if they choose to pursue these benefits. Brochures and signs are placed in high traffic areas such as the ER and Registration. Our staff is trained to identify patients during registration, provide information, and offer assistance in completing the necessary forms. During our billing process, calls are made to patients with outstanding balances. APD staff work with patients to identify problems they are facing in dealing with outstanding balances. Patients are notified again of the many types of financial assistance available for which they may qualify. Programs are explained and assistance is offered, if needed in completing the applications. Due to this multi-level approach and staff that is trained to identify clients who may need financial assistance, very few qualifying patients reach the point of bad debt. Our collection policies and procedures, in conjunction with our small size, allow our organization to place great emphasis on helping all patients who may be in need to apply for, and obtain, the appropriate level of financial assistance. Alice Peck Day Memorial Hospital Part V, Section B, Line 3: The 2012 Upper Valley Community Needs Assessment Report was the product of an almost year-long process coordinated by Alice Peck Day Memorial Hospital, Mount Ascutney Hospital and Health Care, Dartmouth-Hitchcock Medical Center and Granite United Way.Between November 2011 and October 2012, information on health, education and economic needs of the Upper Valley region were gathered through secondary data gathering, two forums with informed stateholders, a stakeholders' survey, and six focus group discussions. The CAN process was guided by a Steering Committee composed of individuals (including the Community Health Director at Alice Peck Day Memorial Hospital) with expertise in the areas of health, education and economic well being. Alice Peck Day Memorial Hospital Part V, Section B, Line 4: Alice Peck Day Memorial HospitalMount Ascutney Hospital and Health CareDartmouth-Hitchcock Medical Center Alice Peck Day Memorial Hospital Part V, Section B, Line 7: Through primary and secondary data analysis, as well as qualitative research that was inclusive of a wide spectrum of health and human services professionals and community residents, twelve key community needs were identified:1. Lack of quality jobs/income2. Transportation access and cost3. Housing cost4. Tobacco/alcohol/drug use5. Oral health6. Mental health7. Obesity/poor nutrition/lack of physical activity8. All health/oral health /insurance access9. Child care10. Asthma11. Isolation/less time for "community" and12. Quality of/limited educationMany of those community needs (1,2,3,9,11, and 12) do not fall within the primary purview of the health care delivery system. While we acknowledge the growing evidence pointing to the interplay between economic and educational status and health, APD as a small, community-based rural hospital is not positioned to directly address those significant areas of concern (an exception to this is need 2, transportation access and cost: APD made a substantial cash donation to the Grafton County Senior Citizens Council, earmarked for the elderly/disabled bus service). As described in other sections of this report, Alice Peck Day Memorial Hospital focuses its community health resources in two major areas: oral health (need 5) and health access (need 8). Alice Peck Day Memorial Hospital Part V, Section B, Line 12h: Alice Peck Day Memorial Hospital offers financial assistance to patients demonstrating need. In making the need determination, APD participates with and honors the founding principles and guidelines of the New Hampshire Health Access Network (NHHAN). Accordingly, decisions regarding the granting of financial assistance will be based primarily on a patient and his or her household income and assets. There will be minimal consideration of expenses except when they identify areas for further investigation or incomplete or inaccurate information. The value of a patient's principal residence is not considered in qualifying a patient for in-house assistance. APD requires exhaustion of other payment methodologies, including but not limited to, Worker's Compensation, Veterans Benefits, Medicaid, liability (auto accidents), victims of crime, and COBRA. When applicable, proof of determination may be required prior to consideration for financial assistance. Alice Peck Day Memorial Hospital Part V, Section B, Line 14g: Please see Part V, Line 3 for a description of the financial assistance program and the efforts made to publicize and promote the program. Alice Peck Day Memorial Hospital Part V, Section B, Line 20d: The hospital facility provides uninsured patients with a 15% discount. At the time the discount was established, the discount exceeded the average of the three lowest negotiated commercial insurance rates for services at the hospital facility. The average of the three lowest commercial insurance rates was approximately 87.5%; the rate applied to uninsured patients was lower than that rate, at 85%, representing a 15% discount. In addition to these eligible patients, a 10% prompt pay discount is offered. Part VI, Line 2: Due to our rural location and size, a collaborative effort between the United Way, Dartmouth Hitchcock Memorial Hospital, Mount Ascutney Hospital, Granite United Way and Alice Peck Day Memorial Hospital created the 2012 Community Needs Assessment that formed the basis for the FY 2013 Community Benefits Plan. Priority needs and health concerns for our community were based upon information collected from community needs assessments and community surveys. Identified population health concerns included tobacco/alcohol/drug use, oral health, mental health, obesity/poor nutrition/lack of physical activity, access to care and asthma. Alice Peck Day used this information to help focus its community benefit efforts to meet the priority needs identified in the Community Benefit Plan. Of special note is the Upper Valley Smiles Program that has served a priority need to oral health within our local community. Upper Valley Smiles has touched the lives of many children ages newborn to eighteen in our community and provided much needed care, particularly for the uninsured. Part VI, Line 3: Alice Peck Day believes that quality health care should be available to all, regardless of ability to pay. Our financial assistance programs and staff are dedicated to helping people obtain the care they need. We reach out to our patients in many different ways to ensure that they are aware that help is available and to help guide them through the process. Brochures and signage are posted in high traffic areas such as the emergency room, registration, and the lobby. Registration staff are trained to identify patients who may be in need of financial assistance. Once identified, staff notify the patient that APD has various forms of financial assistance and explain that assistance is available for anyone who might require help or guidance in completing any necessary paperwork. In addition to the above, our billing staff are trained to help identify and offer assistance to anyone who might require financial assistance. Patients with outstanding claims are contacted by our credit coordinator who works with them to clear up balances through the variety of programs we offer. Assistance is also provided in applying for federal/state programs to those who qualify. Specially trained staff guide applicants through the process to ensure forms are filled out correctly, all required documentation is attached, and the applicants understand what they can expect to happen along the way. Part VI, Line 4: Alice Peck Day Memorial Hospital is part of the Lebanon Health Care service area. The Lebanon service area comprises cities and towns in New Hampshire and Vermont. APD's service area in NH is comprised of 15 towns in addition to the city of Lebanon, including Canaan, Cornish, Croydon, Dorchester, Enfield, Grafton, Grantham, Hanover, Lyme, Newport, Orange, Orford, Piermont, Plainfield and Warren. Vermont towns include East Thetford, Fairlee, Hartford, Hartland, North Hartland, North Thetford, Post Mills, Quechee, Sharon, South Strafford, Strafford, Thetford, Thetford Center, Vershire, West Vershire, West Fairlee, West Hartford, White River Junction and Woodstock Part VI, Line 5: Alice Peck Day actively promotes community-based leadership development. Staff members participate in the Lebanon Chamber of Commerce, Leadership Upper Valley, Vital Communities Corporate Council, Foundation for Healthy Communities, the Rural Health Coalition, and the Advocacy Task Force. As an active member of the community, APD works to be proactive concerning disaster readiness. Staff have participated in onsite training for disaster preparedness as well as off-site training with other regional hospitals. Collaborative efforts include all hazard regional training, emergency response training, and a regional mass casualty response program to help facilitate cooperative efforts if such needs arise. Part VI, Line 6: Alice Peck Day Memorial Hospital is a critical access hospital located in Lebanon, NH. The Hospital is served by a board of trustees consisting of local citizens active in community activities and organizations. The majority of board members are not employed by the Hospital, and include local government and business representatives as well as practicing independent physicians. Despite its small size, APD is committed to giving back to the community to the greatest extent possible. During FY13, cash donations were given to organizations to help those in need. Local financial contributions helped support free primary care clinics for the uninsured, provided transportation for the elderly and disabled to receive medical care, and provided local nonprofit organizations with meeting space and refreshments. Alice Peck Day supported community flu clinics, provided emergency prescription drug vouchers, provided childbirth education classes, offered a dedicated office space for a local public health collaborative, provided space for a satellite free clinic, and worked toward the expansion of local public transportation to ensure all those in need of medical care could receive it. One of APD's most exciting and celebrated programs is the Upper Valley Smiles Dental Program. This program provides an oral health safety net for disadvantaged residents within our service area. In 6 different schools, over 1,600 students received oral health education, with nearly 400 of those children receiving screenings from a dental team. Additionally, over 1,200 preventative sealants were given to 239 low-income, uninsured children. Referrals for follow-up restorative treatment were given to 97 of the 239 children. With grant support, APD continued its Women, Infants and Children (WIC) Oral Health Initiative in Lebanon and Enfield New Hampshire, and in Hartford, Vermont. Under the WIC initiative, a total of 104 low-income children aged 0-10 received oral health education, a dental screening, and preventative care. Individuals were provided with assistance in applying for NH/VT Medicaid to ensure increased access to medical care for this needy population. As a result, a significant number of people were successfully enrolled and received ongoing care. To promote health professional education, APD provided clinical undergraduate training to students from Bay Path College, Geisel School of Medicine at Dartmouth, George Washington University, Lebanon College, New England Institute of Technology, River Valley Community College, the University of Vermont and Yale University. APD annually sponsors district-wide professional development for school nurses in our local area and for others within our region. These initiatives and ongoing efforts continue to address several of the most pressing community needs as identified in our community needs assessment. Reports Filed With States Part VI, Line 7 NH 1 Good Neighbor Health Clinic 70 North Main Street White River Junction VT 05001 030346949 501(c)(3) 18333 Operational support for clinic providing free primary care services to patients in the upper valley area of NH and White River Junction area in Vermont. Patients receiving free care are at or below 225% of the Federal Poverty Level. Grafton County Senior Citizens Council PO Box 433 Lebanon NH 03766 237248316 501(c)(3) 18333 Operational support for transportation services for area senior citizens. The Council provides lift-assisted buses with priority on medical transport for hospital or clinical appointments. 2 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: As part of APD's Access Improvement Plan developed in 2003, Hospital staff and Board members identified the Grafton County Senior Citizens Council and the Good Neighbor Health Clinic (which also includes the Red Logan Dental Clinic) as essential to providing access to health care in the Upper Valley NH and White River VT areas. Based on the needed services provided, the Board approved on-going monetary support for these organizations. The annual amount to be contributed by APD to these organizations is approved annually through the annual budget process. APD receives and reviews each year the organizations' published annual reports and also maintains informal contacts throughout the year to monitor the organizations' operations and services. 0 0 0 0 0 0 0 0 0 Harry G Dorman III FACHE 130523 159528 0 0 17775 21725 3684 4502 10828 13234 162810 198989 0 0 Susan E Mooney MD MS 241428 12707 0 0 16134 849 7541 397 35268 1856 300371 15809 0 0 Beverley Rankin RN BSN 136525 0 0 0 13001 0 4836 0 37193 0 191555 0 0 0 Evalie M Crosby CPA FHFMA 116864 29216 0 0 13599 3399 4118 1029 25743 6436 160324 40080 0 0 J Todd Miller MS 135302 0 0 0 22490 0 4988 0 36318 0 199098 0 0 0 Andrew Best MD 315461 0 0 0 0 0 7156 0 25961 0 348578 0 0 0 Diane C Riley MD 401177 0 0 0 7624 0 9427 0 25722 0 443950 0 0 0 Leonard M Rudolf MD 455192 0 0 0 8347 0 10000 0 19921 0 493460 0 0 0 Douglas Cedeno MD 263965 0 0 0 22500 0 7983 0 14041 0 308489 0 0 0 David R Kroner MD 267907 0 0 0 20499 0 8375 0 24239 0 321020 0 0 0 Part I, Line 3 The compensation of the Organization's CEO/President is determined through a related party, APD Health Systems, Corp, the sole corporate member of the Organization. APD Health Systems used its Compensation Committee, an independent compensation consultant, a compensation survey/study, and approval by its Board's Compensation Committee to establish the CEO/President's compensation and benefits. Supplemental Information Part III Schedule J, Part II: Salary and benefit expense for the CEO/President and CFO are charged to APD Health Systems, Corp. and then allocated to Alice Peck Day Memorial Hospital and Alice Peck Day Lifecare Center, Inc. based on the relative share of services performed for those entities. On the audited consolidated financial statements and 990, these expenses ($459,052) are included in salaries and benefits expense. A Business Finance Authority of the State of NH 521304598 2010-11-30 12282000 Current Refund Existing Bond 0 0 0 A 12282000 12237068 44932 2010 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 1 1 TD Banknorth NA 5.000000000000 0 0 0 0 1 A 1 Schedule K Part IV, Arbitrage, Line 2c Date Rebate Computation Performed Issuer Name: Business Finance Authority of the State of NH Date the Rebate Computation was Performed: 01/03/2011 Form 990, Part V, Line 2a: For administrative purposes, Alice Peck Day Memorial Hospital acts as the common paymaster for both Alice Peck Day Health Systems, Corp. and Alice Peck Day Lifecare Center, Inc. Form 990, Part VI, Section A, line 6 Alice Peck Day Health Systems, Corp., a charitable corporation, acting by and through its board of trustees, is the sole member of the organization. Form 990, Part VI, Section A, line 7a All Trustees shall be elected by the Board of Trustees of the member at the annual meeting of the Member. A nomination slate for the Trustees shall be submitted by the governance committee of the Member. Any Trustee may be removed at any time, with or without cause, by the Member. Vacancies on the Board of Trustees due to death, resignation, or other cause except removal shall be filled by election by the remaining members of the Board. Vacancies caused by removal shall be filled by election by the Member. Trustees elected to fill vacancies shall hold office until the next annual meeting of the Member, at which time successors shall be elected in the manner provided for in the case of original elections. Form 990, Part VI, Section A, line 7b The Organization's annual operating budget and all capital budgets shall be subject to approval by the Member. Any overall strategic plan for the Organization, including the development of off-site facilities or the addition of new programs and affiliations with other institutions, shall be consistent with the strategic plan of the Member as determined by the Member. The borrowing of any sum in excess of $50,000 which has a stated term of greater than one year or which is secured by a mortgage of all or any portion of the Organization's real property or by a security interest in the Organization's assets or revenues shall be subject to approval by the member, provided, however, that the approval by the Member shall not be necessary for any borrowing to purchase or lease equipment or other personal property secured by a purchase money lien or title retention or security agreement, except as incident to the review of the capital budget. Any voluntary dissolution, merger or consolidation of the Organization or the sale or transfer of all or substantially all of the Organization's assets or the creation or acquisition of any subsidiary or affiliate corporation shall be subject to approval by the Member. The Board shall select certified public accountants for the Organization which will audit the books and records of the Member. The Board shall select the President who must be confirmed by the Member. Form 990, Part VI, Section B, line 11 The completed Form 990 is provided to all members of the finance and governance committees of the Board of Trustees in advance of the filing deadline to enable a detailed and conscientious review by all members of both committees. The completed Form 990 is also distributed to all members of the full Board for review no later than the final regularly scheduled Board meeting prior to the filing deadline. All questions and concerns are addressed by the Chief Financial Officer and incorporated into the Form 990 as deemed appropriate. After all input from the Board, finance, and governance committees has been appropriately addressed and incorporated into the final Form 990, a vote of acceptance of the final document is required. The vote is recorded in the minutes of the Board of Trustees prior to the filing of the Form 990. Once approved, senior management files the final Form 990 with the Internal Revenue Service as required. Form 990, Part VI, Section B, line 12c The Alice Peck Day Health System has a multifaceted conflict of interest policy. Members of the Board of Trustees complete conflict of interest questionnaires on an annual basis and any new members complete the questionnaire upon joining the Board. As part of our ongoing monitoring process, our executive assistant reviews all Board questionnaires and disclosures to identify any potential conflicts before they arise. In addition, our executive assistant attends all Board meetings to ensure that if any conflicts arise, they are handled appropriately. If such conflicts do arise, the Organization complies with the State of New Hampshire and federal requirements for disclosures of such events. The Organization is committed to conducting its business in a manner that is both ethical and legal. As part of this commitment, a standard of conduct form is required of all employees of the Organization. This is reviewed with all employees upon hire and on an annual basis thereafter. The standard of conduct covers conflict of interest and other vital matters to ensure all business activity is conducted in a manner that is consistent with the highest standards of honesty, integrity, and fairness. Form 990, Part VI, Section B, line 15 The Compensation Committee of the Alice Peck Day Health Systems, Corp. Board of Trustees is responsible for determining the compensation of the Chief Executive Officer/President. The Vice President of Human Resources and Organizational Development provides compensation data of comparable organizations with approximately the same size staff and spending in a location of similar size. The committee determines the appropriate compensation and approves an amount that is then communicated to Human Resources for adjustment. The CEO/President is responsible for reviewing the performance of senior management staff. The information is brought to the compensation committee of the Board of Trustees along with a recommendation for the salary of each individual. The compensation is determined through a variety of analysis of salary data and performance. Individual salary increases are then based on overall performance, within budgeted increases for the organization. APD Health Systems used its Compensation Committee, an independent compensation consultant, a compensation survey/study, and approval by its Board's Compensation Committee to establish the CEO/President's compensation and benefits. Form 990, Part VI, Section C, line 19 The Organization 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: Dr. Susan E. Mooney is a practicing physician in addition to being the President & CEO. She worked an average of 61 hours per week, of which an average of 59 hours per week were spent on executive matters and 2 in her role as a physician. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Impact of interest rate swaps 90,707. Oversight of Audit Process: Form 990, Part XII, Line 2c: The finance committee acts as the audit committee and oversees the audit process for the Alice Peck Day entities. The audit process for the financial statements did not change from the prior year. Independent accountants performed the audit for the fiscal years ended 9/30/12 and 9/30/13. Form 990, Part IV, Line 34: Alice Peck Day Health Systems, Corp. is the direct controlling parent company of Alice Peck Day Lifecare Center, Inc. (02-0479094) and Alice Peck Day Memorial Hospital (02-0222791). Alice Peck Day Health Systems, Corp. is also the direct controlling parent company of Alice Peck Day Realty Corp. (02-0485369) and Alice Peck Day Health Management Corp. (02-0485370). Both entities are inactive and hold no assets. Alice Peck Day Health Systems Corp 10 Alice Peck Day Drive Lebanon NH 03766 020479095 Promote Health NH 501(c)(3) Line 11b, II N/A 0 Alice Peck Day Lifecare Center Inc 10 Alice Peck Day Drive Lebanon NH 03766 020479094 Independent & Assisted Living NH 501(c)(3) Line 9 APD Health Systems 0 Alice Peck Day Realty Corp 10 Alice Peck Day Drive Lebanon NH 03766 020485369 Inactive NH 501(c)(2) APD Health Systems 0 Alice Peck Day Health Management Corp 10 Alice Peck Day Drive Lebanon NH 03766 020485370 Inactive NH APD Health Systems C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0