2014-08-12T10:57:22-05:00 2013-09-30 010494526 BAKER NEWMAN & NOYES BOX 507 PORTLAND ME 04112 990 2012-10-01 020222157 Monadnock Community Hospital MONA 6039247191 452 Old Street Road Peterborough NH 034581263 Richard Scheinblum 6039247191 2014-08-05 1 Nicholas E Porto P01310283 2078792100 2012 2015-11-30 17:44:51Z Cynthia K McGuire 452 Old Street Road Peterborough NH 034581263 79529693 0 X www.monadnockhospital.org X 1919 NH Critical Access Hospital serving the Monadnock Region of the State of New Hampshire. 16 13 798 132 0 0 816591 1420503 75233641 76958001 1384191 341552 700842 369213 78135265 79089269 0 0 0 0 39571490 39544302 63069 0 434588 39666510 37630255 79301069 77174557 -1165804 1914712 92323694 99482264 45242384 45471971 47081310 54010293 X Monadnock Community Hospital is committed to improving the health and well-being of our community. We create exceptional experiences that engage and inspire our community to achieve the highest level of health and well-being. 0 0 68342173 0 77558261 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. Following is a summary of the services MCH provides in an effort to fulfill its mission, together with key program statistics for fiscal year 2013.Inpatient Services - Includes: intensive care unit, adult stays, pediatric stays, maternity/births, and skilled nursing. During the fiscal year, the Hospital admitted 1,351 patients and recorded 4,617 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 15,472 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, 133,087 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, 2,717 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, 29,889 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 46,192 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, 88,823 member visits were recorded.Monadnock Community Hospital's Financial Grant Program provides assistance with hospital and/or physician bills for qualifying patients. In FY 2013, the Organization recorded $3,446,000 in charges foregone based on established rates. The estimated cost incurred to provide these services was $1,932,000. 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 $2,091,000 in 2013. 68342173 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 103 0 1 798 1 0 0 0 0 0 1 1 0 0 0 0 X 16 13 0 0 1 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 034581263 X Diane Cherwin part year 1.50 X 0 0 0 Robert J Condon Jr 2.00 X 0 0 0 Barbara R Duckett 2.00 X 0 0 0 Peter L Forssell MD part year 1.00 X 0 0 0 David A Hedstrom DDS 3.00 X 0 0 0 Gregory Kriebel MD part year 2.00 X 214771 0 23676 Marcia Ober part year 1.00 X 0 0 0 Amy Pfeil part year 1.00 X 0 0 0 James D Potter MD 4.00 X 121135 0 19296 Charles J Seigel MD part year 1.00 X 0 0 0 Jamie Trowbridge 1.00 X 0 0 0 Fletcher R Wilson MD 1.00 X 0 0 0 Robert L Edwards 3.00 X X 0 0 0 Cynthia Burgess 2.00 X X 0 0 0 Carole Monroe 4.00 X X 0 0 0 Steven H Reynolds 2.00 X X 0 0 0 Norman H Makechnie Esq 1.00 X X 0 0 0 Peter L Gosline 50.00 X X 297159 0 79559 Richard Scheinblum 50.00 X 162339 0 10761 Terrence McNamara DO 50.00 X 520924 0 21324 Ronald Michalak MD 50.00 X 497804 0 28170 Phillip Vuocolo MD 50.00 X 468129 0 26653 Shawn Harrington MD 50.00 X 452158 0 27473 Jennifer Peppers MD 50.00 X 335073 0 16291 3069492 0 253203 46 0 1 0 Monadnock Region Emergency Physicians PL 380 Lafayette Road Hampton NH 03842 Contract Emergency Physicians 1867725 Monadnock Anesthesia Associates C/O Surgical Suite Peterborough NH 03458 Contract Anesthesiologist 1143960 McKesson PO Box 98347 Chicago IL 60693 IS Vendor 913108 Catholic Medical Center 100 McGregor Street Manchester NH 03102 Contract Hospitalist 893727 Hutter Construction Corporation PO Box 257 810 Turnpike Road New Ipswich NH 03071 General Contractor 876300 20 44800 18070 1357633 9957 1420503 Net Patient Service Revenue 621400 73476212 73476212 Other Operating Revenue 621400 3481789 3481789 76958001 481438 481438 283311 396217 26980 -112906 -26980 -139886 -139886 16465 44800 17227 -762 -762 Cafeteria/Vending Machine 722210 344595 344595 Employee Pharmacy Sales 446110 255665 255665 Loss on Extinguishment of Debt 525990 -230285 -230285 369975 79089269 77558261 0 110505 885254 390840 494414 31273962 28370221 2639721 264020 481640 431923 49717 4786134 4189533 570277 26324 2117312 1887075 212069 18168 154626 325 154301 52500 52500 366 366 5148011 4520159 627852 61204 61204 2223918 1024108 1152827 46983 946124 820865 125259 3053456 2814295 239161 55555 28799 25935 821 38104 25369 10039 2696 1210343 1210343 4961382 4795866 165516 603406 467876 135530 Med & Pharm Supplies 7270915 7268097 2818 Provision for Bad Debts 4467531 4467531 Other Med Exp/Service C 3935458 3563022 322703 49733 NH Medicaid Enhancement 2553243 2553243 894113 661822 206814 25477 77174557 68342173 8397796 434588 2208239 5064 11778893 17594099 161575 793082 5527100 5773955 196371 240184 1286731 1242787 573132 867448 80394526 42318410 39419805 38076116 26642255 29923690 3135858 3407090 197606 1393735 1361143 92323694 99482264 5921028 6773500 27234908 26909344 690631 535451 11395817 11253676 45242384 45471971 X 38489800 43706147 1236210 2677614 7355300 7626532 47081310 54010293 92323694 99482264 X 1914712 3293756 1720515 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 13643 0 0 0 13643 0 Explanation of Lobbying Activities: 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: $10,300 AHA, Portion of dues available for lobbying: $3,343 8591510 1127458 819722 234544 10304146 8314205 486841 948400 1157936 8591510 10031251 884501 93759 2695306 8314205 10623404 1266761 200900 2059814 10031251 10282555 1164871 -100136 723886 10623404 0.25990 0.74010 0.00000 1 0 966127 966127 34451014 16051731 18399283 955434 409421 546013 43477404 25857258 17620146 544547 544547 38076116 Interest Rate Swap Agreements 3126651 Estimated Third-Party Settlements 8127025 11253676 X 83668952 3293756 1720515 5014271 78654681 434588 434588 79089269 76739969 0 76739969 434588 434588 77174557 Description of Intended Use of Endowment Funds: 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. Description of Uncertain Tax Positions Under FIN 48: 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 2010. Part XI, Line 2d - Other Adjustments: Increase in fair value of interest rate swap agreement 1,720,515. Part XI, Line 4b - Other Adjustments: Fundraising Expenses 434,588. Part XII, Line 4b - Other Adjustments: Fundraising Expenses 434,588. MCH Golf Classic 61265 44800 16465 640 69 5800 4800 5918 61265 44800 16465 640 69 5800 4800 5918 17227 -762 1 1 1 X 1 X 1 1 1 0 1 1 1905244 0 1905244 0.02620 5856824 5981464 -124640 0.00000 7762068 5981464 1780604 0.02620 740581 0 740581 0.01020 15960 0 15960 0.00020 1653792 0 1653792 0.02270 0 0 133550 0 133550 0.00180 2543883 2543883 0.03490 10305951 5981464 4324487 0.06110 1 2470191 232841 20382727 20254947 127780 X 1 1 1 1 Monadnock Community Hospital

452 Old Street Road Peterborough NH 03458

X X X X Monadnock Community Hospital 1 1 X X X X X X X 12 1 0 1 X 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 X X 1 X X X X X X 1 X 0 1 14 Bond Wellness Center

458 Old Street Road Wellness Center Peterborough NH 03458

Medically-based 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 Street 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 Internists

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 Monadnock Behavioral Health

458 Old Street Road Wellness Center Peterborough NH 03458

Physician practice Rindge Family Practice

145 US Route 202 Rindge NH 03461

Physician practice Monadnock Surgical Associates

454 Old Street Road MAB Building Peterborough NH 03458

Physician practice Antrim Medical Group

12 Elm Street Antrim NH 03440

Physician practice New Ipswich Family Medicine

821 Turnpike Road New Ipswich NH 03071

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 2013 are unreimbursed costs of $591,122 attributed to an outpatient behavioral health practice and $947,167 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 $ 4467531. Part II: See previous footnotes. Part III, Line 4: 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) ($4,467,531). 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. We estimated the amount of charity care in bad debt expense 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.Footnote 1 to the audited financial statements of the Hospital contains the following to address bad debt: Accounts Receivable - Accounts receivable are stated at the amount management expects to collect from outstanding balances. Management provides for probable uncollectible amounts through a charge to operations and a credit to the allowance for doubtful accounts based on its assessment of individual accounts and historical adjustments. Balances that are still outstanding after management has used reasonable collection efforts are written off through a charge to the allowance for doubtful accounts and a credit to accounts receivable. 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. 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. 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 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 Reports Filed With States Part VI, Line 7 NH X X X X 0 1 0 0 0 0 0 1 0 Gregory Kriebel MD part year 211991 0 0 0 2780 0 1989 0 21687 0 238447 0 0 0 Peter L Gosline 263833 0 11213 0 22113 0 58560 0 20999 0 376718 0 0 0 Richard Scheinblum 160949 0 0 0 1390 0 1568 0 9193 0 173100 0 0 0 Terrence McNamara DO 393083 0 125463 0 2378 0 0 0 21324 0 542248 0 0 0 Ronald Michalak MD 497384 0 0 0 420 0 0 0 28170 0 525974 0 0 0 Phillip Vuocolo MD 446323 0 20000 0 1806 0 0 0 26653 0 494782 0 0 0 Shawn Harrington MD 380790 0 70948 0 420 0 0 0 27473 0 479631 0 0 0 Jennifer Peppers MD 285949 0 0 0 49124 0 0 0 16291 0 351364 0 0 0 Part I, Line 4b 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 present value of the policies is reported on MCH's balance sheet in Part X, Line 15 as an Other Asset. The reported present value of this asset as of 9/30/13 was $681,182. Premiums paid during the fiscal year ended 9/30/13 totaled $74,250, which included catch-up payments for the prior year. Included in Mr. Gosline's 2012 deferred compensation in Part VII and Schedule J, Part II, column (C) is $56,063, which represents the net increase as of FYE 9/30/13 in the cash surrender value (CSV) of his split-dollar life insurance policy over amounts previously reported on Form 990. Mr. Gosline was hired in 1999 and the policy was purchased in 2001. This policy is intended to provide an additional retirement benefit for Mr. Gosline's multiple years of service. 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. 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 0.00000 0.00000 0.00000 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: Compliance and Monitoring: 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 20239 Mrs. Patti Potter is the spouse of Dr. James Potter, who is a trustee on MCH's Board 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 Form 990, Part VI, Section A, line 4 Monadnock Community Hospital's Board of Trustees made the following amendments to the bylaws during the fiscal year, which were formally adopted as of October 25, 2012: 1. Added a required minimum quorum of the majority of members for the Compensation, Executive, and Governance committees. 2. Made an allowance for the Executive Committee to appoint a special Compensation Committee to be responsible for the annual performance review of the Organization's President/CEO, including submitting a salary recommendation and submission of the Committee's findings in writing to the Board of Trustees. The Executive Commmittee may choose to continue performing this function itself. Form 990, Part VI, Section B, line 11 A draft of the Form 990 is initially reviewed in detail by key finance employees. Thereafter, the final draft is presented to the full board prior to filing with the IRS. Each member of the board is provided with a draft of the Form 990 in advance of the board meeting. 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. Reportable Compensation for Services as Physician Form 990, Part VII, Section A, Column D The 2012 compensation reported for Dr. Kriebel 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. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Change in fair value of interest rate swap agreements 1,720,515. Audit Review Process Form 990, Part XI, Line 2C 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 9/30/12 and 9/30/13. Form 990, Part I, Principal Officer: In April of 2013, Peter Gosline, President and CEO, announced plans to retire from his position with the Hospital. In February of 2014, Cynthia McGuire was hired to become the next President and CEO of Monadnock Hospital. During the fiscal year covered by this 990 filing, Mr. Gosline was still acting President and CEO. Page 1 has been updated to reflect the new President and CEO, Ms. McGuire, however, Page 7, Part VII will still list Mr. Gosline as President and CEO. Monadnock Health Services - INACTIVE 452 Old Street Road Peterborough NH 03458 020420789 Inactive NH 501(C)(3) 11 Type I N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0