2012-07-30T09:33:01-05:00 2011-09-30 BAKER NEWMAN & NOYES BOX 507 PORTLAND ME 04112 990 2010-10-01 020222157 Monadnock Community Hospital MONA 6039247191 452 Old Street Road Peterborough NH 034581263 RICHARD SCHEINBLUM 6039247191 2012-07-20 1 Timothy R Hepburn CPA 2078792100 2012-07-20 2010 2016-02-24 21:20:13Z Peter L Gosline 452 Old Street Road Peterborough NH 034581263 82867196 0 X www.monadnockhospital.org X 1919 NH Critical Access Hospital serving the Monadnock Region of the State of New Hampshire. 13 10 758 125 0 0 3087080 1878155 71101565 73391780 840036 611666 864293 788518 75892974 76670119 0 0 0 0 37202773 37836736 24020 42108 432636 35526081 36056567 72752874 73935411 3140100 2734708 88337402 89519561 44617733 43706613 43719669 45812948 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 66489677 74178853 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 2011.Inpatient Services - includes intensive care, adult stays, pediatric stays, maternity/births, and skilled nursing. During the fiscal year the Hospital admitted 1,415 patients and recorded 4,912 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 14,187 visits to the ER in the fiscal year.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 four satellite practices located in Antrim, Jaffrey, New Ipswich, and Rindge. During the year, 124,419 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, 2,891 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, 30,687 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, 47,791 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, 94,353 member visits were recorded.Monadnock Community Hospital's financial grant program provides assistance with hospital and/or physician bills for qualifying patients. In fiscal year 2011, the organization recorded $3,194,000 in charges foregone based on established rates. The estimated cost incurred to provide these services was $1,957,022. 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 $2,166,082 in 2011. 66489677 1 1 0 1 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 77 0 1 758 1 0 0 0 0 0 0 0 0 0 0 X 13 10 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 CYNDY BURGESS 13.50 X X 0 0 0 MARYANN B HARPER 3.00 X X 0 0 0 ROBERT L EDWARDS 3.00 X X 0 0 0 STEVEN H REYNOLDS 8.00 X X 0 0 0 ROBERT TAFT ESQ 3.00 X X 0 0 0 NORMAN H MAKECHNIE ESQ 3.00 X X 0 0 0 ROBERT J CONDON JR 3.00 X 0 0 0 BARBARA R DUCKETT 3.00 X 0 0 0 ROBIN C EICHERT 3.00 X 0 0 0 CHERI FRY 3.00 X 0 0 0 DAVID A HEDSTROM DDS 3.00 X 0 0 0 CAROLE MONROE 3.00 X 0 0 0 JOHN HALEY MD 3.00 X 169867 0 18802 AMY PFEIL 3.00 X 0 0 0 JAMES D POTTER MD 3.00 X 167015 0 30890 CHARLES J SEIGEL MD 3.00 X 0 0 0 LUCAS SHIPPEE DO PART YEAR 50.00 X 240045 0 30504 PETER L GOSLINE 55.00 X X 272408 0 23939 RICHARD SCHEINBLUM 50.00 X 163600 0 8582 STEPHEN COFFMAN MD 50.00 X 422237 0 20039 RICHARD FRECHETTE MD 50.00 X 211782 0 34842 GREGORY KRIEBEL MD 50.00 X 209816 0 32068 MARK STEVENS MD 50.00 X 201900 0 34674 SACHIN DAVE MD 50.00 X 200225 0 24797 JAMES HURLEY MD 50.00 X 173176 0 33941 2432071 0 293078 40 1 1 0 MONADNOCK ORTHOPAEDIC ASSOCIATES 458 OLD STREET ROAD SUITE 200 PETERBOROUGH NH 03458 PHYSICIAN FEES 3039722 MONADNOCK REGION EMERGENCY PHYSICIANS 540 LAFAYETTE ROAD HAMPTON NH 03842 CONTRACT PHYSICIAN SERVICES 1596000 MONADNOCK ANESTHESIA ASSOCIATES C/O SURGICAL SUITE PETERBOROUGH NH 03458 CONTRACT PHYSICIAN SERVICES 1095483 HUTTER CONSTRUCTION PO BOX 257 810 TURNPIKE ROAD NEW IPSWICH NH 03071 GENERAL CONTRACTOR 728665 SODEXO INC & AFFILIATES 97 NORTH POLICY ROAD SALEM NH 03079 DIETARY/FOOD SERVICE MGMT 632821 19 18866 82500 1776789 1878155 NET PATIENT SERVICE RE 900099 71948625 71948625 OTHER OPERATING REVENU 900099 1443155 1443155 73391780 458355 458355 6338918 900 5822239 364268 516679 -363368 153311 153311 12015 18866 10570 1445 1445 CAFETERIA/VENDING MACH 900099 410126 410126 EMPLOYEE PHARMACY SALE 900099 376947 376947 787073 76670119 74178853 0 613111 1105867 613523 492344 29310065 26183028 2909289 217748 713310 639938 68022 5350 4682601 4057631 612311 12659 2024893 1782435 227996 14462 180839 4097 176742 49000 49000 42108 42108 5733829 5213340 520489 92901 92901 1414561 734146 649630 30785 741375 662641 78734 3091669 2860764 230905 88601 29053 59470 78 90108 60153 16585 13370 1006716 1006716 4866535 4664015 202520 463853 366596 97257 MED & PHARM SUPPLIES 6501262 6498030 3232 PROVISION FOR BAD DEBT 3742600 3742600 OTHER MED EXP/SERVICE C 3567186 3290710 194672 81804 NH MEDICAID ENHANCEMENT 3168993 3168993 DUES/LICENSES 338074 118977 218329 768 918465 699390 205571 13504 73935411 66489677 7013098 432636 9735266 9923746 9568104 5360993 1972789 473874 4831701 5226529 175953 129269 1240528 1364053 560078 604559 76470441 35780524 37376825 40689917 19158048 21146279 2685300 2736875 1032810 1863467 88337402 89519561 8196184 6091799 29042296 27914594 1040870 561375 6338383 9138845 44617733 43706613 X 33688418 37498743 3126586 1357888 6904665 6956317 43719669 45812948 88337402 89519561 X 2734708 -641429 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 389 0 1 12149 12538 0 Explanation of Other Lobbying Activities: Part II-B, Line 1i: 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: $8,807 AHA, Portion of dues available for lobbying: $3,342 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 $389. 10031251 884501 93759 2695306 8314205 10623404 1266761 200900 2059814 10031251 10282555 1164871 -100136 723886 10623404 0.16330 0.83670 0.00000 1 0 842124 842124 30689746 13008519 17681227 4374354 1045172 3329182 38920049 21726833 17193216 1644168 1644168 40689917 INTEREST RATE SWAP AGREEMENTS 4525901 ESTIMATED THIRD-PARTY SETTLEMENTS 4612944 9138845 76670119 73935411 2734708 80138 -721567 -641429 2093279 75596054 80138 80138 75515916 1154203 1154203 76670119 73502775 0 73502775 432636 432636 73935411 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, 2011 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 2008." Part XI, Line 8 - Other Adjustments: Change in fair value of interest rate swap agreements -721,567. Part XII, Line 4b - Other Adjustments: Fundraising Expenses 432,636. Decrease in fair value of interest rate swap agreement 721,567. Part XIII, Line 4b - Other Adjustments: Fundraising Expenses 432,636. X X X X X 1 Ghiorsi & Sorrenti 255 Madison Avenue Wyckoff NJ 07481 See Schedule G, Part IV 0 0 41035 0 41035 MCH GOLF CLASSIC 30881 18866 12015 5750 3153 1667 30881 18866 12015 5750 3153 1667 10570 1445 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 1735485 1735485 0.02470 6439136 4672321 1766815 0.02520 8174621 4672321 3502300 0.04990 986126 986126 0.01400 68375 68375 0.00100 1006821 1006821 0.01430 105123 105123 0.00150 2166445 2166445 0.03080 10341066 4672321 5668745 0.08070 1 2033379 184254 18831215 18715202 116013 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 13 Monadnock Orthopaedic Associates

458 Old Street Road Wellness Center Peterborough NH 03458

Medical practice Bond Wellness Center

458 Old Street Road Wellness Center Peterborough NH 03458

Fitness center and rehabilitation services Monadnock Regional Pediatrics

454 Old Street Road MAB Building Peterborough NH 03458

Physician practice Jaffrey Family MedicinePT Satellite

82 Peterborough Street Jaffrey NH 03452

Outpatient physician office Monadnock Family Care

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 Surgical Associates

454 Old Street Road MAB Building Peterborough NH 03458

Physician practice Monadnock Internists

454 Old Street Road MAB Building Peterborough NH 03458

Physician practice New Ipswich Family MedicinePT Satellite

821 Turnpike Road New Ipswich NH 03071

Outpatient physician office Monadnock Behavioral Health

458 Old Street Road Wellness Center Peterborough NH 03458

Physician practice Antrim Medical Group

12 Elm Street Antrim NH 03440

Outpatient physician office Rindge Family Practice

31 Sonja Drive Suite 2 Rindge NH 03461

Outpatient physician office 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 2011 are unreimbursed costs of $1,006,821 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 $ 3742600. 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) ($3,742,600). 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 Grant Program (FGP) 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 FGP 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 FGP 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 and published in a brochure that is attached to billing invoices and available 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 FGP and Medication Bridge Program.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). 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 Grant 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 FGP 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 Grant 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 6: 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 Grant 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 7: N/A Reports Filed With States Part VI, Line 7 NH X X X X 0 1 0 0 0 0 0 1 0 JOHN HALEY MD 165230 0 0 0 4637 0 5850 0 12952 0 188669 0 0 0 JAMES D POTTER MD 160816 0 0 0 6199 0 5684 0 25206 0 197905 0 0 0 LUCAS SHIPPEE DO PART YEAR 219261 0 0 0 20784 0 5741 0 24763 0 270549 0 0 0 PETER L GOSLINE 229340 0 25000 0 18068 0 8192 0 15747 0 296347 0 0 0 RICHARD SCHEINBLUM 163300 0 0 0 300 0 5768 0 2814 0 172182 0 0 0 STEPHEN COFFMAN MD 418531 0 3339 0 367 0 0 0 20039 0 442276 0 0 0 RICHARD FRECHETTE MD 205943 0 0 0 5839 0 7347 0 27495 0 246624 0 0 0 GREGORY KRIEBEL MD 204607 0 0 0 5209 0 7342 0 24726 0 241884 0 0 0 MARK STEVENS MD 197072 0 0 0 4828 0 7175 0 27499 0 236574 0 0 0 SACHIN DAVE MD 197736 0 0 0 2489 0 2962 0 21835 0 225022 0 0 0 JAMES HURLEY MD 168327 0 0 0 4849 0 6178 0 27763 0 207117 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 9/30/11 was $467,638. No premiums were paid during the fiscal year ended 9/30/11. 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 0.00000 0.00000 0.00000 1 0 0 0 0 0 0.00000 0.00000 0.00000 1 0 1 0 0 0 0 0 1 0 1 TRANSAMERICA 1.166700000000 1 0 0 Lara K Scheinblum MD Spouse to CFO 104529 Dr. Scheinblum is the spouse of Richard Scheinblum, who is MCH'S CFO and listed in Part VII. Dr. Scheinblum 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 2010 compensation reported for Dr. John Haley and Dr. Lucas Shippee was paid by Monadnock Community Hospital for their services as full-time physicians. Dr. Haley and Dr. Shippee were not compensated for their services as ex-officio voting members of MCH'S Board of Trustees. Dr. James Hurley is listed as a former board member in accordance with IRS instructions. All of the 2010 compensation reported for Dr. Hurley was paid by Monadnock Community Hospital for his services as a full-time physician. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized gains on investments: 80,138. Change in fair value of interest rate swap agreements -721,567. Total to Form 990, Part XI, Line 5: -641,429. 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 9/30/10 and 9/30/11. Disposal of Property and Equipment Form 990, Part VIII, Line 7C, Column (ii) The loss of $363,358 reported for other assets is the remaining book value of depreciated assets disposed of upon the move into the new building and the disposal of software that no longer met the needs of the Hospital. 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