2014-08-08T08:11:28-05:00 2013-09-30 061533253 SASLOW LUFKIN & BUGGY LLP 175 POWDER FOREST DRIVE SIMSBURY CT 06089 990 2012-10-01 060646678 THE CHARLOTTE HUNGERFORD HOSPITAL CHAR 8604966728 540 LITCHFIELD STREET PO BOX 988 TORRINGTON CT 067900988 SUSAN M SCHAPP 8604966728 2014-08-05 1 RICHARD BUGGY P00512316 8606789200 2012 2015-11-30 17:44:51Z SUSAN M SCHAPP 540 LITCHFIELD STREET PO BOX 988 TORRINGTON CT 067900988 132715050 0 X WWW.CHARLOTTEHUNGERFORD.ORG X 1917 CT TO PROVIDE QUALITY, COMPASSIONATE AND COST EFFECTIVE HEALTHCARE TO THE COMMUNITY OF NORTHWESTERN CONNECTICUT. 16 14 1194 185 1212838 -191695 2991772 3015379 118802100 122017519 2267570 2463648 620288 381719 124681730 127878265 12000 12000 0 0 72583360 75560164 0 0 341307 49361413 49401846 121956773 124974010 2724957 2904255 126686772 132607623 64748035 47910218 61938737 84697405 X THE CHARLOTTE HUNGERFORD HOSPITAL PROVIDES QUALITY MEDICAL HEALTHCARE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR ABILITY TO PAY. OUR MISSION IS TO SERVE THE COMMUNITY WITH RESPECT TO PROVIDING HEALTHCARE SERVICES AND HEALTHCARE EDUCATION. IN KEEPING WITH THE HOSPITAL'S COMMITMENT TO SERVE ALL MEMBERS OF THE COMMUNITY, FREE CARE AND/OR SUBSIDIZED CARE, CARE PROVIDED TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT BELOW COST, HEALTH ACTIVITIES AND PROGRAMS TO SUPPORT THE COMMUNITY WILL BE CONSIDERED WHERE THE NEED AND/OR AN INDIVIDUAL'S INABILITY TO PAY COEXIST. THESE ACTIVITIES INCLUDE WELLNESS PROGRAMS, COMMUNITY EDUCATION PROGRAMS, SPECIAL PROGAMS FOR THE ELDERLY, HANDICAPPED, THE MEDICALLY UNDERSERVED AND A VARIETY OF BROAD COMMUNITY SUPPORT ACTIVITIES. 0 0 110539750 12000 120909002 DURING FY 2013 THE HOSPITAL CONTRIBUTED OVER 18,000 HOURS TOWARD THE COMMON PURPOSE OF SERVICING THE HEALTHCARE NEEDS OF THE COMMUNITY. THE VALUE OF THIS CONTRIBUTION IS APPROXIMATELY $145,000, WHICH IS GIVEN BACK TO THE COMMUNITY THROUGH LOWER COSTS IN BOTH PATIENT SERVICES AND OTHER "WELLNESS" PROGRAMS. IN ADDITION THE HOSPITAL GRANTED CHARITY CARE IN THE AMOUNT OF $1,726,098 DURING FISCAL YEAR 2013. THE CHARLOTTE HUNGERFORD HOSPITAL RENDERED THE FOLLOWING SERVICES DURING FY 2013:INPATIENT SERVICES:DISCHARGES 6,533PATIENT DAYS 26,574 SPECIAL SERVICES: OPERATING ROOM CASES 4,145 AMBULATORY SURGERY CASES 3,283 ENDOSCOPY CASES 794 AMBULATORY MEDICAL CASES 2,597WOUND CARE CASES 4,936POST ANESTHESIA CARE UNIT CASES 2,566 DELIVERY ROOM DELIVERIES 452RESPIRATORY THERAPY TREATMENTS 40,178 PULMONARY REHAB TESTS 6,123PULMONARY FUNCTION LAB TESTS 1,631 CARDIO DIAGNOSTIC EXAMS 13,687EEG EXAMS 1,092PHYSICAL THERAPY TREATMENTS 32,047 CARDIAC REHAB TREATMENTS 3,146 SPEECH THERAPY TREATMENTS 663 OCCUPATIONAL THERAPY TREATMENTS 3,194 SLEEP STUDY TESTS 565 DIAGNOSTIC RADIOLOGY EXAMS 26,813 MAMMOGRAPHY EXAMS 9,246 NUCLEAR MEDICINE EXAMS 952ULTRASOUND EXAMS 8,696C.A.T. SCAN EXAMS 12,733 P.E.T. SCAN EXAMS 293 M.R.I. EXAMS 1,110SPECIAL PROCEDURES (RADIOLOGY) EXAMS 1,152 RADIATION THERAPY TREATMENTS 8,501LABORATORY TESTS 603,173 PSYCHIATRIC CLINIC VISITS 35,645 PHP-ADULT/ADOLESCENT VISITS 4,685 RENAL DIALYSIS VISITS 369 EMERGENCY DEPARTMENT VISITS 34,810 OUTPATIENT DIABETES PROGRAM VISITS 1,567 WALK IN CENTER VISITS 10,956 PROFESSIONAL SERVICE CONSULTS 132,553HUNGERFORD EMERGENCY MEDICAL CENTER: CARDIAC REHAB TREATMENTS 1,742 DIAGNOSTIC RADIOLOGY EXAMS 3,761 LABORATORY TESTS 18,381 EMERGENCY DEPARTMENT VISITS 6,162 PULMONARY REHAB TESTS 2,760 110539750 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 1 1 1 0 0 0 0 0 0 1 0 1 1 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 1 207 0 1 1194 1 1 1 0 0 0 0 0 0 0 0 0 X 16 14 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 CT X X SUSAN M SCHAPP 8604966728 540 LITCHFIELD STREET TORRINGTON CT 06790 EDWARD ARUM 2.50 X 0 0 0 RICHARD DUTTON MD 1.00 X 0 0 0 GLADYS CERRUTO 1.00 X 0 0 0 DAVID J FRAUENHOFER 1.00 X X 0 0 0 JAMIE GREG 1.00 X 0 0 0 KENDRICK HOM MD 60.00 X 277169 0 25339 JOHN JANCO 2.50 X X 0 0 0 JOHN LAVIERI 2.50 X X 0 0 0 DIANE LIBBY CPA 1.00 X 0 0 0 JAMES O'LEARY 1.00 X 0 0 0 EDWIN G BOOTH JR 1.00 X 0 0 0 FRANK BUONOCORE JR 1.00 X 0 0 0 STEPHANIE FOWLER MD 1.00 X 0 0 0 MICHAEL PATTERSON 1.00 X 0 0 0 CHARLES W RORABACK 1.00 X 0 0 0 ANDREW SZCZEPENSKI MD 1.00 X 48564 0 4440 DANIEL J MCINTYRE 60.00 X 382486 0 92729 SUSAN M SCHAPP 60.00 X 225452 0 103138 JOHN J CAPOBIANCO 60.00 X 212043 0 113230 MARK PRETE MD 60.00 X 326624 0 55108 RAYMOND J ELLIOTT 60.00 X 185519 0 61049 BRIAN MATTIELLO 60.00 X 161067 0 21462 ELZBIETA LACH-PASKO MD 60.00 X 393459 0 132225 MUSTAFA UGURLU MD 60.00 X 386073 0 47406 TIMOTHY GOSTKOWSKI MD 60.00 X 480418 0 68439 WILLIAM MCGEEHIN MD 60.00 X 429541 0 68468 ROBERT KAHAN MD 60.00 X 381129 0 34843 3889544 0 827876 50 0 1 0 ADULT & PEDIATRIC UROLOGY OF NW CONNECTI 538 LITCHFIELD STREET SUITE 102 TORRINGTON CT 06790 MEDICAL 1455650 BUILDING ONE FACILITY SERVICES 57 OZICK DRIVE SUITE A DURHAM CT 06422 CLEANING SERVICES 1370633 MAYO COLLABORATIVE SERVICES PO BOX 9146 MINEAPOLIS MN 554809146 LABORATORY TESTS 1306027 NWCT EMERGENCY SERVICES 80 S MAIN STREET WEST HARTFORD CT 06107 MEDICAL 870492 NEW MILFORD LAUNDRY 40 COMMONS COURT WATERBURY CT 06704 LAUNDRY/LINEN SERVICES 460644 35 26533 2626383 362463 3015379 NET PATIENT REVENUE 900099 105168170 105168170 LABORATORY SERVICES 621500 11509377 10188647 1320730 OTHER HOSPITAL SERVICES 900099 5339972 5339972 122017519 1616119 1616119 594694 382481 212213 212213 212213 5159460 1392 4313323 0 846137 1392 847529 847529 145011 26533 42420 102591 102591 180295 98561 81734 81734 GAIN FROM EQUITY METHOD 900001 93073 93073 MEDCONN 561499 -107892 -107892 -14819 127878265 120909002 1212838 2741046 12000 12000 1857323 1392992 464331 57493040 51408333 5916225 168482 5628302 5007245 605080 15977 6649991 5916195 714918 18878 3931508 3497684 422663 11161 3177905 2827238 341646 9021 253533 225557 27256 720 109008 96979 11719 310 10931016 9724829 1175156 31031 539279 479772 57976 1531 411337 365948 44221 1168 1411262 1255536 151720 4006 2090117 1859482 224702 5933 18135 16134 1950 51 250825 223148 26965 712 6050075 5382477 650423 17175 2125573 1891026 228513 6034 SUPPLIES 17302210 15392991 1860102 49117 PHYSICIAN FEES 4669548 3502161 1167387 HOSPITAL AUXILIARY EXPE 62023 62023 124974010 110539750 14092953 341307 60839 64643 9947626 9014949 88492 36857 13441100 13504471 2047381 2119166 979386 1512549 149504375 112634596 37852787 36869779 59313706 66334495 2955455 3150714 126686772 132607623 9069553 11483194 147665 298993 1200000 3421466 3219468 50909351 32908563 64748035 47910218 X 41061265 61261338 3256943 3334379 17620529 20101688 61938737 84697405 126686772 132607623 X 2904255 5754530 14099883 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 13492 13492 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE HOSPITAL IS A MEMBER OF THE CONNECTICUT HOSPITAL ASSOCIATION. $13,492 REPRESENTS THE PORTION OF DUES PAID TO THE ASSOCIATION WHICH WERE USED FOR LOBBYING PURPOSES. 53165045 243732 7106906 354906 60160777 46929816 239485 6103897 108153 53165045 49273746 186977 -2264127 266780 46929816 45533758 690138 3824302 774452 49273746 47240328 1043719 -1532480 1217809 45533758 0.61080 0.33410 0.05510 0 0 155467 155467 79680340 54026486 25653854 62919428 54236704 8682724 6749140 4371406 2377734 36869779 INVESTMENTS HELD IN TRUST FOR ESTIMATED SELF-INSURANCE LIABILITIES 4175772 F BENEFICIAL INTEREST IN ASSETS HELD IN TRUST BY OTHERS 16349307 F LONG-TERM INVESTMENTS 38742293 F DONOR RESTRICTED ASSETS 7067123 F 66334495 ESTIMATED AMOUNTS DUE TO THIRD PARTY REIMBURSEMENT AGENCIES 2468522 MISCELLANEOUS CURRENT LIABILITIES 181897 ESTIMATED SELF-INSURANCE LIABILITIES 3527218 ACCRUED PENSION LIABILITY 23133018 PENSION CONTRIBUTION - CURRENT YEAR 3597908 32908563 X 127592905 0 127592905 285360 285360 127878265 124899987 0 124899987 74023 74023 124974010 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ENDOWMENT FUNDS WILL BE USED PRIMARILY FOR CAPITAL PURCHASES, INDIGENT CARE AND OTHER USES AS APPROVED BY THE BOARD IN ACCORDANCE WITH DONOR RESTRICTIONS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL ACCOUNTS FOR UNCERTAIN TAX POSITIONS WITH PROVISIONS OF FASB ASC 740, "INCOME TAXES" WHICH PROVIDES A FRAMEWORK FOR HOW COMPANIES SHOULD RECOGNIZE, MEASURE, PRESENT AND DISCLOSE UNCERTAIN TAX POSITIONS IN THEIR FINANCIAL STATEMENTS. THE HOSPITAL MAY RECOGNIZE THE TAX BENEFIT FROM AN UNCERTAIN TAX POSITION ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITION WILL BE SUSTAINED ON EXAMINATION BY THE TAXING AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. THE HOSPITAL DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS AS OF SEPTEMBER 30, 2013 AND 2012. AS OF SEPTEMBER 30, 2013 AND 2012, THE HOSPITAL DID NOT RECORD ANY PENALTIES OR INTEREST ASSOCIATED WITH UNCERTAIN TAX POSITIONS. THE HOSPITAL'S PRIOR THREE TAX YEARS ARE OPEN AND SUBJECT TO EXAMINATION. PART XI, LINE 4B - OTHER ADJUSTMENTS: TEMPORARY RESTRICTED ACTIVITY 216,769. AUXILIARY REVENUE 68,591. PART XII, LINE 4B - OTHER ADJUSTMENTS: AUXILIARY EXPENSES 74,023. GOLF TOURNAMENT 107845 107845 3532 25622 DINNER DANCE 37166 37166 13266 8 26533 26533 171544 26533 145011 3532 38888 42420 102591 1 1 1 X 1 X 1 1 0 1 1 3409 1613688 0 1613688 0.01290 42458 27835850 22094334 5741516 0.04590 637 228156 152254 75902 0.00060 46504 29677694 22246588 7431106 0.05940 8 4323 37621 0 37621 0.00030 1 55 897 0 897 0.00000 20242175 17246063 2996112 0.02400 1 1 176 0 176 0.00000 10 4379 20280869 17246063 3034806 0.02430 10 50883 49958563 39492651 10465912 0.08370 1 3378061 0 43418966 46946867 -3527901 X 1 1 1 ADVANCED MEDICAL IMAGING OF NORTHWEST CT LLC IMAGING CENTER 0.50000 0.00000 0.50000 2 MEDCONN COLLECTION AGENCY LLC PATIENT COLLECTION AGENCY 0.25000 0.00000 0.00000 3 UROLOGY CENTER OF NW CT UROLOGY CENTER 0.62500 0.00000 0.37500 4 LITCHFIELD COUNTY HEALTHCARE SERVICE CORP PHYSICIANS PRACTICE 1.00000 0.00000 0.00000 2 1 CHARLOTTE HUNGERFORD HOSPITAL

540 LITCHFIELD STRRET TORRINGTON CT 06790

X X X X 2 HUNGERFORD EMERGENCY MEDICAL CENTER

115 SPENCER STREET WINSTED CT 06098

X CHARLOTTE HUNGERFORD HOSPITAL 1 1 X X X X X X X X 12 1 0 1 X X X X X X X X X 0 0 1 1 200.000000000000 1 250.000000000000 1 X X 1 1 X X X X X 1 X X 1 X X X X X 1 X 0 0 HUNGERFORD EMERGENCY MEDICAL CENTER 2 1 X X X X X X X X 12 1 0 1 X X X X X X X X X X 0 0 1 1 200.000000000000 1 250.000000000000 1 X X 1 1 X X X X X 1 X X 1 X X X X X 1 X 0 0 13 NORTHWEST CONNECTICUT MEDICAL WALK IN

1598 EAST MAIN STREET TORRINGTON CT 06790

WALK IN MEDICAL CLINIC THE HUNGERFORD CENTER

780 LITCHFIELD STREET TORRINGTON CT 06790

CARDIAC AND PULMONARY REHAB SERVICES THE CENTER FOR CANCER CARE

200 KENNEDY DRIVE TORRINGTON CT 06790

CANCER TREATMENT CENTER HUNGERFORD DIAGNOSTIC CENTER

220 KENNEDY DRIVE TORRINGTON CT 06790

RADIOLOGY SERVICES THE CENTER FOR YOUTH AND FAMILIES

1061 EAST MAIN STREET TORRINGTON CT 06790

PSYCH SERVICES FOR CHILDREN AND FAMILIES BRIDGES EXTENDED DAY PROGRAM

28 SAINT JOHN PLACE TORRINGTON CT 06790

CHILD GUIDANCE CLINIC WINSTED BEHAVIORAL HEALTH CENTER

294 MAIN STREET WINSTED CT 06098

PSYCH SERVICES SURGICAL ASSOCIATES OF CHH

538 LITCHFIELD STREET TORRINGTON CT 06790

SURGICAL PHYSICIANS PRACTICE NEUROLOGY PBC

780 LITCHFIELD STREET TORRINGTON CT 06790

NEUROLOGY PHYSICIANS PRACTICE CHH PRIMARY CARE

780 LITCHFIELD STREET TORRINGTON CT 06790

PRIMARY CARE PHYSICIANS PRACTICE CHH CARDIOVASCULAR MEDICINE SERVICE

1215 NEW LITCHFIELD STREET TORRINGTON CT 06790

CARDIOVASCULAR PHYSICIANS PRACTICE CHH WOUND CARE AND HYPERBARIC MEDICINE

7 FELICITY LANE TORRINGTON CT 06790

WOUND CARE PHYSICIANS PRACTICE CHH UROLOGY MEDICINE

538 LITCHFIELD STREET TORRINGTON CT 06790

ADULT AND PEDIATRIC UROLOGY PHYSICIANS PRACTICE PART I, LINE 3C: CARE WILL BE PROVIDED FREE FOR THOSE WHO QUALIFY AS UNINSURED AND VERIFICATION HAS DETERMINED THAT THEIR ANNUAL INCOME IS LESS THAN 200% OF THE FEDERAL INCOME POVERTY LEVEL. CARE WILL BE PROVIDED AT HOSPITAL COST, AS ESTABLISHED BY THE OFFICE OF HEALTH CARE ACCESS (OCHA), FOR THOSE UNINSURED PATIENTS WHO REQUEST ASSISTANCE AND VERIFICATION HAS DETERMINED THAT THEIR ANNUAL INCOME IS BETWEEN 200% AND 250% OF THE FPL. CARE WILL BE DISCOUNTED BY 30% FOR THOSE UNISURED PATIENTS WHO REQUEST ASSISTANCE AND VERIFICATION HAS DETERMINED THAT THEIR ANNUAL INCOME IS BETWEEN 250% AND 400% OF THE FPL. THE HOSPITAL WILL ALSO CONSIDER THE TOTAL MEDICAL EXPENSES FACED BY THE FAMILY AND THE FAMILY'S ABILITY TO PAY FOR THOSE EXPENSES, AND WILL CONSIDER OFFERING GREATER ASSISTANCE WHEN POSSIBLE TO THOSE FAMILIES FACING CATASTROPHIC MEDICAL EXPENSES. PART I, LINE 7: A COST TO CHARGE RATIO BASED ON CHARITY CARE CHARGES AND EXPENSES. PART III, LINE 4: IN JULY 2011, THE FASB ISSUED ASU 2011-07, "HEALTH CARE ENTITIES (TOPIC 954): PRESENTATION AND DISCLOSURE OF PATIENT SERVICE REVENUE, PROVISION OF BAD DEBTS, AND THE ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR CERTAIN HEALTH CARE ENTITIES." THIS GUIDANCE ESTABLISHES ACCOUNTING AND DISCLOSURE REQUIREMENTS FOR HEALTH CARE ENTITIES THAT RECOGNIZE SIGNIFICANT AMOUNTS OF PATIENT SERVICE REVENUES AT THE TIME SERVICES ARE RENDERED EVEN THOUGH THE ENTITY DOES NOT ASSESS A PATIENT'S ABILITY TO PAY. SPECIFICALLY, THE GUIDANCE REQUIRES THAT HEALTH CARE ENTITIES PRESENT BAD DEBT EXPENSE ASSOCIATED WITH NET PATIENT SERVICE REVENUES AS AN OFFSET TO NET PATIENT SERVICE REVENUES WITHIN THE STATEMENTS OF OPERATIONS AND CHANGES IN NET ASSETS. ADDITIONALLY, THE GUIDANCE REQUIRES ENHANCED DISCLOSURE OF THE POLICIES FOR RECOGNIZING REVENUE AND ASSESSING BAD DEBTS, AS WELL AS QUALITATIVE AND QUANTITATIVE INFORMATION ABOUT CHANGES IN THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE GUIDANCE REQUIRES RETROSPECTIVE APPLICATION TO ALL PRIOR PERIODS PRESENTED. THIS GUIDANCE BECAME EFFECTIVE FOR THE HOSPITAL BEGINNING ON OCTOBER 1, 2012. THE ADOPTION OF THIS GUIDANCE HAD NO IMPACT ON THE HOSPITAL'S OPERATING INCOME IN THE STATEMENTS OF OPERATIONS AND CHANGES IN NET ASSETS, BUT RESULTED IN ADDITIONAL DISCLOSURES IN NOTE 3. ALL PERIODS INCLUDED HAVE BEEN PRESENTED IN ACCORDANCE WITH THE PROVISIONS OF ASU 2011-07.IT IS AN INHERENT PART OF THE HOSPITAL'S MISSION TO PROVIDE NECESSARY MEDICAL CARE FREE OF CHARGE, OR AT A DISCOUNT, TO INDIVIDUALS WITHOUT INSURANCE OR OTHER MEANS OF PAYING FOR SUCH CARE. AS THE AMOUNTS DETERMINED TO QUALIFY FOR CHARITY CARE ARE NOT PURSUED FOR COLLECTION, THEY ARE NOT REPORTED AS NET PATIENT SERVICE REVENUE. PATIENTS WHO WOULD OTHERWISE QUALIFY FOR CHARITY CARE BUT WHO DO NOT PROVIDE ADEQUATE INFORMATION WOULD BE CHARACTERIZED AS BAD DEBT AND INCLUDED IN THE PROVISION FOR BAD DEBTS.PART III, LINE 2: COSTING METHODOLOGY USED - THE HOSPITAL USES A MODEL CONSISTING OF OUR ACCOUNTS RECEIVABLE BALANCE DIVIDED INTO EIGHT AGING CATEGORIES AS FOLLOWS: 0-30 DAYS, 31-60 DAYS, 61-90 DAYS, 91-120 DAYS, 121-210 DAYS, 211-365 DAYS, AND GREATER THAN 365 DAYS. A PERCENTAGE IS THEN ASSIGNED TO EACH AGING BUCKET BASED ON AGE, WITH A HIGHER PERCENTAGE ASSIGNED AS THE DAYS OUTSTANDING INCREASES. THE RESULTING CALCULATION IS USED TO COMPARE WITH THE RESERVE AND A MONTHLY ADJUSTMENT IS MADE TO DETERMINE THE EXPENSE. ANNUALLY, THIS CALCULATION IS COMPARED TO AN AUDIT OF THE BAD DEBT RESERVES TO DETERMINE IF ANY ADJUSTMENTS ARE REQUIRED. PART III, LINE 8: THE MEDICARE SHORTFALL IS NOT TREATED AS COMMUNITY BENEFIT. THE MEDICARE ALLLOWABLE COSTS OF CARE ARE DERIVED DIRECTLY FROM THE MEDICARE COST REPORT. PART III, LINE 9B: THE HOSPITAL ATTEMPTS TO HAVE INDIVIDUALS FILL OUT ALL PAPER WORK REQUIRED FOR CHARITY CARE. IF THE PERSON IS NOT CAPABLE OF DOING THIS OR IS KNOWN TO BE UNABLE TO DO THIS (SUCH AS A KNOWN HOMELESS PERSON), THEN THE FINANCIAL ASSISTANCE COMMITTEE WILL ADJUST THE ACCOUNT TO CHARITY CARE AND IT WILL NOT BE REPORTED AS BAD DEBT. IF THE ACCOUNT HAS BEEN REPORTED AS BAD DEBT AND INFORMATION COMES FORTH INDICATING AN INABILITY TO PAY, THEN THE ACCOUNT WOULD BE REMOVED FROM BAD DEBT AND MOVED TO CHARITY CARE. CHARLOTTE HUNGERFORD HOSPITAL PART V, SECTION B, LINE 3: THE STUDY WAS CONDUCTED BY THE CENTER FOR HEALTHY SCHOOLS AND COMMUNITIES AT EDUCATION CONNECTION IN LITCHFIELD, CT. THE STEERING COMMITTEE INCLUDED THE FOLLOWING INDIVIDUALS AND ORGANIZATIONS: JIM ROKOS, DIRECTOR OF HEALTH, TORRINGTON AREA HEALTH DISTRICT; LESLIE POLITO, ASSISTANT DIRECTOR OF HEALTH, TORRINGTON AREA HEALTH DISTRICT; SHARON MCCOY, PROJECT DIRECTOR, TORRINGTON AREA HEALTH DISTRICT; STEPHANIE BARKSDALE, EXECUTIVE DIRECTOR, UNITED WAY OF NORTHWEST CONNECTICUT; GREG BRISCO, CHIEF EXECUTIVE OFFICER, NORTHWEST CONNECTICUT YMCA; BRIAN MATTIELLO, V.P. FOR ORGANIZATIONAL DEVELOPMENT, CHARLOTTE HUNGERFORD HOSPITAL; DANIEL BAROODY, DIRECTOR OF HEALTH, TOWN OF SHARON; MIKE CRESPAN, DIRECTOR OF HEALTH, NEW MILFORD HEALTH DEPARTMENT; DONNA CULBERT, DIRECTOR OF HEALTH, NEWTOWN HEALTH DISTRICT; JENNIFER KERTANIS, DIRECTOR OF HEALTH, FARMINGTON VALLEY HEALTH DISTRICT; NEAL LUSTIG, DIRECTOR OF HEALTH, POMPERAUG HEALTH DISTRICT; MARY BEVAN, DIRECTOR, CENTER FOR HEALTHY SCHOOLS AND COMMUNITIES EDUCATION CONNECTION; JIM HUTCHISON, COMMUNITY HEALTH COORDINATOR, SHARON HOSPITAL; ANDREA RYNN, DIRECTOR OF PUBLIC AND GOVERNMENT RELATIONS, WESTERN CT HEALTH NETWORK; MARY WINAR, PROJECTS COORDINATOR, CONNECTICUT OFFICE OF RURAL HEALTH. HUNGERFORD EMERGENCY MEDICAL CENTER PART V, SECTION B, LINE 3: THE STUDY WAS CONDUCTED BY THE CENTER FOR HEALTHY SCHOOLS AND COMMUNITIES AT EDUCATION CONNECTION IN LITCHFIELD, CT. THE STEERING COMMITTEE INCLUDED THE FOLLOWING INDIVIDUALS AND ORGANIZATIONS: JIM ROKOS, DIRECTOR OF HEALTH, TORRINGTON AREA HEALTH DISTRICT; LESLIE POLITO, ASSISTANT DIRECTOR OF HEALTH, TORRINGTON AREA HEALTH DISTRICT; SHARON MCCOY, PROJECT DIRECTOR, TORRINGTON AREA HEALTH DISTRICT; STEPHANIE BARKSDALE, EXECUTIVE DIRECTOR, UNITED WAY OF NORTHWEST CONNECTICUT; GREG BRISCO, CHIEF EXECUTIVE OFFICER, NORTHWEST CONNECTICUT YMCA; BRIAN MATTIELLO, V.P. FOR ORGANIZATIONAL DEVELOPMENT, CHARLOTTE HUNGERFORD HOSPITAL; DANIEL BAROODY, DIRECTOR OF HEALTH, TOWN OF SHARON; MIKE CRESPAN, DIRECTOR OF HEALTH, NEW MILFORD HEALTH DEPARTMENT; DONNA CULBERT, DIRECTOR OF HEALTH, NEWTOWN HEALTH DISTRICT; JENNIFER KERTANIS, DIRECTOR OF HEALTH, FARMINGTON VALLEY HEALTH DISTRICT; NEAL LUSTIG, DIRECTOR OF HEALTH, POMPERAUG HEALTH DISTRICT; MARY BEVAN, DIRECTOR, CENTER FOR HEALTHY SCHOOLS AND COMMUNITIES EDUCATION CONNECTION; JIM HUTCHISON, COMMUNITY HEALTH COORDINATOR, SHARON HOSPITAL; ANDREA RYNN, DIRECTOR OF PUBLIC AND GOVERNMENT RELATIONS, WESTERN CT HEALTH NETWORK; MARY WINAR, PROJECTS COORDINATOR, CONNECTICUT OFFICE OF RURAL HEALTH. CHARLOTTE HUNGERFORD HOSPITAL PART V, SECTION B, LINE 7: NOT ALL NEEDS HAVE BEEN ADDRESSED SINCE THE ASSESSMENT WAS IN YEAR TWO OF A FIVE YEAR PLAN WITH A CONTINUED EFFORT TO REFINE ASSESSMENTS. HUNGERFORD EMERGENCY MEDICAL CENTER PART V, SECTION B, LINE 7: NOT ALL NEEDS HAVE BEEN ADDRESSED SINCE THE ASSESSMENT WAS CONDUCTED IN YEAR TWO OF A FIVE YEAR PLAN FOR CONTINUED EFFORT TO REFINE ASSESSMENTS. CHARLOTTE HUNGERFORD HOSPITAL PART V, SECTION B, LINE 20D: CONNECTICUT STATE LAW (LOONEY BILL) REQUIRES THE HOSPITAL TO ADJUST THE PATIENT'S BALANCE EQUAL TO THE COST OF PROVIDING THE CARE. HUNGERFORD EMERGENCY MEDICAL CENTER PART V, SECTION B, LINE 20D: CONNECTICUT STATE LAW (LOONEY BILL) REQUIRES THE HOSPITAL TO ADJUST THE PATIENT'S BALANCE EQUAL TO THE COST OF PROVIDING THE CARE. PART VI, LINE 2: THE HOSPITAL OFFERS FREE HEALTH SCREENINGS, FREE HEALTH EDUCATION AND LECTURES AT VARIOUS COMMUNITY EVENTS INCLUDING FAIRS, EXPOS, PRIVATE COMPANIES, PUBLIC MUNICIPALITIES, AND PUBLIC GATHERINGS. THESE EVENTS PROVIDE A FORUM FOR RECEIVING INFORMATION AND INPUT FROM THE COMMUNITY. PART VI, LINE 3: THE HOSPITAL COUNSELS ALL SELF PAY PATIENTS BY PROVIDING A MEETING WITH A FINANCIAL COUNSELOR OR SOCIAL WORKER. ALL STATEMENTS DISTRIBUTED TO PATIENTS INCLUDE FINANCIAL COUNSELING INFORMATION. SIGNS ARE POSTED THROUGHOUT THE HOSPITAL, INCLUDING THE EMERGENCY ROOM, WHICH STATE CHARITY CARE POLICIES AND FINANCIAL ASSISTANCE INFORMATION. PART VI, LINE 4: THE CHARLOTTE HUNGERFORD HOSPITAL IS LOCATED IN TORRINGTON, CONNECTICUT, AND SERVES AS A REGIONAL HEALTH CARE RESOURCE FOR 100,000 RESIDENTS OF LITCHFIELD COUNTY AND NORTHWEST CONNECTICUT. RECENT ASSESSMENTS FROM THE AREA THAT THE HOSPITAL SERVES HAS FOUND THE FOLLOWING: - THE COUNTY HAS BECOME MORE RACIALLY AND ETHNICALLY DIVERSE. - THE COUNTY HAS THE HIGHEST PROPORTION OF RESIDENTS AGES 50+ IN THE STATE. - AREA RATES OF OBESITY AND CURRENT SMOKING EXCEED THE STATE AVERAGE. - STUDENTS IN NEARLY HALF OF THE AREA'S SCHOOL DISTRICTS SCORED BELOW THE STATE AVERAGE IN STANDARDIZED PHYSICAL FITNESS TESTS. - NEARLY ONE IN FOUR COUNTY RESIDENTS HAS HYPERTENSION. - NEARLY 40% HAVE BEEN TOLD BY THEIR HEALTH PROFESSIONAL THAT THEY HAVE HIGH CHOLESTEROL. - THE COUNTY HAS A RATIO OF ONE PRIMARY CARE PHYSICIAN TO EVERY 1,123 RESIDENTS. THIS WELL BELOW BOTH STATE AND NATIONAL BENCHMARKS. PART VI, LINE 5: ALL BOARD OF DIRECTORS MEMBERS RESIDE IN THE COMMUNITY SERVED BY THE CHARLOTTE HUNGERFORD HOSPITAL. THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS WHO APPLY FOR SUCH PRIVILEGES. THE HOSPITAL ESTABLISHES AN ANNUAL CAPITAL BUDGET TO ADD OR REPLACE PATIENT CARE EQUIPMENT AND FACILITIES. MEDICAL EDUCATION IS PROVIDED TO PHYSICIANS THROUGH CONFERENCES ON A MONTHLY BASIS. REPORTS FILED WITH STATES PART VI, LINE 7 CT 1 HEALTHCARE SCHOLARSHIPS 12 12000 THE CHARLOTTE HUNGERFORD HOSPITAL AUXILIARY AWARDS SCHOLARSHIPS IN THE AMOUNT OF $1,000 EACH TO STUDENTS PURSUING HEALTHCARE EDUCATION. THE STUDENTS MUST LIVE IN THE AREA SERVED BY THE HOSPITAL. THEY MUST ALSO PROVIDE EVIDENCE OF ACCEPTANCE INTO A COLLEGE PROGRAM OR THEIR CURRENT GRADES IN COLLEGE. APPLICANTS MUST SUBMIT LETTERS OF RECOMMENDATION FROM THEIR TEACHERS AND ALSO FROM NON-FAMILY PERSONS. X X X X 0 0 0 0 0 0 0 0 0 KENDRICK HOM MD 277169 0 0 0 0 0 0 0 25339 0 302508 0 0 0 DANIEL J MCINTYRE 382486 0 0 0 0 0 57762 0 34967 0 475215 0 0 0 SUSAN M SCHAPP 225452 0 0 0 0 0 82527 0 20611 0 328590 0 0 0 JOHN J CAPOBIANCO 212043 0 0 0 0 0 93845 0 19385 0 325273 0 0 0 MARK PRETE MD 326624 0 0 0 0 0 25247 0 29861 0 381732 0 0 0 RAYMOND J ELLIOTT 185519 0 0 0 0 0 44089 0 16960 0 246568 0 0 0 BRIAN MATTIELLO 161067 0 0 0 0 0 6737 0 14725 0 182529 0 0 0 ELZBIETA LACH-PASKO MD 393459 0 0 0 0 0 96254 0 35971 0 525684 0 0 0 MUSTAFA UGURLU MD 386073 0 0 0 0 0 12111 0 35295 0 433479 0 0 0 TIMOTHY GOSTKOWSKI MD 480418 0 0 0 0 0 24518 0 43921 0 548857 0 0 0 WILLIAM MCGEEHIN MD 429541 0 0 0 0 0 29199 0 39269 0 498009 0 0 0 ROBERT KAHAN MD 381129 0 0 0 0 0 0 0 34843 0 415972 0 0 0 MARK PRETE MD KEY EMPLOYEE 134607 PARTNER IN NWCT EMERGENCY MEDICINE P.C. WHICH PROVIDES EMERGENCY ROOM SERVICES TO THE HOSPITAL. 0 DIANE LIBBY CPA GOVERNOR 18000 PARTNER IN ADAMS SAMARTINO & CO, P.C. WHICH PROVIDES ACCOUNTING SERVICES TO CHARLOTTE HUNGERFORD HOSPITAL. 0 FORM 990, PART VI, SECTION B, LINE 11 A COPY OF FORM 990 IS DISTRIBUTED TO THE BOARD OF DIRECTORS BEFORE IT IS FILED WITH THE IRS. THIS ENABLES THE BOARD TO ASK QUESTIONS, AND TO APPROVE THE DISCLOSURES MADE IN THE RETURN. FORM 990, PART VI, SECTION B, LINE 12C THE HOSPITAL DISTRIBUTES A CONFLICT OF INTEREST QUESTIONNAIRE ANNUALLY TO ITS BOARD OF DIRECTORS, ALL MANAGEMENT PERSONNEL, AND PURCHASING AGENTS. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION FOR SENIOR STAFF IS DETERMINED USING THE FOLLOWING STEPS: - A MARKET SURVEY BASED ON CT HOSPITAL ASSOCIATION IS USED AS A STARTING POINT. - ADJUSTMENTS ARE THEN MADE BASED ON THE CANDIDATE'S CURRENT SALARY AND PRIOR EXPERIENCE. - THE COMPENSATION FIGURE IS THEN PRESENTED TO THE BOARD OF DIRECTORS FOR APPROVAL. THE LAST COMPENSATION REVIEW OCCURRED IN AUGUST 2013. FORM 990, PART VI, SECTION C, LINE 19 THE HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND ANNUAL REPORT AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: PENSION RELATED CHANGES OTHER THAN NET PERIODIC PENSION COSTS 14,454,789. NET ASSETS RELEASED FROM RESTRICTIONS -354,906. FORM 990, PART XI, LINE 2C: THE HOSPITAL'S AUDIT COMMITTEE ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND THE SELECTION OF AN INDEPENDENT ACCOUNTANT. THESE FUNCTIONS AND PROCESSES HAVE NOT CHANGED FROM THE PRIOR YEAR. 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