2012-08-15T15:22:27-05:00 2011-09-30 Berry Dunn McNeil & Parker LLC 1000 Elm Street 15th Floor Manchester NH 03101 990 2010-10-01 030183721 Windsor Hospital Corporation WIND 8026746711 289 County Road Windsor VT 05089 Kevin Donovan 8026746711 2012-08-15 1 Rachel Williamson CPA 6036697337 2012-08-15 2010 2016-02-24 21:20:13Z Mt Ascutney Hospital & Health Cente Kevin Donovan 289 County Road Windsor VT 05089 52328077 0 X www.mtascutneyhospital.org X 1933 VT To improve the lives of those we serve. Our activities include providing healthcare. 17 14 582 150 0 0 297511 290914 47613164 44423161 322946 406880 78317 144149 48311938 45265104 0 0 0 0 29468470 28702159 0 0 65671 19087745 17125303 48556215 45827462 -244277 -562358 37681505 39107257 22218581 26322561 15462924 12784696 X Mt. Ascutney Hospital and Health Center's mission is to improve the lives of those we serve. 0 0 37696388 44974190 Mt. Ascutney Hospital and Health Center (MAHHC) operates a not-for-profit critical access hospital which provides primary and secondary health care. MAHHC's primary service area includes Windsor, Claremont, Woodstock, Hartland, Springfield, and Brownsville. The hospital provides essential healthcare services including emergency department, med/surg inpatient, med/surg outpatient, ancillary diagnostic tests, imaging/radiology procedures, and wellness/prevention services. MAHHC staffs a total of 25 acute med/surg beds, 10 acute rehabilitation beds, and 25 extended care beds. During the year there were 2,100 inpatient discharges, 800 outpatient surgeries, 64,000 outpatient lab tests, and 8,000 outpatient imaging procedures. MAHHC identified access to primary care as a central community need and is committed to providing the physician services of family practice, internal medicine and pediatrics in Windsor and Woodstock. During the year there were 42,000 primary care patient visits. MAHHC's service area includes a significant proportion of residents who are uninsured, underinsured, or dependant on Medicare/Medicaid benefits. MAHHC provides free care to patients who meet certain criteria. Foregone charges furnished under MAHHC's free care policy amounted to $1,111,000. 37696388 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 0 1 1 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 65 0 1 582 1 0 0 0 0 0 0 0 0 0 0 X 17 14 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X Theresa Kohler 8026747240 289 County Road Windsor VT 05089 Harold Pyke 1.00 X X 0 0 0 Nancy Loux 1.00 X X 0 0 0 Susan Plausteiner 1.00 X X 0 0 0 Paul Buff 1.00 X 0 0 0 Beach Conger MD 22.00 X 107246 0 27881 Larry Frazer 1.00 X 0 0 0 Pastor David Jones 1.00 X 0 0 0 Michael Newbold 1.00 X 0 0 0 Jane Osgood 1.00 X 0 0 0 Lynn Peterson MD 1.00 X 0 0 0 Alan Cummings 1.00 X 0 0 0 Catherine Schneider MD 1.00 X X 164736 0 0 Shelley Seward 1.00 X X 0 0 0 Nancy Formella 1.00 X 0 0 0 Diane Riley MD 40.00 X 464452 0 36986 Hon Donna Sweaney 1.00 X 0 0 0 Steven Smith 1.00 X 157382 0 64238 Donna VanFleet 1.00 X 0 0 0 David Russo MD 1.00 X 175612 0 71166 Kevin Donovan 40.00 X 1650 0 0 Wayne Bennett 40.00 X 0 0 0 Bennett Beres 40.00 X 132797 0 29330 Jill Lord 40.00 X 134435 0 851 Scott Schreier 40.00 X 90597 0 16136 Christopher Connor MD 40.00 X 347187 0 35238 Richard Meyer MD 40.00 X 256670 0 21107 Leonard Rudolf MD 40.00 X 489952 0 10975 Peter Rauert MD 40.00 X 241173 0 43355 Glen Neale MD 40.00 X 376497 0 52717 Richard Slusky 40.00 X 325127 0 28290 Jeanne McNeil 40.00 X 154829 0 28987 Michael Long 40.00 X 45162 0 5781 3620342 0 467257 35 1 1 1 Emergency Services of New England Inc PO Box 12 Chester VT 05143 Physician Assistance for Emergerncy Room 795422 Valley Regional Hospital 243 Elm Street Claremont NH 03743 Provide Surgeons for Hospital 355632 Staffing Solutions of Vermont 2704 Church Hill Road Woodstock VT 05091 Provide Agency Nurses 318110 University of Vermont TSPIMF 280 East Avenue Burlington VT 05401 Maintenance Contractor 123548 Lora Kent Smith PO Box 71 Canaan NH 03741 Consultant 110500 9 135705 155209 16223 290914 Net Patient Service Re 900099 43832324 43832324 Community Health Team 900099 138999 138999 Miscellaneous Revenue 900099 130854 130854 Cafeteria & Dietary Se 900099 105732 105732 Purchase Discounts 900099 103929 103929 111323 111323 44423161 309910 309910 114126 114126 114126 114126 7139862 8524 7051487 -71 88375 8595 96970 96970 41580 11557 30023 30023 45265104 44423161 0 551029 1042361 636565 405796 20905576 17550788 3312782 42006 1336765 1082780 253985 3808326 3109936 698390 1609131 1303396 305735 84238 84238 164271 164271 3796920 2861969 923219 11732 31533 28605 2928 1010942 1008572 2370 1133868 436675 697193 63597 35278 28319 251727 251727 1864607 1864607 335109 141300 193809 Medical/Surgical suppli 4131805 4113140 18665 Physician Fees 1906708 1906708 Software expenses 544282 124012 420270 Supplies 490023 317520 169395 3108 Dues and Subscriptions 384116 63977 320139 931557 887438 40592 3527 45827462 37696388 8065403 65671 1563 1601 4473870 5796450 5626 6383142 5437430 63938 14037 596225 606056 539577 399107 31007427 17368200 12509935 13639227 9334400 9618618 1800789 1714139 1972440 1880592 37681505 39107257 4715059 4360185 9477506 9968480 8026016 11993896 22218581 26322561 X 9260218 6690592 491962 464786 5710744 5629318 15462924 12784696 37681505 39107257 X -562358 -2115870 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 18871 18871 0 Explanation of Other Lobbying Activities: Part II-B, Line 1i: The Hospital paid $76,420 in the form of dues to the Vermont Association of Hospitals and Health Systems (VAHHS), approximately 22% of those dues were reported as related to lobbying expenses. VAHHS is a member-owned organization devoted to improving the health status of communities throughout Vermont through activities which include advocacy, policy development, education and research. The Hospital also paid $8,964 in the form of dues to the American Hospital Association (AHA), approximately 24% of those dues were reported as related to lobbying expenses. 5787015 -81057 5705958 5710296 76719 5787015 5634030 76266 5710296 0.98660 0.01340 0 0 75418 75418 19339684 10345812 8993872 9263081 6450075 2813006 2329244 572313 1756931 13639227 Other Liabilities 950475 Pension Liability 7907005 Interest Rate Swap 762244 Estimated Settlements with Third Parties 2374172 11993896 45265104 45827462 -562358 -266627 -1849243 -2115870 -2678228 45063146 35421 35421 45027725 27969 209410 237379 45265104 45716625 0 45716625 27969 82868 110837 45827462 Description of Intended Use of Endowment Funds: Part V, Line 4: In general, the amount of the original gift and any required accumulations by the donor are not expendable. However, the market value of the fund may fall below that amount depending on current financial conditions in the underlying investments. Under the policy of the Hospital, the endowment assets are invested moderately with the intent of providing a predictable stream of funding to the Hospital. The Hospital invests in equity funds, bond funds and money market investments to achieve its long-term return objectives within limited risk constraints. Actual returns in any year may vary from budgeted amounts due to market fluctuations. Part XI, Line 8 - Other Adjustments: Unrealized Loss on Interest Rate Swap -49,637. Equity in Income of Subsidiaries -25. Change in Funded Status of Pension Plan -1,724,488. Unrealized Appreciation in Charitable Remainder Trust -5,224. Unrealized Appreciation in Beneficial Interest in Perpetual Trusts -81,426. Fundraising expenses 11,557. Part XII, Line 2d - Other Adjustments: Fundraising Expenses 11,557. Net assets released from restrictions 23,864. Part XII, Line 4b - Other Adjustments: Development Department Expense 82,868. Temporarily restricted contributions 76,905. Unrealized loss on interest rate swap 49,637. Part XIII, Line 2d - Other Adjustments: Fundraising Expenses Part XIII, Line 4b - Other Adjustments: Development Department Expense 82,868. Golf Tournament 41580 41580 435 3340 5439 2343 41580 41580 435 3340 5439 2343 11557 30023 1 1 1 X 1 X 1 1 1 0 1 1 686626 686626 0.01500 7016986 4572223 2444763 0.05330 7703612 4572223 3131389 0.06830 222497 222497 0.00490 113192 113192 0.00250 9916071 7304212 2611859 0.05700 8925 8925 0.00020 10260685 7304212 2956473 0.06460 17964297 11876435 6087862 0.13290 1 1408452 18628887 17616573 1012314 X 1 1 1 1 Windsor Hospital Corporation

289 County Road Windsor VT 05089

X X X X Skilled nursing facility NA 1 Part I, Line 7: A cost accounting system was used to calculate the amounts reported in the table. The cost accounting system addresses all patient segments. A cost-to-charge ratio was used. Part III, Line 4: Management provides for probable uncollectible amounts through a charge to operations and a credit to a valuation allowance 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 valuation allowance and a credit to accounts receivable. The costing methodology used above was the cost to charge ratio. Part VI, Line 3: The Hospital posts its charity care policy on its website. Part VI, Line 4: MAHHC's primary service area includes Windsor, Claremont, Woodstock, Hartland, Springfield, and Brownsville. Part VI, Line 6: The Windsor Community Health Clinic at Mt. Ascutney Hospital was established to serve members of our community who are not covered by Medicaid, VHAP, and private insurance, and who do not have the financial resources to pay for healthcare services. The Clinic offers free clinic appointments to members who have no insurance, or are under-insured and meet certain income requirements. X X X X 0 0 0 0 0 0 0 0 0 Catherine Schneider MD 164736 0 0 0 0 0 0 0 0 0 164736 0 0 0 Diane Riley MD 464222 0 0 0 230 0 9800 0 27186 0 501438 0 0 0 Steven Smith 157382 0 0 0 0 0 0 0 0 0 157382 0 0 0 David Russo MD 175612 0 0 0 0 0 0 0 0 0 175612 0 0 0 Bennett Beres 132581 0 0 0 216 0 5382 0 23948 0 162127 0 0 0 Christopher Connor MD 297401 0 49540 0 246 0 9800 0 25438 0 382425 0 0 0 Richard Meyer MD 256038 0 0 0 632 0 9800 0 11307 0 277777 0 0 0 Leonard Rudolf MD 445655 0 44000 0 297 0 9800 0 1175 0 500927 0 0 0 Peter Rauert MD 240936 0 0 0 237 0 8028 0 35327 0 284528 0 0 0 Glen Neale MD 343497 0 33000 0 0 0 0 0 52717 0 429214 0 0 0 Richard Slusky 196723 0 0 0 128404 0 0 0 28290 0 353417 0 0 0 Jeanne McNeil 154602 0 0 0 227 0 0 0 28987 0 183816 0 0 0 Supplemental Information Part III Catherine Schneider was paid $164,736 in compensation and benefits by Valley Regional Hospital, an unrelated organization, for her services as a physician. She was not compensated for her duties as a trustee. Steven Smith and David Russo were paid $221,620 and $246,777, respectively, in compensation and benefits by Dartmouth Hitchcock Medical Center, an unrelated organization, for their services as physicians. They were not compensated for their duties as trustees. Kevin Donovan was paid $114,166 in compensation and benefits by Dartmouth Hitchcock Medical Center, an unrelated organization, for his services as CEO. Vermont Educational and Health Buildings Financing Agency 237154467 2010-02-05 9244000 Refinancing of 2004 and 2005 Bonds 0 0 0 9244000 128133 1 0 1 1 0 0 0 0 1 0 1 0 0 0 0 Form 990, Part VI, Section B, line 11 The Form 990 is reviewed and approved by the Finance Committee of the Board. The Board receives a copy of the final version and it is discussed at the Board meeting. Form 990, Part VI, Section B, line 12c The Finance and Audit Committees monitor and report to the Board of Directors. Form 990, Part VI, Section B, line 15 The Executive Committee of the Board meets annually to review compensation for the CEO, using independent surveys of area compensation for executives of various sized hospitals. Other officers and key employees salaries are determined, by the HR department, using comparable market data. Form 990, Part VI, Section C, line 19 All internal policies, governing documents, and financial statements are made available upon request Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -266,627. Unrealized Loss on Interest Rate Swap -49,637. Equity in Income of Subsidiaries -25. Change in Funded Status of Pension Plan -1,724,488. Unrealized Appreciation in Charitable Remainder Trust -5,224. Unrealized Appreciation in Beneficial Interest in Perpetual Trusts -81,426. Fundraising expenses 11,557. Total to Form 990, Part XI, Line 5: -2,115,870. Form 990, Part XII, Line 2c The organization did not changes its oversight or selection process during the tax year. Historic Homes of Runnemede 40 Maxwell Perkins Lane Windsor VT 050891206 237396147 Providing Services for the Aging VT 501(c)(3) Supported Windsor Hospital Corporation 0 Mount Ascutney Hospital Community Health Foundation Inc 289 County Road Windsor VT 05089 030300481 To provide healthcare services to the Windor, Vermont community VT 501(c)(3) Service Organization Windsor Hospital Corporation 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 Mt Ascutney Hospital Community Health Foundation Inc P 82599 FMV Historic Homes of Runnemede Inc P 88270 FMV