2013-05-13T14:12:49-05:00 2012-09-30 BAKER NEWMAN & NOYES 650 Elm St Suite 302 Manchester NH 03101 990 2011-10-01 020222791 Alice Peck Day Memorial Hospital % ELIZABETH LOUDERMILK ALIC 6034483121 10 ALICE PECK DAY DRIVE LEBANON NH 037662647 EVALIE M CROSBY 2013-05-07 true TIMOTHY R HEPBURN 8002447444 2011 2016-02-24 21:20:13Z HARRY G DORMAN III FACHE 10 ALICE PECK DAY DRIVE LEBANON NH 037662647 57641594 false X WWW.ALICEPECKDAY.ORG X 1943 NH CRITICAL ACCESS HOSPITAL 22 18 516 55 0 462323 2648403 50223338 51719846 106115 284746 40165 39312 50831941 54692307 41450 40000 0 0 28733724 30812469 86744 256600 678665 20456710 21328367 49318628 52437436 1513313 2254871 33647872 39832951 19624880 23447694 14022992 16385257 THE MISSION OF ALICE PECK DAY MEMORIAL HOSPITAL IS TO PROVIDE PATIENT-FOCUSED HEALTHCARE SERVICES THAT ARE RESPONSIVE TO COMMUNITY NEEDS, TO PROMOTE WELLNESS, AND TO CONTINUALLY IMPROVE THE QUALITY OF HEALTHCARE SERVICES IN THE COMMUNITY. false false 48446594 40000 51628024 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, 2012 CHARITY CARE AT A COST OF $688,102 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, 2012 WERE $1,084,070. 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 CITIZEN'S 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 ITS 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. 48446594 true true false true false false false false false true true false false true true true false true false false false false false true false false true true true false true true false false false false false false false false false false false false false false false true false false false false true X 78 0 true 516 true false false false false false false false false false false X 22 18 false false false false true true true true true false false true true true true true true true true false NH X X ELIZABETH LOUDERMILK 6034483121 10 ALICE PECK DAY DRIVE LEBANON NH 037662647 X MICHAEL R HARRIS 1.0 X X REV DR GUY JD COLLINS 1.0 X X JUDSON T PIERSON 2.0 X X KAREN G KAYEN 1.0 X X DEBORAH A GLAZER MD 1.0 X 37011 MICHAEL J CRYANS 0.5 X HARRY G DORMAN III FACHE 45.0 X X 323433 24433 TERRI C DUDLEY 1.0 X CLAUDIA C GIBSON 0.5 X RICHARD S JENNINGS 1.0 X BRUCE N JOHNSTONE 1.0 X JENNIFER H JUDKINS MD 1.0 X EDWARD T KERRIGAN 1.0 X SARA L KOBYLENSKI 1.0 X MIRIAM M MAGUIRE 0.5 X SUSAN E MOONEY MD MS FACOG 60.0 X X 260260 32847 MICHAEL PWH PAINE FRCS 2.0 X MARTY P CANDON 1.0 X MARK E MELENDY 1.0 X SHELLY L MOSES 1.0 X CLOSEY F DICKEY 1.0 X BEVERLY A RANKIN RN BSN MSA 60.0 X X 139599 20556 CURT A JACQUES II 1.0 X BRETT C PELZTER 1.0 X J TODD MILLER MS 60.0 X 151965 25207 EVALIE M CROSBY CPA FHFMA 50.0 X 144859 26485 BRENDA BLAIR MC SPHR 60.0 X 113535 17423 ANDREW BEST MD 40.0 X 320210 21466 DOUGLAS CEDENO MD 40.0 X 283513 20761 DAVID KRONER MD 40.0 X 284924 25869 DIANE RILEY MD 40.0 X 383303 16685 LEONARD RUDOLF MD 40.0 X 425843 4818 2400163 468292 236550 43 false true false COMBINED SERVICES PO BOX 1320 CONCORD NH 03302 PLAN ADMINISTRATOR 165212 LAVALLEE BRENSINGER ARCHITECTS 155 DOW ST SUITE 400 MANCHESTER NH 03101 ARCHITECTS 472591 UPPER VALLEY NEUROLOGY 106 HANOVER ST LEBANON NH 03766 PROFESSIONAL SERVICE 1936692 VALLEY REGIONAL HOSPITAL 243 ELM ST CLAREMONT NH 03743 LAB SERVICES 173662 COMPHEALTH MEDICAL STAFFING PO BOX 972651 DALLAS TX 753972651 PROFESSIONAL STAFF 331124 7 2648403 6643 2648403 PATIENT SERVICE REVENUE 621400 51399105 51399105 OTHER OPERATING REVENUE 621400 228919 228919 NUTRITIONAL REVENUE 900099 91822 91822 51719846 71205 71205 0 0 52089 12777 39312 39312 39312 3149551 500 2876083 60427 273468 -59927 213541 213541 0 0 0 0 54692307 51628024 415880 40000 40000 0 0 0 829709 77501 752208 0 24268920 23649606 367129 252185 774861 721759 45199 7903 3265644 3042143 190222 33279 1673335 1518571 138187 16577 0 64566 11005 53561 56750 56750 0 256600 256600 0 6334001 5931894 322304 79803 82652 258 82391 3 1143168 838338 290046 14784 92906 88664 3236 1006 0 1143322 973158 164854 5310 252270 224834 25166 2270 0 0 295856 249606 45015 1235 0 1514389 1282033 232356 541743 530089 11343 311 BAD DEBT EXPENSE 2439576 2439576 MEDICAID ENHANCEMENT TAX 1854160 1854160 EQUIPMENT RENTAL/MAINTENANCE 448567 437341 11162 64 MEDICAL SUPPLIES/EQUIPMENT 4463587 4456441 6841 305 600854 79617 514207 7030 52437436 48446594 3312177 678665 296478 49669 6445524 2737368 73430 1833739 7551295 7528117 0 0 0 0 0 0 1220966 1238856 372898 387557 42080929 22981032 12375393 19099897 2827079 3395054 8500 8500 0 0 128010 122544 2348299 3431650 33647872 39832951 6379747 7799569 0 0 0 0 12144107 14807522 0 0 0 0 0 0 495000 0 606026 840603 19624880 23447694 X 13051788 15898995 945364 458576 25840 27686 14022992 16385257 33647872 39832951 X 2254871 107394 X false true true X false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false false true 9337 9337 false false PART II-B, LINE 1 (I), OTHER LOBBYING ACTIVITIES: THE ORGANIZATION PAYS DUES TO THE NEW HAMPSHIRE HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION, A PORTION OF WHICH ARE ATTRIBUTABLE TO LOBBYING ACTIVITIES. true 25840 1846 27686 28065 -2225 25840 26827 1238 28065 26456 371 26827 1.00000 false false false 927577 927577 13168604 7655565 5513039 250651 192510 58141 17941661 14308951 3632710 9792434 824004 8968430 19099897 DUE FROM AFFILIATES 3162650 OTHER ASSETS 269000 3431650 0 DEFERRED ANNUITY 70651 ESTIMATED 3RD PARTY SETTLEMENT 223122 UNREALIZED GAIN/LOSS ON INTEREST RATE SWAP 277830 OTHER LIABILITY 269000 840603 SCHEDULE D,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 Section 501(a) of the Code. Management evaluated the System's tax positions and concluded the System 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 examination by the U.S. federal or state tax authorities for years prior to 2009. X X X X X true GRAHAM-PELTON CONSULTING INC 39 BEECHWOOD RD SUMMIT NJ 07901 CONSULTING false 256600 256600 PART IV GRAHAM-PELTON CONSULTING INC. PROVIDED CONSULTING SERVICES TO THE ENTITY FOR A CAPITAL CAMPAIGN. THEY WERE PAID FOR THESE SERVICES AS DETAILED IN LINE 2 B COLUMN V. NO FUNDS WERE IN THE CUSTODY OR CONTROL OF THE CONSULTANT. true true true X true X 275. true true true false true true 688102 688102 0.01310 6434711 5350641 1084070 0.02070 7122813 5350641 1772172 0.03380 163769 163769 0.00310 38299 38299 0.00070 9980492 6835209 3145283 0.06000 68442 68442 0.00130 10251002 6835209 3415793 0.06510 17373815 12185850 5187965 0.09890 2398 2398 1342 1342 16455 16455 0.00030 18052 18052 0.00040 38247 38247 0.00070 true 1664183 100000 12924698 12798156 126542 X true true 1 1 ALICE PECK DAY MEMORIAL HOSPITAL

10 ALICE PECK DAY DR LEBANON NH 03766

X X X X PHYSICIAN CLINICS ALICE PECK DAY MEMORIAL HOSPITAL 1 true true 200. true 275. true X X X X X X X true true X X X X X X true X X true X X X X X X true X false false 9 RAM CENTER FOR COMMUNITY CARE

10 ALICE PECK DAY DR 5 LEBANON NH 03766

PRIMARY CARE PHYSICIAN CLINIC WOMEN'S CARE CENTER

141 MASCOMA ST LEBANON NH 03766

OB/GYN PHYSICIAN CLINIC APD ORTHOPAEDIC CLINIC

10 ALICE PECK DAY DR 17-C LEBANON NH 03766

ORTHOPAEDIC PHYSICIAN CLINIC GENERAL SURGERY CLINIC

10 ALICE PECK DAY DR LEBANON NH 03766

GENERAL SURGEON CLINIC PAIN MANAGEMENT CLINIC

127 MASCOMA ST 3RD FLOOR LEBANON NH 03766

PAIN MANAGEMENT CLINIC MIDWIFERY SERVICES

57 MECHANIC ST SUITE 2 LEBANON NH 03766

MIDWIFERY CLINIC APD HAND & UPPER EXTREMITY CLINIC

205 BILLINGS FARM RD UNIT 3A WHITE RIVER JUNCTION VT 05001

HAND & UPPER EXTREMITY ORTHOPAEDIC PHYSICIAN CLINIC OCCUPATIONAL HEALTH SERVICES

127 MASCOMA ST LEBANON NH 03766

OCCUPATIONAL HEALTH PHYSICIAN CLINIC NEUROSURGERY SERVICES AT APD (NSAPD)

106 HANOVER STREET LEBANON NH 03766

NEUROSURGERY PHYSICIAN CLINIC SCHEDULE H, PART I, LINE 3B: FAMILY INCOME LIMIT FOR ELIGIBILITY FOR DISCOUNTED CARE RANGES FROM 200%-275% OF FPG. SCHEDULE H, 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 9.89% OF TOTAL EXPENDITURES ON FORM 990, PART IX, COLUMN A, LINE 26, EXCLUDING BAD DEBT EXPENSE. SCHEDULE H, PART I, LINE 7, COLUMN (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. SCHEDULE H, 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. SCHEDULE H, 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 12, 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 ALLOWANCE BASED ON ITS ASSESSMENT OF INDIVIDUAL ACCOUNTS AND HISTORICAL ADJUSTMENTS. ACCOUNTS DEEMED UNCOLLECTIBLE ARE WRITTEN OFF THROUGH A CHARGE AGAINST THE ESTABLISHED ALLOWANCE. SCHEDULE H, 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. SCHEDULE H, 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 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. 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 CONJUCTION 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. SCHEDULE H, PART V, LINE 11: 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. SCHEDULE H, PART V, LINE 13: PLEASE SEE PART V LINE 3 FOR A DESCRIPTION OF THE FINANCIAL ASSISTANCE PROGRAM AND THE EFFORTS MADE TO PUBLICIZE AND PROMOTE THE PROGRAM. SCHEDULE H, PART V, LINE 19D: THE HOSPITAL FACILITY PROVIDES UNINSURED PATIENTS WITH A 15% DISCOUNT. AT THE TIME THE DISCOUNT WAS ESTABLISHED THE DISCOUNT APPROXIMATED THE AVERAGE OF THE THREE LOWEST NEGOTIATED COMMERCIAL INSURANCE RATES FOR SERVICES AT THE HOSPITAL FACILTY. THE AVERAGE OF THE THREE LOWEST COMMERICAL INSURANCE RATES WAS APPROXIMATELY 87.5%, THE RATE APPLIED TO UNINSURED PATIENTS WAS LOWER THAN THAT RATE, AT 85%, REPRESENTING A 15% DISCOUNT. SCHEDULE H, PART VI, LINE 2: DUE TO OUR RURAL LOCATION AND SIZE, A COLLABORATIVE EFFORT BETWEEN THE UNITED WAY, DARTMOUTH HITCHCOCK MEMORIAL HOSPITAL AND ALICE PECK DAY MEMORIAL HOSPITAL CREATED THE FY 2009 COMMUNITY BENEFITS PLAN. PRIORITY NEEDS AND HEALTH CONCERNS FOR OUR COMMUNITY WERE BASED UPON INFORMATION COLLECTED FROM COMMUNITY NEEDS ASSESSMENTS AND COMMUNITY SURVEYS. IDENTIFIED NEEDS INCLUDED: AVAILABILITY OF ORAL HEALTH, AVAILABILITY OF PRIMARY CARE, PRESCRIPTION ASSISTANCE, TRANSPORTATION, AVAILABILITY OF BEHAVIORAL HEALTH AND ACCESS TO ALCOHOL/DRUG TREATMENT. ALICE PECK DAY USED ITS 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 FOR ORAL HEALTH WITHIN OUR LOCAL COMMUNITY. UPPER VALLEY SMILES HAS TOUCHED THE LIVES OF MANY CHILDREN IN OUR COMMUNITY AND PROVIDED MUCH NEEDED CARE FOR A VERY VULNERABLE POPULATION. SCHEDULE H, 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 ANY ONE 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. SCHEDULE H, 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 COMPRISES 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. SCHEDULE H, PART VI, LINE 5: ALICE PECK DAY ACTIVELY PROMOTES COMMUNITY-BASED LEADERSHIP DEVELOPMENT. STAFF MEMBERS PARTICIPATE IN TWO LOCAL CHAMBERS OF COMMERCE, LEADERSHIP UPPER VALLEY, 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. SCHEDULE H, 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 FY 2012, 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 NON PROFIT ORGANIZATIONS WITH MEETING SPACE AND REFRESHMENTS. ALICE PECK DAY SUPPORTED COMMUNITY FLU CLINICS, PROVIDED EMERGENCY PRESCRIPTION DRUG VOUCHERS, SUBSIDIZED SENIOR EXERCISE PROGRAMS, PROVIDED SUPPLIES FOR HURRICANE IRENE RELIEF, 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 PROGRAM. THIS PROGRAM PROVIDES AN ORAL HEALTH SAFETY NET FOR DISADVANTAGED RESIDENTS WITHIN OUR SERVICE AREA. IN 6 DIFFERENT SCHOOLS OVER 1,300 STUDENTS RECEIVED ORAL HEALTH EDUCATION, WITH NEARLY 400 OF THOSE CHILDREN RECEIVING SCREENINGS FROM A DENTAL TEAM. ADDITIONALLY, OVER 1,600 PREVENTATIVE SEALANTS WERE GIVEN TO 260 LOW INCOME, UNINSURED CHILDREN. FOLLOW UP RESTORATIVE TREATMENT WAS GIVEN TO 91 OF THE 26O CHILDREN AND WAS PROVIDED BY LOCAL AREA DENTISTS. ALICE PECK DAY HOSTED TWO FREE ORAL HEALTH CLINICS FOR 18 HOMELESS CHILDREN WHO RECEIVED ORAL HEALTH EDUCATION, A DENTAL CLEANING AND FLUORIDE APPLICATIONS. WITH GRANT SUPPORT, APD CONTINUED ITS PILOT WOMEN, INFANTS AND CHILDREN (WIC) ORAL HEALTH INITIATIVE IN LEBANON AND ENFIELD NEW HAMPSHIRE, AND EXPANDED THIS PROGRAM TO SERVE A NEW SITE IN HARTFORD, VERMONT. UNDER THE WIC INITIATIVE, A TOTAL OF 147 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 COLBY-SAWYER COLLEGE, GEISEL SCHOOL OF MEDICINE AT DARTMOUTH, NEW ENGLAND INSTITUTE OF TECHNOLOGY, RIVER VALLEY COMMUNITY COLLEGE, VERMONT TECHNICAL COLLEGE, YALE UNIVERSITY, AND LEBANON COLLEGE. 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. STATE FILING OF COMMUNITY BENEFIT REPORT 990 SCHEDULE H, PART VI NH, true GOOD NEIGHBOR HEALTH CLINIC 70 N MAIN ST WRJ VT 05001 030346949 501(c)3 20000 OPERATIONAL SUPPORT FOR CLINIC PROVIDING FREE PRIMARY CARE SERVICES TO PATIENTS IN THE UPPER VALLEY ARE 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 20000 Operational support for transportation services for area senior-citizens. The Council provides lift-assisted buses with priority on medical transport for hospital or clinic appointments. Schedule I, Part 1, 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. false false false false false false false true false HARRY G DORMAN III FACHE 278317 45116 9800 14633 347866 J TODD MILLER MS 128608 23357 4605 20602 177172 SUSAN E MOONEY MD MS FACOG 243490 16770 9800 23047 293107 EVALIE M CROSBY CPA FHFMA 131128 13731 5992 20493 171344 BEVERLY A RANKIN RN BSN MSA 125975 13624 20556 160155 ANDREW BEST MD 318824 1386 9800 11666 341676 DOUGLAS CEDENO MD 256365 27148 9800 10961 304274 DAVID KRONER MD 250503 12733 21688 9800 16069 310793 DIANE RILEY MD 382505 798 16685 399988 LEONARD RUDOLF MD 391862 33000 981 4818 430661 FORM 990, SCHEDULE J, PART I, LINE 7: IN FISCAL YEAR 2012, CERTAIN PROVIDERS WERE PAID THROUGH AN RVU (RELATIVE VALUE UNIT) SYSTEM, A PRODUCTIVITY MEASUREMENT SET BY MEDICARE TO ASSIGN VALUE TO SERVICES. FORM 990, SCHEDULE J, PART II: SALARY AND BENEFIT EXPENSE FOR THE CEO 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 THESE EXPENSES ARE INCLUDED IN SALARIES AND BENEFITS EXPENSE. ON LINE 24(E) OF FORM 990, SCHEDULE IX , THESE EXPENSES ($474,767) HAVE BEEN RECLASSIFIED FROM SALARY AND BENEFIT EXPENSE TO LINE 24(E). BUSINESS FINANCE AUTHORITY OF THE STATE OF NH 521304598 2010-11-30 12282000 CURRENT REFUND EXISTING BONDS false false false 0 0 12282000 0 0 12237068 44932 0 0 0 0 0 2010 true false true true false false false false 0 true false true true TD BANKNORTH NA 5. false false false 0 false true X FORM 990, PART I, LINE 5 AND PART V, LINE 2A: FOR ADMINISTRATIVE PURPOSES, ALICE PECK DAY MEMORIAL HOSPITAL ACTS AS COMMON PAYMASTER FOR BOTH ALICE PECK DAY HEALTH SYSTEMS, CORP. AND ALICE PECK DAY LIFECARE CENTER, INC. FORM 990, PART IV, LINE 34: ALICE PECK DAY HEALTH SYSTEMS, CORP. (02-0479095) 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. (EIN 02-0485369) AND ALICE PECK DAY HEALTH MANAGEMENT CORP. (EIN 02-0485370), BOTH ENTITIES ARE INACTIVE AND HOLD NO ASSETS. 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: ALICE PECK DAY HAS A MULTI-FACETED 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 ARISE, THE ORGANIZATION COMPLIES WITH THE 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 COMMITTMENT, 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 SIMILIAR 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. THE COMPENSATION COMMITTEE APPROVES THE BASE COMPENSATION AND SALARY INCREASE AMOUNT. FORM 990, PART VI, SECTION C, LINE 19: THE ORGANIZATION MAKES IT 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 CHIEF MEDICAL OFFICER AND VICE PRESIDENT. SHE WORKED AN AVERAGE OF 61 HOURS PER WEEK, OF WHICH AN AVERAGE OF 41 HOURS PER WEEK WERE SPENT ON EXECUTIVE MATTERS AND 20 IN HER ROLE AS A PHYSICIAN. FORM 990, PART VII, SECTION A COLUMN E: REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS: THE COMPENSATION REPORTED FOR HARRY G. DORMAN III, FACHE, AND EVALIE M. CROSBY, CPA, FHFMA, WAS PAID BY ALICE PECK DAY HEALTH SYSTEMS, CORP. FOR THEIR SERVICES AS FULL-TIME EXECUTIVES. THESE INDIVIDUALS WORKED AN AVERAGE OF 62 HOURS PER WEEK, OF WHICH MR. DORMAN SPENT AN AVERAGE OF 45 HOURS PER WEEK AND MS. CROSBY SPENT AN AVERAGE OF 50 HOURS A WEEK DEDICATED TO ALICE PECK DAY MEMORIAL HOSPITAL. FORM 990, PART XII, LINE 2C: OVERSIGHT OF AUDIT PROCESS: 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 9/30/11 AND 9/30/12. FORM 990, PART XI, LINE 5: OTHER CHANGES IN NET ASSETS OR FUND BALANCE: CHANGE IN INTEREST RATE SWAPS: -61,341 CHANGE IN ANNUITY VALUATION: -15,114 UNREALIZED GAIN ON INVESTMENTS: 178,406 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:HARRY G. DORMAN III, FACHE TITLE:PRESIDENT AND CEO HOURS:17 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:SUSAN E. MOONEY, MD, MS, FACOG TITLE:VP & MEDICAL DIRECTOR HOURS:1 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:EVALIE M. CROSBY, CPA, FHFMA TITLE:VP FINANCE AND CFO HOURS:12 ALICE PECK DAY HEALTH SYSTEMS CORP 10 ALICE PECK DAY DRIVE LEBANON NH 03766 020479095 PROMOTE HEALT NH 501(C)3 LINE 11B,II N/A false ALICE PECK DAY LIFECARE CENTER INC 10 ALICE PECK DAY DRIVE LEBANON NH 03766 020479094 INDEP & ASSIS NH 501(C)3 LINE 9 APDHS false ALICE PECK DAY REALTY CORP 10 ALICE PECK DAY DRIVE LEBANON NH 03766 020485369 INACTIVE NH 501(C)2 APDHS false ALICE PECK DAY HEALTH MANAGEMENT CORP 10 ALICE PECK DAY DRIVE LEBANON NH 037662647 020485370 INACTIVE NH NA C corp. false false false true true false false false false false false false false false true false false false