2013-08-13T10:03:27-05:00 2012-09-30 010494526 BAKER NEWMAN & NOYES BOX 507 PORTLAND ME 04112 990 2011-10-01 020222157 Monadnock Community Hospital MONA 6039247191 452 Old Street Road Peterborough NH 034581263 Richard Scheinblum 6039247191 2013-08-08 1 Timothy R Hepburn CPA P00182393 2078792100 2013-08-07 2011 2016-02-25 16:41:14Z Peter L Gosline 452 Old Street Road Peterborough NH 034581263 79832925 0 X www.monadnockhospital.org X 1919 NH Critical Access Hospital serving the Monadnock Region of the State of New Hampshire. 14 12 777 133 0 0 1878155 816591 73391780 75233641 611666 1384191 788518 700842 76670119 78135265 0 0 0 0 37836736 39571490 42108 63069 450384 36056567 39666510 73935411 79301069 2734708 -1165804 89519561 92323694 43706613 45242384 45812948 47081310 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 70372119 75929573 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 2012.Inpatient Services - includes intensive care, adult stays, pediatric stays, maternity/births, and skilled nursing. During the fiscal year the Hospital admitted 1,377 patients and recorded 4,928 patient days. Emergency Services - MCH offers health services 24 hours per day, 7 days per week. The ER is 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 14,805 visits to the ER.Physician Practices - family health services, programs, and education are integral components of health care 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, 132,374 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, ophthalmology, urology, ENT, and podiatry. In addition, the Hospital offers some non-surgical procedures, including colonoscopies, gastroscopies, and pain management injections. During the fiscal year, 2,898 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, 30,748 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 that feature educational and exercise components. MCH also provides physical and occupational therapy, as well as speech rehabilitation. During the fiscal year, 44,755 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, 92,297 member visits were recorded.Monadnock Community Hospital's Financial Assistance Program provides assistance with hospital and/or physician bills for qualifying patients. In fiscal year 2012, the organization recorded $2,945,000 in charges foregone based on established rates. The estimated cost incurred to provide these services was $1,911,000. In addition, MCH 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 $2,012,000 in 2012. 70372119 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 1 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0 0 0 0 1 74 0 1 777 1 0 0 0 0 0 1 0 0 0 0 0 X 14 12 0 0 0 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 Robert L Edwards 7.00 X X 0 0 0 Cyndy Burgess 5.00 X X 0 0 0 Carole Monroe 4.00 X X 0 0 0 Steven H Reynolds 1.60 X X 0 0 0 Norman H Makechnie Esq 0.90 X X 0 0 0 Robert J Condon Jr 1.00 X 0 0 0 Barbara R Duckett 1.00 X 0 0 0 David A Hedstrom DDS 1.00 X 0 0 0 Peter L Gosline 55.00 X X 289979 0 64563 Amy Pfeil 1.00 X 0 0 0 James D Potter MD 1.00 X 119847 0 20991 Charles J Seigel MD 1.00 X 0 0 0 Robert Taft Esq 1.00 X 0 0 0 Jamie Trowbridge 1.00 X 0 0 0 Fletcher R Wilson MD 1.00 X 0 0 0 Richard Scheinblum 50.00 X 164050 0 14701 Stephen Coffman MD 50.00 X 444070 0 18377 Phillip Vuocolo MD 50.00 X 270611 0 21014 Jennifer Peppers MD 50.00 X 256736 0 13382 Lucas Shippee DO 50.00 X 228307 0 22752 Gregory Kriebel MD 50.00 X 214444 0 24994 1988044 0 200774 38 0 1 0 Monadnock Orthopaedic Associates 458 Old Street Road Suite 200 Peterborough NH 03458 Physician fees 3086263 Monadnock Region Emergency Physicians 540 Lafayette Road Hampton NH 03842 Contract emergency physician group 1721992 Monadnock Anesthesia Associates C/O Surgical Suite Peterborough NH 03458 Contract anesthesiologist group 1129845 Hutter Construction PO Box 257 810 Turnpike Road New Ipswich NH 03071 General contractor 1080313 McKesson PO Box 98347 Chicago IL 60693 IS vendor 1013846 24 16670 75602 724319 816591 Net Patient Service Re 900099 73652417 73652417 Other Operating Revenu 900099 1581224 1581224 75233641 432429 432429 2380881 251191 1326286 354024 1054595 -102833 951762 951762 22260 16670 17350 4910 4910 Cafeteria/Vending Mach 900099 360945 360945 Employee Pharmacy Sale 900099 334987 334987 695932 78135265 75929573 0 1389101 650167 145140 505027 31011839 27886301 2906038 219500 398218 355036 40315 2867 5414844 4685381 707953 21510 2096422 1856447 225693 14282 121370 1120 120250 52500 52500 63069 63069 5529162 5080896 444720 3546 74990 74990 1634170 883724 727848 22598 878928 762097 116831 3363943 3135043 228900 37982 24681 12806 495 70990 41588 11206 18196 1337157 1337157 5138419 4962665 175754 575556 457759 117797 Med & Pharm Supplies 6810425 6806464 3961 NH Medicaid Enhancement 4390173 4390173 Provision for Bad Debts 4271860 4271860 Other Med Exp/Service C 4018781 3641895 300740 76146 1360104 908859 443070 8175 79301069 70372119 8478566 450384 9923746 2208239 5360993 11778893 473874 161575 5226529 5527100 129269 196371 1364053 1286731 604559 573132 79126832 39707027 40689917 39419805 21146279 26642255 2736875 3135858 1863467 1393735 89519561 92323694 6091799 5921028 27914594 27234908 561375 690631 9138845 11395817 43706613 45242384 X 37498743 38489800 1357888 1236210 6956317 7355300 45812948 47081310 89519561 92323694 X -1165804 2434166 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 209 0 1 11776 11985 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: $8,453 AHA, Portion of dues available for lobbying: $3,323 In addition, MCH hosts an annual legislative breakfast, which is a bipartisan event to which legislators, local politicians and other public officials are invited to discuss health care issues in New Hampshire and current and proposed legislation. The total cost of this forum was $209. 8314205 486841 948400 1157936 8591510 10031251 884501 93759 2695306 8314205 10623404 1266761 200900 2059814 10031251 10282555 1164871 -100136 723886 10623404 0.14390 0.85610 0.00000 1 0 842124 842124 30819155 13957164 16861991 4529698 1260256 3269442 42581777 24489607 18092170 354078 354078 39419805 Interest Rate Swap Agreements 4895166 Estimated Third-Party Settlements 6500651 11395817 78135265 79301069 -1165804 2851431 -417265 2434166 1268362 75847187 2851431 2851431 72995756 5139509 5139509 78135265 74578825 0 74578825 4722244 4722244 79301069 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: The audited financial statements for the year ended September 30, 2012 contain the following paragraph pertaining to income taxes in Footnote 1: "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 2009." Part XI, Line 8 - Other Adjustments: Change in fair value of interest rate swap agreements -417,265. Part XII, Line 4b - Other Adjustments: Fundraising Expenses 450,384. Decrease in fair value of interest rate swap agreement 417,265. Provision for Bad Debts 4,271,860. Part XIII, Line 4b - Other Adjustments: Fundraising Expenses 450,384. Provision for Bad Debts 4,271,860. X X X X X 1 Ghiorsi & Sorrenti 255 Madison Avenue Wyckoff NJ 07481 See Schedule G, Part IV 0 0 63069 0 63069 MCH Golf Classic 38930 16670 22260 240 64 9240 4399 3407 38930 16670 22260 240 64 9240 4399 3407 17350 4910 Explanation of Fundraising Payments Schedule G, Part I, Line 2b, Column (v) Professional fees paid for capital campaign counsel and services. 1 1 1 X 1 X 1 1 0 1 1 1671994 0 1671994 0.02230 7352797 6257386 1095411 0.01460 9024791 6257386 2767405 0.03690 766938 766938 0.01020 72078 72078 0.00100 1060899 1060899 0.01410 112472 112472 0.00150 2012387 2012387 0.02680 11037178 6257386 4779792 0.06370 1 2424916 187772 21380629 21249064 131565 X 1 1 1 1 Monadnock Community Hospital

452 Old Street Road Peterborough NH 03458

X X X X Monadnock Community Hospital 1 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

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 with PT services 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 New Ipswich Family MedicinePT Satellite

821 Turnpike Road New Ipswich NH 03071

Physician practice with PT services 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 Rindge Family Practice

145 US Route 202 Rindge NH 03461

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 2012 are unreimbursed costs of $1,060,899 attributed to an Outpatient Behavioral Health Practice. 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 $ 4271860. Part II: N/A 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) ($4,271,860). 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 feel 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 13g: The complete financial assistance policy is available upon request and in the waiting rooms and instructions on how to find out more about financial assistance are posted on the 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 17e: Line E: Description from Credit and Collections Policy:The Hospital Patient Financial Services 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 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 a 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 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).In addition, on a weekly basis, the Financial Assistance Program 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 eligibilty is contingent upon receiving a completed application and required documentation from the patient and/or guarantor. Monadnock Community Hospital Part V, Section B, Line 21: 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 in turn 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 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 Needs Assessment is updated at least every 5 years, most recently in 2008. In 2007, the Regional Community Benefits Steering Committee was formed to prepare a single 2008 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 Peter L Gosline 248637 0 20000 0 21342 0 47526 0 17037 0 354542 0 0 0 Richard Scheinblum 163477 0 0 0 573 0 5781 0 8920 0 178751 0 0 0 Stephen Coffman MD 440551 0 3130 0 389 0 0 0 18377 0 462447 0 0 0 Phillip Vuocolo MD 244757 0 25000 0 854 0 0 0 21014 0 291625 0 0 0 Jennifer Peppers MD 219032 0 0 0 37704 0 0 0 13382 0 270118 0 0 0 Lucas Shippee DO 226013 0 0 0 2294 0 5678 0 17074 0 251059 0 0 0 Gregory Kriebel MD 211678 0 0 0 2766 0 7529 0 17465 0 239438 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 9/30/12 was $626,595. Premiums paid during the fiscal year ended 9/30/12 totaled $185,625, which included catch-up payments for the prior year. Included in Mr. Gosline's 2011 deferred compensation in Part VII and Schedule J, Part II, column (C) is $38,742, which represents the net increase as of FYE 9/30/12 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. NHBFA Revenue Bonds Series 2009 021304598 999999DA0 2009-08-01 9750000 Funding capital projects 0 0 0 NHBFA Revenue Bonds Series 2007 021304598 64468KBH8 2007-10-15 20230000 Advance refunding of the Series 1997 & 2004 revenue bonds & refinance note 0 0 0 9750000 101086 9648914 2011 0 0 1 1 20230000 15100045 201040 4928915 2010 0 1 1 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 1 0 0 0 0 1 1 0 1 TRANSAMERICA 1.166700000000 1 0 0 Patti Potter Spouse to Trustee 21093 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 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 members 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, 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. Reportable Compensation for Services as Physician Form 990, Part VII, Section A, Column D The 2011 compensation reported for Dr. Potter was paid by Monadnock Community Hospital for his services as a part-time physician. Dr. Potter was not compensated for his services as an ex-officio voting member of MCH'S Board of Trustees. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized gains on investments: 2,851,431. Change in fair value of interest rate swap agreements -417,265. Total to Form 990, Part XI, Line 5: 2,434,166. 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 9/30/11 and 9/30/12. 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