2013-08-15T08:19:47-05:00 2012-09-30 061009205 BLUM SHAPIRO & COMPANY PC CPA'S 29 S MAIN STREET PO BOX 272000 WEST HARTFORD CT 061272000 990 2011-10-01 060878822 THE CONNECTICUT HOSPICE INC CONN 2033157500 100 DOUBLE BEACH ROAD BRANFORD CT 064054003 THOMAS MCGOVERN 2033157500 2013-08-14 1 ELIZABETH SOLECKI P00235171 8605614000 2011 2016-02-25 16:41:14Z THOMAS MCGOVERN 100 DOUBLE BEACH ROAD BRANFORD CT 064054003 31519810 0 X WWW.HOSPICE.COM/CTHOSPICE X 1971 CT PROVIDE ADULT AND PEDIATRIC CARE TO IRREVERSIBLY ILL PATIENTS AND THEIR FAMILIES AT HOME AND AT HOSPITAL-HOSPICE. 14 13 365 518 0 0 5603544 3019018 28505044 28159550 118315 218482 91774 122760 34318677 31519810 0 0 0 0 18230359 17292341 0 0 249933 13313134 13354126 31543493 30646467 2775184 873343 20686017 21540952 9615618 9206188 11070399 12334764 PROVIDE ADULT AND PEDIATRIC CARE TO IRREVERSIBLY ILL PATIENTS AND THEIR FAMILIES AT HOME AND AT HOSPITAL-HOSPICE. 0 0 12818924 13176532 PHYSICIAN DIRECTED PAIN AND SYMPTOM MANAGEMENT PROVIDED STATEWIDE TO PALLIATIVE HOSPITAL AND HOSPICE CARE ADULT AND PEDIATRIC PATIENTS AND THEIR FAMILIES 13704068 14983018 PHYSICIAN DIRECTED HOME MEDICAL AND HOSPICE CARE SERVICES TO ADULTS AND PEDIATRIC PATIENTS ON A STATEWIDE BASIS 26522992 1 1 0 1 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 22 0 1 365 1 0 0 0 0 0 0 0 0 X 14 13 0 0 0 0 0 1 0 1 1 0 0 1 1 1 1 1 0 1 0 0 X THOMAS MCGOVERN 2033157500 100 DOUBLE BEACH ROAD BRANFORD CT 064054909 HON DANIEL COSGROVE 5.00 X X 0 0 0 WEN-JEN HWU MD PHD 2.00 X 0 0 0 FREDERICK J MANCHESKI 10.00 X X 0 0 0 ANTHONY J DAROS 5.00 X X 0 0 0 DAVID MCDERMOTT 0.30 X 0 0 0 EUGENE MICHAEL 3.00 X 0 0 0 ROBERT PARKER 0.30 X 0 0 0 HON DONALD POGUE 2.00 X 0 0 0 ARLENE M SAYERS 15.00 X X 0 0 0 WAYNE O SOUTHWICK MD 1.00 X X 0 0 0 JOHN P STACK CPA 0.50 X 0 0 0 FREDERICK ULBRICH 1.00 X 0 0 0 CAPTAIN KAYE WILLIAMS 3.00 X X 0 0 0 PETER YARROW 0.20 X 0 0 0 ROSEMARY HURZELER 55.00 X X 169033 61467 23658 DAVID R GOLDFARB 42.00 X 124400 8886 20357 SANDRA J KLIMAS 40.00 X 120334 15042 20429 RONNY J KNIGHT 43.00 X 132851 6179 12497 THOMAS MCGOVERN 40.00 X 105928 13241 19867 DR JOSEPH ANDREWS 35.00 X 163414 46690 16717 JANICE MATARAZZO 54.00 X 139585 0 8634 DR ANTHONY COSCIA PT 24.00 X 125013 10418 17960 MARIANNE TREANTAFILAS 35.00 X 104370 23856 12328 JAMES PROTA 40.00 X 104996 14999 25989 JOANNE LITEVICH 40.00 X 113896 0 25777 1403820 200778 204213 39 0 1 0 PEQUOT PHARM 1 ANNIE GEORGE DRIVE MASHANTUCKET CT 06339 PHARMACEUTICAL DIST 892646 A&B HOMEHEALTH SOLUTIONS 446A BLAKE STREET NEW HAVEN CT 06515 HOME HEALTH AIDES 854056 PEOPLE'S HOME HEALTHCARE 262 STATE STREET NORTH HAVEN CT 06473 DURABLE MEDICAL EQPT 512960 MAXIM 12588 COLLECTIONS CENTER DR CHICAGO IL 60693 HOME HEALTH AIDES 419071 ARCADIA HEALTH CARE 4639 MAIN STREET BRIDGEPORT CT 06606 HOME HEALTH AIDES 358108 14 3019018 3019018 HOME CARE REVENUE 621610 14983018 14983018 INPATIENT REVENUE 623000 13176532 13176532 28159550 218482 218482 OTHER 900099 67433 67433 FOOD SERVICE INCOME 722210 55327 55327 122760 31519810 28159550 0 341242 726330 307647 400843 17840 13279255 12050946 1093351 134958 310037 272833 34104 3100 1767323 1555244 194406 17673 1209396 1064268 133034 12094 4000000 4000000 115969 115969 135348 135348 2507144 1964251 518029 24864 1826 1826 3084929 2498793 555287 30849 1875 1875 597016 465672 131344 278588 247943 30645 12100 6736 5364 84116 84116 184892 184892 624560 533999 90561 HOSPITALIZATION EXPENSE 870249 870249 HOUSEKEEPING 505400 454860 50540 GROCERIES 193803 174423 19380 OTHER 156311 55128 92628 8555 30646467 26522992 3873542 249933 173906 221853 1331774 2728443 738139 196548 198440 3777105 3072190 829599 704915 5462581 5224710 26371 0 11927099 12462591 20686017 21540952 6535973 6977829 592799 604474 2477346 1395036 228849 9500 0 9615618 9206188 X 8797385 10112537 644622 1653835 1628392 568392 11070399 12334764 20686017 21540952 X 873343 391022 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 101508 101508 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE CONNECTICUT HOSPICE'S MISSION OF PROVIDING INTERDISCIPLINARY, QUALITY CARE, BOTH IN THE SPECIALTY HOSPITAL AND AT HOME, REQUIRES THE ONGOING APPLICATION OF STANDARDS THROUGH REGULATIONS AS IT RELATES TO HOSPICE AND PALLIATIVE CARE. IN PARTICULAR, WITH THE HOSPITAL'S RELOCATION, IT IS IMPORTANT TO ENABLE ALL CONNECTICUT PHYSICIANS THE OPPORTUNITY TO BE KNOWLEDGEABLE OF THE ENVIRONMENT OF CARE AND THESE STANDARDS. 1628392 220000 1280000 568392 1408392 220000 14073 14073 1628392 1228392 180000 90304 90304 1408392 1026081 220000 77538 95227 1228392 0 0 3777105 3072190 704915 704915 DUE FROM J.D. THOMPSON INSTITUTE, NET 12251258 OTHER CURRENT ASSETS 211333 12462591 31519810 30646467 873343 391022 391022 1264365 31910832 391022 391022 31519810 0 31519810 30646467 0 30646467 0 30646467 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: TEMPORARY FUNDS ARE AVAILABLE TO SUPPORT OPERATIONS AND REPAYMENT OF LONG TERM DEBT. THE INCOME FROM PERMANENT FUNDS IS AVAILABLE TO SUPPORT HEALTH CARE SERVICES. 1 0 0 0 1 0 0 271187 271187 0.00830 71591 71591 0.00200 342778 342778 0.01030 20000 20000 0.00060 20000 20000 0.00060 362778 362778 0.01090 0 254301 24820415 28518733 -3698318 X 1 0 1 NOT APPLICABLE 1 1 THE CONNECTICUT HOSPICE INC

100 DOUBLE BEACH ROAD BRANFORD CT 064054003

X NOT REQUIRED 1 0 0 0 0 0 0 0 0 0 0 0 PART I, LINE 3C: THE HOSPITAL PROVIDES SERVICES BASED ON PATIENT NEED REGARDLESS OF INCOME OR ABILITY TO PAY. 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 $ 254301. PART III, LINE 4: FINANCIAL STATEMENTS DO NOT CONTAIN ANY REFERENCE TO BAD DEBTS IN THE FOOTNOTES TO THE FINANCIAL STATEMENTS. BAD DEBTS ARE RECORDED AT ACTUAL UNCOLLECTED REVENUE AS THE ESTIMATED COSTS. PART III, LINE 8: NONE OF THE SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT. PART III, LINE 9B: THE ORGANIZATION HAS ESTABLISHED A WRITTEN POLICY STATING THAT CARE IS PROVIDED REGARDLESS OF ABILITY TO PAY. NO COLLECTION ACTIVITY IS PURSUED FOR INDIGENT PATIENTS IDENTIFIED AS SUCH BY LICENSED CLINICAL SOCIAL WORKERS. PART VI, LINE 2 THE HOSPITAL RESPONDS TO THE NEEDS OF ITS COMMUNITY PHYSICIANS AND REFERRING HOSPITALS. PART VI, LINE 3 PATIENTS AND THEIR FAMILIES ARE INFORMED OF ALL REIMBURSEMENT OPTIONS BOTH VERBALLY AND IN WRITING UPON ADMISSION. PART VI, LINE 4 ALL COMMUNITIES AND DEMOGRAPHIC CONSTITUENCIES ARE SERVED INCLUDING URBAN, RURAL AND SUBURBAN. 1 X X X X 0 1 0 0 0 0 0 0 0 ROSEMARY HURZELER 169033 61467 0 0 0 0 5071 1844 12278 4465 186382 67776 0 0 DAVID R GOLDFARB 124400 8886 0 0 0 0 3732 267 15268 1090 143400 10243 0 0 SANDRA J KLIMAS 120334 15042 0 0 0 0 3610 451 14549 1819 138493 17312 0 0 RONNY J KNIGHT 132851 6179 0 0 0 0 3986 185 7956 370 144793 6734 0 0 DR JOSEPH ANDREWS 163414 46690 0 0 0 0 0 0 13002 3715 176416 50405 0 0 DR ANTHONY COSCIA PT 125013 10418 0 0 0 0 3750 313 12828 1069 141591 11800 0 0 PART I, LINE 4B COMPENSATION AWARDED BUT NOT GIVEN TO THE PRESIDENT/CEO (DUE TO FINANCIAL CONDITION OF THE HOSPITAL). THE AVERAGE SALARY FOR THIS POSITION HAS BEEN $130,000. NO ACCUMULATED LIABILITY WAS GIVEN IN THE CURRENT YEAR. F J MANCHESKI X 800000 604474 0 1 1 604474 FORM 990, PART VI, SECTION A, LINE 7A A NOMINATING COMMITTEE CONSISTING OF FOUR MEMBERS OF THE BOARD OF DIRECTORS MAY ELECT A BOARD MEMBER. FORM 990, PART VI, SECTION B, LINE 11 THE RETURN IS PRESENTED AT A BOARD MEETING PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS REVIEWS THE ANNUAL ELIGIBILITY TEST OF ALL BOARD MEMBERS. FORM 990, PART VI, SECTION B, LINE 15A A COMMITTEE OF TWO OR MORE DIRECTORS OF THE BOARD MEETS PERIODICALLY TO REVIEW THE PERFORMANCE AND COMPARABILITY DATA OF SIMILARLY SIZED HOSPITALS IN THE STATE OF CONNECTICUT. THEY DELIBERATE AND A FINAL DECISION IS MADE. FORM 990, PART VI, SECTION C, LINE 19 INFORMATION IS NOT AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 391,022. VALUE OF CONTRIBUTED SERVICES PART VIII, STATEMENT OF REVENUE, LINE 2 DURING THE YEAR ENDED SEPTEMBER 30, 2012, THE ESTIMATED VALUE OF CONTRIBUTED SERVICES WAS $2,043,000. THE JOHN D THOMPSON HOSPICE INSTITUTE FOR EDUCATION TRAINING AND RESEARCH 100 DOUBLE BEACH ROAD BRANFORD CT 064054003 061003712 PROGRAMS ON EDUCATION, TRAINING AND RESEARCH; MANAGEMENT SERVICES CT 501(C)(3) BOX 9 N/A 0 0 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0 0 0 FACILITY LEASE J 284160 OPERATING LEASE MANAGEMENT SERVICES L 4000000 FAIR VALUE OF SERVICES