2020-07-15T12:18:18-05:00 2019-06-30 010494526 BAKER NEWMAN & NOYES LLC 650 ELM STREET SUITE 302 MANCHESTER NH 03101 990 2018-07-01 020222791 Alice Peck Day Memorial Hospital ALIC 6034483121 10 Alice Peck Day Drive Lebanon NH 03766 Susan E Mooney MD MS President & CEO 6034483121 2020-07-14 1 Nicholas E Porto P01310283 8002447444 2020-07-14 208.105.168.164 2020-07-14 10:03:08 ED P 3452BD8595D9AC820B41F271E29CE8BF50AD3EDC DA1D1F22D002DE74304CAE64996AD19EA354FE22 2018 2020-09-23 17:36:50Z Susan E Mooney MD MS 10 Alice Peck Day Drive Lebanon NH 03766 74909011 0 X www.alicepeckday.org X 1943 NH To improve the health and wellbeing of our community 21 13 576 70 26 0 1105059 682127 70526144 73224665 -58871 1015717 29303 -13498 71601635 74909011 41972 220565 0 0 36709910 43750730 0 0 212314 32554938 32013891 69306820 75985186 2294815 -1076175 60180132 76398452 38514635 47949645 21665497 28448807 X To improve the health and wellbeing of our community 0 1 71171617 220565 73224665 Alice Peck Day Memorial Hospital is a community-based critical access hospital operating in Lebanon, NH. The Hospital began as a small cottage hospital in 1932. From its humble beginnings, Alice Peck Day has continually demonstrated its commitment to provide patient-focused health care services which improve the quality of life within its community and promote wellness for all. Alice Peck Day Memorial Hospital is a charitable health care organization which is dedicated to serving its community. This commitment includes granting credit to patients, substantially all of whom are local residents. The Hospital provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than the established rates. Collections are not pursued for amounts determined to qualify as charity care. The Hospital maintains records to identify and monitor the level of charity care it provides. These records include the amount of charges foregone for services and supplies furnished under its charity care policy, the established costs of the services and supplies provided, and equivalent service statistics. For the fiscal year ended June 30, 2019, charity care at a cost of $323,389 was provided to eligible patients. Estimated costs incurred in excess of payment for inpatient and outpatient services for Medicaid patients in fiscal year ended June 30, 2019 were $2,024,779. In addition to the charity care services described above, the Hospital provided a number of other services for which little or no payment was received. These included: the Upper Valley Smiles dental program of free oral health education, screenings, and preventive treatment offered to low-income children in ten local elementary schools; Elder Friends, a program matching volunteers one-on-one with isolated, home-bound seniors; Lebanon Lunch Friends, which provides 140 free lunches per day, five days each week to eligible local children who no longer have access to free or reduced-price meals at school during the summer; the Tobacco 21 initiative, which involved forming a community coalition to consider supporting a City of Lebanon ordinance that would restrict tobacco and e-cigarette sales to individuals 21 years and older. As a local hospital, Alice Peck Day works closely with community organizations to address community needs. Organizations that were beneficiaries of hospital staff time, meeting space, cash and/or materials included: Alcoholics Anonymous, American Red Cross, Good Neighbor Health Clinic, Headrest, Hanover Chamber of Commerce, Lebanon Chamber of Commerce, Lebanon School District, Lebanon Department of Recreation, the Upper Valley Public Health Council, and Vital Communities. In certain instances, assistance was provided to the community for which no value can be placed. This assistance included leadership in identifying community needs, staff commitment to volunteer for community organizations, and advocacy and support for individuals affected by the social determinants of health. Alice Peck Day considers caring for our community a special responsibility that we are honored to fulfill. 71171617 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 1 X 104 0 1 576 1 0 0 0 0 0 0 0 0 0 0 0 0 X 21 13 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X X Todd Roberts 6034483121 10 Alice Peck Day Drive Lebanon NH 03766 X Clayton R Adams Trustee 1.00 0.00 X 0 0 0 George T Blike Trustee 1.00 40.00 X 0 488454 89309 Rebecca W Holcombe Trustee 1.00 0.00 X 0 0 0 John P Houde MD Trustee; Orthopaedic Surgeon 40.00 0.00 X 516460 0 47438 Patrick F Jordan Trustee 1.00 40.00 X 0 595188 58364 Lisa Kettering Trustee (end 6/19) 1.00 0.00 X 0 0 0 Sara L Kobylenski Trustee 1.00 1.00 X 0 0 0 Michael T Lynch Trustee 1.00 0.00 X 0 0 0 Anne D MacEwan Trustee 1.00 2.00 X 0 0 0 Mark E Melendy Trustee (end 12/18) 1.00 4.00 X 0 0 0 Edward J Merrens Trustee (end 12/18) 1.00 40.00 X 0 710556 48934 Tina E Naimie Trustee 1.00 40.00 X 0 257299 28591 Mary M Oseid Trustee 1.00 40.00 X 0 276886 60259 Scott W Rodi Trustee 1.00 40.00 X 0 332446 60374 John L Scherding Trustee 1.00 1.00 X 0 0 0 Jennifer Sage Schiffman Trustee 1.00 0.00 X 0 0 0 Charles J Wheelan Trustee 1.00 0.00 X 0 0 0 Greg W Lange Chair 2.00 0.00 X X 0 0 0 Marisa D Devlin Vice Chair (beg 1/19) 2.00 0.00 X X 0 0 0 Michael F Long Vice Chair (end 12/18); Secretary 2.00 1.00 X X 0 0 0 Brett C Peltzer Treasurer 2.00 2.00 X X 0 0 0 Brenan Riehl Secretary (end 12/18); Trustee 2.00 0.00 X X 0 0 0 Susan E Mooney MD MS President & CEO 53.00 8.00 X X 394846 34334 62227 Randall D Lea MD MPH VP/Chief Medical Officer (end 8/18) 28.00 1.00 X X 152531 0 23684 Brenda L Blair VP & COO 32.00 29.00 X X 208308 0 28091 Christopher Fallon Interim CFO 40.00 20.00 X 0 0 0 Timothy Graham MBA FHFMA CPA Interim CFO (end 1/19) 40.00 20.00 X 230762 57690 0 Kathryn M Vargo MD Medical Staff President 30.00 1.00 X 172697 0 40489 Ivan Tomek MD Orthopaedic Surgeon 40.00 0.00 X 540741 0 58401 Dale C Vidal MD MS Exec. Dir., Multi-Specialty Clinic 40.00 0.00 X 517597 0 46835 Leonard M Rudolf MD Orthopaedic Surgeon 40.00 0.00 X 476641 0 29493 Paul Sansone MD Anesthesiologist 40.00 0.00 X 432208 0 40672 Diane C Riley MD Orthopaedic Surgeon 40.00 0.00 X 440704 0 34624 4083495 2752853 757785 42 0 1 0 Upper Valley Neurology 106 Hanover Street Lebanon NH 03766 Neurology physician practice services 3484667 EmCare Physician Services Inc 7032 Collection Center Drive Chicago IL 60693 Emergency room/ hospitalist services 1845182 The Chappelle Group LLC 7500 Greenway Center Drive Suite 4 Greenbelt MD 20770 Revenue cycle/ financial services 1134820 American Healthcare Services Associates PO Box 945 Traverse MI 49685 Agency/temp employee services 743718 Conifer Revenue Cycle Solutions LLC PO Box 655025 Dallas TX 75265 Coding operations 595114 14 10000 33000 51825 587302 2145 682127 Patient services 621400 65989656 65989656 NH DSH payments 962140 5699996 5699996 Other operating services 621400 1431314 1431314 Nutritional services 722210 103699 103699 73224665 600027 26 600001 73806 0 73806 73806 73806 415690 0 415690 415690 415690 Loss on extinguishment of debt 621400 -87304 -87304 -87304 74909011 73224665 26 1002193 195358 195358 25207 25207 1308658 694087 610645 3926 36138047 34836235 1193398 108414 527571 519520 6468 1583 3682666 3524254 147364 11048 2093788 1989099 98408 6281 23333 23333 123323 123323 7004639 6654407 329218 21014 53734 53734 1407603 261355 1141950 4298 211151 200594 9924 633 2918746 2772809 137181 8756 176270 167456 8285 529 59371 56403 2790 178 1169218 1110757 54953 3508 2304856 2189613 108328 6915 636370 604552 29909 1909 Drugs/medical supplies 8634076 8202372 405802 25902 New Hampshire MET 3061947 3061947 Repairs/maintenance 2297210 2182349 107969 6892 Provision for bad debts 1756016 1756016 176028 167227 8273 528 75985186 71171617 4601255 212314 1247096 2159 4698217 7063489 158696 120009 7996791 7282615 1322780 735346 892831 205316 64765385 33841742 25585296 30923643 15841735 17948875 8500 9805137 139333 2288857 2311863 60180132 76398452 8894447 8405326 99676 33082 15408101 25740604 399825 248731 13712586 13521902 38514635 47949645 X 21030940 27652645 415262 699162 219295 97000 21665497 28448807 60180132 76398452 X -1076175 -517974 8377459 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 10834 0 0 1 3750 14584 0 Part II-B, Line 1: Alice Peck Day Memorial Hospital was a member of the American Hospital Association and the New Hampshire Hospital Association in the fiscal year ended June 30, 2019. A portion of the dues paid to these organizations were available for lobbying expenditures on behalf of Alice Peck Day Memorial Hospital and the other member organizations in furtherance of their exempt purposes. The total dues paid by the Hospital to these organizations, and the portion that was available for lobbying, are detailed below: American Hospital Association - total dues: $40,577 American Hospital Association - amount available for lobbying: $7,588 New Hampshire Hospital Association - total dues: $14,280 New Hampshire Hospital Association - amount available for lobbying: $3,246 Also, the Hospital belongs to the 10 Mile CAH Coalition which engaged Strategic Health Resources (SHR) for purposes of furthering lobbying efforts with regards to attempts to eliminate CAH status. The CEO participates in periodic telephone calls with this group in attempts to keep the issue of rural healthcare and the key role that CAHs play in rural healthcare in front of the various legislative delegations. 218390 33217 185173 33230 185160 218390 31845 1385 33230 30268 1577 31845 30883 -615 30268 0.47620 0.52380 0.00000 0 0 927577 927577 33997949 13440278 20557671 212775 212775 0 28894020 20188689 8705331 733064 733064 30923643 Investment in affiliate 9805137 F 9805137 Medical liabilities and payables 513000 Estimated third-party payor settlements 1290446 Accrued construction costs for building under development 10568277 Due to affiliates 1150179 13521902 X Part V, Line 4: The Organization uses the income from its endowment funds for use in operations. Part X, Line 2: Dartmouth-Hitchcock Health (D-HH) serves as the sole corporate member of the following entities: Dartmouth-Hitchcock Clinic and Subsidiaries (DHC), Mary Hitchcock Memorial Hospital and Subsidiaries (MHMH), (DHC and MHMH together are referred to as D-H), The New London Hospital Association and Subsidiaries (NLH), Windsor Hospital Corporation (d/b/a Mt. Ascutney Hospital and Health Center) and Subsidiaries (MAHHC), Cheshire Medical Center and Subsidiaries (Cheshire), Alice Peck Day Memorial Hospital and, effective July 1, 2018, Subsidiary (APD), and the Visiting Nurse and Hospice for Vermont and New Hampshire and Subsidiaries (VNH). The "Health System" consists of D-HH, its members and their subsidiaries. The Health System currently operates one tertiary, one community and three acute care (critical access) hospitals in New Hampshire (NH) and Vermont (VT). One facility provides inpatient and outpatient rehabilitation medicine and long-term care. The Health System also operates multiple physician practices, a nursing home, a continuing care retirement community, and a home health and hospice service. The Health System operates a graduate level program for health professions and is the principal teaching affiliate of the Geisel School of Medicine (Geisel), a component of Dartmouth College. D-HH, Dartmouth-Hitchcock Clinic, Mary Hitchcock Memorial Hospital, The New London Hospital Association, Cheshire Medical Center, and Alice Peck Day Memorial Hospital are NH not-for-profit corporations exempt from federal income taxes under Section 501(c)(3) of the Internal Revenue Code (IRC). Windsor Hospital Corporation and the Visiting Nurse and Hospice of VT and NH are VT not-for-profit corporations exempt from federal income taxes under Section 501(c)(3) of the IRC. 1 1 1 X 1 X 1 1 0 1 1 300967 300967 0.00410 6001013 7963826 0 0.00000 6301980 7963826 300967 0.00410 221683 221683 0.00300 8000 8000 0.00010 19653971 14692835 4961136 0.06680 44492 44492 0.00060 19928146 14692835 5235311 0.07050 26230126 22656661 5536278 0.07460 16117 16117 0.00020 17009 17009 0.00020 33126 33126 0.00040 1 1158530 0 16908993 17177309 -268316 X 1 1 1 1 Alice Peck Day Memorial Hospital 10 Alice Peck Day Drive Lebanon NH 03766 www.alicepeckday.org 00016 X X X X Physician Clinics Alice Peck Day Memorial Hospital 1 0 0 1 X X X X X X X X 18 1 1 1 1 X See Part V, Section C X See Part V, Section C X 1 16 1 See Part V, Section C 1 0 1 X 100.000000000000 300.000000000000 X X X X X X 1 1 X X X X 1 X See Part V, Section C X see Part V, Section C X see Part V, Section C X X X X X X X 1 X 0 X X X X 1 X 0 0 Alice Peck Day Memorial Hospital Part V, Section B, Line 5: With a shared Hospital Service Area, Alice Peck Day Memorial Hospital collaborated with Dartmouth-Hitchcock in conducting the fiscal year 2019 Community Health Needs Assessment. Technical expertise was provided by the New Hampshire Community Health Institute, the NH affiliate of JSI, a nation-wide public health management consulting and research organization. Methods employed in the assessment included surveys of community residents made available online and paper surveys placed in numerous locations throughout the region (completed by 2,100 individuals), a direct email survey of key stakeholders and community leaders representing multiple community sectors; a set of community discussion groups; compilation of results from assessment activities focused specifically on behavioral health needs and gaps; and a review of available population demographics and health status indicators. All information collection activities and analyses sought to focus assessment activities on vulnerable and disproportionately served populations in the region including populations that could experience limited access to health-related services or resources due to income, age, disability, and social or physical isolation. Enhanced efforts were made to understand the needs of these populations through targeted surveys and community conversations including facilitated surveys and discussions at community suppers, a regional free clinic, homeless programs, and other community settings serving economically vulnerable residents. The data gathered in the FY2019 CHNA is part of a continual process for considering progress and emerging community needs informed by dialogue with community members, leaders, and experience. Alice Peck Day Memorial Hospital Part V, Section B, Line 6a: Alice Peck Day Memorial HospitalDartmouth-Hitchcock Medical CenterNew London Hospital Valley Regional Hospital Mt. Ascutney Hospital and Health CenterVisiting Nurse and Hospice for VT and NH Alice Peck Day Memorial Hospital Part V, Section B, Line 6b: Technical assistance for the Hospital's 2018 CHNA was provided by the New Hampshire Community Health Institute. Alice Peck Day Memorial Hospital Part V, Section B, Line 11: Please see attached Implementation Plan. The most recent CHNA was made widely available to the public in tax year 2018. The Implementation Plan that was approved by the board for that CHNA was done in November of 2019, which is within the deadline as prescribed by 501(r). Due to IRS filing instructions, since this approval date is after the tax year covered by this return, the previous Implenetation Plan date has been indicated in Schedule H, Part V, Line 9. Both Implementation Plans have been attached to this return. Alice Peck Day Memorial Hospital Part V, Section B, Line 13h: Alice Peck Day Memorial Hospital offers financial assistance to patients demonstrating need. In making the need determination, APD participates with and honors the founding principles and guidelines of the New Hampshire Health Access Network (NHHAN). Accordingly, decisions regarding the granting of financial assistance will be based primarily on a patient and their household income and assets. There will be minimal consideration of expenses except when they identify areas for further investigation or incomplete or inaccurate information. The value of a patient's principal residence is not considered in qualifying a patient for in-house assistance. APD requires exhaustion of other payment methodologies, including but not limited to, worker's compensation, veterans benefits, Medicaid, liability insurance, victims of crime, and COBRA. When applicable, proof of determination may be required prior to consideration for financial assistance. Alice Peck Day Memorial Hospital Part V, Section B, Line 16j: Please see Part V, Line 3 for a description of the financial assistance program and the efforts made to publicize and promote the program.Alice Peck Day Memorial Hospital prints and distributes its financial assistance application in Spanish when requested. Part V, Line 7a & 7b: CHNA can be found on the Hospital's website at:https://www.alicepeckday.org/assets/FY2019_DHAPDVNA_Community_Health_Needs_Assessment.pdf Other websites: https://www.dartmouth-hitchcock.org/documents/fy2019_dhapdvna_community_health_needs_assessment.pdf Part V, Line 10a: Implementation Plan in effect during the tax year covered by this return can be found at: https://www.alicepeckday.org/assets/APDMH_CH_Implementation_Plan_2017.pdfThe Hospital's Implementation Plan for its most recent CHNA (see narrative for Schedule H, Part V, Line 9 can be found at:https://www.alicepeckday.org/assets/ADOPTED_APD_Community_Health_Implementation_Plan_November-1-2019.pdf 7 1 - Neurosurgery Services at APD (NSAPD) 106 Hanover Street Lebanon NH 03766 Neurosurgery Physician Clinic 2 - RAM Center for Community Care 10 Alice Peck Day Drive Lebanon NH 03766 Primary Care Physician Clinic 3 - APD Orthopaedic Clinic 10 Alice Peck Day Drive Lebanon NH 03766 Orthopaedic Physician Clinic 4 - Women's Care Center 10 Alice Peck Day Drive Lebanon NH 03766 OB/GYN Physician Clinic 5 - General Surgery Clinic 10 Alice Peck Day Drive Lebanon NH 03766 General Surgeon Clinic 6 - Pain Management Clinic 10 Alice Peck Day Drive Lebanon NH 03766 Pain Management Clinic 7 - Occuptational Health Services 10 Alice Peck Day Drive Lebanon NH 03766 Occupational Health Physician Clinic Part I, Line 3c: Alice Peck Day provides sliding scale coverage with 100% coverage for those with household income below 100% of the Federal Poverty Limit (FPL) and partial coverage for those with household income between 101% and 300% of FPL. The coverage tiers are maintained on the APD website, and are available from all financial counselors or by mail upon request. Part I, Line 7: APD has several hospital clinical services and hospital-owned physician practices. Per instructions for IRS Form 990, Schedule H, Worksheet 6, organizations may include any applicable physician practice that the Hospital subsidizes (i.e., operates at a loss) in the completing of Schedule H. Therefore, the Hospital has included the following hospital clinical services and hospital-owned physician practices that operate at a loss (i.e., are subsidized by the Hospital) and the associated costs of these practices:a. Primary care clinicb. Pain Management c. Women's Care d. General Surgerye. Orthopedicsf. Occupational HealthThe above-listed hospital clinical services and hospital-owned physician practices have a community benefit (i.e. aggregate loss or subsidy from the Hospital) of approximately $4.96 million. In addition, the community benefit does not take into account bad debts, charity care, or contractual adjustments. Thus, this community benefit of approximately $4.96 million is a conservative figure that reconciles to the community benefit information reported on IRS Form 990, Schedule H, Part I, Line 7g, Column e. Part I, Ln 7 Col(f): See Footnote 4 on Page 15 of the attached audited financial statements. Part II, Community Building Activities: Alice Peck Day actively promotes community-based leadership development. Staff members participate in the Lebanon Chamber of Commerce, Mascoma Savings Bank Board of Directors, Foundation for Healthy Communities, the Rural Health Coalition, and the Advocacy Task Force. As an active member of the community, APD works to be proactive concerning disaster readiness. Staff have participated in onsite training for disaster preparedness as well as off-site training with other regional hospitals. Collaborative efforts include all hazard regional training, emergency response training, and a regional mass casualty response program to help facilitate cooperative efforts if such needs arise. Part III, Line 2: Bad debt cost is calculated using a cost to charge ratio using a step-down cost allocation methodology consistent with Medicare cost reporting. In FY18, accounts written off to bad debt included 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. We estimated the amount of charity care in bad debt expense based on the number of applications for charity care. We believe the amount is minimal based on our extensive efforts to educate our patients and staff about our various payment plans and charity care 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, time-payment programs, or a combination of the above. Due to these efforts, the amounts written off to bad debt that could qualify as charity care are minimal. The Hospital utilized Worksheet 2 from the IRS Schedule H instructions and guidance to determine the ratio of patient care to cost to charge (65.97% for fiscal year 2019), and multiplied this ratio by the Hospital's total bad debt expense of $1,756,016 to determine the Part II, Line 2 bad debt expense of $1,158,530.Management performs collection rate look-back analyses on a quarterly basis to evaluate the sufficiency of the allowance for estimated uncollectibles. Throughout the year, after all reasonable collection efforts have been exhausted, the difference between the standard rates and the amounts actually collected, including contractual adjustments and uninsured discounts, will be written off against the allowance for estimated uncollectibles. In addition to the review of the categories of revenue, management monitors the write offs against established allowances as of a point in time to determine the appropriateness of the underlying assumptions used in estimating the allowance for estimated uncollectibles. Part III, Line 3: See narrative for Schedule H, Part III, Line 2 and Line 4. Part III, Line 4: See Footnote 4 on Page 15 of the attached audited financial statements. Part III, Line 8: Form 990, Schedule H instructions and guidance contain a template (Worksheet 2) that may be used to determine the overall cost to charge ratio that could be applied throughout Schedule H in order to convert charges to cost. Where applicable, the Hospital has utilized Worksheet 2 for various calculations. The only areas where Worksheet 2 was not utilized for Part III, Line 8 was Schedule H, Worksheet B, Line 2 & 6, Medicare Allowable Costs and Payments Related to Subsidized Health Services. The Hospital utilized the Medicare cost report for estimated cost and payment for these services. The Hospital believes that its hospital clinical services, hospital-owned physician practices, emergency room and inpatient psychiatric units listed above should all be considered community benefits. These services, facilities, and programs provide a benefit to community members, and are both offered and subsidized by the Hospital. Medicare shortfall is reported to the State of New Hampshire in the Community Benefits Report, under Section 4, Unreimbursed Costs, Government-Sponsored Health Care.In prior years, the State of New Hampshire used MET dollars to service the general fund of the State. However, recently the State has used these dollars to directly fund medical and other related budgetary goals. As a result of this change in the State's appropriation of these funds, the net MET/DSH impact is considered a healthcare-related expenditure by the Hospital. Part III, Line 9b: Our bad debts collection policy applies to all patient accounts in a consistent manner. The policy specifically indicates that, after a second statement is sent with no payment received, a patient accounts representative will contact the patient by phone to determine if a financial assistance application or payment plan is appropriate. This is completed to avoid further escalation of past due account(s) if the patient may qualify for full or partial relief under the charity care policy. If the application is successful, then the qualifying balance or balances are classified as charity care and no longer pursued for collections. Once a patient balance is classified as charity care, it is not subject to collection activities. Alice Peck Day is committed to helping our patients obtain quality healthcare, regardless of ability to pay. Our financial assistance programs encourage and enable our patients to make healthcare decisions free of financial barriers. We educate our patients about our programs and provide assistance prior to their receiving services, at registration for services, and during our billing process to ensure that any and all patients in need of assistance are provided with the help they qualify for under APD programs. Brochures and signs are placed in high traffic areas such as the ER and registration. Our staff is trained to identify patients during registration, provide information, and offer assistance in completing the necessary forms. During our billing process, calls are made to patients with outstanding balances. APD staff work with patients to identify problems they are facing in dealing with outstanding balances. Patients are notified again of the many types of financial assistance available for which they may qualify. Programs are explained and assistance is offered, if needed, in completing the applications. Due to this multi-level approach and staff that is trained to identify clients who may need financial assistance, very few qualifying patients reach the point of bad debt. Our collection policies and procedures, in conjunction with our small size, allow our organization to place great emphasis on helping all patients who may be in need to apply for, and obtain, the appropriate level of financial assistance. Schedule H, Part V, Section B, Line 16a-16c: Financial Assistance Policy, Financial Assistance Policy Application, and Plain Languange Summary can be found at: https://www.alicepeckday.org/patients/financial_services Part VI, Line 2: In addition to completing a comprehensive needs assessment every three years, the Organization's Community Health Director serves on the Steering Committee of the Public Health Council of the Upper Valley, one of the State of New Hampshire's 13 regional health networks, which also serves 22 communities in Vermont. The PHC is comprised of community leaders and representatives from multiple community sectors, working together to set regional health priorities, provide guidance to regional public health activities, and ensure coordination of health improvement projects. In 2014, the PHC created the Upper Valley Agenda for Public Health, and the following year, the 2015-2017 Upper Valley Community Health Improvement Plan. This plan will be updated in the summer of 2019 with input from APD's Community Health Director. The Public Health Council provides a "finger on the pulse" of the community, and by serving in a leadership role, Alice Peck Day Memorial Hospital is able to stay abreast of the health care needs of our local service area. Part VI, Line 3: Alice Peck Day believes that quality health care should be available to all, regardless of ability to pay. Our financial assistance programs and staff are dedicated to helping people obtain the care they need. We reach out to our patients in many different ways to ensure that they are aware that help is available and to help guide them through the process. Brochures and signage are posted in high traffic areas such as the emergency room, registration, and the lobby. Registration staff are trained to identify patients who may be in need of financial assistance. Once identified, staff notify the patient that APD has various forms of financial assistance and explain that assistance is available for anyone who might require help or guidance in completing any necessary paperwork. In addition to the above, our billing staff are trained to help identify and offer assistance to anyone who might require financial assistance. Patients with outstanding claims are contacted by our credit coordinator who works with them to clear up balances through the variety of programs we offer. Assistance is also provided in applying for federal/state programs to those who qualify. Specially trained staff guide applicants through the process to ensure forms are filled out correctly, all required documentation is attached, and the applicants understand what they can expect to happen along the way. Part VI, Line 4: Alice Peck Day Memorial Hospital is part of the Lebanon Health Care service area. The Lebanon service area comprises cities and towns in New Hampshire and Vermont. APD's service area in NH comprises 15 towns in addition to the city of Lebanon, including Canaan, Cornish, Croydon, Dorchester, Enfield, Grafton, Grantham, Hanover, Lyme, Newport, Orange, Orford, Piermont, Plainfield, and Warren. Vermont towns include East Thetford, Fairlee, Hartford, Hartland, North Hartland, North Thetford, Norwich, Post Mills, Quechee, Sharon, South Strafford, Strafford, Thetford, Thetford Center, Vershire, West Vershire, West Fairlee, West Hartford, White River Junction and Woodstock.Demographics: Age: According to the 2016 American Community Survey, the population of the APD Service Area is slightly older on average than the New Hampshire and Vermont populations. 17.5% of the service area is over age 65, compared with 15.8% in New Hampshire and 17% in Vermont.Income and poverty: 11.5% of children in the hospital service area live at or below 100% FPL, with 25.7% living below 200% FPL. Education: A higher proportion of the hospital service area (94.4%) have earned at least a high school diploma or equivalent compared to New Hampshire (92.6%) and Vermont (91.9%) overall.Language: The percent of the hospital service area, ages 5 or higher, who report speaking English "less than very well" is 0.8%, compared with a statewide rate of 1.5% in New Hampshire and 0.7% in Vermont. Part VI, Line 5: In addition to initiatives to deliver affordable care to our under and uninsured patients through our Financial Assistance programs, the Organization provides a wide variety of no-cost or low-cost programs and services for the community. We work in partnership with local and state agencies, including but not limited to: the Lebanon, Mascoma, Hartford, Hartland and Newport school districts; the Good Neighbor Health Clinic; Grafton County Senior Citizens Council; NH Division of Health and Human Services; NH Oral Health Coalition; Vermont Oral Health Coalition; the Public Health Council of the Upper Valley; and the Vermont Dept of Health. Among the free programs and services APD offers in response to demonstrated community need are: cash support and an in-kind donation of space for the Good Neighbor Health Clinic; vouchers for emergency prescription assistance and one-on-one assistance with applying for prescription assistance programs offered through drug companies; cash support to the Grafton County Senior Citizens Council for transportation; cash donations to human service agencies; and administrative support for "Elder Friends," a companionship program for frail, isolated elders in the community who are matched with a volunteer.APD's Community Health Department is well known in the region for Upper Valley Smiles, a unique school-based oral health program for low-income elementary school children enrolled in ten schools across the Upper Valley. The APD dental team visits each school annually, providing classroom oral health education, dental screenings, fluoride varnish, sealants and (in NH only) decay-stopping fluoride treatments and interim therapeutic restorations, all at little or no cost to parents. During FY '19, the Upper Valley Smiles program of oral health education, dental screenings, preventive treatment, and referrals to dental offices was offered in ten elementary schools. This year we also began a new program known as FitScripts. The APD FitScripts program aims to get patients exercising more and leading healthier lifestyles. FitScripts allows our primary care providers to write referrals for their patients age 16 or older, who are living with one or more chronic conditions, and for whom the cost of a gym membership has been a barrier. APD has partnered with the Carter Community Building Association (CCBA) in Lebanon, New Hampshire, and the Upper Valley Aquatic Center (UVAC) in White River Junction, Vermont, to offer this program. APD pays for the gym memberships and other associated costs. There is no cost to our patients. This year we also hosted the opening of the Mascoma River Greenway, a multi-use pathway that runs adjacent to the hospital. During the fiscal year ending June 30, 2019, cash donations were given to organizations to help those in need. Local financial contributions helped support free primary care clinics for the uninsured, provided transportation for the elderly and disabled to receive medical care, and provided local nonprofit organizations with meeting space and refreshments. Alice Peck Day also supported a free summer lunch program for low-income school-age children in Lebanon public housing sites, emergency prescription drug vouchers for uninsured patients, and "before school" morning activity program for children in the Canaan Elementary School.To promote health professional education, APD provided tuition reimbursement for students in the Surgical Tech Training Program, and hosted a Nurse Residency Program. These initiatives and ongoing efforts continue to address several of the most pressing community needs as identified in our community needs assessment. Part VI, Line 6: Alice Peck Day Memorial Hospital is a critical access hospital located in Lebanon, NH. We are a member of the Dartmouth-Hitchcock Health system (D-HH). D-HH is New Hampshire's only academic health system and the state's largest private employer. Its serves a population of 1.9 million across northern New England. D-HH provides access to more than 1,800 providers in almost every area of medicine, delivering care at its flagship hospital, Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, NH.The other members of D-HH include Cheshire Medical Center/Dartmouth-Hitchcock, Mt. Ascutney Hospital and Health Center, New London Hospital, and the Visiting Nurse and Hospice for Vermont and New Hampshire (VNH). Part VI, Line 7, Reports Filed With States NH 1 Grafton County Senior Citizens Council PO Box 433 Lebanon NH 03766 237248316 501(c)(3) 12000 Support for services that enable seniors to age-in-place Good Neighbor Health Clinic 70 North Main Street White River Junction VT 05001 030346949 501(c)(3) 5000 Support for free medical and dental care for patients in need New Hampshire Hospital Association 125 Airport Road Concord NH 03301 026012527 501(c)(6) 111460 Funding to enhance and support the performance of New Hampshire-based hospitals 2 1 Tuition Assistance 12 25207 Part I, Line 2: APD provides support for selected community organizations that address needs identified in the Community Health Needs Assessment and are part of APD's Community Health Improvement plan. For this reporting period, hospital staff identified the Carter Community Building Association and Upper Valley Aquatic Center for a new program known as FitScripts. The annual amount to be contributed by APD to these organizations is approved annually through the annual budget process. APD receives and reviews each year the organizations' published annual reports and also maintains informal contacts throughout the year to monitor the organizations' operations and services. Additionally, the Hospital provides tuition reimbursement for some health professional employees. The employees must have been employed by the Hospital or a related entity for at least one year and be in good standing. X X X X 1 1 0 0 0 0 0 1 0 George T Blike Trustee 0 420653 0 5250 0 62551 0 52781 0 36528 0 577763 0 0 John P Houde MD Trustee; Orthopaedic Surgeon 486460 0 5500 0 24500 0 5500 0 41938 0 563898 0 0 0 Patrick F Jordan Trustee 0 593350 0 250 0 1588 0 21080 0 37284 0 653552 0 0 Edward J Merrens Trustee (end 12/18) 0 629398 0 10250 0 70908 0 28864 0 20070 0 759490 0 0 Tina E Naimie Trustee 0 256492 0 250 0 557 0 19498 0 9093 0 285890 0 0 Mary M Oseid Trustee 0 257606 0 250 0 19030 0 37819 0 22440 0 337145 0 0 Scott W Rodi Trustee 0 331782 0 250 0 414 0 24846 0 35528 0 392820 0 0 Susan E Mooney MD MS President & CEO 300084 26094 72222 6280 22540 1960 22080 1920 35169 3058 452095 39312 0 0 Randall D Lea MD MPH VP/Chief Medical Officer (end 8/18) 129765 0 16310 0 6456 0 3228 0 20456 0 176215 0 0 0 Brenda L Blair VP & COO 180594 0 22793 0 4921 0 1968 0 26123 0 236399 0 0 0 Timothy Graham MBA FHFMA CPA Interim CFO (end 1/19) 207000 51750 0 0 23762 5940 0 0 0 0 230762 57690 0 0 Kathryn M Vargo MD Medical Staff President 150606 0 388 0 21703 0 3617 0 36872 0 213186 0 0 0 Ivan Tomek MD Orthopaedic Surgeon 511741 0 4500 0 24500 0 23000 0 35401 0 599142 0 0 0 Dale C Vidal MD MS Exec. Dir., Multi-Specialty Clinic 475304 0 17793 0 24500 0 5500 0 41335 0 564432 0 0 0 Leonard M Rudolf MD Orthopaedic Surgeon 452141 0 0 0 24500 0 5500 0 23993 0 506134 0 0 0 Paul Sansone MD Anesthesiologist 418708 0 250 0 13250 0 5500 0 35172 0 472880 0 0 0 Diane C Riley MD Orthopaedic Surgeon 411704 0 4500 0 24500 0 5500 0 29124 0 475328 0 0 0 Part I, Lines 4a-b The following individuals had an actuarial change in pension value during the year reported in Schedule J, Part II, Column C: Edward J. Merrens, MD - $2,284 George Blike - $26,201 Mary Oseid - $11,239 All amounts reported in Column C will be included as part of taxable wages in the employees' Form W-2 when paid out. An eligible employee is a participant in the Dartmouth-Hitchcock retirement plan and/or any prior pension arrangements sponsored by Dartmouth-Hitchcock (including a qualified defined benefit plan) who would be entitled to additional contributions or benefit accruals under the terms of the plans for the plan year, but are limited by IRC Section 401(a)(17) and/or 415. For eligible employees, the employer will pay the eligible employee an amount determined by the employer each year to offset the amount of the reduction in the benefit accrual or contributions as a result of limitations imposed by IRC Sections 401(a)(17) and/or 415. Schedule J, Part II, Column B, Parts (i), (ii), and (iii) represent actual amounts paid to employees by Alice Peck Day Memorial Hospital or Dartmouth-Hitchcock. These amounts are reported to employees on their annual Form W-2 as compensation. Columns C and D represent items earned, however, not paid directly to the employee as cash payments during the calendar year. Column C includes retirement benefits as well as any changes in pension actuarial value (if applicable) in a calendar year. Column D represents nontaxable benefits such as the cost of healthcare coverage sponsored by the Organization or a related organization. Part I, Line 7 A portion of compensation to certain employees is at-risk and variable, and payment depends on the quality of job performance. Form 990, Part VII-A, Line 5: During the fiscal year, Alice Peck Day Memorial Hospital had an interim CFO, Timothy Graham through January 2019. Mr. Graham was compensated through a consulting firm, Healthcare RESQ, LLC, during the calendar year. The total amount paid to Healthcare RESQ, LLC for his services was $258,750. Mr. Graham was directly compensated an additional $29,702 to cover travel expenses. Alice Peck Day Memorial Hospital had an interim CFO, Christopher Fallon from January 2019 through June 2019. The amounts of Graham's compensation allocated as specific to the filing organization are broken out in Form 990, Part VII. The total amounts allocated to each related organization are also codified in Part VII. Fallon did not receive any compensation in calendar year 2018. Therefore, in accordance with IRS Instructions for Form 990, no amount of the compensation paid to Fallon has been reported on the filing organization's Form 990, Part VII. A NH Health and Education Facilities Authority 020279866 2018-08-15 25865000 Refund bond issued 11/30/2010 0 0 0 A 25865000 289249 25575751 2018 1 0 1 1 A 0 1 1 1 0 0.00500 0.00000 0.00500 0 0 1 A 0 1 0 0 0 0 0 0 1 A 1 Form 990, Schedule K, Part II, Column A, Line 11: The other spent proceeds are the refunding proceeds of the issue that are no longer in escrow. Timothy Graham MBA FHFMA CPA Chief Financial Officer 288452 During the fiscal year, Alice Peck Day Memorial Hospital had an interim CFO, Timothy Graham through January 2019. Mr. Graham was compensated through a consulting firm, Healthcare RESQ, LLC, during the calendar year. The total amount paid to Healthcare RESQ, LLC for his services was $258,750. Mr. Graham was directly compensated an additional $29,702 to cover travel expenses. These totals represent payment for services to Alice Peck Day Memorial Hospital and Alice Peck Day Lifecare Center. All transactions were at arm's length. The amounts allocated as specific to the filing organization are broken out in Form 990, Part VII. The total amount paid to Healthcare RESQ, LLC for Mr. Graham's services to the entire APD system has been reported in Schedule L, Part IV, Column (c). 0 Jennifer Sage Schiffman Trustee 26506 Jennifer Sage Schiffman serves as a trustee on the Hospital's board of directors. Jennifer's husband holds an ownership interest in the entity Nomad Communications, which provides publication and communication services. During the tax filing period, the Hospital contracted with Nomad Communications for professional marketing services. This was part of an on-going arrangement, and the rates paid by the Hospital were agreed upon at fair market value. 0 Form 990, Part III, line 3 Effective July 1, 2018, Alice Peck Day Memorial Hospital, an affiliate of Dartmouth-Hitchcock Health (D-HH), became the sole corporate member of the Alice Peck Day Lifecare Center. As such, the Lifecare Center became an affiliate of D-HH, which constituted a change in control at the Lifecare Center. Form 990, Part V, Line 1a & 2a: For administrative purposes, Alice Peck Day Memorial Hospital acts as the common paymaster for Alice Peck Day Lifecare Center, Inc. Form 990, Part VI, Section A, line 3 During the fiscal year, Alice Peck Day Memorial Hospital had an interim CFO, Timothy Graham through January 2019. Mr. Graham was compensated through a consulting firm, Healthcare RESQ, LLC, during the calendar year. The total amount paid to Healthcare RESQ, LLC for his services was $258,750. Mr. Graham was directly compensated an additional $29,702 to cover travel expenses. Alice Peck Day Memorial Hospital had an interim CFO, Christopher Fallon from January 2019 through June 2019. The amounts of Mr. Graham's compensation allocated as specific to the filing organization are broken out in Form 990, Part VII. The total amounts allocated to each related organization are also codified in Part VII. Mr. Fallon did not receive any compensation in calendar year 2018 from the Hospital or its affiliates as his tenure did not begin until 2019. Therefore, in accordance with IRS Instructions for Form 990, no amount of the compensation paid to Fallon has been reported on the filing organization's Form 990, Part VII. Compensation information for Mr. Fallon will be reported on the Hospital's 2019 Form 990 for fiscal year ending June 30, 2020. Form 990, Part VI, Section A, line 6 The Membership of the Corporation shall consist of Dartmouth-Hitchcock Health (D-HH) as the sole member. Form 990, Part VI, Section A, line 7a The Member will retain the reserved power to appoint without limitation one-third of the Trustees (which appointees, before final appointment by Member, will be discussed with the Board Chair and other Trustees selected by the Chair for their input). The D-H/D-HH CEO or designee will serve on the Board ex officio, with full voting rights, and will count toward the one-third membership appointed by Member. Form 990, Part VI, Section A, line 7b The Member will retain the following reserved powers over APD, which, except as otherwise required below, will be exercised by the D-HH Board of Trustees or the D-HH CEO, as determined by the D-HH Board of Trustees: 1. To initiate and/or to approve or disapprove all material governance, programmatic, and financial decisions of the Board of Trustees, including without limitation the elimination or addition of any material health/health care services or programs; 2. To appoint without limitation one-third of the Trustees (which appointees, before final appointment by Member, will be discussed with the Board Chair and other Trustees selected by the Chair for their input). The D-H/D-HH CEO or designee will serve on the Board ex officio, with full voting rights, and will count toward the one-third membership appointed by Member; 3. To ratify those trustee candidates nominated by the Board in accordance with Section 2.04 of the Corporation's bylaws (meaning the ability of Member to approve or disapprove, based on a good faith and reasonableness standard, each trustee candidate nominated by the Board of Trustees and upon such approval, the ability to install such approved candidate to the Board); 4. To remove by a vote of two-thirds of the D-HH Board of Trustees any Trustee if the Member determines in its reasonable good faith discretion that such removal is in the best interests of the D-H System which will include APD and taking into consideration the impact on APD and the community it serves, following prior consultation with the Board Chair; 5. To approve of borrowings (debt) and dispositions of material assets by APD; 6. To approve any key strategic relationship(s) between APD and another organization(s) (key strategic relationships defined as the ownership or contractual participation in a network, system, affiliation, joint venture, alliance or similar arrangement with an organization that is not part of the D-H System or which is not addressed in a Member approved APD strategic plan); 7. To initiate and/or to approve all operating and capital budgets as well as all strategic plans of APD; 8. To approve all policies relating to academic and research programs and affiliations; 9. To allocate the non-donor restricted assets and resources of APD and D-H/D-HH as appropriate to serve the overall best interests of the D-H System (which will include APD), taking into consideration the impact on APD and the community it serves; while Member will retain this reserved power, Member will exercise this reserved power only after consulting with and providing reasonable time and opportunity for the Board of Trustees to provide meaningful input and recommendations which shall be considered in good faith. For one (1) year following the effective date of its bylaws any material reallocation of assets or resources will also require an affirmative vote by a majority of the Board of Trustees. 10. Except as limited by the affiliation agreement, to appoint, evaluate the performance of, and terminate the APD President and CEO, subject to prior consultation with the Board of Trustees and a reasonable time and opportunity for the Board to provide meaningful input and recommendations which shall be considered in good faith. 11. To approve any proposed amendment or repeal of the APD articles of agreement or bylaws which proposed amendment or repeal would (i) impact the powers reserved to Member in its bylaws, or (ii) reasonably be expected to have any material strategic, competitive or financial impact on the D-H System. No change in the provisions of APD's bylaws shall be binding on D-H/D-HH or APD unless such change(s) is/are approved by way of amendment to APD's governing documents approved by Member. 12. To approve the dissolution or liquidation of APD, following such approval by the Board. Form 990, Part VI, Section B, line 11b Management provides a notice that the completed Form 990 is available to the Finance Committee prior to filing. Management advises the Finance Committee that the completed Form 990 is available on a secure website that requires an assigned user name and password. The Chair of the Finance Committee advises the Financial Committee members to review the Form 990 for content and raise any issues with Board Leadership or Management. The Chair of the Finance Committee advises the Chair of the Board and the full Board that the Form 990 is available for review. That notice is in advance of the filing deadline to enable a detailed and conscientious review by the Board. All questions and concerns are addressed by the Chief Executive Officer and are incorporated into the Form 990 as deemed appropriate. Management files the final Form 990 with the Internal Revenue Service, as required after the above review is concluded. Form 990, Part VI, Section B, line 12c Alice Peck Day has a multi-faceted conflict of interest policy. Members of the Board of Trustees complete conflict of interest questionnaires on an annual basis and any new members complete the questionnaire upon joining the Board. As part of our ongoing monitoring process, our Executive Assistant reviews all Board questionnaires and disclosures to identify any potential conflicts before they arise. In addition, our Executive Assistant attends all Board meetings to ensure that if any conflicts arise, they are handled appropriately. If such conflicts arise, the Organization complies with the New Hampshire and federal requirements for disclosures of such events. The Organization is committed to conducting its business in a manner that is both ethical and legal. As part of this commitment, a standard of conduct form is required of all employees of the organization. This is reviewed with all employees upon hire and on an annual basis thereafter. The standard of conduct covers conflict of interest and other vital matters to ensure all business activity is conducted in a manner that is consistent with the highest standards of honesty, integrity, and fairness. Form 990, Part VI, Section B, line 15 The Human Resources Committee of the Alice Peck Day Memorial Hospital Board of Trustees is responsible for determining the compensation of the Chief Executive Officer/President. The Chief Administrative Officer or her designee provides compensation data of comparable organizations with approximately the same size staff and spending in a location of similar size. The committee determines the appropriate compensation and approves an amount that is then communicated to Human Resources for adjustment. Dartmouth-Hitchcock Health reviews the compensation of the CEO/President in addition to the process described above. The CEO/President is responsible for reviewing the performance of senior management staff. The information is brought to the Human Resource Committee of the Board of Trustees along with a recommendation for the salary of each individual. The compensation is determined through a variety of analysis of salary data and performance. Individual salary increases are then based on overall performance, within budgeted increases for the organization. The Human Resources committee approves the base compensation and salary increase amount. Form 990, Part VI, Section C, line 19 The Organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Form 990, Part VII, Section A, Column D: Dr. Susan E. Mooney is a practicing physician in addition to being the Chief Executive Officer. She worked an average of 61 hours per week, of which a majority of time is spent on executive matters. Approximately 8 hours per month is spent as a physician. Form 990, Part XI, line 9: Net assets transferred from affiliates 8,377,459. Form 990, Part XII, Line 2c: The finance committee acts as the audit committee and oversees the audit process for the Alice Peck Day entities. Independent accountants performed the audit for the fiscal year ended 6/30/19. For the fiscal year ended 6/30/19 the Hospital was included in the Dartmouth Hitchcock Health System consolidated audited statements. Form 990, Part XII, Line 3a: Alice Peck Day Memorial Hospital was included in the consolidated audited financial statements of the Dartmouth-Hitchcock Health System. During fiscal year 2019, Mary Hitchcock Memorial Hospital expended federal funding which met the minimum threshold set forth in the single audit act and OMB Circular A-133. Due to the nature of the consolidated financial statements, the audit was performed on the financial information of all organizations, including Alice Peck Day Memorial Hospital. Alice Peck Day Lifecare Center Inc 10 Alice Peck Day Drive Lebanon NH 03766 020479094 Independent & Assisted Living NH 501(c)(3) Line 10 APD Memorial Hospital 1 Alice Peck Day Realty Corp 10 Alice Peck Day Drive Lebanon NH 03766 020485369 Inactive NH 501(c)(2) APD Memorial Hospital 1 Dartmouth-Hitchcock Health One Medical Center Drive Lebanon NH 03756 264812335 Govern Integrated Health System NH 501(c)(3) Line 7 N/A 0 Dartmouth-Hitchcock Clinic One Medical Center Drive Lebanon NH 03756 222519596 Physician Services NH 501(c)(3) Line 10 Dartmouth-Hitchcock Health 0 Mary Hitchcock Memorial Hospital One Medical Center Drive Lebanon NH 03756 020222140 Hospital NH 501(c)(3) Line 3 Dartmouth-Hitchcock Health 0 The New London Hospital Association Inc 273 County Road New London NH 03257 020222171 Hospital NH 501(c)(3) Line 3 Dartmouth-Hitchcock Health 0 Windsor Hospital Corporation 289 Country Road Windsor VT 05089 030183721 Hospital VT 501(c)(3) Line 3 Dartmouth-Hitchcock Health 0 Cheshire Medical Center 580 Court Street Keene NH 03431 020354549 Hospital NH 501(c)(3) Line 3 Dartmouth-Hitchcock Health 0 OneCare VT ACO LLC 111 Colchester Avenue Burlington VT 05401 455399218 Shared Saving VT N/A Alice Peck Day Health Management Corp 10 Alice Peck Day Drive Lebanon NH 03766 020485370 Inactive NH N/A C 0 Hitchcock Health Connect One Medical Center Drive Lebanon NH 03756 800908979 Telehealth DE N/A C 0 Imaginecare Inc One Medical Center Drive Lebanon NH 03756 813105071 Software Tech NH N/A C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 Alice Peck Day Lifecare Center S 382657 Actual per books