2011-08-11T10:35:19-05:00 2010-09-30 Bollus Lynch LLP 89 Shrewsbury Street Worcester MA 01604 990 2009-10-01 042126583 ATHOL MEMORIAL HOSPITAL INC ATHO 9782493511 2033 MAIN STREET ATHOL MA 01331 DEAN FLEMING 9782493511 2011-08-09 1 Barbara E King 5087557107 2011-08-03 2009 2016-02-24 21:20:13Z DEAN FLEMING 2033 MAIN STREET ATHOL MA 01331 21937233 0 X www.atholhospital.org X 1918 MA HOSPITAL 20 20 287 0 -20900 -20900 292977 184350 21697629 21427842 43022 54061 -17423 135367 22016205 21801620 0 0 13104926 11706060 0 0 10218592 10800427 23323518 22506487 -1307313 -704867 12848504 11953499 6568384 6331500 6280120 5621999 TO PROVIDE INPATIENT, OUTPATIENT, EMERGENCY CARE AND HOME CARE SERVICES FOR RESIDENTS OF WORCESTER AND FRANKLIN COUNTIES. 0 0 19500615 21427842 athol memorial hospital is a critical access hospital (CAH) serving the nine towns of the north quabbin region. the areas relatively small population (28,000) is dispersed over a large geographic area ( 357 square miles). inherent in the hospital mission of providing healthcare services are efforts to help improve the health and lives of our community. this intent is the framework for our community benefits activities.senior transportation van - one of our major community benefits programs is the athol memorial hospital senior transportation van, offering free door to door service to medical appointments for seniors (65+) to access care. many of the communities in the hospitals service area (which includes the towns of athol, erving, new salem, orange, pertersham, phillipston, royalston, warwick and wendell) are not served by the existing transportation and non-driving residents are dependent on family and neighbors for rides to medical appointments. the service has grown considerably since the van began operation in March of 2002. at that time, we provided service on a limited schedule: Tuesday and Thursday from 8 A.M. to 12 p.m. and by special arrangement. within six months service hours expanded to Monday through Friday from 7 a.m. to 3 p.m. to meet increase demand and since july 2004, our service hours increased by an additional five hours per week (until 4 p.m. each day).the average number of trips per month has increase to 196, up from last years 140, and the previous years 90 trips per month. this demonstrates the increasing value of the athol memorial hospital senior transportation van as a significant and reliable means of transportation for our area seniors in providing rides to the hospital and medical arts building for appointments and treatment. the hospital maintains an internal system for ride requests, dispatch, and tracking; a dedicated phone line for ride request phone calls; and a specially trained driver to guarantee safety and demonstrate sensitivity to persons with disability issues. publicity for the senior transportation van is completely designed and produced in-house to minimize costs. in previous years, advertising was through local media, and distribution of brochures and flyers throughout the community. target market opportunities, such as flyer distribution through council on aging programs and the good life senior newspaper, have also been used when appropriate.support group sponsorship - the hospital provides free space and publicity to the following support groups, which are open to the public. hospital staff members facilitate some of the groups, as indicated:acoa alanon- for adults raised by alcoholic caretakers/parentsalanon- for family and friends of people with alcohol related issuesals support - for people, caretakers, and family seeing help in coping with this illnessbereavement support - for people seeking compassionate environment to help cope with the death of a loved one. facilitated by kate hart, licsw, hospital social worker.cancer support - facilitated by the amh oncology clinics bonnie frank hume, licsw.diabetes education and support - offers practical information and caring emotional support. led by marjorie sobil, rd, ldn, hospital dietitian.healthy hearts and lungs club - for anyone with cardiac or lung disease or at risk for developing the diseases. facilitated by hospital staff members joyce sawyer, bsn, and ron rayment, rrt.smart recovery - is a cognitive/rational approach to overcoming addictive behavior and maintaining abstinence. facilitated by hospital staff member marcia maglione flynn.smoking cessation - facilitated by tim sweeney, tobacco treatment specialist. athol memorial hospital provides a stipend to the facilitator, who is not a hospital staff member.healthcare scholarship program - athol memorial hospital offers scholarships to local area students earning a degree in healthcare related fields. the purpose of the athol memorial hospital scholarship program is to encourage area residents to enter and train in healthcare fields. persons working toward an associates, bachelors, master, or other healthcare degree certification will be considered. qualifying areas of study include nursing (rn, lpn, or cna) clinical laboratory, radiology technologies, pharmacy, respiratory, occupational, physical and speech therapies, and registered dietician, amongst others. participation in any healthcare related field will be considered for this program. students planning to enter, or matriculating toward, a healthcare related degree program are invited to apply. the program is available to all residents of the north quabbin region, excluding current hospital staff. hospital staff members are eligible for other hospital-sponsored programs to help with educational costs. scholarships are awarded on a combination of academic achievement, extracurricular and community activities, references and students essays and not on a financial need basis.outreach activities - athol memorial hospital actively pursues educational and service opportunitites in the community. many hours are contributed to activities in the community such as wellness week at a local high school, health and safety fairs, and seminars on health related topics. the hospital also provides blood pressure and/or glucose and cholesterol screenings at senior clinics and community events. staff members visit local area schools to teach about topics such as recognizing signs and symptoms of stroke, healthy eating, and careers in healthcare. the hospital supports community initiatives such as the healthy smiles dental fair, senior health and fitness day, healthy kids day and is a major participant in the area annual food-a-thon. the hospital also sponsors brown bag medication checkups where individuals may bring in their prescriptions for pharmacists to review. 19500615 1 1 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 27 0 1 287 1 1 1 0 0 0 0 1 0 0 0 0 20 20 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 MA X DEAN FLEMING 9782493511 2033 MAIN STREET ATHOL MA 01331 REBECCA BIALECKI 2.00 X 0 0 0 ROBIN BROOKS 2.00 X 0 0 0 CHENEY CASTINE 2.00 X 0 0 0 LAWRENCE ESTELLE JR 2.00 X 0 0 0 DANILO FUNA MD 2.00 X 0 0 0 ROBERT KNIGHT MD 2.00 X 0 0 0 JANET KRAFT 2.00 X 0 0 0 ROY LAKE 2.00 X 0 0 0 WAYNE MILLER MD 2.00 X 0 0 0 DONALD MRUK MD 2.00 X 0 0 0 CURTIS RAND 2.00 X 0 0 0 TIMOTHY SOULE-REGINE MD 2.00 X 0 0 0 DAVID SPACKMAN 2.00 X 0 0 0 DOUGLAS A STARRETT 2.00 X 0 0 0 YOGENDRA THAKER MD 2.00 X 0 0 0 JAMES MEEHAN JR 2.00 X 0 0 0 WILLIAM MEEHAN 2.00 X 0 0 0 MOHSEN NORELDIN MD 2.00 X 0 0 0 LAUREY KENERSON 2.00 X 0 0 0 STEVEN PENKA 40.00 X 148089 0 0 DEAN FLEMING 40.00 X 128328 0 0 mark wu md 40.00 X 406302 0 0 682719 0 0 3 0 1 0 baystate emergency service 44 crosby road ashburnham MA 01430 er doctors 1564206 robert sprague md 20 comes street gardner MA 01440 physician 418456 cpsi po box 850309 mobile AL 36685 it 236267 north quabbin computer 119 new athol road orange MA 01364 it 132590 4 184350 184350 PATIENT SERVICE REVENU 624100 21427842 21427842 21427842 54061 54061 270980 135613 135367 135367 -20900 156267 21801620 21427842 -20900 210328 9584343 8183741 1400602 1369784 1169611 200173 751933 642050 109883 124737 124737 36000 36000 739600 729197 10403 42935 42935 30367 30367 429163 379489 49674 25543 19477 6066 103707 103707 474313 397448 76865 222219 69116 153103 SUPPLIES 2424089 2328848 95241 PHYSICIAN EXPENSE 2200119 2069872 130247 BAD DEBTS 1361570 1361570 DRUGS 874800 874800 SERVICE CONTRACTS 788787 490485 298302 922478 681204 241274 22506487 19500615 3005872 0 440830 502729 5386940 4631752 519453 466543 120817 186363 18556150 13429167 5388081 5126983 992383 1039129 12848504 11953499 3745645 3282745 1445461 1012345 1377278 2036410 6568384 6331500 X 5174274 4395417 113463 187453 992383 1039129 6280120 5621999 12848504 11953499 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 992383 46746 1039129 1013033 -20650 992383 1.00000 0 1 1 71990 71990 6872045 4084196 2787849 10111223 9344971 766252 1500892 1500892 5126983 pooled investments 1039129 F 1039129 due to third party payors 956410 due to parent 1080000 2036410 21801620 22506487 -704867 46746 46746 -658121 21983979 182359 182359 21801620 0 21801620 22642100 135613 135613 22506487 0 22506487 Part V, Line 4: Description of Intended Use of Endowment Funds: endowment assets are comprised of beneficial interests in perpetual trusts. the hospital is named as the beneficiary of this perpetual trust. under the terms of the trust, the hospital receives quarterly distributions equal to 40% of income from the trust. such distributions are recorded as unrestricted income when received. although the assets of the underlying trust are not owned or controlled by the hospital, the fair value of the trust's assets has been used as the basis for recording the hospital's interest in the future income of the trust. the beneficial interest, and any subsequent adjustments tot he fair vaue of the trust assets, is considered permanently restricted. 0 1 1 4099850 247633 3852217 0.17120 4981806 4690754 291052 0.01290 96024 104403 -8379 0.00000 9177680 5042790 4134890 0.18410 9177680 5042790 4134890 0.18410 1 1361570 142520 4315580 4272424 43156 X 1 1 athol memorial hospital

2033 main street athol MA 01331

X X X X Part III, Line 4: Bad debts are determined after a set procedure that involves several statements, letters and calls which are determined by a credit collection policy that has been approved by the Commonwealth of Massachusetts Attorney Generals office. After the accounts have been determined as bad debts they are forwarded to a collection agency for the final attempts at settlement. the amount on this form is the balance recorded as a provision of bad debts noted on our financial statement. Part III, Line 8: Athol Memorial HOspital is a "critical access hospital" that is reimbursed by medicare at 101% of medicare costs. The amount of lines 5 and 6 are actual reimbursements from the medicare filed 2552 fy 2010 report. Part VI, Line 2: the mission of the community benefits program is to encourage healthy lifestyles through outreach, education, and support to the communities we serve (Athol, Erving, New Salem, Orange, Petersham, Phillipston, Royalston, Warwick and Wendell).The underlying principle of encouraging healthy lives guides our existing community benefits activities and will be carried forward as we formalize our community benefits plan.the hospital spearheaded a community health needs assessment in 2008 for the specific purpose of identifying unmet needs in the community and to inform future community benefits activities. this exercise was critical to the hospital's community benefits process, an assessment had not been conducted in seven years.The community health needs assessment report was presented to the steering committee in September 2008. a similar steering committee will reconvene in another three years to direct the next community health needs assessment. the report was also presented to the hospital's board of trustees at their january 2009 meeting and accepted unanimously. the board determined that the report should be forwarded to the hospital's strategic planning committee, a sub-committee of the hospital's board of trustees. the board of trustees further determined to form a community benefits advisory committee that would review the reports and recommend a community benefits plan to the strategic planning committee. the community benefits advisory committee is comprised of members of the community health needs assessment steering committee, the hospital board of trustees, hospital staff, and community groups. Part VI, Line 3: athol memorial hopsital has two employees whose primary position is to educate and assist patients with questions on health care. they work closely with central registration and patient accounting personnel to protect the hospital's financial interest with regard to persons who present for services, and have no health insurance or may qualify for assistance as underinsured.They maintain knowledge of mass health virtual gateway and commonwealth connector application processes and health insurance products available; maintain knowledge of which commonwealth care and commonwealth choice plans athol memorial hospital and its staff physicians contract with in order to advise applicants of choices available within our nine-town area. They Assist patients to apply for Masshealth, commonwealth care, commonwealth choice, and uncompensated care by completing a virtual gateway common intake form or masshealth mbr or smbr form. They assist patients to apply for commonwealth care and commonwealth choice plans via the commonwealth connector. They Assist patients with re-enrollment and completion of masshealth review process and assists patients referred by nursing, social services, or other clinical areas that may be unable to afford prescription medications and may be eligible for assistance through the drug manufacturer or any other source. They assist patients who have insurance but may be unable to afford co-insurances or deductibles assessed by the health insurance plan to apply for additional asistance through health safety net. They make every effort to establish contact with any patient or their guarantor/guardian when admission to inpatient status has occurred and availability of health insurance coverage has not been established or declared health insurance is determined to be inactive. They contact patients who have been approved for masshealth, commonwealth care or commonwealth choice to offer assistance to help ensure patient activates and maintains coverage. They perform outreach by mailing information flyers, telephone calls, etc. patient accounting staff will forward names of patients, whom it has established are uninsured or underinsured, for outreach contact.they review daily private pay accounts for assigned segment of alpha to ensure accuracy;performs the necessary collection steps as specified in the hospital credit and collection policy (i.e. attempt phone contact, and send deliquent account reminder letters).They review patient pay statement list weekly to assure statements are being sent to the appropriate patients. Part VI, Line 4: athol memorial hospital is an independent, not-for-profit, critical access hospital primarily serving the nine towns of the north quabbin region (athol, erving, new salem, orange, petersham, phillipston, royalston, warwick and wendell).The area's population (approximately 28,000) is dispersed over a large geographic area (357 square miles). seven of the service area towns are sparsely populated, rural communities. the majority of the area residents live in the towns of athol and orange, former industrial centers where now only a few factories and major businesses remain. the service area sits across two counties, at the northwest corner of worcester county and the northeast corner of franlin county.athol memorial hospital is firmly rooted in the community. the hospital opened its doors in 1950 as the result of a grass roots effort to bring healthcare services into the area. the hospital is the region's primary acute care facility and the second largest private employer. strong ties to the area and institution exist within the staff and patients alike, as neighbors are often caring for neighbors. this spirit of community is inherent in the hospital's mission and has provided the framework for our community benefits activities to date.in fy 2010 the hospital contributed 9,530 hours of community benefit time, beyond its direct scope of services to efforts in and for the community. this included health and wellness education; cardiopulmonary resuscitation (CPR) training (AMH is a regional training center for the american heart association); flu and blood pressure clinics; support for a community food drive, dental fair, senior health fairs and other events; work force development through scholarships, externships and interships; assistance in accessing healthcare through direct referral; marketing and enrollment in health insurance programs; providing meeting space for support groups and other community entities, and substantial emergency preparedness efforts. MA X X 0 0 0 0 0 0 0 0 0 mark wu md 406302 0 0 0 0 0 0 0 0 0 406302 0 0 0 Form 990, Part VI, Section A, line 2 james meehan jr, (chairman) and william meehan (vice-chairman) are brothers Form 990, Part VI, Section B, line 11 FORM 990 WILL BE CIRCULATED TO THE BOARD IN ELECTRONIC FORMAT PRIOR TO FILING. COMMENTS AND QUESTIONS WILL BE ADDRESSED BY THE CFO. ONCE APPROVED, THE RETURN WILL BE FILED. Form 990, Part VI, Section B, line 12c THE BOARD OF TRUSTEES REVIEW THE ORGANIZATION'S CONFLICT OF INTEREST POLICY ANNUALLY IN ORDER TO ENSURE THAT THE ORGANIZATION'S BOARD OF TRUSTEES, OFFICERS, AND EMPLOYEES ARE REGULARLY AND CONSISTENTLY MONITORING AND ENFORCING IT. Form 990, Part VI, Section B, line 15 SALARIES ARE DETERMINED BY THE BOARD OF DIRECTORS CONSIDERING COMPARABLE SALARY INFORMATION FOR OFFICERS OF OTHER ENTITIES OF A SIMILAR SIZE AND LEVEL OF ACTIVITY. Form 990, Part VI, Section C, line 19 REQUESTS FOR REVIEW OF THE FORM 990 ARE FORWARDED TO THE CFO WHO MAKES ARRANGEMENTS FOR THE REVIEW. greater quabbin health system 2033 main street athol MA 01331 222720658 manage, conduct fundraising, coordinate planning for athol memorial hospital MA 501(c)(3) 170(b)(1)(a)(vi) quabbincare inc 2033 main street athol MA 01331 222720562 inactive MA 501(c)(3) 170(b)(1)(a)(vi) greater quabbin health system 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 greater quabbin health sustem E 1080000