2013-08-15T09:55:29-07:00 2012-09-30 990 2011-10-01 050259004 MEMORIAL HOSPITAL MEMO 4017292000 111 Brewster Street Pawtucket RI 028604499 Arthur Deblois 4017292000 2013-08-15 2011 2016-02-24 21:20:13Z Arthur DeBlois III 111 Brewster Street Pawtucket RI 02860 192492178 0 X www.mhri.org X 1901 RI Our mission is primary care and preventive medicine, providing advanced diagnosis and treatment with a focus on teaching and research. 17 17 2296 192 0 0 7486800 6741668 169468374 164562569 3500122 1695187 916445 934931 181371741 173934355 0 0 0 0 114049334 116518297 0 0 27351 72311225 70566696 186360559 187084993 -4988818 -13150638 101761596 83812240 89347255 99298742 12414341 -15486502 Our mission is primary care and preventive medicine, providing advanced diagnosis and treatment with a focus on teaching and research. An essential resource in achieving our mission is the medical expertise provided by our competent and caring professional staff. We strive to achieve the timely and efficient delivery of care in a compassionate atmosphere. 0 0 167090276 0 0 Healthcare & Management Funds received were used to provide funding for the exempt purpose of general patient care. The Memorial Hospital is an acute care not-for-profit teaching community health institution and research facility serving the Blackstone Valley community of Rhode Island and Massachusetts. Memorial, which is located in Pawtucket, Rhode Island is a teaching affiliate of the Warren Alpert School of Brown University and the chief site for the medical school's primary care academic program housed in the Center of Primary Care. Memorial's goarls are to provide quality multi-disciplinary services, to see patients regardless of race, color, national origin, socioeconomic status or place of residence and to act as ana educational resource for patients, physicians, nurses and the community. Memorial provides care to patients that meet certain criteria under its charity care policy without charge or at amounts less than its established rates. Because Memorial does not pursue collection of amounts determined to qualify as charity care, they are not reported as revenue. Memorial provided 27,731 patient days of service int he year ending September 30, 2012. Memorial had 5,749 admissions with and ALOS of 4.82 days. Memorial operates a Level 2 trauma center ER, which serves patients regardless of ability to pay. For the year ending September 30, 2012 Memorial provided (continued on Schedule O, Statement 2). 0 0 0 167090276 1 0 0 1 0 0 0 0 0 1 1 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 1 72 0 1 2296 1 0 0 0 0 0 0 X 17 17 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 1 1 RI X X Arthur DeBlois III 4017292000 111 Brewster Street Pawtucket RI 028604499 Robert Andrade 0.25 X X 0 0 0 Paul Mooney 0.25 X 0 0 0 John J Partridge 0.25 X 0 0 0 Virginia Roberts 0.25 X X 0 0 0 Karl Sherry 0.25 X X 0 0 0 Arthur Deblois III 60 X X 147693 0 2486 Alfred Degen 0.25 X 0 0 0 William Kapos 0.25 X X 0 0 0 Gary E Furtado 0.25 X X 0 0 0 William J Hunt 0.25 X 0 0 0 Patrick J Murray 0.25 X X 0 0 0 Greg Scown 0.25 X 0 0 0 Edna Poulin 0.25 X X 0 0 0 Francis R Dietz 40 X X X 185900 0 0 Martin Tursky 60 X X X 231000 0 31514 Augusto Rojas Jr 0.25 X 0 0 0 Deborah Cylke 0.25 X 0 0 0 Irene Schmitt 0.25 X 0 0 0 Michael J Ryan 50 X 201663 0 42426 Michelle MacDonald Gallagher 50 X 266121 0 44582 Thomas Gough 50 X 187676 0 39556 Jeffrey Borkan MD 40 X 284542 0 23290 Brian Wiley MD 40 X 298393 0 13832 Noubar Kessimian MD 40 X 271500 0 23028 John Riedel MD 40 X 283441 0 23268 Michael Pepi MD 40 X 275001 0 23099 2632930 0 267081 116 1 1 0 Aramark Healthcare Food Lockbox 25271 Network Pl Chicago IL 606731252 Dietary Services 1007842 Brown University PO Box 1939 Providence RI 02912 Physicians 809999 BWPO Medicine PO Box 3684 Boston MA 022413684 Physician Services ( E/R and Cardiology) 1383544 Aramark Corporation 24863 Network Place Chicago IL 60673 Environmental Services 532462 ARUP PO Box 27964 Salt Lake City UT 84127 Laboratory Services 548805 109 0 0 0 0 5231802 1509866 0 6741668 Patient Service Revenue 622000 164562569 164562569 0 0 0 0 0 0 164562569 95596 0 0 95596 0 0 0 0 0 0 0 0 0 0 20152114 5300 18557823 0 1594291 5300 1599591 0 0 1599591 0 Cafeteria Revenue 561499 920912 0 0 920912 Pharmacy Sales to Employees 561499 14019 0 0 14019 0 0 0 0 934931 173934355 164562569 0 2630118 846477 0 846477 0 83277076 73833640 9418029 25407 6919642 6136842 782800 0 19877732 17629020 2248712 0 5597370 4962431 632995 1944 456362 0 456362 0 209615 0 209615 0 11003351 8499535 2503816 0 17400 15432 1968 0 19507969 19018907 489062 0 2367400 1705794 661606 0 335419 323588 11831 0 909945 909945 0 0 3938536 3492980 445556 0 2080791 1524657 556134 Provision for Bad Debt 15130585 15130585 0 0 Licensing Fee 7568922 7568922 0 0 Physician and Grants 5119966 5119966 0 0 Equipment Rental & Maintenance 556903 493902 63001 1363532 724130 639402 187084993 167090276 19967366 27351 789126 311840 0 0 56325 7180 34280331 31162448 0 0 0 0 0 0 737772 688676 876596 932265 114858407 84273682 33011001 30584725 0 30107963 19268109 0 0 1902482 856997 101761596 83812240 22237145 21479468 0 0 0 0 11106099 9518714 0 0 0 0 56004011 68300560 89347255 99298742 X 1647034 -27288950 1297954 1562926 9469353 10239522 12414341 -15486502 101761596 83812240 X -13150638 -14750205 X 0 1 1 X 1 1 X 0 0 0 0 0 0 0 0 1 3377 3377 0 SchC_P2B_S00_L01 Schedule C, Part II-B, Line 1 Memorial Hospital is a member of the Hospital Association of Rhode Island (HARI). The Hospital pays annual membership dues to HARI. HARI lobbies on behalf of all its members. 9469353 0 770168 0 0 0 10239521 9713167 23 -243837 0 0 0 9469353 9361014 34 352119 0 0 0 9713167 9438660 0 -77646 0 0 0 9361014 0 1 0 1 0 1787586 0 1787586 48497884 0 30113735 18384149 0 0 0 0 61387961 0 52658948 8729013 3184976 0 1500999 1683977 30584725 Stocks 7921615 F Bonds 1423396 F Other 9923098 F 19268109 Minimum Pension Liability 64921724 Current Portion of Long Term Debt 1587385 Insurance Claim Reserve 1663316 Accrued Interest Payable 128135 68300560 173934355 187084993 -13150638 1401425 0 0 0 0 1401425 -11749213 175361111 1401425 0 0 0 1401425 173959686 -25331 0 -25331 173934355 187110324 0 0 0 25331 25331 187084993 0 0 0 187084993 SchD_P05_S00_L04 Schedule D, Part V, Line 4 Memorial's Endowment Funds are intended primarily for providing charity care. SchD_P13_S00_L02d Schedule D, Part XIII, Line 2d Assets released from restrictions for general operations. 1 1 1 X 0 1 1 1 0 0 0 0 12969918 8330543 4639375 0 0 0 44319509 33823630 10495879 0 0 0 0 0 0 0 0 0 57289427 42154173 15135254 0 0 0 18606 0 18606 0 0 0 24772994 6388036 18384958 0 0 0 0 0 0 0 0 0 5826835 5202696 624139 0 0 0 0 0 0 0 0 0 30618435 11590732 19027703 0 0 0 87907862 53744905 34162957 0 1 7089036 5776072 34890575 36450969 -1560394 X 1 1 1 1 The Memorial Hospital

111 Brewster Street Pawtucket RI 02860

X X X X X X The Memorial Hospital 1 SchH_P01_S00_L03c Schedule H, Part I, Line 3c The Hospital provides free care to all patients whose income is at or falls below 200% of the current Federal Poverty Guidelines (Patient Rights Policy #25). For all patients whose income does not qualify for free care the hospital provides a 40% discount for all services not covered by insurance if paid within six months of service or determination that health insurance will not cover service. This discount is not dependent on icome level or asset testing. SchH_P01_S00_L07 Schedule H, Part I, Line 7 The cost of services were calculated by multiplying the charges for those services by the ratio of cost to charges as determined in the 2012 Medicare Cost Report. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 Following is the text of the footnote describing bad debt expense: "In addition to the cost of charity care and other community service programs, the Hospital provided $15,147,513 and $16,371,134 for uncollectible patient accounts during the years ended September 30, 2012 and 2011 respectively. The ratio of cost to charges of .4680 was used to determine the bad debt cost reported on line 2. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 The Medicare Cost Report was used as the source of the Medicare cost used on line 6. The result is a surplus on line 7. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b The Hospital's Credit and Collectrion policy (Patient Rights Policy #23) states that "The Hospital will at all times provide essential care and treatment regardless of the ability of the patient to pay for the service." The Patient Accounts Department will investigate the financial ability of each patient to pay for services and will provide financial counseling in order to ensure that the patient obtains any eligible medical coverage through their employer, the Federal Government, the Department of Human Services, or the Hospital's Community Free Care". SchH_P06_S00_L02 Schedule H, Part VI, Line 2 The Hospital has an ongoing strategic planning process which assesses the needs of the community and the Hospital's plans for meeting those needs. This planning process includes evaluation of data provided by the Hospital Association of RI, the RI Dept of Health and othe agencies on healthcare trends in the community. The input of the City of Pawtucket as well as other community stakeholders is continuously sought. The plan is reviewed at a joint leadership retreat which includes leaders of the medical staff, administration and the Board of Trustees. The Hospital has a strong community Board of Trustees which insures that the needs of the community are represented in the governance of the Hospital. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 The following procedures are followed to inform patients of their eligibility for assistance. Notification of Free Care is posted at every registration area throughout the MHRI system. The notice is posted in English, Spanish and Portuguese and has the telephone number of the Financial Counselor. The Notice of Charity Care is printed on the patient's billing statement. The Emergency Department Clinicians are educated in regard to proper referral process. If the patient states that they are uninsured and need toseek Charity Care through discussion with the clinician then they will be referred to the Family Care Center at Memorial Hospital. We pre-screen all self pay Emergency Department patients for Community Free Services. If they pass the screening they are sent to the financial counselor for assistance in filling out any necessary forms. The hospital staffs a Financial Assistance Counselor in our Family Care Center t qualify patients for medical assistance or free care. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 The following cities and towns in the State of RI are within the primary service area of the hospital: Pawtucket, Central Falls, Cumberland, East Providence, Riverside, Rumford and Lincoln. In addition the hospital serves the following cities and towns in Massachusetts: Attleboro, Seekonk, North Attleboro and Plainville. The majority of the patients served during the current fiscal year were from the city of Pawtucket (59%) followed by Central Falls (16%). The city of Pawtucket has a population of approximately 71,000 and is the fourth largest city in the state. Pawtucket was a major center of manufacture of cotton textiles during the American Industrial Revolution. Slater Mill built in 1793 by Samuel Slaterin downtown Pawtucket was the first fully mechanized cotton spinning mill in America. The textile business in Pawtucket declined during the 1930's with many manufacturers closing or moving their facilities. As of September 2012 the city's unemployment rate was 10%. According to the 2010 census the median income for a household in the city was $31,775 and the median income for a family was $39,038. Males had a median income of $31,129 versus $23,391 for females. The per capita income for the city was $17,008. About 14.9% of families and 16.8% of the population were below the poverty line including 24.5% of those under age 18 and 15.2% of those 65 or over. The racial makeup of the city is 75.39% white, 7.31% African American, 10.75% from other races and 5.34% from two or more races. Hispanic of any race were 13.9% of the population, 20.6% of Pawtucket residents are French or French-Canadian descent and 11.6% of Portuguese descent. The hospital operates the Notre Dame Ambulatory Center in Central Falls, RI. Central Falls has a population of 19,042 and represents approximately 16% of the hospital's discharges. The median income for a household in the city was $22,628 and the median income for a family was $26,844. About 25.9% of families and 29% of the population are below the poverty line including 40.8% of those under age 18 and 29.3% of those age 65 or over. The unemployment rate was 14.6% in September 2011. The racial makeup of Central Falls is 51.16% white, 5.82% African American, 28.35% from other races and 7.38% from two or more races. Hispanic or Latino of any race are 47.77% of the population. X 0 0 0 0 0 0 0 0 0 Arthur Deblois III 147693 0 0 0 0 0 0 0 2486 0 150179 0 0 0 Francis R Dietz 185900 0 0 0 0 0 0 0 0 0 185900 0 616516 0 Martin Tursky 231000 0 0 0 0 0 0 0 31514 0 262514 0 456543 0 Michael J Ryan 201663 0 0 0 0 0 0 0 42426 0 244089 0 227198 0 Michelle MacDonald Gallagher 266121 0 0 0 0 0 0 0 44582 0 310703 0 303156 0 Thomas Gough 187676 0 0 0 0 0 0 0 39556 0 227232 0 0 0 Jeffrey Borkan MD 284542 0 0 0 0 0 0 0 23290 0 307832 0 305790 0 Brian Wiley MD 298393 0 0 0 0 0 0 0 13832 0 312225 0 314874 0 Noubar Kessimian MD 271500 0 0 0 0 0 0 0 23028 0 294528 0 292159 0 John Riedel MD 283441 0 0 0 0 0 0 0 23268 0 306709 0 297998 0 Michael Pepi MD 275001 0 0 0 0 0 0 0 23099 0 298100 0 0 0 Rhode Island Health and Educational Building Corp 521300173 762243EY5 2003-12-24 25358159 Capital Renovations and Equipment Purchases 0 0 0 0 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b Once the independent audit is complete, the Controller of the organization gathers all the necessary information from various employees, departments and governing members. Several schedules are prepared to tie out different line items of the Form 990. The Controller then ulilizes an on-line software to complete the 990. The software used ensures that all required fields and supplemental schedules are attached. The software verifies when the form is complete and there are no errors. The draft 990 is then printed and submitted to the President for review. Copies are made and presented to each board member for their review. All discussion of the 990 is documented in the minutes. The President informs the Controller of any changes or additions to the Form that result from the Board review. The Controller makes all necessary changes and resubmits to the President for signature. Once signed the 990 is electronically submitted to the IRS. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c Every Board member, volunteer and employee is required to complete a Conflict of Interest Form on an annual basis. Any conflicts of interest must be disclosed. Signatures are required on all forms. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 The organization has an Executive Committee which also acts as a Compensation Committee for the compensation of the CEO. In order to determine compensation, surveys are conducted for area CEO's. The committee also utilizes 990's from other hospitals in the state of RI. The compensation is then approved by the Board of Directors and a written employement contract is signed. The CEO's salary is reviewed each year and is usually increased by a percentage no higher than the employees receive from the hospital. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 The Annual Reports for the hospital are posted on the orgaqnization's website. It is noted ont eh website that the hospital has a Conflict of Interest Policy and that the copies are available upon request. The phone numbers of the Public Relations Department are posted on the website as well. The PR Department has been instructed to direct any requests for Audited Financial Statements and or 990's to the Controller's office. Both are made available in hardcopy or electronically. F990_P11_S00_L05 Form 990, Part XI, Line 5 The Additional Minimum Pension Liability accounts for the majority of the decrease in Other Changes in Net Assets in the amount of $15,846,329. Unrealized gains account for the rest. RS Realty Company 111 Brewster Street Pawtucket RI 02860 050343043 Provide rental property for affiliated subsidiarys and employees RI 501(c)2 N/A Southeastern Healthcare System Inc 111 Brewster Street Pawtucket RI 02860 061476858 Develop and maintain an integrated healthcare system RI 501(c)3 11 Type II N/A SHS Ventures Inc 111 Brewster Street Pawtucket RI 02860 050510341 Provide Primary Healthcare Services RI 501(c)3 9 N/A Blackstone Health Inc 111 Brewster Street Pawtucket RI 02860 050427007 Provide a continuum of care RI 501(c)3 9 N/A Primary Care Centers of New England Inc 111 Brewster Street Pawtucket RI 02860 050423957 Provide Support Staff to affiliates RI N/A C 1 Memorial Physician Hospital Organization Inc 111 Brewster Street Pawtucket RI 02860 050462438 Health Service Contracting RI N/A C 0.5 0 1 1 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 RS Realty Company j 57600 Checks written RS Realty Company i 57600 checks received SHS Ventures Inc b 300000 cheks written SHS Ventures Inc k 38991 amount invoices for percentage of collections SHS Ventures Inc j 104790 rental agreement Southeastern Healthcare System Inc k 60000 checks received Blackstone Health Inc k 37080 checks received Primary Care Centers of New England Inc l 348819 actual cost of salaries and related benefits expensed as purchased services in outpatient areas of PT, OT Lab and Radiology. An extension was filed because Schedule H and Schedule of Community Bebefits would not be completed by May 15th.